My group of grad-school pals, forged in the decrepit (but cheap!) Harvard medical campus dorm in the mid-1990s had a running joke about our friend Marty. Whenever someone noticed he wasn’t with us, we’d surmise that, while we were goofing off or decompressing, he was cranking out another peer-reviewed research paper.

We marveled at how he somehow found countless hours the rest of us couldn’t, cozying up to the faculty’s brightest lights and figuring out a research question aligned with their interests. He knew no journal would publish a study authored only by a student, so he would network with these researchers, learn from them, and collaborate on an interesting project. The rest of us were just trying to figure out logistic regression or the Krebs cycle, and we good-naturedly ribbed him for being an over-achiever that was making us all look bad.

By the late 1990s, Marty and I were in our first post-graduate jobs - both having landed at Georgetown University in DC - he was in his surgical residency, I was on the research faculty. We were so poor in those days, and I could always count on Marty to let me know where we could score free food at some Pharma-funded reception on campus. Probably the last time either of us benefited from Pharma influence-peddling.

Over the years, our careers were different but we ran in the same church circles in the city and stayed friends as our professional paths overlapped more and more. He wrote his first book, Unaccountable, about his ridiculous experiences during residency, which placed him squarely at odds with the broken status quo of Big Hospital’s underbelly. That book, published in 2012, was eventually adapted to become the TV show, The Resident (with Manish Dayal playing the Marty-type character).

Continuing in that vein of calling out corrupt systems, Marty’s research interests at Johns Hopkins started to intersect more with my professional interests as well. By then, he had settled down as a pancreatic surgeon and public health professor, and I had left full-time epidemiology for the Senate staff. His work involved developing the patient safety checklist in the OR (so you don’t operate on the wrong knee or leave a surgical instrument in the patient’s belly - yup, that happens). He had a knack for attracting the smartest people to work with him on his research, like health care quality guru Christi Walsh, CRNP, the most prolific health financing expert Dr. Ge Bai, PhD, and applied health quality business leader Dr. Will Bruhn, MD.

It was Marty who first turned me on to the absolute degeneracy of the Health Care Swamp. While I was still spouting Republican talking points about how we have to protect the “free market” in health care (editor’s note: health care is neither free nor a market), he was exposing just how failed and distorted that market was. He was publishing on how doctors in different specialties were reimbursed for the volume of their procedures, not the quality of their care, at great cost and risk to patients. He and his team convened groups of expert physicians in every specialty and facilitated their development of a new type of quality metric, asking them to agree on the most indefensible types of overtreatment in their specialty and then using Medicare data to provide every doctor in that specialty his or her rate of that overtreatment. This idea morphed into his team’s creation of a powerful set of “appropriateness” measures that are now used across the country (including in my business helping employers steer their workers to high quality care).

Around this same time, Marty co-wrote a book, Mama Maggie, about his Aunt Maggie Gobran, the Egyptian Coptic Christian humanitarian and Nobel Peace Prize nominee known as Cairo’s Mother Teresa. I suspect that her example of unconditional love for the forgotten children of the Cairo garbage slums helped form Marty’s acute sense of justice. There is often a sort of simmering anger just under the surface when he talks about those who would exploit the weak. Indeed, vulnerable populations became the focus of much of his research, and a theme he wrote about in his books.

Fast-forward to 2018 or so, I was working in the Trump White House and joined Marty and his colleagues at a courthouse in Fredericksburg, Virginia. I was alarmed to discover that, every other Friday of the month, the courtroom docket was reserved exclusively for lawsuits being brought by the local academic medical center, tax-exempt Mary Washington Health, against their own patients who couldn’t afford to pay their medical bills. On this day, like all such Fridays, Marty and his team would stand at the door and intercept the defendants as they filed in. These were working class people, often showing up in their job uniform, embarrassed, not knowing what to expect but grim-faced with the recognition that they were in deep trouble.

Marty offered to serve each one as a medical expert on their case, reviewing their bills and offering to testify on their behalf - if, as was almost always the case, the bill was unfair or predatory, riddled with upcoding, inappropriate care, and other contradictions. The team included a local lawyer, the young whipper-snapper Joey Kirchgessner, who would argue the case until the hospital cried uncle. They helped a lot of people every time they were there. I was so proud of Marty and felt honored to be with the team that day.

Not too long after that, Marty was finishing up his next book, The Price We Pay, about the predatory practices of the health care industry that exploit the poor and sick in our country.

This problem had my full attention, because I was drafting an executive order on ending secret health care prices. So naturally, it was Marty I called to kick the tires on ideas and help me think through the issue. Later, when the draft order was circulated around the White House and HHS, and was facing internal resistance, I sent Marty’s book to about a dozen key officials and insisted (begged) forcefully that they read it. I might have been imagining it, but their objections seemed to take a less strident tone as they read story after story of ways that the ordinary incentives created by the health care system produced extraordinary harm for everyday people.

When I left government, I looked around at the apocalyptic health care system and despaired at the idea of having anything to do with the corrupt industries fleecing the American people. Most people with my resume end up shilling for this or that special interest from Big Pharma to Big Hospital, helping them lobby to keep the taxpayer gravy train rolling. I just couldn’t do it.

It was Marty who told me about a remarkable organization called Health Rosetta, a growing tribe of insurgent, honest benefits advisors helping employers fire the big carriers and PBMs and build re-humanized health plans. These advisors - whose business model was differentiated on radical transparency and independence from the usual conflicts of interest that ruined the rest of the industry - were the only bright light that I could see in the health care landscape. They took me under their wing, and the most generous among them mentored me as I built my business on Health Rosetta principles.

Marty and I occasionally edited each other’s writing or speeches, and collaborated on academic papers here and there. When I was invited to give a keynote somewhere, he mercilessly mocked my slides: “nobody wants to read your bulleted notes to yourself on a slide. Use pictures only.” My speechifying has improved significantly since.

When he was nominated for FDA Commissioner, I gave him a warning as serious as a heart attack: “You’d better get right with God, buddy, because you’ll be taking on the most demonic, most powerful industry on earth.”

I meant it.

I reminded him that my friend and colleague Daniel Best, the first-term HHS official in charge of developing the president’s plan to lower drug prices - a plan that the pharmaceutical industry despised - mysteriously fell to his death off a balcony. It was ruled a suicide. He had a wife and young kids and no apparent sign of depression. There was shell-shocked chatter about how none of us had seen it coming, but maybe that’s because it hadn’t been coming. Everyone around me seemed to accept the approved narrative, for reasons I never understood.

Although the forces allied against reform of FDA-regulated industries are first and foremost spiritual - early in the process, Marty faced more earthly obstacles. As he tried to assemble a team during the presidential transition period and during the pre-confirmation process, he struggled with how the personnel vetting system made it next to impossible to recruit qualified people who didn’t have demonstrated Republican or Trumpian bona fides - even though many people who make their careers outside of politics do so successfully only by keeping their political loyalties on the down-low.

There is another structural flaw in staffing up to execute the MAHA agenda:

• There are the MAHA experts - activists, scientists, researchers and practitioners who have been toiling in the MAHA vineyard of the Lord for decades.

• And there are skilled and experienced government operators, who know how to drive an agenda through the deep state bureaucracy, industry opposition, Congressional bed-wetting and White House political hackery.

These two circles on the Venn diagram do not overlap.

The president learned the hard way in his first term the importance of having loyal people in office, who can beat back the deep state and drive his agenda. So it’s understandable that the Presidential Personnel Office (PPO) - the White House unit responsible for vetting and recruiting the 4,000 or so political appointees placed throughout the administration to serve at the president’s pleasure - would prioritize MAGA or at least traditional Republican street cred over almost anything else.

But traditional Republicans often didn’t have any sort of MAHA street creds. And to make matters worse, the hiring process at the beginning of the second term strangely excluded many first-term Trump appointees - loyal soldiers who had stayed through COVID, through the election chaos, through January 6th, and turned the lights off on Jan 20th, 2021. I can’t tell you how many friends and former colleagues who wanted to return (I liked my life too much to join them!) - experienced operatives and MAHA friendly, absolutely loyal to the president - who found themselves on some blacklist for some reason. Many of them were never hired. Some only found their way in after heroic efforts, many months after the Inauguration. I don’t know about other agencies, but I do know that this problem was especially acute at HHS, and as a result, there has been a massive vacuum in the department’s policy operation - lacking the skilled policy experts to drive the MAHA agenda, surrounding the agency heads like the Secretary, Marty and NIH Director Dr Jay. Bhattacharya.

Almost every advisor or deputy Marty wanted was rejected by this political machine. Worse, lawyers at HHS schemed and undermined him from the beginning. They, as well as the pharmaceutical industry and a particular social media influencer who can get the president’s attention (and who I suspect was paid by a certain drug company), went after his most trusted deputy, the incomparable Dr. Vinay Prasad MD. Dr. Prasad was widely respected for being a take-no-prisoners expert on how most studies utterly fail to answer the questions they intend to, and how medical practice guidelines can go deeply off the rails as a result. Of course, when he started bringing this much-needed bullshit-meter to the FDA, they naturally ran him out of town.

