I am grateful to for publishing my latest piece for his audience. Travis’ work is deeply paternal - part coach, part drill sergeant, part philosopher, and all with the heart of a lion. I commend it to all of you. This article was born of questions he sent me after reading my article on boys and young men. His questions were about cultural/societal issues related to women, modernity, feminism and such. They were reasoned, linear, logical… masculine. My answers, try as they could, showed up markedly different, as this article. Thanks, Travis, and hope you all enjoy the reprint!

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“EARTH, SWALLOW ME WHOLE.”

The 13-year old had been dancing in her basement to a Go-Gos record, cranked up to 11, holding her hairbrush-microphone, singing her heart out (as one does) - fantasizing about adoring crowds, wishing they could be as radiant and famous as she was, and singing along to the words they’d memorized.

And then she heard it. The snickering. She froze at the sight of their laughing faces. And then, they ran away to tell the world.

The neighborhood boys - the meanest ones - had been watching her performance. The basement window near the ceiling was ground-level outside the house, and provided a perfect view into her daydream.

Little did she know that one day she would sing in acappella groups and recording studios, dance at salsa conventions in Puerto Rico, get paid to sing at weddings and funerals and professional sports matches. She never could have imagined that she’d give keynotes, appear on podcasts (what are those?), or fly on Air Force One. That she would be confident in her own skin one day, with nothing to prove.

No. All she knew was that the entire neighborhood was laughing at her now. Her cheeks on fire with humiliation, the sweat beads forming on her forehead, she searched for any closet she could curl up into and never emerge again.

“Earth, swallow me whole!”

Up to that point in my life (you knew it was your humble correspondent, right?), I had already learned pretty well to suppress the girlish tendency to twirl in pretty dresses and coquettishly cry out “look at me!”

I blamed my body for why that universal feminine instinct had to be smothered.

I was pudgy. I had fat cheeks and freckles. Thin, mousey-brown hair that, without the spiral perm I was sporting, would have been neither curly nor straight. And even if I looked cute in girly, pretty clothes, which I didn’t, there weren’t any such clothes in a decade filled with neon colors, shoulder pads and stiff raised collars.

I wasn’t nearly the ogre that I thought I was, I mean, apart from the perm. But after years of being picked last on the team, called fat, never being the object of anyone’s junior high crush, I had concluded that being feminine wasn’t in the cards for me. No one would ever stop at the sight of my beauty, climb up a castle tower to rescue me, draw his sword to defend my honor, bring me flowers, buy me diamonds, or any number of other things I thought happened to girls who were better at being girls than I was.

So I took whatever feminine impulses nature had cruelly planted in me and I tied them up and shoved them down into the cellar of my soul. I only took them out for a walk (or a dance) when I was alone (or so I thought) in the cellar of my house with the Go-Gos.

And that’s how I found myself curled up in a shame-spiral that day. Because boys had seen me trying to be feminine. Twirling prettily in a sparkling outfit on a stage that only I could see. Receiving the admiration of crowds conjured up only in my mind.

And that was the last of her that anyone ever saw again. Feminine Katy.

The cope had already started before that moment, of course - be smart enough or funny enough to distract anyone who might otherwise be tempted to make fun of or reject me for not being good enough in the feminine ways. Now the cope was all there was.

It didn’t help that all of society was out to kill the feminine too. This was the era of Gloria Steinem and Geraldine Ferraro, of Sandra Day O’Connor and Margaret Thatcher. Anything men could do, we could do better. The war on womanhood in my basement was merely the micro to the macro narrative playing out around the world.

Femininity was weak. Femininity was vulnerable. Femininity was dangerous. Femininity went underground - in my life and in the culture, for the next few decades.

Other girls played things differently. I thought I was ugly, so I went the direction of suppressing the feminine so that it wouldn’t get crushed by rejection.

Other girls went the other way - putting a stake in the heart of their own femininity by distorting it into crass materialist promiscuity. Perverting the icon of Woman as the pursued and desired beauty, baring their bodies, taking fleeting comfort in the boners that followed and outwardly scoffing at the idea of lasting love the way a soldier would on R&R in the red light district.

Whether it was the solitude of my camp or the abortion rate of the other camp, all of us rejected and reinvented womanhood in ways that felt safer than actually embracing our femininity and offering it up to the world where it could be rejected or violated.

And so, femininity was dead.

But this week every year, we are reminded that not all dead things stay dead.

There were signs of life that tried to emerge.

I was drawn to beauty like a moth to a flame. When I first moved to Washington, I used to sit on the steps of the National Cathedral after work each day and play my guitar by a fountain like it was Woodstock. That impulse reached full flower as I was drawn into Catholicism by its beauty - the stained glass, the candles, incense, the Latin, the martyrs. I was so entranced by the beauty of a group of nuns in their bright blue veils, I became one of them for a few years, thinking that if I put beauty on the outside of me, the inside might improve as well. It didn’t take.

When I returned to my life in politics, it felt so familiar and comfortable. Walking around again in the Hart Senate Office Building felt like returning to the high school in your home town.

By that time, I was a “leader.” I was Management in any office I worked in. I made a lot of decisions, hired, fired, had an impact, made a difference. I declared the wars. I negotiated the peace. My career was a battlefield that felt familiar but always unsafe. I was still the little girl who wanted someone to protect her. Every woman is.

A lot of talk these days centers around women like this. We get scolded for letting our ovaries wither while we recklessly and selfishly push our careers to center stage.

But that’s not at all what we’re actually doing - not most of us.

We’re not prioritizing career over marriage and motherhood. We didn’t choose to be single. We’re just trying to pay our bills while we desperately - DESPERATELY - search for and hope for Prince Charming to come save us. Not all of us admit this openly. But we all admit it in our hearts. If we had found him at 19, 25 or 35, most of us would have dropped our careers in a flash and followed him to the ends of the earth.

Being raised with feminism in our blood and on our lips, sometimes by our parents, but always by the culture, we had fortunate opportunities to become good at things that are useful in the economy. That freedom made it easier to pay those bills when Prince Charming was dallying. So we advanced. We got raises, titles, PhDs. We weren’t doing it because we preferred this path. We were doing it because we were good at what we did and it paid the bills and you’re not going to turn down promotions and opportunities when no one else is offering to pay your rent.

Some fields are easier to advance in without becoming a warrior. Most aren’t.

As women advance: more responsibility, more demanding problems, bigger egos everywhere, more on the line, vicious competition, higher stakes.

It all translates to warfare.

Every workday - at a certain stage in a moderately successful career, usually between age 30 and 50 - is a battleground. Whether it’s sales or science, the stock market or social media - all jobs have an adversarial or competitive edge. That’s the nature of the modern workplace.

To continue providing for ourselves, women have to succeed in this battlefield. As we succeed, we take on the nature and culture of battle: jaded, profane, calculating, cynical, shrewd, results-oriented, single-minded, competitive. You know, like men.

The longer this goes on, the more we repel actual men. It doesn’t help that half of us are on birth control just to control the agonizing hormonal chaos twisting our uterus every month and the other half are on birth control to make sure that the soul-crushing hookups each weekend don’t destroy anyone else’s life but our own.

These are lives unfit for human women.

Women are not made for battle. Even if we’re good at it.

I am very good at battle, as my resume attests. I’ve lived on the cortisol-spiked fumes of warfare for most of my adult life. Most successful women in traditional careers have. By “traditional career,” I mean leaving home each day, toiling under fluorescent lights in a sterile, beige, impersonal, climate-controlled box of sameness, competing for accolades, accomplishments, sales, awards, advancement, money in a professional culture built for and by men, generations ago. Even in workplaces where women outnumber men, they still operate under the rules and rituals built when men were the primary ones living and working this way. This is not how human females flourish.

• The rush we feel when we win at work? Cortisol.

• The panic we feel when we lose at work? Cortisol.

• The racing heart at the sound of the alarm in the morning? Cortisol.

• The to do list scrolling as we try to get to sleep? Cortisol.

Elevated cortisol was my boyfriend.

Many of us succeed, appearing to thrive, in these workplaces. We sit in traffic before the sun rises and after the sun sets, and we tell ourselves stories, real or imagined, about necessity, scarcity, pride, passion, contribution, intellectual satisfaction.

The story behind those stories? Security. Solidarity. Purpose.

We don’t have security the way biology intends - through a community of men who defend us, provide for us, look at us with wonder, and stabilize our crash landings.

We don’t have solidarity the way biology intends - through a community of other women who co-create beauty with us, who validate our feelings, who rub our backs and understand us.

We don’t have purpose the way biology intends - through a community of children who take us outside of ourselves, make us laugh until we cry, who give us a reason to live and a reason to die.

That’s the security, solidarity and purpose of femininity - only through community with men, other women, and children. Isolated femininity trying to operate in the world built for men - even if it’s populated by half or more women now - is not safe. It’s not welcome, it’s not productive or polished or predictable or useful.

And that threat, that not-so-low-grade fight-or-flight - that’s why our bodies are falling apart, from sleep deprivation, insulin resistance and inflammation (guess what triggers glucose release into the bloodstream? Cortisol.) That’s why a quarter of us are on SSRIs. Why almost a million of us get abortions every year - a fifth of our babies.

It’s not safe to be feminine in a world without men. And it’s not safe to be feminine in a world built for men. So we’re not.

By the time we partner up with men, the fight-or-flight is just our personality, and he can’t make us safe or happy. That’s why divorce rates are so high - and why most divorces are initiated by women.

RIP femininity.

Even when I got those things, albeit late in life - a man to defend me and crash my waves on, children to get out of bed for - I was a professional man for most of the day. So the femininity still didn’t really take.

I didn’t realize any of this - cortisol was my constant friend, drug, fuel, bestie - even after I had escaped the battleground of my political career, and was building my business from home in my yoga pants where I should have been safe and self-assured.

And then my business coach, the ethereal Marissa Levin, grabbed my attention and called me out. She said that every single word that came out of my mouth was based in fear.

She demanded that I use different words if I wanted to have different thoughts and create different outcomes. That was the beginning of the end of the walking dead.

Which brings us back to Easter.

I started realizing that even when I should have been safe - no more White House battles, no more lonely dinners for one, no more single filer tax returns - I was still coasting on cortisol fumes.

Cortisol withdrawal was a long and fraught process. It required a hard look at how I sought safety and why. The root cause? What I expected was a festering corpse of femininity inside my soul, with a masculine boss-bitch costume trying to cover up the stench.

That’s when my logos had to make a decision. Was I going to roll away the stone and look at the fetid, putrid fruit of a half-century of rejection and fear and self-hatred?

“But Lord, already there is a stench because he’s been dead for four days,” says the ever helpful Martha to Jesus in the Gospel of St. John. Or four decades, in the case of my feminine soul.

St. John. You know - the same guy who starts his story with this:

This is the Logos, literally the mind or intellect - in whose image we - man, woman, masculine, feminine - are so fearfully and wonderfully made. If that Logos can raise the dead and it made our own logos, what might our own logos be able to resurrect?

So I started to push that stone one small bit at a time. I used a variety of methods - online programs, coaches, books, retreats, nature. I cleaned up my body - diet (push), movement (push), toxins (push), sleep (push), sunlight (push).

That journey cleared some cobwebs in my biology enough that my logos could start to speak life to my psychology. The need for control (push). The fear of intimacy (push). Viewing money as a scarcity (push). Approval-seeking (push). Victim-mindset (push). Rejection of intuition and feminine knowing. (push)

Eventually, the stone was rolled away enough for me to notice that there was nothing rotting in there at all. Just the folded up man-suit I had worn in a previous life as a security blanket.

My logos had done the impossible.

There’s still a long way to go before the stone is completely rolled away. I swear like a sailor. I argue with my feelings. I’m not as quick with kindness for myself or others. Menopausal weight gain feels like punishment and less like feminine rhythm. I dread birthdays because, “old,” rather than “wise.” I occasionally fall into viewing events as happening to me instead of for me.

After all, I’m just a lowercase logos. Some things require an assist from the Uppercase Version.

For my brothers who love the feminine and would like to see more of her, then be a rock. Affirm and draw out her femininity by making her feel cherished and secure. Give her time and space to nurture beauty, not worry about money, look at the sun, play with babies. Tell her she’s gorgeous (like once an hour). Look at her in wonder like you mean it. Bring her flowers at least once a week. If it won’t bankrupt you, buy her diamonds. Don’t whine about manicures, throw pillows, bird-feeders and essential oils. Remember, she spent the past few decades internalizing that beauty and mysticism and bonding with nature were frivolous at best, and dangerous at worst. Don’t pile on.

And for my sisters, if Feminine-You got stabbed in the heart and shoved in the trunk of the car of life, let this Resurrection season give you a reason to hope. She’s only mostly dead.

I bet if you turn on the Go-Gos and grab a hairbrush, you’ll see some signs of life.

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The thing I didn’t understand until I was well out of government is that the system isn’t broken. It’s working exactly as designed. It profits from your sickness. It has no structural incentive to produce your health.

I helped build parts of that machine, and I still got screwed by it - which either means I was naive, or the thing is more powerful than any of us on the inside wanted to admit.

(Both. It was both.)

What I know now - as a naturopath, as a former White House advisor, as someone who finally cleaned up her own health after watching her sister die too young - is that the best defense is to stop needing the system so much.

Sleep like a human. Eat like a human. Get some sunlight on your face. These aren’t woo. They’re species-specific requirements, and we’ve been talked out of them by a culture that profits from our dysfunction.

I spilled all the tea. Check it out and let me know what you think.

I have a dream of a post-network world.

Not in a think tank’s this-will-never-happen-but-we’ll-still-write-white-papers-about-it sense. I mean a real world in which employers - the ones running the health plans that cover most Americans - can buy health care the way they buy everything else: by comparing prices, negotiating directly, and refusing to overpay when a seller is out of line.

Because right now, that’s obviously not how this market functions.

Carrier networks operate less like marketplaces and more like Hotel California.

Employers are allowed to choose between networks, but they are not meaningfully allowed to operate outside of them. When they try, they discover very quickly that the system has been engineered to make that choice cartoonishly painful.

Once you’ve chosen a network, it operates like a plantation.

Employers - the ones funding the entire enterprise - are held hostage to that network. This isn’t an accident - it’s the result of specific contractual hostage-taking, honed over years of dominating the health care landscape.

But I’m increasingly running into people building the underground railroad, allowing a few, obscure, invite-only escape routes. Some have been doing this for a couple years. Some are just starting. The tipping point isn’t even showing yet, but it’s on its way. I’m starting to partner with these insurgents, and so are others.

At this point, we’re all just hobbits taking on Mordor (but you know how that story ends).

To understand how we get out, let’s walk through how the system works to trap us in the first place.

[Industry people: Yes, we’re doing the 101. Feel free to skip ahead.]

Every employer-sponsored health plan has three core functions (even if they are bundled together in practice for most):

The first is plan administration. Someone has to receive the bills (“claims”) from doctors, hospitals, or pharmacies (we’re going to call them “providers” in this article even though that word makes them want to burn me at the stake, I know), figure out if the claims are for covered services, confirm the patient is actually enrolled on the plan, calculate what they’ve already paid against a deductible, and write the check to the provider. Someone also has to keep records of every transaction, pay the other vendors on the plan, and send the client regular reports. The companies that do this are third party administrators (TPAs) - and they can be either carriers themselves or they can be separate companies (“indie TPAs”).

The second is risk assumption. In other words, whose bank account is the TPA reaching into to write those checks to providers? For plans in the individual and small group market, the TPA itself is bearing risk - this is called a “fully-insured plan,” meaning the TPA is the true owner of the plan, it’s assuming your risk. If you cost them more than the premiums you pay, they lose and you win. I mean, until they raise rates for everyone next year, but you get the point. That’s why these markets are the most expensive - those insurance companies aren’t going to lose money on you - they’re going to build a huge buffer against that in the form of overpriced premiums. These plans are regulated partly by the ACA as well as state insurance commissioners.

Bigger companies (though they can be as small as 50 or 100 employees) usually choose a different model, one where the employer itself bears all or most of the risk. This is why this type of plan is called a “self-funded” plan - not because you the patient are funding things, but because the employer is funding its own risk. When you pay your premiums with payroll deductions, you’re actually paying them to your employer’s account, and your employer pays premiums each month to itself in that same account. Then the TPA writes checks to providers out of that account. Most employers that are smaller than 5,000 or so will actually buy some stoploss reinsurance for themselves, just in case of a really bad year or a particularly high-cost patient. These plans are regulated federally, by the Department of Labor (and a little bit by the ACA).

The third is pricing - or more accurately, re-pricing. Of the bills from doctors, hospitals, and pharmacies, to be specific. For some sick reason, health care is billed at a sticker price that is inflated far above what would be a reasonable cost-plus-some-profit rate. You need a way to access discounts off that list price, as a result. A network is nothing more than a set of contracts with providers for a certain contracted rate (usually, though not always, below the sticker price). There are other ways to get discounts, which we’ll discuss later.

So the claim goes FIRST to the network, which applies its contract with the provider, and sends the contracted rate, along with the claim, to the TPA for processing and payment. The big insurance companies all have their own network. So for most health plans, all this happens under one roof, either because the plan is fully-insured and the carrier is doing all three core functions, or because the plan is self-funded, and hires the carrier to both administer the plan as the TPA and to provide its network (even though that employer is paying all its own claims).

An employer can also fire the carrier as the TPA, and hire an indie TPA to do the plan administration, while still keeping a network, by renting a carrier’s network. Indie TPAs partner with a few carriers to offer their networks to these employer clients. Most clients still want a network on their plan, even if they don’t want a carrier administering their plan. So indie TPAs contract with the carrier networks as a distributor of sorts for their network. The employer then signs a network access agreement when it hires the TPA, essentially renting the network.

Again, networks are simply a set of contracts between the carrier and providers. So doctors, hospitals and pharmacies all have their own contracts with networks, if they “take insurance.” That’s what makes them “in-network.” Some providers couldn’t come to agreeable terms in a contract or they didn’t even want to try, and those are considered out-of-network. That means that there’s no agreement as to how much they get paid for members of that plan.

So, regardless of how the pieces are arranged, almost every employer in the country ends up in the same position: dependent on a carrier network for access to care.

And once you are inside that network, you are not just getting a price list. You are entering into a set of contractual obligations that govern how care can be purchased, and, critically, what alternatives are off-limits.

Most employers do not realize how restrictive those obligations are until they try to step outside them.

The Obvious Question: Why Not Just Eliminate Networks?

Some employers have asked that question. A small number have gone further and actually done it. This is what is commonly referred to as reference-based pricing (RBP) plans.

Instead of relying on a carrier network, an RBP plan sets its own allowable reimbursement rate for providers, typically indexed to some percent of Medicare. As we’ve discussed in my post about how not to get financially screwed by the medical system, anything up to about 150 percent of the Medicare rate is considered pretty good. 150-200 percent is fair. 200-250 is iffy, depending on the type of service. 250 percent and above is rapey (it’s also the nationwide average carrier rate, which is precisely why RBP plans exist - to pay less than they would with a carrier network). On an RBP plan, patients can, in theory, go to any provider, and the plan pays a defined amount, usually somewhere between 125-180 percent of Medicare rates.

At first glance, this looks like the cleanest possible solution. You remove the middleman. You define a rational price. You let the market work.

In practice, it introduces a set of tradeoffs that are often minimized in sales pitches and only fully understood once a plan is live. I have built and run this type of plan, so I’m not throwing stones, just being honest.

The first problem an RBP plan faces and must find a solution for is balance billing. By definition, there’s no contract/network. So, providers have not agreed to your Medicare-based rate (“plan allowable”), and, absent a contract, they retain the right to bill the patient for the difference between what the plan pays and their billed charges. There are vendors who specialize in negotiating those balances down after the fact, often landing somewhere above the plan’s allowable but below commercial rates. That process can work when your vendor is good, but it is reactive, and it puts the patient in the middle of a negotiation they did not initiate, sometimes even being sent to collections while the parties in the background are negotiating (or playing hardball) - sometimes for months and months.

That is the visible problem.

The more serious problem is one step earlier in the process, and it is less discussed because it is harder to solve: patients often can’t get the appointment in the first place.

I learned this the hard way with a small group of Catholic nuns. I’ve mentioned them in previous posts. They were so desperately tired of being bankrupted by Blue Cross, they begged me for a solution that saved significantly. So we went with my first (and last) RBP plan.

Recently, a desperately sick sister needed to see a specialist at NYU-Langone Medical Center. Historically, that system had seen patients from this plan without issue. But something shifted a year ago or so - subtle changes in how they describe on their website about accepted insurance coverage - a tightening of language that signaled a change in posture.

When Sister called to schedule, she was told they did not take her plan. She tried to explain, correctly, that she did not have a network and could go anywhere. The response did not change. They would not schedule her.

The only option they offered was for her to pay cash upfront.

That might sound like a workable fallback until you remember who we are talking about. She had no income. She did not have a bank account. “Pay upfront” was not a logistical inconvenience; it was a hard stop.

We tried to engineer around it. Could the TPA send funds in advance? Yes, but only to the sister, they can’t pay a hospital for care not yet rendered. But she didn’t have a bank account, couldn’t receive a check. Could the TPA just pay with a credit card and be reimbursed by the plan later? This TPA - like most - wasn’t set up for that. Typically, auditors frown on payments for services not yet rendered, as well as on TPA transfers to themselves from client bank accounts.

As I do when I’m in a pickle with a hospital, I called my dear friend who is an executive with the hospital trade group. She put me in touch with an NYU executive. He didn’t understand what an RBP plan was, and kept suggesting that we were a health care sharing ministry or some other type of non-plan. In other words, a hospital executive was flummoxed in exactly the same way that most front-desk or scheduling staff are when patients call and try to explain their RBP plans.

She needed care. The system would not let her access it. The sisters scrambled to come up with the cash - which they raised from benefactors - and lived without it somehow until the plan could reimburse them.

This is the tradeoff: reference-based pricing plans can be extremely inexpensive, but they shift friction onto the patient in ways that are not always tolerable.

“Cheap” is no help if you can’t get in the door.

The Hospitals Aren’t Confused.

Hospitals understand what a threat RBP plans are to them. They are making calculated decisions.

They understand that if they create enough friction - if patients encounter enough resistance, enough uncertainty, enough delay - those pressures will flow back to the employers, which, after all, are running plans that cover their own families. All it takes is one high-friction experience with the CEO’s wife - a delayed appointment, a collections notice, an aggravated doctor - and the calculus changes.

The employer reinstates a carrier network. The broker who recommended the alternative is replaced.

And the conclusion, reinforced through experience, is that the system cannot be changed.

A particularly notorious case of this pattern was when University of Pittsburgh (UPMC) - the health system that monopolizes half of Pennsylvania - went gangster on its own community. A bunch of public sector health plans - the local school system and various municipalities - adopted the RBP model to try to save on costs. UPMC refused to schedule any patient covered by those plans. None of them lasted more than two years before giving up and buying into the local Blue network or UPMC’s own (overpriced) plan offering. UPMC became a hero and role model for other hospital systems across the country. NYU-Langone has apparently followed their lead, icing out the Catholic nuns’ plan that they had been taking for years.

This playbook makes it clear: try to pay less by dropping networks that pay confiscatory rates to hospitals and you’ll pay less alright - by not being able to get care at all. The hospitals are in league with the networks against their own communities.

But there are early signs that the ground is shifting.

Regulatory pressure has begun to expose pricing in ways that were previously not possible. New requirements were just passed by Congress on PBMs, but they also threw in a little gem that effectively applied them to TPAs, which would force transparent disclosure from all plan vendors about their rapey rates and conflicts of interest and secret revenue streams they’ve been hiding from their client employers. The Department of Labor (DOL), which oversees larger employer plans, doubled down on this concept, essentially saying that these schemes are illegal transactions that no employer is allowed to tolerate. It’s a one-two punch - first you have to disclose your business model. Then, your clients aren’t allowed to have a plan vendor with that kind of business model. I wrote about these fantastic policy innovations here. I called them a nuclear bomb on the status quo.

