Is Anything Real?

Healthcare is broken. But treating it like an unavoidable force of nature is not leadership.

In this episode of Is Anything Real?, Adam W. Barney is joined by David Silverstein, founder and CEO of Amaze Health and author of The Lean Health Plan: How American Businesses Can Fix Our Broken Healthcare System, for a systems-level conversation about healthcare, employer responsibility, and the leadership cost of learned helplessness.

David’s argument is direct:
American businesses are not just victims of healthcare complexity.
They are active sponsors of the system their employees live inside.

And if employers are funding the system, selecting the vendors, sharing the cost with employees, and carrying fiduciary responsibility, then they cannot keep pretending healthcare is “just how it works.”

They have to understand it.
They have to question it.
They have to manage it like the major business system it is.

In this episode, we unpack:
  • Why employers became central to the American healthcare system
  • Why many leaders treat healthcare like weather, taxes, or annual bad news
  • How complexity creates learned helplessness inside the C-suite
  • Why self-insured employers have more responsibility than they may realize
  • The hidden administrative machine behind claims, networks, TPAs, PBMs, and pricing opacity
  • Why businesses tolerate healthcare complexity they would never accept in payroll, procurement, travel, or supply chain
  • What “active sponsorship” means for leaders managing health benefits
  • Why the government is unlikely to rescue employers from this system
  • How AI and blockbuster drugs may accelerate healthcare cost pressure
  • The Broken System Audit leaders can use on healthcare or any recurring operational migraine
One of the clearest takeaways:
Complexity does not excuse inaction.

Leadership is not the search for perfect answers.
It is the discipline of taking responsibility inside imperfect, complex systems.

Guest: David Silverstein - Founder + CEO, Amaze Health
Host: Adam W. Barney - Transition Leadership Coach | Creator of EnergyOS | Author of Make Your Own Glass Half Full

Creators and Guests

Host
Adam W. Barney
Adam W. Barney helps transitioning leaders navigate career and leadership inflection points with clarity and momentum. Author of Make Your Own Glass Half Full and creator of EnergyOS. Based in Boston, fueled by family and music.

What is Is Anything Real??

Is Anything Real? is the Reality-First Leadership podcast for builder-leaders who want outcomes, not optics. Each week, Adam W. Barney sits down with founders and operators to unpack positioning, marketing, community, energy management, and influence - plus the numbers behind what actually worked.

You’ll hear: a quick Reality Check, a practical Proof Stack (inputs → actions → outcomes), and one EnergyOS habit you can run this week. Specifics over slogans; humane systems over hustle cosplay.

New episodes every Wednesday at 12:00 PM ET.

👉 Book your 20-min Exploration Call: https://calendly.com/adamwbarney/explorationplugin-20min

[00:05.7]
Here's a myth that lets a lot of leaders off the hook. Health care is broken. But it's too big, too complex, and too entrenched for employers to do anything about it. Actually. Well, nope, that's not leadership. That's surrender with a benefits consultant.

[00:22.4]
And somewhere along the way, American business learned to treat health care like the weather. Premiums go up, plans get worse, employees get confused, everyone complains. Then we run the same ritual again next year. But what if the real problem is not just that the system is broken?

[00:41.1]
What if the real problem is that too many leaders have been trained to believe they're powerless inside it? Welcome back to "Is Anything Real?", the reality-first leadership show where we test advice, publish the receipts, and ship what actually works under pressure. I'm Adam W. Barney, transition leadership coach, author of Make Your Own Glass Half Full, and builder of EnergyOS, where I help leaders rebuild their operating system when the tools that got them here stop working.

[01:09.5]
Today's guest is David Silverstein of Amaze Health. David is building in one of the most complicated systems on earth: American healthcare. And what makes this conversation different is that David does not come at healthcare as a physician or a traditional healthcare lifer.

[01:29.4]
He comes at it as a systems thinker, an innovator, and someone who has spent decades solving hard problems across industries. And there's also a timely reason this conversation matters, right now. David has a new book coming out called The Lean Health Plan: How American Businesses Can Fix Our Broken Health Care System.

[01:51.3]
Now, I got an early look at it. It's not enough to pretend I've digested all 300-plus pages, but it's enough to know this conversation matters. Because if David is right, business leaders are not just victims of health care complexity. They're actually sitting on more power than they realize.

[02:08.3]
David, welcome to the show. Yeah, thanks for having me, Adam. You got it. Apologies for that long intro here, but there's a lot to put into play here. I want to start exactly there, though. The title here is not How Doctors Can Fix Health Care.

