I said something to a reporter last month that I have been thinking about since: “ We’re in wartime in U.S. healthcare, and many folks have adopted a peacetime mentality. ”

The distinction is not rhetorical. Peacetime institutions optimize, convene, refine, and wait for evidence. That is the right behavior when the status quo is basically sound and time is on your side. Neither is true here. The status quo is deeply broken, and the dominant techniques of the American healthcare elite reek of people who believe there is time.

I am as guilty as anyone. Everything in the list that follows, I have done.

Publications. The idea that the next article will change how we solve problems is nice, but quaint. There are occasionally writers whose perspectives and carefully chosen words enter the zeitgeist. They are rare. The rest of us are mostly talking to each other, having the same conversation on repeat.

Conferences. People coming together to exchange ideas is as old as humanity. But convening at the St. Regis to discuss cuts to Medicaid has an underlying moral bankruptcy that makes the conversation neither credible nor effective. The dialogue is polite. The proposals are incremental. Everyone leaves energized and nothing moves.

Interest groups and trade associations. Organizing around parochial interests reliably descends into full-throttle defense of the status quo. The mission statement says patients. The comment letter says margin.

And the one we never name: the pilot. The first three are all talk, which makes them easy targets. The pilot is peacetime action , which makes it worse — it looks like doing something. Three years, a favorable evaluation, a conference panel about lessons learned, and no scale. The demonstration that demonstrates nothing is healthcare’s most sophisticated form of standing still.

None of these four is useless. Each is defensible on its own terms, which is exactly what makes them dangerous. I have spent the last several years writing about what I call the moral alibi — an explanation that is technically accurate and fundamentally dishonest, because it converts genuine agency into performed helplessness. The peacetime repertoire is the moral alibi in its most respectable form.

Not I couldn’t . Something better dressed: I published. I convened. I piloted. I raised it with the association.

All true. None of it the thing itself.

An unvarnished description of the status quo. We have to say clearly what is wrong and who and what needs to go. This is harder than it sounds, because the vocabulary we have built over thirty years is designed to prevent it.

These phrases have no defendant. They describe a weather system. That is their function — an alibi works by removing the actor from the sentence.

So let me be specific. The enemy is the prior authorization queue engineered so that a predictable share of people give up. The enemy is the risk adjustment operation that produces revenue without the requisite commitment to improving underlying care. The enemy is the nonprofit hospital suing its patients, sometimes patients who are employees, while its board celebrates financial performance. The enemy is the onerous quality measurement industrial complex that has the effect of distracting from actually caring for people.

And here is the part we avoid: practices have owners. Every one of these was approved by someone, funded by someone, and defended in a meeting by someone who went home afterward and thought of himself as a good person. It is easier to name what the insurer down the street or the hospital across town is doing wrong than to account for what we have approved, what we have allowed to continue, and what we have the power to fix. Wartime means being willing to do that. Starting with ourselves.

Self-indictment before indictment. In the spring of 2021 I sat in a conference room at SCAN during a patient access review. A slide came up: average wait for an oncology appointment for newly diagnosed cancers, one medical group in one quadrant of Los Angeles County. Forty-two days.

The presenter read it in the same tone he had read the slide before it. Nobody’s posture changed. Nobody set down a pen. The conversation moved on. Everyone in that room had come to healthcare to make things better, and everyone in that room was doing their job well.

Forty-two days means a person hears we found something , drives home, waits for the phone to ring, and learns the earliest appointment is six weeks out. Then they sit in a room for six weeks with a cancer growing inside them.

There was a pause in the conversation where I could have said this. I had the words forming. The moment passed, someone else was already talking, and I wrote a note on my agenda.

I have spent five years since trying to understand that silence — my own, and everyone else’s in the room.

Five years later, a SCAN member broke her wrist and could not get in front of an orthopedic surgeon. She called us, patiently. We had nothing to give her. By the time a surgeon saw her two weeks later, the bone had set wrong and had to be surgically rebroken and reset. That one was not a failure of nerve. It was a failure of design: a narrow network we chose deliberately, a release valve we never built, and a network adequacy standard we met on paper while her wrist set wrong anyway. I never learned her name.

I am not telling you these things because confession is cleansing. It isn’t, and an executive who confesses well has simply found a more sophisticated place to hide. But self-indictment can build trust. It tells people you know you have room to be better, and that you are not going to gaslight them — or yourself — about what happened. I have spent a career writing about accountability, and the honest version of that argument begins in the room where I said nothing and, worse, did nothing.

Unilateral moves with a price tag. The test of a wartime action is whether it costs you before it pays you. Publish your denial rates next to your competitors’, even if it makes you look bad. Drop prior authorization on a category without waiting for a regulation to make you. Exit a profitable line of business because it should not exist. Most acts of courage and leadership have a real cost. We should get used to paying it.

Defection from the guild. Nearly every one of us belongs to an association that has taken a public position we privately find indefensible. Breaking with it, publicly, with your name attached, is one of the clearest wartime acts available to a healthcare executive, and it is almost never done. The reason is not conviction. It is that the room is small and the meetings are quarterly.

Personnel as strategy. Wars are decided by who gets promoted. The values of an institution are not in its values statement; they are in the résumé of the last person elevated to the executive committee. If the people who rise are the people who are easiest to sit in a room with, you are in peacetime regardless of what you publish or proclaim at conferences.

Speed as a moral variable. Three fiscal years is a long time in the life of a seventy-eight-year-old. The sector’s default clock — pilot, evaluate, socialize, scale — is not neutral; every month spent deciding whether to fix a known failure is a month someone lives inside it. So name one thing your organization has been deliberating for more than a year, and set a date this quarter. Not a date to decide. A date to have done it.

Wartime language confers no virtue. An organization can use it to justify being ruthless toward the people it covers. What I mean is a willingness to bear cost ourselves, not a willingness to impose it on them.

Somewhere in your organization is a number that should stop a room cold and doesn’t. You know what it is. You have seen it presented in the same tone as every other number, in a deck that moved on, in a meeting that ended on time.

You do not need a new strategy to begin. You need to be the person who says the number out loud and refuses to let the meeting move on. That is an unglamorous act. It will not be described as leadership. It might even be described as disruptive. It will be mildly awkward, and the people in the room will be professionals about it, and someone will suggest taking it offline.

Do it anyway. And then do it again. Then do the harder thing, which is to attach a name and a date to what happens next — yours, and soon.

The peacetime version of this essay would end with a call for further dialogue. We have had the dialogue. We have had thirty years of it, at good hotels, with excellent panels. What we have not had is enough people willing to be the friction in the room.

That is the whole job now. Be the friction.