Equally encouraging, the Department of Justice (DOJ) has begun to pursue antitrust enforcement actions, targeting provider-side contracting practices. Cases like the one against OhioHealth (which I wrote about here), and a similar case that just dropped on New York Presbyterian, one of the truest Bond villains in the country, focus on provisions that require plans to include entire systems, regardless of cost or quality variation between facilities in that system, as a condition of access to any of their network rates.

Those provisions matter. Removing them would create more flexibility on the provider side.

I appreciate DOJ taking action. I tried to get them to pay attention to this stuff when I worked in the White House, and they said it was FTC’s job, and FTC said it was DOJ’s job, and neither of them did their own job. But even if these contract provisions were ruled illegal, we would still be a long way from the Holy Grail of a post-network world.

It’s not that better options don’t exist that could hasten us toward that future. It’s that they are contractually suppressed.

Let’s walk through exactly how carrier agreements govern payment behavior, why even independent TPAs are constrained in ways that disadvantage innovation-minded employers, and what I believe are illegal network contract provisions preventing the emergence of a true price-based market, strangling it before it can breathe.

Then I’ll describe why the three most popular work-arounds - reference-based pricing, direct contracting, and cash pay - all run into structural limits, even when executed well.

And finally, because I’m not in the business of handing you a burning building and walking away, I’ll lay out what would actually have to change, at the policy and enforcement level, for my dream of a post-network world to become reality.

That part is for paid subscribers.

If you’re trying to build something different, advising someone who is, or trying to regulate this market in any meaningful way - you need what’s behind this paywall more than you need whatever you’re doing next.

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Most medical professionals have never seen physiological birth.

That’s birth without any medical intervention (such as membrane sweeps, immobilization, fetal monitoring, induction, augmentation, epidural, coached pushing, or surgery, among other things).

Think about that.

The people who define “best practices,” who write the guidelines, who tell women what is safe and what is dangerous, who decide when your body is “failing” and when your baby needs to be “rescued” - most of them have never actually witnessed birth functioning the way it is designed to function.

They have only ever seen birth inside a system that is actively interfering with it. And then they have the audacity to call that version “normal.”

The truth is that birth is not a medical event.

It is not a pathology or a condition to be managed. It is not a problem to be solved. Mammalian females are exquisitely-constructed gestating and birthing ecosystems that The Science, as it pretends to be in the U.S., utterly fails to improve upon.

Birth, as nature designed it and when nature controls it, is a biological process - hormonally orchestrated, neurologically precise, exquisitely sensitive to environment and perception.

It is also, inconveniently, something that works best when you leave it the hell alone. Which is exactly what modern obstetrics is structurally incapable of doing.

You already understand how this works

Imagine you are trying to poop.

You know exactly if you can hold it, for how long, and if it’s time to head to the toilet. You know if you need to push or just relax. You know how long to push and when you’re done. Your body often naturally constipates when you’re traveling a lot or when it’s impossible or inconvenient to poop. Your autonomic nervous system - the same system making your heart beat, stabilizing your temperature, monitoring your oxygen saturation - is driving this bus and you rely on it every single time.

And then suddenly, three people in scrubs walk into the bathroom.

They close the door behind them. They start explaining that pooping can be dangerous, that sometimes people hemorrhage or tear or have “complications,” and they just want to keep you “safe.”

They hook you up to monitors, they bring in brighter lights and beeping machines. You can’t sit in a squatting position anymore but you’ll have to poop on your back in bed. They tell you when to push. Then they tell you not to push yet, it’s too soon, you might “swell,” you might get hemorrhoids.

Every few minutes, someone puts on gloves and checks your butthole to assess how things are progressing. They start talking to each other about you. If you object to all this, they roll their eyes a bit and sigh heavily and explain condescendingly, “You’re not progressing.” “We may need to intervene.”

How is your ability to poop going?

Gone. Immediately.

Now, swap out the poop for an orgasm - another brilliantly organized feat of biology and neurology, subjected to these same interventions.

Exactly.

And birth is vastly more complex, more hormonally sensitive, more neurologically dependent than either of those processes. But this is how we do it.

And then when we can neither poop nor orgasm nor birth under such conditions, we thank GOD the “system” was there and rescued us from this dangerous failure of our broken bodies.

That sometimes, on rare occasions, pooping can become complicated and require medical intervention, does not thereby render pooping a medical event more broadly. Similarly, birth can, in rare situations, require medical intervention, but that doesn’t mean it’s a medical event more generally.

The physiology we keep interrupting

Here is what birth actually is: a hormonal symphony.

Oxytocin builds in waves, creating contractions that are rhythmic, responsive, and adaptive. Beta-endorphins flood the system, altering consciousness, dulling pain, pulling the woman out of her analytical brain and into something older, deeper, more primal. At the end, catecholamines surge and trigger the fetal ejection reflex - a powerful, involuntary expulsion of the baby.

This process depends on a very specific neuropsychological state: privacy, safety - including safe people. No strangers, not even most beloved family members, no one watching, evaluating, observing, asking you questions, or shining lights in your eyes. No artificial lights, no uncomfortable environments, no restriction of your instinctive movements.

Because the moment you feel watched, assessed, judged, your neocortex lights up, your stress hormones rise, and the entire process can stall. Even one fluorescent light can cause cortisol to rise.

Cortisol turns off oxytocin.

This is not controversial biology. This is how mammals work. All of them.

And since cortisol turns off oxytocin, with all the prenatal fearmongering and medicalizing, all the induction for “safety” and monitors just to make sure baby is “ok” - what might the effect on cortisol be?

The conditioning starts long before labor

Let’s walk through what we actually do to women, because this is where the system stops being merely counterproductive and stupid and starts being abusive.

The conditioning starts long before labor.

From the moment a woman gets pregnant, she is pulled into a system of surveillance: appointments to make sure “everything is ok.” Measurements, compared against what’s “normal” without any mention of how frequently ultrasounds are off (A LOT), how wide a variation there is in “normal” for every possible metric you can imagine.

Everything framed around risk. Everything framed around what could go wrong.

You aren’t asked about what your intuition is telling you - the whole system is designed to train you to ignore your intuition and to submit to the worst substitute for it ever - epidemiologically irrational metrics where the evidence base is upside-down. (And that evidence base originates from births that have been in the system. It’s like trying to understand animal behavior and health only using animals in a zoo.)

You are told what to worry about. You are taught, over months, that your body is a liability. That your baby is in danger. That safety lives outside of you, in machines, in experts, in protocols.

And the tools we use to reinforce this are not even particularly reliable.

Ultrasounds - which women are told are precise, authoritative, definitive - are off-base all the time. Even under ideal conditions, ultrasound estimates fall within 10 percent of actual birth weight only about 60–80 percent of the time. Early ultrasounds can be accurate within about a week, but accuracy counterintuitively goes out the window for the ultrasounds performed closer to full term.

Even the ghouls at the OB/GYN trade association admit that gestational age estimates can be off by enough to affect induction rates later. Forty-week due dates are treated like deadlines but they’re really mid-points. Half of all babies, when left to their own devices, show up later than that, and one in five of them wait until 41 weeks and beyond.

But the system does not tolerate variation.

So what happens? At 38 or 39 weeks - before many babies are even ready - women are told it is “safer” to induce.

• “Your hips are too big for the baby’s head” (which we probably measured wrong, as we usually do) - because nature is just that stupid.

• “You’re old and we need to control what’s likely to be a disaster and have the surgeons ready.”

• “Your placenta is starting to deteriorate - or it will in a week” (because disintegrated placenta kills a lot of babies, oh wait…).

• “Your baby is breech” (even though almost all babies move a lot and can reposition for birth, so their position a week or even days before birth is not dispositive).

And a bunch of other made-up nonsense according to a model that treats deviation from the average as pathology.

So we take a baby who might naturally gestate for another two, three, even four weeks - which is a massive percentage of its total development - and we evict it early.

Then we act surprised when things don’t go smoothly. And women leave the hospital convinced and grateful that the system saved their baby or themselves from the complications it created.

How it starts: the cascade of interventions.

Induction - it sounds benign, helpful even, we’re just “getting things going.” What it actually means is that we are overriding the body’s timing, precisely attuned to a million metrics that nature has been monitoring outside the view of human consciousness.

We are forcing the body into a process that nature’s regulators - the mother’s hormones - are not ready for. And then we have to compensate for that. If the waters break on their own, that used to mean something. It meant the symphony was starting. All the instruments were tuned up, the musicians with full attention to each other and the Divine Conductor, with their sheets of music turned to the same page.

But instead, we force the violin section to start while they’re all still standing around getting their violins out of the case, and force the rest of the musicians to scramble to catch up - some of whom may never even arrive.

And the clock starts. “Your body has X hours to perform or we intervene.” (Usually 12. Even though 20-25 percent of women naturally don’t start labor after 12 hours.)

Why? Because the system cannot tolerate waiting. After all, the doctors get paid the same thing whether you labor for six hours or sixty. That math doesn’t work.

Waiting on Mother Nature is inconvenient, unpredictable, and costly (for them).

Chemical Assault Replaces Physiological Surrender

So then, we “augment.” In other words, cue more of the drug they probably gave you for the induction: Pitocin - Big Pharma’s counterfeit for oxytocin, which induces intense uterine contractions (and a zillion other things known and unknown).

Actual oxytocin is released in pulses. It rises and falls. It is responsive to feedback. It is part of a complex loop between brain, body, and baby. It also shuts down when cortisol spikes - this is so that mom’s labor stops if a bear is nearby and she might have to run. Isn’t nature brilliant?

Guess what also causes cortisol to spike? Fluorescent lights, a bunch of strangers, beeping machines, thirst and starvation, being pushed around, fearmongered, monitored, and not being in control of the most important thing your body has ever done - and a million other things that happens the minute you enter the hospital.

So, for many, many women, that cortisol spike and the oxytocin suppression signal that your body knows something that our system doesn’t know or refuses to acknowledge. You’re not safe here. This isn’t normal. You’re not ready. Your baby isn’t ready. This isn’t what your body wants. Labor can’t happen right now.

Even if your birth started naturally, half of first-time moms aren’t moving fast enough for the hospital’s or doctor’s convenience, and receive Pitocin. For first-time moms who were induced in the first place, almost 70 percent get Pitocin, because, of course, their bodies were even less ready than those whose waters had broken before the Pitocin.

Pitocin delivered in this way is not the same as your body’s oxytocin - it’s a fire alarm interrupting the hormonal symphony. It floods the system and creates contractions that are stronger, longer, closer together, and completely unregulated by the body’s own feedback mechanisms.

It is, quite literally, an assault.

Those contractions can be so intense that they reduce oxygen flow to the baby. Now the baby shows signs of “distress.” Now we are in an emergency - that we manufactured. At the same time, the mother is in agony, because these are not physiological contractions. Real labor is intense enough - counterfeit labor is something else entirely.

Enough of this Symphony Business

So of course she begs for relief. And of course the staff encourages it. “Would you like to be more comfortable?” is the usual question.

At this point, after hours of synthetic contractions, who wouldn’t? So she gets the epidural. Now she is numb. Now she can’t move the way her body normally would - to help position the baby properly, to allow her muscles to work their magic, to direct her energy and breathing in all the right ways, both intentionally, as well as simply intuitively. Her natural oxytocin, which is responsive to what’s going on, has been replaced and blunted. Her cervical dilation slows.

Now she can’t feel what her body is doing. Now the labor slows, because movement matters, position matters, feedback matters. Her blood pressure slows, which can deprive baby of oxygen. Meanwhile, the Pitocin is keeping contractions faster, harder, closer together, stronger but less effective. Baby can’t adjust, move around, re-position properly because of less oxygen and getting pounded by the walls constantly closing in on her like the trash compactor in the first (and best) Star Wars movie.

So now we have “failure to progress.” “Fetal distress.” More Pitocin, get this baby moving faster. More urgency. Beeping going off. More fear, more cortisol. More things going haywire in mom. You know what comes next.

Thank God for the Surgeon Who Saved My Baby’s Life

C-section - presented as lifesaving. Thank God we were at the hospital! Thank God that doctor was so good. Thank God baby survived (thank God indeed for that).

There’s no time to tell her that it will destroy the baby’s microbiome, or that the lifelong health of babies born by C-section are worse. That it’ll hurt her future children because she’ll forever be deemed “high-risk” for vaginal birth, and coerced into C-section again and again. That it will distort and impede the postpartum hormonal magic so critical to mother-baby attachment, baby’s development and mom’s recovery. That it will lead to worse outcomes in her future pregnancies. We just tell her it’s essential, it’s non-negotiable, it’s right now. Because somehow, nature just breaks a sixth of the time and babies can’t come out, apparently.

Twice as many babies than that actually are born by C-section because for every emergency version, there’s a non-emergency, elective C-section scheduled in advance by choice. Combined with the “emergencies,” fully a third of all births are deprived of nature’s brilliant protection.

Before Everyone Loses Their $@*% on Me

Sometimes, c-sections are truly lifesaving, such as the extremely rare situations that have quite clear signs and presentations which help facilitate intervention if they occur. Ironically, the system which treats every birth like these emergency situations often fails in these cases. With uterine rupture, a mother knows that something is wrong most of the time (if she’s conscious and not anesthetized with an epidural). The pain changes dramatically. The contractions often stop, she usually comes out of her limbic brain and tries to explain that something is wrong. Perversely, the infantilization and disrespect of women in hospitals often ignores these signs, or the interventions (like an epidural) hide them until it’s too late. And it’s not without horrific consequences.

The window for intervention once rupture occurs is incredibly short - 10 to 18 minutes. Six percent of babies experiencing a uterine rupture don’t survive. Delayed diagnosis is associated with worse maternal outcomes - meaning more transfusions, more hysterectomies, more women leaving that table permanently diminished.

This is what it looks like when the system fails at the one thing it actually exists to do - and it happens inside the same cascade of interventions that potentially caused or contributed to the problem. Uterine rupture, for example, occurs in 3/100,000 of births with no prior c-section, but that risk is increased 9.5 times with augmentation with Pitocin and almost 11 times with epidural. Uterine rupture isn’t the only deadly emergency that industrial birth produces.

Many (Most?) Emergencies Are Created by Intervention

Cord prolapse is extremely rare, and dramatically increased by the cascade of interventions. Cords are designed to withstand pressure, twisting, squeezing, tension, and only extremely rarely do they break, unless of course, the body is acting in ungodly, unnatural ways that the cord was never meant to withstand, such as Pitocin overdose. “Membrane sweeps” early in labor are a key risk factor, where doctors shove their fingers through the cervix and try to physically separate the membranes holding the baby from the uterine wall. Characterized as just “helping get things moving,” this is excruciating, and dangerous as hell. It introduces infection, and lets the fluids rush out and the cord fall downward when the baby is still positioned high in the uterus and not where he would be when waters naturally break (with head down, sealing the cervix so the cord can’t prolapse).

Even mechanical obstructions such as placenta previa or transverse positions have pretty clear signs and also are extremely rare. Ironically, many women are told that they have previa or are previa-adjacent at some prenatal ultrasound and this starts the emergency vibe unnecessarily. Placentas lying low get pulled upwards as the baby grows and the uterus expands, and especially, as the cervix opens and the uterus contracts. True placenta previa that prevents natural, uninterrupted birth, is quite unusual, but many women are put into the high-risk (and high-revenue) c-section assembly line based on foolish early “diagnosis.” That c-section then becomes the final step in a chain reaction that never needed to start.

Silly Wabbit, Instincts Are for Other Mammals

All the mother’s inner knowing - the most powerful instrument we have in birth - when things are wrong, when things change, when something is off, or something hurts - badly - in a different way than labor - gets shut down. It’s shut down mechanically by the anesthesia in her spine. But it’s also shut down by the culture of the totalitarian bureaucracy that is industrial birth - the most misogynistic system on earth. She is treated like she is barely sentient and whatever she feels doesn’t matter anyway. She’s condescended to, patronized, dismissed, with mock sympathy and feigned powerlessness to change “protocol,” “for her safety.”

Like she is a hysterical child who needs to be managed. Talked over. Corrected. Coached. Positioned. Starved. Dehydrated. Told when to push. When not to push. Probed and sexually violated, over and over and over again. Measured. Monitored. Managed. Her instincts are not just ignored, they are actively suppressed.

So she is trained out of it, long before she ever arrives at the hospital. And by the time she is in labor, many women have been so thoroughly conditioned that they no longer trust themselves at all.

They’ve outsourced all their instincts and knowing about how to care for themselves and baby, how to trust their bodies, how to assess their own health, how to protect their autonomy so that nature works well in delivery - all of that is drilled out of them during the prenatal visits, the tests, the measurements, the toxic glucose tests, and so forth. They turn outward - to the monitor, the nurse, the doctor, the protocol, the system. They hand themselves over because they’ve been trained to fear birth as a medical emergency that doctors are in charge of. To do anything else is reckless, irresponsible, selfish, stupid, dangerous.

The Illusion of Control

And then there’s fetal monitoring. Continuous electronic fetal monitoring - the belts, the machines, the constant tracking. Women are told this is essential, that it keeps the baby safe, that it helps detect distress.

What she is not told is that decades of evidence have shown that continuous fetal monitoring does not improve outcomes for normal pregnancies. But it sure does increase intervention.

It keeps women on their backs, it restricts movement, it produces ambiguous data that is frequently misinterpreted, and leads to constant interruptions as the damned things are forever moving out of place and raising alarm bells at the nurses station. And of course, it leads to more C-sections. Which means it’s not just useless, it’s dangerous. And totally standard - required even - because it gives everyone the illusion of control.

The fact is that no birth is risk-free, and a hell of a lot of those risks are created or increased by our “best practices” in hospitals. Birthing outside the system also has risks, such as in the case of a rare true emergency that can’t get to the hospital in time (though this could be mitigated by choosing a birth location that is close to a hospital).

The only choice a mother has is which set of risks she’s assuming, not whether she’s assuming them.

The Most Unintentional Saboteur

And the fathers - can we talk about the fathers?

Because they are victimized too. Charitably and respectfully, men know absolutely nothing about birth (see my awe-inspired post on what men do know and their many wonders). Why would they? Why should they?

They have been told their entire lives that birth is dangerous and doctors save women and babies. So when the system starts talking about risk, about safety, about what could go wrong, labeling the woman who is the only reason they get out of bed as high-risk, or geriatric, or diabetic or whatever, they go into high-protection mode.

And then they become gentle, but effective enforcers and underminers of mom’s brilliant inner knowing.

“Maybe we should just do what they say.”

“I don’t want anything to happen to you or the baby.”

It sounds loving, and protective. But it’s fear - born of what they don’t understand and can’t control. Birth is wild. It’s not something he can save her from. That kind of helplessness, uselessness, impotence is exactly the kind of feeling that makes a man want to die or shrivel. It’s unbearable to experience. He knows that this baby has become more important to her than life, than him, than anything, and that if she’s not happy, successful and alive at the end of all this, nothing will ever be the same.

So he understandably pushes her further out of her own power - the autonomy, wisdom and intuition that makes mammalian birth “safe and effective,” and deeper into submission to the system. At least if something goes wrong in the system, it won’t be because he failed in some way.

But it’s the system that renders him useless and impotent, not nature.

Nature has a critical job for Dad to do, protecting the perimeter of her birth space from interruption or intervention so that physiological birth can unfold in its brilliance.

We’re Doing it Wrong… And It Shows

We look at the outcomes and we pretend they are inevitable. We have one of the highest maternal mortality rates in the developed world. We have a C-section rate that has climbed far beyond what global health authorities consider appropriate. We have women leaving birth traumatized, or anesthetized so much they don’t even notice. We have babies separated from their mothers within minutes of being born.

And we say this is the safest way.

What it is is the most convenient way for the health care providers and the facilities involved. This is why C-sections on women who showed up to deliver vaginally are 27 percent less likely to occur on weekends or evenings and are far more likely to occur mid-day rather than off-hours, even for supposed “emergencies” like shoulder dystocia (often not actually dystocia, but whatever).

Putting women on a 12-hour clock after their waters break and then insisting they start Pitocin by playing the dead-baby card if they don’t - that makes everything run smoothly for everyone involved. I mean, except mom and baby.

A likely more important reason than convenience for the cascade of interventions, however, is far more crass. Drugs, procedures, and surgeries pay way better than standing outside a closed door for 72 hours while a mom and baby surrender to nature’s brilliant design.

Burn the Witches!

And when women start to notice this - when they start to question it, or opt out, or choose something different - the reaction is immediate and vicious.

Media hit pieces against the most vocal among them. Moral panic. Worst-case scenarios presented as the norm. Entire communities smeared as reckless, dangerous, irresponsible.

This is not new - this is how all convenient, lucrative systems respond under threat. Because that is what this is.

If birth is reclaimed as belonging to women, as controlled by mothers, as untamed and beautiful as a lioness, if emergency care is only given for, you know, emergencies, then there are a lot of losers in the status quo system.

And that can’t be allowed.

It has to be discredited. Ridiculed. Shut down.

The dirty little secret is that industrial birth has never been about safety. It’s about control.

If you’re tired of being managed, measured, and handed back your own instincts in a paper cup, you’re in the right place. If this made you furious, good. Just remember paid subscribers keep the fury funded.

The free Diet Coke in the West Wing was the highlight of my day.

I am not joking. I would sprint over from my office multiple times before lunch to refill. I was in charge of health policy for the President of the United States, and my sole hydration was a product I’ve since described as fridge cigarettes. (I have since written a whole article about this. It is embarrassing. You should read it.)

That is who the 600 Pound Down podcast invited onto their show.

Coaches Justin and George are leading a weight loss and wellness movement comprised of people doing the hard, unglamorous work of actually changing their lives — not the Instagram version, the real version. Blue collar workers, middle class families, people who’ve been failed by the system and are figuring out what to do about it.

They are not policy wonks. They are not DC insiders. They are exactly the kind of people I spent two decades in Washington wanting to help.

So when they asked me to come on and just... tell the truth? I did.

We covered a lot of ground; here are a few of the highlights:

The medical cartel you’ve never heard of.

The AAMC, the American Association of Medical Colleges, is the trade group for medical schools. Their entire business model depends on scarcity.

Fewer doctors = higher salaries.

They fight like hell against any effort to open new medical schools, diversify curricula, or let anything other than petroleum-based pharmaceutical products count as medicine.

This isn’t conspiracy theory. I was lobbied by these people. I watched them frame issues for my colleagues before anyone else could get in the room. That’s how the game is played.

The Rockefellers figured this out in the 1930s. They needed a profitable use for petroleum byproducts. They commissioned the Flexner Report, which conveniently declared that the only legitimate medicine was the kind that prescribed petroleum-based pharmaceuticals - and formed state licensing boards to shut down every homeopathic, naturopathic, and osteopathic school that disagreed. The word “doctor” comes from the Latin for teacher, by the way. Not “prescriber of symptom-suppressing drugs.” Teacher.

We have been living inside that rebranding project ever since.

The PBMs are the real bond villains.

People assume the pharmaceutical manufacturers are the worst actors in this system. They’re not. They’re sub-demon tier. (A meaningful distinction.)

The real carnage is happening at the level of the middlemen - specifically the three PBMs that control 80% of the market: ExpressScripts, CVS Caremark, and OptumRx. Check your insurance card. If one of those logos is on it, your employer is being systematically robbed, and they probably don’t even know it.

In the Trump administration, a colleague of mine came in from the PBM industry to help us figure out how to lower drug prices. He put together a plan that would have cost the PBMs and pharmaceutical manufacturers real money.

He fell off a balcony in DC.

It was ruled a suicide. He had a family. Small kids. He was not miserable.

I’m not saying I know what happened. I’m saying nobody ever talked about it again.

Your body is not attacking you. It’s trying to save you.

We spent a long time on this one, because Justin and George’s audience lives it. The chronic pain, the infertility, the weight that won’t move no matter what. They are not random “failures.” They are your body doing exactly what it was designed to do when it thinks you’re being chased by a bear.

The problem is that the bear is your Instagram account. Your boss. Your commute. The fluorescent lights you’ve been sitting under for eight hours while eating from a vending machine because there was nothing else and you didn’t have time anyway.

Your body is not safe to reproduce. Your body is not safe to digest or detox. Your body is running every non-essential process on minimal power until the threat passes.