[02:24.2]
It's also not How Washington Can Fix Health Care. It's How American Businesses Can Fix Our Broken Healthcare System. That's a swing. So what's the myth employers believe about healthcare that you want to break first? Yeah, I think, there's really two things at work there.

[02:42.1]
One is it's very important for businesses to understand how they became the core of the American healthcare system in the first place. And so, I dedicate the whole first section of the book to the history, and if you had a chance to look at some of it, it's actually pretty fascinating history.

[02:59.6]
It's not something that people, who have read it thus far, find boring. It's one of those things. It's kind of like reading the history of the United States for the last 75 years, really, since World War II. So employers, without going into all the detail, employers kind of own healthcare for the working-age population in this country.

[03:21.2]
And the second part of your question is employers have come to think of health care. You know, you, you describe it as weather, which is a good analogy. I describe it as a tax. Right. Taxes are inevitable.

[03:36.5]
Sure, we'd like strategies to minimize our taxes, but at the end of the day, taxes are just something business leaders sort of suck up. But I've looked a little bit deeper at why companies are ignoring the problem of healthcare, even though the costs are raising at 2-4X the general rate of inflation every year.

[03:56.2]
I mean, think about that. Is there anything else in a business that a CFO or CEO is going to allow to rise that fast without really putting a spotlight on it? So the second problem that I think we have is we tend to want to ignore things that we don't understand.

[04:15.2]
Yep. Right. And it doesn't feel good to not understand something, so we think we're delegating it to somebody else. The third factor is a little bit of groupthink. If every other executive that I interface with isn't really doing much about this and is just taking it on the chin.

[04:37.6]
And it's kind of okay for me to do the same thing. Right. If suddenly, though, my board members are challenging me, if suddenly shareholders are asking why costs are going up so fast, if suddenly it's really starting to eat into the bonuses of my employees, then that's going to change.

[04:55.2]
But for now, the mindset that we're looking at attacks, we don't understand what's going on, and it's become socially acceptable - those three things really converge. Say, we've taken our eye off the ball. And another thing that I cover that's really, really important in the book is anybody that thinks government's going to come to our rescue or the dynamics are going to change are just plain wrong.

[05:21.5]
And that's why I dedicate so much time to the history. You got to understand how we got here to understand why businesses are stuck in the business of healthcare. And the cavalry is not coming. Nobody's letting them off the hook. Yeah, yeah, well, and that's the piece. You know, David, that kind of hit me immediately.

[05:38.7]
You know, most treaters, at least traditionally, I think, treat health plans like something that happens to them, and somehow that gets, you know, it's been treated as mature leadership, but it's not maturity. I think it's actually learned helplessness wearing a Patagonia vest.

[05:55.1]
Right. And even just looking at the architecture of the book, I want to, you know, caution people that it doesn't read like a rant. It's actually a systems map. But let me ask it this way. When does an employer become more than a buyer of benefits?

[06:11.9]
When do they become responsible for the system they're sponsoring? Is it from day one of the business, or is it later than that? Yeah. So, you know, in a very small business these days, it's common to not offer benefits to your employees at all. Right. And it's cheaper to do things that way.

[06:28.6]
There's lots of ways to evolve into a business of 5, 10, 15, 20 people where you don't have to worry about benefits because, you know what, the only people who are going to come work for you are people who are either young and healthy and don't care, or people who have a spouse with a good job and they're on their benefits plan.

[06:45.9]
But once you get up to that 10, 15, 20 person mark, you're really starting to become limited in the ability to hire the people you need. So I'd say it's somewhere in there that employers really have to start taking healthcare benefits seriously.

[07:02.3]
But they're small, so they're just buying healthcare, as what would be described as a fully insured company. Just like you're buying car insurance, like you're buying homeowners insurance. But once the company gets above about 50, 60 employees, they have to start thinking about self- insuring themselves.

[07:20.1]
Self-insuring is a little bit of an odd concept, right? We don't self-insure even in very big companies. We don't self-insure our automobiles. Right. Our delivery trucks. We buy insurance through an insurance company, maybe until you get super big, like perhaps an Amazon insuring itself.

[07:38.3]
But everything in between, we buy insurance from somewhere else. Something really interesting happened back in the early 1970s, and it happened by accident. In the early 1970s, Congress was trying to deal with a problem that had nothing to do with healthcare.

