From May through September, your humble correspondent is basically a lizard on a warm rock.

My mornings start on the patio with my dog, bare feet in the grass, face turned toward wherever the sun is climbing over the trees. Then I wander down to my favorite little organic coffee shop for hot tea, eggs and avocado toast, and carry the whole operation back outside. I work on the patio or the front porch for the rest of the day. My clients and colleagues have long stopped asking why my Zoom background is my backyard or a wall of yellow siding. Extension cords snake out the back door, giant fans roar, umbrellas get repositioned every hour to chase the shade.

I love every minute of it, and my body and mind feel fed in a way I can’t fully explain. And then the air turns, as it’s turning right now.

For a few weeks I fight it. I wrap up in a blanket and stubbornly keep my porch office open past its natural expiration date. Eventually I lose that battle and retreat to the rocking chair in my office (regular viewers of my TV hits will recognize it). Eventually the space heater comes out of the closet, and I build myself a cozy little nest.

It’s comfortable. It’s also not the same.

The vitality drains out of me. My energy flattens. My nearsightedness, which I’ve been beating back with an out-of-the-system neuro-optometrist (more about that here), creeps forward a little every winter like clockwork. My vitamin levels and hormones go a bit haywire. By February or March I’m scheming about a beach trip with the urgency of a woman planning a prison break, because if I don’t get some real sun on my face soon, I’m going to lose my mind.

My entire year, if I’m honest, is built around the summer months.

So why not just move somewhere sunny? You already know the answer, because it’s probably your answer too. Aging parents. Kids. Grandkids who still think I’m fun. A husband with a job that isn’t portable. All of it conspires to keep us planted in Virginia and all four of its mostly temperate seasons. And the places where you can live outdoors in the winter have their own problem: by July they turn into pizza ovens, and everyone there hides inside in the air conditioning. Trade-offs everywhere.

For decades, The Authorities have had a name for what happens to me every winter. I think they got it wrong.

The Disorder That Isn’t

In 1984, psychiatrist Norman Rosenthal and colleagues at the National Institute of Mental Health described “seasonal affective disorder.”

They found it through a newspaper survey and were surprised by how many people responded. They also discovered that bright light helped. Today the psychiatric manual files it under major depression “with seasonal pattern.”

Let’s look at who gets it.

Prevalence runs around 1 percent in Florida, roughly 5 percent at the latitude of New York, and about 10 percent up in New Hampshire. Something like 90 percent of people report at least some seasonal shift in their mood or energy.

When nine out of ten people feel a thing, and the thing tracks precisely with distance from the equator, I’d call that physiology not pathology.

Our bodies are responding exactly as designed to a dramatic change in inputs. Every fall we pack ourselves into boxes lit by bulbs and filtered through window glass, and our bodies register the change and object. As loyal readers know, I don’t think symptoms are malfunctions. They’re messages, and this one is pretty easy to read.

Americans already spend about 87 percent of our time indoors and another 6 percent in vehicles, according to the EPA’s big national activity survey. But that’s averaged across the year. In the winter it’s worse.

And indoors is dark in a way our brains notice even when our eyes don’t.

A well-lit office runs around 300 to 500 lux. An overcast day outside delivers thousands of lux, and bright sun can top 100,000. As far as your biology is concerned, your cheerful kitchen is twilight.

Ultra-Processed Light

Which brings me to the article that’s had my head spinning as the temps drop.

Graham Lawton has a feature in New Scientist (yes, that New Scientist, the mainstream science weekly, hardly a crunchy wellness blog) with the delightfully alarmist headline, “[t]he shock revelation that light bulbs are wrecking your metabolism.” It’s an excellent read.

Here’s the short version.

What changed. Starting in the early 2000s, two energy-efficiency technologies took over. LEDs replaced incandescent bulbs, and window glass was engineered to block infrared light so heat stays in or out. Between the two of them, the light we get indoors got stripped of its long wavelengths, the red and near-infrared end of the spectrum. LEDs give off essentially nothing beyond about 750 nanometers. UCL neuroscientist Glen Jeffery estimates we lost roughly 95 percent of the spectrum.

Who cares? For all of human history, those long wavelengths were everywhere. They’re in sunlight, moonlight, campfires, candles, oil lamps and the good old incandescent bulb, whose spectrum is close to the sun’s. Red and infrared light - the only light most humans until recently ever saw after sunset (in a fire) - passes right through your clothes and penetrates deep into your tissues. It bounces around inside you (that red glow when you press your finger over a flashlight) until it gets absorbed. Some of it is absorbed in your mitochondria, the little power plants inside your cells, where it speeds up the electron transport chain that makes ATP, (what The Science claims is) your body’s energy currency. Bob Fosbury, an astrophysicist turned light biologist, calls it photometabolism and sums it up in four words: “Light is a nutrient.” Meanwhile, the blue light pouring off our screens and LEDs appears to slow that same energy machinery down. We took away the good stuff and piled on the bad.

What happens when you’re deprived? Fosbury compares long-wavelength light to a vitamin, and he compares the deprivation to scurvy, the vitamin C deficiency that killed sailors by the tens of thousands. The scurvy comparison works because the damage builds slowly. He and Jeffery think red-light deprivation may be one of the biggest drivers, possibly the biggest, of the obesity, type 2 diabetes, dementia and early-onset cancer we’re drowning in (and, I’d argue, infertility, but more on that below). Scott Zimmerman, a lighting company founder who works with them, likens LED light to ultra-processed food.

Ultra-processed light. The light equivalent of Taco Bell.

Who’s acting on it? After Jeffery’s team found essentially no long-wavelength light in the beautiful new critical care unit at King’s College Hospital in London, the hospital opened a six-bed rooftop ward this spring so patients (and staff!) can get outside. Patients with access to daylight have long been known to go home sooner. Two more London hospitals are considering the same. Readers who remember my rant about hospitals as Soviet-style hellscapes with locked windows will appreciate that somebody’s finally reading the memo.

The epidemiologist in me has to say it: the article itself admits the exact mechanism is still debated and the evidence on red-light therapy is patchy. I’d love to see more than mechanism and expert hunches. But the hunches line up with a pile of other evidence.

The Receipts

• Blood sugar. In a small 2024 study from Jeffery’s lab (Journal of Biophotonics, 30 people), 15 minutes of 670 nm red light before a sugar drink cut the rise in blood glucose by about 28 percent and the peak spike by about 7.5 percent. Fifteen minutes of light changed how the body handled glucose.

• Eyesight. In 2020, the same lab found that three minutes a day of deep red light for two weeks improved color contrast vision by up to 20 percent in people over 40 (Journals of Gerontology). Older eyes have tired mitochondria. Feed them light and they perk up.

• Mood and sleep. A UK Biobank analysis of about 400,000 people (Journal of Affective Disorders, 2021) found that more time in outdoor daylight was associated with fewer depressive symptoms, less antidepressant use, better sleep and less insomnia.

• Myopia. A randomized trial in Guangzhou (JAMA, 2015) added 40 minutes of outdoor time to the school day, and three-year myopia rates dropped from 39.5 percent to 30.4 percent. In Denmark, where daylight swings from about 7 hours in winter to 18 in summer, children’s eyes lengthened, and their nearsightedness advanced, faster during the dark half of the year (Ophthalmology, 2013). So my annual winter eyeball creep has company.

• Vitamin D. North of roughly 37 degrees latitude, the winter sun sits too low in the sky for your skin to make meaningful vitamin D for months at a stretch. That’s the classic Boston research by Michael Holick’s group. My patio is at about 39 degrees north. No wonder my labs wobble every winter.

Notice something about those first two studies. They used lab lamps. But I am not about to tell you to buy a red-light panel. Some of those gadgets are overpowered enough to cause inflammation, according to the very scientists who study this. The reason those studies matter to me is that they show what happens when you hand a red-light-starved body back a tiny fraction of the wavelengths it evolved on. And God already hung the best full-spectrum lamp ever made right outside your front door - free of charge.

Light, Darkness and the Fifth Vital Sign

Regular readers know where my mind goes next.

If you read “Do You Want the Baby or the Bear?“ you know I think a woman’s reproductive system works like a full-time safety inspector. It stays on the job only when the body believes conditions are good enough to carry a baby. Most of the time I’ve written about the bear as stress: a bad marriage, a grinding job, a bank account with no cushion. But light belongs on that inspection list too. Our hormones evolved on a schedule set by the sun and the moon, and we’ve scrambled both.

Start with the moon. In 2021, chronobiologist Charlotte Helfrich-Förster and colleagues published an unusual dataset in Science Advances: menstrual records that a few dozen women had kept for up to 32 years. For long stretches, many of those cycles lined up with the lunar cycle. The lining up was strongest when the women were younger, and it weakened when the women were exposed to more artificial light at night. The authors put it gently, but the implication is that our light pollution may be drowning out a signal women’s bodies used to keep time by. Our great-great-grandmothers got real darkness most nights, with a full moon a few nights a month to break it up. We live under streetlights and phone screens.

Then there’s darkness itself, which turns out to be a fertility nutrient of its own.

Your brain makes melatonin only in the dark, and melatonin does a lot more than help you sleep. Concentrations in the fluid around a developing egg run higher than in your blood, where it acts as a powerful antioxidant that shields the egg from oxidative damage. Hiroshi Tamura’s group in Japan found that women with more melatonin in that fluid had less oxidative damage. In women with a history of poor egg quality, adding melatonin roughly doubled fertilization rates in IVF (not that you should participate in IVF - please don’t). I’m not telling you to buy melatonin gummies, for the same reason I’m not selling red-light panels. The point is that your body makes this protective hormone for free, as long as you give it real darkness. Light at night shuts production down.

Night-shift workers run that experiment every day. In Harvard’s Nurses’ Health Study II, nurses who’d spent long stretches on rotating night shifts reported more irregular cycles. A 2016 review of the shift-work research found the evidence increasingly points to night work as a risk factor for miscarriage. Men aren’t exempt either. In a 2020 study of 116 men at an Israeli fertility clinic, more evening and bedtime screen use went with lower sperm concentration and motility.

Now add the daytime half of the story. Eggs are among the most mitochondria-packed cells in the human body, and egg quality falls as their mitochondria tire out. If Jeffery and Fosbury are right that our mitochondria are starving for the red and infrared light we stripped out of our homes, I’d love to know what that has done to our eggs. As far as I can find, that study hasn’t been run. I’d bet my last Diet Coke it’s worth running.

So picture the modern woman trying to conceive. She spends her days under LEDs behind infrared-blocking glass, and her nights bathed in blue light from three different screens. Her body gets too little long-wavelength light when the sun is up and too little darkness after it goes down. Then she acts victimized by bad luck and fate when her cycle goes haywire and a specialist hands her a label.

I know that woman, because I was her.

I spent my reproductive years in windowless Senate offices and fluorescent hearing rooms, sleeping four hours a night and scrolling until I passed out. No doctor ever asked me how much daylight I got. None of them suggested turning off the lights at night. They handed me birth control, and later, a diagnosis.

Light isn’t the whole story, but I’m increasingly convinced it’s a big chapter, and one of the easiest to rewrite.

Congress Banned a Nutrient

Now for the Washington twist, because of course there is one.

In 2007, Congress passed an energy law (signed by a Republican president, for those keeping score) that set efficiency standards for light bulbs. In 2022, the Biden Department of Energy finished the job, requiring 45 lumens per watt. Since mid-2023, that’s kept standard household incandescent bulbs off American shelves, and an even stricter standard arrives in 2028. In the name of climate policy, Congress outlawed an essential nutrient.

The plot twist: on September 30, Senate Energy and Natural Resources Chairman Mike Lee advanced his Liberating Incandescent Technology Act (the “LIT Act,” clever, Mike!) out of committee. The Department of Energy testified in support two weeks earlier, asking why the government should centrally plan which lighting technologies people can use. Amen. It still needs 60 votes on the Senate floor, and it has zero Democratic cosponsors, so don’t hold your breath. But for the first time in nearly twenty years, someone in Washington is asking whether the bulb Nazis were wrong.

Of course, now Congress and the President are trying to turn all our mornings into pitch blackness so that the golf courses can stay open later, by making Daylight Savings Time permanent. Our biology would function much better if Standard time were made permanent instead. Last I checked, one stubborn (blessed) Senator was holding the line for sanity. May God continue to buck him up!!

Your Fall Light Diet

You don’t need a gadget, a prescription or a plane ticket (though I’ll get to that last one).

Here’s what I’m doing this fall - feel free to join me!

1. Take your morning coffee outside. Wrap yourself in a blanket, grab your coffee or tea, and go outside within the first hour you’re up. Stay a few minutes, longer if you can, facing toward the sun. Leave the sunglasses inside. A window doesn’t count, because the glass strips out the exact wavelengths you’re going for. Cloudy days still count; overcast skies deliver many times the light of your living room.

2. Put your feet on the ground. If you can stand the cold, give your bare feet a few minutes on grass or dirt. The electron transfer from the negatively-charged ground, combined with the light, recharges your internal battery.

3. Go back out at midday. Take a walking meeting, eat lunch on the porch, or do your phone calls in the car with the windows down. Ten minutes of real daylight beats eight hours of the office kind.

4. Dump the LEDs. Swap in incandescent bulbs everywhere you actually spend time, starting with your desk lamp and reading lamp. Jeffery suggests an incandescent on a dimmer: even turned way down, it still pumps out plenty of infrared and draws about as much electricity as an LED. (I’m not that fancy though.) And yes, you can still get incandescents on Amazon. They often look a little smaller or a little odd-shaped (that’s how they squeak past the rules), but they screw into a normal socket and look perfectly ordinary under a lampshade. Stock up before somebody in Washington notices, or until the Senate does its job.

5. Give your body real darkness. After sunset, light your evenings like your great-grandmother did: candles, the fireplace, dim warm lamps. Put the screens away an hour before bed. Sleep in a truly dark bedroom, with blackout curtains and no glowing chargers. Your eggs (or his sperm) and sanity are counting on that melatonin.

6. Book your sun before you need it. Plan your February or March escape now, and treat it as the medicine it is.

Every year I’ll mourn the end of porch season, and every year my body will remind me what it needs. This year I’m going to listen to it a little better.

See you on the patio in May. Bring a blanket until then.

If this resonated, share it with the friend who’s already dreading November. And if you want more on how to hack the systems that run your health, join the Revolution and subscribe to AllBetter.

Sources

• Lawton, “The shock revelation that light bulbs are wrecking your metabolism,” New Scientist (2026)

• Yale Winter Depression Research Clinic

• Klepeis et al., National Human Activity Pattern Survey (2001)

• UCL: Red light can reduce blood glucose levels (2024)

• UCL: Declining eyesight improved by looking at deep red light (2020)

• Monash University: UK Biobank daylight study, Journal of Affective Disorders (2021)

• He et al., outdoor time and myopia, JAMA (2015)

• Danish seasonal myopia study, Ophthalmology (2013)

• Helfrich-Förster et al., women’s cycles and the moon, Science Advances (2021)

• Tamura et al., melatonin and egg quality

• Nurses’ Health Study: rotating shift work and menstrual cycles

• Fernandez et al., night shift work, fertility and miscarriage (2016)

• Green et al., evening screen use and sperm quality, SLEEP (2020)

• Inside Lighting: LIT Act advances out of committee (October 2026)

• Facilities Dive: DOE supports bringing back incandescent bulbs (September 2026)

Dan Neissany spends a lot of time talking to people who own clinics.

Doctors. PTs. Chiropractors.

Practice owners watching reimbursements fall, denials climb, and everything else they pay for (malpractice, salaries) move stubbornly in the opposite direction.

So when he had me on All Things LOCS, we got right to who’s squeezing them.

Everything in health care is upside down.

Employers pay more to the carrier, and doctors get paid less. Cut the carrier out, and the doctor gets paid more while the employer pays less.

For my clients, I start with the network. An employer can fire Cigna and still rent Cigna’s network. Your claim goes to Cigna first, Cigna applies its contracted rate, and then the employer pays.

The contracts everyone signed (the employer, the TPA, and you) say the network is Plan A. Nobody gets to cut a better deal around it unless the network approves. I’d argue those provisions violate the Sherman Act, and DOJ’s antitrust division ought to be coming after them.

Most specialists who stay in the network are making a rational choice.

A rheumatologist needs enough RA cases every year to justify walking away from the volume the network delivers. Independent practices can’t break out one at a time. For it to work well, it has to be a movement: employers, local hospitals, the chamber of commerce. Monthly lunch-and-learns with local CEOs and HR leaders. One conversation at a time.

Nobody's jumping off a cliff right now. You're just learning.

In one Midwestern community, it’s already happening. Three hospitals (one big academic medical center and two smaller ones) built their own network, put their own employees on it first, then contracted with the independent specialists and primary care docs they needed. They’re beating Blue Cross rates. The carriers don’t see it coming. But even with everyone on board, a build like that takes one to two years.

The endgame isn’t a better direct contract.

It’s actually cash pay at scale. One price for every service, with providers competing on it like every other industry.

Dan asked what a practice should do first thing tomorrow. That’s an easy one.

Clinicians should take a hard look at their cash price and make it competitive.

Make sure your billing software and your card processor can handle it. Put it on the wall. Tell every HR leader you know. Then get to know your local churches, because many of their members belong to health care sharing ministries looking for cash-friendly practices.

There is a way out. Give the episode a watch:

Loyal readers have met my nuns before. They were my first clients, and trying to make their health plan work has taught me more painful lessons about American health care than all my years on the Hill and in the White House put together. Here’s the latest.

One of the sisters needs a joint replacement. Desperately. Her pain is intense and brutal, the kind that turns every step into a nightmare.

We found her a wonderful surgeon. He’s high quality with great outcomes, and, by some small miracle, a kind and devout Catholic man. He operates at, and is employed by, a tax-exempt community hospital with a religious name invoking Jesus. So we called the hospital right away with the offer every hospital CFO claims to dream about: we’ll pay cash, upfront, all in. One bundled price, no claim denials, no chasing us for 120 days. Just give us a fair rate.

Our plan’s standard allowable rate is 125 percent of Medicare, so that’s where we started. The hospital came back at 250 percent.

Fine. That’s a negotiation. Our navigators went back and explained who they were dealing with. The sisters have no income. They raise money from donors to cover their medical bills. Every one of them would qualify for both Medicaid, and for the financial assistance program this hospital is required by federal law to offer poor patients as a condition of its tax exemption. And we weren’t asking for charity. We were offering to pay not only more than Medicaid, but more than Medicare, the rate this hospital accepts for most of its patients because most of its patients are seniors. We just weren’t going to pay two and a half times Medicare’s rates for an all-in, upfront cash price.

Then my navigators called me with the hospital’s answer. The price had doubled again.

Eighty thousand dollars, for a surgery Medicare pays about $16,000 for. Five times the Medicare rate, quoted to a woman who took a vow of poverty, because her health plan had the gall to ask for a discount.

This is the spite reserved for no-network plans that dare to flee the network plantation. Ask for a fair price and you get a surcharge for your trouble.

We felt terrible, but we had no choice but to look for alternatives. We started looking for a physician-owned outpatient surgery center, one with reasonable prices and no hospital anywhere in its ownership. That meant our sister would have to start over with a new surgeon.

When her surgeon found out what his own institution had done, he was (appropriately) horrified. At time of publication, he is in discussions with the hospital’s leadership himself, asking them to accept what we told them would be our final offer: 1.8 times the Medicare rate - $30,000.

Bless his heart.

If that doesn’t work out, I will name this hospital in a future post.

Charity, Hospital Style

Now you might be asking yourself, “Self, aren’t these hospitals supposed to be charitable organizations and thereby tax-exempt under IRS rules?”

That would be a good question. Let’s look at what federal law says about this.

Under Section 501(r) of the tax code, which the Affordable Care Act added, a tax-exempt hospital can’t charge a patient who qualifies for its financial assistance policy more than the “amount generally billed” to patients who have insurance. Hospitals are allowed to calculate that amount using what Medicare would pay.

So if our sister had walked in uninsured and filled out the hospital’s charity application, which she would almost certainly qualify for, federal law would cap her bill at roughly what Medicare pays. Because she has a health plan offering to pay more than Medicare, in cash, before the surgery, the hospital felt free to quote her five times that.

Get your surgery as a charity case and the law protects you. Show up with a plan willing to pay a fair price and you’re fair game.