The threat doesn’t pass.

When I was a teenager with debilitating period symptoms, no doctor ever said: get more sleep, eat real food, reduce your stress, get outside. They just handed me birth control, which suppressed my symptoms beautifully while everything causing those symptoms festered for another two decades.

By the time I was ready to have children, the damage was done - well… maybe, but that’s a story for another time.

I am not anti-medicine. I want to be very clear about that. If you have a bullet in your belly, there is nowhere on earth I would rather be than a U.S. operating room. Broken arm? Go.

But chronic disease - the stuff that is killing us at scale, the stuff that half the country is now drowning in - conventional medicine cannot cure that. It can suppress it. Manage the decline. Slow the bleeding. But it cannot teach your body to heal, because it was never trained to do that, and the cartel that controls its curricula has a vested interest in making sure it never is.

Nobody is coming to save you from this. Washington is not coming. Your doctor is not coming.

They are working with the tools they have, inside a system designed to get paid only for those tools, and they mostly believe they’re doing the right thing.

You have to become the authority on your own body - and if you think about it honestly - you already are.

Which is either terrifying or the most liberating thing you’ve heard all week. I’m told it depends on the person.

If this kind of thing makes you furious (and it should), this is what we’re here for. Every piece I write is an attempt to hand you a weapon: something you can know, something you can do, some corner of this machine you can refuse to fund.

Several years ago I closed a deal to design and build the health plan for a publishing company headquartered in Manhattan. It was a mid-sized firm - about 1,200 employees - and the project would have been a multi-year engagement worth several million dollars. My company and a business partner’s company were teaming up to do the work. We had negotiated the terms, shaken hands, and the client’s lawyers were finishing the contract.

Then my business partner called. He was embarrassed - mortified, actually.

The client had called him - not me - and said they would move forward with the project only if I were removed from the team. Their lawyers had googled, and they didn’t like my views on “women’s health.”

This was interesting, because I didn’t actually have a public record on women’s health. What I had was a public record on abortion.

I had served as a health policy advisor to President Trump and to pro-life Senators before him. I had written and spoken openly about my pro-life views. I had helped defend the Little Sisters of the Poor when the Obama Administration tried to force them to buy birth control pills for their employees.

Apparently that was enough.

So I wrote a long letter to the woman who had been our main contact at the company. I explained all the ways my professional and personal life had served women and girls - from HIV/AIDS policy in foreign aid to anti-trafficking initiatives and inner city ministry with teen girls.

She never answered. The verdict had already been rendered. I was against “women’s health.”

Got it.

Women's Health™

For years, that phrase has functioned as a cowardly euphemism. It was the polite way to call pro-life women anti-woman. “Women’s health” became shorthand for exactly one thing: abortion. Well, that and its ugly step-child, hormonal contraception.

The vast mystery of the female body and mind - our hormones, metabolism, immune system, fertility, aging, and adaptations to environmental toxins or stressors - it was all shunted to the wayside. Women’s health = not being pregnant.

The most wondrous thing that women alone can do that men can’t, the most womanly thing we can do - carry and deliver a baby - had been defined as the central threat to women’s wellbeing. Preventing or terminating pregnancy was treated as the organizing principle of the entire field.

This narrowing didn’t just distort politics. It distorted the medical science. Entire areas of female biology were neglected, understudied, or dismissed while the debate over reproduction consumed the field.

That was then.

Something interesting is happening now.

It has been a banner year for women’s health. And by “women’s health,” of course, I mean, for once, women’s health.

The Estrogen Lie

Let’s start with the FDA’s dramatic reversal on hormone replacement therapy (HRT).

For more than twenty years women were warned - sternly and repeatedly - that estrogen was dangerous. (I mean, estrogen outside of a birth control pill, of course, which in that context is essential - ESSENTIAL - for women to be free. Or whatever.) Doctors delivered the message with the calm authority that accompanies “settled science.” Estrogen could cause breast cancer. It could cause strokes. It might cause heart disease. It might cause dementia. Women were told to avoid hormones unless the symptoms of menopause became absolutely unbearable. A black box warning - the FDA’s strongest alarm before pulling a product altogether - was placed on vaginal estrogen.

The obvious happened. Most women were gaslit and told their symptoms were normal - and were never even told their symptoms could be cured with HRT. Cured. Think about it - there are vanishingly few treatments in medicine that actually cure.

For women who were too “weak” to buck up through the hot flashes, insomnia, brain fog, joint pain, bone loss, mood swings, and the slow metabolic derailment that often accompanies menopause, an intrepid clinician might risk everything by prescribing the lowest possible dose for the shortest possible time.

This consensus was disseminated so confidently that few physicians stopped to question the originating evidence for it. Until Dr. Marty Makary wrote a book about the ways medical science has screwed up and killed people. His chapter on the unscientific defamation of HRT was devastating.

Now that Dr. Makary is FDA Commissioner, the agency recently convened an unprecedented roundtable on hormone replacement therapy and has finally pulled the black-box warnings that terrified two generations of women away from estrogen therapy. It was based on a press release written about a 2002 Women’s Health Initiative study, where the study didn’t find what the press release said it did - that estrogen therapy caused breast cancer and stroke. The lead investigator simply lied (as he admitted to Dr. Makary when interviewed for his book), because he truly believed the hypothesis that his study results had failed to validate. Several on the study’s author list dropped off, horrified at the gaslighting that would quickly spread like wildfire. Millions of women stopped taking what often feels like a miracle - almost overnight. Millions more were never even presented the option, and simply left to deal with the catastrophic consequences.

Commissioner Makary’s mom, as he tells it, was one of the victims of this religious dogma in practice. She suffered a painful fracture resulting from what was potentially preventable bone loss.

The episode should serve as a cautionary tale about scientific humility.

Medicine is extraordinarily good at projecting a confident authority that is usually undeserved and unfounded.

I’ll add one personal note here. I’m one of the women that needed to find a unicorn - an enlightened doctor - to prescribe enough HRT to actually produce the benefits it promises rather than the bare minimum to keep me from meltdown.

But the resurgence of HRT raises a larger question.

What Broke Our Hormones?

If a very large percentage of post-menopausal - and even perimenopausal - women need hormone replacement, what the bleep is going on?

Our ancestors, if they survived childbirth and poopy drinking water, lived long lives without the epidemic of hip fractures, metabolic dysfunction, morbid obesity, autoimmune disorders and hormone-related cancers that are decimating us today. God didn’t have to plant HRT trees in the Garden of Eden to keep menopausal women alive.

So why do we suddenly need it so badly? This question is screaming out for attention - because the answer is no doubt upstream from the modern woman’s quest for competent pharmaceutical endocrinology.

Over the past several decades our microbiomes have been annihilated by antibiotics, hand sanitizer and other antiseptic products, and for a third of us, C-sections (which prevent the critical initial microbiome seeding occurring in mom’s birth canal). Meanwhile, our bodies are swimming in and teeming with endocrine-disrupting chemicals: microplastics, PFAS “forever chemicals,” pesticide residues, and industrial compounds designed to mimic or interfere with human hormones. Many of these chemicals behave like synthetic hormones once they enter the bloodstream.

These poisons are in our water, our food and its packaging, our cosmetics, shampoo, lotion, deodorant, dental floss, our bras, panties and tampons. And our carpets, our couches, laundry detergent, dish soap, children’s bedding, cookware, literally everything. These are not chemical exposures our foremothers experienced.

We are conducting a planetary experiment in endocrine disruption.

So yeah, our daughters are bent over in agony during their periods, our sisters are being referred to IVF to bypass extinction-level infertility rates, we are clawing at our OB/GYNs for prescribed menopause relief, and our mothers are cracking their hips from standing up wrong.

Could it be that maybe abortion and contraception sucked up all the oxygen in the women’s health conversation so long that the scientific enterprise that could have been exposing these problems and offering policy and therapeutic solutions went into hibernation?

Well, as I mentioned… that was then.

Washington Finally Showed Up

Something happened in Washington policy circles last week that took me by surprise. And that’s really hard to do, because I’ve been around the block.

HHS convened a three-day conference devoted to women’s health - not abortion or other culture-war politics, but the physical and mental health of women across the lifespan. The agenda included:

• Menopause and the lying liars who harmed our mothers

• Bone health and the underprescription malpractice

• Mental health and the calamity caused by SSRIs (taken by a quarter of all women)

• Autoimmune disease decimating young women

• Metabolic dysfunction and cardiovascular risk in women that has made our population literally unrecognizable physically from our ancestors

• Infertility and the miracles that can heal (not just work around) it.

Abortion wasn’t the organizing theme.

For anyone familiar with Washington health policy, that alone was remarkable.

The atmosphere was equally unusual. If you’ve spent enough time in Washington policy circles, you develop a finely tuned radar for hierarchy. You know instantly who the Important People are supposed to be. You know who gets fawned over, who gets ignored, and who everyone is supposed to pretend is brilliant.

Government officials are walled off in green rooms - with their staff making themselves invisible - until they give their keynotes. Researchers sit on panels on the dais, boring everyone to tears. Activists sit in the audience, desperate for anyone to acknowledge the cause they’re living and dying for. Administration loyalists are invited to fill the seats and clap like seals. Everything is choreographed and segregated.

That dynamic simply wasn’t present.

Senior government officials mingled easily with scientists and clinicians. Younger researchers spoke comfortably with policymakers. Activists were honored and included on the panels. Even lifelong staffers got their own panel. Conversations moved freely across institutional lines. Partisan jerseys were left at the door. Nobody was treated like a celebrity. Nobody was treated like a nobody.

It felt like a real scientific meeting.

And credit where it’s due: this HHS deserves recognition for convening it. The event was collaborative, intellectually curious, and refreshingly free of the ideological scripts and formulas that usually dominate these types of events.

I’ll admit something embarrassing - standing there among them, I felt a little out of place. I was the only one bringing grizzled, jaded, seen-it-all, cynicism to the room, searching for the things that would no doubt annoy me. But all the smiles and breaths of fresh air hammered chinks into my usual armor.

What struck me most was the tone of the scientists themselves. Many of them have spent years studying aspects of womanhood that are paramount priorities in the lives of half the population (and the other half who love them), but have historically received little funding or attention. They were literally sparkling with enthusiasm, earnest in their optimism, grateful to be invited and consulted, impressed by all the other attendees, collaborative and eager to connect with new allies, and humble about what we still don’t know.

That humility was striking.

Because the medical profession has not always been known for it. Medical students get about five minutes of epidemiology and then spend the rest of their careers talking down to patients about “The Science.” Their toolkit of drugs and cutting has such an abysmal record of healing and curing, you would think there would be more modesty and curiosity about what we’re missing.

The HRT debacle, now being righted, is a reminder of why curiosity matters. Because now that we’re no longer fighting about whether we need it, the more ominous and challenging question lurking of why so damned many of us need it, might get the next dose of desperately needed attention.

The answers to that question - how literally everything in our environment is novel in the human experience, and is destroying our health - will be uncomfortable and will require political courage like we’ve never seen. The conglomerated interests aligned against the policy solutions to these problems will be of epic proportions and, frankly, demonic power.

And who do demons fear the most?

Yeah, HER. Maiden and Mother.

It will take a dedicated community of strong and righteous Wonder Women and Warrior Princesses to save the world.

Let’s get healing.

Oceans are such wise teachers. They immediately communicate reality - that you are small, that life is dangerous, wild, adventurous, exhilarating, peaceful and soothing, all at once. A few days in front of one has provided the opportunity to observe some truths about humanity - our soul, our purpose, our nature.

Specifically, boys and young men.

I’m not sure I believe in school for boys. Boys can be taught to read and do basic math without going to school. Everything else can be learned through curiosity and imitation and necessity and internal drive. Otherwise, their souls die.

Boys are meant for adventure. For doing crazy, dangerous $@%#. For potty jokes and testing the power of their arms and legs and endurance. For competing until they pass out. For running wild, as fast as they can, after a wave or a seagull or a bug. For playing games over and over and over again.

They are made to imitate men.

This is their education, for better or worse (choose wisely, women). Boys are built to watch and beg to try and do it themselves and participate. How to hook the bait, how to spool the fishing rod, how to shuffle the cards, how to stay standing on a moving boat.

They want to do it. They want to try. When they fail, they want to be shown how not to fail by a man (not a woman).

When they’re out of control, as they tend to be, they respond primarily to a man telling them so, honestly, sternly, sometimes a little too frankly for a woman’s taste.

This is the animal kingdom.

Young men are being killed by our culture and its norms.

My state, like many states, makes cannabis available everywhere in all ways and places. Not your granddaddy’s weed, at 15% THC. These are synthetically manufactured 85% THC oils and products, infused with endocrine-disrupting fragrances and flavors, burned directly into the lungs and, from there, changing the brains, spirits, and organs of our young men at a scale never seen in human history.

Their drive, their ambition, their adventurous souls are being snuffed out by these toxic levels of “sedative,” in the name of something “natural,” “plant-based” and “just like a beer” to help relax and deal with the pressures of modern life.

As young men, the boundless energy and curiosity, adventure and out-of-control-ness - so innocent and adorable at five or seven years old - are still in there, often manifesting as intense emotions, anxieties, hyperactivity, destructive tendencies.

These are now problems needing cures, control, suppression - they don’t serve them well in prison school or their mindless, entry-level jobs where they’re supposed to behave, sit still, conform and obey.

Minimum wage in hyperinflationary metropolitan areas makes it nearly impossible for a young man to get ahead, or even to pay today’s bills. Saving, investing, owning - those are so out of reach and imagination that he doesn’t even dream or plan for them.

And yet.

Young men can still emerge from the vaping, gaming, minimum-wage grinding basement of their lives into the sunshine of a coastline that offers an enticing challenge, wave after crashing wave.

Their desire to conquer and master nature, whether by paddleboard, fishing line, or fire pit, dribbles out hope that the man they’re meant to be has not been altogether suffocated.

Monosyllabic communications turn into complete sentences. Zombie visages can melt into smiles like a sunrise. Disinterest in others can turn into coaching, correcting, ribbing, connecting.

With no one else to engage with, he can turn to the little ones as playmates.

Will he go too far? Will he be too harsh? As he cajoles the scared little girl into the ocean, as he picks her up to bring her to his playground, he doesn’t force or coerce. She cries. He puts her down and lets her make her own choice.

The masculine dignity that is both powerful and kind is in there. It’s been in there, waiting for the rhythms and majesty of nature to blow away the cobwebs of the modern poisons on the soul of man.

I say to the parents out there: it is worth being totally different. It is worth being annoying and weird. It is worth protecting the influence of nature (outside of them and within them) on your sons.

Keep them away from fluorescent lit prisons run by adults who don’t love them, and populated by children you don’t want them imitating. This is not the way they should spend the majority of time that the sun is up.

Keep their bare feet on the ground, and their eyes squinted at the sun, their hair stringy from the rain, their fingernails dirty. Tell them stories around a fire, read them books born of adventure, teach them to use dangerous tools and do dangerous things. After a certain age, let their fathers and brothers and uncles and grandpas be their heroes and helpers and primary teachers of most stuff.

Humans are not built for gaggles of little boys to be caged behind a desk or sitting still in a circle, raising hands and repeating canned answers asked by a kind-faced woman who shares no history with them. Who wasn’t there at their birth or who doesn’t see through the dirt-smeared face to admire the heart of a lion that only comes out in private moments.

Manhood is scary as hell. It requires risk and failure and humiliation. Anyone sensible, if left to his own devices, will seek to avoid that hard stuff, or medicate the anxiety of it with escapist screens or psychoactive chemicals - drugs, booze, ultra-processed food. That is obviously much, much easier than becoming a man.

(Nota bene: A nagging woman criticizing all this as it happens in front of her doesn’t change the trajectory, it only intensifies his impulse to hide from his birthright.)

Put a bunch of “peers” facing the same terrors and pressures together and see new heights of slavery and destruction caused by the worst habits metastasizing, ritualizing into elaborate self-justification schemes, unchallenged by reality or wisdom.

Humans are not built for armies of teenaged boys and young men to be isolated with each other, building their subcultures of misunderstandings, misplaced values, and mind-numbing habits. They’re meant to run with the men, and the little boys, in the sun and the rain, and to build things, to learn things that are useful, to teach those things to the younger ones, with their muscles and minds engaged.

As they read and watch and learn, those who are destined to pursue more formal education will emerge. Most already reject “higher education” as neither high nor educational in the things that matter or that give them a reason to get out of bed.

Over time, imitation and experimentation become skills, initiation becomes apprenticeship, and play transforms into something that some might call work, but that he calls a purpose. That something - it makes him useful and interesting to a woman, and eventually indispensable to her and the little ones who start the cycle of wonder all over again.

That feeling of being useful and needed and admired - that is the jet fuel for the masculine soul.

Many of us women know this, but we don’t know how to draw it out from what seems like an already-crushed soul of a son, a brother, a husband, a father. All we have on offer seems to come out as judgment.

And so I offer this to my sisters: you control the family schedule.

Take them away from school and “jobs.” These prisons will wait, even if they say they won’t. Even if these places threaten bad things if you do it. They are the bad things.

Bring them to the sun. To the mountains. To the water. To the woods. It may take a few days or longer for them to emerge. Which will annoy you. Be patient.

Do things that require their help, their muscles, their hands. Ask them to take the little ones into nature for a few hours, as a favor to you. Let them make all the decisions about what that looks like. Do your nails while you bask in the sun or rock on a porch or gossip with your mom. Be happy.

You are the writer of their destiny. You are the maker of worlds. You are the mother of men.

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I was about to fire another vendor.

They weren’t delivering for my client - a group of Catholic nuns who were my very first client, and still dear to my heart. (I spent two years as one of them during a phase of my Senate career that made me want to fake my own death, run away to the nunnery and never speak to another lobbyist. So… I pretty much did.)

I eventually learned what everyone who’d ever met me already knew: I am not cut out for a life of asceticism and obedience.

But when I realized I could help the sisters stop getting mugged in broad daylight by double-digit Blue Cross rate hikes year after year, I figured I could at least rack up some points on the ol’ heavenly ledger (where the deficit was starting to show).

The Holy Trinity of Vendor Firings

I helped the sisters:

• Fire Blue Cross and replace with an independent plan administrator,

• Fire ExpressScripts (one of the corrupt “Big-3 PBMs”) and replace with a transparent, fiduciary PBM,

• Fire their conflicted, commissioned broker, and replace with, well, me.

Then we launched my first - and last - reference-based pricing plan.

For the non-biz readers, here’s what that means: instead of using a network where prices are set in secret contracts between carriers and providers, we set a rate that was a percentage above Medicare’s rates. Providers sent sticker-price bills, we paid the Medicare-based amount, and then we negotiated if they refused.

Result: the sisters saved 30 percent in year one, and they’ve continued saving every year.

Also: I gained a permanent twitch in my left eye.

The Part They Don’t Put On The Sales Slide

Reference-based pricing can work. It can also be… how do I say this delicately… a liturgical reenactment of the Passion.

Doctors and hospitals don’t love “take it or leave it” pricing. And if the sister can even get an appointment (major friction point), providers often bill her for the difference between the plan payment and the sticker price.

Which means the success of this kind of plan is almost entirely dependent on whether your vendor stack can actually execute the unglamorous, unsexy, “someone has to do it” work:

• Help providers understand the plan (that they’ve never heard of) and accept it — so the sister can even get in the door

• Confirm eligibility/coverage when providers call

• Get prior auths done quickly and correctly

• Negotiate one-off or group agreements and reprice bills to contracted rates

• Receive bills and reprice them against Medicare-based terms

• Fight balance bills fast, erase them when appropriate, and still protect against being fleeced

• Pay the repriced amount and any negotiated resolution amount

In a normal carrier plan, all of that happens inside the carrier borg. It feels seamless to the patient, even as the hidden kickbacks, profit-shifting, and even illegal fiduciary violations abound.

In an unbundled plan design, it’s spread across multiple vendors - plan administrator (TPA), PBM, prior-auth team, repricer, negotiators, lawyers - and now, rented networks. Yes, I’m done with reference-based pricing plans because of all the pain points. We rent a network now for our plans, and then work hard to steer patients around it and within it to highest-quality sites of care.

Regardless, network or no-network, these unbundled plans require intense oversight.

And that changes things, whether you’re a benefits advisor like me, an employer like my clients, a health care provider, or a vendor that serves these plans.

Congratulations, You’re Now The Quarterback (And The Offensive Line)

Most benefits advisors are basically messenger/middlemen between the client and the carrier. In practice? Often the carrier’s sales force wearing a “trusted advisor” costume.

In an unbundled plan, the advisor has to put in way more effort, in order to quarterback:

• running procurement,

• negotiating contracts,

• integrating vendors,

• building workflows,

• enforcing performance,

• and catching grenades at 9:47pm on a Sunday.

When it works, you save money and improve quality. Of course, when it doesn’t, everyone wants to fire everyone.

We All Need an Honest Coach

After the White House, I looked at the usual post-government career options for someone with my resume.

It wasn’t pretty: industry shillery.

No chance.

I’d met Health Rosetta - part nonprofit, part vendor, part revolution - while I was on the inside. They are a community of advisors building self-funded plans that ditch the carrier “bonus and commission” machine and actually act like fiduciaries. They helped me build my practice without having to sell my soul or pretend I didn’t notice the incentive rot.

A Health Rosetta leader - a seasoned plan administration veteran - called me when I was mid-rage, ready to fire a vendor.

She listened. Patiently.

Then she said:

“The problem is you.”

She was probably more diplomatic than that, but that’s what I heard.

Not because I was personally failing on balance bill resolution or overcoming scheduling friction. But because my job was to design and oversee client-specific workflows so tight that the gaps couldn’t swallow people whole.

She stepped in and worked with the plan vendors and me, modeling what this looks like, and we got years more out of that vendor without a disruptive replacement.

Generous mentors are gold in this business.

And over time, I learned something else: it’s often easier to blame people than it is to fix process, incentives, contracts, and workflow design. The demagoguery and “othering” of various parties - that had occasionally helped drive my policy agenda in government - weren’t as useful in the real world of mostly good people serving these unbundled, independent health plans.

I’ve picked up more strategies over the years. This post is about how to avoid unnecessary vendor divorces - and how to vet partners like a ninja.

Because in unbundled plans, you’re quarterbacking what feels like an army. It’s never perfect. But I’d still take this chaos over the status-quo pillagery of off-the-shelf, non-fiduciary, high-cost, sick-care plans.

I like sleeping at night.

If you use this step-by-step guide, you’ll stand out as ten times better than your competitors and peers, whether you’re a plan sponsor, an advisor, regulator or plan partner/vendor.

You’ll spot the landmines early and avoid them. Paid subscribers get the full ninja training.

And while there’s plenty of time to make your own mistakes - can you really afford to repeat mine?

Vendor Vetting Like A Ninja (So You Don’t Get Stabbed By Your Own Stack)

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If you’ve been paying attention to your humble correspondent’s musings of the last two weeks, you might have noticed some, shall we say, animus, toward hospitals.

Like, “may everything about the totalitarian culture and corrupt and abusive business model of the modern American hospital system burn to the ground and salt the earth with its ashes” - you know, that kind of animus.

Loyal readers may even recall that I urged Congressional Republicans to outlaw the anticompetitive contract provisions between hospitals and health plans that prohibit plans from navigating patients away from price-gouging doctors and facilities of substandard quality.

One thing I forgot to mention - anticompetitive practices are already illegal, under the Sherman Act. It’s easy to forget that because DOJ’s antitrust division NEVER EVER ENFORCES this law against hospitals.

I know, because when I worked in the White House, we were very interested in seeing that change. So we hauled in DOJ’s Antitrust Division. They said “well, we only focus on horizontal monopolies, like when one hospital eats another hospital. Go see FTC.” So then we hauled in FTC. They said “well, we only focus on for-profit companies, and most hospitals are technically (very technically) not-for-profit. Go see DOJ.”

Maddening.

Later, when we were pushing for hospital price transparency, FTC pushed out an old blog post they had published under the Obama administration that argued that price transparency would increase prices. Because that happens in every other industry where prices are known in advance. Oh wait, no it doesn’t.