[07:54.0]
Right. It was the era of pension plans failing and retirement funds getting raided. Right. We had the mob taking over unions and raiding their pension plans to fund casinos in Las Vegas. Congress was under a lot of pressure to rein in the out-of-control management of pension plans, and created ERISA.

[08:16.5]
Right. So, most business folks are familiar with ERISA. Not everybody knows what it stands for, Employee Retirement Income Security Act. But that was the law that was designed to exert a lot of federal control over health plans. One of the things that companies complained a lot about back in those days was having to deal with all of the different states' pension and retirement laws.

[08:41.9]
Right. And so in order to relieve that burden on companies, ERISA, federalized or what's often known as ERISA preemption. Federal law preempts state law. Right. So companies would just have to deal with one set of law, just the federal government. And tucked into ERISA, was just a tiny few words that included welfare benefits, which in the language of American law means healthcare.

[09:09.0]
And so all of a sudden, healthcare was also potentially freed from every state's insurance commission. Different state laws. The states were starting to tax health insurance benefits. So very quickly, the lawyers figured out, hey, we've just been given the green light to move into this self-insuring space.

[09:35.1]
And so big companies, the IBMs, the GMs, the Procter and Gambles, right, all the companies that we know from history, they all jumped into self-insuring really, really fast. And so this era of employers self-insuring themselves began. You know, at first, healthcare was all about procurement.

[09:55.0]
You buy things, you buy healthcare services. But in the decades that followed ERISA and this self-insurance paradigm, we let ourselves somehow get sucked into the systems of claims. Right?

[10:10.4]
Medical claims. We send $3 drugs through a claim system. We send a routine doctor's appointment, a well-child visit through a claim system. These are not insurance events. So we have created this monster administrative machine that literally sucks 50 cents of every dollar out of the provision of health and medical services into an administrative engine.

[10:35.3]
I refer to that engine as a system of toll booths. I think a lot of our listeners, probably from the outside, are just thinking, oh, healthcare is one industry, but you're right there. Inside it you've got payers, providers, employers, brokers, TPAs, PBMs, networks, claims, regulation, pharmacy pricing, opacity, member behavior.

[10:58.6]
And it's a comedy of errors over the course of 75 years. You know, a good example that helps people understand this comedy of errors is HIPAA. When I say the word HIPAA, what word comes to mind for you? Right? Think like a psychologist, you're doing an ink blot.

[11:14.6]
I say HIPAA, you say. Patient privacy. Privacy. Right. So what does the P in HIPAA stand for? Patient No. Privacy information. And it doesn't stand for privacy. HIPAA was not about privacy.

[11:31.4]
HIPAA stands for the Health Insurance Portability and Accountability Act. HIPAA was created to allow you to take your insurance from one employer to another employer. It had nothing to do with privacy. It was designed so that you can maintain continuity and bring your insurance with you.

[11:49.6]
Of course, you couldn't. So if you were working for a company that was on an Aetna health plan, and you went to a company on a United Health plan, you didn't take your insurance with you. You know what you could take with you though? Take your disease. Yep. Right. You could take your injury. So we created this law that allowed you to make your disease portable.

[12:06.9]
It didn't make your insurance portable. The way we gave you that right is by saying you don't have to tell your next employer about your illness. That was the reason that privacy was built into the HIPAA law, was to enable you to take your disease with you to another company.

[12:23.4]
It wasn't because we wanted to create a $50 billion industry around protecting your privacy. Right. Healthcare is the only industry that uses the words revenue cycle management. Right. It's the craziest that we've got a whole vocabulary.

[12:42.0]
Doctor writes a prescription for you for penicillin because you've got a strep throat. You know what a penicillin pill costs? About half a penny. So to fill that prescription, it might cost the pharmacy down the street, 3x/day, 10 days, might be $0.15, $0.20 worth of actual drugs that's going into that pill bottle for you.

[13:02.8]
But then we put in place this entire administrative engine. The pharmacy has to check your eligibility on your insurance card. Then they have to submit a claim. A claim goes through a clearinghouse. The clearinghouse sends it to your claims administrator.

[13:20.3]
They have to check everything again. They may deny it, they may approve it. They have to send you letters called EOBs, explanation of benefits, telling you how much of that $20 now prescription that should have been $3. How much of it do you have to pay versus how much is your insurance company going to pay?

