Trying to fix complicated problems

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 challenging, like when they had to use soil freezing to build a huge tunnel in soft soil, directly under some railroad tracks.

How'd it go? Well, now when it gets nice out in late Spring you see a bunch of families hanging out in the greenway, instead of some massive highway full of stop-and-go traffic. It is just fantastic. Driving to the airport went from a massive inconvenience to a simple drive down the Mass Pike. Traffic dropped, carbon monoxide levels improved, the dirt was used to convert a literal dump into a beautiful harbor island with a beach and some walking trails.

On the other hand, it clearly did not go well. The finances were a mess, it cost twice as much as they planned and became the most expensive U.S. highway project ever. Seemingly everything ran into problems, seemingly everyone messed something up, and it finished way behind schedule. A number of companies got sued and someone died.

So now you get the sense that it did long-term damage even if it was basically a success. You do an impossibly complicated project, a project it seems like you weren't quite able to manage, and before long your name ends up in the paper... what are you supposed to work on next?

The MBTA

So there has been cynicism about all sorts of projects and infrastructure issues in Boston, going back for decades, but then MBTA made things even worse in 2021-2022 with a string of crashes, derailments, and several deaths. They put in slow zones all over the place, and travel times went way up.

Then in March 2023, Maura Healey appointed Phil Eng to be the general manager. All of a sudden things turned around, and in the end it took less than two years to get rid of all the slow zones.

I think every person in the city would have laughed, if you told them, in February 2023, that in two years the whole system would be fixed. This kind of thing isn't supposed to happen in Boston!

I don't know what kind of dark magic enables Phil Eng to do what he does, but there are some things that stand out about his approach. Apparently he rides the T every day and takes pictures when he sees a coffee stain, so someone can clean it up. And then if someone brings up a problem he is unusually calm and down to earth about it. His whole thing seems to be making people more comfortable talking about problems, so they can be promptly addressed and not hidden from view.

The vaguer thing is that he just seems... really good at his job? It's as if he lives in a world filled with people who are focused on the politics, whose idea of success is getting public praise from the governor, and he is the only one who actually likes the work. For Phil Eng it seems like the political success is just currency he needs to do what he really wants, which is to go fix a million tiny little problems so the trains will run better.