So yeah, these guys were on Team Hospital, and not Team America.

But times have changed.

Last week, the Department of Justice and the State of Ohio sued OhioHealth, the dominant health system in the state capital of Columbus, and surrounding counties. The complaint? Anticompetitive practices driving up prices and lowering clinical quality for patients and employers.

You guys, this lawsuit is a miracle. It’s chicken soup for the health reformer soul.

Let’s take a lackadaisical stroll through the 25 pages of government at its best, shall we?

America’s original “stop acting like a cartel” law

First, a primer on the Sherman Act, which is America’s original “stop acting like a cartel” law. If you’re conspiring to rig the market, fix prices, carve up territory, or otherwise strangle competition, congratulations - you may have just volunteered for federal court. It’s the statute that tells monopolists and their little friends: compete or get enjoined.

The government accuses OhioHealth of conspiring to choke competition from other hospitals and to prevent health plans from offering lower-cost, higher-quality coverage options that exclude OhioHealth’s shoddy care and way-above-market rates. These shenanigans, implemented primarily through corrupt and allegedly illegal contract provisions with health plans, have driven up the cost of both care and coverage in Columbus.

But even if you’re nowhere near Columbus, you can’t afford to click away yet. What OhioHealth is doing matters to all of us. It’s happening everywhere. And what the court decides here will change hospital and network contracts across the country - for good.

If you keep reading, you’ll get the list of what employers, health plans, network sponsors, policy makers, everyday citizens, and hospitals and other providers who contract with networks need to be doing right now to prepare for the fallout.

Paid subscribers get the inside scoop.

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Everything that happened to my dying sister in that hospital was legal, standard, and indefensible.

She’d been in her local hospital for the past week. The giant tumor overtaking her pelvis had become unbearable with the weak pain management by her oncologist. So she went to the nearest ER and was admitted.

(Obviously a failure of medical oncology here, but that’s an article for another time).

She also happened to have a massive, radical surgery planned for the following week. They had already surgically bypassed her cancer-ridden colon in favor of a “stomach poop bag” as she called it. But this new surgery was going to go in to get the tumor out “for good.” Her bladder, uterus, vagina, cervix would all be removed in the process. Her confident surgeon said “we’re going for the ‘cure’ on this one,” so we were all hopeful.

(Obviously a failure of surgical oncology here, in imposing their wishful thinking on patients and loved ones, but that too is an article for another time.)

She would need to be strong to get through that.

Since she couldn’t eat, couldn’t sleep and was fading quickly under the pain, she had made the rational choice to spend the week before her surgery in the hospital having her pain actively managed, and IV nutrition provided so that she could rest and prepare. It made some perverse sense in our degenerate system.

At the time, I was President Trump’s lead health advisor on the White House Domestic Policy Council. My career had been in health policy and public health. So I was a pretty informed and aggressive competent patient advocate.

The inpatient admission was largely a fail.

The meds were never adequate to manage her pain, there was never a doctor available to adjust them, the interventional pain specialist couldn’t come over to do the nerve block until most of the week was over - so she wasn’t resting. She was constantly interrupted by useless and unnecessary vitals checks (we can monitor the vitals of astronauts from space. What the hell with the interruptions?). Beeping. Announcements. Fluorescent lighting.

What she desperately did need - competent and timely pain management - was always too little, too late.

Her big surgery was taking place at the flagship facility of the system she was in, about a half-hour away. We assumed she’d be transferred the day before or the morning of, by ambulance. Two days before, we were informed she was going to be transferred that evening. I objected: by the time we arrived, the real doctors would be gone for the night, the transition wouldn’t be great, she’d had such a bad week already, and had only just gotten the nerve block that allowed her to rest.

Why not put off the transfer as long as possible? “Well, there’s a bed open now. We can’t guarantee that there will be a bed right before her surgery and if not, we’ll have to cancel her surgery (that she’d waited months for).”

I didn’t buy it.

They could transfer her straight to the surgery check-in the morning of and then she’d be admitted inpatient right after. They could transfer her early in the day tomorrow. There was no need to risk a bad transition for such a fragile patient who needed to rest. I called my sister’s surgeon, and her on-call colleague called me back. She assured me it would be fine - my sister’s pain meds wouldn’t wear off and would be managed - she’d make sure of it.

The ambulance was delayed and it was now the dead of night. I called her back pleading that she intervene - why couldn’t this wait until the morning when the hospital would be bustling with full clinical staff? She was mad at being awakened and implied I shouldn’t call her again.

What happened next was the worst night of my life.

My sister had many bad nights in her short life, so I can’t say if this was the worst for her, but if not, it was close.

The ambulance ride was unbearable. But that would likely have been true no matter when it happened. On arrival, there was no bed available in the surgical unit where she was supposed to be admitted, so they stashed her in some empty corner of the neurology floor.

To say the transition went badly would be an understatement.

There was no continuity of care. Nobody knew anything about her when she arrived. There was no doctor anywhere to be found. There were no pain meds. She might as well have been dumped at a bus stop.

She was screaming in agony, begging me to do something.

The nurses were apologetic but powerless to deliver an actual prescriber of any sort to the room. There was only one hospitalist in the entire building and he was busy in the ER. For hours.

I found this out because, like a crazy person, I literally ran from floor to floor of the entire hospital, trying to find an oncology or surgical wing where they knew how to manage pain. I went to every single nursing station demanding someone with prescribing power - crying, desperate, enraged, frantic. I was about 5 seconds from having security called on me.

None of it made a damned bit of difference.

I finally retreated back to my sister’s bedside, since, if she was going to suffer so much, the least I could do was be there and hold her hand. While I waited, I tweeted my rage, tagging the hospital. I called the chief lobbyist for the American Hospital Association - a wonderful human and longtime friend of our family - to try to get hold of the hospital’s leadership.

A few hours later, the doctor was freed up and prescribed the first pain meds my sister received in eight hours.

Early that morning, I stepped out to make some calls. When I came back, it was clear that that some of my overnight tweeting and networking had gotten through. The on-call surgeon I’d spoken to - she of the broken promises - and various hospital suits, were all crowded in my sister’s room. I was too broken and filled with white-hot fury to even speak.

If one of the most “powerful” health officials in the country couldn’t save a patient from this malpractice, what possible chance does anyone else have?

Hospitals don’t just torture us at the end of life - their mediocrities and incompetencies are on full display at the beginning of life too.

Last year, my daughter was due with her third baby.

She’d been induced with her first two babies, and so when her water broke naturally, she panicked. What does one do, when labor starts on its own, dear God in heaven?!

We showed up at the hospital about an hour later at 3 cm - the same dilation she’d been days before at her last prenatal visit. The right thing to do? Send her home to labor naturally until things got real. That’s what they used to do, decades ago. But then babies might accidentally, you know, come out without the hospital cash register dinging in the background.

So, instead, they strap her in. First the IVs. Why can’t she feed and hydrate herself? She’s completely healthy. Oh right, because the c-section rate is so disgracefully high in this country that they starve laboring women for hours and hours on the not-so-off chance that they end up in surgery.

Then the fetal monitor which, despite our ability to land on the moon, is completely beyond our powers to keep in place on a big belly. Constant interruptions because the stupid monitor strap has moved.

Why do you need to monitor? This is a low-risk, no-drama situation.

“It’s protocol.”

What is the evidence of fetal monitoring improving outcomes rather than hastening the imposition of dangerous interventions?

Blank stare. “It’s protocol.”

What if she refuses?

“She can’t. It’s protocol.”

No really, what if she refuses?

“She can’t deliver here.”

So she can just walk out of here?

“Well, we’d have to call CPS.”

Ah yes, the CPS card.

And so, like clockwork, the cascade of interventions began. First, of course, since she wasn’t actually in active labor (remember the 3 cm?), she was just sitting there for a few hours while nothing happened. Taking up a bed. Unacceptable.

Time for “augmentation.” That’s when they jack you up with pitocin - a synthetic counterfeit of the natural hormone oxytocin that is responsible for regulating uterine contractions to correspond with the rest of the hormonal symphony present in physiological birth (which no L&D doctor or nurse has ever actually observed).

Pitocin, unlike oxytocin, doesn’t wax and wane with the needs of the bodies involved, and instead just asserts itself aggressively and immediately. Unnatural, shocking, and unbearable contractions start within 30-60 minutes. Not the natural kind that gradually grow and build on each other, productively moving the baby when the rest of the body is ready.

My daughter was no exception. And so of course, the epidural.

The vast majority (like 80-90 percent) of women given pitocin end up with an epidural - almost 25-50 percent more than those not given pitocin.

Epidurals stop or slow the contractions. And often the baby’s heart rate. Failure to progress. Fetal distress. So then, emergency c-section. See how this works?

I’m sure it has nothing to do with how the hospital makes more money if they can move women through the process in 12 hours, ending with a (dangerous, expensive) invasive surgery, and on to the next lady. Rather than sitting with a mother’s labor for the 48-72 hours it might naturally take under the oxytocin-suppressing hospital conditions.

Every mammal on earth retreats to dark, enclosed, solitude to birth their young.

That is the optimal environment of safety that signals their hormonal symphony to get to work. Any bright light, interruption or the slightest stress (caused by observation of others, noises in the woods, etc) causes cortisol to spike. Cortisol shuts off oxytocin. Uterine contractions slow or stop until the animal is safe again.

So you can imagine the cortisol/oxytocin impact of bright, fluorescent lighting, beeping, constant interruptions, monitoring, observation, and an entire culture built around fear-mongering this process as a medical, life-threatening emergency.

No wonder we have the highest, most disgraceful, most scandalous c-section rate of any nation on earth. Babies don’t come out easily under these conditions.

In my daughter’s case, that wasn’t going to happen. That’s why I was there.

Even still, after my granddaughter was born without a c-section, the shenanigans continued.

Mom and baby were moved up to a different unit at 1:00 am, naturally exhausted and wanting to just snuggle and sleep. The new nurse comes in with a clipboard and insists on explaining how we need to keep track on this complex chart of the timing and amount of each poop and pee drop, each feeding, for how long, on which boob, and we have to make sure there’s no feeding the baby within an hour of the three-hour glucose heel-prick, and on and on.

The nurse was actually surprised and butt-hurt when we told her, politely, to buzz off.

We will not be doing your chart-tracking. We will not be following your instructions. Leave us alone until morning.

They did not comply. That night was so miserable for my daughter, with the beeping and lighting and constant interruptions, she got no rest. In the morning, she had decided that it was neither good for her nor her daughter to spend another night there. Even though the hospital revenue model “protocol” demanded two nights.

Thank goodness I had warned her about the CPS card before they played it, or she might have buckled in shock. But she was prepared, and I was never so proud as when she stood her ground. We left that afternoon.

They did call CPS. Because, of course they did.

My daughter swatted that away later, but the totalitarianism of the mindless, and often dangerous hospital rituals knows no bounds.

Every family has these stories, to our nation’s great and calamitous shame.

My father’s heart condition means my family has spent many, many hours, days and weeks observing the bureaucratic banalities of a Soviet-style system:

• Patient menus and cafeterias with nothing but processed, pesticide-soaked offerings. Heart patients are forbidden to order steak but required to consume “heart-healthy” concoctions riddled with seed oils, sugar, petroleum-based food dyes and refined carbs.

• Windows locked to exclude fresh air, unfiltered sunlight and the healing sounds of birds and rustling leaves.

• Dehumanizing prison garb for patients that strips them of their dignity, warmth and comfort.

• Protocols written by lawyers rather than humans, such as “fall prevention” implemented as heart-attack-inducing alarm-blaring and stern ninnying from nurses, when a grown-up dares to rise from a bed.

• Disrupted rest in the form of hourly vitals checks, beeping machines that alarm if a tube twists wrong, fluorescent lighting that can’t be fully turned off.

• The pretense of clinical oversight without the presence of actual clinical oversight. Armies of scrub-wearers constantly circling, but disempowered to adjust prescriptions and dietary orders, waive senseless protocols, and otherwise exercise discretion. This is particularly egregious in the off-hours, when it’s not uncommon for a facility to have one clinical decision-maker onsite.

• Revenue-driven and convenience-driven protocols such as drugging or cutting a baby out of its mother prematurely, or transferring medically fragile patients overnight unnecessarily.

• Death-by-hospital:

  • Between 44,000-98,000 preventable deaths per year.

  • A maternal mortality rate more than twice the average of developed nations - four or five times the rate of many of our peer nations, as well as 25 percent higher infant mortality than the average for developed countries. (OECD)

  • Almost 2 million hospital-acquired infections per year, killing 100,000 patients. (CDC)

In short, this is a business model that should be burned to the ground. It is unfit for human participation. It is incompatible with health or healing.

Hospitals do not provide health care. They’re where you go when health care has already failed.

They monetize and capitalize on our extinction-level chronic illness rates. They invent reasons for their own existence, such as convincing the world that mammalian birth is a medical emergency. They have to threaten you with the government stealing your children just to keep you there.

There is an important caveat here: mechanics.

When you have a bullet in your belly, a third-degree burn, or a bone sticking out, you need a skilled mechanic waiting in the OR next to the ER. When you’re having a stroke or a heart attack, an American ER is just the place to be. When one of those patients doesn’t make it, you want their organs transplanted into someone who might, waiting in the OR down the hall.

There might be a few other use cases I’ve forgotten, but by and large, that’s it. The rest of the giant compound sitting on multiple acres of tax-free real estate is just a profit center of misery, selling a false sense of blue-lit security.

The life-saving, acute services that are valuable are not profitable. They cannot be made profitable.

They require an expensive crew of high-skill labor, cutting edge technology, the most expensive forms of ground and air transport, with 24/7/365 access for a catchment area that does not produce enough of these needs each year to recoup costs.

The rest of the hospital complex has been created to subsidize it.

Growing year over year, the amount of high-cost stuff done to sick people is where the profit is. Stuff that doesn’t have to be done in a hospital. Stuff that turns out worse when the abusive culture of a hospital is infused into patient experience.

When ten people with broken bodies arrive at an ER after a multi-car pileup, the protocols and procedures must be rigid and enforced, because there’s no time and no room for error. This is the theory behind military discipline, whether in Fallujah or your local trauma bay - where the stakes are so high and the crisis so kinetic.

But that culture of top-down authoritarianism loses all appropriateness and perspective when the stakes are routine, such as elective surgeries, cancer palliation, birthing babies. Nonetheless, the culture created for the trauma context infuses the entire complex so overwhelmingly as to inhibit or reverse healing and health rather than protect it.

Not to mention the cost.

What cannot be sustained will not be.

Fortunately, technology is emerging just in time to save us from these totalitarian bureaucracies we call “health” systems.

Increasingly, the hospital is being unbundled into solutions that are based at home, where value is rewarded in the form of greater dignity, comfort, nourishing food, incandescent lighting, and peace and quiet (or the health-promoting chaos of grandkids and goldendoodles). This model promises to produce better outcomes than the overpriced, Soviet-style hellscape we’ve been tolerating.

Decentralized solutions and vendors are now able to bill your health plan for true hospital-level care in the home: IV antibiotics, oxygen, imaging, daily physician oversight. Tools like continuous glucose monitors, Holter monitors and cardiac patches, and wearables like Oura rings turn episodic vital-sign snapshots into continuous streams of data. We’re even starting to be able to do imaging with handheld devices at home. Home-based lab draws are already becoming mainstream.

Tele-ICUs, at-home monitoring, virtual-first care models, predictive algorithms that detect deterioration before crisis - all of it is overthrowing the hospital-based religious cult that has us cowed in our paper gowns with our butts hanging out.

Right-sizing hospitals to true emergencies and intensive rescue will destroy their business model. It will preserve the least profitable services and replace the most profitable ones with more efficient, more humanity-compatible models in the home and community where healing is far more likely and affordable.

Policy-makers will need to decide what that means.

Maybe if we’re not subsidizing the behemoth, tax-exempt compounds charging facility fees for routine care, we’ll be able to more generously subsidize the urban and rural ERs that are struggling to keep their doors open.

This transformation can’t happen fast enough.

Between the predatory collections and billing practices I wrote about in my last piece, and the soulless torment of fragile patients like my sister, the world would be better without the vast majority of what hospitals are inflicting on us every day.

But dismantling a failing system requires more than my white-hot fury.

It requires reimbursement reform that stops cross-subsidizing bureaucratic sprawl.

It requires site-neutral payments that end the incentive to drag routine care into the most expensive square footage in America.

It requires regulatory relief that allows hospital-at-home models, independent surgical centers, community birth centers, home birth attendants, and virtual-first care to compete on equal footing.

And it requires political courage. Hospitals are usually the largest employer in every congressional district. Protecting their current business model is not the same thing as protecting patients.

We do not have to accept the ungodly status quo as the price of modernity. We do not have to confuse bureaucracy with safety, or institutional control with care. Systems built by human beings can be dismantled and rebuilt by human beings - this time around dignity, autonomy, and actual healing.

All Soviet empires must fall.

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A quick note before we get into it.

My last couple of articles were in the weeds — PBM reform, insurance market mechanics, the government shutdown drama — the stuff that makes benefits advisors and policy wonks nod along.

This one is for everyone else.

And for the experts on the inside, this is the article you send to your mom. Your neighbor. Your buddy who just got a $14,000 bill for an ER visit where they gave him Tylenol and told him to follow up with his doctor.

This is for the people you love who are still getting taken advantage of by these corporate conglomerates — the people you won’t always be around to fight for.

I have a dream… that one day there will be a single, transparent, competitive cash price for every health care service, with no games, no exploitation and no financial abuse. Until then, consider this a cheat sheet. Print it out. Send it to everyone you know. Stick it on the fridge. Because the system is not going to hand patients this information voluntarily and they freaking need it.

For those of you who don’t know me yet… Hi! I’m Katy.

I’ve spent enough years inside health care policy to figure out exactly where and how the money moves.

I've been in this fight from the Senate, the White House, my sister's hospital bed, my granddaughter’s birth, my own home office. I've worked on Medicare reimbursement rules, negotiated with hospitals, fired insurers, and helped write the laws that were supposed to protect patients from price gouging and surprise bills.

I understand how claims get paid, how hospitals set prices, and how the contracts between insurers and providers actually work behind the scenes.

And even with all of that knowledge, I still get gouged if I don’t walk into the system loaded for bear.

No one is immune.

Because the system is built to assume your inattention — and to exploit it. So if you show up passively, sign whatever they put in front of you, and assume the bill that shows up six months later is what you actually owe, you will almost certainly overpay.

Not by a little. By a lot. It’s practically guaranteed.

Here’s how they run their scheme:

You’re in the ER. You’re in that gown — the paper napkin designed to make every human being on earth feel like a large, drafty toddler. You’re in pain, or scared, probably both. A girl about 20 years old wheels her computer over to your bedside: “I just need you to sign a few things while you wait for the doctor.”

Then you sign. Of course you sign.

Because you’re sitting in an emergency room and this is not the moment you expected to become a contract attorney. So you just do what you’re told. You submit. That’s exactly what they’re counting on.

If you’re not in an ER, but rather a doctor’s office, the assault might come in the forms given to you on an iPad rather than the workstation on wheels.

Buried in those forms is your consent - not just to be treated today, but to be charged whatever they feel like charging. To assent that, whatever your insurance doesn’t pay is on you. At whatever price. Regardless of what’s fair (or if you can afford to pay it). Because the billing Borg spits out whatever price it wants (or thinks it can get away with), and you just signed away your right to argue about it later.

I know this because I helped write the very rules that were supposed to stop this practice. Most of you have no idea those rules exist — much less that they handed you actual weapons.

So let’s fix that — right here, right now. What follows is your step-by-step guide to stopping the pillage.

Before You Walk In: Know More than They Do

When you go to the manicure place, they have a price list on the wall. The grocery store. The salon. The dry cleaner. All have prices visible before you buy. But health care? That’s a complete secret.

We couldn’t possibly tell you what this costs. It’s too complicated. And we know you’ll be too scared to walk away, so pay us a little deposit, sign these forms, and don’t you worry your pretty little head about what comes next - we’ll make sure you know how much you owe… later.

Yeah, no.

Here’s what you do before you set foot in that facility (unless it’s an emergency of course, but don’t worry we’ll cover that too).

Get the billing codes

These codes are what you’ll use to figure out what’s considered a reasonable price for the specific thing you are having done. Sounds complicated, but it’s not as hard as you might think.

Call the doctor’s office (or hospital or other facility) you plan to see and ask: “What CPT codes are you going to bill for this?”

CPT codes (pronounced C-P-T) are the billing codes attached to every single thing they do to you since your electronic medical record is basically a glorified cash register. (That’s also why the doctor’s always staring at a screen instead of looking at you. Every click is a charge.)

And when you ask, the front desk may not immediately know what you’re talking about. Don’t let this bug you. They’re not dumb people — they’re just not trained on this, because the system prefers you don’t ask. Be patient. Persist. Someone should be able to provide them. Your new favorite phrase: “I’ll wait while you find out.”

See how much Medicare would pay for each code

This is how we start to figure out what’s considered reasonable.

When you get the codes, throw them into the Medicare Procedure Price Lookup tool, or even easier, into ChatGPT, and ask for a Medicare rate range. This gives you the baseline cost.

And while you won’t usually get away with paying the Medicare rate as a commercially insured patient, you will use this to smell a gouge from across the parking lot.

Crunch the numbers.

Here’s the math that allows you to decide what’s reasonable.

Most people think health care pricing is complicated. It’s not, really. It’s just opaque. The Medicare rate is the closest thing to what a procedure actually costs, and many in the industry base their prices as a multiple of it.

• A good price is 125–150% of the Medicare rate. A 25–50% markup above cost. You should always start here.

• A fair price is 150–200%. This is what smart employers often aim for.

• A predatory price is anything above 250%.

Keep this framework in mind anytime you evaluate pricing. The framework varies based on type of service, but this crude scheme will generally serve you well.

The average commercial price for outpatient services? 250% of Medicare. And an inpatient hospital stay? 300%. That’s the average. So if you’re wondering whether you’re getting gouged — you are. You just didn’t know it because nobody ever showed you the math.

Side Note: If you want to go full nerd (and I know some of you do) Patient Rights Advocate has a free tool that lets you download your hospital’s price transparency files — the ones they’re required to post publicly. You’ll get a spreadsheet. Search it by CPT code, find the column for your insurance plan, and now you know what they told the government they’d charge your plan. Other free tools worth bookmarking: Sage Transparency and Simple Healthcare. Which is all useful ammunition for later when the bills show up and the numbers don’t match.

Now you know what’s “reasonable.” But we’re not quite done.

Ask about “site of care.”

You can get the exact same surgery, often with the exact same doctor, at a wildly different price — depending on where they physically do it. Meaning the same surgery, by the same doctors, with the same anesthesia costs different amounts depending on where it’s performed.

Any place owned by a hospital charges a facility fee on top of everything. And “owned by a hospital” doesn’t mean it looks like a hospital. It might look like an office building, a strip mall or a converted Pizza Hut (not making this up). If you see a hospital logo on the intake forms, the building, or the website — you’re paying the hospital tax with an extra facility fee. You have to ask.

So ask your doctor: “Do you also do this procedure at a freestanding facility?”

Freestanding imaging centers, freestanding labs, freestanding surgery centers exist everywhere. Asking is how you find them.

One of the AllBetter subscribers learned this the hard way and then pivoted in self-defense. She needed an MRI, but her insurance said she couldn’t schedule one within thirty days of an upcoming, unrelated colonoscopy. Rather than get tangled in the authorization nightmare — which would’ve pushed her into the new year and a new deductible — she called around, found a freestanding center, and paid cash. Her cash price for an MRI and two X-rays was less than she would have paid using her insurance plan. Same day. No authorization. No drama. This is NOT uncommon.

Find out how many people are going to bill you.

Most people think their surgeon is the only one who’s charging.

But there’s probably an anesthesiologist. A pathologist reading the biopsy. A radiologist — possibly in a different time zone — sending a separate bill. Even in the ER, the hospital and the ER doctor who saw you for exactly 2.5 minutes bill you separately.

Ask upfront so you’re not blindsided later: “which facilities and professionals will be billing me for this procedure?”

