Where Does it Hurt

How can you take control of your health care in a system that often feels impossible to navigate, painfully expensive, and maddeningly bureaucratic? In Where Does It Hurt?, Jonathan Bush—cofounder and CEO of athenahealth and member of the famed Bush family—argues that the real cure for America’s health care crisis isn’t more government control or policy reforms. It’s unleashing the creative power of entrepreneurs and giving patients the freedom to make informed choices about their own care.

Bush contends that America’s $2.7 trillion health care industry has become a bloated, inefficient, and unresponsive system dominated by large hospitals, insurers, and regulations that reward complexity rather than quality. Yet paradoxically, its inefficiencies represent massive opportunities for innovation. He sees the system’s chaos as an entrepreneur’s playground—a chance to transform health care into a vibrant marketplace that values results, transparency, convenience, and human connection. In short: fixing health care means treating it like a real business.

A Broken Industry and the Promise of Markets

Bush opens with his firsthand experience as an ambulance driver and medic in New Orleans, witnessing hospitals treat chronic poverty and sickness as a form of endless crisis care. He asks: what if hospitals were forced to operate like any other business, responding to customer demand and price competition? Imagine paying $39.95 to manage hypertension at home instead of thousands for an emergency room visit. Entrepreneurship, Bush argues, could turn health services into something affordable, humane, and convenient—like Jiffy Lube for the human body.

This idea extends through the book. Bush believes competition and customer choice—shopping for care, comparing prices, demanding transparency—can do for health care what markets did for retail, technology, and even coffee shops. (Think Amazon treating shopping as a science, or Starbucks turning coffee into an experience.) He shows how allowing patients to act as customers, and caregivers as innovators, can awaken the sleepy, monopolistic system into a dynamic ecosystem akin to other industries that thrive under market pressure.

Why Bureaucracy Holds Us Back

In Bush’s view, bureaucracy—both governmental and institutional—has paralyzed progress. Antikickback laws, state licensing restrictions, and outdated data regulations keep newcomers out and protect bloated incumbents. Hospitals, doctors, and regulators are all locked into perverse incentive structures that prioritize billing over healing. He illustrates this with absurd examples, like laws preventing one doctor from paying another five dollars to share medical records, or regulations that stop patients from accessing their own data.

Bush’s memorable story about nearly losing his company to government regulation illustrates the problem. When the federal government tried to encourage electronic health records, legislators wrote outdated rules that favored old hardware over new internet-based systems like athenahealth. Bush personally lobbied Congresswoman Nancy Johnson to add the three words “and Internet services” to the law—an intervention that saved his company and, as he implies, opened the door for modern cloud-based health systems. It’s a vivid reminder of how tiny bureaucratic details can block innovation worth billions.

The Human Side of Reform

Beyond economics, Bush emphasizes the emotional heart of health care—the relationship between doctor and patient. He invokes Abraham Verghese’s concept of medicine as a sacred human encounter and the painting “The Doctor” by Luke Fildes, showing a physician deeply focused on his patient. To Bush, this intimate moment of care is health care’s purest form, and everything that distracts from it—paperwork, coding, bureaucracy—corrupts it. True reform, he argues, isn’t about replacing human compassion with machines but freeing doctors to be present for their patients by automating and outsourcing the administrative chaos.

A Call for a Health Care Renaissance

Bush challenges everyone—doctors, entrepreneurs, policy makers, and patients—to see themselves as participants in a coming renaissance of health care. He wants governments to open more space for innovation, doctors to think like entrepreneurs, and patients to become shoppers who demand choice and accountability. He paints a future where millions of “crazy ones” (to borrow Apple’s famous slogan) reinvent the industry from the ground up, making medicine more transparent, data-driven, and profoundly human.

Core Message

Health care isn’t broken because it’s too expensive—it’s broken because it isn’t a market. Every inefficiency, every waiting room, every outrageous bill is an opportunity for someone brave enough to fix it. Bush’s message is radical yet practical: save lives by unleashing capitalism’s creativity and giving choice back to those who need care most.

