Mayor Lurie argues for holding city-funded non-profits accountable, but reveals a critical flaw: the city fails to pay these partners for up to 12 months, forcing small organizations to float the government's massive budget. True accountability requires efficiency from the government itself.

Treat government programs as experiments. Define success metrics upfront and set a firm deadline. If the program fails to achieve its stated goals by that date, it should be automatically disbanded rather than being given more funding. This enforces accountability.

San Francisco's non-profits are often paid based on the number of homeless individuals they serve. This creates a perverse financial incentive to maintain and manage the homeless population like a "flock" rather than pursuing solutions that would permanently reduce their numbers and, consequently, the NGO's funding.

An entrepreneurial view of public goods dictates that any service should generate more value than its costs. If a division, like public transit, consistently loses money, it's a market signal that society doesn't value it at its current price. Subsidizing it is an emotional, not a logical, decision.

Anduril advocates for performance-based contracts, a controversial model in government where payment is contingent on the product working. This forces internal accountability and aligns their interests with the customer's, contrasting with traditional cost-plus models that place all risk on the government.

Unlike for-profits with direct customer feedback, NGOs must please funders, who are not the beneficiaries. This misaligns incentives away from pure impact, creating a market inefficiency. For impact-maximizing professionals, this systemic weakness represents an opportunity to deliver significant value in a less-optimized space.

The disastrous rollout of Healthcare.gov deeply scarred the D.C. policy community. The received wisdom became to never bear technology risk directly. This incentivizes outsourcing everything to contractors, not just for expertise, but to create a buffer that can be blamed if a project fails, preserving the politician's reputation.

Public agencies increasingly hire third-party consultants as 'owner's reps' to manage projects. Contractors report these reps can become a source of delays, as their compensation is tied to the project's duration, creating a misaligned incentive that inflates costs and timelines.

The core issue preventing a patient-centric system is not a lack of technological capability but a fundamental misalignment of incentives and a deep-seated lack of trust between payers and providers. Until the data exists to change incentives, technological solutions will have limited impact.