Get a Good Faith Estimate.

Under the Consolidated Appropriations Act of 2021, they’re required to give you a Good Faith Estimate of all the charges for your service no later than three days before the visit. They’re not legally bound to hit that number exactly, but they can’t wildly deviate without risking “bad faith," which isn’t allowed. The estimate gives you ammo in case they dramatically blow past it later.

Compare the cash price.

Especially if you have a high deductible you haven’t met.

Always ask: “What is your self-pay rate?” or “What’s your cash price?”

Some places will just hand you their sticker price (anywhere between six and thirty times the Medicare rate) and call it their cash price (which will look inflated because you’ve done the work comparing to percentage of Medicare). And when you spot it, just know that’s probably not their real cash price. It’s just them trying to dissuade you.

Then say something like: “That’s 350 percent of Medicare. You mean there’s no discount for me paying upfront, right now, day of service? No discount for not making you bill my insurance and wait six months to get paid something crappy?”

That usually recalibrates things.

And follow up with HR.

One reason that people don’t pay cash even though it’s way cheaper than their insurance rate is because they worry that this spending outside their plan will increase costs later in the year because it’s not applied to their deductible. After all — your plan can’t apply payments to your deductible that they didn’t know about.

This is a reasonable concern, which is why Texas and Tennessee have required plans to apply cash payments against deductibles. But even if you don’t live there, most employers can see the value if you bring it to their attention. Go to your HR department and tell them that the cash price is lower than the egregious rate their stupid carrier charges them and ask them to apply your cash payment to your deductible. They may claim that they can’t do it, but if they’re a larger “self-funded” employer (which is almost all employers over a few hundred employees), they’re wrong. Tell them to make the request of the plan on your behalf — remind them that the value prop that their carrier is selling is to get better rates for health care than they could get without the carrier.

One more thing on cash pricing — doctors are contracted with your plan if they’re in network. That contract usually prohibits them from accepting cash for a patient that they know is covered by the network plan (which is why I propose to outlaw those contract provisions in the plan described in a previous article). So ask them about their cash price before you’ve shown them your ID card. If you’re already their patient in their system, tell them your insurance has changed and you’re now a self-pay patient. You can always change back later when you don’t want to pay cash in the future. That helps them check the contract box.

A few special cases to consider:

Watch the calendar. Your deductible resets January 1st (probably - some plans do this mid-year, so you might check if you’re not sure). Pre-op labs in December and surgery in January = two deductibles. If you have any control over timing, keep everything in the same calendar year.

Check for financial assistance. Almost every hospital is required under the ACA to have a financial assistance program. They’re also required to tell you about it. Most don’t. And some have been caught actively hiding it and bullying employees not to mention it to needy patients.

Google: “[hospital name] financial assistance program.”

If your household income is under roughly 400 percent of the federal poverty level — around $132K for a family of four — you may qualify even if you have insurance. And if you do, under the program, they must charge your out-of-pocket costs based on “amounts generally billed,” a formula weighted toward low-paying programs like Medicare, Medicaid and the VA. Translation: your $800 out-of-pocket obligation might drop to $300.

Once you have a bill, be sure to ask the hospital about financial assistance. If you’d like help with this, one of the greatest charities in the world is DollarFor.org — they erase medical bills by helping you apply for the charity program and getting that bill reduced or eliminated based on your income. For the same procedure. Same hospital. Same doctors. Just different math - because you asked.

The Day Of Service: How to Evade Their Trap

You’ve done most of the hard work at this point, by figuring out what price you should expect to pay, whether’s it’s reasonable, whether cash or charity might be a better solution. (I promise, it’s downhill from here.)

Now it’s just you, that drafty gown and that darn iPad the nice lady just shoved in your face. And the best way to deal with that pesky screen is to get rid of it altogether.

Ask for paper forms.

You are allowed to. They won’t love it. They’ll be discombobulated or annoyed. That’s a them-problem, not a you-problem.

“I’d like paper forms please. I don’t mind waiting.”

If they push back, act confused, or start giving you a hard time, escalate: “You are required to give me paper if I ask for paper. I’ll wait.”

Because you can edit paper. There are two forms you need to pay attention to:

1. The “consent to treat” form isn’t just consent to treat — it’s your consent to be gouged at whatever rate they choose, with you on the hook for whatever insurance doesn’t cover. No ceiling. No recourse. No bueno.

2. The No Surprises Act disclosure is supposed to explain your right not to be surprise-billed by out-of-network professionals you didn’t choose — the anesthesiologist who wandered in or the radiologist reading your scan from New Zealand. But instead, the form often asks you to waive those rights (yeah, we’re not doing that either).

How you handle them depends on where you are.

If you’re in the ER, they must treat you no matter what you write on a piece of paper. So edit freely. Every time you see the word “amounts,” cross it out and write: “reasonable amounts not to exceed 150 percent of the Medicare rate.” Then sign it. On the No Surprises form, sign nothing. It is supposed to be a notice of your right not to be screwed. If they’re asking you to sign something, it’s to get permission to screw you.

If you’re in a non-emergency setting, they can refuse to see you if you start visibly marking up their paperwork. And they’ll often insist on the iPad. So be subtle. On both forms, when you get to the signature line, instead of signing your name, write, very legibly: “I do not agree to this.” They’re not checking. They just want the forms back. And later, when they try to hold you to the terms: “Show me where I agreed.”

If any of this is on an iPad instead of paper, just advance the pages to the signature line(s) and write the you-did-not-agree verbiage. Stealthy ninja!

(Are we having fun yet?)

After: When the Bills Start Rolling In

Never pay the first bill.

This is a community creed, borrowed from the late great journalist and health reformer Marshall Allen and his book of the same name — and boy was he spot on.

1. Explanation of Benefits: The first thing you’ll get is an Explanation of Benefits from your insurance company in the mail or in your online portal. It looks like a bill but it’s not — and it’ll say so in the fine print. It tells you what the doctor or hospital charged, what insurance is paying, and what’s left for you. This is useful information. Hang onto it.

2. Inadequate Bill: Then the actual hospital or doctor bill arrives with a vague description of service, a date and a number — do not pay it.

Call the number on the bill and say: “I want an itemized bill with CPT codes.”

(Remember those? You’re already an expert here.)

3. Itemized Bill: This is where it gets interesting. When they have to lay out every line item, the bottom line charge frequently drops compared to the first bill they sent you. Sometimes dramatically. Because they were padding the bill with charges they were hoping you’d never question.

4. Check the math. Once you have the itemized bill, you can check the math using the procedure we outlined above. Is it “reasonable” as a percentage of Medicare? Does it match their price transparency filings? The Good Faith Estimate? Is it six hundred percent of Medicare?

5. Pay what’s fair. Now here’s the move — pay what’s fair. I recommend 150 percent of Medicare for a hospital bill and, if you’re feeling generous, 180 percent for a doctor bill — NOT whatever the bill demands when you receive it. But to make sure this works well, you also want to…

6. Include a “Demand Letter.” Sounds ominous, but it’s actually very simple. Mine goes something like this:

“I didn’t agree to this price in advance. You never disclosed it. It wasn’t in my Good Faith Estimate (or it’s well above the estimate). I can’t find it on your transparency filings (or worse, you didn’t make transparency filings). And check my consent form — I didn’t agree to it.

Under the Uniform Commercial Code, when there is no agreed-upon price in advance, the highest price that can be charged is the price a judge would find reasonable. I assert that 150 percent of Medicare is reasonable. In fact, I’ve already paid you that amount. Please zero out my remaining balance.”

I’ve used this letter. Multiple times. It works.

They won’t write back and say “gosh, you caught us!” They’ll just quietly stop chasing you. The first time I did this, I kept calling like a lunatic. “Have you zeroed out my balance yet?” “Have you zeroed out my balance yet?” “Have you…” Then one day I checked my portal and it was just… zero. No fanfare. No apology. Just silence and a zero balance. (I’ll take it. And you should too.)

7. Plan B. If that doesn’t work, take that same letter to any lawyer in town. Have them put it on their letterhead and serve it via legal process to the hospital’s registered agent (they’ll know how to do this). Might cost you $200–500, but if it saves you thousands, that’s an ROI you can take to the bank.

One last note on collections.

If collections contacts you while you’re in this process, respond immediately, in writing or on a recorded call.

Say this: “This bill is actively under dispute. I do not accept that I owe this amount.”

They cannot report you to the credit bureaus while you’re actively disputing. So just make it clear that you are disputing. Document it. And do not panic.

The System Is Not Going to Tell You Any Of This.

A lot of these pro-tips exist because of government rules — many of which I personally fought for from inside the White House.

But the system has zero incentive to make any of this easy for you.

Hospitals profit from your confusion. Insurers profit from your passivity. And those iPad forms are designed to strip away the very protections we built for you.

Walk in knowing the math. Edit the forms. Demand the itemized bill. Pay what’s fair — and not one dollar more.

You are not a child in this system. You’re not a serf. You are the customer. And it’s high time they started treating you like it.

P.S. Before you go, I know I already asked, but this article means everything to me — and it’s free. I gave decades of my life to help create these protections and I desperately want patients to understand how to use them.

After you share, come find me in the comments. I want to hear your billing horror stories. Or your ninja victories. Both are welcome here.

In my review of an employer’s PBM contract, I found 45 different provisions that were so egregiously disadvantageous, no prudent fiduciary under state or federal law could have signed it in good conscience.

That employer, with about 2,000 employees, had asked me to review the contract with ExpressScripts, their pharmacy benefit manager (PBM). PBMs are obscure middlemen that are part of every health plan. The industry, with only three giant companies controlling almost 80 percent of the market, claims a value prop of getting volume discounts from drug makers that the employers couldn’t otherwise get themselves.

The HR manager, the one who signed the contract, year over year, looked at me plaintively and said, “but what are we supposed to do? They won’t negotiate these terms with us — they don’t need our business.”

She was right that they wouldn’t negotiate. Her PBM serves 118 million lives. They’re not going to get religion to win the business of a few thousand. Instead, they present their contract to an employer, and it’s a take-it-or-leave-it proposition. Most employers don’t think they have a choice.

But this employer did have a choice. The next year, I helped them fire ExpressScripts and hire an honest, fiduciary-minded PBM. Their drug costs dropped 36 percent in the first year — a savings of more than $2 million.

A similar employer elsewhere in the country, with almost the same demographics, in the same industry — kept their Big-3 PBM. Their drug costs increased by almost 50 percent in one year.

Both clients experienced higher medical (non-Rx) costs that year, so it wasn’t a different risk profile per se that explained their different drug spend. Apart from the PBM, their plan designs and vendor stacks were similar.

But the difference between them on prescription drug costs was mind-blowing.

The Federal Government is Dropping Thermonuclear Bombs

Which is why the past week has been so earth-shattering.

A law just enacted by Congress and an even more detailed, but little-noticed regulatory action proposed last week by the Department of Labor are about to turn the corrupt business model of these too-big-to-compete conglomerates to ash.

These new requirements will force PBMs to expose the panoply of ways they fleece American businesses and their workforce.

The PBM empire will strike back. I know because I’ve seen this movie before.

When I was in the White House working on what became the Trump price transparency rule for health plans, the president was constantly haranguing us to get drug prices lower — a noble cause, to be sure. So of course, the final rule included a section requiring PBMs to post their secret drug prices.

The industry cabal filed a couple lawsuits, both of which were negotiated away by the Biden administration: HHS announced an indefinite delay of the PBM piece of the Trump rule. Later that week — coincidentally, I’m sure — the PBMs pulled their lawsuit. The other lawsuit, filed by the smarmy PBM trade group, got pulled when the Biden administration agreed to keep their pricing information confidential, safely hidden from, you know, the people who pay those prices — employers and patients.

Last week, the Department of Labor not only reversed this travesty, but they doubled down in the most aggressive way possible. Congress then passed a bill a few days later that not only doesn’t conflict with the proposed rule, but it will essentially require DOL to finalize an even tougher version.

They have captured every single problem that I could possibly have thought of as needing exposure. There’s no money game, shenanigan, or known corrupt practice they haven’t demanded that PBMs admit to their clients. The new law goes beyond ERISA plans to include small groups, individual market plans, Church plans and government plans.

These policies lay out the playbook for how PBMs, GPOs, PBM-controlled pharmacies, consultants and yes — plan sponsors — can go to federal prison more easily.

CEOs, CFOs, HR leaders — you’ll need to understand how to use these new requirements to prevent that. And trust me, you’ll have fun doing it, because both Congress and DOL have just turned on the lights — watching the cockroaches scramble is a recipe for a good time.

Yes, PBMs (and the Sweet HR Lady Down the Hall) Could Go to Federal Prison.

ERISA is the law that governs most larger group health plans. Most people think ERISA enforcement is boring, civil, and toothless: fines, settlements, a slap on the wrist.

That’s wrong.

ERISA has always had criminal teeth. The new law and DOL’s proposed rule make it much easier for prosecutors to bare them — not just against PBMs, but against employers and other plan sponsors who lie, conceal, or even just look the other way.

Under current law, willful violations of fiduciary, reporting, or disclosure duties can lead to fines, federal prison time, or both. Fiduciaries like CFOs, CEOs, HR leaders, Benefits Committee members, Directors and others can be held criminally and civilly liable, severally and personally, which means that you can’t say “I was acting in my corporate capacity — sue the company, not me.”

Prosecutors usually pair ERISA charges with wire fraud, false statements, or conspiracy. This has historically been used most in pension cases - but it applies to employer health plans too.

The new law makes PBM compensation disclosure a condition of keeping your plan on the right side of ERISA’s prohibited transaction rules.

If any of the manifold disclosures under the law’s new requirements are false, misleading, or incomplete, your contract with the PBM could be deemed presumptively unlawful.

To be clear, PBMs and plan sponsors wouldn’t go to jail for mistakes. But you can go to jail if you (or your PBM):

• Knowingly lie on these new proposed PBM disclosures

• Hide spread pricing, rebates, or payments to consultants pretending to be independent

• Cover up self-dealing or steering to PBM-owned pharmacies

• Look the other way as a plan sponsor, despite criminally egregious red flags

• Mislead auditors or regulators.

The new law lists, and the proposed rule spells out in greater detail, exactly what must be disclosed. After that, “we didn’t know” gets a lot harder to claim.

Plan sponsors are ERISA fiduciaries. If you knowingly accept opaque PBM arrangements — and most plan sponsors today are doing exactly that, because they think, like my client did, that they have no other option — you’re no longer able to claim that you were an innocent bystander. You could be deemed a co-fiduciary or a participant in prohibited transactions.

Below follows a stroll through the highlights of all the rigorous (and occasionally hilarious) new requirements that either DOL or the new law (or both) have imposed on PBMs and their ilk (aka their agents, consultants and affiliates).

Paid subscribers get access, and trust me, you can’t afford not to know.

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In this workshop, I break down how to assess each type of holistic practitioner to figure out which type is more likely to match your needs and priorities. A good match dramatically increases your likelihood of success with that type of practice. We also talk about the finances - what insurance covers, what your HSA secretly covers. How to spot red flags before you shell out too much.

Would love to know what you learn and which parts you find most helpful.

And thank you for being a paid subscriber. You’re the ones making AllBetter possible.

Katy

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The largest taxpayer subsidy for abortion in America isn’t for Planned Parenthood.

It’s your paycheck.

Employer-sponsored insurance is entirely tax-free under federal and state law. Employers can – and often do – cover abortion. Some states even mandate it.

In fact, more than half the country – 180 million Americans – get their health coverage on the job. At least a third of larger employers report that their plans cover abortion. Another forty percent don’t even know, because they can’t interpret the fine print in their policy documents. If even half of those “unknown” plans do cover abortion, that’s 100 million Americans with tax-free abortion coverage today.

This makes employer-sponsored health insurance the largest government subsidy for abortion in the United States.

Awkward Silence.

Larger than Title X. Larger than Medicaid. Larger than Planned Parenthood. And yet those programs consume nearly all pro-life attention at the federal level.

Meanwhile, since Roe v. Wade discovered a constitutional right to abortion in 1973, Congress has repeatedly expanded tax-advantaged insurance or access to it: ERISA in 1974, FSAs in 1978, COBRA in 1985, HIPAA in 1996, and finally HSAs in 2003. Every expansion increased tax-preferred abortion, with little evidence of serious pro-life opposition at the time – certainly none loud enough to cause pro-life legislators to vote no.

This is a hard and heartbreaking truth.

Last week, in The Health Reform Showdown: What’s Actually Happening, I explained the various health reform efforts currently playing out in Washington – the shutdown deadlines, the Moreno deal, the reconciliation opportunity.

(Go read it if you haven’t. I’ll wait here.)

But there’s a reason I wrote that piece first: to show you why none of it will move until Republicans have a family meeting.

Democrats, please step out of the room for a moment.

How Abortion Became A Tax Deduction

Most Americans think abortion policy is set by courts and legislatures. But one of the most consequential decisions was made by IRS bureaucrats in 1973, right after Roe. That's when the IRS decided, by fiat (Revenue Ruling 73-201), that abortion was tax-deductible “medical care.” Medical care, under Section 213(d) of the code is deductible.

That means that:

• Individual out-of-pocket spending on medical care, including abortion, is deductible.

• Individual health insurance (including abortion coverage) is deductible.

• Employer-sponsored insurance (including abortion coverage) is deductible.

Once abortion entered the tax code, its tentacles slithered everywhere.

The reason why we’re thinking about this today, more than half a century later, is because Republicans have always wanted to expand Health Savings Accounts (HSAs) as a way to bring free market principles to health care – let people pay for most medical care and insurance out of HSAs, making their own decisions rather than a government or employer calling the shots.

The laws of economics make it clear that the consumers that pay also choose. Those who choose will be competed for, which will over time increase quality and decrease cost. Our current system has obscured this simple economic proposition with the imposition of a parade of market-distorting middlemen. HSAs are a powerful antidote to this sorry status quo.

There Has to Be a Catch

But HSAs are also tied to this IRS abortion ruling.

HSAs can only be used to pay for “qualified medical expenses” under section 223 of the code. But qualified medical expenses include that same “medical care” under 213(d) — aka abortion.

The law does not call abortion medical care. Congress never went that far. In 1973, they wouldn’t have dared.

Instead, IRS bean-counters forced every American taxpayer to give tax breaks for abortion in every single possible context.

Unelected. Unaccountable. Effective.

That’s why pro-life groups now oppose HSA expansion. As long as unelected, unaccountable IRS bureaucrats say abortion counts as medical care, expanding HSAs = expanding tax-free abortions.

Even though the pro-life movement didn’t raise the alarm in 2003 when HSAs were created.

Or when ERISA dramatically expanded employer-sponsored insurance in 1974.

Or for every coverage-expanding law in between.

And yet, for the past twenty years, this problem surfaces every time Republicans attempt serious health reform.

Health policy – especially in the commercial markets – is tax policy. Whenever Congress wants to do anything that affects insurance, they have to amend the tax code, because payments toward premiums are excluded from income. Employer contributions are tax-free. Credits and deductions move billions. Every reform reshuffles tax advantages.

Since the ACA was enacted (a large part of which was in the tax code), Republicans have been trying to figure out a better way. But every way they proposed involved doing something with subsidies or HSAs or both. And so, pro-life concerns have consistently stopped Republican health reforms at this choke point.

The clean solution would be simple: enact a law that clarifies that abortion isn’t medical care for tax purposes (or any other purpose, obviously). That would collapse this entire conflict. And of course, it’s been tried.

But it’s never had both a House majority and sixty Senate votes. Without the votes to enact the fix, health reforms that do have majority support die because pro-life legislators walk away.

Compliance Theater

Democrats mollified the Catholic bishops back in 2009-10 by adding a provision sold as keeping subsidies from funding plans that covered abortion. But the provision was weak, and Democrat presidents didn’t enforce it.

In the Trump White House, we tried to strengthen enforcement by requiring insurers to bill separately for an unsubsidized abortion “rider” attached to subsidized plans. Life groups appreciated the effort but considered this small abortion “surcharge” to be insufficient protection.

The surcharge was trivial. Expanding coverage to include abortion doesn’t cost more, it costs insurers less. Killing babies is cheaper than delivering them alive. So, carriers charged a few bucks to check the compliance box – hardly a speed bump.

From the pro-life perspective, any proposal that moves ACA subsidies – already usable for plans that cover abortion – into tax-advantaged HSAs that could be used to purchase abortion coverage or abortions outright looks like an expansion of tax-free abortion.

That concern is understandable. But it is also incomplete.

They’re the same cause.

Most people work these issues from one lane – health staffers wish pro-lifers would stand down, and pro-lifers want health policy to bow. I’ve had to straddle both lanes.

I’m better known for advising President Trump on health care, but the other half of my portfolio was pro-life policy and related issues - so much so I made all the right enemies lists. I care deeply and desperately about both causes, because they’re actually the same cause.

Jesus lauded the Good Samaritan’s care for the wounded with just as much fervor as He wished a millstone onto the necks of those who harmed little children.

The pro-life movement has fought for decades in a morally clear and all-encompassing struggle – overturning Roe, waging state-by-state referendum knife fights, building pregnancy resource centers, adopting unwanted or foster children, and standing with women and children when it mattered most.

Fixing a predatory health care system that is crushing the poor and stealing the American Dream from the working class is different - not because the moral high ground is less clear, but because the work is brutally technical and complex. Most people can’t even understand the arcane details of this work, much less appreciate it.

Redeeming health care means clawing incremental gains out of the contracts empowering corporate behemoths, navigating layers of middlemen, protecting patients from bureaucratic abuse without empowering quackery, and forcing a fifth of the American economy to stop preying on the people it’s supposed to heal and the lives it’s supposed to save.

Health care reformers rarely get the emotional satisfaction from such clear-cut victories comparable to how pro-lifers feel when a Planned Parenthood “clinic” closes its doors.

But redeeming the health care system is holy work. It is life-saving, devastating, demoralizing and exhausting work.

It is pro-life work.

It’s time to stop sending it to the back of the legislative bus.

To be clear, pro-lifers didn’t sideline health reform because it wasn’t important or worthy. We sidelined it because the tax code made it messy, imperfect, and politically uncomfortable.

Welcome to health care – a steaming pile of trade-offs that makes everyone want to walk away.

This isn’t the fault of pro-lifers, of course.

Speaking of Steaming Piles of…

It’s the fault of predatory, so-called “charity” hospitals, many of whom perform abortions and are almost never subjected to pro-life protest.

It’s the fault of almost demonic insurance companies who deny care as a business model, hide secret revenue, steal from their employer clients, crush independent physician practices until they sell to the insurers, and then raise prices with impunity.

It’s the fault of shadowy PBMs whose names most normal people don’t even recognize, but who lobby to exempt themselves from anti-corruption laws, charge more for a drug than the uninsured cash price, and sue to avoid price transparency.

It’s the fault of giant insurance brokerages pretending to be the consumer’s “agent” while actually taking bribes and kickbacks from insurance companies and PBMs to steer employers and families into bad coverage.

It’s the fault of drug and device manufacturers who hide evidence of harm, evade product liability, stretch patent monopolies, advertise products on the nightly news that are so unaffordable that families are forced to choose between insulin and food.

These “health care” entities present themselves to tax authorities, regulators and the public as white-coated angels devoted to access, quality and innovation.

In reality, they consume a fifth of the American economy, almost half of federal spending, while laughing all the way to the bank. Meanwhile, Americans are still the sickest, fattest, saddest, most depressed, anxious, and infertile population in human history.

Principalities and Powers

Nothing short of radical, sweeping disruption by Congress of these entrenched interests - at every level of law, regulation and business - will be able to tilt the scales back in the direction of the people desperate for healing.

My Democrat colleagues largely agree with this diagnosis. Their solution is for the government to take over the whole mess.

Among the many fears I have about such an eventuality – one we are barreling toward if nothing changes – is that government-funded abortion will become completely normalized.

We’ve seen this movie in Canada, the Netherlands and elsewhere.

When the state pays for death, you get more of it.

But acknowledging that fear does not justify freezing reform that saves even more lives. Nor does fear justify ignoring the far larger, already-existing abortion subsidies embedded in our current system.

