Nobody has a precise figure for the cost of healthcare sludge, but Richard Thaler puts it in the hundreds of billions per year for the US alone. The problem is that so much of it is consumed time — invisible on any balance sheet.
Where this was said
At 12:25 · chapter starts 9:30
Thaler begins with what he calls 'inadvertent and/or incompetent sludge' — design failures like Norman doors, where the physical affordance of a door handle tells your brain to pull when you need to push. These aren't malicious, just thoughtless, and the architects responsible deserve 'a special place in hell.' He then pivots to the unsubscribe trap: where one click signs you up for a service but cancellation requires a phone call, a wait, and a sales pitch. That, Thaler says, is clearly intentional. He cites gyms during COVID that required members to physically enter a closed facility to cancel their membership — nobody designs that innocently. He notes he has personally tried to convince subscription companies to stop these practices, and been told bluntly that it would cost too much. Thaler's rough estimate: healthcare sludge alone costs the US hundreds of billions annually, though almost none of it is formally measured.
During COVID lockdowns, some gyms required members to physically show up at a closed gym to cancel their membership. Richard Thaler's verdict: nobody designs that innocently — it is pure, strategic sludge.
Richard Thaler estimated the sludge cost of the US medical system alone is in the hundreds of billions of dollars per year.
Predictions that AI would eliminate radiologists were spectacularly wrong. Since those predictions, Mayo Clinic's radiology staff grew 55% and the specialty became the second-highest paid in medicine. The reason: AI automated scan-reading, but only 36% of a radiologist's time was ever spent doing that.
Self-help fails because people are sold one universal cure by the hyper-responders who had a transformative result from it. The real problem is context: every method works for the right person at the right time, which is almost never you just because the author says so.
Spencer Greenberg was once so socially anxious his heart pounded just approaching a stranger. His therapist gave him homework: go to a bar alone, talk to 5 strangers. Starting with asking for the time, he worked up to asking men for hugs — and his anxiety fell dramatically in 6 months.
A person who flies regularly but obsessively checks weather forecasts before every flight is not doing exposure therapy — they're teaching their brain that flying is only safe with the ritual. Safety behaviors prevent the brain from ever learning that the feared thing is actually fine.
The worry-time technique assigns all worries to one scheduled slot (e.g. 5 PM). Every time a worry surfaces, you write it down and ban yourself from engaging with it until that time. When 5 PM arrives, most worries feel trivial and the act of batch-worrying exposes how little it actually accomplishes.
In a randomized study of 20 habit techniques, 'habit reflection' stood out: recall a past habit you successfully built, write down what helped you succeed, then apply those same strategies to your new habit. It works because it's self-adapting — it uses whatever worked for YOU.
The tiny habits technique — always having a minimal version of your habit you can do when life gets in the way — keeps the mental machinery of habit formation from breaking. Paradoxically, people given a tiny-habit fallback option were MORE successful at the full habit, not less.
Fears and worries act like playground bullies — they want to ambush you. But when you deliberately seek them out and choose the time of engagement, they lose their power. The volitional act of starting the fight on your own terms is one of CBT's most underappreciated insights.
Most downtime defaults are things you regret immediately after — phone scrolling, binge TV. 'Glad you did it' activities meet the same need for rest but leave you feeling like you spent your time well. The switch from a bad screen to a documentary, a book, or a walk costs almost no extra effort but compounds into identity over time.
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