Other deputies and trusted aides that Marty appointed were under attack from the get-go. His counsel Hillary Perkins was accused of being inadequately pro-life (this was defamatory) and run out after two days on the job. Dr. Tracy Beth Høeg, MD, PhD, an epidemiologist who saw the truth during COVID and said so, was criticized most of her tenure until being fired in a perp-walk kinda way last week, with no reason given.

The job is hard enough when the administration has your back, but when they’re never satisfied with you or your people, it makes it very difficult to persevere in doing good. I will also note that this administration has a particularly obnoxious pattern of putting tons of effort and agony into getting people through Senate confirmation, and then driving out these Senate confirmed people within a year. There is something that feels inappropriate about this waste of Senate time (that the Senate could be using to fix health care), though of course, they’re perfectly good at wasting their own time:

That said, to be honest, no matter how many competent staffers, no matter who is president, the Commissioner job is impossible for anyone. Even if a Commissioner were totally committed to rubber-stamping industry wish-lists and pom-pomming the status quo, that too would create massive headwinds from a variety of anti-status-quo quarters (though not as powerful). Those headwinds obviously become Category-5 for someone who wants to actually drive reform.

Nobody who comes into this job has ever run anything as life-or-death important, complex, politically charged, and many-mastered as the FDA. The agency regulates a fifth of the economy, including, as I mentioned above, some of the most powerful industries on earth: Big Pharma, Big Food, Big Tobacco. Pharma alone employs almost three lobbyists per member of Congress, and believe me, those lobbyists make life a living hell for any Commissioner.

A CEO who runs in elite, business-leader circles, recently recounted for me a conversation with two pharma and biotech executives, a couple months ago. They were bragging that “our cabal is planning to eliminate Makary. We have a plan and we will replace him, Bobby (Secretary Kennedy), and their deputies with our people.”

It’s clear the plan is executing on schedule.

Just peruse the almost dozen op-eds in the Wall Street Journal since last Fall, haranguing Marty for not approving a drug by Replimune that has unreliable data coming out of its flawed trials - you can see the strategy at work (three independent scientific teams at the FDA recommended against approval. Marty defended the scientists). Scan the political trade press daily and you’ll see chatter about the constant whining from the industry to the White House office established to placate aggrieved donors. Or the disgruntled former FDA employees serving as sources for every media hit, even though what they perceived as draconian DOGE layoffs happened before Marty took office. The rare-disease patient groups, being told by Pharma about how the FDA is delaying their new wonder-drug that could cure Huntington’s disease (even though the actual study methodology was at best controversial), ginned up anti-FDA grievance on social media and to the White House office established to placate aggrieved stakeholder groups (yes, there’s a relationship-babysitter WH office for everything).

Now, if you ask some insiders - even some of the non-corrupt ones - the story that you might hear is that Marty was partly to blame for his own downfall. All I can say is that when someone pushes the envelope and doesn’t trust the people who have presided over the status quo, they often look like the problem instead of the solution.

I wasn’t in the meetings. I couldn’t have witnessed anything that took place at FDA, HHS or at the White House between Marty and anyone else. So I can’t know the exact facts.

But I have checked in with Marty pretty regularly during his year and a half journey, and over that time, watched him go from sounding enthusiastic and hopeful during the pre-confirmation process to frustrated and disappointed by government corruption. The let-down has been palpable over not being able to fully reverse the agency capture and put the public back in public health.

I know that people who know us both are saying I only see the best side of Marty. That’s true - I do. But I’ve loved him like a brother since we were both bright-eyed kids and it has pained me to watch the dream for Making America Healthy Again that we both shared for so long cut brutally short.

Still, FDA under Marty’s leadership managed to eek out important reforms that we can all celebrate. Here are some of my favorites:

• Took the black box warning off of menopausal hormone therapy

• Removed artificial dyes from food

• Flipped the Food Pyramid to promote real food rather than processed crap at the base of the old pyramid.

• Cracked down on misleading Big Pharma advertising

• Reduced cruel animal testing

• Implemented surprise inspections of manufacturing facilities (rather than pre-announced, pre-warned and therefore useless scheduled inspections)

• First real-time clinical trial where regulators watch data signals in the cloud rather than waiting years for researchers to report results

• Made drug rejection letters public

No matter how you hear Marty’s record characterized, who likes him or who hates him, never forget this: the industries that FDA regulates are not your friends.

They do not profit from you being healthy. They have long, scandalous histories of knowingly peddling deadly products, rather than coming clean for the sake of patient safety. They have paid tens of billions in enforcement penalties for fraud, cover-ups and other violations. They will spend and are spending more money than God to thwart FDA’s scrutiny and oversight and any effort to reform their ways.

As their market share and bottom lines have grown to almost $2 trillion over the past century, FDA has presided over the American people becoming sicker, fatter, sadder, more infertile, more addicted - but more medicated - than we’ve ever been in our country’s history. The agency’s long decades of regulatory capture have contributed to our extinction-level chronic disease crisis.

The FDA exists to protect the American public from the depravity and corruption of the regulated industries, not to protect them from public scrutiny or accountability, or to cheerlead their products.

That’s why we have to continue to demand that the FDA take your side over corporations - everyday and always. Leaders who try to do this will get painted by the industry and its allies as radicals, cowboys and assholes. It’s a kamakazi suicide mission that you’d have to be crazy even to consider. But what choice do we have but to keep trying to recruit them and support them in office?

None of us is perfect, and no one has ever been truly prepared to take on this mother-of-all-jobs as FDA Commissioner. But win or lose, my brother-in-arms Marty has always been on your side.

I know he’ll continue to fight for you in his future endeavors.

PS: It’s muh-CARE-ee, not MACK-uh-ree or muh-KAH-ree. You’re welcome.

Specifically we discuss:

• Why I asked Tony Fauci and Francis Collins back in 2017 to take a meeting with Bobby Kennedy off-campus - and why I sent him an apology email five years later (then wrote about it.)

• Why public health doesn’t focus on “do no harm” - but rather, “cause no epidemics.”

• Why the “evangelist physician” is the most dangerous person in medicine - the lobotomy doctors, the pain management evangelists who handed us the opioid crisis, Public Health and their six feet distancing and cloth masks. All literally evangelizing.

• Why Big Pharma’s interests align with us being patients for life.

• Why “live like a human” (sleep like one, eat like one, pray like one, raise children like one) is one prescription we all need to write ourselves.

• And because Dr. Drew is Dr. Drew, we landed on Sigmund Freud. Specifically: the difference between serious mental illness and ordinary misery. Some of what we’re medicating now is ordinary misery. Ordinary misery is what makes us human. It can often tighten family bonds, deepen our relationship to God, or drive us to make a difference.

Take a listen!

I once had a colleague on a Senator’s staff with whom I shared a daily ritual.

Almost every afternoon, one of us would appear in the other’s doorway with the same expression that addicts probably recognize in each other instantly: you wanna go?

And off we’d march, through the marble hallways or circling the Capitol grounds, coffee in his hand, Diet Coke in mine, to enjoy what can only be described as an emotional cigarette break.

We complained.

About do-nothing staffers. Cowardly senators. Misguided activist groups. Reporters too lazy to figure out facts. Agency bureaucrats subverting oversight. Consultants whose messaging lost elections, and Congressional leadership whose corruption made good faith negotiations impossible.

We were very smart, you see. Everyone else was the problem.

At the time, I didn’t recognize these walks for what they were. I thought we were “processing.” I thought we were blowing off steam. But really, we were getting high.

Blame feels fantastic. Especially combined with genuine human connection - blaming loves company.

Politics runs on this fuel.

In Washington, one of my favorite exercises during policy debates was a game I called “demagogue it.” We would sit around asking: how will the other side distort this policy? How will they twist our motives? What’s the most emotionally devastating version of this argument?

And whenever I wanted to kill a bill, I would take a provision from it and imagine the absolutely most extreme and craven use of that authority and write a talking point accusing the bill author of having only that intention all along.

This works to win arguments and elections because the human brain is built for victim stories.

We instinctively organize the world into heroes, villains, and innocents. The problem is that once you start seeing yourself primarily as the innocent victim in the story of your life, you’ve already surrendered your ability to be the hero.

At some point, I realized something disturbing about those afternoon complaint walks.

The stories my colleague and I told each other were changing me.

People would frustrate me during the day, and then during our walk I’d construct a whole psychological profile for them. They weren’t just misguided; they were corrupt. They weren’t just difficult; they were malicious. They weren’t just limited; they were fundamentally defective people standing in the way of progress, success, justice, truth, or whatever noble thing I imagined myself pursuing at the moment.

This “othering” made it harder to collaborate, to connect, to feed the higher part of my soul or the other’s soul. Which robbed me of the kind of happiness that outlasts the victories or defeats of a given moment.

Every explanation for why my life or work was difficult rested on someone else’s failures.

If only they weren’t incompetent.
If only they weren’t corrupt.
If only they listened to me.
If only they changed.

I was assigning myself too much power and too little power at the same time. Too much power because I assumed I possessed the wisdom to fix everything - if only everyone listened. But far more important - this mindset gave me too little power because I was outsourcing my own effectiveness, peace, and happiness to the vagaries of other people that I couldn’t control.