That is Why I’m Calling This Family Meeting

I do not believe it is right to hold transformative health reform hostage, simply because the IRS said abortion was health care fifty years ago. Or because not enough members of Congress disagree with them now to change it.

If we were talking about small-ball reform, the trade-offs might look different. But when we have the opportunity to enact reform at a scale that could actually dethrone the kleptocracy that delivers debt bondage and piss-poor health outcomes to American families, I say it’s worth it.

If we have a chance for School Choice for Health Care, direct deals between buyers and sellers of health care without a carrier middleman, price transparency with teeth – we have to take that chance.

Policy makers will answer to God for how and whether they confronted the industry that is raping and pillaging the American countryside.

The real fight isn’t stopping a marginal expansion of HSA-funded abortion when 100 million Americans already have tax-free abortion coverage through their employers.

The real fight is removing abortion from the definition of medical care in the tax code entirely. That would be the most consequential pro-life policy change of our lifetime – far more consequential than blocking any single health reform bill.

We once believed that overturning Roe would be the victory for the ages. I wept on my knees the day it happened. That fight was righteous, necessary and primary.

But there are more abortions today than ever before.

According to the Guttmacher Institute (Planned Parenthood’s research arm), abortion rates have increased since Roe was overturned, driven largely by the explosion of medication abortion – now accounting for nearly two-thirds of all U.S. abortions.

With the same vigor that we fight to defund Planned Parenthood, we also must channel our energy – our persuasion, our door-knocking, our apologetics, our prove-me-wrong tables, our marches and more – toward the next great pro-life fight: starving the abortion industry of its insurance-company blood money.

Not merely on the exchange plans covering 23 million people, but across the commercial market that covers 180 million Americans.

We have a lot of work to do to persuade the public, and from there, the Congress. I will be in this fight, right next to my pro-life friends and mentors. I will do everything I can.

But Doing Nothing Does Things

And as we wage that holy war, we must walk and chew gum - reforming a medical system decaying from moral rot at the core of its corrupt business model. There are real people who are harmed when we decide to leave the field of battle because we can’t stop every bullet.

Like many people, I morally or scientifically object to any number of things that are called “medical care” under current law or even “best practice.” That doesn’t mean I think health care itself should be frozen in place until every dispute is resolved. Refusing to act because we don’t have enough votes to make it perfect doesn’t preserve principle; it simply guarantees that the worst features of the status quo continue to fester.

We already follow this logic in other contexts. We don’t let bridges collapse because some people drive on them recklessly. We don’t block repairs to libraries because we object to certain books they carry. We don’t stop arresting criminals because we can’t catch them all. We reform and repair anyway – because the alternative isn’t more morality, it’s less.

From a prudential standpoint, blocking reform because (albeit grave) moral disputes remain unresolved doesn’t hold the line – it entrenches defeat. It locks in the very definitions, incentives, and access points we object to, while taking off the table the only changes that are actually achievable. The system doesn’t pause while we withhold consent. It just keeps hurting people, predictably and at scale.

This is what makes our current pro-life posture so self-defeating.

We are not being asked to ratify abortions, tax-free or otherwise. We are being asked whether, given the world as it is, we will refuse to make it less cruel because we cannot yet make it just.

I know it sounded off-putting to pro-life ears, but this is why President Trump has intuited that health reform might require us to be “flexible on Hyde,” as he put it.

But only as tactical flexibility, not as surrender.

Some might argue that HSA expansion or, as I call it, “school choice for health care,” is morally trivial compared to the pro-life cause. But is it?

Transferring the power of choice to individual families rather than giant health care conglomerates would fuel competition and innovation that will incentivize higher quality and more affordable care.

At health care’s trillion-dollar scale, those incentives matter: medical errors are the third or fourth leading cause of death. Medical issues are the number one cause of bankruptcy.

The current strategy – blocking health reforms while simultaneously ignoring the massive employer-insurance subsidy for abortion – isn’t protecting the unborn. It’s protecting a status quo that already funds far more abortions than any HSA expansion ever would.

Once real reform is underway, we can and must also refocus pro-life advocacy on this most critical fight – the fight that’s been neglected by our movement for half a century: removing abortion from the definition of medical care in the tax code.

One Last Thing (Before the Dems Come Back In)

The president could do this by executive action - today.

Specifically, by directing the Secretary of the Treasury to revoke Revenue Ruling 73-201. This would take tax-free abortion out of our health plans, HSAs and ACA subsidies.

It might not be permanent without legislation. But it would immediately disrupt the insurance-fueled abortion gravy-train. It’s not a complete solution, but it’s a start – and it’s available right now in the president’s power.

Whaddya say we ask him to use it?

Read Part 1: The Health Reform Showdown for the full context on what’s happening in Washington on health care right now.

You may have heard that the bipartisan deal-making on health care is falling apart. Don’t believe it.

There will be a deal — because there has to be one.

The next government shutdown deadline is January 30th, and Washington doesn’t do ideological purity when the lights are about to go out.

But there’s a reason health reform keeps failing — and it may not be not the one you think.

I worked on these issues for fifteen years in the Senate and the Trump White House — health care and pro-life policy, both portfolios, at the same time. I know how this sausage gets made (and how it doesn’t), and I have the scars to prove it.

There’s a lot more to say in next week’s article: The Tax Code’s Abortion Problem. But for now, let me explain how we got here, and what’s actually going on behind closed doors.

How Health Care Became the Hostage

Like clockwork, last Fall brought us the end of the fiscal year and, with it, another round of brinkmanship to keep the government funded. At the same time, Open Enrollment for the 2026 ACA marketplace was approaching, which corresponded to the expiration of the COVID-era expanded subsidies at the end of 2025. These subsidies increased the amount of premium assistance for people already subsidized before COVID (with incomes up to 400 percent of the federal poverty level), as well as extended new subsidies to populations not previously eligible — with no income cap at all.

No Republican had ever voted for the ACA or the COVID-era subsidies, and they’re running the place now. Many of them hoped that government welfare designed to help people in a lockdown economy during COVID might finally expire.

But some Republicans, especially those in swing states, were panicking about being blamed for steep premium spikes caused by the subsidies ending.

Warnings of a health care apocalypse echoed through the halls of the Capitol. And for many marketplace consumers, the looming costs were all too real.

That’s when ACA policy collided with the annual shutdown showdown.

Most bills, though not all, as we’ll discuss later, require minority support because they’re subject to the Senate filibuster, including appropriations bills to fund the government. The filibuster is simply the procedural fact that the Senate votes on whether to vote. Even though it takes only 51 votes to pass a bill, it takes 60 votes to vote to vote on the bill, which is why it matters if Democrats will play ball. So yeah, it takes more votes to vote on whether to vote on a thing than it takes to vote on the thing. Got it?

This is why the minority party has so much power in the Senate.

The Shutdown Hoe-down

Democrats seized the moment, demanding an extension of the COVID subsidies as a condition of supporting the spending bill that would keep the government open with the start of the new Fiscal Year, October 1st.

Republicans countered by offering an extension (a major concession, since it would be a precedent-setting first time that Republicans go on record voting for the ACA). There was just one catch: the extension had to include beefier guardrails to enforce the existing law and prevent illegals from receiving taxpayer-funded benefits. The ACA technically prohibited such subsidies, but enforcement had been a joke.

Democrats refused.

Republicans pounced back, characterizing Dems as putting illegals above Americans. Sombrero memes exploded. Feds got an unpaid vacation. Pressure mounted on both sides of the aisle as the longest shutdown in history persisted (did you even notice?).

Round-and-round they went, with performative posturing and mutual mockery. After six weeks, seven swing-state Democrats crossed the aisle to support a short-term deal in November, ending the shutdown and pushing the next deadline to January 30th. The deal was sold as a cooling-off period to negotiate a serious, bipartisan solution to the subsidy cliff and broader health system failures.

Because bipartisan health care breakthroughs happen a lot.

Oh wait.

No they don’t.

The Hostage Exchange

No deal was reached before the holidays.

I know – you’re shocked.

This brings us to the present, with Washington once again staring down a January 30th shutdown. When that short-term funding deal expires, government funding runs out. Again.

Senators Bernie Moreno and Susan Collins have been leading the dealmaking efforts and have made some progress.

Reportedly, Democrats would get:

• An extension of COVID-era subsidies for several more years.

• Preservation of current, weak-sauce pro-life protections on subsidy money, rather than stronger Hyde protections (which outright prohibit any taxpayer support for elective abortion).

To get Republican votes, this deal needs a policy pound of flesh, something real that can plausibly be called a compromise.

My bet: ACA subsidies — both COVID-era and baseline — are allowed to flow into health savings accounts (HSAs), instead of being sent directly to big insurance companies. In other words, “School Choice for Health Care,” the policy I described a few weeks ago and which President Trump has repeatedly demanded.

That raises new pro-life concerns. (More on those next week.)

Behold, Budget Reconciliation

The Moreno shutdown deal isn’t the only path to reform this year.

Right before Christmas, Speaker Johnson pushed a largely symbolic health care bill — a nothing-burger of nits and nats — designed to give members something to say they did on health care over the holidays, while COVID subsidies expired.

In exchange, he promised Republicans a real shot at reform using the budget reconciliation process.

Ah, reconciliation! Doesn’t it just have that ring of bipartisan peace and love? In reality, it’s the exact opposite. Reconciliation allows the majority party to pass major policy changes without having to overcome a Senate filibuster or garner a single Democrat vote.

Control both chambers and you can pass the bill by majority vote in the House and then move a bill in the Senate with 51 votes — not the 60 needed to overcome a filibuster on regular legislation — which was exactly how Democrats passed the ACA.

Republicans are no stranger to the process either; the doomed repeal-and-replace bill I described in an earlier post was a reconciliation package, as was last year’s One Big Beautiful Bill.

The ACA: the Sideshow that Washington Treats as the Main Event

For fifteen years, Washington has acted as if the ACA was the health care system.

The bickering and blame-shifting, the hostile committee hearings and fiery floor speeches — if it was about health care, it was usually about the ACA. Politicos treat the exchange plans as if they are the center of American health care rather than a small slice of it.

That is a mistake and both parties have repeatedly made it (though President Trump’s focus on price transparency and drug costs in the first term was the first break in this pattern).

In the broader commercial market, premiums have been skyrocketing. Hospital consolidation has accelerated the monopolies driving up prices. Entire industries of middlemen sprung up that most people have never even heard of. Insured patients have been dying from delayed or denied care and unthinkably high deductibles.

Real Reform Worth Fighting For

Done right, reconciliation could disrupt the commercial market — where employer-sponsored coverage, off-exchange plans, and non-insurance arrangements operate. These reforms would transfer power away from health care special interests and back to the people who pay for care — patients and employers.

Rumor has it the package will likely include:

• School choice for health care: employer dollars into worker-owned accounts usable for ACA plans, off-exchange plans, sharing ministries, and direct-pay arrangements.

• All-in cash prices: upfront, all-in direct-pay prices equal to or lower than insurers’ best rates.

• Site neutrality: no more hospital tax — the extra cost (sometimes three to five times higher) for the same service, just for the privilege of having it done at a building owned by a hospital.

• Price transparency on steroids: enshrine Trump first-term rules, beef up their requirements for precision and jack up enforcement to eleven.

• PBM fiduciary obligations: require PBMs to treat patients and employers like clients to whom they owe a debt of responsibility.

• Health care sharing tax parity: stop discriminating against health care sharing ministry members in the tax code.

These reforms may sound wonky but they’re earth-shattering.

They would burn down the predations of the current system. (More details on why and how here and here.)

There is no free market in health care, but a reconciliation bill containing these provisions would be the jet fuel to the birth one. Which is why you can expect the industry shills to swarm Capitol Hill to try to stop it — there are between four and five health industry lobbyists for every member of Congress.

Again, it’s always dangerous to bet against Congress doing nothing. So, it may not happen, if House Republicans let Speaker Johnson out of his promise because they’ve decided health reform is just too hard, and the premium increases on the exchanges are water under the bridge.

But I’m more hopeful than I’ve been in many years. For the first time in decades, Republicans know what they want, they can describe it in plain, populist language, and the president is on their side: money going straight to the people instead of Big Insurers, and the kind of transparency and fiduciary requirements that help employers actually get an edge on the special interests owned by Wall Street.

But, wait.

The brutal reality is that none of these important bills will happen — neither the Moreno ACA deal, nor the reconciliation bill on everything else — until Republicans face a question they’ve been avoiding for decades.

I know because we’ve been here before. Many times.

Every time serious health reform gets proposed, it dies at the same intersection: the place where health policy meets pro-life imperatives.

HSA expansion? Dead.

Subsidy reform? Dead.

Tax deductions for innovations? Dead.

The reasons are complicated, rarely explained publicly, and almost entirely misunderstood — even by the legislators voting on them.

You know I advised President Trump on health care. But the other half of my portfolio was pro-life policy, and the guerrilla wars I fought in that crusade are too radioactive to talk about publicly. I care deeply and desperately about both causes, because in my view, they’re actually the same cause.

So next week, I’m calling a Republican family meeting to discuss The Tax Code’s Abortion Problem.

Don’t miss it, subscribe and share. Part 2 drops on Shutdown Day: January 30th.

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You’re not alone. And you’re not dumb.

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My name is Katy, and I’m a Diet Coke addict. (Hi Katy).

True confessions time. I’m a naturopathic doctor. People ask me for health advice, and they’re not expecting the kind they get from an MD — the kind that says, “well, it’s zero calories so it’s better than regular soda.” From me, they expect something more along the lines of, “if your great-greats didn’t drink it, then it’s not fit for humans.”

And to be honest, I DO say that. Even about Diet Coke. Especially about Diet Coke.

After all, it messes with your gut, your brain and probably your metabolism in ways I tell other people to avoid.

Like a big fat hypocrite, I coach people to stay off the stuff the way a grizzled, toothless meth-head threatens to shoot his dealer in the head if he tries to sell to his sister.

For me, it started young.

Origin Story: A Generational Curse

My grandmother, all 4 foot 10 inches of her, was surgically attached to her glass bottles of Coca-Cola.

Her addiction transmitted seamlessly to my dad. With his heart condition and his waistline battleground, doctors gave him the business in his mid-40s or so.

His solution was to swap out the fridge inventory with Diet Coca-Cola.

I was twelve.

In high school, once I started to drive, I’d stop at the 7-11 on the way to school and arrive with a 32-oz Big Gulp full of heaven every morning.

Ah Yes, the Trauma Bond

It wasn’t just the morning 7-11 stop, I learned to love it all day. The sound of the can opening, the fizzy pouring over ice, right before the battery acid burn down my throat — if the Balm of Gilead had a sound, that’s it.

They say that the first step is admitting you have a problem and you are powerless to stop.

Many times over the years, I’d give it up for Lent in a fit of penitential zeal, and would last a few weeks before I weakened. (My resolve was not helped by going hog-wild on Sundays when Lent is quasi-suspended.) Surely, Jesus wouldn’t ask for permanent surrender, right?

When my little sister died a gruesome, protracted death from colorectal cancer in 2019, I made a solemn vow: that sure as hell wasn’t gonna happen to me. And so began my health journey.

The sobering facts about aspartame and the desire to embrace a more Earth-Mama identity gave me the impetus to ditch the “fridge cigarettes” (as a friend calls Diet Coke in an attempt to shame me into quitting). And I did quit. Well, at least at home anyway.

The problem was, I was away from home quite a lot, and my permission structure made it a nice treat when I was out and about. Every day.

The point is, I never really went cold turkey.

And so I’d slide back into relapse. With a sheepish tone, I’d ask my long-suffering husband to grab a 35-can pallet at Costco. Or five.

I’d tell myself that I was gaining too much weight on the kombucha that I had used to replace the fizzy acid zest. Or that I would just have one or two a day. And other lies.

Before I knew it, I was going through a pallet in less than a week, drinking no other liquids, even at night. Even first thing in the morning, the way I had in college.

So this article is an intervention for myself and maybe for you or someone you love.

Friends don’t let friends get hooked on Diet Coke.

Here’s why.

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Aspartame: Whispering Sweet Nothings

Let’s start with the obvious villain: aspartame.

It’s the king of all “non-nutritive” sweeteners, as they’re calling them these days. The human trials have fairly robustly failed to show that aspartame is going to kill us. They do however seem to suggest that it might kill animals, so that’s not great.

The obvious concern, cancer, seems to be intensely dose-dependent and overblown – for most people. The WHO only classifies aspartame as a Group 2B cancer risk, meaning that you have to hit twelve cans a day to approach the danger zone. (Granted, these are the same people who blamed COVID on eating bats.) But still, I’m just saying that certain heavy users (cough, not it, cough) maybe ought to be concerned.

So if it isn’t going to kill us, at least not that easily, what’s so bad about aspartame?

Aspartame acts as a domestic abuser showing up with flowers but depriving us of consistent support and nourishment.

Our brains evolved to associate sweetness with incoming energy (calories).

With aspartame, the sweetness arrives but the calories don’t, creating a reward-prediction mismatch in the brain. What was supposed to be the feature might actually be a bug.

In animal and mechanistic studies, decoupling sweet taste from calories can create a disconnect between the sensory signal and the expected energy procurement.

When that mismatch happens repeatedly, the neural systems involved in appetite regulation may adapt in ways that increase subsequent sweet-seeking. Bottom line: you end up craving, and therefore likely eating more sweet foods — taking in more calories, not fewer.

Musso et al. (2017) demonstrated a proof-of-concept version of this phenomenon in biology’s favorite lab rat: the fruit fly. They described a “caloric frustration” effect, where exposure to non-nutritive sweeteners altered mental learning about sweetness and increased motivation to seek sweet foods.

Broader reviews of sweet taste, reward pathways, and energy balance (e.g., Murray et al., 2016) suggest this mechanism is biologically plausible, even if the size and scope of the effect in humans remain uncertain.

This tracks for me.

Since my most recent relapse onto the all-Diet Coke hydration plan, I’ve noticed that my cravings for carby sweets have jacked up to eleven, with increasing intensity. It reminds me of a car’s seatbelt warning that starts gently, but turns into a screeching schoolmarm if your disobedience continues.

Your body is saying: “Listen honey, if you’re going to put out an amber alert for calories, I’m going to send the national guard to kick in doors until we find them.”

While randomized control trials tend not to show increased diabetes, obesity or other metabolic chaos among aspartame users, the observational studies do show an association. Back in epidemiology school, we learned to conclude from that sort of paradox that there’s usually a related third factor not being captured in the observational studies. This factor, called a confounder, is associated with both the outcome (obesity/diabetes) and the exposure (aspartame).

“Experts” (since COVID, I always put that word in quotes) have suggested that the people drinking aspartame are the same ones that are already at risk for metabolic problems because they are overweight or have some other risk factor.

My theory is that one confounding third factor could be the amber-alert-for-calories phenomenon that’s driving the apparent relationship between aspartame and metabolic risks.

Caffeine: Thirst that Lies

Caffeinated drinks, when they become your primary source of hydration, have a few subtle effects worth noting. In regular caffeine users, the classic diuretic effect is largely blunted — your kidneys adapt, and you’re not actually flushing out more fluid than you take in.

What does seem to happen, however, is that caffeine contributes to dry mouth and altered thirst perception. You can feel parched even when your body isn’t meaningfully dehydrated. In that sense, Diet Coke starts to behave like a self-licking ice cream cone: a drink that temporarily relieves dryness while nudging you to take another sip.

It’s almost as if Coca-Cola intended to create an addictive beverage that makes you think you need more when you don’t.

The Battery-Acid “Hit”

There’s something undeniably refreshing about that biting, acidic hit. You addicts know what I’m talking about.

Diet Coke is to my taste buds and brain what a good exfoliation is to my face: it wakes things up, makes me feel kind of amazing for a second, and distracts me from whatever stress, boredom, or anxiety might be driving the bus.

I notice I throw back the most cans in the middle of stressful, frenetic days - when I’m busy, keyed up, and don’t like the way frustration, overwhelm, or fear feel in my body.

Better medicine would probably be a few deep breaths, some sunshine, singing Copacabana out loud, or some other low-tech nervous-system hack.

But It’s 99% Water, Right?

Coca-Cola’s manufacturing process for Diet Coke starts with heavily filtered municipal water, often using reverse-osmosis–style purification.

Minerals are then added back, not because Coke cares about your nutrition, but to stabilize the chemistry and ensure it tastes the same everywhere in the world.

That means that if Diet Coke becomes my primary — or sole — source of hydration, I’m opting out of whatever modest but real contribution mineral-rich water can make to electrolyte balance and acid buffering.

While most essential minerals come from food, water as our primary hydration still provides a steady background supply of minerals that support nerve, muscle, and acid–base balance. Replacing that with a highly acidic, essentially non-mineralized beverage may not cause outright deficiency, but it’s also not neutral.

This may be why I’ve developed leg cramps and accelerated dental erosion since my latest fall off the wagon.

The dental piece, at least, is not controversial: Diet Coke has a pH around 3, squarely in the range known to erode tooth enamel with repeated exposure – more acidic than most drinking water and comparable to vinegar or citrus juices.

At home, our drinking water comes from a nearby mountain spring (findaspring.org), filtered naturally through the Appalachians and picking up calcium, magnesium, potassium, silica, and other dissolved minerals along its path to my jug. Its pH is typically close to neutral.

I’m starting to think that swapping that out for an acid-washed soda all day long may be an exercise in lifelong low-grade demineralization.

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Aluminum. Microplastics. Repeat.

I drink most of my Diet Coke from aluminum cans poured over ice.

Modern cans are lined with plastic to keep the aluminum from leaching into the drink. That lining is now marketed as “BPA-free,” which is comforting in roughly the same way “natural flavors” (like MSG) or “low tar” (still tar) once were.

Heavy consumption can creep toward a meaningful slice of what regulators call the “safe” weekly intake threshold. And that’s on top of the aluminum dosing we’re already getting everywhere — food additives, processed foods, deodorant, and the near-universal use of aluminum cookware. Each source looks trivial in isolation. Together, they form a low-grade, always-on exposure that never quite trips an alarm.

But aluminum isn’t inert filler.

At higher or chronic exposures it interferes with bone mineralization and nervous system function. Regulators will tell you this still falls within “safe” limits, but those limits are built for averages, not for outliers who stack exposures day after day, year after year, like life-long Diet Coke-heads.

BPAF is Still Plastic AF

So about that BPA-free lining of the can. “BPA-free” does not mean bisphenol-free. BPA is just one member of a larger chemical family, and Coca-Cola won’t say whether their cans are lined with BPA’s cousins — like BPF, BPS, or even BPAF (yes, that’s real).

As endocrine-active compounds, they’re up to the same estrogenic shenanigans as BPA. They can interact with hormone signaling — often weakly, inconsistently — which can be hard to suss out when we’re all already reeling from hormonal chaos from so many other sources. Add in the growing evidence that these cans shed microplastics, and what you’re left with isn’t a single obvious toxin but a background hum of chemical interference accumulating over time.

When regulators assure us that all of this falls “within safe limits,” it’s worth remembering how those limits are set. They’re rarely derived from independent, long-term human data on cumulative exposure. More often, they emerge from industry-funded studies, negotiated risk thresholds, and regulatory frameworks designed to answer a narrow question: Does this cause obvious harm quickly enough to justify restriction?

Regulatory capture doesn’t require bribery — it just requires that the bar for action be set high enough, and the definition of harm narrow enough for commercial expediency.

Now I like the current commissioner, but the FDA is not your mom. And all these approvals happened before his time anyway.

FDA exists to decide what companies are legally allowed to sell — not what you should be using as a hydration strategy.

So yeah, Diet Coke is terrible for you. And me.

Whaddya say we try to shake this thing?

The Case for Cold Turkey

Stick with me.

I tried super-tart kombucha to recreate that SHAZAM you get from the first few sips of Diet Coke. The SHAZAM, yes. The metabolic fix, nope.

Kombucha still has sugar (or fructose), still has caffeine, and still clocks in at 50–70 calories. Swapping a sweet, caffeinated drink for a slightly less-sweet, less-caffeinated drink doesn’t fix the metabolic signaling problem. It just puts a probiotic spin on it.