[13:37.4]
Like we set off this entire cascade of unbelievable expense. None of which adds value, all of which adds headache and friction. It's the craziest system in the world. Well, and I mean, you know, most listeners here aren't running healthcare or healthcare-adjacent companies, but I think every leader, from a leadership lens, listening is operating inside systems they don't fully control.

[14:01.5]
But then I would take that, David. You know, complexity does not excuse inaction. Complexity absolutely punishes arrogance on the other side of it though. Right. We've got so many other industries that are not core competencies to our business. Payroll systems.

[14:17.1]
Right. We use an ADP or a Paycom. We have to buy electricity. We lease vehicles. All things that are outside the core competency of a business, let's say that makes computer chips. They're not a travel agency, but they still have to manage travel.

[14:34.0]
So we figure out how to do all of these things. But in every other part of the business we're managing a procurement system and we have accidentally allowed everything in healthcare to be sucked into this opaque black box of pricing and claims.

[14:51.2]
Something we wouldn't tolerate in any other part of the business. If that was going on when it came to travel expenses, we would change travel agencies, or we would bring it in-house as many companies do. If we don't understand why we're being charged for certain vehicle maintenance, we're going to change vendors that provide that procurement.

[15:10.2]
We have supply chain management teams. We have procurement teams. Most companies though spend, in many companies, the second or third largest item on their P&L, after their payroll itself, is healthcare. In a manufacturer, it might be raw materials and then healthcare.

[15:27.3]
And yet there are very few people in the company dedicated to managing the healthcare spend. Most of them don't understand it. And we've turned everything over to big healthcare to manage for us in a black box. It's absolutely crazy. Well, and I think in a wider leadership lens, that gets into, you can't do every task, you should not do every task, but you still own the system you sponsor.

[15:53.8]
And of course, one of your chapters in the book is called The Active Sponsor. And that feels important because active sponsorship, in health plan context, is a really critical distinction. I look at it as passive sponsorship as we offer benefits, but active sponsorship is, we understand the incentives, the architecture, the member experience, the cost, the outcomes, and the trade-offs.

[16:18.4]
And that's a very different kind of broader leadership perspective also. Well, and it's a legal obligation. So when, industry went down the path of self-funding, taking advantage of ERISA law, every employer that did so, which the latest stats are about 80% of companies with 100 or more employees are self-insured.

[16:40.7]
There is a fiduciary obligation to manage that healthcare spending and it is not just the spend of the company. You know, when a company decides to put up a new factory, that is purely an expense that is the responsibility of the company.

[16:56.8]
Employees don't get a say in that. But when a company takes on healthcare expense, they share that expense with their employees because their employees pay premiums into that health plan. Employees are also responsible for their deductibles.

[17:12.7]
So under ERISA, under the law, the health plan actually has more responsibility, for this, the health care spend, than it does for other expenses of the business because it is acting as a fiduciary on behalf of its employees.

[17:28.9]
Wow. This is getting used now to drive change in the system. In 2025, 22% of all lawsuits brought against employers under ERISA had to do with health care.

[17:44.1]
Not 401ks and not pension plans. Wow. So the class action attorneys are going after big companies. There are cases pending right now against Wells Fargo, JPMorgan Chase, Johnson and Johnson. Right. They make drugs themselves. J&J is being sued by its own employees for allowing them to pay thousands and thousands of dollars for drugs that should have cost tens of dollars.

[18:08.4]
Wow. And, you know, there's a lot of pressure coming from the federal government, coming from class action attorneys, to hold employers accountable for getting back into the game of managing their healthcare spend.

[18:24.2]
And that's why I titled the book How American Businesses Can Fix Our Broken Healthcare System. It's not going to start with the government. The government is the most conflicted buyer of health care of all because the government pays for 50% of all healthcare.

[18:40.3]
For Medicare, Medicaid, the Indian Health Services, child health insurance plans. And so the government is not going to fix the system for employers because to do so risks causing costs to go up for the government. So employers are going to have to do this on their own.

[18:59.1]
And the only way they're going to do it is if they start to say, you know what, there is no reason for many of these things to go through a claims process in the first place. We're just going to procure health care services, medications, medical devices.

[19:15.5]
We're going to procure them for our employees. Like everything else. We're not going to get sucked into this administrative game. You know, David, I want to kind of build this towards we wrap here into a system that listeners could run this week. And I want to call it something like The Broken System Audit.

[19:33.0]
Right. Pick one system in your business everyone complains about but no one truly owns. It could be healthcare, hiring, onboarding, so on and so forth. But it's something that's a recurring operational migraine your team has quietly normalized. And then just ask three questions.

