A 237-Year-Old Lesson on Healthcare's Fractured Future

MADISON, WI – November 26, 2025

In an astonishing discovery that rewrites a pivotal chapter of American history, researchers have unearthed a 237-year-old speech by Melancton Smith, a key figure in the debate over the U.S. Constitution. Delivered on July 23, 1788, the speech reveals the calculus behind his fateful decision to abandon his deeply held opposition and support ratification, effectively ensuring New York's entry into the fledgling union. While a landmark event for historians, this discovery offers a far more immediate and disruptive lesson for an industry facing its own constitutional crisis: American healthcare.

The finding, announced by the Center for the Study of the American Constitution, provides a transcript of the speech that historians long knew of but had never seen. In it, Smith, the Antifederalist floor leader, stands before a divided convention and articulates a masterclass in strategic compromise. His choice to align with his rival, Alexander Hamilton, was not a surrender of principle but a courageous recognition of a greater imperative. This moment of profound political sacrifice holds a mirror to the fractured landscape of healthcare today, challenging its leaders to ask the same difficult questions Smith faced.

An Imperfect Building, A Fateful Choice

To understand the weight of Smith's decision, one must appreciate the stakes. New York in 1788 was deeply polarized. The Antifederalists, including Smith, feared the new Constitution would create an overbearing central government that would trample on individual liberties and state sovereignty. They had the votes to reject it. Yet, ten of the thirteen states had already ratified, and the threat of New York City and the southern counties seceding to join the new union was very real. The nation was at a breaking point.

In his rediscovered speech, Smith grapples with this reality. He admits frankly, “I did not approve the building as it stands,” a sentiment that will resonate with anyone familiar with the critiques of our current healthcare system. Yet, he immediately follows with a crucial insight: “the whole is made of good materials.” He saw the potential within the flawed framework. Rather than clinging to ideological purity and risking national collapse, Smith chose to enter the "family mansion" and work to improve it from within, trusting that "common interests and common prudence" would lead to necessary amendments.

This was not a capitulation; it was a strategic pivot. Smith recognized that the momentum for the new system was irreversible. The choice was no longer between his ideal system and the proposed one, but between an imperfect union and no union at all. He chose to join the "great American family," arguing that New York’s goals could "best be obtained" by aligning with other states to push for a Bill of Rights. It was a profile in courage, prioritizing the long-term viability of the nation over the short-term victory of his faction.

Healthcare's Warring Factions

The parallels to modern healthcare are impossible to ignore. Our system is also composed of "good materials"—world-class clinicians, groundbreaking research, and life-saving technologies. Yet, it is an "imperfect building," plagued by soaring costs, inequitable access, and maddening inefficiencies. Like the Federalists and Antifederalists, the industry is paralyzed by its own warring factions, each defending its territory with ideological fervor.

On one side are the incumbents: the large hospital systems and insurance carriers locked into the fee-for-service model, a structure that rewards volume over value. On the other are the disruptors: the tech startups, value-based care advocates, and retail health players championing new models that threaten the old guard's dominance. We see battles over data interoperability, where proprietary systems function as walled gardens, impeding the free flow of information that is critical for patient care. We witness the clash between the promise of AI-driven diagnostics and the regulatory and reimbursement structures that are slow to adapt.

Each side believes in the righteousness of its cause. Traditional providers argue for the importance of established clinical protocols and the doctor-patient relationship, fearing that technology-first approaches will depersonalize care. Innovators argue that the status quo is unsustainable and unethical, and that radical change is the only path to a more efficient and equitable system. Like the delegates in Poughkeepsie, they are often talking past one another, entrenched in their positions while the system itself groans under the strain.

The Melancton Smith Mandate for Leadership

What would Melancton Smith do? His rediscovered speech offers a mandate for today's healthcare leaders. It is a call to look beyond the immediate battle and assess the larger strategic landscape. The digital transformation of healthcare, much like the ratification of the Constitution, has an air of inevitability. The question is no longer if data, AI, and patient-centric models will reshape the industry, but how—and whether the transition will be a chaotic collapse or a structured evolution.

The Smith mandate requires leaders to exhibit the same courage he did: to acknowledge the system's flaws while recognizing its valuable components. It demands a willingness to make painful compromises for the greater good. For a hospital CEO, this might mean embracing data-sharing standards that reduce their competitive advantage but contribute to a regional learning health system. For an insurance executive, it could mean partnering with a disruptive primary care provider on a value-based contract that cannibalizes existing fee-for-service revenue but leads to better long-term outcomes and lower total costs.

Smith took solace in the fact that the union was supported by "many wise good men." Healthcare leaders must do the same, building coalitions with rivals and trusting in the "common interests" of patient well-being. The goal is not to win the argument for fee-for-service or value-based care, but to build a resilient, patient-centered system that incorporates the best of both. This requires moving from a zero-sum mindset to a recognition that, as Smith put it, America was witnessing "one of the most astonishing events in the history of human affairs." We are at a similar inflection point in health, and clinging to the past is a guaranteed path to obsolescence.

The discovery of Smith's speech, along with emerging scholarship identifying him as the author of the influential 'Brutus' essays, adds another layer of complexity. The man who penned some of the most potent arguments against the Constitution ultimately became one of its saviors. This demonstrates an incredible capacity to evolve one's thinking when faced with new evidence and changing circumstances. Healthcare leaders must be prepared to do the same—to question their own long-held assumptions and be willing to pivot when the data shows a better way forward. Just as New York had to choose whether to "withdraw...and seek our fortunes separately" or join the "family mansion," every healthcare organization today faces a similar choice: remain in a defensive silo or join a new, interconnected ecosystem of care. Melancton Smith's choice 237 years ago shows us the path.