This all sounds very silly and petty in the context of politics, where it’s obvious that I wasn’t actually a victim of anybody or anything. The more serious question is what to do with actual victimization.

Because real evil exists. Real injustice exists. People genuinely betray, abuse, neglect, exploit, humiliate, and wound each other, intentionally and unintentionally.

Think about children, for example, who suffer traumatic abuse and are removed from their homes. Then they might spend years suffering further inside systems supposedly designed to protect them. By the time the time they enter actual safety at some point, they could have a thousand legitimate reasons to rage at the world.

And some of that rage is necessary.

One of the cruelest effects of childhood trauma is that children often assume everything was their fault. To heal, they have to learn the truth - they were the victims, not the instigators. But there is a danger waiting on the other side of that awakening.

Once someone puts on the victim identity, it can be very difficult to take off. It becomes a convenient explanation for everything: why trust is risky, why discipline is cruel, why relationships fail, why self-control is unrealistic, or why self-destruction is inevitable. Why selfishness is your right, and sacrifice is for suckers.

Victimhood moves from being not just about what we experienced, but rather, who we are - the organizing principle of our entire identity.

And once that happens, every challenge we face gets re-framed as persecution. Obstacles are personal affronts rather than problems to solve. Failure is someone else’s fault.

This is one of the reasons I think our culture is becoming psychologically fragile in ways that no amount of material abundance can fix. We are teaching people to interpret suffering almost exclusively through the lens of blame. Social media is largely fueled by this mentality - take a gander at your favorite feed - you’ll notice that most of what’s viral is victim mindset:

Who caused this?
Who’s responsible?
Who should pay?

Now, those questions matter sometimes, of course; civilization requires accountability and justice. But there is another question that, in terms of our own individual story, matters so much more:

What now?

The secret to all power, all happiness, purpose and achievement is in the question: now that these things have happened, what do I do next?

There’s a concept in The 15 Commitments of Conscious Leadership - a deceptively simple, but radical book - that I found particularly powerful. The authors distinguish between those who view life as happening “to me” and those who trust that life is happening “for me.”

At first glance, that sounds absurdly simplistic. Offensive, even.

Was abuse “for” someone?
Was betrayal “for” someone?
Was death “for” someone?

No. Not in the simplistic Hallmark-card sense that people sometimes mean when they say “everything happens for a reason.”

It’s obviously a theological matter, but we Catholics do not hold that God delights in suffering, that tragedy is inherently good or that death is always a gift.

But I do know that I know that I know this to be true: once something has happened, the only thing that makes any difference at all is what you do next.

That’s the difference between continuing in defeat and helplessness or becoming great. Nobody who wallows in the past, ruminates on the wrongs of others, or the devastating circumstances of the present has a future that is strong, bold, brave, heroic.

Don’t you want to be the one who overcame instead of the one who was ruined? The only person who can make that choice for you is you. Because nobody dictates what you do next, regardless of any circumstance, except you.

That’s true even in the darkest prisons, where control over others is the rule.

Aleksandr Solzhenitsyn, writing about the Soviet gulags, and Viktor Frankl, writing after Auschwitz, arrived at the same subversive conclusion: there is a dimension of human freedom no regime can fully extinguish. Frankl called it “the last of the human freedoms” - the ability to choose your own attitude in any given set of circumstances. Solzhenitsyn observed that, even in prison, where every external liberty had been stripped away, some men became spiritually smaller while others became larger.

St. Maximilian Kolbe, a Catholic priest also imprisoned at Auschwitz, volunteered to die in place of another prisoner at the same camp. In a place engineered to reduce human beings to terrified animals, witnesses described him leading prayers and comforting other condemned prisoners as they starved to death together.

These men weren’t saintly, inspirational and heroic because they changed their circumstances. Their circumstances remained hellish. Their stories are still retold and inspiring today because they understood that, even when all powers and freedoms seem to be stripped, we still have one left: the meaning we make of our suffering. The name we have for ourselves - “victim,” “victor,” or anything in between - is entirely and profoundly up to us.

Most of us don’t have such a hard task in front of us - not even traumatized foster children or most other innocents you can imagine. Our task - and theirs - is usually much more mundane: to look at today - the day in front of us - and take 100 percent responsibility for what we do with it and how we respond to what comes of it. To recognize that everything about what this day means in the story of our life is 100 percent ours to determine. Even if we’re fired today. Even if someone hurts someone we love today. Even if we’re given a diagnosis today.

I used to objectify all the other drivers on the road as out to kill me, hinder me, wrong me, or otherwise try my patience. I looked at the cars as my enemies, obstacles to where I was trying to go. In other words, every time I got on the road, I was deep in victim mindset. If I was on a wide-open country road, with the windows down and the sun on my face, singing at the top of my lungs, I was happy and content. Anything that deviated from that utopia, I interpreted as a grievous injustice and infringement on my God-given dignity and I reveled in feeling offended.

After learning the “to-me” v. “for-me” framework, I decided to adopt the mindset that everyone on the road was there for me.

I started repeating a mantra: “everyone deserves acceptance.” Your mantra might be different - that was just the one that helped me. It changed my relationship with driving from one of frustration to one of embrace. If I was held up, I had more time for podcasts, audiobooks, prayer, or singing the Indigo Girls at the top of my lungs like I did in high school. I found that I started welcoming traffic or slower speed limits because I got more “me time” in this mindset. Traffic, delays, distance - they were no longer happening to me, they were happening for me.

My work building health plans for employers tests this “new Katy” every day: firing insurance carriers, PBMs, and quarterbacking a million vendors, daily fire-drills, vendor mishaps, client concerns, and a fifth of the economy trying to burn down my business model. A few years ago, I was operating on the sleep deprivation and low-grade fight-or-flight that the victim mindset bathes in. I told myself that this is why I was successful - the only way - I was the only consultant that cared this much and so that’s why clients should hire me.

When I intentionally renounced the victim mindset, I started recognizing that everyone was doing their best in an imperfect business. I recognized that the real value I delivered for my clients wasn’t perfection but rather, sophisticated problem-solving built on trust - a commitment that the problem can and will be solved, that solutions will appear. That the work our team performs is wrapped in love for our client’s workforce like we love our own family. And that I couldn’t control everything that happened to our clients, but by changing my own mindset, I could relax emotionally - knowing that whatever came at our team every day, we would face it with best-in-class commitment, collaboration, and service. Victory doesn’t always look like the bumper sticker I’d like it to be, but I see more and more of it every day.

One mindset creates anxiety and paralysis. The other creates agency and purpose. Which one feels like where you’d like to live?

That doesn’t mean the second mindset hurts less. In fact, it often hurts more initially, because it forces you to relinquish one of the ego’s favorite narcotics: righteous helplessness.

Victimhood is seductive because it relieves us of responsibility. If my failures are someone else’s fault, then I no longer have to confront my own fear, laziness, cowardice, bitterness, pride, impulsiveness, or lack of discipline.

I can remain exactly where I am forever and call it justice or fate.

But there is no real power there. There is only permanent dependence on the repentance, apology, punishment, or transformation of other people. And if your peace depends on that, you are handing other people the keys to your nervous system.

When bad stuff is happening, there’s no way out but through. Nothing will change what happened, whether just now or long ago. The only choice we have is what we do next. If we blame someone for why we can’t do this or that next, then the only result is that we’ve disempowered ourselves. There’s no winner there. You haven’t won the argument. You haven’t been vindicated. You haven’t gotten back at them. You’ve only hamstrung yourself. You’ve only let the people who hurt you yesterday continue to ruin your today and your tomorrow.

The older I get, the more convinced I become that the secret to life is largely a head game.

The victim mindset is low vibration (the same frequency as shame and fear) and I choose not to waste time there anymore - it doesn’t serve me or anyone else.

That’s why the victim mindset is so spiritually corrosive. There’s nothing remotely inspirational about it - especially to yourself. It’s a salve to the bruised ego, but at the price of actual change.

Even when your grievances are legitimate - especially when they are - building your identity around them guarantees that the people who harmed you continue their power over your life long after the original injury occurred.

Meanwhile, life is moving on.

Your children are growing closer or more distant.
Your marriage is either deepening or eroding.
Your gifts are being developed or buried.
Your body is aging.
Your time is running out.

People who choose radical agency, who focus only on their own responsibility and their own contribution in every situation, their own next step, no matter what came before, are fabulously dangerous and subversive.

Those who believe they can alchemize suffering into wisdom or purpose become invincible. Ungovernable. Mastered, yes, but only by themselves, to serve their own goals and highest ends.

Where are you falling into a victim mindset?

If I do my own inventory, it’s probably social media and body image. When you identify your traps, you’re already halfway there. Start naming the people and circumstances who are to blame for those areas of your life. Then, take a few long, deep breaths, close your eyes, and ask yourself:

“Recognizing who and what my ego wants to blame, nonetheless, what do I do next?”

Your highest self will whisper the answer.

Be brave!!

We recently observed World Homeopathy Awareness Week.

What the bleep is homeopathy, you ask? Good question.

It’s a wild, wonderful world of medicine that you’ve probably heard of, but never quite known what it is.

But before we get into what it is, let’s set the stage a bit.

Conventional medicine is based on the premise that our bodies respond best to biochemical inputs - drugs, food, mechanical intervention like surgery.