This is the kind of greed, corruption and, well, uncharitable behavior that employer health plans deal with every day. My sisters are just the most sympathetic possible victims of it.

What We’re Paying For

Start with the size of the pie. Americans spent $1.6 trillion on hospital care in 2024, nearly a third of every health care dollar in the country, according to CMS data as analyzed by KFF. Hospitals also drove 40 percent of the growth in national health spending between 2022 and 2024, more than any other part of the system. The vast majority of hospitals collecting that money are nonprofits.

And the nonprofits are doing just fine, thank you.

By 2022, according to the incomparable Ge Bai, a fabulous health economist at Johns Hopkins, they had piled up $447 billion in investment assets, and the richest 1 percent of hospitals held 42 percent of it. That’s a lot of charity parked in the stock market.

On top of all that, we give them a tax break.

In a 2024 study in JAMA, Bai and her colleagues valued that perk at $37.4 billion for 2021 alone: $11.5 billion in federal income tax they didn’t pay, $9.1 billion in sales tax, $7.8 billion in property tax, and the rest in state income tax, tax-deductible donations and cheap tax-exempt bonds.

Like the investment portfolios, the tax breaks flow to the top. The biggest 7 percent of nonprofit hospitals collected as much as the other 93 percent combined.

So what did $37.4 billion buy us?

That same year, nonprofit hospitals provided $15.2 billion in charity care. That might sound like a big number, but it’s really only about 41 cents of charity for every dollar of tax break we handed them. Measured against the whole hospital pie, their charity care comes to pennies on the dollar.

It gets more embarrassing when you line them up against the hospitals that pay taxes.

Once again, Dr. Ge Bai to the rescue, reporting that nonprofit hospitals spend about $2.30 on charity care for every $100 in expenses. For-profit hospitals spend $3.80, and government hospitals spend $4.10. The tax-paying hospitals give away more free care than the ones we excuse from taxes in the name of charity.

Every other charity in America has to pass what the IRS calls the operational test.

A tax-exempt charitable organization must be “primarily” engaged in its charitable purpose. Hospitals pass because the IRS counts delivering medical care as “promoting health.” But for-profit hospitals deliver medical care too. So what makes one hospital a charity and the one across town a taxpayer?

Under the IRS’s 1969 rules, it comes down to a checklist: a community board, an emergency room open to everyone, accepting Medicare and Medicaid patients, and putting surpluses back into the hospital instead of paying them out to shareholders. For-profit hospitals take Medicare and Medicaid patients too. Since 1986, a federal law called EMTALA has required every hospital with an emergency room that takes Medicare to screen and stabilize anyone who walks in, whether or not they can pay. Once you set aside what every hospital already has to do, the real difference is who keeps the profits. For-profits pay theirs to shareholders. Nonprofits spend theirs on seven-figure CEO salaries and a half-trillion ($447 billion) investment portfolio.

The Lown Institute runs the numbers hospital by hospital, comparing what each one spends on charity care and community investment with what its tax breaks are worth. In its latest analysis of 20 states, 54 percent of nonprofit hospitals came up short, by a combined $11.5 billion a year.

Ge Bai has spent years dragging these numbers into the light. President Trump has nominated her to be HHS Assistant Secretary for Planning and Evaluation, and the Senate Finance Committee advanced her nomination on Thursday. I can’t think of a better person to have running the numbers at HHS. Confirm her, Senate, and let her bring her spreadsheets.

The Natural Experiment

This month’s news gives us the cleanest test of the question I’ve seen.

Three economists at Georgia State University, Sukriti Beniwal, Federico Corredor and Meghna Paul, just published a peer-reviewed study in the Journal of Regulatory Economics. It follows 150 hospitals that converted from for-profit to nonprofit status between 2010 and 2023.

The design is elegant. When a hospital converts, the building stays the same, and so do the neighborhood, the patients and mostly the doctors. The main thing that changes is that it stops paying taxes. If the tax exemption buys charity, this is where you’d see it.

You don’t see it.

The conversions “did not produce a meaningful increase in charity care.” Total uncompensated care fell about 4 percent after conversion, mostly because the hospitals wrote off less bad debt. And the local school districts, which depend on property taxes, lost an average of $25 per resident once the hospital came off the tax rolls.

So when a hospital becomes a “charity,” the charity care stays flat and the local schools take the hit.

How Charity Got Written Out of the Charity Rules

It wasn’t always like this. In 1956, the IRS said a hospital earned its exemption by caring for patients who couldn’t pay, “to the extent of its financial ability.” Charity was the whole point.

Then came Medicare and Medicaid in 1965.

With the government now paying for the elderly and the poor, the IRS decided hospitals didn’t need a charity care requirement anymore. In 1969 it replaced the old standard with a vaguer one called “community benefit,” meaning - promoting the health of the community. The hospital in that 1969 ruling admitted only paying patients. It qualified as a charity anyway, because it kept an emergency room open to everyone. In 1983, the IRS decided even the emergency room was optional.

Congress has noticed now and then.

In 2006, Ways and Means Chairman Bill Thomas introduced a bill requiring nonprofit hospitals to adopt charity care policies for low-income uninsured patients. It went nowhere. Senator Chuck Grassley kept up the pressure for years, and eventually the ACA gave us Section 501(r): hospitals have to do a community health needs assessment every three years, have a written financial assistance policy, cap what they charge eligible patients, and follow some (but not many) limits on collections.

What 501(r) doesn’t include is any minimally acceptable amount of charity.

The Government Accountability Office has been pointing this out for years. In 2020, GAO told Congress that “the law is unclear about what community benefit activities hospitals should be engaged in,” and found 30 hospitals that reported spending nothing at all on community benefit in 2016. In 2023, GAO noted that the IRS “does not have authority to specify activities hospitals must undertake.” When the IRS revoked a hospital’s exemption under the ACA rules for the first time, in 2017, the reason was that the hospital hadn’t done its needs assessment and posted it publicly.

In other words, the one enforceable rule is that a hospital has to write a report. It doesn’t have to be charitable.

The Rap Sheet

I laid out the hospitals’ crimes in Part III of my series on needing less health care, so here’s the short version.

According to RAND, hospitals charge private plans an average of 254 percent of Medicare for inpatient care and 279 percent for outpatient care, which is WAY beyond what they need to break even (usually under 150 percent, according to the National Academy of State Health Policy). That’s before a hospital decides to double its price out of spite.

Providence, one of the largest “Catholic” health systems in the country, hired McKinsey to design a revenue program called “Rev-Up.” According to Washington’s attorney general, staff were trained to “ask every patient every time” for payment and “don’t accept the first no.” Providence stopped screening patients for charity eligibility and sent Medicaid-eligible patients to debt collectors. In other words, it hired the most overpriced management consultants in the world to help it better hide its federally-mandated charity program from needy patients. In 2024, Providence agreed to $157.8 million in refunds and debt forgiveness for nearly 100,000 Washingtonians.

Meanwhile, researchers at Rice University’s Baker Institute found that nonprofit hospital CEO pay rose 34 percent between 2012 and 2019, to about $1.3 million on average. Nurses’ pay rose 2.3 percent over the same period. CEO pay tracked size and profits much more closely than quality of care.

The Only Value in the Whole Enterprise

What gets me most about my nun’s case is her surgeon.

The doctors and nurses are the ONLY source of value in that building. They’re the ones who fix the joint, deliver the baby, find the tumor, monitor recovery, exercise judgment, hold patients’ hands. It’s their work that produces literally all the revenue, and yet, they see pennies on the dollar of what the hospital charges for their work. Then the institution that employs them turns around and squeezes the poorest and sickest patients, making doctors and nurses complicit in the corruption.

That’s moral injury, and I see it in earnest clinicians all the time.

Most of them never find out what their hospital quoted the patient. This one did, and he’s putting his own standing on the line to fix it. He is doing more to live up to the word “charity” than the hospital’s entire board of directors.

So Are the Tax Exemptions Worth It?

For most hospitals, based on the numbers and my own experience, no. But I’m not asking for the tax exemption to be abolished. I’m asking Congress and the states to make it buy something.

1. Set a floor. Tie each hospital’s required charity care and community investment to the value of the tax breaks it receives. Bills have been introduced in this Congress to do just that. A hospital that can’t clear its own tax bill shouldn’t be called a charity.

2. Count honestly. Require facility-level reporting, which GAO has recommended, so a system can’t hide one hospital’s zero behind another’s surplus. Count charity at actual cost and publish it in a way ordinary people can read.

3. Build open-to-all into the brand. A tax-exempt hospital should be required to care for all patients, regardless of their ability to pay, but especially those willing to pay an upfront cash price without having a rapey network logo on the front of the ID card.

4. Outlaw spite pricing. Post a real cash price and honor it for everyone, including self-funded plans and the people in them. If it charges a cash-paying plan more than it charges its insured patients, it should lose its exemption. If a hospital raises its price because a needy patient asked for a discount, that should count as evidence against its charitable status.

5. Let local assessors do their jobs. Property tax is where communities feel the exemption most. In 2010, the Illinois Supreme Court upheld the state’s decision to strip a hospital of its property tax exemption because it provided so little charity care. More counties should ask the same question.

6. Employers, go around them. Until the law changes, the best leverage a plan has is its feet. Independent, physician-owned surgery centers and direct contracts with doctors are often a fraction of the hospital price, and they don’t punish you for asking.

The Church teaches that charity is a theological virtue, the love of God working through us toward our neighbor. At most nonprofit hospitals, charity is a line on a tax form.

I’ll let you know how the surgeon’s appeal goes. If the hospital says no, you’ll get its name.

Sources

• Beniwal, Corredor & Paul, “Tax Exemptions Without Community Benefits,” Journal of Regulatory Economics (2026)

• KFF: The Estimated Value of Tax Exemption for Nonprofit Hospitals Was About $28 Billion in 2020

• Congressional Research Service: Nonprofit Hospitals, Tax Benefits, and Charity Care

• Congressional Research Service: 501(c)(3) Hospitals and the Community Benefit Standard

• IRS: Limitation on Charges, Section 501(r)(5)

• Lown Institute: Hospital Fair Share Spending

• GAO-20-679: Opportunities Exist to Improve Oversight of Hospitals’ Tax-Exempt Status

• GAO-23-106777: IRS Oversight of Hospitals’ Tax-Exempt Status

• Healthcare Dive: IRS revokes hospital nonprofit status for the first time

• Washington Attorney General: Providence must provide $157.8 million in refunds and debt relief

• Alaska Public Media: Providence pressured patients to pay, even when eligible for free care

• Rice University Baker Institute: Nonprofit hospital CEOs rewarded more for size, profits than quality of care

If you know anything about the bogus practices of the AMA, you can imagine why she reached out.

When she reached out to ask if I’d join her podcast, it was an easy yes.

You see, Barbara has spent her career building a practice area most lawyers have never heard of: the legal rules for people who want to keep you healthy instead of billing you for being sick.

She founded the Center for Health and Wellness Law, wrote the American Bar Association’s book on workplace wellness programs, and teaches health law at UM-KC. She also once worked in-house at a large health insurer, so she knows exactly which rooms the bodies are buried in.

We started with the AMA.

You probably think of it as the nice little trade group for your doctor down the street. Most people do.

Well, it’s a scam, and a very profitable one.

Every medical bill in America is written in CPT codes. Medicare requires them. They’re part of the infrastructure of HIPAA-compliant billing. No employer plan will pay a claim without them. They are, for every practical purpose, law.

But the AMA owns them.

It makes roughly $300 million a year on the codes, and providers pay for access to the words they are required to use.

My friend Cynthia Fisher runs PatientRightsAdvocate.org. I worked with her on the price transparency rules when I was at the White House. Hospitals and insurers now have to post their prices, and they love to post them in file formats your computer can’t even open.

Cynthia’s team converts those files into spreadsheets actual humans can read.

And those spreadsheets contain CPT codes.

So now we’re fighting over whether a private organization gets to charge the public for access to something the government requires everyone to use.

Cynthia sued the AMA. (My money’s on Cynthia.)

We also got into what I do at AllBetter.

Health care is often the number two line on an employer’s P&L, and it climbs by double digits every year. Any other line item behaving like that would get the vendor, the product, and the account manager fired.

Instead, HR renews the Blue Cross plan, because nobody ever got fired for buying Blue Cross, on the advice of a broker who is paid by the sellers.

A reminder: Blue Cross is not reaching into its own deep pockets to pay your medical bills.

It’s reaching into your employer’s.

So we fire the carrier. We fire the PBM. We rebuild the plan with independent vendors who are paid by the employer and nobody else.

The thing I like to say that makes CFOs ask 100 more questions is that the only way we’ve found to save employers money is to make the benefits more generous.

• Concierge primary care.

• A nurse navigator for every group.

• Deductibles waived when you go to the high-quality site.

Barbara asked where corporate wellness fits.

Wellness 1.0 paid the healthiest employees a premium discount to check boxes they were going to check anyway, while 5% of the workforce drove half the claims.

That was never going to work.

Wellness 2.0 is primary care that owns the patient.

And direct primary care is finally starting to bill as a claim, which sounds boring and changes everything.

I work with Catholic priests scattered across the country. Our nurses can now drop a priest into a DPC practice in any town without negotiating 200 separate contracts.

That’s how direct primary care starts to scale.

Wellness 3.0 is the functional labs, the nutrition counseling, the naturopath, the acupuncturist.

All the ways to keep people well that don’t require writing a giant check to a giant corporation called “Saint Whoever” down the street, pretending to be a charity.

Give it a watch.

And if you run a company and you’re tired of watching that number two line eat your margin, come find me at AllBetter.

Blue Cross of Idaho ran Scentsy’s health plan. Blue Cross of Idaho also sold Scentsy the insurance policy that pays out when an employee’s medical bill gets huge - a policy with an end date. Every week Blue spent processing a huge claim was a week closer to the day it owed Scentsy nothing.

Hmmm.

A $1.4 million claim for a critically ill baby missed the deadline by about ten weeks. Scentsy paid it out of pocket. Then Scentsy sued.

If your carrier runs your plan and also provides your reinsurance policy, you’re sitting in Scentsy’s chair (PS that’s most employers). Read this before your next renewal call. (Or forward it to the person who does. I’ll wait.)

Here’s the 411.

Bottom Line

On September 3, a federal judge ruled that Blue Cross of Idaho broke its fiduciary duty to Scentsy (I know, you’re shocked). A $1.4 million claim for a baby’s care showed up too late for Scentsy’s stop-loss reimbursement, Blue (wearing its reinsurer hat instead of its plan administrator hat) refused to pay it, and Scentsy covered it out of its own pocket. The judge says Blue has to make Scentsy whole.

If your third party administrator (TPA) also sells your stop-loss, you’ve got the same setup Scentsy had.

Definitions, in Plain English

Self-funded plan. The employer hires a plan administrator (like Blue, Aetna, or in my clients’ case, indie vendors), who writes checks to pay employees’ medical bills out of the employer’s own bank account, instead of just paying inflated monthly premiums to the carrier to, well, carry that risk and pay bills out of its own deep pockets. Scentsy (yes, the wax warmer people) runs one.

BUCAH. Blue Cross Blue Shield, UnitedHealthcare, Cigna, Aetna, Humana, aka the big carriers that run most employers’ claims and would love to sell you everything else too.

TPA (third party administrator). The company the employer hires to process the claims and pay the bills with the employer’s money. For big employers (over a couple hundred employees usually), the BUCAH is just a TPA for their plan. Blue was Scentsy’s TPA. The contract calls it the “claims administrator.”

Stop-loss or reinsurance. Insurance the employer buys to cap its risk. Once claims for a plan enrollee pass a set dollar amount, the stop-loss reinsurer reimburses the employer for everything above it. Here the trigger was $200,000 per person, and the contract calls it an “Excess Loss Contract.” This is so that self-funded plans don’t go bankrupt over a particular high claimant.

ERISA. The federal law that governs self-funded plans.

Fiduciary. Someone legally required to put the plan and its participants first. The Ninth Circuit calls the ERISA fiduciary duty “the highest known to the law.”

The window. The reinsurance policy period during which a claim has to be paid to count towards stop-loss reimbursement. It gets its own section below.

What Happened

Scentsy’s plan covered a baby who was born in February 2022 with serious birth defects. She was transferred to a children’s hospital in California and ran up two enormous claims there.

Blue paid the first one, about a million dollars, under the stop-loss policy. It refused the second one, about $1.4 million. Blue said the bill arrived on September 19, 2022, which was after the stop-loss window closed on July 30. So Scentsy paid the second claim itself, then sued.

What the Hell Is the Window?

Like your auto insurance, a stop-loss reinsurance policy has a start date and an ending date, and this one ran from May 1, 2021 to April 30, 2022. You’d think that means any big claim for care during that year gets reimbursed. It doesn’t work that way. The contract only covers care that was provided during the coverage year, but also, crucially, paid during that year plus three months after. That’s the window. Care has to happen inside the contract period, and the claim has to be paid by the cutoff date after it.

Say a patient racks up a million-dollar bill in March. Someone has to get the bill from the hospital, review it, and pay it, and if that takes long enough, the cutoff passes. The care happened on time, but the payment didn’t, so the stop-loss carrier owes nothing and the employer eats the bill. That’s why every employer expects its TPA to pay attention to big claims and to hustle to process and pay them quickly so they land inside the window.

The policy coverage window for when the bill had to be paid by closed July 30, 2022, three months after the contract period ended. The baby’s second claim covered care from March through April 22, 2022, and Blue says it got the bill on September 19 and paid it on October 10. That’s about ten weeks late by Blue’s math.

Why Scentsy Was Mad

Because the company was in charge of running out the clock was the same one that owed the money if the clock didn’t run out. Blue decided how fast Scentsy’s claims got processed, and Blue also had to write the stop-loss check if a big one got processed in time.

You might be asking yourself, “Self, how could Blue have known that the big expensive bill would come in for this baby after the cutoff? Blue isn’t clairvoyant, right?”

But actually, Blue knew about this baby, and it left a paper trail months before the window closed. The court found no evidence that Blue ever told Scentsy it was sitting on the claim, and no evidence that Blue tried to rush the claim or pay it after the fact.

Judge Amanda Brailsford has now granted Scentsy summary judgment on its two ERISA fiduciary counts. Regular readers know how I feel about Blue (the B in my BUCAHs), so you can guess whose side I’m on.

Below the paywall: how the judge found that Blue was wearing two hats (oops) and how Blue gets hoisted by its own email. (And its own underwriting director. And its own contract.) Paid subscribers get the to-do list about how to not end up like Scentsy. Everyone else, forward this to your CFO.

Read more

Like arguing with physicists over whether gravity is a thing. I tell that story in detail here.

But after years, and since Spencer and I recorded this conversation only a few months ago, the economists have come around.

In June, the White House Council of Economic Advisers estimated that banning certain anti-competitive hospital contract terms could save workers and employers about $45 billion a year in premiums. Two days earlier, DOJ proposed a settlement requiring OhioHealth to stop using the challenged provisions. Its case against NewYork-Presbyterian remains open.

Welcome aboard, fellas.

But there’s another contract problem I think deserves attention.

When self-funded employers rent a network, those agreements can require them to use the network’s rates - even when an employer and provider might happily make a better deal directly.

Spencer asked whether we should even be comparing networks anymore, or stripping them of their power over price.

Now you’re speaking my language.

We spent a good chunk of the episode on why I believe those restrictions deserve antitrust scrutiny by DOJ, what a post-network world could look like, and why the endgame should be much simpler: providers competing on transparent cash prices.

We also got into my concern that AI in the exam room may be accelerating upcoding, the changes coming for PBMs and fiduciaries, and my “school choice for health care” idea: put far more of the money currently spent on someone’s coverage into an account they control and let them choose how to spend it on care and coverage.

And yes, we talked about Washington’s affection for incremental HSA changes when I’d rather see much bigger structural reform.

Watch The Full Episode Here.

I identify as a recovering epidemiologist. Unfortunately for this study, I still remember how the scientific method works.

Last month, a client texted me to ask whether she should “go on the ivermectin protocol” for her joint pain. When I asked where she’d heard ivermectin could help with that, she told me everyone in her homeschool group was talking about the study showing an “84% benefit” in cancer patients. And if it could do that for cancer, she figured, surely it could help with inflammation too.

A number - 84 percent - detached from the thing it was supposedly measuring, floating around group chats and inspiring people to find more reasons to put pharmaceutical products - each with their own risks - into their bodies.

