When I told ProPublica that it was too expensive to protect us, I was naming what every number in this piece confirms. The system made a calculation about what our lives were worth, and it got the math catastrophically wrong.

I have been a nurse for almost 20 years, working in emergency departments, intensive care units, and eventually the back of a helicopter as a flight nurse. I have watched the best clinicians I know walk away from medicine, not because they stopped caring, but because the system stopped investing in the conditions that allow caring to be sustainable. And when I finally sat down with the economic data, what I found was not just troubling; it was enraging. The money was always there. It was just being spent on the wrong things.

The shadow ledger

Every health care organization maintains two sets of books. The official ledger tracks revenue, expenses, and margin. But there is a second ledger, a shadow ledger, that tracks the cost of organizational dysfunction. It is enormous, and almost no one is looking at it.

The 2025 NSI Report puts the average cost to replace one bedside nurse at $61,110. Some estimates reach $88,000 when you include productivity losses and agency staffing. The average hospital loses $3.9 million to $5.7 million annually from nursing turnover alone. Each single percentage point change in turnover costs or saves $289,000 per year.

But the turnover number conceals a crueler economic reality. The nurse who costs $61,110 to replace is not a generic labor unit. She is a seven-year veteran carrying thousands of pattern-outcome associations that no orientation program can transfer. Her clinical gestalt, her capacity to park the crash cart outside a room before the monitor alarms; these are invisible assets the replacement cost captures and the balance sheet cannot. The system is not losing nurses at random. It is selectively losing the ones whose expertise makes them unable to tolerate what less experienced nurses have not yet learned to perceive.

Below turnover lies everything else. The American Hospital Association estimates workplace violence costs $18.27 billion annually, with $14.65 billion spent on remediation and only $3.62 billion on prevention, a four-to-one ratio of reactive to preventive spending. Pharmacy staff spend 24 hours per week per facility managing drug shortages, doubled from pre-pandemic levels, with 43 percent of facilities reporting medication errors as a direct result. Charge nurses spend 45 minutes per shift on redundant documentation. Denied claims consume administrative bandwidth that could be directed toward care coordination. Communication failures produce duplicate testing, missed handoffs, and adverse events that generate their own cascading costs.

A 2024 meta-analysis of 85 studies and 288,581 nurses confirmed a strong association between burnout and lower patient safety grades. Under Hospital Value-Based Purchasing, up to 2 percent of Medicare reimbursement is withheld based on HCAHPS scores. Burnout does not just cost you nurses. It costs you revenue. Add it up across a system and you are looking at a staggering hemorrhage disguised as operational normalcy.

COVID-19 provided the controlled experiment for what happens when organizations refuse to invest. The $5.4 billion in Ebola preparedness funding expired in May 2020, the same month the virus surged. The Strategic National Stockpile held less than 1 percent of the respirators a pandemic would require. The “savings” from cutting preparedness transferred costs directly to hospitals scrambling for PPE at 1,000 percent markups, to health care workers fashioning masks from office supplies, and to the families of the estimated 3,600 U.S. health care workers who died in the first year. The shadow ledger does not forgive debt. It collects with interest.

$935 billion in waste

Donald Berwick and the IHI estimated that 25 to 30 percent of U.S. health care spending, approximately $760 billion to $935 billion annually, constitutes waste. This is not waste in the abstract. It is waste with categories and price tags: $158 billion to $226 billion in overtreatment, $102 billion to $154 billion in failures of care delivery, and $265 billion in administrative complexity. The United States employs roughly one administrator for every physician; other developed nations manage with a ratio closer to one to four.

We spend $4.5 trillion a year, 17.6 percent of GDP, and rank dead last among 10 high-income countries in health care outcomes. The 2023 Missing Americans study quantified the human translation: 705,331 excess U.S. deaths compared to peer nations in a single year. Nearly half were in people under 65. These are not statistics about a system that needs tweaking. These are statistics about a system that is converting money into death at an industrial scale.

The war chest principle

Here is the part that should keep every CFO awake at night: The funding for transformation already exists in every hospital’s operating budget. It is currently being spent on failure.