In the chapters that follow, Bush explores how this transformation unfolds—from collapsing hospital empires to nimble start-ups, from empowered doctors to informed patients, and from stagnant data silos to fast-moving information networks. Like a business manual for health care revolutionaries, his book is both manifesto and playbook for a new era of medical freedom.

Jonathan Bush’s journey through health care isn’t theoretical—it’s lived experience, full of mistakes, grit, and reinvention. He began as an ambulance driver in New Orleans, witnessing inefficiency and human suffering firsthand. He saw emergency departments treating non-emergencies, bureaucracies wasting billions, and patients enduring indignities no business would survive. This chaos sparked a question that shaped his life: What if health care ran like a business?

Lessons from Life and Boot Camp

As a medic in the U.S. Army during the Gulf War era, Bush discovered something profound: ordinary people, trained with clear systems and protocols, can perform sophisticated medical tasks at a fraction of the cost. This democratization of skill led him to imagine civilian equivalents of “army medics”—trained professionals who could deliver front-line care efficiently. It was one of the first glimpses of the “focused factory” approach he would later champion.

(In comparison, Atul Gawande’s The Checklist Manifesto explores similar ideas—how systems and training can make complex procedures safe and efficient. Bush’s view adds an entrepreneurial twist: systematize care and scale it through business innovation.)

Building and Breaking the Birthing Business

Bush’s first company, Athena Women’s Health, tried to overhaul childbirth by mixing empathy and efficiency. Inspired by his nurse wife’s insights, he imagined a “Starbucks for birthing”—a chain of warm, welcoming clinics focused on customer experience rather than hospital bureaucracy. Supported by a Harvard MBA dream and venture capital, he built beautifully designed centers where midwives led affordable, patient-centered births.

But reality hit hard. Insurance rules and hospital monopolies crushed innovation. Although the clinics delivered healthier babies at lower cost, insurers dropped them for being “too efficient,” driving Bush’s company toward bankruptcy. Yet in adversity, he found opportunity: the billing and data software he had built for his clinics was far more valuable than the clinics themselves. The pivot from birthing to billing gave birth to athenahealth, the cloud-based data giant that would redefine health technology.

The Pivot to Data and the Internet Revolution

Recognizing that poor payment systems were killing small practices, Bush and his cofounder Todd Park built software to simplify billing and insurance verification. They coded what Bush called “digital Gladys”—an automated system embodying the tireless rule memorization of every medical clerk. This innovation transformed chaos into clarity and marked the shift from paper nightmares to networked data.

Bush’s story of saving athenahealth from extinction through government lobbying—adding “and Internet services” to federal law—shows how entrepreneurial persistence can bend the system toward progress. He evolved from ambulance driver to policy warrior and tech CEO, illustrating his message that only those willing to break rules can fix broken industries.

Essential Lesson

In health care, failure isn’t fatal—it’s formative. Bush’s birthing business collapsed but revealed the power of information. Every administrative pain point is an invitation to innovate. Each inefficiency hides a billion-dollar market waiting for disruption.

Bush’s entrepreneurial journey teaches that transformation starts at the margins—with one ambulance, one clinic, one frustrated entrepreneur. Innovation rarely begins in hospitals; it begins in garages, basements, and broken systems where visionaries dare to see order in the chaos.

Bush challenges the notion that big hospitals should dominate health care. He compares them to department stores offering everything but specializing in nothing—expensive, inefficient, and slow. To survive, hospitals must stop doing everything and focus only on what they do best. He calls this the focused factory model—specialization through efficiency.

From Saks and Target to Health Care

Bush describes how research hospitals like Massachusetts General and Brigham and Women’s created monopolies by merging and overcharging insurers for routine tests. This consolidation produced the “Upper Right Quadrant Syndrome”: once dominant, institutions stop competing and grow through coercion—by forcing higher prices and locking customers in. He compares this to other mature industries before disruption, like IBM before Apple or Blockbuster before Netflix.

The Underdogs Strike Back

Enter the challengers. Steward Health turned underperforming community hospitals into efficient providers offering care at lower cost. Florida Woman Care reinvented obstetrics with better outcomes and half the price of hospitals. FastMed and MedExpress built urgent care clinics with customer service inspired by Ritz Carlton and Starbucks. Even Walgreens and CVS joined the fray, adding clinics to retail stores and treating millions for simple ailments.