A group of authors associated with The Wellness Company published a study about the association of a hodge-podge of custom ivermectin-mebendazole protocols with a hodge-podge of individual self-reported cancer outcomes. In a peer reviewed journal, Anticancer Research.

All of us in the medical freedom movement - physicians, epidemiologists, naturopaths, homeopaths, activists, parents - have built reputations on distrusting sloppy institutional science.

We’ve endlessly mocked The Authorities for cutting scientific corners. Which means we’ll rightly be held to even higher standards than ever when we play in their sandbox.

The Problem Is, I Like These People

This isn’t a hit piece on the people involved. The author list includes physicians and researchers I profoundly admire - people who have put their licenses, their reputations, and their livelihoods on the line to say true things that were unpopular. Which is why this particular study does more damage to our movement than a hundred sloppy papers out of pharma-funded academic mills ever could. When The Authorities publish garbage, it’s business as usual. When our team does it, it’s a gift to everyone who wants more excuses to dismiss us and our credibility.

About That “84%”

The paper is referred to by The Wellness Company’s press release as a “groundbreaking… study.” And “The Largest Peer-Reviewed Study on Off-label Ivermectin + Mebendazole in Cancer Treatment Published in Anticancer Research Journal.” That sounds like legit science.

But in the actual paper, the published version in the journal, the authors more accurately call it a “prospective observational cohort.” And their findings? “The first real-world therapeutic signal.” “Hypothesis-generating” and calls for randomized clinical trials (RCTs). Of course, only a well-designed, large RCT can actually demonstrate clinical effectiveness of a therapeutic protocol when compared to current standard of care or placebo. The authors acknowledge that.

Not all observational studies are inherently terrible. (Just most.) But a useful one has to make a serious effort to identify and account for other factors that could explain the results - the pesky things epidemiologists call “confounders.” Which our intrepid author list didn’t do.

Here’s what actually happened, according to the paper: 197 patients who were already customers of The Wellness Company, already taking the compounded ivermectin-mebendazole capsules they’d bought from TWC’s telehealth platform, were invited to fill out a digital survey about how they were doing. Of those 197, only 122 (61.9%) completed the six-month follow-up survey. The other 75 - about 38% of the starting group - didn’t come back to complete the next survey. We don’t know what happened to any of them - whether they got better and stopped caring, got worse and stopped answering emails, or died. The paper doesn’t say, and by its own design, it can’t.

Of the 122 who stuck around, 84.4% reported “clinical benefit” - a composite the authors call the Clinical Benefit Ratio, combining self-reported “no evidence of disease,” tumor shrinkage, and stable disease into one headline figure. That’s the number that made it into every press release and Telegram forward. Remember - the inputs (cancer + drug combo) and outcomes were all self-reported. As in, no scans, no labs and no pathology. The paper said the patients started with “confirmed cancer” but no methods for confirming that cancer except for asking the patient are described. The dose wasn’t standardized either - patients and prescribers picked how many capsules to take, “most commonly one or two,” and reordered the drugs “as desired.” And during the six months being measured, 27.9% of participants were also on chemotherapy, 21.3% were getting radiation, 19.7% had surgery, and roughly half were taking other supplements while over a third had changed their diet. Forty percent of the patients were taking “other,” unspecified treatments.

If they had surgery, that likely meant that a tumor was removed or as much of it removed as the surgeon could get. Which means that the patient would, of course, be able to report “tumor shrinkage” on the basis of surgery alone. But these patients appear to have been included in the 84 percent reporting positive results associated with the ivermectin/mebendazole combo. The drugs are potentially getting credit here for cutting the tumor out of the bodies, even though it was a surgeon who did that.

There’s no version of the scientific method, ancient or modern, mainstream or dissident, in which you can hand people with an un-verified disease state an unstandardized dose of two drugs, let a bunch of them also do chemo or radiation or surgery or both, lose track of 38% of your subjects, ask the survivors to self-report their own cancer status with no verification, and then report a single clean percentage as if you’ve isolated what the drugs did. What got measured here was noise. What got reported was signal.

The Authors Know All This

To be completely fair: the paper’s own discussion section says almost all of this itself. Quoting directly: “Limitations are inherent to the observational, self-reported nature of the data. Outcomes were not clinically adjudicated or radiographically confirmed, no control group was available, and confounding from concurrent conventional therapies, supplements, and lifestyle changes cannot be excluded.” They go on to say the results “should therefore be regarded as hypothesis-generating” and call for “rigorous randomized, double blind, placebo-controlled trials.” If the press release had led with that paragraph instead of giant-font “84.4% reported clinical benefit,” we wouldn’t be having this conversation, and my client wouldn’t have texted me about her knees.

But TWC’s media team skipped straight past that paragraph, and so did every outlet that ran with the number. A Clinical Benefit Ratio of 84.4%, printed at the top of an abstract under the banner “Anti-Cancer Research Journal,” does a huge amount of work that the caveats three pages later can’t undo.

And, by the way, the drug everyone on Telegram thinks this study is about is fenbendazole, the veterinary drug from the Joe Tippens story that’s been floating around the health-freedom world for years. This paper tested mebendazole instead - a related but different, human-approved anthelmintic.

Has Hell Frozen Over?

You know it’s bad when two groups who agree on almost nothing arrive at identical take-downs within weeks of each other.

On one end, Dr. Tom Cowan - about as far from a status-quo defender as it gets - devoted a full podcast to walking through this study line by line, and landed on nearly every problem I just listed: the self-reported diagnoses, the unexplained 38 percent dropout, the absence of any control group, the patient-chosen dosing, the fact that many participants were also getting conventional treatment at the same time. His sharpest point, and I think it’s the right one: if you would never accept a patient’s unverified self-report of “I have diabetes” as grounds for publicly claiming your “banana diet” (or whatever) cures diabetes, you don’t get to accept unverified self-reported cancer status as grounds for publicly claiming a drug combination could be treating cancer.

On the other end, TechARP - a status-quo fact-checking outfit whose entire mission is to make all of us in the med-skeptic crowd look like dummies - ran its own line-by-line breakdown and rated the 84% claim “False.” Its critique overlapped with Cowan’s almost point for point: unverified self-report, no control group, a cohort that was pre-selected for having already bought and started the protocol (which makes the placebo effect more likely and selection bias enormous), and confounding from concurrent chemo, radiation, and surgery that the study design has no way to separate out. TechARP added one thing Cowan didn’t emphasize: most if not all every single one of the twelve listed authors is affiliated with, or draws salary from, The Wellness Company - the same company that sells the compounded ivermectin-mebendazole protocol being evaluated.

But I actually appreciate the honest conflict-of-interest disclosure - a helluva lot better than we get from sneaky pharma-funded authors in most peer-reviewed articles.

Still, when Dr. Cowan and a Fauci-worshiping, COVIDian fact-checking site independently produce the same list of methodological failures, it gets my attention. We can’t wave off the critics with the usual “well, of course the establishment hates it” or “of course the fringe are quacks.”

Pay no attention to those peer reviewers behind the curtain.

The journal’s own walk-back got lost in the outrage cycle over the summer.

Anticancer Research issued an Expression of Concern about the paper in June, and it initially raised questions that sounded ethical in nature - institutional review board approval, verification of participants’ baseline diagnoses, medical documentation. That’s the kind of language that implies someone did something dishonest.

Then, in a September update, the editorial board walked that specific framing back. They withdrew the audit request tied to IRB approval and diagnosis verification, and they said so explicitly: “No allegation of fabrication, falsification, plagiarism, image manipulation, or other research misconduct is made against any author.”

All of this ethical rigamarole was really just fig-leafing for the fact that the journal’s so-called “peer-review” process was a complete fail on the merits of the study. By dancing around the fact that they investigated and found no ethical failings - the authors didn’t lie or cheat - the journal delayed having to confront the much more embarrassing problem: its peer reviewers apparently thought this was good enough science to publish.

And when journals publish that kind of paper, the outcome is predictable. It produces the “Study finds…” headlines, social media frenzy and the patients like my client who are now more likely to purchase drugs with a known risk profile, from the company the authors own or affiliate with, with an unknown benefit for a disease they don’t even have.

For the record, I got nothin’ against Ivermectin

You could make an argument that the healers and researchers who are working outside the conventional sick-care system shouldn’t be trying to prove ourselves inside the academic literature clown car at all.

After all, one of the most foundational principles of my fields of naturopathy and homeopathy is bioindividuality - the idea that each person is an unrepeatable ecosystem responding to a custom set of material, energetic, and immaterial inputs all at once. That makes it very difficult to group patients with similar symptoms into a treatment group that receives a new protocol or into a control group that receives the standard of care or placebo.

I get it. Why play by the RCT rules when they assume a premise we reject?

But it’s not actually the scientific method we reject. Even without an RCT, as a recovering epidemiologist, I don’t dismiss all observational studies outright. There can be well-designed ones that do provide useful information and “hypothesis generation,” even if they don’t demonstrate causation.

I’m not asking for a Vinay-Prasad-approved double-blind trial before anyone’s allowed to make a clinical recommendation - plenty of good, honest care happens without one, and I practice plenty of it myself. But when you decide to publish something with “Anticancer Research” in the title and a quantitative finding in the headline, you hold yourself to a standard that would survive being read by someone who wants you to fail (which is most of the white coat religious cult). This one wouldn’t have survived a first-year biostatistics section, and, ironically, the people I would have considered the most qualified to have caught that before publication were the twelve authors on the byline.

Sources:

• Original study: Real-world Clinical Outcomes of Ivermectin and Mebendazole in Cancer Patients (Anticancer Research, Vol. 46, Issue 6)

• Editorial Board update: Update to the Expression of Concern (Anticancer Research, September 1, 2026)

• TechARP fact-check: Ivermectin Cancer Study: 84% Fact-Checked

• Dr. Tom Cowan podcast discussion (September 2, 2026)

Congressman Eric Burlison told me he’d never heard anyone say “the medical cartel” out loud until he heard me say it at a podium.

(And that might just be the best summary of the entire problem right there.)

Burlison represents Missouri’s 7th District and hosts Fresh Freedom, which he started in his first year in Congress and has kept going into his second term. He spent a decade inside Cox Health before he ever ran for anything, so when he talks about what hospitals have become in Springfield, it’s cuz he knows.

Nate Lucas co-hosts.

Between the two of them they let me talk for twenty minutes about kickbacks, which is more runway than I usually get on the Hill.

Here is where we ended up.

The worst actors in American health care are the nonprofit hospitals. They wear the white hat in their communities, collect the tax exemption, and plunder the working class on the way out the door. On average they spend less than three percent of revenue on actual charity, maybe a little more if you count all uncompensated care (most of which they didn’t agree to in advance out of the goodness of their hearts).

If you still think they might be the good guys, remember that Providence hired McKinsey to help them hide their charity program from the poor people the ACA requires them to serve. They’re not just one of a few bad apples, trust me.

A hospital I’m trying to do surgery for a Catholic nun whose health plan I run just doubled the demand price for a knee replacement to $80K when we tried to negotiate down from their already outrageous $40K initial demand. If she doesn’t pay cash on the day of service, they won’t see her. She would qualify for Medicaid, but her plan WANTS to pay. They just don’t want to get raped.

But tell me again, El Camino Health in Santa Clara, CA, like every other whiney hospital I ever talk to, how you’re “barely surviving.”

Let me count the cranes.

The carriers and the PBMs (but I repeat myself) are running the same play from the other side. The entire value proposition of a network is that they can get you a lower price than you could get yourself. But the opposite is true almost everywhere.

And when cash beats the negotiated rate. I can’t remember anymore what the network is for.

On the podcast, Nate asked if I have PTSD from July 28, 2017. I do. We had bought off every vote we could find in the House and turned repeal and replace into something Frankensteinian we could barely defend, and then the Senate looked at it and knew the dog wouldn’t hunt. Several of them voted no.

I am glad it failed. It was a bad bill.

What we did do, surgically, in the tax bill the next year, was zero out the individual mandate penalty. That is the pattern. Republicans keep trying to do Obamacare but slightly less of it, and then they wonder why nobody is inspired.

They asked me for a thirty-second pitch to Republicans at the end. Here it is.

We’re going to lose if we don’t do something about the affordability crisis, and health care is the biggest piece of it. If we won’t help people with the number one thing that is life and death to them, we don’t deserve power. We should go home. Nobody needs us here.

Watch the whole thing below.

Washington loves a deadline.

And if you spend enough time there, you learn the weeks before one are generally when you should start paying more attention, not less.

The Senate returns September 14. The current Farm Bill extension expires September 30, and Senate Agriculture Chairman John Boozman has said he intends to bring Farm Bill 2.0 back up shortly after lawmakers return, after it failed to advance out of committee in August.

For the moment, the pesticide liability language that caused such an uproar earlier this year is out. (Thank you to everyone who contributed to that happening by throwing a well-justified fit.) The House stripped those provisions from its bill after Anna Paulina Luna forced the issue in April, and the Senate proposal does NOT contain a comparable liability shield - yet.

That’s very good news. I’m just not declaring victory while Congress is still engaging with the bill.

Which makes my recent conversation with Jennifer Galardi and Jay Richards on RAW particularly well-timed.

We talked about the story behind my recent confession, the autism moms who came into my Senate office more than twenty years ago, the RFK Jr. meeting I later routed away from the Trump White House, and the very long road from true believer in our public-health institutions to asking considerably more uncomfortable questions about them.

But we also got into something especially relevant to the Farm Bill fight: incentives.

Markets depend on transparency, meaningful choice, accountability and some avenue of recourse when a product causes harm. Start removing those things and eventually you have to ask what mechanism is left to keep the system honest. That was the point we kept coming back to, and why I said creating that kind of liability structure around another class of products would be “the height of public health malpractice.”

We also covered informed consent, FDA labels, hospital food, and why people who publicly admit they got something wrong should probably be encouraged rather than beaten back into silence.

The whole conversation is below.

Take a listen and let me know what you think.

Fertility conversations usually start with the ovaries.

Terms like egg quality. Estrogen. AMH. FSH. Progesterone. But the first decision about whether an egg gets released isn’t made in the ovary at all. Like so many things, it starts upstream, in the feminine brain. Where her mind is constantly taking inventory of the environment and asking a more fundamental question:

Is it safe here?

My nephews and I were on horseback in the hills outside of Yellowstone. It was hot and beautiful. The horses were slow and plodding. And then the guide’s tone of voice changed: “I’m going to need everyone to start shouting and to turn around right now and go back the way we came.”

I was in the middle of the group, the boys were in front of me, closer to the guide. At first we were all just confused and not following what was happening. Then someone said the word “grizzly.”

The mind gets concentrated in a nanosecond. We all started shouting to scare off the bear, as we’d been prepared to do in the safety session before leaving camp. Many of the riders, brand new to steering, struggled to turn their horses around. As an experienced rider, I was focused on circling around the young boys in my care and encouraging them to move quickly without scaring them, while twisting around in the saddle to locate how close the bear was.

It was the guide’s horse that had saved the day. He had detected the danger and pulled up short, alerting us to the problem ahead.

I never did see the bear. Most of the group didn’t. But the awareness of the bear’s presence was enough to set off extreme stress physiology in everyone. Hearts racing. Shallow breathing. Blood pressure spiking. Cortisol carpet-bombing the bloodstream. Liver dumping glucose. Circulation routing to the vitals and away from extremities.

Also, each pair of ovaries in the female riders shutting down.

The bear parted ways with us and we finished our ride peacefully, with a fun story for the dinner table. Thankfully, it takes longer than a few minutes of potential bear attack to destroy an ovulatory cycle. One scare on a trail ride isn’t going to cost you a baby.

But what if the bear isn’t on the trail? What if it’s your husband? Your boss? Your bank account?

Those grizzlies don’t wander off after five minutes. They don’t get bored and amble back into the tree line. They show up again tomorrow, and the day after that. Your body can’t tell the difference between the life-threatening grizzly on a trail and a marriage that’s been running on fumes for three years.

That’s the whole essay, really. Your reproductive system was fearfully and wonderfully made to turn on and off at the answer to one question: is it safe here?

Not safe in the sense of “no immediate physical danger.” Safe in the sense of “I could actually sustain a pregnancy and raise this child to adulthood under these conditions.”

Let’s revisit just how vulnerable and dependent you would be if you were pregnant: hyper-sensitive, hyper-vulnerable, slow to move, extremely tired, often nutritionally depleted/nauseated, in pain from gas, joint pressure, breast tenderness, reassurance-seeking, intensely interested in nesting.

And it’s not just pregnancy.

During birth, your vulnerability is the most intense. The exquisitely orchestrated hormonal process of birth - the dance of catecholamines, oxytocin and other hormones which ensure cervical softening, contraction pacing, movement of the baby, natural pain suppression, uterine closing and hemorrhage prevention immediately after birth - all of this works best when you are alone or near-alone, unobserved, unjudged, with no threats, no sounds, no smells, low light and no anxious or negative energy in your immediate, six-foot field.

After birth, that hormonal symphony continues with oxytocin pulsing every time baby cries or feeds. That hormonal matrix ensures proper development and attachment between mother and baby. It heals mother’s body, regulates baby’s body temperature, turns on the full milk drop, and helps mom integrate the physical earthquake she just experienced - without PTSD.

Guess what turns off oxytocin?

Cortisol.

(I covered the glories of physiological birth and its grotesque saboteur, industrial birth, in detail here.)

Even the slightest insult to this brilliant process - the mere perturbance in the field - signals to the body to turn off all these hormones. Because it’s not safe to do any of this.

And the first time this safety signal is demanded by the body is before conception.

The hormones that control ovulation are excruciatingly attuned to stress.

One grizzly incident, over and done, might be noticed but it won’t shut down ovulation. Your body is designed to weather the coming and going of occasional surprise grizzlies.

But when the stress is chronic and serious - your autonomic nervous system reads that as potential for starvation, abandonment, exile from the tribe, violent attack, and any number of other circumstances that render baby-making, baby-baking, baby-birthing and baby-nursing as too physiologically expensive. Your body knows that all its energy right now needs to be on survival. When survival is at risk, all other biological imperatives take a back seat so that all the body’s resources are directed toward the top priority. Lesser priorities - especially those that are metabolically expensive - get shut down. Things like digestion. Detoxification. Reproduction.

Pregnancy and breastfeeding are two of the most metabolically expensive things a human body can do, and a body under chronic threat triages against a pregnancy it doesn’t believe it can carry to term and support afterward. Your body is a competent risk manager. Here’s what that looks like biologically.

Your ovaries aren’t actually in charge

Ovulation depends on a signal that starts in the brain (not the ovary).

The hypothalamus releases gonadotropin-releasing hormone (GnRH) in careful pulses, which tells the pituitary gland (also in the brain) to release luteinizing hormone (LH) and follicle stimulating hormone (FSH), which work together in the ovary to mature a follicle. A final LH surge pops an egg loose. Each domino in this chain has to fall in the right order and at the right rhythm for ovulation to happen. (Friggin’ miracle it ever does!)

Chronic cortisol interferes with that chain at the very first domino. It suppresses the kisspeptin and GnRH neurons in the hypothalamus, which blunts the pulsing of FSH and LH. No proper pulse, no LH surge. No LH surge, no egg release. Doctors have a name for the extreme version of this: functional hypothalamic amenorrhea - fancy words for “no more periods.” You hear about this with extreme athletes or war refugees.

But amenorrhea is merely the loudest end of a wide continuum. Most women reading this still get a period every month like clockwork and have no idea their cycle is in trouble. That’s because bleeding only proves you made estrogen. It doesn’t prove you ovulated.

Ask me how I know.

A cycle can look completely normal on the calendar and still miss the point entirely. Even when the LH surge is blunted enough that the egg never releases at all, you can still get a withdrawal bleed on schedule when estrogen drops. Or the egg does release, but the corpus luteum that’s supposed to form afterward is weak, so you get a short luteal phase and not enough progesterone to sustain implantation even if fertilization happens. Same 28 days on the calendar, completely different story hormonally.

Sadly, this isn’t a rare glitch.

One study that tracked women with regular, predictable cycles using daily hormone measurements found that more than a third of them failed to reach an ovulatory progesterone threshold in a given cycle. Widen the lens to a full year and roughly two-thirds of normal-weight, regularly-cycling women had at least one cycle with a missed ovulation or an inadequate luteal phase, all while bleeding right on time.

