Trying to fix complicated problems — Epi Notes

Epi Notes

Trying to fix complicated problems

Published on June 11, 2026

One day I watched a video where David Pruess goes through an analysis of a chess position (David is an amazing chess teacher and commentator), and he goes through like a dozen moves before pointing out one random little detail that reverses the conclusion. This is kind of funny because a less talented chess player looks at the position, miscalculates everywhere, gives up and goes, "well idk, White must be losing." An advanced player knows what they're doing -- and clearly, White is winning. And a tiny handful of players say hmm, something seems off here, and they get great joy out of looking for that random little detail, and that detail wins them the game. The real world seems more like chess than checkers, and most of us aren't that good.

Healthcare

Healthcare sticks out to me as the system that everyone thinks is horribly broken, but cannot be fixed. In 2018, Amazon and JPMorgan and Berkshire Hathaway founded a joint venture, Haven, that was supposed to make a big impact on healthcare. They picked Atul Gawande as the CEO, and that was the part that got my attention because Atul Gawande is a legendary healthcare writer and thinker, and I'd read a bunch of his books and articles. I figured he would do a great job, but I guess I was wrong, because Haven lasted only a few years and accomplished nothing.

There's also this book by Elisabeth Rosenthal called An American Sickness, about all the ways healthcare economics is messed up. I read it a while ago, and it has this list of rules to summarize how messed up the American healthcare market is. There are rules like:

"More treatment is always better. Default to the most expensive option."

"Amenities and marketing matter more than good care."

"More competitors vying for business doesn't mean better prices; it can drive prices up, not down."

I'm sure some of them are supposed to be provocative and get you to read the rest of the book, which has a lot of interesting stories, good research and a bunch of proposals. But these rules definitely aren't true, right? I mean, doctors who hype up ineffective treatments have a tendency to get in trouble over it. More treatment is not always better. There are lots of things that patients do not want, or doctors don't want to give them!

You could try to reduce unnecessary treatments somehow. You could argue well, maybe an MRI isn't really necessary in the workup of such and such cancer and maintaining an MRI machine is expensive, great, that's something we could do better. These MRI companies and hospitals want us to use it, but that's wrong. Now if a big insurer says "let's stop covering these MRIs," what do you think will happen? Doctors will enjoy having to call and argue? Patients will side with the insurance company? If an expensive treatment is routinely prescribed and paid for, I don't know, maybe it's just something patients and doctors both want.

On the other hand, the rules are sort of obviously true. Are you kidding me with the amount of money your insurance pays for things? There was that fun story from 2019 about someone getting billed $600 for putting on a band-aid. An American Sickness covers a bunch of interesting examples as well. These are somewhat old stories now, but I doubt things have gotten much better.

I think what I find suspicious is the idea that all this is just being forced onto helpless people, and it's easy for the evil healthcare system to just trick us all into giving them money. I don't know, aren't we sort of proud of the fact that America has the fanciest doctors? That costs some money. So does being the medical research leader of the world, having to wait less than Europeans do, having an insurance plan that covers big academic hospitals and lets you keep the same doctor no matter what plan you had before. The thing about the big academic centers is people really do want to go to them, and they're willing to pay a higher insurance premium to be able to. Same goes for that super expensive drug that extends your life only by a modest amount.

That means waging a war against insurance or large hospital systems probably won't work. The answer is probably way more boring and a lot more detailed.1 And a lot less satisfying too, because you probably can't make real progress without a bunch of specific concessions, like the modestly effective drug.

The Big Dig

In Boston, the Big Dig2 still comes up in conversation. 15 years of construction, after another decade of planning, billions of dollars spent, and a plan so complicated that it involved 118 separate construction contracts. Along the way, the project had to work with a number of very vocal neighborhood groups, undergo extensive environmental review, relocate a huge number of utility lines, and do whatever it is you do when you discover a shipwreck in the way of your tunnel. The technical work was extremely...