But you already know that there’s more to the story than that.

Conventional medicine sometimes admits it too - MRIs are based on identifying resonance patterns using big magnets on the body, for example.

Women’s menstrual cycles seem to sync up in ways that science hasn’t figured out.

Tuning forks interact with each other - strike one and an un-struck fork across the room will start to vibrate. Move the fork into the 6-foot energy field that surrounds a human, and the sound will actually change.

Water is one of the most responsive substances on earth to resonance and frequency. Play a tone next to water, and then examine it microscopically - the molecules have arranged themselves into amazing patterns.

One of the most radical sciences being conducted today is the work of water researcher (and whisperer) Veda Austin.

She places petri dishes with thin layers of water on top of photographs or paper with words on them, or plays music for them, or even directs thoughts at them. And then she throws the petri dishes in the freezer “with the peas and carrots,” as she puts it. The water flash-freezes into designs that actually reflect - sometimes in creative and wild ways - the influence that was given. Sometimes the frozen design mimics the picture it was in contact with. Sometimes it answers a question. It’s wild. And thousands of people have been taught Veda’s technique and are replicating it around the world.

What does all this have to do with homeopathy?

To many people, the word “homeopathic” is simply a synonym for “holistic” or “natural” or “alternative,” as in - pursuing homeopathic care instead of or in addition to taking prescription drugs or getting surgery.

But homeopathy has a very specific meaning relating to a very specific scientific framework.

Homeopathy is the science of how the frequency, resonance, and energy of a thing interact with water, how the water takes on that energetic footprint and carries it into our bodies to address symptoms or conditions that are also caused by the thing.

More than two centuries ago, a German physician named Samuel Hahnemann (n. 1755) had grown increasingly unimpressed with the bloodletting and mercury poisoning that his profession called “treatment.” (Raise your hand if you can relate.) He began paying the bills by translating medical texts.

He was translating a book by William Cullen about cinchona bark (the source of quinine) and its usefulness for malaria. Cullen speculated its effectiveness was due to its bitterness and tonic effects on the stomach. Hahnemann didn’t buy it and decided to perform an experiment.

He took cinchona bark himself as a tincture - not in the form it was used as a medicine, but in high doses heated in alcohol the way tinctures are made. After a few days, he developed symptoms that were a lot like malaria: fever, chills, weakness, palpitations, throbbing headache. The symptoms came on in waves - similar to the cyclical waves of a malaria episode.

His imagination was sparked.

Hahnemann’s hypothesis was that “like cures like.” He speculated that substances that cause certain symptoms in large doses in healthy people are actually nature’s perfect remedy (in very small doses) for healing those symptoms in sick people.

He went on a frenzied bender to “prove” a bunch of remedies - systematically dosing himself and other healthy volunteers with every substance he could find. The volunteers would dose themselves with a form of the substance - powders, infusions (like tea), extracts and tinctures - and record exactly which symptoms developed. These detailed “symptom profiles” included not only physical ailments of the body, but emotional, psychological, and personality changes.

Once the symptom profile was developed, Hahnemann and his disciples started treating patients with similar profiles. The problem was that the patients’ symptoms often temporarily intensified. He took that to mean that the remedy was working, but too aggressively.

So he began diluting the substances in water and alcohol. He wasn’t trying to make the medicine weaker; he was trying to make it gentler. But he discovered something amazing - the medicines actually worked more effectively and more quickly - the more diluted they became, but without any of the harsher effects.

Each dilution was accompanied by vigorously shaking the container, or striking it, so as to get the substance’s essence into the water. Over time, this process rendered less and less of the measurable substance and more of the frequency or resonance of the substance in the water.

Hahnemann called this process “potentiation” - the idea that a substance’s energy or essence became more powerful the more it was diluted.

Carrying these liquid remedies had some practical distribution problems. The liquids were hard to dose properly, and each remedy had a bunch of different dilutions to be used based on the specifics of the patient’s case. Since each remedy had such a unique symptom profile, and there were hundreds of remedies, Hahnemann realized that carrying around a bunch of liquid jars didn’t make sense. They could easily degrade or break, and it just wasn’t practical.

So he took the technique that was commonly used to deliver medicine at the time - sugar pills doused in a liquid medicine - and he used them for his own remedies.

He doused each pellet with the diluted remedy and, voila, he had little vials of dozens of doses that were much easier to schlep around.

The pellets were also much easier for the patients to take. They could put a few under the tongue until they dissolved, or crush them in a glass of water and drink a few sips.

Babies and toddlers, and even pets and livestock, could get the doses in their water or crushed over their food. Even crops riddled with pests or fungus could be treated by crushing the pellets into the water sprayed on them.

The name of Hahnemann’s framework was Greek for “similar” (homoios) and “suffering” (pathos) - based on the “like cures like” foundation. His disciples grew as the remedies’ undeniable success became more and more recognized. He published his first paper in 1796, and homeopathy spread to the elites of Europe at first, much preferred by patients to the brutal techniques of conventional medicine of their day (and our day too). Hahnemann eventually moved to Paris and gained broad acclaim in the early 19th century.

In the U.S., homeopathy was widely adopted during the same period, with the American Institute of Homeopathy - one of the first medical societies - founded in 1844. By the late 1800s, there were more than 20 homeopathic medical schools, over 100 homeopathic hospitals, and thousands of homeopathic practitioners.

Embraced by European royal families and the wealthiest American families, homeopathy enjoyed legitimacy and scientific credibility and, in many areas, the use of homeopathic medicine rivaled or even exceeded conventional medicine. Homeopaths were reported to have lowered mortality rates during outbreaks of cholera, yellow fever and typhus.

In other words, homeopathy wasn’t fringe, and it wasn’t “woo.” It was mainstream - a parallel medical system.

Until, of course, the same villain that went after naturopathy - the medicine of using natural methods (such as nutrition and herbs) to restore health - turned its sights on homeopathy: Big Oil.

The Rockefellers and Carnegies got together to fund medicines derived from petroleum byproducts, in league with Big Chemical, led by Bayer. Bayer was gearing up to marry the conglomerate that manufactured the gas for the Holocaust’s slaughter, but they also led the way at turning petroleum-based products into standardized “medicines” that could be patented.

(When I say “patent,” you say “profit.” Patent! PROFIT!)

Many of these medicines were merely snake oil, and a good number of people were used to the more affordable homeopathic remedies and herbal naturopathic remedies, but nature can’t be patented as easily. So the Bigs put out the Flexner Report in 1910, which got wide acclaim for trashing all the medical schools where the curricula and treatments being taught weren’t “standardized” according to pharmaceutical and biomedical laboratory-grade standards endorsed by the Carnegie Foundation and funded by the Rockefellers.

They also funded what was then a small organization called the American Medical Association, and helped it grow and discredit all types of medical doctors and schools that didn’t follow the pharmaceutical model.

Within a few decades, most of the homeopathic and naturopathic medical schools had closed. Medical licensure boards emerged in states, using their power to discredit and muzzle these practitioners in favor of their white-coated, pharmaceutical-prescribing version of medicine that we all know so well today.

And yet. Even as homeopathy was pushed out of medical schools and hospitals, it never disappeared from law.

In 1938, the FDA’s founding legislation explicitly recognized the U.S. Homeopathic Pharmacopoeia - giving homeopathic remedies formal recognition in the U.S. regulatory system that still exists today.

(This is thanks to Senator Royal Copeland, a homeopathic physician, who fought to protect homeopathy from the pharma mafia. Wish he were still around today).

Around the world, homeopathy is the second largest medical system after conventional medicine. Countries such as India formally recognize homeopathy, and there are hundreds of homeopathic medical schools there and hundreds of thousands of practitioners. In the UK, homeopathy has been used by the royal family for generations, and it is still respected there, as well as in France and Germany.

If homeopathy were as irrelevant as its critics claim, it wouldn’t have survived for more than 200 years, spread across continents and embedded itself in national health care systems.

Homeopathy isn’t fringe - it’s global, and in some countries, it’s just called medicine.

So How Does It Work?

Typically, homeopathy is not looking to suppress symptoms. It views symptoms as your body’s effort to do something important. Fever is the body’s attempt to speed something up - metabolism, circulation, immune activity - and to restructure water molecules in your system. Inflammation is designed to create a watery environment - since healing often occurs in fluid environments - to summon the body’s tools of healing to the scene of the crime, and also to create an internal cast that cushions the injured tissue while it recovers. Pain protects that cast - by keeping you from moving it while it’s doing its job of healing.

Homeopaths will tell you that their job is to help your body move through that healing process, including any symptoms with more ease and speed than it otherwise would.

The remedies interact with what Hahnemann called the “vital force” - the dynamic intelligence that animates the body and coordinates its response to stress, injury, degradation, and threats. In today’s modern assault on all things human - our indoor, fluorescent-lit existence, low-grade (or not-so-low-grade) fight-or-flight, poisoned food and water, and disconnection from the sun, from the earth, from God and from our tribe - our vital force is often anemic at best.

Homeopathic remedies are designed to engage the vital force by exposing it to the energy or resonance of some unexpected substance that stirs it up and recruits it back into action of healing and maintaining homeostasis - the perfect balance of health.

