“It’s ultra stable. Health care doesn’t move. If you biopsied American health care in 2010 and again in 2026, no one could figure out which slide was which.” — Robert Pearl, MD

Bad news. The patient, I’m afraid, is ultra-stable. Robert Pearl, former CEO of Kaiser Permanente for eighteen years and author of ChatGPT MD, returns with the bleakest diagnosis we’ve heard all month. American healthcare, Dr Pearl says, is “ultra stable.” That might sound good. But it’s actually very very bad.
If you biopsied American healthcare in 2010 and again in 2026, Pearl says, no clinician could tell the slides apart. Both were and are overpriced. Both underperforming. Hospitals still represent between 30-35% of expenses. Costs continue to rise at between 7-9% a year. There remain four hundred thousand misdiagnosis deaths annually. Burnout is stuck at 50%. The numbers haven’t moved in fifteen years.
Meanwhile, a stealth revolution is already underway. 40% of Americans use generative AI every month for medical questions. 70-80% of physicians use it weekly. While the patients and doctors have moved, the system hasn’t. It remains ultra-stable. It’s a Kodak moment — healthcare’s business model, Pearl suggests, is selling sickness. The new new medical thing is GLP-1 drugs that cost $5 to manufacture and sell for $400.
So will the system collapse? No, Pearl insists. It has too much strength for that kind of drama. Instead, it will quietly ration us to death — more chronic disease, earlier deaths. Ultra-stability is what is killing the American healthcare system. It will, quite literally, ration us to death.

Five Takeaways
• Out of the Library and Into the Subaru. After winning the Pulitzer for G-Man, Gage drove across America in thirteen trips. Six months on the road. The car broke down constantly.
• Historians Don’t Think Enough About Geography. The Virginia presidents were neighbours. The Erie Canal was a reform corridor. Frederick Douglass and Susan B. Anthony lived near each other.
• Disneyland Is a Parable About American History. Main Street USA is Walt Disney’s childhood. Frontierland is the heroic past. Tomorrowland is Cold War optimism.
• The Third Road Between Pride and Shame. Some Americans told her: celebrate the country. Others said: only say the good stuff. Her book lives in the tension.
• Upstate New York Reimagined America. Douglass and Anthony as neighbours. Writing their own constitutions. Rethinking the Declaration.

About the Guest
Beverly Gage is a Pulitzer Prize-winning historian and the John Lewis Gaddis Professor of History at Yale.
References
This Land Is Your Land: A Road Trip Through US History by Beverly Gage

About Keen On America
Nobody asks more awkward questions than the Anglo-American writer and filmmaker Andrew Keen.
Website: https://keenon.tv/ Substack: https://keenon.substack.com/ YouTube: https://youtube.com/@KeenOnShow

Chapters:
00:00:31 Introduction: AI and the American healthcare sector
00:01:47 ChatGPT MD: chronic disease and the trillion-dollar opportunity
00:04:50 The stealth revolution: 40% of patients, 80% of doctors
00:06:53 Ultra stability: the 2010-vs-2026 biopsy
00:09:50 Three years of generative AI and counting
00:11:13 Will the system collapse? No — it will quietly ration
00:13:33 The drip-drip of preventable deaths
00:16:08 GLP-1 drugs: $5 to make, $400 to buy
00:18:23 Vibe coding enters the conversation
00:21:22 Will AI replace clinicians?
00:28:08 Trump Rx and why it won’t help most people
00:30:41 RFK Jr., vaccines, and the war on science
00:33:23 The midterms as the political reckoning
00:35:29 The three-step fix: capitation, transition, capital
00:39:48 Vibe coding and the heart failure example