Healthcare Leadership in a Harmful System
Our healthcare system, most often celebrated for its technological advancements and life-saving capabilities, is a machine of harm. This harm is not accidental—it is systemic, deliberate, and deeply embedded in the architecture of healthcare itself. Profit-driven incentives, structural inequities, and entrenched power dynamics create a system where harm is not only tolerated but incentivized. Yet, defenders of the status quo cloak these realities in euphemisms like “efficiency” or “cost containment,” obscuring the human cost of their decisions.
This essay unpacks the hidden realities of healthcare’s architecture, exposing its structural flaws and the rationalizations that sustain them. It also offers actionable strategies and visionary what-ifs to dismantle this machinery and reimagine healthcare as a system rooted in equity, dignity, and justice.
How Harm Is Built Into the System
Healthcare in the U.S. operates within a framework that prioritizes financial gains over patient well-being. This isn’t a bug; it’s a feature. The system’s design ensures that harm is not incidental but inevitable.
Profit-Driven Incentives
Both for-profit and non-profit hospitals are tethered to profitability to survive. This imperative distorts priorities, incentivizing practices that prioritize revenue over care quality.
The Mayo Clinic explicitly directed staff to prioritize privately insured patients over those on Medicaid or Medicare—a decision that underscores how profit motives can override ethical obligations.
High-margin services like elective surgeries receive significant resources, while essential but less profitable services—such as mental health care and primary care—are underfunded or eliminated altogether. This prioritization of profit over care reflects a deeper systemic issue: human lives are commodified.
Commodification of Care
Healthcare has been transformed into a commodity, where patients are treated as consumers and care is delivered through market-based transactions. This commodification fragments care systems, prioritizes profit over need, and creates a multi-tiered system where access depends on one’s ability to pay.
Over the past decade, more than 100 rural hospitals have closed in the U.S., leaving millions without access to emergency care. These closures were justified as financial necessities but disproportionately harmed low-income and minority communities.
This market-driven approach fosters unethical practices such as unnecessary medical interventions, inflated pricing, and aggressive marketing tactics that exploit patients’ lack of information. It reduces healthcare to a transactional relationship, stripping away its human element.
Structural racism is deeply embedded in healthcare policy and financing. Historical policies excluded racial minorities from employer-sponsored insurance plans and underfunded Medicaid programs in states with large minority populations. This legacy continues today through segregated systems of care and inequitable resource allocation.
Private hospitals in urban centers often exclude uninsured patients or maintain separate facilities for Medicaid recipients, creating de facto racial segregation in healthcare delivery.
Even well-intentioned reforms like the Affordable Care Act (ACA) failed to address these systemic inequities fully. While the ACA expanded coverage, it left intact a fragmented payer system that disproportionately disadvantages racial minorities. Structural racism manifests in unequal access to care, poorer health outcomes, and a lack of representation in decision-making processes.
Leadership’s Role: From Idealism to Complicity
Healthcare leaders often begin their careers with good intentions but become complicit in harmful practices due to systemic pressures. Their career trajectories reveal how ambition aligns with systemic violence:
The Idealistic Technician: Early-career professionals focus on operational efficiencies—like streamlining claims processing—without considering the human impact.
Example: An analyst develops an algorithm to flag “suspicious” claims, celebrated internally for saving costs but systematically denying necessary treatments.
The Rationalizing Manager: Mid-level managers justify harmful decisions with euphemisms like “cost containment” or “resource optimization.”
Example: During COVID-19, hospitals furloughed thousands of nurses despite receiving billions in federal aid.
The Strategic Operator: Senior leaders institutionalize exploitative practices such as union suppression or automated claim denials.
Example: Anthem Blue Cross automated denials for high-cost procedures while bankrupting patients.
The Systemic Enforcer: At the CEO level, leaders shape industry norms and public policy to entrench inequities.
Example: Health insurers spent $158 million lobbying against Medicare for All in 2022.
Rationalizing Harmful Practices
Healthcare leaders often use specific narratives to justify their actions:
"The Data Made Me Do It": Decisions are framed as data-driven necessities.
"We’re Protecting the Institution": Harmful actions are rebranded as sacrifices necessary for survival.
"Tough Decisions Are Leadership": Austerity measures are valorized as hallmarks of decisive leadership.
"The System Is Broken, but I Didn’t Break It": Blame is shifted onto systemic constraints.
These rationalizations obscure accountability while perpetuating harm.
Strategies for Change
Transforming healthcare requires bold strategies that dismantle its harmful architecture:
Realign Incentives: Tie executive compensation to metrics like patient outcomes rather than profitability.
What if CEOs earned bonuses only when racial health disparities decreased?
Increase Transparency: Mandate public reporting on claim denials and lobbying expenditures.
What if every hospital had a public dashboard showing how much it spends on patient care versus executive pay?
Democratize Governance: Include patient advocates and frontline workers on boards.
What if hospital boards had mandatory representation from marginalized communities?
Expand Universal Healthcare Access: Advocate for systems like Medicare for All.
What if we eliminated medical debt entirely?
Build Equity-Centered Leadership: Train leaders to prioritize equity through competency-based programs addressing implicit bias.
What if every medical school required courses on structural racism?
Reimagining Healthcare
Imagine a healthcare system where:
Mental health was prioritized equally with physical health, with integrated services available without stigma or barriers.
Community health workers became central figures, bridging gaps between providers and underserved populations.
Technology created seamless patient experiences, allowing individuals to schedule appointments or access records effortlessly through user-friendly apps.
Preventive care was king, reducing chronic disease rates by investing heavily in nutrition programs and wellness initiatives.
Global best practices were adopted, adapting successful models from other countries into domestic policy reforms.
Dismantling the Machinery of Harm
The architecture of harm in healthcare is not an accident—it is a deliberate construction shaped by profit-driven incentives and systemic inequities. But just as this system was built piece by piece, it can be dismantled—and rebuilt into something better.
This transformation requires changemakers who see through euphemisms like “efficiency” or “cost containment” and demand transparency, accountability, and justice.
The stakes couldn’t be higher: lives depend on dismantling this machinery of harm. Let’s imagine boldly—and act decisively—for justice, equity, and the future of healthcare itself.