Testimonies abound of patients struggling with infertility, autism, eczema, snake bites, sprained ankles - and every other possible malady that nature contrives - being improved or mitigated under the influence of a homeopathic regimen. (NOTE: this is not medical advice, and the wonderful thing about homeopathy is that it doesn’t interfere with conventional medical care that you can obviously and many times should obviously seek as well).

The wild thing is that when a homeopath is called to the scene, very often, the remedy chosen first heals things that the body/soul/vital force actually considers more important than the symptoms that are annoying the patient.

My own story is similar - I engaged a homeopath to help with some minor but persistent symptoms, and it turned into a months-long series of remedies that unlocked massive healing of my wounded femininity (which I’ve written about quite a bit here and here), before ever getting around to the symptoms that started the process. My body-mind intelligence knew that was a far bigger priority, and it was right.

So Naturally, The FDA is Trying to Cancel Homeopathy

As I described above, homeopathy has technically been recognized in U.S. law since 1938, but in recent years, that protection has started to erode.

In 1988, FDA laid out a framework whereby it recognized homeopathic remedies as drugs that technically should go through the regular drug process (involving expensive safety and effectiveness trials and extensive FDA review and oversight), BUT that the agency would choose to exercise its enforcement discretion instead, and embrace a posture of non-enforcement. The guidance stated that the remedies could avoid enforcement if certain criteria were met - namely that they were listed in the U.S. Homeopathic Pharmacopoeia, they weren’t mislabeled, contaminated, and didn’t claim to heal serious conditions if sold over-the-counter.

This wasn’t perfect, but it was a reasonable stand-off. But then the Obama FDA, starting in 2015, held hearings about whether homeopathic remedies were “safe,” had sufficient “evidence,” and were labeled properly. By December of 2017, the Trump FDA - right under my nose as the White House policy lead for FDA - replaced the 1988 framework with a new regime.

I note for the record that I did not receive this guidance in draft form as part of a formal review process, and I damned well should have for such a significant policy change. More deep state shenanigans.

In any case, the 2017 draft guidance declared the remedies unapproved drugs, with a priority to go after and shut down those remedies that were targeted for serious conditions (like cancer), vulnerable populations like the elderly or infants (the ones most likely to benefit). In other words - the priority was the remedies that are most likely to interrupt Big Pharma’s profit drivers: blockbuster cancer drugs and the Medicare patient pool.

FDA finalized this guidance and withdrew the 1988 “safe harbor” policy in 2019 - after I had left the White House.

Advocacy groups like Americans for Homeopathy Choice argue that this new framework isn’t outright criminalization, but more of a slow squeeze. Because once you declare homeopathic remedies to be unapproved drugs requiring approval, then you’re forcing billion-dollar clinical trials for remedies that can’t be patented and barely make a profit.

I would argue that homeopathic remedies are still legal, ever since 1938. But now the FDA is going to decide if they’re “risky” and come after the ones they feel like coming after.

But let me point out the absolute farce:

There is no active ingredient left in most homeopathic remedies.

(Remember the dilution, and the shaking, and the dilution some more, and then more shaking, on and on until there’s only the “essence” of the thing and not the actual thing left in the water?)

So how can water with no active ingredient, dropped onto a sugar pill, be dangerous?

It can’t. This is why homeopathy is so safe for use. Pregnant women can use homeopathy. Newborn babies. People taking a bunch of prescription meds - water and sugar don’t interact with other drugs.

This has been the basis of FDA’s whining about labeling - they argue that any claim that there’s actually a substance in there is a lie. And that any claim that it treats a disease is therefore also a lie. Because it’s sugar and water.

So they can hardly then complain that these products are somehow “risky” at the same time.

FDA needs to pick a side - either these products have some active ingredient in them with a risk profile, which requires safety studies, or they don’t, which requires caution about marketing claims. But you can’t demand BOTH safety studies to prove the effectiveness of some active ingredient AND caution about marketing claims because there’s no active ingredient.

The truth is, at most potencies that are used, such as 12C, 30C or 100C, the dilution is past what’s known as Avogadro’s number, 6 x 10²³, which is the threshold dilution of a substance after which there is considered to be unmeasurable/untraceable substance left. For lower-level potencies such as 1X (where the substance is 1/10th of the liquid) or perhaps even 10X (where it’s 1 part per ten billion), I might understand a risk-based approach. But most homeopaths are using the C remedies or even greater dilutions, and the over-the-counter, first-aid type remedies are almost always those levels. So maybe FDA just needs to wake up and put the kibosh on the deep state.

If you’ve made it this far, you might see that homeopathy is not what most people think it is. And you might be asking yourself: why have I never heard any of this before?

Because once you start to understand how homeopathy works - and even more importantly, how to use it - it’s glaringly obvious how incomplete our current model of health really is.

And more than that, you step into a completely different relationship with your body, your health, and your family’s care. One that is less dependent, less reactive, and far more intuitive and self-directed.

Behind this paywall, I’m going to show you what that looks like in practice - how to find a homeopath, what happens in a session, how remedies are chosen, what the course of treatment generally involves, and how to begin using homeopathy yourself for first aid and everyday situations. I’ll also walk you through how to get involved in protecting access to this kind of care, starting with supporting Americans for Homeopathy Choice.

Nobody is coming to save your health.

Paid subscribers get the play-by-play for how to incorporate the hidden treasure of homeopathy into your life, and use it to take back your health - and your family’s - from the people who were never going to fix it for you.

Let’s get down to brass tacks.

When Should I Use Homeopathy?

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It was 2017. We had hauled the CEOs of a bunch of pharmaceutical companies into the Oval Office so that President Trump could berate them about their drug prices. (Always a good time.)

Somehow, the word “vaccine” came up in the conversation. When that happens in the president’s presence, then, now, last month, and probably next week, like clockwork, he always starts telling the same story. A woman who worked for him at the Trump Organization back in the day. Her two-year-old son, who was “perfect, beautiful, magnificent, flawless.” Then he got a shot and he was “just gone. Gone. Never the same. Beautiful boy. Then, just gone.”

The CEOs all shrank back and turned the response to this story over to their colleague Ken Frazier, then-CEO of Merck, a prominent vaccine manufacturer. I don’t remember what he said. I’m sure it was the usual safe-and-effective incantation.

The president had an instinct. I had the credentials. What I didn’t have was an answer.

But it brought me back to 2002.

The autism moms, like other groups of moms did every day, were lobbying me to do something to help their children. I was a staffer on the U.S. Senate committee that oversees CDC. It was my job to recommend, when it came to public health, which bills to write, which bills to move, which bills to kill, which issues to conduct oversight on and which agencies to subpoena.

Each mom told the same story of a vaccination, and the subsequent regression of their children into the signs of autism. They wanted the CDC to rigorously study the safety of vaccines and assess the relationship of vaccination to the subsequent diagnosis of autism.

I was torn.

I was a Harvard-trained infectious disease epidemiologist. I believed, religiously, that vaccines were the gold standard of public health interventions.

Not because I had been shown the evidence for their effectiveness and safety in public health school, by examining the seminal clinical trials demonstrating as much (I hadn’t). But because I had been trained in the orthodoxy of public health, where it was assumed that someone had studied this and it had been demonstrated at some point - so now we could all focus on more pressing matters, like how to get vaccines in more kids’ arms around the world. I had spent my early career gallivanting overseas, controlling infectious disease from guinea worm in South Sudan to HIV/AIDS in Russian drug users and inner city DC prostitutes. I was the hero in the story I told myself.

But also, I am a woman. And I deeply revere the intuition and wisdom of mothers. And it was not my nature, when a bunch of moms tell me about an observed fact pattern in their children’s lives, to disbelieve or dismiss them.

So I did what any young, naive staffer in her first job on the Hill would do: I called the CDC.

They gave me some bland pablum about debunked studies and how “correlation doesn’t equal causation” and what-not. I was left with a weird disquiet and wasn’t sure what to do. But I knew my boss, the committee’s Ranking Republican, would be loath to wade into such a hornet’s nest. Not to mention that the committee’s chairman, (ironically) Ted Kennedy - whose party controlled the Senate - would try to thwart us at every turn - and we were already in enough battles with him.

Besides, Rep. Dan Burton and Rep. Dave Weldon, MD, were already holding hearings over on the House side - if something came of those, I could maybe interest my boss then. So I went on to the next meeting and the next ask from the next group of moms of kids with the next condition.

Fast forward fifteen years and several other Senate staff jobs. It was 2017, and I was now President Trump’s lead health advisor on the Domestic Policy Council, and we were all still trying to find the bathrooms in the White House.

I was now far more experienced and savvy a staffer, and utterly untrusting of federal agencies - especially the CDC. But I still believed with all my heart that vaccines were life-saving, critically-needed interventions to protect children, and that they worked best when uptake and the subsequent herd immunity was high.

I was told that Robert F. Kennedy, Jr, an acquaintance of candidate Trump, had gotten him to commit to establishing a Vaccine Safety Commission once he was in office. Mr. Kennedy was now calling and wanted to get the promised commission going.

It was my job to make this problem go away.

I was all in.

