Revenge of the Tipping Point: Overstories, Superspreaders, and the Rise of Social Engineering

by Malcolm Gladwell

When I was driving around Miami with Pérez and Porras, I asked them about a man named Rick Scott. I didn’t expect them to answer the question—the matter is too sensitive for people employed by the federal government. But I could guess what they were thinking, because you can’t work in Miami, under the Miami overstory, and not wonder about the impact that people like Rick Scott had on people like Philip Esformes. Scott used to be the CEO of the large national for-profit hospital chain Columbia/HCA. In 1997, federal agents raided Columbia/HCA. In the first wave of the investigation, five senior company officers were ordered to appear before a grand jury. What division of the company were they all from? You can guess: Florida. Scott was not charged in the case, nor implicated in any wrongdoing. But he was forced to resign in disgrace. And a few years later, Columbia/HCA pleaded guilty to fourteen felonies—involving kickbacks to doctors, false billing, making illegal deals with other providers, and on and on—and ultimately paid what was then a record $1.7 billion in civil settlements. Where did Scott end up moving after leaving HCA? You

can guess that too: Florida. A few years after that, he decided to run for governor of… you guessed it: Florida, where he served two terms before moving on to represent… yes, Florida, in the United States Senate. For a portion of the years that Philip Esformes ran a billion-dollar scheme of kickbacks, false billing, and illegal deals, the governor of his state was someone who had presided over a hospital system that ran a billion-dollar scheme of kickbacks, false billing, and illegal deals. When Philip Esformes went home at night and saw Rick Scott holding forth on television from the most powerful position in the state, do you think it changed the way he thought about his own behavior? The canopy high over the forest floor casts a shadow on everything beneath it. The overstory is specific. It is tied to a place. It is powerful. It shapes behavior. And it does not emerge out of nowhere. It happens for a reason. 7.

Philip had always told us that he had an ace up his sleeve… and he told me one day that he had connections to make things go away. Which he did, by the way. We saw things go away… Q: Let me stop you right there. So what did he mean—or what did you understand him to mean by he had aces up his sleeve…? A: Well, he said he had some government connections. There was a guy, Jeremy, [who] was connected to the government. I found out—my brother told me he gave a huge donation to a presidential campaign. So he was always throwing it around. Willy Delgado said that under oath in federal court in February 2019. In December 2020, Philip Esformes had his sentence commuted by Donald Trump.4 And where did Donald Trump move after leaving the White House? South Florida. Of course.

Just to be clear, the Esformes were not absolutely honorable. They had a few, relatively minor, run-ins with state regulations in Illinois. But nothing on the scale of what happened in Miami. 2 It should also be pointed out that this does not necessarily mean that you are better off getting a heart attack in Boulder than in Buffalo. On the contrary, cardiac catheterization is very expensive. It carries risks of its own. There’s little evidence that you are more likely to die of a heart attack in Buffalo than in Boulder. If anything, a case could

made that the notoriously wasteful and expensive American medical system would be much improved if everyone who had a heart attack got shipped to western New York State for treatment, and we spent the money saved on encouraging people with high blood pressure to eat better and get more exercise. 3 They once found a firm that would stage a pharmacy for $5,000. “They could get you four bars of soap. You know, pairs of glasses… the minimum amount of stuff that you need on your shelves to show that you’re a functioning pharmacy.” 4 In a final Miami twist, after Esformes was granted clemency by Trump, the prosecution took the unusual step of trying to retry him on a variation of the charges they used initially. This time around, Esformes pleaded guilty to avoid a second trial. Under the agreement, he was spared jail time in exchange for a multimillion-dollar fine.