If you’ve been told your labs are “normal” and your cycle is “regular” and you still can’t get pregnant, this very well could be where the real story is happening.

“But women get pregnant during war and rape all the time”

Now you might wonder: if stress really shut down fertility, women in war zones, refugee camps and abusive situations wouldn’t be getting pregnant, and they clearly do, so stress must not actually matter that much.

This conflates two different stressors which your body scores differently in the “is it safe to get pregnant” evaluation.

A single violent event, even a horrific one, is akin to one bear sighting. It’s an acute spike: cortisol floods in, then clears. The hypothalamic suppression described above requires the bear to move in and stay, week after week, month after month. A rape is a devastating acute trauma - a temporary lapse in safety that doesn’t necessarily signal an ongoing threat to survival. It’s not, on its own, the same physiological exposure as living for two years under famine or siege or bombardment or an abuser’s roof.

And if you actually look at the historical record on sustained, chronic conditions, it doesn’t undercut this argument - quite the opposite.

The best-documented case is the Dutch Hunger Winter, the WWII famine in the German-occupied Netherlands, where amenorrhea rates spiked sharply during the famine months. The same pattern has been reported in other sustained famine and siege conditions, like wartime Leningrad, and in long-term refugee and displacement camps: population-level fertility and cycle regularity drop for the duration of the crisis. Individual women still got pregnant in these settings, because some were already mid-cycle when the crisis hit, or because women’s minds perceive the same events differently, and so their bodies suppress reproduction with lots of variability. But across all of these, the base rate moved in precisely the direction chronic stress physiology predicts.

A word to my regular readers

If you’ve read “Your Body Isn’t Out to Kill You,” you already know where I land on this.

Your body isn’t the enemy here. It’s running a protective program to save your life in the immediate term (and therefore your fertility in the longterm). This is the same kind of program that shows up as a lump or a rash or a flare, except this time it’s pointed at your ovaries. I made the fuller case for that framework in that post, so I won’t relitigate it here.

Your body is still your ally, not an adversary: this time, fertility edition.

So where’s the protocol?

I know what some of my Type A sisters want right now. Morning sun, box breathing, magnesium before bed. Fix the cortisol, fix the ovaries, pregnant by spring, amiright?

Doing breathwork while the actual grizzly is still standing in your kitchen isn’t going to deliver the results you want. You can regulate your nervous system beautifully for an hour on a yoga mat, but if you’re not changing the thing your subconscious mind has decided isn’t safe for baby-making, your ovaries won’t be fooled.

The answer isn’t the right supplement stack. And the science was never really the point either.

The reason I spent a few paragraphs above talking science was to demonstrate that your body isn’t crazy, broken, or betraying you out of spite or bad luck. If your reproductive system has shut down without telling you, something in your life is registering as unsafe, even if nothing “bad enough” has happened to justify that word out loud.

I’m not talking about catastrophe. It doesn’t have to be anything that you’d define as “trauma.” Most of the women I know whose bodies are running this program aren’t in danger in any way they’d describe as dramatic. It’s a marriage that’s civil but empty, a job that’s low-grade dread five days a week, a bank account with no buffer, a loneliness so old they’ve stopped noticing.

In my own case, my privileged life with a high-responsibility, high-stakes career, combined with doom-scrolling-induced sleep deprivation, nutrient depletion due to my vending machine diet and Diet Coke habit, and complete disconnection from nature - it all meant that I spent every waking moment of my life in a cortisol bath cooked up by my autonomic nervous system.

Your own reality, the perfectly “normal” life you’ve built on the backs of Gloria Steinem and Susan B. Anthony - the life everyone told you was supposed to feel “liberating” - could very well be at complete odds with biology and its deepest subconscious needs.

Our bodies didn’t get the memo from the Sexual Revolution

When you were a little girl, did you dream of having to pay your share of the bills and taxes, leaving your baby with strangers six weeks postpartum, while your leaky nipples destroy all your power suits?

Because if that’s what having a baby would look like with your current partner, your current life - your subconscious mind may have already told your ovaries that he’s not the one (even if he really is the one!). Your lizard brain isn’t interested in DEI or marital harmony, it wants a strapping, strong, competent provider and protector so you can focus your attention on baby at home - permanently. Your PhD doesn’t get a vote.

On the other end of the spectrum, maybe your marriage is high-conflict, high-drama. Maybe he’s a cheater or a gambler. He may be the strapping stud described above, but your subconscious mind knows he could leave you and baby for the younger, sexier pre-partum crowd at any time. Only you know if this is the program your mind is running.

Maybe you’re chronically malnourished because of a diet made of 80% ultraprocessed food. Maybe you have chronic anxiety and panic disorder. There are a million reasons why your subconscious mind could be reading your life as unsafe for baby-making - which raises an obvious question - what about women whose lives look objectively unsafe and whose fertility seems completely unphased?

The women who are actually unsafe but who keep making babies.

You might know someone like I do - someone with tons of childhood trauma, watching her parents fight, break up, get back together, hit each other, and use drugs, on repeat. She’s been with an abusive partner since she was 17. They’ve made four babies together, through the kind of high-conflict, on-again, off-again chaos that should, by every argument I just made, be suppressing her fertility into the ground. It hasn’t.

The body’s whole reproductive shutdown depends on one thing: whether the environment is read by the autonomic nervous system as unsafe. I’ve been writing this whole piece as if that evaluation is objective, as if a body just automatically knows real danger when it sees it. It doesn’t. It’s calibrated, and it’s calibrated early, mostly by whoever raised you.

When a child’s parent is also her source of fear, and this happens over and over before age eight, the nervous system runs into a conundrum: stay close to survive, but closeness is where the danger lives. Researchers call the result disorganized attachment. This is what a nervous system does when love and danger seem joined at the hip in the same person, in the same house, for years.

There’s actual experimental evidence for what this does downstream. A large fear-conditioning study measuring biometric signals of stress found that adults with childhood adversity show a blunted ability to physiologically discriminate between danger cues and safety cues. Their alarm system doesn’t fire the same way at the same things. Their threat-detection software got confused early and stayed there.

And it runs both directions.

Chaos doesn’t just fail to register as dangerous, calm registers as dangerous instead. Quiet and predictable can feel like the held breath before the next blowup, the same way it did with alcoholic Dad in childhood. Some people provoke (or attract) conflict without knowing why, because conflict is at least a known, survivable state, and peace is unfamiliar territory with no map.

“Unsafe” is in the eye of the beholder

The flip side of the traumatized Fertile Myrtle is what so many of my clients look like: they’re privileged, professional women - like I was - with no obvious (even to themselves) reasons to feel unsafe. Their high-functioning cerebral cortex, though, isn’t driving the bus. The amygdala is. Brain stem. Lizard brain. And usually, I just have to dig a little bit with my clients: “what about your life might be registering to your unconscious brain as incompatible with the vulnerability and dependence of pregnancy and childbearing?”

They often know. The tears usually spring up quickly.

They know where their deepest fears and vulnerabilities are hiding. They know their marriage is crushing their soul. Their career and their professional identities are making them feel trapped or victimized. Their money problems feel insurmountable. Not being able to buy a home they feel happy in, stuck in a rental they despise. Their Instagram feed as a source of tribal rejection or constant pick-me-ism, hour after inadequate hour.

What is the thing - that thing you know in your heart is the answer to my question about what makes you feel unsafe - costing you? Are you willing to let it cost you the baby you’re desperate to have?

What about the grizzly bear that’s so familiar we don’t even notice it consciously anymore?

And if you’re being honest, what if there’s actually no grizzly left at all, but your subconscious mind is still causing your body to brace for one anyway? What’s the old threat-detection program running long after its usefulness has expired?

Are you so afraid to rock the boat that you’d sacrifice your chance to rock your baby?

Inertia is incredibly powerful. But I’ve also discovered, working with women, that there’s no status quo powerful enough to thwart a woman who wants a baby more than life.

Infertility is a screaming red siren from your biology and your deepest, most primal self. I ignored its signs until it was too late. Don’t be me.

If you know what is behind the safety signal, you probably have a million stories about why you can’t change it. Why you’re trapped. Why there’s no hope. Why escape is impractical, irresponsible, selfish, reckless.

It’s ok to choose the bear. Many women quietly sacrifice their bodies (and their deepest needs) to the bear every day.

There are no easy answers.

This isn’t that kind of article. No five-step plan, no call-to-action, no “link in bio.”

Just the question I opened with, and only you know the answer. If you’re struggling to get pregnant, your body may already be answering for you.

A mother will do anything to keep her baby safe. And a mother’s subconscious safety patrol starts before conception - by scanning her own internal and external environment - and prioritizing her immediate survival, so she lives to mother another day. But if we don’t slay the dragons shutting down our fertility now, that future day may never come.

Are you so attached to the grizzlies in your path that you’d give up a chance for a baby?

I hit submit on a federal comment letter this week with about four hours to spare before the deadline (on-brand, sigh). CMS, the agency that runs Medicare, has proposed injecting rationality into a program that has long since lost its way, and they deserved an attaboy. They also got a set of rebuttals to the hospital lobby’s hysterics.

Hospitals have been living off the fat of this land for way too long, and enough is enough.

Below is the whole thing, as it went to CMS, because a good rant is wasted if the bureaucrats are the only ones who read it.

Dear Dr. Oz:

I am writing in strong support of your proposal to reimburse hospitals for drugs acquired through the 340B program at a price that more accurately reflects what those hospitals actually, you know, paid for them.

Finalize it as written, no matter what the whining, corrupt hospital lobby says.

Believe me, I’m familiar with the hospital lobby. I did health care policy in the Senate for almost 15 years, and then in the first Trump White House, before starting a company that helps employers build re-humanized health plans.

When prospective employer clients hand my team at AllBetter Health a few years of claims to audit before they sign with us, we find all kinds of shenanigans. But one of the most egregious is a hospital-owned infusion center billing a patient on a self-funded plan four or five times (or 100x!) what the drug cost the hospital to acquire. My benefits advisory firm was built specifically to fight back against the fleecing of American patients and the employers, unions and taxpayers who support their care.

What The 340B Fracas is All About

As you know, in 1992, Congress created what’s now called the 340B program to let a defined set of safety-net providers, community health centers, Ryan White HIV clinics, hemophilia treatment centers, and hospitals serving a disproportionate share of low-income and uninsured patients, buy outpatient drugs from manufacturers at steep, statutorily mandated discounts. The stated purpose, straight from the legislative history, was to let these providers “stretch scarce federal resources as far as possible, reaching more eligible patients.” Congress was picturing a rural HIV clinic in Alabama being able to buy more vials of AZT, or hire more nurses to serve its HIV-positive patients.

Then Congress moved on and never came back to tighten any of the vague definitions in the law, which have now been abused beyond all recognition. The statute doesn’t require a hospital to pass its 340B savings to the patient who generated them. It doesn’t cap how many contract pharmacies a single hospital can run the drugs through, or if those pharmacies have to be on the North American continent. It doesn’t require disclosure of what happens to the spread between the discounted price the hospital buys at (sometimes, pennies) and the billed price to all the hospital’s payers, including my employer clients and their workforce. It barely defines “covered entity” beyond a list of categories, and it says nothing at all about how CMS should ever go back and check whether the discount that the hospitals are getting still matches what the statute assumed in 1992.

Thirty-four years of legislative laziness on the details turned a program designed for community health and AIDS clinics into a million-headed monster of contract pharmacies, more than 34,000 of them, feeding an $81.4 billion-a-year business in which the top 100 health systems alone captured over $40 billion of the $53.7 billion moved in 2022. Congress wrote a vague blank check to corrupt, giant corporate hospital conglomerates, and now the same vagueness that let them build this monster is the vagueness their lawyers are using to try and stop CMS from fixing it.

What CMS Has Proposed, and Why

The law governing Medicare’s outpatient drug payments gives CMS two ways to set their rate.

Door #1: pay every hospital Average Sales Price (ASP) plus 6 percent “margin,” no exceptions, no separate treatment for any group.

Door #2: pay hospitals what a hospital acquisition cost survey says they actually paid for the drug, and Congress explicitly allowed that rate to vary by hospital group if the survey supports it.

Back in 2018, CMS tried to walk through Door #2 without doing the survey that Door #2 requires, cutting the 340B rate to ASP minus 22.5 percent and defending the number as though it were self-evidently justified. The Supreme Court unanimously slapped that down in American Hospital Association v. Becerra in 2022, in an opinion Justice Kavanaugh wrote for the whole Court. He drew the line at varying the rate without a survey, not at varying it at all.

This time, CMS ran the survey first, its own drug acquisition cost survey (ODACS), and built the ASP-33.4 percent rate directly from what hospitals told it they paid, now proposing that rate in its annual payment rule for outpatient services.

But Wait, Isn’t CMS Eliminating the Very Spread the Program Intended?

Supporters of the 340B program might argue that the whole design of 340B was for covered entities to buy the drug low, bill the normal rate, and keep the difference to fund more care for people who can’t pay. If that’s right, doesn’t paying hospitals close to acquisition cost undo the exact mechanism Congress built?

Not for Medicare.

Congress didn’t intend for Medicare rates to always be ASP+6, world-without-end. That’s the whole reason for Door #2 - to be able to adjust what the government reimburses hospitals for drugs based on what they actually pay for them - which might be more than ASP+6 (in which case Door #2 provides a mechanism to pay the hospitals more), or it might be less than ASP+6 (in which case Door #2 allows the government to remind hospitals that they’re pretending to be charities when the IRS comes knocking).

Also - Medicare patients have to pay their 20 percent coinsurance off the Medicare rate. If the hospital is getting a drug for pennies, their coinsurance ought to be 20 percent of pennies, not a fifth of a rapey ASP rate.

Won’t Hospitals Just Cost-Shift to My Employer Clients if Medicare Cuts Their Reimbursement under 340B?

Some will try. But let’s not pretend that hospitals are somehow, somewhere exercising pricing restraint in what they’re charging employers right now because of all that sweet, sweet 340B cash they’re raking in. No. They’re extracting exactly as much value out of their local communities as those markets will possibly bear without steering too many patients away from them.

An employer can self-fund, negotiate, or route its members around a hospital’s markup, which is exactly what I help them do at AllBetter Health. A Medicare patient getting chemo can’t. If the 340B cross-subsidy model is going to exploit someone’s cost-sharing without their consent, it shouldn’t be a fixed-income senior’s.

What’s more, the CMS proposal isn’t even a cut. Instead, CMS has cleverly redirected these overpayments for 340B drugs to other outpatient services. As a result, the tapeworm-like hospitals - eating up more and more independent outpatient practices and slapping their logo on the building, in order to raise prices and stifle competition - should do just fine.

“But, CMS Used Incomplete Cost Data to Come Up with Its Proposed Rate!”

The hospital lobby is whining that when CMS surveyed hospitals to find out what they actually paid for 340B drugs, they didn’t get enough data in response, and so their proposed rate is based on inaccurate, incomplete survey data.

Specifically, “CMS’s survey includes data from less than a quarter (23.1%) of 340B hospitals and less than a third (29.8%) of total hospitals.”

This is the exact same hospital lobby group that, just this January, joined seven other hospital trade groups in a letter telling CMS it was “wrong to tell hospitals and health systems that they ‘are to’ complete” this exact survey, because nothing in the statute makes a response mandatory. In other words, the AHA spent the winter encouraging its members to skip the survey.

They’re now spending the summer arguing that not enough of their members answered it. You know how you get the government to take your costs seriously? Give them your cost data when they ask nicely for it. If AHA wants all hospitals to do so, they’re welcome to reverse their messaging to members about next year’s survey.

“But You Didn’t Ask Us What We Paid for EVERY SINGLE drug!”

The hospital lobby is comically suggesting that CMS can’t set an average rate based on data it got from, you know, almost a third of AHA’s members because it didn’t calculate a separate, statistically valid acquisition cost for every individual drug.

Their proposal, I guess, is that CMS build an independently powered statistical estimate for every one of the thousands of individual National Drug Codes covered by 340B before it could ever correct the rate for any of them, using a response rate the same trade association just spent seven months arguing hospitals have no obligation to improve. No survey of a voluntary program has ever cleared that bar, and the hospitals raising the objection benefit the most from nothing ever changing.

“But We’ll Die - Die, I Say - If 340B Isn’t as Golden a Goose as It Has Been!”

Let’s not forget: a hospital’s real acquisition cost for a drug doesn’t change because of this proposal. CMS isn’t increasing costs for hospitals by one dollar. This proposal only changes the profit that the hospital makes on 340B drugs given to Medicare patients. Now, if hospitals were actually using that spread the way the law intended, and the way they’re obligated to use it, they could argue that they would serve fewer uninsured or underinsured patients.

But it would be almost impossible for hospitals to help fewer poor people tomorrow than they do today.

Mt. Sinai stopped taking Medicaid patients. Providence hired McKinsey to devise better ways to keep poor patients from finding out about their statutorily-required charity program. NYU Langone, NY Presbyterian, and many other systems have, in the last year or two, started turning away my clients - a group of Catholic nuns with no income, whose plan has no network. Rather than taking the plan, knowing that they might get paid less than overpriced network rates, they insist that these sisters pay cash upfront or they won’t schedule them for care. University of Pittsburgh Medical Center, University of West Virginia, Sutter Health are all doing the same to working class patients whose health plans don’t have a network, because they might be paid more than Medicare but not 3-6x Medicare that a network contract would provide.

The IRS requires almost nothing of these systems, continuing year after disgraceful year to exempt them from taxes.

Kaiser Health News reported in 2021 that “nonprofit” hospitals are sitting on more than a quarter trillion dollars of investment assets: stocks, hedge funds, private equity, venture funds and more. Of that amount, less than seven percent ($19 billion) of those investments are principally devoted to their nonprofit missions rather than simply raking in more revenue.

Hospitals captured more than 87 percent of the 340B program’s $53.7 billion total in 2022, rather than the clinics the program was built around. The AHA, the top lobbying group, is also the organization that sued to block federal hospital price transparency rules and lost at trial and on appeal, spent $29 million on federal lobbying in 2024 and another $7 million in the first quarter of 2025 alone.

So any hysterics about the reduction of the “safety net” ring demonstrably false.

But Let’s Say You’re Not Persuaded By These Arguments

Maybe you think that all these arguments fall short, and the CMS proposal is simply gutting the spirit and the letter of the 340B law.

Good.

As long as it’s legal (and the Supreme Court says it is), Congress deserves to have their red-headed stepchild gutted like a stuck pig. This well-intentioned program should never have been allowed to grow into what it is, a system where the sickest, most expensive patients in the country generate margin for the wealthiest hospitals in the country in the name of helping the poor.

And if CMS is using the authority Congress gave it to undermine a program Congress created because Congress itself is too lazy, craven or incompetent to reform it properly, then Congress had it coming.

Finalize It

I’ve written elsewhere that a hospital is a failure of health care, the place you end up after everything else didn’t work, and it shouldn’t be the most profitable real estate in town. A program built in 1992 to help a clinic treating AIDS patients in rural Alabama stretch a drug budget was never supposed to generate the kind of legal firepower on display in this docket.

Specifically, I’d urge CMS to:

1. Finalize the ASP-33.4 percent 340B payment rate as proposed, without delay or a second comment period.

2. Reject the “sample wasn’t large” objection from the same organizations that spent all year telling hospitals the survey was optional.

3. Reject the “no per-drug estimate” objection as an unmeetable standard offered in bad faith, not a genuine statistical concern.

4. Continue running the acquisition cost survey every year, so the sample size the industry complains about today only grows, and this objection has no future to hide behind.

Respectfully submitted,

Katy Talento, ND, ScM

CEO, AllBetter Health

Hopefully this gets some attention. Hopefully it highlights (some of) the stealing. Either way, I said my piece.

Now we’ll see if Dr. Oz can ignore the industry’s tantrum.

This conversation was recorded a few months back, but revisiting it this morning highlighted how little has changed - and what has.

In this episode I talk a lot about how nobody in Washington is coming to save employers, and that they will have to save themselves - that’s still true.

ERISA is still minded by the labor committees of Congress (no ambitious health policy staffer has ever wanted a job on the labor committees). The people who oversee coverage for 160 million Americans are still pension experts or labor wage union types.