The keto and carnivore crowd are right about one thing (and many other things too): sugar needs its own 12-step program. Its grip reminds me of trying to extract our teenage son from the Dave payday loan app (how is that kind of predatory usury even legal?).

I’m increasingly convinced that Diet Coke is making it worse by keeping the sweetness craving roaring all day.

So here’s my plan:

• Carbonate my mountain spring water with a SodaStream

• Splash with lime juice at first, less over time

• Lots of ice for the refreshing blast

If quitting a “zero-calorie” “diet” drink is the price of appetite mastery, I’ll pay it.

Goin’ cold turkey.

I’ll report back.

You are and always have been your primary care provider.

It doesn’t matter whose name is on the intake forms, who you call when you’re sick, or how elite your doctor is. Nobody cares about your health more than you (okay, maybe your wife does — I see you, bro).

You’ve lived in your body every minute of your life. You notice subtle changes. You run pattern recognition. You test hypotheses. You already act as the world’s leading expert on your own body.

As we discussed in last week’s article, the placebo effect is one of the most powerful drugs on earth. It works through a three-part cocktail: healing rituals, safety signals, and, most important, trusted authority.

If you accept that you are the most consistent authority on you, you can unlock the rest of the cocktail. Not by rejecting medicine, but by reclaiming agency.

Although the materialist “experts” try to deny knowledge found outside a medical journal, both they and you already rely on inner knowing every day — anticipating danger in traffic, smoking out a teenaged daughter’s lies, knowing that you don’t need to quit your job, you just need to sleep more (or vice versa).

What if you intentionally honored this reliable expertise as part of your healing plan?

And what if you took the other elements of the placebo effect — healing rituals and reassuring safety signals — and crafted your own treatment protocol?

You can tap into your own placebo power, no matter if your illness is anxiety, chronic pain or cancer. There are no guarantees, but the placebo effect is your best leverage in The Art of the Heal.

IMPORTANT NOTE: Your Placebo Playbook may not be the entirety of your plan. There is an important place for conventional medicine for many of us.

Write Your Own Prescription: Intentional Rituals That Signal Healing

When we enter a hospital and go through the rituals of intake, surgery prep, kind welcomes from nurses, stripping of our worldly garments, and hooking up to machines, our subconscious mind is receiving the message that help has arrived and healing is on its way.

That signal is often where recovery begins.

Research on “sham” surgeries shows that people can heal even when the procedure itself does nothing — because the ritual of undergoing what seems like a surgery is good enough for your subconscious mind.

That’s the power of the healing ritual.

When you receive care in a medical facility, you take time out of your work day and your routine schedule, and you do something different. People on chemo or dialysis have very different rhythms in their daily schedules, because they’re following those healing protocols.

To activate the placebo power in your own life, you too need intentional disruption: something that feels like a treatment protocol, even if it’s non-medical.

Important caveat: this is not to say that healing rituals must become your full time job. Live like someone who is healing, but not necessarily like a full-time patient whose identity is wrapped up in a disease label.

Healing rituals are prescriptions you write for yourself, and can include a number of the following evidence-based elements:

• A major dietary shift — whether plant-based, ancestral, keto, carnivore or something else — signals that there’s a new sheriff in town to your body and can turn on healing almost better than anything else. If it’s real food that can be found in nature, rich with nutrients and free of poisons, it’s a win.

• Move outside. Humans were made to move about in nature. Only sick or dying people didn’t and our ancient subconscious wiring interprets indoor sedentary days as a death sentence. No matter how serious your symptoms, find a way to move, even a little, outside. The benefits are overwhelmingly documented.

• Community and connection. We’re pack animals and we die without a tribe — fact. Loneliness is the new smoking. Facebook friends don’t count – find ways to be in person with other humans, especially ones that support you and make you laugh.

• Personalized practices. Consider any other ritual that resonates deeply with you. There’s a podcast or influencer for every biohack out there, so be discerning, whether it’s a sauna, grounding, supplements or tea. Close your eyes and ask for guidance. If it feels like medicine and you believe it’s beneficial, your body is more likely to believe you.

  
  Next: How to switch off the stress physiology that's blocking your healing—and the questions most doctors expect you not to ask.

Safety Signals: Soothe the Lizard Brain and Restart Healing

The autonomic nervous system — our lizard brain — has one toggle: “safe” or “unsafe.” It only switches on healing when it feels safe.

Placebo research teaches us that treatment delivered in hospitals works partly because the environment signals safety — smiling staff in special uniforms, calming spaces, the sense that you’re in good hands.

Many of us live with the toggle permanently switched to “unsafe,” and that fight-or-flight stress physiology, often originating in childhood, underlies many pathologies:

• Shallow breathing

• Increased heart rate

• Increased blood pressure

• Hypervigilance, pupil dilation

• Circulation changes drawing blood away from extremities toward vitals

• Adrenal hormones blasting through the body

• Glucose and fatty acids flooding the bloodstream

• Digestion practically stopping

• Detoxification shutting down

• Fertility functions turning off

This sequence, designed to outmaneuver a grizzly, is at the root of many disordered processes that can turn into chronic inflammation, pain, tumors, or autoimmunity.

That’s why one of the most important elements of your placebo protocol is to replace (or supplement) the safety signals that we get from being in the medical system with our own set of safety signals.

Create a daily safety protocol from the menu below or your own alternatives.

Meditation or meditative prayer has a physiological effect in the short and long term that has been exhaustively documented. The studies show that personal prayer is more effective than intercessory prayer by others at a distance. Focus your sessions on breathing, trust, and love, rather than pleading, demanding, or negotiating.

Interrupt the obsessive thoughts that take over when we’re struggling with illness. This is a hard-wired survival adaptation designed to help us escape the grizzly. But it’s the opposite of a safety signal and it turns off healing and keeps stress physiology on high alert.

The practical way to rewire that unhelpful thinking is to create a custom set of safety distractions and practice implementing them every time you catch yourself spiraling, or even at the first hint of negativity.

My favorite is singing all three verses of Copacabana, preferably with dancing and acting out the lyrics. I also love wrestling on the floor with my dog. An abbreviated version is picturing my dog adorably bouncing through a meadow, sharing her joy for thirty seconds with my eyes closed and a smile on my face (smiling actually cues the parasympathetic nervous system to relax you).

Lose the SVU. Purge your TV time of all dark, crime/procedurals or anxiety-inducing thrillers. Remember the story of public intellectual Norman Cousins who recovered from a crippling, life-threatening condition with comedy TV and belly laughs. Faithful readers will have noticed that The Princess Bride and Parks and Recreation references make regular appearances in my writing, because, well, they make me happy.

Bullet out your blessings in a daily gratitude log. It may sound cliché, but the research on the impact of gratitude on health is rock solid. It dials down inflammation, insulin resistance and immune suppression caused by fight-or-flight.

Treat your symptoms as a message, not a betrayal.

Most of us understandably just want some white-coat to do something and make our symptoms stop. But our bodies are ecosystems that are part of nature, and nature never randomly goes on the blitz or breaks. Nature adapts.

Symptoms are the check-engine alert that our subconscious mind is sending our conscious mind through our body. Paying a mechanic to turn off that alert without doing anything else is counterproductive in the extreme.

Don’t shoot the messenger. Cultivate curiosity rather than contempt toward your symptoms. Ask yourself:

Sherlock those symptoms — they might be signaling a toxic exposure, nutritional deficiency, a battery depletion related to sleep, sunlight or nature deprivation, repressed anger, self-devaluation, trauma or childhood pattern.

Symptoms and illnesses can often expose situations in our life that have to change. They might be the way our subconscious mind is telling us to cut the crap, lose the deadweight, break free from toxic people, situations, or jobs. Sometimes the most powerful placebo is taking a tangible step away from whatever is sucking our life-force. In this way, we’ll look back on our illness as an incredible gift.

Watch your language, as your mother would say. Speak about your condition as a “healing phase” and your symptoms as “healing signs.” Call yourself a human and not a [fill-in-disease] patient.

Avoid taking verbal possession of your disease: “my cancer,” “my asthma,” “my bum knee.” If you’re part of an online group that identifies primarily as victims of a certain disease, run.

What About Trusted Authority?

White Coats Are Consultants. You’re the CEO.

We’ve been through how to establish the healing rituals and safety signals. But your subconscious mind won’t trust those rituals and signals enough to actually heal you if it doesn’t trust YOU.

You can’t trick your subconscious mind or lie to it. You have to provide evidence in order for the mind to believe enough to change.

Trusting in yourself as a wise expert authority therefore becomes the foundation of the placebo effect. But most of us don’t trust ourselves — we’ve been conditioned to trust the white coats above all else. As the placebo literature demonstrates, much of the power of a doctor’s orders to initiate healing comes from that trust we have in the doctor, and sometimes less from what was actually ordered.

We must reclaim our own confidence in order to dissolve that victimization vortex or reverse the hex of a scary diagnosis or doomsday prognosis.

Here are some hacks to build trust in your own expertise and power.

1. Trust your gut. Your intuition is guiding you every day. But so often we ignore that little voice inside. That email you know you shouldn’t send. The weird vibe you’re getting from your teenager. The inexplicable sense that this is the year to replace the roof.

   Scripture speaks of a logos – the Greek word for the immaterial and powerful mind that lives in all of us and is connected to the absolute Logos that created everything. If you’re made in the image of an omniscient God, then your intuitions might be far more worthy of attention than you think.

   Set an intention to obey your intuitions, starting right now. I’ve never regretted doing so, and have regretted many times that I didn’t. Honoring your inner wisdom signals to your brain that you’re not a victim, you’re a BOSS.

2. Log your wins. I like coupling those I’m-grateful-for bullets each day that we talked about earlier with a few more bullets of daily wins. This provides evidence to your subconscious mind that you are crushing this healing business.

   Maybe it’s that you got through two verses of Copacabana today. Maybe it’s that you didn’t murder your brother-in-law. Maybe today you downed one less Diet Coke than yesterday (that one’s for me). Maybe it’s that you got three minutes of sunlight before the cold made you want to cry and run inside.

   The point is, you’re honoring your own agency. That converts to placebo-powered greatness.

   

3. Honor the white-coats as useful mechanics. Doctors have useful but limited tools — drugs and surgery, for the most part. Receive their orders or recommendations as offerings to be evaluated.

   You are not there to be infantilized, shamed, fearmongered or otherwise under their thumb. Good doctors will position themselves as supporting players on your team, rather than as the coach.

   For the others, your attitude of disinterested observer of their recommendations — rather than groveling peasant — can be disorienting and may cause unpleasant reactions.

   Bless their hearts.

Grit your teeth and ask:

• What are the data and literature behind your recommendations?

• How many cases have you seen with my similar symptoms and history?

• How often do you perform the procedure you’re recommending?

• What is the absolute number, percent, and nature of successes you’ve had with your recommended protocols?

• What is the duration of the relief the protocols provided to your other patients?

• What do you know about the root causes of my symptoms?

• What was the improvement rate in the placebo group in clinical trials of your recommended protocol?

• How much greater was improvement in the treated group compared to the control group — in other words, how much of the treated group’s improvement was likely attributable to placebo?

Your secret weapon here is the ability to thank the doctor for the suggestions and promise to take them under advisement.

And then walk away.

Not because you’re going to do nothing. But because you’re going to consider the doctor’s offering as part of a larger menu of placebo-powered options. Because you’re the BOSS.

You don’t have to be rude — this role reversal can sometimes be primarily a mental shift, especially when your doctor is a decent human.

But this shift is a powerful message to your subconscious mind that you are the trusted authority, recruiting and quarterbacking a variety of consultants and subject matter experts to your team as they present their offerings, opinions and tools. The team might include doctors, holistic practitioners, nutritionists, pastors, family members, the bowling league, puppies, comedians, among others. All have healing powers that might be right for you.

You get to choose the tools that resonate with you. You leave the rest, because you are your primary care provider.

The Secret Ingredient

You’ve trusted in your own authority and prescribed yourself healing rituals and safety signals. That’s the placebo playbook. Well, almost.

There’s one last thing — vision.

Scripture teaches that “faith is the assurance of things hoped for, the conviction of things not seen.” (Hebrews 11:1).

When the placebo effect works, it’s because the patient envisions that the package of healing rituals, safety signals and submission to trusted authority are going to work.

The superpower here is your own imagination. Create an intentional daydream.

I don’t mean just closing your eyes and repeating some mantras.

Instead, concentrate your attention on imagining how it will feel to be healed.

Name those emotions — the freedom you’ll feel, the things you’ll do when you’re healed. Let yourself bask in the joy, the delight you’ll take in health, the time you’ll get back and how you’ll spend it.

This can be as little as doing this for 30 seconds every time you go to the bathroom — using that throne time to feel all the healing feels, smiling the whole time, visualizing your life.

It can also be an hour-long guided meditation or a week-long retreat. I like to write out this vision, record myself saying it and replay it regularly, using an app like Think Up. The details are all up to you.

But don’t skip it.

Your immaterial mind — like the divine Logos whose image it bears — lives outside of time and space. Your subconscious mind does not know the difference between what’s happening tangibly in space and time and what’s just taking place in your imagination. It experiences them both as equally real.

So sing at the top of your lungs.

Binge Parks and Recreation, Blades of Glory or Monty Python.

Snuggle with a dog or a cat or a husband or a toddler.

Build in all the chicken soup you can — the nutrient-dense kind and the for-your-soul kind.

Listen to the doctors and evaluate their offerings with detachment.

Honor your symptoms with curiosity and patience.

And let the placebo-powered healing begin.

You're here because you believe healing belongs to you, not the system. Please consider sharing this publication with one person in your life that needs to hear that message.

Epilogue: Just to prove I mean it…

Imagine this: the most powerful drug isn’t locked in a pharmacy — it’s sloshing around in your skull: free, refillable, and with zero adverse effects (except maybe too much hope).

I’m talking about the placebo effect, that sneaky Jedi mind trick. But what if we could unpack its secrets and bottle it as an essential element in our own healing?

Back in epidemiology school, one of the most memorable things I ever learned was that the biggest modifiable predictor of people quitting smoking wasn’t family, fear, or government-funded PSAs — it was a doctor telling them to.

That’s the power of trusted authority.

We’ve turned modern medicine into a religion, with priests in lab coats prescribing penance, and prognosticating doom or salvation.

Doctors have an unmatched level of trust in society, and with that trust comes power and authority. We believe they know what they’re talking about. We believe that their protocols will work.

But what if the secret sauce behind the healing they deliver isn’t the protocols but the belief itself?

The placebo effect isn’t just woo-woo — it’s hard evidence that your mind can change your biology. That expectation can trigger your body to make its own opioids for pain relief, tweak immune responses, and heal arthritic joints.

By “bottling” it — harnessing expectation, meaning, emotion, and context – you can take significant power over your prognosis.

Early caveat: I’m not doling out medical advice here, and medicine absolutely has its proper place. If you’ve got a bullet in your belly, a bone sticking out, or a tumor blocking your colon, there’s nowhere on earth I’d recommend being more than an operating room in the U.S. If your organs are shutting down from sepsis, antibiotics are critical. If your kidneys have failed, I want you on a home dialysis machine at night.

But for a lot of the rest: we’ve ignored a massive lever that science keeps demonstrating matters way more than you think.

The evidence is wild.

The Science of Placebo – Your Mind’s Underground Lab

Placebo isn’t “fake healing” — and it’s not just the idea that pain or disease is “all in your head.” It’s your mind turning on your biology’s inherent adaptive capability.

You even have a built-in pharmacy–

• Dopamine boosts for mood,

• Endocannabinoids (your body’s own medical marijuana),

• Endogenous opioids for pain (without the criminal record),

• Oxytocin for calming and safety signals, and on and on.

Your mind can also work against you – snarkily called the “nocebo” effect – where you believe you’re given a poison or a curse, and your biology responds in kind.

A diagnosis can also be a nocebo, acting like a hex, and a prognosis as a sentence, locking in a bleak despair that tanks clinical outcomes and accelerates disease progression.

If all this sounds too “woo,” consider a more familiar example.

You’re walking home in the dark. You hear someone’s footsteps approaching a little too fast from behind.

Nothing has happened to your body externally. No attack, no words exchanged. But your mind is now in overdrive, and fight-or-flight physiology is switched on. Your heart rate quickens, your breathing shallows, your circulation changes, digestion stops, detoxification stops.

Because of your mind.

Your mind is the single most powerful influence on your biology. And it’s beyond your brain.

Your brain is processing the sound waves from the footsteps, to be sure. But it’s your mind that gives those footsteps the “unsafe” meaning that turns on the stress physiology.

This time of year, many of us reflect on the Incarnate Word becoming flesh.

The Greek word for, well, “Word,” used in this context is Logos, which connotes not so much the spoken word, but rather the intellect, the rationality, the system of coherence and meaning, the thoughts — aka, the mind.

Christians believe that we’re made in the image of God, and that, through that Logos, all things were made.

Well, if the Logos of God creates all physical reality, and we’re made in the image of that Logos, then it makes sense that our own logos has a creative power too, even if only a shadow of the divine version.

Indeed, the science suggests as much.

Consider a type of research called “sham surgery” trials.

In these studies, one group receives the standard surgical procedure while the placebo group undergoes a “fake” one: they’re wheeled into the OR, put under anesthesia, given an incision, subjected to some trivial poking and prodding, then sewn back up — without the actual standard surgery ever being performed.

The results will blow your mind:

• A 2002 study published in the New England Journal of Medicine showed that sham knee arthroscopy improved pain and disability as much as real surgery.

• A 2009 study published in the New England Journal of Medicine showed the same thing when testing vertebroplasty (cement injection for painful osteoporotic fractures) v. sham surgery: no difference between actual surgery and fake surgery.

• A 2014 systematic review of randomized, sham-controlled trials, published in the British Medical Journal Open, found that across 55 trials, 75 percent showed improvement in the placebo (sham) arm, and more than half showed no difference between the real procedure and the sham.

• A 2015 systematic review of randomized, sham-controlled trials, published in the British Medical Journal Open, found that across 39 trials, the placebo effect (as measured by post-sham improvement) was on average 65 percent of the benefit of actual surgery. For some procedures, like weight loss or pain surgeries, it was well over 70 percent of the benefit.

Consider spontaneous cancer remission.

Many people think of cancer remission as something that only happens via chemotherapy, surgery, or radiation. But Kelly Turner’s best-selling book Radical Remission – a compilation of hundreds of unexpected remission cases – documents that in real life, people sometimes recover in ways that conventional science can’t yet fully explain, and that mindset, meaning, community, and lifestyle often figure prominently in their stories.

Are we measuring the wrong treatment?

The placebo effect is not just doing nothing and getting better by chance. The placebo effect is doing something and getting better because of it.

The common factor between both groups in placebo-controlled trials is that both the treated group and the placebo group believe something good is happening.

When a placebo-controlled trial is run, and there appears to be, say, 30 percent improvement in the treated group and 30 percent improvement in the placebo group, the typical interpretation is that the treatment doesn’t work, because there’s no difference between the groups.

But nobody ever talks about what IS working, which is the absolute wizardry hiding in plain sight.

It’s not that the treatment doesn’t work. It does work, 30 percent of the time.

The “treatment” is the healing ritual of: submitting to trusted authority, entering an institution that is respected by society as being built to heal. It’s taking off your worldly garments and adornments and putting on the classic patient gown. It’s getting caring attention from smiling nurses, buoyed by glossy photos and testimonials in the hallways, the placards thanking rich and important donors who valued this place enough to fund it, and all the other reassurances that this is the way. “You’re in good hands.”

It’s not that the surgery didn’t work. It’s that everything else about the healing ritual did work.

Your Biology Listens to Your Mind

Some have suggested that the placebo effect is just in your head and that your body isn’t really being affected. Your mind is just tricking you into thinking your pain (or nausea or some other symptom) is better without actually changing your biology. Apparent improvements are merely coincidental and the placebo effect is simply the name for what would have happened without intervention.

This theory is belied by the evidence.

The intervention is actually essential for the placebo to work. Doing nothing often doesn’t work. (And let me state again for the record that this article is not an endorsement of doing nothing.)

When you take out the ritual and its trusted authority and context, and you don’t get good results, that doesn’t disprove the placebo effect, it proves it. It shows that the experiences we have and the meaning we place on them are what change our biology. It does not imply that spontaneous healing would have happened without all that context.

When it comes to chronic illness or pain, there’s nothing spontaneous about healing.

Our minds and our beliefs and the meaning we ascribe to things say “jump” and our biology says “how high?”

A 2009 meta-analysis by Satin et al. found that depression was associated with a 25 percent higher risk of cancer mortality.

This is purely associational, meaning that we don’t know which comes first — the depression or the cancer progression and death. The nocebo effect would suggest it’s both. A cancer diagnosis is depressing. Biology is listening to the hopelessness and anxiety of that depression. The cancer grows, in part, as a result, which causes more depression. And the interplay continues, until death.

One of the strongest proofs that the placebo effect is real biology — not our minds playing tricks on us — comes from experiments using a drug called naloxone.

Naloxone is what ER doctors use to reverse opioid overdoses; it blocks the brain’s opioid receptors. In placebo pain studies, subjects are told they’re receiving a powerful painkiller but are actually given a saline injection. Many experience real pain relief anyway.

The placebo doubters would say that the degree of perceived pain is just driven by mind tricks, not by actual biology. But here’s the kicker: to test that theory, researchers conducted the study as normal, observing pain relief from the placebo injection. But then they gave the subjects naloxone along with the placebo. Their previous pain returned. The only thing naloxone does is block opioid receptors, which means the placebo had triggered the brain to release its own morphine-like chemicals. When naloxone was added, those endogenous opioids were blocked and the pain relief ended.

By the way, even when patients know they’re getting placebo, the placebo can still deliver.

Ted Kaptchuk’s work at Harvard Medical School’s Program for Placebo Studies (yes, that’s a real thing) shows that these so-called “open-label placebos” (where you know it’s fake) still reduced IBS symptoms, chronic pain, cancer-related fatigue, and even improved treatment retention in drug addiction trials.

What if medicine’s “magic” is mostly placebo in fancy packaging?

Population-level data on cancer treatment is sobering:

• A landmark 2004 analysis (Morgan et al.) found cytotoxic chemotherapy contributed only two percent of 5-year survival in adult solid tumors – most gains were not from chemo but rather from surgery, radiation, or natural history (including placebo effect or chance). That suggests that huge amount of the positive clinical trial results before FDA approval might have been placebo.

• A 2022 review, published in the Journal of Clinical Oncology, of hundreds of oncology drugs (including targeted and immunotherapies) showed median overall survival benefit of under three months.

• A similar review two years later, published in The Lancet Oncology by Huseyin et al. showed that only a third of new drug indication approvals that were approved using surrogate endpoints like tumor shrinkage demonstrate clear survival advantage of any time at all.

• A 2024 review by Liu et al, in JAMA confirmed that, when cancer drugs given “accelerated approval” by the FDA, usually by observing less meaningful endpoints rather than reliable survival data (usually in a rush to speed “cures” to patients rather than waiting on so-called “red tape” at FDA), it turns out that fewer than half the drugs later show any survival benefit, even after years of follow-up.

Nonetheless, most cancers that are “treated” – even with these weak-sauce or overly toxic chemo drugs – are more likely to go into remission than “untreated” cancers. In other words, the process of undergoing cancer treatment is more effective than the controlled trials of the chemotherapy itself would predict.

Doctors swear by the cut. Sham trials whisper: “Hold my scalpel.”

Accelerated approvals based on non-meaningful clinical end-points? Over half fail to confirm actual benefits later. White-coats have way less monopoly on expertise than advertised.

We’ve shredded the myth that healing is pure mechanics or pharmacokinetics.

Now the juicy part: real people who bottled this power and flipped the script on grim diagnoses.

Plus the exact steps to start hacking your own mind today.

Ready to uncork the placebo potion? It’s for those serious about agency.

Real Stories of Bottled Magic – Outliers That Teach Us Leverage

Data points are cold. Stories are fire. These aren’t guarantees — they’re proof of what’s possible when you bottle expectation and ditch nocebo spells.