These examples underscore Bush’s thesis: when customers can shop, the fat cats lose. Hospitals that once charged $5,000 for an MRI now face competitors charging $99 in strip malls. Every new entrant cuts waste, improves service, and brings humanity back to medicine.

Why Failure Is Healthy

Bush insists that letting some hospitals die is not tragedy but progress. Failure frees up talent and resources for better businesses. Just as bad restaurants close while good ones thrive, weak hospitals must give way to focused suppliers. He envisions a future where specialization rules: cancer hospitals handle cancer, heart centers handle hearts, and community clinics handle maintenance care. By right-sizing medicine, the system saves money and enhances quality.

Key Takeaway

Disruption in health care isn’t cruelty—it’s evolution. Hospitals must become focused factories that excel at specific, high-value services instead of hoarding everything under one costly roof. Quality increases when competition thrives.

Bush’s disruptive vision echoes Clay Christensen’s theory of “disruptive innovation.” When technology and efficiency empower smaller, agile players, giants either adapt or collapse. Health care, Bush insists, is overdue for its Clayton Christensen moment.

In Bush’s reform model, doctors are not victims of the system—they’re its potential saviors. He urges physicians to move beyond being technicians inside bureaucratic machines and instead become entrepreneurial providers who manage health as a holistic service.

From Technicians to Providers

Doctors should “sell mobility” rather than hip replacements, Bush argues. He envisions providers offering complete packages—from diagnosis to rehabilitation—at transparent, fixed prices. These doctors become “shoppers,” seeking the best labs and clinics for patients rather than waiting for hospitals to dictate costs. By taking on risk through bundled care contracts, they earn more by keeping patients healthier and spending efficiently.

Organize, Don’t Sell Out

While many physicians have surrendered independence to hospital employment, Bush insists they hold the true leverage: patient trust. By organizing instead of selling out, doctors can form groups that compete with hospitals on quality and service. The Houston-based HealthCare Partners—bought by DaVita for $4.4 billion—proved that patient management, not procedures, drives future value.

The Power of Data and Collaboration

Bush emphasizes that modern doctors must master data as well as medicine. Like entrepreneurs tracking KPIs, they should measure outcomes, benchmark performance, and exchange insights with peers. Physicians who analyze their results—not just their cases—can optimize their operations and improve care. Collaboration through technology transforms isolated practices into intelligent networks.

Lesson for Physicians

Don’t let bureaucracy define your profession. Treat your practice as a business, your data as an asset, and your patients as partners. Doctors who think like entrepreneurs will drive the next great health care transformation.

Bush’s advice humanizes economics: entrepreneurial doctors aren’t just wealth builders, but catalysts for better, more personal care. The freedom to experiment and self-manage turns medicine back into the calling it was always meant to be.

Bush’s relationship with government is complex—both adversarial and cooperative. He sees it as the biggest obstacle to innovation but also the greatest enabler if reformed. His blueprint for government action challenges traditional partisan ideas: at times, government should step aside; other times, step up.

Get Out of the Way—Smartly

Bush argues that overregulation suffocates health care entrepreneurs. Rules like state licensing barriers, cross-border insurance restrictions, and antikickback laws prevent competition. He cites absurd examples—ophthalmologists barred from reimbursing colleagues for shared patient records—and calls for trimming laws that criminalize cooperation. His mantra: let innovators experiment first, regulate later.

Encourage Startups and Risk

At the same time, Bush advocates bold government support for seed innovation. He proposes a “Fannie Mae for health insurance startups,” offering temporary financial backing until new insurers achieve scale. Expanding Medicare Advantage and creating true capitated, market-driven plans could bridge public care with private competition.

The Dialysis Example and Industry Capture

Bush’s conversation with policymaker Bob Kocher exposes how lobbyists and entrenched corporations manipulate legislation. Amgen, he explains, used its influence to sustain obsolete dialysis procedures and overpriced drugs—“profit before patient” embodied. This exchange reveals the structural flaw in central planning: Congress cannot reform industries it depends on financially. Only open markets can.