Meanwhile, out in the real world, network contracts still say the claim goes to the carrier, the carrier’s rate is the rate, and employers and doctors/hospitals can’t cut a better deal with each other directly. This is the wall between us and a real cash pay economy.

But in just a few short months, things have moved significantly on our side of the table.

Cash pay has continued getting the attention of employers, patients and social media. It’s also becoming more “doable,” one vendor and one plan at a time. My nuns are even having luck getting seen at NYU. (Read the full story on how things are going here.)

And that is the story behind the headlines.

Nothing has been fixed for us. But some of us built around it anyway, and it’s working - slowly but surely.

Full episode below.

The bullet went through the hull of the boat and into the leg of the sleeping nineteen-year-old.

The year was 1978. A group of young aristocrats had gathered on an Italian island near Corsica for some fun in the sun. The former Miss Germany, Birgit Hamer, had just met them while her family vacationed in nearby Sardinia. She’d been invited on a day-trip by boat, and she’d brought along her 19-year-old brother Dirk to join them.

They didn’t make it home that night. They were stranded on the island due to nasty weather. Around three in the morning a drunken argument broke out among the others.

Someone had borrowed a dinghy without asking. It belonged to Vittorio Emanuele of Savoy, son of Italy’s last king. Vittorio came across the water with a carbine (allegedly, reportedly), screaming that he was going to kill them all. Two shots went off. (The deep dive into these events is the subject of a 3-part Netflix documentary called The King Who Never Was.)

Dirk was asleep in a cabin on another boat. A round seared through the hull and opened up his femoral artery.

He struggled to live for the next four months, in hospitals in Ajaccio, Marseille, and finally Heidelberg. They took his leg. They took a kidney. And after nearly twenty operations, his remaining kidney failed, and he died in the arms of his father, Ryke Geerd Hamer, MD.

Dr. Hamer, an internist who took care of cancer patients in Tübingen, was diagnosed with testicular cancer two months after his son’s death. Because he’d been so healthy throughout his life, and because of the timing, Hamer hypothesized that the cancer might have been related to his son’s death somehow. Given his daily access to the clinic’s oncology patients, he started systematically interviewing them and asking about their own stories.

He started in the gynecological clinic. All the women with certain types of cancers - breast, ovarian, cervical - told a similar story of a particular type of psychological shock or conflict that preceded their diagnosis. This alone was remarkable, but what was even more extraordinary was that the type of shock corresponded with the type of cancer.

Mammary duct cancer showed up in women who’d lost someone they experienced as being “ripped from their breast” - not just any separation, but the kind that felt like a nursing infant torn away.

Mammary gland cancer followed a different shock: not a loss, but deep anxiety about someone in the immediate family - an argument, financial trouble, a mental health crisis, usually someone in the same house.

Cervical cancer traced to sexual trauma: unwanted sex, sexual rejection, a partner’s infidelity, or even some escalation in “daddy issues.”

Ovarian cancer traced to a profound loss - a child, a close friend, even a beloved pet. That same conflict, it turned out, showed up in the men he later examined with testicular cancer, himself included.

It gets even weirder.

Around this same time, CT technology was coming onboard mainstream medicine. The inventors received the Nobel Prize in 1979, and scanning machines had made their way into prominent hospital systems a few years later when Hamer was sleuthing around about cancer.

He started looking at the brain CT scans of his cancer patients, and found that every single case had a ring, or concentric rings, in the exact section of the brain responsible for the organ that had developed cancer. Rings on a 2-D image are the signature of a sphere rippling outward. How sharp or fuzzy the rings were let him timestamp the event precisely, like a tree - sharp rings meaning recent, fuzzy meaning distant - and the age of the rings lined up, not with the cancer diagnosis, but with the exact moment of the psychological shock he was starting to suspect had caused it.

In other words, when people got a shock in their lives - a terrible argument, a death, a betrayal, the suffering of a loved one, a sexual assault - at that same moment, there was a mini earthquake in their brain, right around the section that controlled the organ that later developed cancer.

Every time.

Hamer’s colleagues were skeptical - CT artifacts from the machines could look like rings, they said, probably just noise. But an artifact wouldn’t correlate with the location in the brain linked to the exact organ affected, every single time, while a real signal would. So they tested him blind: CT scans of patients he’d never met, and asked him to name the diagnosis. He always got it right.

Every time.

Hamer had discovered a pattern so consistent and predictable that he named it the “Iron Rule of Cancer.” It became the first of what he later developed into his Five Biological Laws.

As Hamer branched out into more and more disease conditions beyond cancer, the pattern held. A shock, trauma, or as he called it, a “conflict,” of a certain type was associated with symptoms or pathology of a certain type.

Liver inflammation, cirrhosis or cancer: “starvation” conflict - a loss of a job or a spouse who was sole breadwinner, or fear of chemo-induced vomiting.

Skin conditions? “Separation” conflict.

Bone/blood conditions such as anemia, cancer, or osteoporosis? Severe “self-devaluation” conflict.

Blindness, myopia, cataracts? A conflict related to seeing something you didn’t want to see.

Deafness? Something you didn’t want to hear.

The rings appeared around whatever part of the brain controlled the organ that got sick, timed to the moment the patient first experienced the shock. The conflict didn’t have to be objectively awful, just perceived as awful by that patient - which meant a schoolyard insult could set off disease in a child as easily as a cruel word from a spouse could in an adult.

Hamer’s findings shook the foundations of everything medical students are taught about pathogenesis.

Naturally, he had to be silenced.

At first, management just told Hamer to stop spouting this nonsense - especially to patients. Then the government authorities who controlled his license gave the same order. When he couldn’t un-see what he’d seen, and refused to un-say what he was saying, they chased Dr. Hamer to the ends of the earth for the next 20 years. They stripped him of his medical license, and arrested him multiple times in Germany and France - officially for not following “protocols,” but in reality, for telling patients what he’d found. After the license was gone, and he was hounded for practicing without one, his followers excised the word “medicine” from the name of his discovered framework. Heretofore called German New Medicine (GNM), and then renamed as Germanische Heilkunde, roughly translated as Germanic Healing Knowledge (GHK) - which sounds more woo-woo than it actually is. The more straightforward GNM is still used by most enthusiasts.

Despite the smear campaign, desperate patients, who had been failed by mainstream medicine, continued arriving at Dr. Hamer’s door. This only further infuriated “The Authorities” intent on delegitimizing him. Sound familiar?

His method was largely to inquire about their symptoms, identify the “conflict” associated with those symptoms in the affected organ/tissue, obtain a CT scan to confirm, and then work with the person to identify a way to resolve the conflict.

While in exile or on the run, Hamer kept refining the patterns behind the conflict shock that turns on disease. To count, from the patient’s own perspective, a conflict has to be acute and dramatic, unexpected, and isolating - the sense that no one can save you in that moment.

It happens in an instant: discovering your cheating wife, a termination notice, a fight with a neighbor, a punch from the bully at recess.

What’s more - different people experience the exact same event differently, and turn on different disease programs, or none at all. One woman whose husband dies might feel it as a starvation conflict (”who will bring home the bacon?”) and develop liver disease. Another might feel him ripped from her breast and develop mammary duct cancer. A third might feel nothing but relief, because she hated him - or maybe she killed him herself, so it wasn’t exactly unexpected!

Based on how the person experiences that conflict, the brain rattle occurs right at that moment - creating the sharp concentric rings around the exact spot in the brain that controls the organ or tissue that is simultaneously turning on the disease process.

After the initial conflict shock, there are two phases: while the conflict is still active, and after it resolves. In the active phase, your body runs on fight-or-flight - you might have trouble sleeping, racing thoughts, cold hands and feet.

At the organ level, one of three “programs” runs - tissue loss, tissue growth, or functional loss - depending on which embryonic germ layer the affected tissue came from: endoderm, mesoderm, or ectoderm. Tissue loss is the sneakiest: you usually don’t realize it’s happening, as with anemia, until it’s already severe.

This only turns off when the conflict is truly, permanently resolved - so resolved it no longer produces any emotional charge when you think about it. For the cheated-on spouse, that might mean a new love. For the fired worker, a better job. Reconciling with the neighbor. Beating the schoolyard bully.

Once you resolve the root cause, your body goes into the healing phase: the affected area of the brain gets filled with fluid to heal the impact zone from the mini-quake, and then that fluid is eventually pushed out about halfway through the healing phase (though the rings remain forever, fuzzy now on the scan). Dr. Hamer, and the disciples who learned from him, could look at someone’s CT and read back their own trauma history.

I had my own CT read by one of these experts, and it was uncanny - every major negative experience of my life, projected backward with almost creepy precision: a rejection around age 5 that showed up in the part of the brain that controls the cervix, a bully at age 12 created a ring around the brain region tied to bones, heartbreak a decade ago circled the brain region for my left ovary, unresolved anger from five years back was marked on the part of the brain controlling the teeth. Each one matched a symptom I remembered or was still living with, because I hadn’t resolved it. Most of us are running at least ten active conflicts by the time we’re adults.

At the organ level, the healing phase reverses whatever happened during the conflict phase. Endoderm-derived growth gets broken down again, often with the help of microbes; mesoderm and ectoderm tissue that was lost gets rebuilt. Both processes are what actually cause most of your symptoms - inflammation, fever, pain, fatigue. Your body is a demolition or construction zone, and it needs rest.

For the tissues that lost function during the conflict phase, such as vision loss or pancreatic function, that function can be restored in some cases. In other cases, it can’t be restored, but the loss stops.

By the way, this framework isn’t just for humans.

It happens throughout the animal kingdom too, though animal conflicts are more tangible: a predator, a lost territory fight, exile from the pack. In the wild, the conflict is over quickly, one way or another. Humans are the only species that go back to work with the predator every day, or marry the territory-encroacher, rehashing the same rejection for years instead of ever resolving it. That’s what turns a survival mechanism into cancer, osteoporosis, or diabetes.

Alternatively, we can start the resolution process, and then talk ourselves into or get triggered by others right back into the conflict again, back and forth, which essentially puts us into what Dr. Hamer called a “hanging healing.” Perpetual inflammation. Recurrent UTIs. Autoimmunity. Arthritis. Allergies. These too can become dire or deadly.

He was also a master at helping people resolve a conflict once its root was identified - if it was a hanging healing from childhood, he might have the patient re-enact the drama with an alternate ending. The therapeutic side of GNM often overlaps with other mind-body medicine, trauma healing, homeopathy, and practices like deliverance prayer or family systems work.

The framework kept getting refined over tens of thousands of patients, plenty of whom couldn’t remember their original conflict until Hamer patiently interviewed them, sometimes over several sessions, until he found it. His students have carried it forward since, and schools teaching his method have sprung up worldwide, churning out new practitioners by the thousands each year. Though Dr. Hamer died in 2017, the elaborate mind-body map he uncovered lives on.

GNM is so complex, it takes a lifetime to truly master. Your humble correspondent has been diligently studying for years, and once you learn the pattern, you can’t un-see it - it’s almost impossible not to start asking, of any symptom, “what was going on in my life when this started, and is it still going on?”

Biological ecosystems don’t just go off the rails.

The most beautiful principle that Dr. Hamer outlined is the last of his Five Biological Laws: the tissue growth/loss cycle associated with conflicts has a critically adaptive purpose. Your body isn’t a machine that randomly breaks down from bad luck or wear and tear like a Goodyear tire. Even a UTI has a purpose: the urethra widens through cell loss during a territory fight so an animal can mark territory better, then rebuilds, with the help of inflammation and microbes, once the fight is over. Conventional medicine calls it an infection. Nature calls it survival of the most adaptive.

Our symptoms are a message that the body is adapting to something, trying to make us stronger. Because we’re overthinking humans instead of reactive animals, we can keep those conflicts running long past their biological usefulness. That’s GNM’s whole view of chronic illness.

One note: GNM intentionally excludes malnutrition, injury, and poisoning from this framework. If Tonya Harding’s boyfriend takes a police baton to your knee to keep you out of the Olympics, the resulting inflammation and pain isn’t a psychological conflict working through a healing phase - it’s just a baton to the knee.

There’s a live debate inside the GNM community, too: purists who insist “it’s not the food,” against the more MAHA-minded adherents who think garbage food and pesticides are their own form of poisoning and the diseases that follow aren’t therefore governed by GNM principles - or at least may make a conflict response worse.

You Can’t Teach a Drowning Man to Swim

Every GNM teacher I’ve studied under says some version of the same thing, usually with a sigh: “you can’t teach a drowning man how to swim.” We’re all marinated from birth in mainstream medical dogma, and the day you’re diagnosed with stage 4 anything is not the day to start unlearning it.

GNM itself doesn’t pretend otherwise. It has always made room for conventional medicine, especially when the body’s own rescue attempt becomes the thing that might kill you. A hanging healing that’s dragged on for years can turn into disease severe enough to need a scalpel or a drug, not a conversation about your mother.

The healing phase has its own dangers built in - the microbe overgrowth that helps break down a tumor can spiral into sepsis. The heart attack that shows up when a territorial-loss conflict finally resolves is a real heart attack, capable of killing you. Hamer never denied any of this.

He built it into the framework from the start.

The terrified patient who’s just been handed a diagnosis that sounds like a death sentence is often surrounded by family who love her and are just as scared. Everyone in the room is looking to the doctor as the only source of hope in the building. For most people, that’s the moment of peak compliance, understandably so.

Which is exactly why the useful place to build awareness of the GNM mind-body map is way before that moment, far from a hospital bed. It’s at home, with a toddler, years before any of this is life-or-death. It’s the skin rash that shows up on the two-year-old who can’t stand being left behind when Mommy goes to work. The hay fever that flares the same week a kid gets scared by something out in the grass. Watching your own gut answer anger with constipation and forgiveness with its opposite, and actually noticing it. The sinus infection that hits a teenager three days after he is grounded by his parents - because let’s be honest, that stinks (yup, there’s a “stink” conflict), and his body agreed.

None of that is high stakes, and none of it asks you to distrust your oncologist someday. But a household that notices these small, unremarkable things out loud, with wonder rather than alarm, is teaching a kid to listen to his own body instead of fearing it. That’s a skill you build over a lifetime of small, safe practice - not something you can start in the crisis. If it ever matters later, in a moment that’s actually serious, it’ll already be there.

Hamer’s Revenge

Functional and holistic medicine got there first, and conventional medicine is catching up fast: chronic stress and unresolved trauma are finally being taken seriously as real drivers of disease, as the insulin-inflammation-metabolic cascade and the associated low-grade (or high-grade) fight-or-flight syndrome is being recognized as underlying everything from Alzheimer’s to infertility. Meanwhile, Hamer wrote about this in the 1980s, while being stripped of his license for it.

GNM is the union of the immaterial mind and the material brain and organ - all changing in an instant, in sync together.

The best practitioners I know, MDs, DOs, chiros, NDs, are the ones who’ve absorbed this the most, whether or not they’ve ever heard of Hamer. They dig deeper in the exam room, asking what was actually happening in a patient’s life around the time the symptoms started - the divorce, the layoff, the years of caregiving for a dying parent. They treat the body as an ecosystem working its way back toward balance, and read its symptoms as information and adaptation rather than malfunction.

Meanwhile, the GNM movement is going gangbusters. The MAHA moms, the freebirthing hippies, the homesteading, homeschooling homeopaths, the wellness podcast circuit, the COVID skeptics - everywhere I go, someone’s talking about him, whether whispering or shouting from the rooftops.

The German doctor in exile - with an engineer’s mind and a father’s broken heart - is finally being vindicated.

Matthew Zachary cleverly called our episode “Nun, Done, and Uninsured.” So before we move forward, I’d like the record to show that the nuns are very much insured.

(I’ve got the headaches and the scar tissue to prove it, Matthew, LOL.)

The trip to Manhattan was worth every minute. Matthew and I had a blast talking through some of the darkest parts of our lives and of modern American medicine. Maybe that’s because we’re both trying to fuel the same patient movement. Or maybe it’s because he’s also Gen X, so we spent the first ten minutes on nun jokes, classic rock, and the 1978 sedan my father bought me because he knew exactly how I drove.

For anyone who doesn’t know him, Matthew was diagnosed with cancer thirty years ago and then built the young adult cancer survivor movement, largely because nobody else had done it.

He opens his show with: “I’m as mad as hell and I’m not going to take this anymore.” And that’s the posture of his whole show.

We talked about our personal run-ins with medicine. How the reproductive specialists watched my ovaries for about a minute and then handed me a label without ever mentioning that my routine of four hours of sleep wasn’t going to make me more fertile. Nobody asked about the Diet Coke I was using as hydration. Nobody asked about the cortisol bath I was living in at work. And I just believed them.

Matthew shared how he went on COBRA at 22, a week after his treatment ended, and found out what insurance charges a young survivor for the privilege of staying alive.

He’s spent 30 years on the receiving end of the dysfunction. I spent 30 years trying to rewrite the rules, and now building around them.

The best stretch was about cash.

Matthew is a Cost Plus member. Four of the seven medications he takes daily are generic, and he says paying cash instead of running them through insurance saves him about $200 a month for the same pills.

Then I told him about my nuns. The way I run their health plan. How I fired Blue Cross, I fired Express Scripts, and it’s better now. And how when a sister needs an appointment at NYU, NYU says they don’t take our plan.

NYU would rather turn away a nun than take the money. Though that’s starting to change.

We also got into why change is slow.

The asymmetry of sophistication between a multi-trillion-dollar industry and a Senate health staffer who doesn’t know what he doesn’t know. Why the money in politics doesn’t corrupt so much as it guarantees the industry gets to frame the issue first. And the new fiduciary rules that could take the PBM business model apart, if anyone enforces them.

Matthew closes every episode by asking his AI which three pop culture characters his guest would be. I got Dana Scully, Michael Clayton, and Olivia Benson. I’ll take it.

Listen below, and subscribe to Out of Patients while you’re there.

Friday afternoon, an email landed in my inbox with the kind of subject line that makes me pause: “PRA Sues AMA to Make Medical Billing Codes Freely Available to the Public.” It was from Cynthia Fisher.

You guys. This is a good one.

For those of you who don’t know Cynthia - you should. A business owner and entrepreneur, she has spent her money and her winsome stubbornness on something almost nobody with her resume bothers to fight for: making American health care prices public. She founded PatientRightsAdvocate.org (PRA) in 2017 and has been the single most relentless force behind hospital and health plan price transparency rules ever since.

She’s functionally the reason any of us can look up what a hospital actually charges for anything.

The price transparency files, that Cynthia and I fought so hard to require be posted, really can be hard to access, read and interpret. That’s exactly the problem that PRA tries to solve - they post every file as an excel spreadsheet, for free, on their website. So they need to be able to publish the CPT codes and the short description associated with each code on their website in order to fulfill their mission. They also grade every hospital twice a year on its compliance with the reporting requirement. In other words, PRA is a national treasure.

So, if Cynthia is suing you, you’re bad. You’re on the wrong side of history. You’re corrupt. You’re fleecing patients and employers and everyone else who pays for sick care.

If you haven’t done much investigation into the dealings of the American Medical Association, you might be surprised to see them listed as the opposition. Aren’t they supposed to be the good guys?

Most doctors don’t even think so.

In the 1950s, the AMA represented 75 percent of American doctors. Today it’s closer to 15 percent, and even that number is generous, because the AMA’s own membership totals fold in medical students and residents who aren’t even billing anybody yet.

That kind of collapse would kill most trade associations. It didn’t kill this one, because the AMA stopped depending on its members a long time ago. Instead they’ve transformed their business model into the shenanigans outlined quite nicely in Cynthia’s lawsuit.

Cliff’s Notes on the Suit

Ok, the Cliff’s Notes version (do non-GenXers even know what that means?): every time doctors bill for anything - a checkup, a stitch, an MRI - they use a five-digit code from something called Current Procedural Terminology, or CPT. It’s not optional. Medicare requires it. Medicaid requires it. Every HIPAA-covered transaction requires it. Forty-five-plus states require it too. Skip it, get it wrong, or try to work around it, and you can eat a civil penalty of up to $50,000 per violation.

So CPT is, functionally, the law.

It’s baked into federal regulation so completely that you can’t legally bill for most health care without it, period. Which is why your ACA or employer-sponsored plan also requires it in order to pay their share of your medical bills.