We couldn’t have a meeting, an event, or a commission that communicated to the world that vaccines were anything less than the Greatest Public Health Victory we all believed them to be (can I get an “amen?”). So I called up NIH leaders Francis Collins and Tony Fauci and asked them to go ahead and take the meeting, but off-site somewhere, far from the White House and the public view.

That meeting, which took place at the NIH campus in Bethesda, Maryland, has become somewhat notorious in MAHA lore.

Mr. Kennedy, as well as Del Bigtree and Aaron Siri with the Informed Consent Action Network (ICAN), met with The Authorities about The Science. All of them have spoken publicly about that meeting, where Dr. Fauci assured them of the mountains of studies demonstrating vaccine safety. Reportedly, when asked to produce them, he rifled through his papers as if they were just at the tip of his fingertips. When he couldn’t find them, he promised to deliver the studies later. Which never happened. ICAN filed a Freedom of Information Act lawsuit to get them.

HHS settled the lawsuit with a stunning admission - on the record - that no such studies existed.

But I didn’t know any of that. I only knew that I had done my job and saved children.

For the next few years, I worked on a variety of policies I was really proud of (ending secret health care prices, lowering drug prices, combatting opioid addiction) and others that didn’t go quite as well (the doomed repeal-and-replace-Obamacare misadventure). The demands of working in the White House are brutal. While many of my colleagues had become like family, my real family could no longer pick me out of a line-up.

By mid-2019, my stress level had peaked. For many reasons, it was time to move on. My younger sister, a 39-year-old mother of two, was dying of colorectal cancer, and I spent the next five months taking care of her, thinking a lot of deep thoughts about the limits and the hubris of medicine.

When COVID landed on our shores a few months later, there was certainly some FOMO.

Global respiratory disease popping off, and I just left the White House?

I published an op-ed in March of that year, expressing relief that my friend and former colleague, Deborah Birx, had just been appointed the head of the White House COVID response. In the summer and Fall of 2020, I helped the Trump re-elect campaign by doing media interviews defending the administration’s COVID efforts.

I put on a happy face for the cameras, but as the year wore on, the unscientific demands from The Authorities were causing cognitive dissonance.

Masking mania made no sense in light of the size of a viral particle. Masks worn loosely, re-used, touched with unsterile hands all day, and forced onto children were a crime against epidemiology. And yet, The Authorities like Birx and Fauci, who I knew would know better, were still pretending.

Lockdowns were being implemented in ridiculous and scientifically unjustifiable ways. Churches - no. Mom-and-Pop restaurants - no. Gyms - no. Walmart - yes. There seemed to be no effort to explain the totalitarian disconnect that was being imposed from on high.

I had moved to Loudoun County, Virginia shortly after my sister passed away, in order to be close to her two young boys. We wanted to make friends in our new community, and the only people daring to gather were the patriots and dissidents involved in the Loudoun County Parents’ Resistance™, fighting the school closures and other policy malpractice. That put me in touch with the hodge-podge of nontraditional allies that the COVID era united: Catholic homeschoolers and hippie homesteaders. Medical freedom activists and election integrity watchdogs.

We loved the meetups with these unafraid humans, one of whom was a mom of a vaccine-injured child who ran our state’s medical freedom group.

She persuaded me to watch the documentary Vaxxed.

The movie narrated the tale of CDC’s early 2000s vaccine/autism research - the kind those autism moms had demanded, not knowing that the CDC had already done it but was hiding the results.

It documented the U.S. House hearings by Reps. Weldon and Burton, trying to uncover the truth, and the later whistleblower, William Thompson, who confirmed all the moms’ worst fears. It was a searing indictment of my own paralysis during these events decades ago.

Here is the text I sent that same friend as the credits rolled, along with the tears down my cheeks:

Still, because I was an epidemiologist, people in my circle would come to me for answers about The Science, including potential prevention and treatment for COVID.

I became the Underground Railroad in our community for hydroxychloroquine, ivermectin, nebulized steroids, and other countermeasures frowned on by The Authorities. Whenever someone in our social circle would fall desperately ill, I would help them get medicines from the semi-secret network of doctors, bravely providing these lifelines by telemedicine across the country.

Wanting more knowledge and credentials to help people, I enrolled in a degree program to become a naturopathic doctor.

I watched in disgust and confusion as the new administration doubled down on crazy, with so many in federal and state governments seeming to throw basic rules of microbiology and epidemiology out the door.

And then, something happened in late summer of 2021 - a set of legal contortions between Big Pharma and the FDA that started to make everything painfully clear.

I was familiar with a public health law called the PREP Act that passed when I had worked in the Senate. It provided liability protection for manufacturers, doctors, and even employers during a declared public health emergency, provided that certain criteria were met. One of those criteria, when it came to drugs or other emergency countermeasures, was that the law’s legal immunity only applied to products with either FDA licensure or Emergency Use Authorization (EUA).

The government had a number of problems brought on by aspects of the PREP Act and the law establishing the EUA process:

Problem #1: To get an EUA for a product, there have to be no other “approved, adequate and available” therapies. And there seemed to be quite a few: ivermectin and hydroxychloroquine, for starters. Since it was going to take a while to get FDA licensure for the product that was going in all those arms under the EUA, the EUA had to be protected.

That would only be possible if cheap, generic, widely used, safe and FDA-licensed hydroxychloroquine and ivermectin (or anything else) were intentionally not recognized as effective therapeutics for COVID.

These therapies had to be suppressed and delegitimized by The Authorities as ineffective or dangerous as treatments for COVID, or else the coming vaccines - new, experimental products with limited safety trials conducted at “warp speed” - would be subject to crippling lawsuits if they injured anyone. Given that they would likely be distributed to the entire population en masse, it was a statistical certainty that someone would be injured.

This represented a massive problem for manufacturers. And that meant it was a massive problem for The Authorities, because Pfizer was threatening not to sell their product in any country that didn’t immunize them.

This EUA problem would go away once the vaccine was licensed by the FDA. But the required clinical trials weren’t done yet. Also, they weren’t coming out so great: of the 29 deaths in the clinical trial leading to licensure, 15 were in the vaccinated group, one more than in the unvaccinated group.

Problem #2: Only FDA-licensed products can be mandated or added to the childhood schedule, not EUA products. (And the Biden Administration was plotting nationwide mandates, because, of course they were.)

Problem #3: The FDA license for the Pfizer vaccine would not apply to the whole population because the clinical trials that would form the basis of that approval didn’t include important sub-groups, like pregnant women and children under 16. So the EUA would still be needed to immunize Pfizer against lawsuits arising from injuries to those groups until the FDA-approved product could be added to the children’s schedule (which required more data from kids) - after which nobody could sue Pfizer ever again over the vaccine.

What happened in August of 2021 was a diabolical solution to both problems 2 and 3:

• The FDA approved the Pfizer Comirnaty vaccine - a legal artifact because this product label wasn’t actually being used in the U.S..

• Simultaneously, the FDA extended the EUA on Pfizer partner BioNTech’s vaccine, which was the vaccine label being used widely.

In doing so, both problems were solved.

The EUA on the product being used (including for kids aged 12-15 yr) remained protected by the PREP Act liability shield. And the identical product label not being used anywhere in the U.S. by anyone received FDA approval so that it could be mandated by the feds for all employers nationwide.

No news outlet reported what had happened.

They all announced that the vaccine everyone was getting in their arms had received FDA approval, which wasn’t true. Nationwide mandates were announced two weeks later.

That was it. It was clear that there were dark, powerful forces at work behind the public health enterprise and I no longer wanted any part of it.

I had started listening to Robert F. Kennedy Jr’s podcast. Having thwarted his efforts, years prior, in the White House, I was now ironically mesmerized by how rational he (all of a sudden) seemed.

When Mr. Kennedy’s book, The Real Anthony Fauci, was released in Fall of 2021, I devoured it.

Kennedy’s meticulously-sourced description of how The Authorities had been planning for a global coronavirus pandemic - just a few months before it actually happened - was chilling.

But even closer to home was the detailed accounting of Fauci’s funding of ghoulish, invasive and debilitating HIV/AIDS experiments on often very ill foster children across the country. I had invested a good portion of my career in combating HIV/AIDS, both at home and abroad, and the book exposed how that career had been aligned with the monsters that tortured helpless innocents to bring the first of Big Pharma’s AIDS drugs to the market. I had made my bones in the Senate demanding the federal government prioritize the delivery of medicines (and not just condoms) to AIDS victims all over the world.

I had cried tears of joy and vindication when that agenda was realized in President Bush’s 2003 State of the Union address, where he unveiled his commitment to funding billions of dollars in antiretroviral treatments.

Now I was seeing evidence that these treatments were developed on the broken bodies of forgotten children, who were powerless to fight the unholy alliance of Big Pharma and Big Science.

If untrue, the claims in Kennedy’s book were so utterly defamatory that they should have spurred a parade of lawsuits. To my knowledge, no such lawsuits have ever been filed.

This cascade of eye-opening episodes eventually forced me to confront a painful reality: my 2017 take on Mr. Kennedy and his Vaccine Safety Commission had been a massive mistake.

What if there had been a Vaccine Safety Commission already in place during Operation Warp Speed? During the consideration of federal mandates by the Biden team? Adding COVID vaccines to the childhood schedule? What if Mr. Kennedy had been given regular access to President Trump in the first term?

