The Department of Government Oversight and Efficiency has uncovered waste, fraud and abuse that is troubling, but not unexpected. The real scandal, however, is that it’s gone on for decades. Where was Congress? Where was the oversight? As I’ve long said in healthcare and beyond: we have the money to provide access to high-quality care for all Americans and to run a government that works. We’re just not using it wisely.
DOGE has a rare opportunity to do what should have been done years ago. But only if it takes a measured and thoughtful approach. We need strategic discipline, not indiscriminate cuts. That means knowing what to fix, and how to fix it.
DOGE’s findings reaffirm what many of us have documented for years. In my 2012 book “Healthcare at a Turning Point” and again in my 2016 book “Bringing Value to Healthcare,” I estimated that in healthcare alone 500 billion dollars were lost annually to waste, fraud and abuse.
As Elon Musk and other DOGE senior leadership recently reported in a conversation with Bret Baier, government IT systems are outdated, siloed and not secure, costing taxpayers billions and enabling rampant fraud. At NIH, they describe 27 different CIOs managing 700 incompatible software systems. At Social Security, 40% of phone calls are reportedly from fraudsters. At the IRS, 1,400 people provision laptops and phones. These are not sustainable operating models.
No public company could function this way. We’re talking about systems unable to pass an audit, lacking payment verification and reportedly sending money to infants and centenarians who don’t exist.
We need the U.S. government. But we can’t afford the bureaucratic weight that’s holding it back. The answer lies in intentional design. Think of it this way: on one axis of a chart, you have structure. On the other axis, performance. Too little structure? Chaos. Too much? Paralysis. Productivity peaks in the middle, a space with clarity, direction and room for innovation. That’s the zone DOGE and leadership in the Administration must steer us toward.
We won’t get there by swinging a sledgehammer. Broad-based cuts feel decisive, but they’re usually destructive. Whether public or private, layoffs and budget cuts must be calibrated to efficient operations, not optics. In one department, you may cut 90%. In another, just 5%. That’s the discipline of strategic reform.
In a recent column, I wrote about how indiscriminate staffing cuts in healthcare and pharma erode critical capabilities. The same lesson applies to the government.
You don’t protect taxpayers by gutting oversight or collapsing essential operations. You do it by identifying where duplication, redundancy and process failures are hiding, and cutting with a scalpel, not an axe. The key question must always be: what are we trying to achieve–and what tools do we need to get there?
President Trump’s administration has rightly emphasized voluntary exits and generous separation packages. Fewer than 0.15% of federal workers have been involuntarily terminated. Voluntary exits create space to reshape teams and redirect talent without triggering the disruption, legal risk and political blowback that often come with forced terminations. They allow for strategic realignment while preserving institutional knowledge and morale–key ingredients in any successful reform effort.
Unless this effort succeeds, our country will be weakened. But done right, fundamental reform will strengthen the delivery of critical services. Legitimate Social Security recipients will see fewer delays and less fraud. Medicare will function with greater integrity. And taxpayers will finally have a government that treats their money with respect.
DOGE has begun to open the black box. Now comes the harder part: execution. We can’t afford to waste this moment with bureaucratic reshuffling or performative cuts. The goal is accountability, not austerity for its own sake.
I’ve spent decades arguing for this kind of reform in healthcare–and now the same principles must guide our broader federal systems. Outcomes and strategy matter now more than ever. How we go about reforming the government will determine whether we leave the next generations a solvent nation or one that can no longer pay for essential services. Let’s get it right.