And the people who wrote the first draft own the copyright. The AMA claims to own CPT outright and charges you for the privilege of looking at it - $137.89 for a physical copy of the codebook. $82.50 up front plus $18.50 per user per year if your practice, hospital system, insurer, or vendor wants electronic access, and every biller and coder in your building needs a seat. Multiply that across every hospital, insurer, and vendor in the country and you can see how the business model generates sweet, sweet cash: $296.4 million in “books and digital content” revenue for the AMA in 2025, netting $267.5 million in profit. CPT royalties alone reportedly clear $300 million a year off a coding system nobody in America is legally permitted to avoid using.

With that kind of annual cash, at least the AMA is successfully lobbying for doctors to get better pay and working conditions every year. Oh wait.

The $137.89 sticker price on a codebook is bad enough. But the scandal doesn’t stop there. Even more insidious is what AMA’s control over CPT codes does to the entire, multi-trillion dollar market that’s a fifth of the U.S. GDP. They are controlling the codes that every plan uses to pay… THEM. And you can bet your butt that they are distorting those codes in their own interest and not “solely in the interest of plan beneficiaries” - to quote the legal standard that every plan fiduciary has to follow when paying service providers with a health plan’s assets. And to be clear, when I say “their own interest,” I mean the AMA’s institutional and financial interest - not the interests of most doctors.

Hospitals and insurers have spent years slow-walking every price transparency rule anyone’s tried to force on them, and now here’s the AMA fighting in court anyone who tries to make the item descriptions on that menu public too. Hiding what something costs, apparently, wasn’t sufficient. They went after your ability to even know what the thing was called.

“No One Can Own the Law.” The AMA Apparently Missed That Memo.

On August 13th, PatientRightsAdvocate.org filed suit against the AMA in federal court in the Northern District of Illinois, and their legal theory is refreshingly blunt: you can’t copyright the law, and CPT is the law in every way that matters.

PRA leans on a doctrine the Supreme Court reaffirmed just a few years ago in Georgia v. Public.Resource.Org - when a standard gets incorporated by reference into a government regulation, the private party that wrote it doesn’t get to keep charging for it. The complaint argues CPT clears that bar in three ways: the AMA exercises what amounts to delegated lawmaking authority in maintaining it, it’s incorporated wholesale into federal regulations, and the government itself co-authored parts of it.

Beyond that, PRA argues plain old fair use - nonprofit, noncommercial re-publication of a standard incorporated into law is about as clean a fair use case as exists in copyright doctrine.

PRA also argues my personal favorite, copyright misuse, as the Ninth Circuit called it in its 1997 ruling in Practice Management Info. Corp. v. AMA. The court recognized that the AMA had misused its CPT copyright over a backroom deal it cut with the government: the AMA let the government use CPT for Medicare billing, and in exchange, the government agreed never to adopt a competing coding system. The AMA was using the government’s own regulatory muscle to guarantee itself a permanent, captive customer with zero competition, forever, at a price it alone got to set.

As a feign to that ruling, the AMA supposedly “renounced” the exclusivity clause to satisfy the court order, but by that time, the rot was so entrenched in every health care transaction in the country, that the exclusivity was already baked into everything, with or without AMA’s insistence.

The cartel takes any threats to its racket seriously.

I’ve had my own run-ins with the organized medical mafia. Years ago, working for a U.S. Senator, I recommended he co-sponsor a bill letting Certified Registered Nurse Anesthetists (CRNAs) practice at the top of their license and bill independently for standard surgical anesthesiology services they were already performing, unsupervised, every day. Here’s the arrangement the bill would have chipped away at: one anesthesiologist MD sits in a back office, doesn’t touch a single patient, and collects the professional fee for six CRNAs actually doing the work in the operating room, while those CRNAs get paid a fraction of what their labor generates.

The state anesthesiologist cartel didn’t respond with a strongly worded letter or a polite meeting request. Its leader walked up to me in a hallway, put his literal finger in my chest, and informed me that his group had a very close relationship with the Senator, had invested heavily in his career, and expected him to deliver accordingly. Just one of the many House of Cards moments in my government career.

The state’s university system, not wanting the anesthesiologists to have all the fun, later went after my job over the same bill - because I’d used what their hospital‘s CRNAs had told me about how the 6:1 nurse/MD ratio worked, to help make the public case for the legislation. Nobody disputed that the exploitation was real. What got their whining lobbyists on the phone was a Senator daring to say it out loud, with the nurses’ own quotes attached.

This is why I reach for the words I reach for when I write about them: “cartel,” “gangsters,” “mafia,” a “white-coat-religious cult” that treats its own rank-and-file as revenue units whenever that’s convenient, and treats anyone who threatens the revenue model - patients, nurses, employers, legislative staffers, competitors, entire nonprofits founded by biotech executives - as an enemy combatant to be intimidated, litigated, or fired into silence.

Same playbook, hospital edition.

If the CPT fight sounds familiar, it should. PRA is currently defending itself against a completely separate lawsuit the American Hospital Association (AHA) filed back in December, in the very same Illinois courthouse, over PRA’s plan to publish the UB-04 manual - the hospital-billing equivalent of CPT. In this case, PRA provoked the lawsuit by notifying the AHA of their intention to transparently post the information in the manual. The AHA sued first, seeking a permanent injunction and statutory damages. UB-04 licenses aren’t cheap either - the 2026 edition runs from $182 for one user up to $4,523 for 33 to 50 users, scaled like a bad SaaS pricing model for a product you’re legally required to buy.

And this isn’t the AHA’s first rodeo, losing when they try to hide prices, either. Go back to the first Trump administration’s hospital price transparency rule, which forced hospitals to post negotiated rates (you’re welcome, America). The AHA sued to block it, arguing patients didn’t have a right to know prices in advance. They got laughed out of federal district court, appealed to the D.C. Circuit, and got laughed out of there too, unanimously. Two-for-two, total defeat, and they’re still out here today running the identical playbook - sue first, delay, threaten, hope the other side runs out of money - against anyone who tries to make their billing paperwork legible to the people paying for it.

It doesn’t have to work this way

CPT isn’t the only mandatory coding system in American medicine. When your plan is billed, the bill includes the CPT code showing what service was rendered, but also why it was rendered, i.e. the diagnosis code. These diagnostic codes, known as the ICD-10-CM, are maintained by the CDC, federally mandated and baked into every claim just like CPT.

Also, completely free.

You can download the entire current-year file from a government website right now, no license, no per-seat fee, no $50,000 penalty, because the agency that maintains it treats a mandatory code as infrastructure, the same way it treats highway signage or a zip code. Weird, right?

CPT is the odd one out. It alone got claimed by a private trade group early enough, and lobbied hard enough for long enough, that it’s still treated as somebody’s intellectual property fifty-plus years later, generating $300 million a year for an organization pretending to represent doctors.

One Final Argument

When the federal government finally forced hospitals and health plans to post their prices - the hospital price transparency rule from the first Trump administration, and the Transparency in Coverage rule for insurers that came later in the first term - it didn’t ask for a vague range of potential prices. The rules required every hospital and health plan in the country to post actual negotiated rates, service by service, alongside cash price and sticker price, in free, public, machine-readable files that anyone can download right now, no account and no dime required. If you add the government’s own published Medicare fee schedules on top of that, also free and public, then every category of rate in American health care is sitting out in the open.

And virtually every line of every one of those files is identified by a CPT code, because that’s the coin of the realm.

So yeah, the government already requires every hospital and health plan in America to publish, for free, an enormous dataset entirely organized around CPT codes - including their supposedly proprietary short description of what each code stands for - codes the AMA insists that nobody like PRA may reproduce or give away without paying first.

Remember, you pay for those codes every day, even if you don’t buy access from AMA. You pay for them in the taxes that fuel almost half of all spending on health care in this country - the half that is paid for by government. The feds mandated the exact activity the AMA claims to own the exclusive right to license. Every one of those files complies with federal law by doing a version of exactly what PRA is asking a judge’s permission to do: attaching public information to a CPT code and putting it online for free.

Practically speaking, the government has already normalized the exact outcome the AMA calls catastrophic: CPT-tied information, at massive scale, free to the public, happening every day, because of these transparency rules. The AMA’s business model depends on Americans believing that free access to CPT is dangerous, even though the government’s own rules already prove otherwise, at a scale dwarfing anything PRA is proposing.

PRA and Cynthia aren’t the only ones to notice this corrupt model.

CMS’ proposed rule on 2027 physician payments, published in July, specifically asked for public comment on the “harms or challenges associated with AMA’s monopoly over CPT-4 licenses.”

Senator Bill Cassidy, chairman of the Senate committee overseeing HHS (and always eager to remind everyone, as the first sentence of every tweet or speech, that he’s a physician himself), has publicly accused the organization of abusing a “government-backed monopoly” and charging “exorbitant fees.”

In other words, litigation, congressional scrutiny, and active rulemaking are all converging on the same target at once.

Why This Costs You

You can’t audit a bill written in a language you’re not fully allowed to read, share, or build tools around, and you can’t negotiate a fair price for a medical service when the code that defines it is licensed and priced by the trade group lobbying to keep the system opaque.

Every price transparency win I’ve celebrated in this space - the machine-readable files, the posted rates, the progress toward patients and employers actually being able to make decisions based on price - depends on the vocabulary of billing being genuinely usable by the public, not just technically postable in a format nobody can parse. Right now that vocabulary is rented, from a guild that’s spent decades making sure the dictionary stays just illegible enough to protect the racket.

If you’re an employer or benefits leader, you already know the practical version of this, even if you’ve never thought about the CPT copyright. As a plan fiduciary, you have a legal duty to spend your people’s health care dollars prudently, and every vendor you hire to audit claims, every reference-based pricing plan, every TPA trying to build you a smarter network, is working with a vocabulary kept deliberately hard to use at scale.

I don’t know exactly how the lawsuit shakes out (though it seems slam-dunk to me). Courts move slowly, and both the AMA and the AHA in these legal fights with PRA have already vowed to “vigorously defend” their “intellectual property” (LOL).

You don’t hate these two groups enough.

Go read the complaint. Then go pull up your last Explanation of Benefits and get mad about it all over again, because it’s the same racket, hiding behind the white coats you trust, and - for now, anyway - the same hidden dictionary standing between you and understanding your own medical bill.

If a hospital or a physician group has ever played games with you, your practice, your legislation, or your paycheck, you already know why this lawsuit matters. Plenty of people have grumbled about this for decades. Nobody with Cynthia’s money and guileless stubbornness has ever so completely threatened the AMA’s empire. If PRA wins - and I believe they will - it’s the death knell for half a century of billing-code extortion masquerading as intellectual property. It can’t happen fast enough.

I’ve followed their work since they started. Their host, Ann Forti, has been in this fight for decades, and it shows in the questions she asks.

Halfway through our conversation, Ann mentioned that her daughter is going in for knee surgery on Monday. The estimate came back at $38,000. They are cash pay, so they asked for the other number. The other number was $6,000.

That is the health care in a nutshell, and it is why a conversation about vaccine injury turns into a conversation about hospital pricing. Because once this system hurts you, you find out fast that the billing arm runs the same playbook as the clinical arm.

Ann wanted to know why nothing is moving.

Kennedy is in. Bhattacharya is in. The wins are small and the reversals are loud.

My answer is not that the good guys sold out. My answer is that there is no functioning policy process right now, and policy is being driven by bedwetting from outside entities.

Media hits, donor dinners, a chairman threatening a nomination.

In a normal White House all of that gets aired in a room with people who can push back on it. Now it goes straight to the top with nobody there to say the polling is wrong and the science is wrong and you campaigned on this. ( I wrote about this here.)

We also got into the compensation fight for the vaccine injured. My skepticism there is about Congress, not about the people doing the work.

Don’t despair. Where everything is now is not where it will be in six months.

But no one is coming from Washington to save your health.

Listen to the episode, and then go look at what React 19 is actually doing.

The story of a nurse from Alaska is circulating around the podcast circuit these days.

McKenna West, a single mom of two, signed up to be a surrogate mother last year to make some extra money. Twenty weeks into the pregnancy, a scan found the baby had hypoplastic left heart syndrome - a serious but survivable condition requiring early surgeries but also, for most kids, an otherwise normal childhood.

The couple who’d contracted with her invoked the abortion clause in their surrogacy contract. She refused, and they sued her for a quarter million dollars. She fled to Texas, where they frown on forced abortion. The baby, Gabriel, was just born this week. The courts have ordered that he be provided the life-saving care he needs, but also that his genetic parents should have custody of him. As a result, McKenna wasn’t even allowed to hold him and provide the skin-to-skin contact that triggers a variety of critical developmental cues for him after birth.

This is just the latest, but by no means the only, controversy arising out of our country’s status as the most permissive IVF haven in the world. With President Trump and most of Congress trying to convert IVF into an entitlement, employers better buckle up.

Congress is Coming for Your Health Plan

There are a couple versions of a mandate on employers to cover IVF that have been floating around Congress for a few years now.

The Democrat-only one was actually attracting Republican support a couple years ago before the pro-life community (including, aggressively, me) raised heated opposition. That bill, sponsored by Senator Cory Booker, then and now, requires every employer plan in the country to cover IVF, with no religious exemption and no limits. It also would offer IVF to anyone, whether they’ve been diagnosed with infertility or whether they just want IVF. The bill explicitly bans “discrimination:” meaning, you’d better offer IVF to same sex couples, singles, transgender people, and senior citizens, presumably including the costs associated with commercial surrogacy, gamete purchase, etc.

The bill with bipartisan cover isn’t much better. H.R. 8119, introduced in March by Rep. Zach Nunn, a Republican from Iowa, along with Rep. Debbie Wasserman Schultz has picked up a dozen cosponsors from both parties. It requires an infertility diagnosis before coverage kicks in (nice try), but the definition of “infertility” would include seniors, people who’ve never reproduced before (maybe because they’re same sex attracted or transgender or single) - anyone whose “reproductive history” or “physical findings” render them infertile.

The bill with Republicans on it is actually worse in one way: it comes with a draconian reporting regime: every employer has to prove to the Department of Labor every year for five years that its IVF benefit is generous enough to pass muster. The Labor Secretary can order corrective action against plans deemed to be insufficient, and then fine them $100 a day and name-and-shame them publicly in a report sent to Congress.

Where Do We Even Start?

Let’s set the moral case aside for a second and look at the cost. Because employers are already saving so much money on health care these days.

Oh wait…

A single IVF cycle runs $15,000 to $30,000, and most women need more than one, and are associated with higher risk and complicated pregnancies, and more expensive pregnancies and deliveries.

Family premiums have more than quadrupled since 1999, from just under $6,000 to $27,000. Ten percent of families with job-based coverage are already costing employers over $30,000 a year. Almost half of all large employers report that they’re raising what employees pay next year just to keep up with the costs already on the books. The bills amend ERISA - the law that governs the health plans that cover two-thirds of all Americans who get their insurance on the job - and more than half the country overall. The Democrat bill covers all non-ERISA plans too. So this is a much bigger impact than the usual in-fighting in DC about health policy in the 20-million ACA market.

Remember what happened to the price of insurance when the government mandated that everyone buy it?

IVF still runs largely on cash right now, which is one of the only things keeping any lid at all on the cost. Mandate a benefit like this and you know what happens to the price of that benefit in the marketplace.

A business scared of getting on the DOL naughty list is going to overspend on IVF coverage to stay safely above suspicion, and then tighten the screws somewhere else - a higher deductible here, a stingier coinsurance rate there. Who suffers the most from this cost-shifting? Employees dealing with cancer, expensive drugs, or a kid with a genetic condition. Chemo doesn’t come with its own federal reporting mandate demanding proof your employer is paying enough for it.

What Coverage Actually Buys

Most of the “should employers cover this” debate treats it as a binary question - yes we cover it or no we don’t. But covering IVF means funding an entire industry’s standard operating practices. Most people (and politicians) haven’t looked under the hood on those.

According to CDC and IVF industry data, 90 percent of the tiny humans created by IVF die before making it to live birth. IVF has recently surpassed non-IVF abortions as the leading cause of death in children. Most fertility clinics create a batch of embryos at once rather than one or two at a time, because creating them one at a time is brutally expensive and bad for the clinic’s business model. They want you coming back to try again with your frozen embryos when the process fails the first time, without having to re-do the agonizing (and dangerous) step of hormonal manipulation, ovarian hyperstimulation and egg retrieval.

Every embryo gets eugenically screened for “fitness” (however the clinic determines it at the time) and the ones not implanted get frozen indefinitely, at your (or your employer’s) expense, or discarded. Genetic screening and sex selection are routine. After the embryos are transferred into the mother’s or the surrogate’s womb, if too many of them fail to die, then you have what’s called “selective reduction” - that’s Orwell-speak for aborting the extras to improve the odds for the one, two or three left alive.

Surrogate contracts ensure that the eugenics continue - the “terminate per contract” boilerplate provision requires the surrogate to undergo an abortion if some prenatal test along the way makes the buyers of the baby uncomfortable. Like Gabriel and his treatable heart defect.

By the way, health conditions later in life are more common in babies created under these unnatural circumstances, to the surprise of no one. Mother Nature dominates all other competitors.

And then you have third parties introduced into the IVF “benefit.” Third parties are baked into a shocking share of IVF cycles, which is an ethical and legal minefield that your company’s Benefits Committee has never been briefed on.

Motherless and Fatherless By Design

Every time a health plan pays for sperm procurement, egg procurement, or a surrogate, it’s paying to manufacture a child who will grow up permanently severed from at least one biological parent, on purpose, before he’s even conceived. Adoption exists to heal that wound after tragedy strikes a family. IVF with purchased gametes (can we drop the charade about “donors?”) creates the wound as a business model.

The research on these babies when they grow up isn’t encouraging - struggles with identity, a documented longing to know the missing half of their genetic story, higher rates of depression and a sense of being a product rather than a person.

The Egg Market

Don’t look too closely at what actually happens to the young women who sell their eggs to fund somebody else’s family.

To harvest enough eggs to make a cycle worthwhile, clinics shut down a woman’s own cycle with Lupron and synthetic hormones, then hyperstimulate her ovaries to produce ten or twenty eggs in a single month instead of the one nature intended. The known risks include Ovarian Hyperstimulation Syndrome, ovarian torsion, kidney disease, and a documented link between the estrogen doses involved and breast and uterine cancer, stroke, and blood clots.

Some women have lost their own fertility permanently from a process meant to replace somebody else’s.

And of course, when all this goes down, the egg seller isn’t the clinic’s client or the “patient” being treated. (The person paying for the cycle is the customer.) The genetic mother is merely a vendor, and a disposable one. If something goes wrong with her ovaries, her kidneys, or her fertility, either right away or years later, there’s no established system connecting that harm back to the sale, no long-term registry tracking her outcomes, and no incentive for the clinic that profited off her eggs to find out whether she’s okay.

The Sperm Market

Sperm collection sounds clinical until you say it plainly: it happens in a room down the hall from the waiting area, stocked with pornography, where a man is paid to masturbate and ejaculate into a cup. That’s true whether it’s an anonymous seller or the intended father producing his gene pool. Either way, if your plan covers the procedure, it’s covering that room and what happens there. Your company becomes complicit in all the trafficking, exploitation and other crimes pervading the porn industry.

The sperm market runs on the same eugenic sales pitch as the egg market - catalogs sorting sellers by IQ, height, athletic history, eye color, complexion, and race, sold to customers shopping for the most “desirable” genetic material available. And the vetting on the supply side has failed spectacularly and repeatedly. Indianapolis fertility doctor Donald Cline inseminated dozens of his unsuspecting patients with his own sperm through the 1970s and ‘80s - at least 50 confirmed children, by some counts closer to 100. Prosecutors discovered that what he’d done wasn’t even a crime under Indiana law at the time.

Surrogacy and the Farms

Surrogacy breaks asunder what God has joined: motherhood. Nature gives one woman all three jobs: the genetic mother whose egg gets fertilized, the birth mother who carries and bonds with the baby, and the social mother who raises the child. Surrogacy turns that into a menu - rent one role, buy another, skip a third entirely.

Once you add a surrogate mother to the mix, you’re not just buying a service, you’re buying into an industry that too often goes looking for the cheapest, most desperate wombs on the planet. Anand, a small city in Gujarat, India, became a global surrogacy hub in the 2000s precisely because poor Indian women could be recruited for a fraction of what an American surrogate charges - until India banned the practice in 2021. Ukraine’s BioTexCom, the largest surrogacy clinic in the world, got in a pickle when Russia invaded in 2022 and dozens of newborns ended up living in a bomb-shelter basement, cared for by nannies, because the foreign parents who’d ordered them couldn’t get into the country to collect them.