Now, I’m not naive enough to think that a commission - any commission - would have had some immediate or obvious influence on vaccine policy. I know better than most how slowly government works. And no doubt Team Biden would have either immediately shut down the commission or replaced the commissioners with card-carrying members of the consensus class.

Still, as I listened to Mr. Kennedy speak out about his experience with the first Trump administration, I understood that at the very least, the vaccine safety conversation that is going mainstream today could have gotten a major head start.

So in January of 2022, I wrote Mr. Kennedy a contrite email confessing my sins, probably hoping for some sort of absolution. He was gracious, and he looped in his colleague Lyn Redwood from Children’s Health Defense. When we spoke shortly thereafter, she slyly asked me what I planned to do to atone for my sins - how I would contribute to the movement. I had no answers at that time. I was still totally disoriented.

The nationwide COVID vaccine mandate that had been announced in the Fall took effect in January (though, thankfully, was stymied in part by a number of lawsuits). Regardless, I would not comply. I never wore a mask again. No one in my family would get another vaccine. And I would never blindly trust a white coat (or many of the products they peddle) ever again. They’re not malicious (most of them anyway), but their education was just as flawed as mine.

Once I was “radicalized,” I started questioning many of the public health shibboleths. I discovered the Weston A. Price Foundation and the Wise Traditions dietary principles prioritizing all the naughty things like saturated fat and raw milk. I embraced the long-suppressed medical frameworks of homeopathy and German New Medicine. I started helping women birth at home, outside the medical system.

It was all quite heretical.

Most importantly, I realized that no one from Washington and no white coat is coming to save my health or anyone else’s.

I became my own primary care provider. You can too.

I still work on making health care less predatory and corrupt. I help employers fire insurance companies and rehumanize the health plans for their workforce. I provide all kinds of “friendly” advice to Congress and the current Trump team, even (especially?) when they don’t ask. And now that I’m a staffer for nobody and answer to no one, I am uncensored and unafraid, writing in my own voice about all of this right here.

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So thank you to the autism moms who got under my skin decades ago, even though I didn’t quite know what to do about them.

Thank you to Reps. Burton and Weldon and their staff (who conducted investigations of the CDC autism data).

Thank you to Andy Wakefield (the much-maligned “debunked” study author) and William Thompson (the CDC whistleblower).

Thank you to that friend who urged me to watch Vaxxed, and to Del Bigtree, who made the film.

And thank you most of all, Secretary Kennedy.

When he ran for president, I was nervous. If the Democrats nominated him, I was anxious that President Trump could lose to him. So it was a great relief when the Democrats blew their chance at victory by running him out of their party. And when those pyrotechnic fireworks popped off on the Turning Point USA stage, framing Kennedy and Trump and the birth of MAHA, I knew that a generational opportunity was upon us.

And yet, even now, I can’t quite shake the image that started all of this.

A line of mothers, sitting across from me in a Senate office in 2002, asking for something so simple: Please look. Please study. Please don’t dismiss what we are seeing in our children.

I trusted The Authorities instead. I told myself there would be time later, that someone else was handling it, that The Science must already be settled.

It’s a strange thing to realize that my biggest failures weren’t the fights I lost - but the ones I didn’t start. And that, in some of the stories I’ve been telling myself about my career, I was the villain and not the hero.

So this is where I am now: I don’t outsource my judgment anymore. I don’t confuse authority with truth. And I don’t ignore mothers, even when the consensus has lost all curiosity.

If that makes me a heretic - consider this my excommunication from the public health cult.

My son hasn’t forgiven me for school.

He’s 22 and he still brings it up.

And this wasn’t public school. It was the best school money could buy.

I was working in the White House. Our values mattered, and so I hunted down the most faith-based, boy-centric school I could find. All boys. All male teachers. Sports in the middle of the day. Kids hanging off tree branches instead of chained to desks. I walked in and thought: this is a boy’s paradise.

He hated it. Intensely.

It wasn’t the school I picked. It was school itself.

I sat down with Casey Harper at The Washington Stand’s Outstanding podcast to talk about this - about why our boys are cratering (5x lonelier than men their age a generation ago, 70% of overdose deaths, falling behind in every educational metric we can measure), and what I wish I’d understood before I made the choices I made for my son.

We get into:

• Why I’m not sure I believe in school for boys anymore

• How we medicalized normal boy behavior of risk-taking, stick-wielding, wall-bouncing and called it a disorder

• The “chickified” culture (thanks, Rush) and now we can’t tell the difference between a boy who wants to climb a tree and a boy who needs Adderall

• Why the same fire that drives a 9-year-old to beat dents into an oak is the fire that makes a 19-year-old willing to die for his country (and what happens when we extinguish it)

• And the question I’m wrestling with live on the air: what would it actually take to homeschool my grandkids while running my businesses?

I don’t have the answers.

(I keep telling people this. They keep asking me anyway.)

I’m a Gen X mom with a son who won’t let me forget the choices I made. I’m also a naturopath who’s spent years watching the “health” system manufacture sickness in adults, and I can see how we are doing something similar to our boys in real time.

Nobody at HHS is coming to save your son. Nobody at his school is either.

His teachers are lovely women. They don’t love him.

Read the article. Watch the full conversation.

Share it with the dad getting pressured into signing his 5-year-old up for kindergarten. Send it to the mom who just filled an ADHD script and feels weird about it. Forward it to the grandparent who still thinks daycare is progress.

We’re going to have to raise this generation ourselves.

Radically. Creatively. Generationally.

Hey Everyone!

I’m trying something new today.

is a coach, educator, and author who has spent years thinking about what it takes to raise a son in a culture that has largely forgotten how. He is also generous, thoughtful, and willing to answer hard questions head-on, which is why I sent him seven of them.

You may not agree with every line and, of course, that’s okay. Given the disastrous breakdown in family structure, and the screen-ification, pornification and weed-ification of our environment, there are no easy answers for how to navigate this kind of soul-crushing, vitality-draining, degenerate culture.

One area we didn’t touch on was the impact of economic factors - mass immigration that competes for our sons’ jobs, the flight of manufacturing to Mexico and China forcing those without college degrees into waiting tables instead of high-paying union jobs, and inflation that makes buying a car or home much more difficult than it was for we GenXers.

My husband was born in Italy and he speaks often about how European adult children often live with their parents indefinitely because there is no affordable housing or fair-paying jobs, and interest rates keep everyone in real estate their family has owned for generations. Are we turning into Europe? There are still affordable cities in the U.S., but an economy that forces children to leave their hometowns and never return, permanently severing young parents from the family structures that make economic survival and children’s flourishing easier is not quite the American Dream as advertised. And is it only getting worse as AI’s devastation is only starting to transform the job market?

Or maybe this is all just sophisticated excuse-making, with my maternal empathy undermining the hero’s journey for my son and everyone’s son. Unclear. But the need for the father’s voice to push the bird out of the nest and learn to fly has never been more urgent.

What I love about this piece is that Travis said “yes” to a real conversation, and that is exactly the kind of exchange AllBetter is down for.

Read it. Consider it. Argue with it. These are the dialogues we can’t afford to stop having.

But first - a note from Travis:

I recently had the opportunity to work with . While most people who seek to tap into my expertise throw softballs, Katy did not. She fired questions at me like Nolan Ryan fastballs: precise, relentless, and impossible to dodge. I had to think, dig deep, and work harder than usual to respond.

I loved every second of it.

Her insight and creativity are extraordinary. While I asked questions that required reflection, she responded with a beautiful, experiential art form that revealed her depth and perspective. You can check out that article here. She has a rare ability to challenge while inspiring, to push you without making you defensive, and to make even the most difficult conversation feel electrifying.

As part of our effort to understand the world we are trying to improve, here are her questions and my answers. This is the kind of work that truly matters.

Enjoy,

Travis

The Interview:

1. Is it too late for a family that is in the classic masculinity death spiral - they’re letting their early-20s son live in their basement while he works a minimum wage job he doesn’t like and doesn’t respect himself, and he smokes weed and plays video games - is it too late for them to turn things around and there’s no other option but to just kick him out? If the answer is yes, are there situations where the answer changes (trauma history, mental illness, suicidality)?

Short answer is yes. It is too late for parents to have a marked impact on a young man if he’s already at that stage. The most formative time has certainly passed. There is good news, thankfully. Massive and meaningful changes are still possible. The difference is that a young man is going to have to choose to make changes on his own.

Though the active parental influence has largely gone away, the passive and lasting influence remains. The teaching of right and wrong, the boundaries, the structure, the worldview, they’re all still in there. This is the time when he must go out into the world and try his own version of life (maybe that’s what you taught him, maybe he wants to try his own deal) and see if his worldview works. He will make mistakes. The more rebellious among us will make LOTS of mistakes. This is good! Those mistakes are how we learn the right and wrong of the world. The structure of our culture. The boundaries of life.

Men are built genetically to conserve their energy for battle. This is why men are so good at ‘vegging out.’ If things are easy, men will want to enjoy that, since battle can pop up at a moment’s notice. This being the case, forcing the lethargic young male to leave the nest and make his own way is the only answer here. Unless your long-term plan is to have him at home indefinitely, he’s got to go. It’s better if it’s his idea, but it’s necessary either way. (note #3 below) He must undertake the hero’s journey, for better or for worse. To some extent, you’re hindering that by providing comfort. And that’s regardless of underlying factors.