One of the most famous placebo stories in the medical literature comes from a 1957 case report by physician Leonard Cobb. A cancer patient named Mr. Wright had terminal lymphosarcoma, orange-sized tumors, days to live.

He begged for a drug known as Krebiozen, despite his physicians’ skepticism. Within days of taking it, his tumors reportedly shrank dramatically. He was discharged and went into near-miraculous remission.

Shortly thereafter, Mr. Wright read news stories that Krebiozen was showing itself as ineffective and he became convinced that the drug wouldn’t really work. His tumors reappeared and he was deteriorating rapidly.

His clever physician, Dr. Cobb, told him that a new and improved version of Krebiozen had just been released and he administered this drug (actually a saline placebo). Mr. Wright’s tumors regressed again, his symptoms improved, and he rallied for several months. Later, the American Medical Association formally denounced Krebiozen as ineffective. When he heard this news, Mr. Wright lost belief entirely and he died shortly thereafter.

Modern placebo researchers cite Mr. Wright — not because his story is typical — but because it illustrates something uncomfortable:

In 1964, journalist and public intellectual Norman Cousins faced a dire diagnosis: ankylosing spondylitis, a crippling spinal disease for which he’d been hexed with a one-in-500 chance of recovery. Perceiving that the hospital’s rigid protocols, toxic food, stressful lighting and noise, and loss of agency were hurting him rather than helping, he checked into a hotel nearby.

His sympathetic doctor monitored him as he dosed himself with high levels of vitamin C and — most famously — prescribed himself daily marathons of Marx Brothers films and Candid Camera episodes.

Against all expectations, Cousins steadily healed, regained full mobility, and lived another 26 vibrant years. His story, first printed in a 1976 New England Journal of Medicine essay and later expanded in the bestselling Anatomy of an Illness as Perceived by the Patient, reminds us that joy, humor, and an active role in our own healing can be true medicine. Cousins is a forceful demonstration of the power of agency, intuition and trusting in your own expertise.

Honest synthesis: These are stories and not guarantees. They demonstrate the power of your mind as leverage — perhaps the most important leverage — over what your body does next.

Back to our friend walking home in the dark. What if his pursuer suddenly calls out in his teenaged daughter’s voice, “Dad, wait! Slow down!”

All the biological threat-response he had turned on would immediately switch off and endorphins of relief and love would flood his body as he turns and welcomes this surprise encounter of his daughter with delight.

What if we translate that process into a longer version of a health journey, where the footsteps are symptoms of a fearsome disease? And what if instead of the daughter’s voice, our own voice and daily practices create a healing ritual that communicates to our subconscious mind and body that everything is ok and happening for our good?

How to Bottle It – Your DIY Mind-Pharmacy

Bottling placebo isn’t passive — it’s active hacking. Start here, backed by science:

• Reframe threats: See symptoms as healing signals from your subconscious mind to your conscious mind, using your body as the messenger (fever as immune activation, insulin resistance as a sign of stress response, inflammation as a rest request).

• Cultivate expectation: Daily visualization or mental rehearsal of a future healed state. Feel the heal of tomorrow today. Your subconscious doesn’t know the difference.

• Build meaning & social nets: Social connection is life. Release toxic emotions. Forgive to slash stress hormones.

• Ditch nocebos: Reject the hex of a scary diagnosis or doomsday prognosis. These are just words doctors use to match up symptoms and lab numbers with a certain drug or procedure from their short list of limited tools. Shift identity from “victim” or “[disease X] patient” to “resilient agent.”

• Amplify with habits: Concoct significant healing rituals to communicate to your body that you are a trusted authority (such as meditation), going to special places designed for healing (like exercise in a gym or nature), administer healing elixirs (such as food-as-medicine, certain teas, supplements, and so forth).

Doctors won’t script this — it threatens their authority. But you can brew it daily.

The Placebo Revolution

We’ve been sold the lie that healing is just mechanics: pills, protocols, and scalpels.

Science keeps shouting the truth: your mind is the ultimate bootleg pharmacy, serving up its own opioids, dopamine, and sometimes even miracles on demand. Bottle it with raw expectation, deep meaning, and unapologetic agency, and watch the white-coat nocebo empire crumble.

In the next post, we map out a more detailed Placebo Playbook: how to become your own Primary Care Provider, recruiting and quarterbacking white-coats and other consultants to your healing journey like a BOSS.

(My last article explained the problem Republicans face in trying to fix health care. This post focuses on the solution.)

We can’t afford not to have insurance because the prices are so high. But we also can’t afford insurance because the premiums are so high.

Which is why almost every American requires a significant subsidy from someone else in order to afford insurance – whether it’s government ACA subsidies, employer subsidies, or government-run Medicare, Medicaid and other programs.

With the COVID-era expanded subsidies for people on the ACA exchanges about to expire in a few days, there’s a growing panic among policy-makers about what to do.

You may have noticed that I’ve been warning Republicans in recent articles about the pitfalls of the various proposals reportedly under consideration. Their response back is understandable:

So what's the plan?

This article is my answer to that question.

My proposal is the same as the president’s.

(But not the weak-sauce version being kicked around by some in Congress.)

So what details would put flesh on the bones of the president’s all-caps social media screeds against insurers?

Is there hope for a bill that can pass – satisfying both the moderates and the conservatives in the party, without screwing over voters and losing elections?

Answer: YES.

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One of the problems with most Republican proposals is that they are only targeting the small fraction of Americans on the ACA exchanges. That’s 23 million people – a lot, to be sure. But 180 million Americans – almost 54 percent – get their insurance on the job, nine times more than ACA enrollees.

That said, we still have to have a solution for the affordability problem for those 23 million currently on ACA plans. Because the premiums are so astronomical, almost all (92%) of those people are receiving free or heavily subsidized coverage, paid for by you and me.

That government cash goes straight from the Treasury to the deep pockets of the “money-sucking insurance companies,” to quote President Trump (he’s not wrong!).

As I’ve mentioned in previous articles, if we take money away from people who are currently getting subsidies, we will lose the mid-terms, period. We lost the 2018 mid-terms just for trying.

No amount of wailing and gnashing of teeth from conservatives will change this. I wish it weren’t true, because it’s extortion. But it is true.

If we lose the mid-terms, Democrats will come in and make things even more impossible the next time we’re up at bat for a chance to fix this.

So here’s my four-point plan, or rather, what I think the president might have meant with his social media posts.

Let’s start with the executive summary, followed by a deeper dive for the bravest among you.

1. School choice for health care: ACA Market edition

Convert all subsidies currently going to insurers on behalf of ACA exchange enrollees into dollars put in a tax-advantaged Health Freedom Account, or “Health Wallet,” “Care Fund,” “MediStack,” “Trump Card,” whatever branding you choose. It’s an account owned by the enrollee. For now we’ll call it an HFA.

They can use the money to buy the same plan they’re on now, a different plan, a plan off the exchange, a membership like a health care sharing ministry or direct primary care, or just cash-paid care.

Trust them to choose their own health expenses, including holistic care, without the government dictating what medical care is or should be.

Let anyone else contribute to it as well, up to the max subsidy amount available for an ACA silver plan, or whatever cap above that Congress decides on (see below).

2. School choice for health care: for everyone else

Allow everyone in America to have an HFA - including employees of businesses. That way, employers who want to provide financial support for their people – but don’t want to be in the health care business, having to manage a complex group health plan for their workers – still can provide robust health benefits. By contributing to their workers’ HFA, businesses could free up employees to make their own health choices rather than having their bosses make those choices for them.

3. Cut out the middlemen between buyers and sellers of care

• Require doctors and hospitals to publicly post and accept a cash price for all services that is equal to or lower than the lowest carrier rate.

• End discrimination against uninsured patients by requiring providers to treat cash-paying patients the same way they would patients using insurance.

• Prohibit insurance contracts from banning employers or doctors from cutting out the insurer and negotiating a better deal directly between themselves, or simply transacting in cash on behalf of patients.

• Prohibit state/local laws from banning new hospitals and repeal federal law prescribing who can own hospitals, like doctors.

• Require pharmacy benefit managers and third party plan administrators to assume fiduciary obligations to the plans and enrollees they serve.

4. End secret health care prices

• Codify the first-term Trump price transparency rules and supercharge them with more details, more ease of access, and excruciating penalties for noncompliance.

• Entitle all buyers of health care to have full access to their claims data, including individual patients, employers, unions, and governments, again, with excruciating penalties for non-compliance.

That’s it, that’s the plan.

You’ll note that I’m proposing to extend a form of the COVID subsidies.

Conservatives don’t want to do this. I know. I hear you. I don’t want to either.

But I like winning elections, and I know you do too. We have no margin in the House – every moderate in a swingy, unsafe seat has to vote for a package in order for it to pass.

Moderates are currently signing up for a totally clean (i.e. reform-free) three-year extension of the subsidies right now. That would get us all the current costs and no policy wins in return, enshrining the premium-spiking death spiral we’re in now.

Moderates have rightly figured out that they have to extend the subsidies or they’ll lose their seats. I don’t want them to lose. Do you want them to lose?

Conservatives in safe seats have to sacrifice our principles more than moderates do, when margins are this tight. I’m sorry. I wish it weren’t so.

However, if it’s any consolation, this is one of the only proposals that actually would lower costs throughout the entire commercial market (not just the ACA exchanges), because it would facilitate actual price competition and greater efficiencies through cash/direct-pay and direct contracts between employers and hospitals.

I urge you to consider that, if prices come down through these reforms, premiums would come down too, including the silver benchmark plan premium that subsidies are tied to. In this way, there’s a path for the extended subsidies in this proposal to actually pay for themselves in lower health costs nationwide.

Moderates, you get to say you took nothing away from anyone and you gave them more options, more control over their own destiny, and more affordability.

Conservatives, setting cost aside, you’d be getting all your health policy hopes and dreams.

Conservatives have long wanted to move subsidies into private accounts, to give people choices away from the limited government-approved options in Obamacare, and to move employers away from defined benefit health coverage towards defined contribution coverage. This proposal would do all of those things.

My experience is that you can actually get big policy reforms done in Washington. But you always have to buy them. Meaning, you have to spend more than you’re comfortable spending. That’s usually the compromise, and I’ve found that it’s generally worth it, if your policies are the right ones.

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So that’s my pitch. And now here’s the deep dive.

If you want to look under the hood a bit more...

1. SCHOOL CHOICE FOR HEALTH CARE - ACA market edition

All current subsidies going to anyone on the ACA exchanges will continue flowing, but they will be given to the people themselves, not the insurers, so that the people can buy whatever health care or coverage that they want.

Put all subsidies that any American qualifies for today (including base ACA subsidies, COVID expansion subsidies and Cost-Sharing subsidies) into an HFA.

The amount that goes in is the exact amount of the max subsidy that the person would qualify for today under the ACA for an average silver plan. This amount changes every year based on the rate of inflation or some other standard index, rather than just a blank check covering whatever insurers feel like charging.

HFAs can be used, tax-free, for:

• Insurance premiums for ACA exchange plans (people can buy the same plan they’re currently on if they want)

• Insurance premiums for off-exchange insurance plans

• Membership fees for Health Care Sharing Ministries

• Membership fees for Direct Primary Care

• Out-of-pocket insurance-related expenses such as deductibles, coinsurance, copays

• All other qualified medical expenses under Sec 213(d) of the tax code, EXCEPT abortion or sex-rejecting (transgender) procedures.

No one loses a single dollar that they currently are getting in subsidies (i.e. it’s an extension of the COVID subsidies, only through a different mechanism).

If you are on an ACA Blue Cross plan today and Blue Cross is receiving your subsidies, you will now get those subsidies in your HFA. You can take that money and give it right back to Blue Cross to buy your same plan. You lose NOTHING.

But if you want a different plan, like say, an off-exchange plan or a health care sharing ministry membership, you can use your subsidy money to buy that instead, and keep whatever’s left over in your HFA for other medical expenses.

NOTE: If Republicans insist on ending the expanded (COVID-era) subsidies, I recommend that they only do so for the richest people. Pick a threshold that everyday Americans would all agree is “rich” (and therefore, fair), say, above $150,000 or $175,000.

ANOTHER NOTE: Ok, ok, what about phasing down the COVID-era subsidies after a few years? You could maybe get them down to pre-COVID era – or even lower over time. Unlike most reform plans, this one actually rescues the rest of the commercial market and not just the ACA – that means that underlying prices will now be subject to competition at scale. That could lower premiums and save money in the end by lowering the indexed subsidy amount allowed in the HFAs each year.

AND YET ANOTHER NOTE: It’s important – both politically and morally – to prohibit HFAs from being used to pay for stuff that is violent toward self and others like abortion and sex-rejecting procedures like cutting the breasts off little girls. That’s not health care – conventional, holistic, woo-woo or otherwise. Sorry, not sorry.

Goodies for MAHA

Little-known fact – you could use the HFA for MAHA tax breaks.

HFAs could be used, not just for insurance premiums or membership fees, but for “qualified medical expenses,” as defined by the tax code. That means it could also include expenses that help you live like a human, like physical training, visits with an acupuncturist, Traditional Chinese Medicine practitioner, a functional nutrition expert, a fertility health coach, and so forth.

BUT here’s the proviso – to comply with current IRS rules, you would need to get a licensed clinician to write a letter of medical necessity saying that the clinician is prescribing these less-conventional services or equipment in order to treat a specific diagnosed condition like obesity, depression, lower back pain, infertility, and so forth.

In other words, tax breaks for MAHA.

This policy would make things a lot more fair for people like me, who are more woo-woo, and don’t want insurance at all.

More and more Americans are extracting ourselves from the white-coat religious cult and would prefer to treat with time-tested home remedies, and pay cash if we need to set a bone or get an x-ray.

But since catastrophic care is still so unaffordable, maybe we join a health care sharing ministry in case we’re attacked by radicals on a college campus and need a burn unit or ICU.

Further, why not let us donate unused money in our own HFA to someone else’s health care whose costs exceed their HFA limit?

2. SCHOOL CHOICE FOR HEALTH CARE – for Everyone Else

Why not open up HFAs to all Americans, not just those currently getting ACA subsidies?

Remember those 180 million Americans getting their insurance on the job? This has turned every company into a health care business – whether they want to be or not. What if they could get out of that business and focus on their core competency, while still helping their workers afford health expenses?

HFAs would not only be available to people getting subsidies today. HFAs would be available to anyone else (only without the government pre-funding).

This would build on a policy created by President Trump in the first term where employers were allowed to set aside money for workers to buy their own coverage rather than buying it for them.

Anyone could contribute private money to the HFA – tax free to them and tax free to the account-holder – up to a cap equivalent to the amount most people would use for an insurance premium and out-of-pocket costs. Another cap could be used instead, such as the maximum ACA subsidy amount.

That private money can be contributed by the account owners themselves, or anyone else on behalf of the account owner, including employers, health care sharing ministries and other charities, crowd-funding sites, churches, or family members.

Employer-sponsored health benefits are already tax free, so putting that same money into a worker’s HFA won’t drain the Treasury - well, not anymore than it’s already drained.

3. CUT OUT THE MIDDLEMEN BETWEEN DOCTORS AND PATIENTS

There’s a hostage crisis in the 180 million-person employer market. Secret contracts with middlemen keep prices high for ALL Americans by prohibiting buyers and sellers from making better deals with each other - directly.

America’s health care system is full of good doctors, nurses, and (a few) hospitals. American businesses want to do the right thing by their employees, but they’re drowning in double-digit rate hikes year over year, threatening their ability to survive in the economy and compete with foreign companies.

Charities, churches and health care ministries just want to help patients get care at affordable rates.

But one group quietly controls the entire system: health insurance companies.

Insurance contracts hold every stakeholder hostage.

Behind the scenes, insurers use their contracts to lock up doctors, hospitals, employers, ministries and patients – all to block competition.

And if you’re wondering exactly how they carry out their dirty work, these contracts:

✘ Stop hospitals and doctors from accepting fair, lower direct-pay prices from patients:

Even when a doctor wants to accept a lower direct price for someone paying cash, the insurer contract often forbids it.

When patients who are enrolled in one of my employer-client’s plans show up at a doctor’s office, they are asked to present their ID card. If that ID card has a carrier logo on it, then that doctor isn’t allowed to accept cash from us for a lower price. He has to send the bill to the insurance company and charge us those predatory rates. And we’re not supposed to even offer cash in that situation either, because of our own contract with the carrier.

We’re all held hostage to this middleman.

✘ Stop doctors and hospitals from giving employers a better deal without the insurance network.

If a local employer wants to contract directly with a hospital for lower prices, insurers often ban the hospital from saying yes. Employers are hostage to the insurer’s deal—even when everyone knows the insurer negotiated a terrible one.

My employer-clients often want to do a deal with their local hospital. But both my client and the hospital have their own separate contracts with, say, Cigna. We have to get permission from Cigna to do that deal. If the deal is too likely to disrupt Cigna’s profiteering, they veto the arrangement and we’re both out of luck.

✘ Stop patients from getting appointments unless they have the “right” insurance.

One of my employer-clients isn’t an employer at all, they’re a religious order of Catholic nuns.

They wanted a health plan without a carrier network so that they were free to pay cash directly to doctors or hospitals, or to negotiate their own contract.

Just last month, NYU hospital (a so-called “charity” that doesn’t pay taxes) told a desperately sick nun, “sorry, we won’t let you in the door because your ID card doesn’t have a carrier logo on it. Even though your plan will pay. Even if one of our doctors very much wants to see you.” I had to use my fancy DC connections to get hold of an NYU executive, just to be allowed to pay cash at the door, before this poor sister could be seen. By the way, this sister would qualify for Medicaid and NYU’s financial assistance program. We actually wanted to PAY the hospital instead of going that route.

If you want to pay out of pocket — or if your employer or health care sharing ministry wants to pay on your behalf — you should be able to get the appointment.

✘ Punish doctors if they offer lower prices to anyone else. Insurers often include:

• “Most-favored-nation” (MFN) clauses – requiring the doctor or hospital to give the carrier the best price compared to any other purchaser, no matter what.

• “All-products” clauses – requiring doctors to participate in every network offered by the carrier if they want to participate in one.

• “Anti-steering” clauses – prohibiting employers from steering patients to doctors outside the network who are higher quality or lower cost.

• Outright bans on doctors or hospitals offering lower prices outside an insurance network.

These contract provisions block doctors and hospitals from giving anyone a better deal — patients, employers, even charities like my nuns.

Congress should make it explicitly illegal once and for all.

To put an end to these gangster tactics by insurers, Congress should:

✅ Require a direct-pay option for all care

Every health care provider must post and accept ONE single “direct-pay price” for each service – the same price for every patient, employer, or non-insurance payer willing to direct-pay, upfront and in full.

The published direct-pay price must be equal to or lower than the lowest commercial insurance rate accepted by the provider. Insurers lose the power to keep cash-paying customers or employers from getting a better deal. Being paid cash upfront and in full eliminates the need for pre-certification, eligibility checks, chasing patients for their cost-sharing obligations, sending claims, waiting around for payment while the insurer makes billions on the interest earned by delayed reimbursements, and collections efforts. That’s why it makes sense that the direct-pay price without all that bureaucracy and inefficiency should be equal to or lower than an insurance rate.

NOTE: Providers should still be allowed to negotiate a hardship discount between doctors and patients.

✅ End discrimination against cash-pay patients

Congress should ban the practice of turning away direct-pay patients, or otherwise discriminating against them, such as refusing to schedule, delaying an appointment, putting you at the back of the line, requiring you to use insurance if you have it, requiring you to submit claims to your insurance first, imposing any extra hoops or extra steps, simply because you (or someone paying on your behalf like your employer or a ministry) are willing to pay the posted direct-pay price.

✅ Establish a right to cut out the middleman between the buyers and sellers of care

Insurance contracts with health care providers (or employers) can no longer prohibit:

• Direct contracts with employers

• Direct contracts with health care sharing ministries

• Community-based arrangements between a local hospital that’s part of a giant conglomerate system and its surrounding community of employers or patients

• Lower-rate contracts outside insurance carriers

• New payment innovations that insurers historically block or control, such as subscription-based models or bonuses for achieving certain clinical outcomes.

Hospitals and doctors can finally say, “yes, we’ll give your business or your ministry a better deal than your insurer does.” Insurers lose their veto pen.

✅ Ban state “certificate of need” (CON) laws

CON laws are truly cons. They give state and local governments, as well as competitor incumbent hospitals, the power to ban new hospitals from being established in communities. These CON laws are anticompetitive clap-trap designed to protect predatory price-gougers from competition.

✅ Repeal the ACA’s ban on physician-owned hospitals

The Democrats who wrote the ACA thought that fat-cat MBA executives are somehow less self-interested than doctors would be when it comes to hospital revenue. This is crazy. Those of us trying to contract with doctors and hospitals on behalf of employers know that the very best facilities are the ones that are owned and run by the physicians who practice in them. They also happen to be the most willing to contract with employers, health care sharing ministries and cash-paying patients. I wonder why incumbent hospitals might not want that in their communities?

✅ Make PBMs and TPAs fiduciaries again

Middlemen often buy each other up to become bigger, grosser middlemen. This has happened with insurance companies buying up pharmacy benefit managers (PBMs) and vice versa. So then you have the situation where the profiteering gets even more opaque and harder for employers and other plan sponsors to see or avoid.

Insurance companies serving as third-party plan administrators (TPAs) might pretend to have low or transparent fees with their employer-clients. But they’re profiteering on the PBM side of the house and not telling you. They are driving up your costs and screwing you in more ways than a poor HR manager or even the best benefits advisor can suss out.

Worse, when employers do figure this out and then sue, too often they get told in court that these entities didn’t have to act as prudent fiduciaries — that was all on you, so too bad, keep paying them money to rape and pillage your workforce. These court cases have often been preempted in the first place by contract provisions forcing disputes into arbitration rather than the cold light of the court record.

It’s time to give guidance to courts who have been all over the place on this. Congress should set the record straight: make it clear that, when PBMs and TPAs exercise discretion that could help or harm plan beneficiaries, or when they act in their own interest rather than the plan’s, they’re fiduciaries and they can be sued like one. This will force the lawyers at these giant corporations to clean up their act and could bring sanity to the transactions and contracts that are bankrupting all Americans.

4. END SECRET HEALTH CARE PRICES

President Trump’s health care price transparency initiative, which we described in a previous article, required secret prices to be publicly available for the first time ever. Congress should enshrine those rules into law so that it’s harder for the industry special interests to undo them (they’re always trying!).

They should be beefed up even more, and enforcement penalties for noncompliance should be excruciating. Right now, penalties are basically a slap on a wrist or nominal fines.

What’s more, any purchaser of care – a patient, an employer, a union, or government program – should be provided the absolute right under the law to demand and receive all their claims data, every single raw data field, including the sticker price, the contracted rate (or the out-of-network allowable amount), the paid amount (including all extra fee shenanigans on top of contracted rates), rebates attributable to a given drug, and every single other data point associated with that claim.

This is essential so that the people that, you know, buy the stuff know what they’re paying so they can make sure they’re getting the best deal (SPOILER ALERT: they’re not!). Getting the best deal is actually required under the law for fiduciaries like employers but these middlemen are preventing them from complying.

More excruciating penalties should be imposed on any middleman holding claims data who does not turn it over within 24 business hours of the request.

I have had to get lawyers involved to get claims data out of these douche-bags for my employer-clients — and this protracted fight has taken — by design — months and months before the middlemen give in, and then they usually turn over garbage data, and well after it’s too late for the client to make the decision to fire them that year.

This chicanery should be illegal, immediately.

The Fifth Step of the Four-Step Plan

If you’ve made it this far, first of all, thank you for being a paid subscriber. Second, you obviously care deeply and so I’m going to ask you to, well… pray.

Health care is so personal, so intimate, so scary, so important. We have to get it right, and it’s so hard.

It’s a multi-trillion dollar industry, a fifth of the economy, and controlled by almost demonic forces profiteering off the suffering of the American people.

The expertise that’s necessary to understand it all is held by no one, nowhere, least of all in Washington.

So it’ll take divine intervention to redeem this industry and make health care great again.

Let’s bow our heads together.