And the babies born through this system are subject to exactly the kind of quality control you’d expect from an industry that treats them as a product. In 2014, an Australian couple hired a Thai surrogate to carry twins, and when a prenatal test found that one of the babies had Down syndrome and a heart defect, they asked her to abort him. She refused. They took the healthy twin sister home to Australia and left the boy, whom she’d named Gammy, behind with her.

Thailand banned commercial surrogacy for foreign clients that same year.

Things are no better in America: it’s still poor women, often of color, who choose to give away their own children, or rent their wombs for the gestation of others’ children, becoming the only voice, the only smell, the only heartbeat that baby has ever known, only to be ripped away at birth, forever.

Nobody Checks Who’s Buying

Adoption in America comes with home studies, background checks, courts involved and mounds of regulatory oversight. Commercial surrogacy and gamete markets come with none of that.

In the case of the Australian couple who left Gammy behind in Thailand, David Farnell, the father, was a convicted child sex offender with three young girls as his victims. He flew home with his daughter anyway, and it took reporters digging after the Gammy story broke to find out who he actually was.

That same year, Thai authorities and Interpol investigated a young Japanese man who had fathered at least sixteen children through Thai surrogates and reportedly wanted ten to fifteen more a year. He was never charged with anything, because there was no framework in place that required anyone to ask why. Laws in every country, including ours, are woefully behind the whack-a-mole of ethical nightmares created by Big Fertility.

Legal quagmires, even for the normal couples

Now, you might be thinking about the earnest couples who try to sidestep all these ethical landmines: they create only the embryos they intend to implant, implant every one, and skip the genetic screening. That version of IVF is theoretically possible, but it’s rare, since it’s the most expensive, inefficient version and clinics have every incentive to steer people away from it.

And of course, couples break up or get divorced. There are numerous high-profile examples of celebrity couples fighting in court over the fate of their frozen embryos, with one parent wanting to keep them and one wanting to throw them away.

Then there’s the question of what happens to the embryos themselves once they’re sitting in a freezer somewhere, which is where I guess Congress wants your employer’s money sitting too, sometimes for years, sometimes for decades.

The current political frenzy over IVF traces back to a single freezer accident.

In December 2020, a patient wandered into the unsecured storage unit at a fertility clinic attached to a Mobile, Alabama hospital, reached into subzero cryogenic tanks out of curiosity, burned his hand on the cold, and dropped several embryos on the floor, destroying them instantly. Three couples whose embryos were among the ones destroyed sued the clinic. When they won because Alabama applied its definition of minor child to the embryos, political hysterics ensued. Republicans, starting with President Trump, running for his second term, competed with each other to prove who was the most committed to making IVF as accessible as a car wash - calling it pro-life, pro-family, with zero due diligence.

Whose Money, Whose Conscience

Neither bill in Congress lets an employer opt out on religious or moral grounds. Almost a quarter of the country is Catholic, and the Church teaches plainly that IVF is intrinsically immoral and that Catholics can’t fund it, cooperate with it, or look away while it happens on their payroll. Plenty of other faiths object to parts of it too. Under either bill, a Catholic hospital, a Christian college, a family business like Hobby Lobby, or a small pro-life advocacy group - all of them would be required to pay for deeply objectionable, unethical aspects of the IVF playbook, along with every employee whose premium dollars would help cover a colleague’s embryo olympics, whether they believe it’s right or not.

We already ran this exact fight over the Little Sisters of the Poor, a group of nuns who take vows of poverty and who spend their lives caring for the elderly, when the Obama administration tried to force them to pay for their non-nun employee’s birth control. It went to the Supreme Court, and the government lost. I know, because I was at the White House, holding a gun to the Trump DOJ’s head to make them settle with the sisters and the 100+ other plaintiffs.

The Employer Checklist

If you’re still determined to add IVF to your plan after all this, at least your eyes are open a little wider. But you don’t get to just check a box marked “covers IVF” and call it a day. You have to actually write the policy (I write policies for a living and it’s way more complicated than you think) which means putting an answer, in writing, next to every one of these questions:

Who gets the benefit?

• Does it cover only married couples, or anyone with a policy and a pulse?

• Does it cover same-sex couples and single people, meaning you’re paying to create a child who will grow up without a mother or a father by design?

• Does it cover transgender employees who sterilized themselves as part of their transition?

• Is there an age cutoff, or will you pay for a 60-year-old employee to become a parent using a purchased egg and a surrogate? What about the 45 year old who, statistically, is extremely unlikely to be successful, no matter how many cycles her employer pays for?

• Is there an age too young - do teenagers qualify?

• Will you cover employees who want to sell their own sperm or eggs, or serve as a surrogate, including for a family member or a colleague?

Third parties

• If you’re buying eggs: are you paying for the hormone injections, the hyperstimulation, and the retrieval? What happens if she develops Ovarian Hyperstimulation Syndrome, or loses her own fertility as a result, immediately or years later? Who decides that the harm is connected to the egg retrieval, and who pays for it then? Does the plan still pay if none of her eggs turn out to be usable?

• If you’re buying sperm: are you paying for the room and the materials facilitating the sample collection?

• If you’re covering a surrogate: what happens if she miscarries? Do you pay for a second surrogate? A third? Is there a cap on how many surrogacy arrangements you’ll fund per employee per year? Will you cover a surrogate based overseas, and if so, how will you verify her medical bills, her age, or whether she was recruited, coerced, or trafficked into a surrogacy farm? If you won’t cover the surrogate’s own costs, will you still cover everything else if your employee chooses a foreign surrogate from a farm anyway?

Embryos

• Will you pay for genetic screening of embryos? Just viability, or also disease risk, the parents’ preferred sex, and other traits?

• If none of the embryos created are graded as “fit,” do you still pay for a transfer if the couple wants to try anyway?

• How many embryos will you pay to create in a single cycle?

• How many will you pay to transfer into the womb at once - all of them? Two? Three?

• If too many implant, will you pay for the abortion, I mean, “selective reduction” that follows? How many implanted embryos count as an acceptable number to let survive?

• Will you pay to freeze the embryos that aren’t used? For how long? What happens to that bill after five years? Ten?

Procedure coverage

• How many cycles will you cover per employee, and is there a dollar cap per cycle or per lifetime?

• Does the benefit cover egg freezing for an employee who just wants to delay having kids, with no infertility diagnosis at all?

Conscientious objectors

• What’s your plan for employees with a sincerely held religious objection to funding a plan that covers IVF?

• Will you offer a separate plan option that excludes IVF, or are you prepared to defend this one in court?

Not trying to be judgey. I’ve been there.

I got the “infertile” diagnosis myself more than a decade ago, off one ultrasound cycle, from a doctor I never thought to question. I didn’t do a single savvy thing with that information. I didn’t investigate root causes, didn’t fix my hormones, didn’t find some enlightened doctor who bothered to ask why my body wasn’t working. I believed her, grieved it, and my husband and I adopted.

Years later, studying to become a naturopath, I learned that infertility was a symptom, not the disease, very often reversible rather than a life sentence. That ought to give employers a better option when it comes to helping their workers have the babies they so desperately want. The real gap in coverage is for functional, root cause healing. Infertility is the tip of the iceberg of metabolic and other bodily meltdown that will translate to misery and high employer costs later. But health coaching, functional lab tests, couples counseling, homeopathy, and holistic sleep specialists - the type of services that can help reverse the metabolic disorder, inflammation, and hormonal chaos behind much infertility - are rarely covered by your employee health plan.

Beyond the whole-system approach, more targeted, restorative reproductive medicine is a burgeoning field that has finally started to go mainstream. When coded properly, it’s usually covered by health plans, but it’s important for employers to check on that, as it’s been a gap in the past.

None of this requires an ERISA mandate, a federal reporting scheme, or a conscience fight.

Back to the Question

So, should your health plan cover IVF? Should any employer health plan cover IVF?

Well, sure. If your company is down for doing a deal with the devil: a business with a 93 percent loss rate, routine eugenics, intentional separation of children from their biological parents, and contracts that treat a baby’s heart defect as grounds for forced abortions. Her body, her choice, amiright?

Baby Gabriel is still in some NICU, separated from the only mother he’s ever known, waiting on the parents who tried to force her to kill him to oversee the medical care for him that a court had to order over their objections. Unless we want this story at industrial scale, employers should opt way out of this one and fight any legislation being recklessly pushed by uninformed politicians - who clearly need better staff - with everything they have.

The national atheist group was testifying against me that day. Well, against my cause. Which, I guess, bodes well for me in the heavenly brownie points ledger.

I was at the witness table at a state legislative hearing in one of those hyper-blue states it’s easy to complain about. The chairman of the committee had introduced a bill, written by the atheists, that, if passed, would impose an ungodly (and unconstitutional) amount of requirements on health care sharing ministries operating in the state.

The atheists were testifying virtually - on the jumbo screen to my left. I was there in person, because I have learned that when a fight is on, something very important can give you an advantage as your electromagnetic field overlaps with someone else’s. Human connection matters. (Maybe someone could let Fauci’s diary in on that).

The national atheist group was going around to a variety of blue states and finding legislators with hostile records on religious liberty, and getting them to rubber stamp their “model” bill persecuting Christians who come together to share medical bills.

One problem with the bill in this particular state: it had laughably over-the-top provisions, like requiring health care sharing members to be finger-printed by the state. One other problem for the atheists: the bill sponsor didn’t even realize what was in his bill. He got flummoxed when I pointed out the fingerprinting. Denied it. Had to correct himself when we pointed out the chapter and verse. Whoops!

How to properly staff a committee chairman is a class I’ve actually taught to graduate students, but I’ll leave that for another day. The point is, the atheists lost that battle, the bill stalled out (for now), and we lived to fight another day.

I bring this up not to toot my own horn - there were plenty of less awesome hearings during the six years I ran this trade group - but because it’s a pretty good encapsulation of where health care sharing ministries sit in this country right now: growing fast, confusing regulators and legislators, occasionally infuriating them, occasionally deserving to infuriate them, and almost never explained well to the people actually trying to decide whether to join one.

Ask me how I know

I’ve been inside this fight from more angles than almost anyone alive.

I worked on health care sharing policy from inside the government - both in the Senate and the White House - back when most of official Washington couldn’t have told you the difference between a health care sharing ministry and a health savings account. Then I left government and ran the trade association for the handful of ACA-recognized, nonprofit religious ministries for six years. That meant testifying, lobbying, and even getting deposed, in front of the continuum of regulators - from hostile to confused to friendly - in dozens of state capitals and DC.

I have patiently explained the concept of “this is not insurance, and here is why that’s legal” more times than I’ve explained anything else in my career (including why ending secret health care prices doesn’t drive up health care prices, which I thought had maxed out my tolerance for repetition).

Herding cats doesn’t begin to cover it.

Some of these ministries have deeply held, decades-old convictions about how they operate and would rather close their doors than change a comma. Others want to move fast and disrupt the health care status quo. My job was to get all of them rowing in the same direction toward the same regulators without anyone getting walked down the plank. Mostly, I succeeded. Sometimes I did not, and I have the scars - and the rolodex full of lawyers - to prove it.

Full disclosure, I currently sit on the board of one of the largest brands in the health care sharing world. So you should know, going in, that I have skin in this game, and that I like the model enough to put my own name on it. That also means that this isn’t a takedown piece. But it is the truth, the way I’d explain it to a friend who just texted me “hey is one of these things legit or is it a scam?” - which, incidentally, is a text I get about once a month.

So, What Actually Is a Health Care Sharing Ministry?

Strip away the logos and the theology, and here’s the mechanism: a health care sharing ministry is a nonprofit religious charity where members - bound by a shared set of faith convictions - agree to help pay each other’s medical bills.

Not “insure.” Help pay.

Each month, you send a fixed monthly amount to another member with a medical bill. For big bills, multiple members contribute. The ministry makes the match and facilitates the transfer. This isn’t a premium. There’s no insurance contract, because there’s no insurance company. When you get sick or hurt, you (or your health care provider) submit the bill, the ministry checks it against a public set of sharing guidelines that the membership itself agreed to in advance, and then the ministry facilitates moving money from enough other members to assist with that need.

Nobody is legally guaranteeing they’ll pay you a dime. This is the whole design: you are voluntarily, prayerfully, financially showing up for people you’ve never met, and trusting that they’ll show up for you.

Some of these communities are tiny - a few hundred people in a closed Anabaptist or Mennonite fellowship who’ve been doing this for a century. Others are bigger - nationwide, open to any believer who adopts the statement of faith, with memberships in the hundreds of thousands. In between, you’ve got dozens of others of every size and flavor. Roughly a hundred organizations nationwide - mostly the tiny variety - currently meet the federal government’s technical definition of a health care sharing ministry. Only a handful of the big national ones account for the overwhelming majority of actual members.

Congress weighed in

The Affordable Care Act (ACA) recognizes health care sharing ministries who meet a (limited) set of good-actor criteria and members of such ministries get a get-out-tax-jail-free card. To get that credential, an organization has to have been sharing bills a long time (since 1999), have a religious or ethical basis for membership, independent audits, and so forth. All of this was Congress’ way of saying “no, you can’t just spin one of these up next week and declare yourself exempt from insurance law.”

Once certified, members of that ministry are exempt from the ACA’s individual mandate (a largely academic point now that Congress zeroed out the mandate penalty for everyone in 2019). It also means that the ministries aren’t insurance and don’t have to comply with the rest of the law telling insurers what to do - what they have to cover, what it has to cost, making healthy people pay the same as sick people at the starting line, and so forth.

That last part is the whole ballgame, legally speaking.

It’s also exactly why some state regulators - hi, Colorado - keep circling back with new reporting requirements, because “not insurance” makes them nervous, even when it’s Congress, not a loophole, that put it there.

Can This Actually Get Me Out of My ACA Premium?

So while nobody needs an exemption from the ACA anymore, what you’re still trying to escape these days is the price on that monthly premium bill, which, if you’re anywhere near the upper end of the subsidy cliff, just got a lot uglier now that the pandemic-era enhanced subsidies expired at the end of 2025. A lot of middle-class families who got used to a manageable premium are staring at a bill two or three times higher this year, for a plan they barely use because of good health, high deductibles or narrow networks.

Health care sharing ministry memberships generally cost between 50-70 percent of what insurance costs. If this model might be a good fit for you (more on that later), it is WELL worth serious consideration.

Some come for the cost and stay for the faith. Others come for the faith - if you’re a regular reader, you know that I think insurance carriers are largely doing the devil’s work, and it shows. Having a solution for expensive medical bills without feeding the bureaucratic, profiteering United, Cigna or Blue Cross Borg feels like a gift of the Holy Spirit.

Here’s the honest version of what a ministry can and can’t do for you.

It can, for many families and individuals with genuine religious conviction, meaningfully lower your monthly outlay to manage your medical bills - especially compared to an unsubsidized ACA plan - sometimes dramatically. It can connect you to a community that will actually pray for you and check in on you when you’re sick, which no insurance company is known for.

One of the ministries sends care packages to families who experienced a miscarriage. Another one shows up in person when a member passes away, to personally hand a donation check to the family to help with funeral costs. Most ministries have extra charity funds outside their regular sharing programs to help members with hardships of various kinds. That community feels quite different from insurance.

Still, these are charities, and as such, they don’t promise you anything. Not legally, not contractually. There is no regulator you can appeal to if the ministry decides your bill isn’t shareable under its guidelines. There’s typically a waiting period, or an outright exclusion, for pre-existing conditions - every reputable ministry discloses this up front, but it will absolutely matter to you if you have one. You are agreeing, in writing, to certain lifestyle commitments consistent with the ministry’s faith statement, and yes, they can and do check if you happen to accidentally slice your finger off when sacrificing a goat (looking at you, my atheist-lobbyist friends!). And when your bill comes in super high for that cancer treatment, you are relying entirely on the ministry’s governance, transparency, the cash position of its members, and its integrity - not on state guaranty funds or federal law.

This may sound risky to those outside the fold.

And depending on just how far outside the fold you go, it very well could be risky. Christians in community are used to relying on each other, though - that’s not a foreign concept for us. When a family in my Catholic circle has a baby, they can take it to the bank that there will be five casseroles that show up on their doorstep within a week. Churches enter into million-dollar construction projects on the reliability of the faithful’s pledges in a capital campaign.

Christians also know that you don’t send your tithe by carrier pigeon to a PO box owned by some storefront “church” that hung a shingle in the strip mall down the street last Saturday. We do our due diligence. We ask around, we check the pastor’s credentials, we check charitable records, we google for scandals, we donate through a secure portal that we’ve used before, dedicated solely to churches.

Which brings us to the actual point of this article.

The Four Kinds of Sharing (Not All Involve Jesus)

After twenty-some years of watching this space from all angles, I’ve come to sort health care sharing organizations into one of four buckets.

Jesus in Action

This category is the real deal, doing exactly what they say on the label. A church, an association of churches, or a nonprofit with the IRS paperwork to prove it. Religiously grounded, and not as a marketing veneer. Actual Christians that you know in real life who have experience as members. Transparent sharing guidelines, published where anyone can read them before they join. HHS-certified, meaning they’ve been continuously operating since the last century - not a shell that filed paperwork last spring. Audited financials that are available to anyone who asks, because they’ve got nothing to hide.

Increasingly, the best of these have also gone through independent, voluntary accreditation - a process launched a few years back (with my help, full disclosure) specifically because the good actors in this space got tired of being lumped in with the bad ones, and wanted a way to prove their integrity. That accreditation digs into governance, conflicts of interest, related-party transactions, how fast they actually share bills, what percentage of your dollar goes to overhead versus actual member need. It’s not required by law. The ministries that volunteer for that level of scrutiny are telling you something important about who they are.

This is obviously the category of ministries where I’d point my own family.

Jesus-Adjacent

This bucket includes two sub-buckets, both of which are organizations that appear - to me, anyway - to be good organizations trying to do things right. First are the HHS-certified, honest-to-goodness nonprofit ministries. Real faith community, real sharing, nobody’s running off with your money. Probably.

The reason for the “probably” is that they haven’t sought outside accreditation. It might be fine - nothing illegal, nothing fraudulent — just less independent tire-kickers checking the boxes. Maybe they’re a newer organization and therefore don’t have the HHS certification (HHS stopped certifying a while ago). Maybe they’re small and accreditation is expensive (it is, but not that expensive for an organization that exists to help with medical bills - the most expensive bills on the planet).

The other sub-bucket of Jesus-adjacent organizations is for those organized around ethical principles rather than religious beliefs. In other words, they take all comers. They’re non-profit orgs that are in this game for a noble purpose - to disrupt health insurance with a radical, non-insurance model - but not a Biblical purpose (to operationalize Acts 2:45, for instance). There are three organizations in this bucket that I’m aware of that are reputable and do a good job, and that are run by good humans who care. But still, they’re relatively new, and as far as I know, don’t have any independent third parties scrutinizing their operations. Also, without the religious exercise defense, they tend to have a thinner legal/constitutional shield when hostile regulators come at them. As such, they don’t operate in all fifty states and some members in unfriendly states could find themselves out of luck if their healthshare gets on the wrong insurance commissioner’s radar. But to be clear, I absolutely am pulling for them and wish them success!

Jesus, Inc.

Health care sharing organizations are generally not-for-profit. But a few try to turn this model into a money-making machine, either directly or indirectly, and they make everyone else look bad. Either they’re legally not-for-profit organizations but they spin off for-profit entities as vendors serving the ministry, which happen to be owned by friends and family, or they’re just for-profit entities from the get-go. I far prefer the latter - if you’re going to be a for-profit, Christian company, go ahead. (After all, my own businesses are for-profit, Christian companies.)

When the organization itself is technically not-for-profit, but the profit motive is pursued through for-profit vendors enriching the founders or their families, it can be the hardest kind of risk for an outsider to spot. The 501(c)(3) letter looks the same. The HHS certification looks the same. The prayer newsletter looks the same. The self-dealing is buried in a related-party footnote most members will never read, if it’s disclosed at all.

The other sub-bucket - sharing organizations that are openly for-profit companies - has many of the same risks that any for-profit endeavor in health care can - misaligned incentives. Equating saving money with denying or delaying care, choosing vendors that pay them better rather than serve their members better, cutting corners with staff ratios or AI bots, and on and on.