[19:49.2]
Right. Where have we mistaken complexity for inevitability? You know, in plain English, what have we done just because it's always been annoying or accepted? Second being, who benefits from us not understanding this clearly? I think that gets spicy quickly.

[20:04.3]
You know, confusion is rarely neutral. Complexity is sometimes accidental, but it's sometimes profitable for whoever's on the other end. And then the third is, what would active sponsorship look like here? You know, it's not micromanagement pretending to be the expert, but active sponsorship.

[20:20.6]
Clearer questions, better incentives, visibility, ownership, measurement, and human experience. But, what would you add to that audit quickly?

[20:31.2]
So I think you, I think you sort of nailed it with the right questions. The next part of that is the belief system. If employers do not believe that they can do something about it. Right. They're going to answer those questions. They're going to be unsatisfied with the answers.

[20:47.0]
They're going to look in the mirror and say, my God, what have we done? We've let a monster evolve here and it is just sucking the life and the money out of our company. They have to believe that they can actually change that dynamic. Because if you don't believe you can change it, then you just keep kicking the can down the road.

[21:05.2]
You keep listening to those insurance brokers and agencies. Because you don't have the expertise in-house. We've somehow come to believe that healthcare is something managed by human resources. Right. But you need to look at it through a different lens.

[21:25.6]
And it's the lens of procurement, vendor management, supply chain considerations. And that requires an understanding of finance. It requires an understanding of how we purchase things.

[21:41.4]
HR can manage a third-party insurance agency, but they're getting taken to the bank over that. Right. So, the C-suite has to look at healthcare and say, okay, we need to run this like a P&L center here. And we need to run this like a business.

[21:58.0]
It's one of our biggest expenses. It's out of control, and it's going to get a lot worse. So maybe the fourth question that you add: what do the next five years look like? Well, right now, the pipeline of blockbuster drugs that is coming is good.

[22:13.8]
What we've seen happen with GLP1's here over the last couple of years, which has already become 10% of the healthcare spend. The pipeline of blockbuster drugs that are coming is just immense. And so this problem is only set to get worse.

[22:29.4]
AI is going to make it a lot worse. Everybody thinks AI is going to make healthcare cheaper. No, no, no. AI might make a hospital or a doctor's office a little bit more efficient, but what it's also doing is making our ability to discover new groundbreaking medications, surgical techniques, medical devices.

[22:48.2]
That is coming much faster as a result of AI, and somebody's going to have to pay for it. So the problem is last year companies saw an average about 10% increase in their cost. So about 3x to 4x the rate of general inflation.

[23:03.4]
The predictions are already out for this year. That was not an anomaly. Companies are being told to expect double-digit increases in cost again this year. And there's no sign that this is a fad, a trend. There's not going to be any mean reversion going on here in the next few years.

[23:21.3]
The problem is here to stay, and so, companies have to start managing it. I mean, David, I think you know how we end here. After all of this, healthcare complexity, employee responsibility, paradox, abstraction, broken systems.

[23:37.3]
Is anything real? And it's, unfortunately, it's very real. Well, I think what's real is this. Right? You know, leadership and healthcare. It's not the search for perfect answers; it's the discipline of taking responsibility inside imperfect, complex systems.

[23:58.6]
Very well said. Awesome. David, where should people learn more about Amaze Health, follow your work, and get a copy of The Lean Health plan when it drops. Yeah, so amazehealth.com Easy to find. I'm very easy to find on LinkedIn. D. Silverstein is my LinkedIn handle.

[24:17.9]
Right now I've got a preview of the book up there. It'll go to Amazon for publishing and Kindle availability by the end of the week. In which case we'll take that version down. And my site where I write about the challenges of the healthcare system is brokenhealthcare.com Beautiful.

[24:37.1]
All right, we'll of course link to those all in the show notes below. But if this episode hit, I would challenge our listeners to send it to one leader who keeps saying, with a shrug of their shoulders, that's just how the system works. Because sometimes that sentence is wisdom and sometimes it's actually just a very, very expensive excuse.

[24:57.4]
And if you're navigating a leadership transition, promotion, burnout, pressure reinvention. There's a 20-minute foundational call with me linked in the show notes below as well. But, David, thank you for being here. This was an absolute systems power one. Right. And until next time, stay grounded, stay human, and keep questioning the noise.

[25:16.8]
But, David, thank you. All right. Thank you, Adam. Take care.