Denver Health implemented Lean principles and saved $158 million over a decade through the elimination of wasted steps, redundant processes, and inefficient workflows, with no staff reductions and no service cuts. Virginia Mason Medical Center applied the Toyota Production System and achieved dramatic reductions in inventory costs and defect rates while improving both patient outcomes and staff satisfaction. Medicare ACOs have generated $6.6 billion in total savings, with shared savings growing 40 percent year over year, by investing in care coordination, prevention, and relationship continuity.

The IHI Leadership Alliance coined the term “exnovation,” systematically removing non-value-added practices, and proposed eliminating 50 percent of non-value-added waste. Peter Drucker prescribed the same medicine decades earlier. He stated that the first step in a growth policy is not to decide where and how to grow; it is to decide what to abandon.

Every drug shortage workaround eliminated is clinical attention returned to patients. Every denied claim that does not need to be filed is administrative capacity redirected toward care coordination. Every broken process fixed is organizational capacity freed for the relational work that actually produces healing.

The prevention paradox in one line item

No single entry in the shadow ledger illustrates the inversion more completely than nurse education. Linda Aiken’s research, involving 232,342 surgical patients across 168 hospitals and replicated in nine European countries with 422,730 patients, demonstrates that a 10 percent increase in BSN-educated nurses decreases patient mortality by 4 to 11 percent. The Vizient and AACN Nurse Residency Program documents first-year retention rates exceeding 86 to 95 percent with a return on investment of 326.5 percent. Every dollar invested in nurse education returns three.

And yet, consider this: 71.5 percent of hospitals classify paid training time as “non-productive.” The median hospital budgets 16 hours of education per nurse per year, or two days for all professional development including regulatory compliance. Over 76 percent of education departments are classified as pure cost centers, making them structurally first on the chopping block in every budget cycle. The national median staffing ratio is 70 nurses per one education FTE. Nurse educators earn a persistent 20 to 30 percent less than equivalent clinical roles.

The person most directly responsible for preventing the errors, turnover, and competency failures that cost hospitals millions is the first person defunded when those millions are needed.

The economic trap

Organizations stuck in survival mode pay the shadow ledger costs repeatedly with each turnover cycle, each communication failure, and each surge. They cannot invest in prevention because all resources are consumed by remediation. Every potential investment dollar is absorbed by the ongoing hemorrhage. A hospital managing 323 drug shortages, fighting 15 percent claim denial rates, running on 1 percent operating margins, and drowning in failure demand has no remaining capacity for the transformation that would stop the bleeding.

This is why the economic case is not about discretionary spending. It is about the only path to financial sustainability. The choice is not between investing in your workforce and saving money. The choice is between investing now and paying the shadow ledger forever. And right now, most hospitals are choosing the shadow ledger by default. This is not because anyone decided it was the better option, but because no one has made the invisible costs visible.

The question is not whether you can afford it

Research by Gabrielle Adams found that people systematically overlook subtractive solutions. In experiments, 59 percent of participants added complexity rather than removing it, even when removal was free and more efficient. Health care organizations do the same thing. We add resilience programs instead of removing the conditions that deplete resilience. We add wellness apps instead of subtracting the workload that destroys wellness. We add another initiative instead of stopping the three that are not working.

The war chest is not hidden. It is in plain sight, disguised as the way we have always done things. Every hospital that has done this math has found the same answer: The resources for transformation were never missing. They were misallocated. The question is not whether you can afford to invest in the conditions that retain your workforce, reduce errors, and improve outcomes. The question is how much longer you can afford not to.

The money is already being spent. You are just spending it on failure.

Kristen Cline is a professional development practitioner for the Emergency Service Line at Stanford Tri-Valley Medical Center and holds an academic affiliation with Stanford University.

With over 15 years of experience in emergency departments, intensive care units, and critical care transport, she brings clinical depth and a commitment to education and advocacy.

Kristen is board-certified in multiple specialties and speaks nationally for organizations such as Paragon Education and Solheim Enterprises, focusing on certification review and emergency nursing practice.

She has authored and co-authored several publications and textbooks, including contributions to the Emergency Nursing Scope and Standards of Practice, 3rd edition.

Her peer-reviewed work includes articles in Annals of Emergency Medicine, on “Optimizing Pediatric Patient Safety in the Emergency Care Setting,” and in Pediatrics, on “Access to Optimal Emergency Care for Children.”

Recognized among ENA Connection’s “20 under 40,” she advocates for nurse wellness and trauma-informed care through speaking engagements, her Medium blog, and social media platforms like Instagram and Facebook.