I feel strongly that, for a cooperative sharing model to work best, it needs to be a nonprofit community of people who share the same goals: helping each other get the best care at the lowest cost, not enriching owners or founders. The IRS has a robust set of rules around governance and conflicts of interest for tax-exempt organizations, and that framework, when followed scrupulously, helps protect the model.

Jesus Front Groups

And then there’s outright fraud.

These aren’t sharing organizations at all. They’re for-profit insurance-adjacent schemes that borrow “sharing ministry” language purely to dodge state insurance regulation, with zero intention of running an actual faith community or honoring sharing guidelines. Health care sharing ministries get unfairly criticized for being “unregulated.” That’s not true - they’re regulated by every state’s Attorney General, who is responsible for making sure charitable organizations don’t lie, cheat or steal from the citizenry. Fraud is illegal everywhere and when it happens, the AG can and should get involved.

The worst case of this involved a front group that reportedly siphoned 84 cents of every member dollar toward a for-profit venture owned by its founding family, while routinely denying the medical bills it was supposedly there to help pay. Eventually, a dozen or so state AGs caught up with the scheme. The subsequent bankruptcy left tens of thousands of members on the hook with medical debt. This is what regulators picture every single time a real ministry walks into a hearing room. It’s exhausting. It’s also, I’ll admit through gritted teeth, quite reasonable of them to want to prevent.

So How Do You Tell the Difference?

You don’t need a law degree. You need to ask specific questions and actually demand the paperwork, the same way I taught state regulators to ask them.

☐ Can you produce an HHS certification letter? This is an older credential, but at the very least it confirms the organization has actually been around for a quarter-century, and meets the most basic criteria laid out in the ACA (not-for-profit, independent audits, etc).

☐ Have you received, or are you actively pursuing, independent accreditation? Ask which accreditation body, look at their website and the standards they use. An organization that’s opened its books to outside scrutiny is telling on itself in the best way.

☐ Do you have an IRS (c)(3) determination letter and, if applicable, are you filing Form 990s? Every legitimate ministry above a certain size has one and you can find the info at the IRS charitable organization search tool. One of the biggest ministries, though, is actually an association of churches not required to file 990s, so you won’t find the form for them.

☐ Are your sharing guidelines public, in plain English, before I pay you a dime? Not a sales call. Not a PDF that materializes after you’ve enrolled. The entire program is posted publicly in writing, for everyone to see.

☐ What happens with my pre-existing condition, specifically? Get any waiting period, exclusion or dollar limit in writing. If you aren’t sure about whether bills arising from your pre-existing condition are shareable, be sure to ask specifically about that. The ministry may need to look at your health records to sort out exactly what will be excluded and what will be shareable, so give them time to do this. You want the answer to be correct and for your future to be predictable before you make any decision.

☐ What percentage of my monthly share actually goes to paying member medical needs, versus overhead? A real ministry will know this number cold and tell you without blinking. Bigger ministries will have numbers like 70-80 percent or higher. Smaller ministries can still be doing a great job at 55 percent or higher - their lower number of sharing requests compared to their payroll expenses can skew the ratio - as long as the other good-actor boxes are checked for them.

☐ Are you a member of the Alliance of Health Care Sharing Ministries? This is the trade group I mentioned earlier. Their members are the handful of large, nationwide ministries that are the most reputable, religiously based, and HHS-certified. They are the standard-setters and are generally the group advocating for the freedom of all health care sharing organizations to operate, interfacing with governments at the state and federal level. The Alliance is pretty insistent that their members behave, so membership is a good sign.

What are the Blaring Red Flags?

• Anyone on the phone describing it as “just like insurance, but cheaper.”

• Anyone who says it’s “ACA-compliant” without producing an HHS certification letter.

• No published sharing guidelines you can find on your own before you call.

• A broker coming on strong like a used car salesman and deflecting when you ask about insurance options so you can weigh whether insurance or a healthshare is best for you.

• “Ministry” language with no religious affirmation or lifestyle commitment required at all - that’s a tell that the “ministry” part is decorative.

• And this one’s free - if it feels like buying a timeshare more than joining a church, run.

Assuming the HealthShare is Reputable, Why Wouldn’t Everyone Join?

Health care sharing is an amazing and affordable solution - IF:

• You’re generally healthy without significant pre-existing conditions requiring treatment or medications that you can’t afford to pay cash for. (Looking at you, MAHA Moms!) Most sharing organizations don’t share in bills arising from conditions you have when you join. That includes pregnancy, FYI. They are designed to help you with illness or injury that arises after you join. Some ministries have health coaching programs that they encourage or require you to participate in if you enter the community with certain conditions that can be reversed with lifestyle interventions.

• You take ongoing medications, but they’re generic. Most sharing programs don’t share in long-term medications, so if you’re on BP or cholesterol meds, an asthma inhaler, an SSRI or hormone replacement therapy, be sure that you know the cash price and can afford it. If you or someone in your family needs a $9,000/mo drug like Skyrizi for psoriasis, this model is not for you.

• You have conscience objections to what most insurance plans cover - especially in states that require insurance plans to cover (and enrollees’ premium dollars to subsidize) killing unborn babies and trans-ing kids. Religious health care sharing ministries are not going to spend your money on immoral stuff. (I mean, except for price-gouging hospitals pretending to be charities. There’s no escape from that degeneracy.)

• You are a committed Christian or, if the sharing organization isn’t religious, you are truly committed to the non-insurance model. Most ministries require more paperwork or bill negotiation, or dialogue with providers around cash pay. That kind of extra effort means that you have to really believe in what you’re doing. But if you do, you’ve found your people - the ministry community allows opportunities for prayer, socializing and additional service between members.

I Want to Offer This for My Employees!

Everything above was written for an individual or a family shopping for themselves.

Alternatively, if you’re an employer looking to facilitate or subsidize access to ministry memberships for your team, health care sharing can be a great fit. But there are lots of caveats and compliance requirements, as every HR leader is all too familiar with. The most important advice I can give you is to work with an independent benefits advisor who does not have a financial relationship or other conflict of interest with the sharing organization, beyond any transparently-disclosed commissions. I’ve seen churches get caught up in schemes where their spending on an insurance offering and their health care sharing offering were co-mingled inappropriately into one confusing, noncompliant benefit created by a legally unsophisticated sharing organization trying to do too much. This can attract unwanted attention from a state insurance commissioner, or a lawsuit by a disgruntled employee.

Being Different is Worth It

I’ve been deposed by state attorneys general as a plaintiff defending the constitutional rights of health care sharing ministries. I’ve been grilled by insurance commissioners, Hill staffers for the atheist caucus (yeah, there’s a caucus for that), and hostile producers from the John Oliver Show. The reason why the enemies of the faith keep coming for health care sharing ministries is because they are truly subversive to the insurance Leviathan.

Some people truly need an insurance policy. But not everyone.

There are at least a million Americans who are members of a health care sharing ministry today. I’ve heard hundreds of their testimonies, from a variety of different ministries, describing how their faith community came through for them when they were scared, vulnerable, and suffering.

Many of us are working hard to treat our bodies right, stave off chronic illness, and remain squarely outside the conventional medical system almost all the time - but we’d like the peace of mind that, when we have emergencies, there’s a community holding a safety net underneath us. For us - health care sharing is a fantastic fit.

So yeah, I believe in this model.

Not blindly - there have been Bucket Four baddies scamming innocent people. But I’ve also watched truck drivers, small business owners, and young families who can’t afford a $2,200/month ACA premium find something beautiful in health care sharing that no insurance company has ever once offered them: a community that actually shows up, prays and pays.

Do your homework. Ask the hard questions. And if and when you find your match, stick it to Big Insurance in the best way possible - by opting out.

Kevin and Donna are both pharmacists.

Donna’s focus is deprescribing: getting people off medications that are hurting them more than helping. Kevin digs deeper on the digital health and systems side of things. They both see the consequences of good and bad health policy first hand, day in and day out. Perfect setting for a chat.

We started with some background. How I began my career as an infectious disease epidemiologist with dreams of going to Africa, wearing a space suit, and quarantining towns. How, when I got to South Sudan, I figured out I didn’t have the diplomacy skills for negotiating with warlords. And how when I came home, Capitol Hill sucked me in. All of it led me, somehow, to the White House. When I finally got out of DC, I couldn’t bear going out to shill for industry, so I decided to use my health care chops to build health plans so I could sleep at night.

Then we got into the good stuff I’ve learned through it all:

→ Why your fee-for-service doctor needs their patient panel to be sick
→ What you find underneath a health plan once you unbundle it and the conflicts of interest are finally visible
→ Why our health plans run on one nurse who knows your name instead of a call center
→ And why they incorporate direct primary care which is expensive, but not as expensive as unmanaged chronic illness.

And the most important thing, even if you don’t care about health policy at all:

Washington isn’t coming to save you. Neither is your insurance plan. And especially not the white coats at the hospital.

Nobody cares about your health more than you. Nobody is more of an expert in your body than you are. YOU are your primary care provider.

We break it all down in this episode.

Watch Here

I say “my” because, I was, in fact, one of them. Two years in the convent, a decade before I ever dreamed I’d end up as their benefits advisor.

As regular readers may recall, in the middle of my Senate career, I got sick of government and wanted to escape.

I’d recently become Catholic, fell in love with the Church and figured that meant I should probably become a nun. As one does.

In reality, I was just burned out by a stressful career and thought joining a convent would be like going on retreat for the rest of my life. Which still sounds awesome.

It turns out that a need for a vacation, being impressed with Catholic theology, and fatigue with the whole hair/makeup/heels ritual did not actually mean God intended for me to marry Him. I mean, who could blame Him?

So I washed out. The breakup was entirely amicable.

They literally sang me down the aisle, Sound-of-Music style.

What I never managed to escape was their health plan.

Back then, when I was still in the convent, it was a garbage fully-insured Blue Cross plan with a $4,000 deductible. Not one of the sisters (myself included) had a penny of income, of course.

They never will. (That’s kinda the point of the vow of poverty thing).

Shortly after I left, like Job, my life was restored to me - my parents gave me back my dogs, my sister gave back my cats, we kicked the renters out of my Capitol Hill house, and I returned to my career in health policy in the Senate like nothing had happened. That’s when the sisters started asking me for help with their health plan.

Couldn’t I do something about the constant rate hikes?

I called up the BCBS lobbyist I knew and tried shaming. It didn’t work, unsurprisingly I guess.

I went back to my life, periodically trying to help the sisters with ideas over the next few years. Then, in the White House, I met a group called Health Rosetta - a tribe of insurgent benefits advisors - and learned that you could do radical things with health plans.

What I didn’t know then was that it would lead me exactly where I am today.

[Now, all you Health Rosetta readers out there, you know what’s coming next - the formula for saving a health plan - so this won’t be any big news to you!]

We Fired Everybody

A year or so after that initial meeting, I left the White House and called up the sisters and said “I think I now know how to help you guys.”

And so began the inevitable argument with their insurance broker at the time, a nice man who sold status quo garbage for a living, who refused to obtain their data so we could do any analysis on their fully-insured plan. (“Fully-insured” = garbage, overpriced, carrier-owned plan. “Self-funded” = employer-owned plan that may also be garbage if run by a carrier, but can also be awesome, depending on how you run it).

No matter.

We fired Blue Cross. We fired Express Scripts - their rapey/pillagy pharmacy benefits manager, the largest in the country.

We went all in on the most radical plan design - no network.

The plan’s “allowable amount” - that’s the starting point for negotiations for what the plan pays docs and hospitals - was set to 125 percent of Medicare rates. Readers might recall from previous posts that Medicare rates are used as a proxy for wholesale cost of care, and that a 50-80 percent markup above that rate is generally considered a “good” rate on a commercial plan. If you can get health care providers to accept that rate most of the time, then you can still save a ton even with the few times that a provider tells you to pound sand and you have to pay more. So, 125 percent is aggressive.

But my thinking was: start at a really good price and threaten anyone who doesn’t accept that rate with a long time in purgatory for having screwed over nuns.

Gob-Smacking

We just started the eighth year since ditching the Blues. The results are truly gob-smacking.

In case you don’t believe your eyes, yes, after slashing spend by 32 percent in year 1, we have beaten the 2018-2019 fully-insured Blue Cross rates every year in terms of absolute, non-inflation-adjusted dollars - and that’s with increasing enrollment from 108 sisters when we started to about 120 now.

In other words - almost a decade later, with a dramatic increase in overall inflation as well as health care inflation - the sisters are still paying WAY less today than they were with Blue. The dollar figure associated with these savings, in absolute, non-adjusted dollars, is $1,272,504 less than what they paid for their garbage plan in the 2018-2019 plan year - if Blue had never raised their rates since 2018.

But of course, Blue did raise their rates each year, and how.

So, to estimate a savings amount based on some assumptions of what Blue might have raised the rates to be, let’s assume a ridiculously unrealistic health care inflation rate of, say, five percent each year. That’s ridiculous because the actual annual trend has been closer to 10 percent each year.

Assuming only that five percent, the sisters have saved $2,347,379 since leaving Big Blue.

But we can do better than just make conservative trend assumptions. We can actually ask Blue to tell us what they’d charge the sisters by requesting a quoted premium price if the sisters were to come back to the Blue plantation - which we did a few months ago. The quote came back at almost three times what the sisters are currently spending.

But wait, it gets better! Remember that $4,000 deductible on the old Blue plan that the sisters would have to raise and pay for a sister, before their coverage even kicks in at all?

Their new, un-Blue plan was designed to have no member costs. Zero. Meaning, no deductibles. No copays. No coinsurance. Since the sisters have no personal income and the religious order was going to have to raise money for “member” costs as well as “plan” costs regardless, we just eliminated all the member costs.

It Wasn’t Easy

This hasn’t been a cake-walk.

Regular readers will know that this group was both my first - and my last - reference-based pricing plan (RBP), full stop. RBP or no-network plans can save a ton of money. But when a provider doesn’t accept the plan’s 125 percent of Medicare rate, the patient gets a balance bill. That problem has real consequences - nuns being sent to collections (apparently, eternal damnation is not a deterrent to every health care provider. But we already knew that, didn’t we?). However, it is also easy to solve when you have a competent vendor that negotiates with the aggrieved doctors and hospitals. Which we have now.

That’s the easier problem.

The harder problem to solve is the access friction with a no-network plan, which can be agonizing. Front desk people at the doctor or hospital insist that they don’t take the plan (because there’s no network logo on the ID card) and refuse to give the sisters an appointment. It has taken years of adjustments to the navigation and negotiation workflow to get things just right so as to minimize delays in care.

We’ve had our horror stories.

I will say that only this year - for the first time in seven years - have we landed on a navigation partner who can actually pay cash upfront and effectively overcome this problem once and for all. I am so grateful for this partnership.

Nothing but cash-pay has ever worked for us on the access friction question.

Some advisors hack this problem by doing direct contracts with a bunch of providers in their local community, essentially creating a custom network. But the sisters are spread all over the country in little groups of 3-8 - not enough volume to lure a hospital into doing contracts with us.

Cash is king! Cash is the future! All hail cash!

But Don’t They All Qualify for Medicaid or Charity Care?

As I mentioned, none of the sisters has any personal income, which means they would all qualify for Medicaid - the government safety net insurance program for poor people. But the sisters prefer not to use government programs most of the time. Although we do occasionally request charity care from nonprofit hospitals.

Scheduling staff see that the sister has a plan ID card and think, not knowing anything about self-funded plans, that the sisters have some deep-pocketed carrier insuring them. It takes significant effort to explain that, no, the sisters fund their own plan (hence, “self-funded”) through charitable fundraising, and so they still qualify for most hospital charity programs.

The ACA requires all tax-exempt, “not-for-profit” hospitals (LOL) to have a financial assistance program to offer poor patients. It requires nothing about how big or generous that program has to be, who is eligible, or any other rules. We generally steer the sisters far away from hospitals for all the reasons I’ve written about before. But when emergency or inpatient hospital care is unavoidable, we offer cash first, a single-person contract for that sister second, and if we can’t get fair rates either way, then we will often apply for the hospital’s charity care. Hospitals are free to turn down the sisters, but they usually don’t, at least in cases when the care has already happened. This is because you usually can’t even apply for the financial assistance program until you’ve already received service and now have a bill in hand.

Sometimes you can apply earlier in the process - but only once you’re already a patient, meaning, at least after you’ve been scheduled for care. But as I mentioned earlier - the sisters often can’t get in the door to get scheduled without paying cash upfront or negotiating a single-member contract. Once you’ve done one of those things, the hospital isn’t going to give you charity - they got their money.

Even if they do accept you into the charity, usually the program only covers the member’s cost, not the plan cost. But recall that the sisters don’t have member costs. So then the hospital will say, “but you have no costs, and your plan is covering everything, so why do you need charity?” It’s very hard to make them understand that the plan itself is just the religious order, that has no income just like the sister has no income, and the plan has to raise charitable donations to cover the sister’s bill. It just doesn’t fit the use case these hospitals expect.

Hospital Charity Programs Can Work for Your Employer Plan Too

We apply for the programs on behalf of the sisters ourselves, and they are easy applications because there is literally no income, no tax returns, nothing. Your workforce might be more complicated. But that doesn’t mean you don’t have lower-income workers and dependents on your plan who would qualify. There are vendor partners out there who can help you design your plan to actually optimize the use of hospital financial assistance programs for your lower-income plan enrollees. And if you design the benefits with this in mind, you could save your enrollees a boatload. You can save the plan a ton as well.

If the Plan Doesn’t Have Money Except Donations, What Happens When the Bill Is Insanely High?

Good question - the sisters don’t have deep pockets.

When they get hit with a surprise multi-thousand dollar bill for one dose of a medicine, they have to take deep breaths, just like you or I would. Fortunately, we’ve planned for this situation.

Once claims on any one sister exceed the plan’s level of risk tolerance - their stop-loss reinsurance coverage kicks in. They pay a small - under $100 a month premium per sister - for this risk mitigation in the case of per-member claims that exceed $40,000 in a given year.

Even with this layer of fixed cost baked in, their annual spend has been dramatically improved compared to when they were “fully-insured” with Blue.

What Does All This Mean for Me?

Most of our clients don’t want to assume cost control measures quite as aggressive as the sisters do: no network, very low payment rate compared to Medicare, paying cash upfront for almost everything, use of charity programs when appropriate.

Your plan probably uses a network. And network plans - even when the carrier itself has been fired as the plan administrator, and the plan is just renting the carrier’s network - have had a wildly volatile few years recently. With the infusion of AI into exam rooms listening to your conversation with your doctor for opportunities to gouge you more, and with anti-competitive (I would argue, illegal) network contracts (with both employers and with providers), even the most aggressive employers are rarely enjoying plan performance as sweet as my nuns’.

But the nuns’ experience is worth examining anyway, because it shows what’s possible in the cash-pay health care economy of the future.

That future is increasingly being built, one plan at a time, partnering with next-gen vendor partners who are able to bypass networks or leave them off altogether. Innovative plan designs that don’t yet use cash can still obtain dramatic cost reductions compared to status quo plan designs.

It is well worth you calling up HR at your company and asking:

• Have we considered firing our carrier and just renting a network?

• Does our plan have a solution for paying cash to save money?

• Have we fired our PBM in favor of an indie, less conflicted version?

• Are we making use of hospital financial assistance programs for our lower-income colleagues?

• Do we have access to our claims data so that we know what’s driving our costs?

Most HR directors are by nature extremely risk-averse. They don’t want you to have a bad experience with the health plan that you rely on. They’re overworked already and look quite askance at a big change management project that a new plan transition can require. But if they start getting asked these questions by you and your colleagues - along with your reassurance that you would welcome and encourage these kinds of reforms to your company’s plan, they’re far more likely to entertain crazy ideas!

And every bit counts.

Any step you can take - even a simple health reimbursement arrangement program that allows workers to pay cash and get lower prices - represents progress toward disrupting the corrupt status quo that we spend so much time excoriating in this space.

Trust me when I tell you: no one is coming from government to save your company’s health plan.

The revolution starts with you and your colleagues, refusing to be fleeced by big carriers eating away your wages and your company’s growth year after year.

Be the change!

(And of course, if you need help, that’s what I do).

If the cost of health care is crushing you, this one’s for you. Send it to your HR director. And your CEO. Then leave a comment below, let me know what they said.