Core Insight

Regulation should protect consumers, not incumbents. Government cannot design innovation—it can only clear the field so entrepreneurs can play. Health care reform must aim for competition, not control.

Bush’s pragmatic politics defy easy labels: he’s pro-innovation liberal and pro-market conservative rolled into one. His prescription for government is nuanced—less ideology, more experimentation. Let the crazy ones try things, and watch what works.

Bush envisions health care’s future as data-driven, democratized, and personal. Information is power—once locked inside hospitals and insurers, now ready to flow freely among doctors, patients, and innovators. He believes that the explosion of medical data can finally make health care transparent, efficient, and human again.

Three Revolutions in Data

• Operational data: enabling businesses to run efficiently, pay bills, and reduce waste.
• Population data: helping physicians manage entire communities, track disease trends, and improve outcomes.
• Personal data: empowering individuals to know their own bodies, predict risks, and shape choices for longevity and wellness.

Real-Time Learning Health Systems

Bush showcases how organizations like Hudson Headwaters use data dashboards to monitor diabetes rates, screenings, and workflow efficiency. Doctors compare results to peers, identify outliers, and correct problems in real time. This “learning loop” democratizes improvement and replaces guesswork with science.

The Consumer Data Revolution

Bush’s enthusiasm for wearable tech and sensors anticipates today’s health tracking culture. Devices like Fitbit and glucose monitors will merge with clinical systems, allowing personalized care and performance feedback. He imagines insurance companies adjusting premiums based on fitness data and chronic disease management—a fairer, smarter future.

Data Ethics and Ownership

Critically, Bush argues that data belongs to you—the patient. He urges universal digital record access, interoperability, and a competitive market for medical information, where providers pay for the privilege of access rather than hoard it. He compares health data systems to ATMs—networked, paid for, and shared securely worldwide.

Essential Truth

Data will do for health care what money did for commerce: make transactions visible, measurable, and accountable. Information equals empowerment—first for doctors, then for patients, and ultimately for society.

Bush’s faith in “fast data” echoes visionary thinkers like Peter Diamandis and Clayton Christensen, merging tech optimism with moral urgency. In his world, health care isn’t a fortress—it’s a network shaped by knowledge and choice.

Late in the book, Bush delivers his boldest argument: we can’t fix health care until we confront our fear of death. Medical spending skyrockets because we chase immortality, funneling fortunes into procedures that prolong suffering. The solution isn’t to ration care—it’s to give people choices, including the right to refuse costly interventions.

The Hysterectomy of Granny Cornelia

In a shocking anecdote, Bush recounts a doctor urging his ninety-year-old grandmother to undergo major surgery for terminal cancer. Bush refused: “She doesn’t need a hysterectomy; she needs a glass of scotch.” The moment epitomizes his fight against “Big Dumb Medicine”—a system obsessed with procedures, indifferent to dignity, and insulated from cost awareness.

Money, Mortality, and Meaning

Bush reveals that a quarter of Medicare’s budget goes to care in the last year of life—mostly for patients who’d rather die at home. He proposes financial incentives for hospice choice: those who opt out of heroic hospital care could save the system thousands and receive added benefits for their heirs. His hypothetical—earning $200 monthly toward a retirement legacy by choosing hospice at 65—illustrates how freedom and responsibility can coexist.

These unorthodox ideas highlight a moral paradox: we claim to value life yet design policies that trap patients in unwanted treatments. Bush turns policy into philosophy—arguing that death, like health, deserves agency.

Choosing Health à la Carte

Bush likens health insurance to cable TV: overpriced bundles forcing us to pay for services we don’t use. In his vision, we pick plans like channels—minimalist for young, comprehensive for vulnerable. Freedom to choose sparks competition and innovation. Just as streaming destroyed cable monopolies, choice could collapse health care’s one-size-fits-all bureaucracy.

Philosophical Conclusion

Health care isn’t just about survival—it’s about self-determination. Risk, imperfection, and autonomy are part of being human. Bush’s final message: reclaim your right to choose, even in life’s last chapter.

In confronting death, Bush completes his blueprint for freedom. Health care, stripped of fear and force, becomes a mirror of our values—a system that honors both the dignity of living and the grace of dying.