Why American Healthcare Fails the Sickest, and What We Can Do About It

May 12, 2025

Lisa is 48 years old. She lives in a modest apartment on the edge of town, the kind of neighborhood where sidewalks crumble and convenience stores sell more liquor than lettuce. She works two part-time jobs, neither of which offer health insurance. On her kitchen counter sits a half-used bottle of Metformin, a box of instant noodles, and a letter from the ER billing department that she hasn’t opened yet. She’s not ignoring it. She’s just too tired.

Last year, Lisa was hospitalized three times for complications from type 2 diabetes. Once for a foot infection that nearly turned gangrenous. Once for dangerously high blood sugar after running out of insulin. And once when she fainted from dehydration at work and hit her head on a metal shelf. In total, her care cost the system over $80,000. She doesn’t know that number. But we do. We, the taxpayers, the insurers, the policymakers, the doctors. And we’ve seen this story play out thousands of times. We nod, we sigh, and then we write another check.

But what if we told Lisa’s story differently? Not as a tale of personal failure, but as a case study in what happens when we ignore the top of the river and build an entire system around catching people as they drown.

Million-Dollar Murray, Revisited

In his essay Million-Dollar Murray, Malcolm Gladwell chronicled the life of a man who was homeless, mentally ill, and repeatedly picked up by police in Reno, Nevada. Murray Barr didn’t commit violent crimes. He didn’t deal drugs. He just needed help. And the city gave it to him, over and over. He went to detox. He went to jail. He went to the ER. Again and again. It was a patchwork of crisis care that added up to over a million dollars.

Murray didn’t need a million dollars’ worth of interventions. He needed a place to sleep. He needed someone to believe he was worth helping before he collapsed.

Lisa doesn’t need a million dollars either. She needs something far more radical: a $75 bag of groceries each week. A community nurse. A place to walk that doesn’t feel dangerous. A health system that doesn’t shame her for being late on appointments she can’t afford to miss work for.

But like Murray, Lisa’s not rare. She is the rule, not the exception.

The Real Cost of Chronic Disease

In the U.S., 5% of the population accounts for roughly 50% of healthcare spending. Most of these are people like Lisa, those with diabetes, heart disease, obesity, autoimmune disorders, mental health challenges, or all of the above.

They don’t just need medicine. They need a different life.

Yet the entire healthcare system is built downstream, on surgeries, prescriptions, hospitalizations. Our hospitals are gleaming temples. But try finding an affordable dietitian or a mental health counselor with openings this month. Good luck.

And this isn’t just inefficient. It’s inhumane.

We blame people for being sick in the exact environments that produce sickness.

We scold the drowning for not learning to swim, while we build the waterfalls higher and higher.

Why Don’t We Intervene Earlier?

Because we don’t yet value what we can’t measure.

We know how to track ER visits. We don’t know how to track whether someone finally felt safe enough to go for a walk in her neighborhood. We have data on amputations and dialysis. We don’t have data on whether someone with prediabetes managed to switch from soda to water this week.

So we ignore the things that actually heal: food, movement, connection, purpose, agency, and hope.

The False Promise of Personal Responsibility

Let’s be clear: people like Lisa are often blamed for their health problems. She should eat better. She should move more. She should try harder.

But behavior doesn’t occur in a vacuum. It’s driven by environment, access, trauma history, social pressure, stress exposure, and dozens of micro-barriers that build up over a lifetime.

Habit science tells us something crucial: people repeat what’s rewarded in their environment and what’s frictionless. If healthy habits are expensive, inconvenient, or socially unsupported, they won’t stick. It’s not a character flaw. It’s neurobiology.

So if we want different outcomes, we must build different environments.

What We Can and Must Do Differently

1. Redesign the environment, not just the individual.

Instead of saying “make better choices,” let’s build better default options:

Put healthy food in every corner store.
Make stairwells clean and well-lit.
Subsidize produce like we subsidize corn syrup.
Offer walking groups at workplaces and neighborhood centers.

Microshifts in context produce macroscale changes in health behavior.

2. Deploy community health workers.

Lisa doesn’t need a specialist. She needs someone like Maria, a community health worker from her own neighborhood who visits twice a month, brings fresh food, helps track her blood sugar, and reminds her she’s not alone.

Programs like this exist. They just need funding. At Duke University Hospital, an individualized care plan program for high-utilizing patients led to a 50–56% reduction in hospital admissions and nearly 48% in hospital costs within 6 to 12 months.

3. Make upstream healing visible.

We track surgeries. Let’s start tracking:

Number of patients who went a month without an ER visit
Pounds of produce delivered
Hours of walking clubs held
Number of stress-reduction classes completed

What we measure becomes what we value. Let’s value healing, not just treatment.

4. Incorporate healing habits into healthcare.

Every clinic visit should include:

A question about stress and sleep
A check-in on food access
A micro habit recommendation (walk 5 minutes after lunch, try a breathing practice before bed)
A community resource map (nearby free exercise programs, cooking classes, support groups)

We know the science. What’s missing is the system.

5. Adopt a new narrative: The Healing Mindset.

We must stop treating health as a personal virtue. It’s a collective outcome.

Yes, personal responsibility matters. But it’s only possible when people have agency and access. When we talk about the obesity or diabetes epidemic, we should also be talking about the trauma epidemic. The food desert epidemic. The loneliness epidemic.

We are not broken people. We are people living in broken systems.

The Woman at the Waterfall

Imagine Lisa not at the ER, but at the top of the waterfall.

She’s sitting on a park bench in a walkable neighborhood after attending a free community cooking class. She’s just checked in with her health coach. Her fridge has fresh greens. Her legs are sore from walking. She feels proud, not ashamed. She’s not perfect. She’s healing.

And she hasn’t been to the ER in 14 months.

This is not a fantasy.

This is a public health choice.

But only if we are finally brave enough to stop relying solely on life rafts, and start building the bridges upstream that prevent people from being swept into the current in the first place.

P.S. If this piece made you think differently about the healthcare crisis, please consider sharing it. Comment with your thoughts, restack it to spread the message, and help us start a conversation that moves the spotlight upstream where healing truly begins. The more we talk about the real causes, the closer we get to real solutions. Thank you for your support.