2. There seems to be a resurgence of young conservative families arguing for keeping their sons in the home in young adulthood rather than the tough-love, kick them out, sink or swim approach we all used to take. Do you think that’s wise, dangerous, a countercultural cope, or excuse-making?

I rarely give my opinion on topics like this, but here I agree wholeheartedly with the research. Parents are keeping their sons at home, and the reason is not the sons. It is the parents.

Modern parenting has swung so far toward comfort that it has lost its balance. Everything is softened, cushioned, and extended. The kind of firm, fair fathering that once pushed young men toward independence has faded so much it is almost unrecognizable. In many cases, parents are choosing what feels easier emotionally instead of what actually prepares their children for reality.

Because yes, independence is hard. Work is hard. The world will knock you down. But that is not new. The same parents enabling this situation did not grow up living indefinitely in their own parents’ basements. So what changed?

At some point, good parenting requires discomfort. When there is nothing pulling young people forward, there has to be something pushing them out. That tension between challenge and opportunity is what drives growth.

You can run toward something, or you can run away from something. Historically, young people have done both. They move toward opportunity and away from stagnation. When neither force exists, they stay exactly where they are.

That is not a failure of the child alone. It is a failure to launch, and the launchpad matters. Tough love is your savior here. He won’t like it, but you don’t need his permission to want your home back. He will thank you when he has his own family.

3. Given that fatherlessness is so epidemic now, what do you recommend to the single mom with sons to help them get “fathered” and mitigate the damage? The answer used to be Boy Scouts, but…

Go back to the Hero’s Journey and look at step four. A boy does not become a man on his own. He is shaped by men who demand something from him. It starts with his father. That is the standard setter. Later, the world reinforces it through other men or institutions like the military, police, or fire service. They do not coddle him. They correct him.

That is where alignment happens. When his actions match his values, he becomes dangerous in the right way. Focused. Disciplined. Reliable. When they do not, he turns into a contradiction. All talk, no spine. He knows what is right and still avoids it. That kind of man stays stuck, blaming everything except the gap between what he says and what he does.

Now remove the father.

You do not get the same outcome. You get confusion. You get delay. You get a young man who has never been forced to carry weight, never been checked hard enough to grow. The data backs it, but you do not even need the data. You can see it. Direction drops. Discipline drops. Accountability disappears.

This is where people get uncomfortable, so they lie about it.

A single mother cannot replicate a father. Not with love. Not with effort. Not with sacrifice. Those are not the same thing as pressure, example, and authority from a man who has already walked the path. When that is missing, something critical is missing. That gap does not magically fill itself.

And yes, choices matter. Removing a father from the home is not a neutral act. It is a decision with predictable consequences. Pretending otherwise is not compassion. It is denial.

If the damage is already done, then the only option is to patch the hole with whatever structure you can find:

· Male coaches who demand discipline

· Male teachers who do not lower standards

· Male clergy who hold the line

· Male neighbors who correct behavior

· Uncles who step in and stay consistent

· Older brothers who force accountability

These are substitutes, not solutions. They can help, but they cannot fully replace what was supposed to be there from the beginning.

And let’s be honest about one more thing. Mom’s new boyfriend is not the answer. It is instability. It teaches confusion, not discipline. It creates more problems than it solves. And the statistics on Sexual Assault from a step parent are staggering.

None of this is complicated. Hard truth rarely is. If you remove structure, you get chaos. If you remove accountability, you get drift. If you remove the father, you make the path harder and the odds worse.

You can ignore that. A lot of people do. Reality does not care.

4. What is the most powerful thing a mother can do or say to her son at age 10? 15? 20?

At ten years old, a boy needs a few simple things. I love you. You are safe. I believe in you. That is the foundation. To some extent, this is the best mothering for the duration of his life.

After that, words start to matter less. What he watches matters more.

How his mother treats his father becomes one of the most important lessons he will ever absorb. Not what she says about respect, but what she shows him every day. Boys do not learn relationships from lectures. They learn from patterns.

By the time he reaches high school, the concrete is hardening. At that point, his father becomes the primary model for masculinity. Not theory. Not slogans. Behavior. Discipline. Restraint. Responsibility. Whether the father is perfect or not does not matter. The example is still being taken in.

And the mother is still teaching, whether she realizes it or not.

Because how she treats the father becomes the blueprint. That is what her son will recognize as normal. That is what he will tolerate. That is what he will expect from a woman later in life.

Respect shown becomes respect expected. Disrespect shown becomes disrespect accepted. You do not get to opt out of that lesson. It is happening whether anyone acknowledges it or not.

5. What are your thoughts on the decline of sperm count worldwide, reportedly half what it was in 1970 and dropping by one percent a year? Causes? Solutions?

I have read the work of Dr. Anthony G. Jay, and none of this is coming out of nowhere. Hormonal imbalance is part of it. A culture that centers everything around comfort and approval is part of it. Plastic plays a role. Hormonal birth control in the water supply is a factor. Sedentary habits and garbage diets are part of it. Fatherlessness is the biggest part of it.

And here is the reality people do not want to admit. None of these exist in isolation. They stack. They reinforce each other. Weak inputs create weaker outputs, and then people act surprised by the result.

You do not get strong, disciplined, grounded men out of an environment that avoids hardship, rejects structure, and replaces standards with excuses. That is the bad news.

The good news is even simpler, and it is why there are no real excuses left. Every single one of these factors is, to a large extent, controllable. You can fix what you eat. You can move your body. You can reject passive consumption and build something instead. You can seek out discipline, even if it was never given to you. You can find male mentors, even if your father was ejected from your life.

None of that is easy. That is the point. The environment may be working against you, but it is not absolute. At some point, it comes down to a decision. Stay shaped by it or start pushing back against it.

6. I recently wrote an article on the effects of school on young men. Do you think boys should go to school? If so, what kind? If not, how should they learn whatever you think is minimally necessary?

I’ve written lots of articles on this myself, as you know. My degrees and much of my adult life are rooted in education. I am not guessing about this. I have seen it up close as a teacher, coach, school board member, and mentor.

There are school structures that engage boys, challenge them, and actually produce results. Not just for boys, but for girls too. The difference is they demand something. They build discipline, ownership, and competence instead of managing behavior and calling it success.

Look at what Apogee Schools is doing. Look at Matt Beaudreau. He is proving, in real time, that boys respond when expectations are high and excuses are not tolerated. I’m proud to know this guy. He’s crushing it, and public education is ignoring him right into their own obsolescence.

So this is not a mystery. It is a choice.

Public education, as it stands, is outdated and heavily tilted toward compliance over challenge. It rewards passivity, punishes risk, and then wonders why boys check out. Call it what it is. It is a system that has been softened to the point where many boys do not recognize themselves in it.

And when boys disengage, people blame the boys instead of the structure that failed to reach them. At some point, that excuse falls apart.

There are models that work. There are people doing it right. The only difference is they are willing to step outside a system that refuses to adapt.

And for the young man who did not get the fathering he needed, this matters even more. Because now he is not just learning academics. He is trying to build a foundation that should have been laid years earlier.

That is a harder road. But it is still a road. The question is whether he is placed in an environment that demands he walk it, or one that quietly lets him sit still.

When it comes to what a man actually needs, hoping he “figures it out” in a culture that avoids discipline and rejects structure is not a plan. That is neglect. Boys are no longer guaranteed the guidance they once had. Habits, standards, and real-world skills are no longer absorbed by osmosis.

That is why I wrote my second book in 2022, Ideal Man: Reviving Masculinity. It is a direct, comprehensive guide of time-tested habits every young man should pursue. Clear expectations. Real standards. Practices that build competence, discipline, and self-respect.

This is not optional. The young men who embrace it will separate themselves from the drift of entitlement and passivity. Those who ignore it will continue to struggle in a world that rewards readiness, not excuses.

7. What is the role of spirituality on the development of men? Is the answer different if the question is religion instead of spirituality? Is there a danger of feminization of faith on the souls of men?

No man can reach his potential without something larger to serve. It is built into him. Purpose beyond self is what shapes action, discipline, and endurance. Without it, strength becomes aimless and drive becomes frustration.

There is a clear difference between faith and religion, and that distinction matters. My own experience in this area may be unusual, but I own it. It has shaped me, and I am proud of it. I even recorded on this solo some time ago, exploring that tension.

Spirituality is personal, but its effect is universal. When a man aligns his actions with something greater than himself, everything else (habits, choices, resilience, etc.) falls into place. Without it, all the skills and discipline in the world remain partial, unfocused, and incomplete.

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Final thoughts

Thoughtful discussion is how communities actually think. Travis showed up, answered every question without flinching, and gave us something real to work with.

Thank you, Travis, for the generosity of a full-throated answer.

Now it’s your turn. Tell me where he’s right. Tell me where he’s wrong. Tell me what I missed. Tell me what you think of this format. The comments are open.

Thanks for reading,

Katy

Health policy stars in DC do not grow up dreaming about ERISA and the House Ed & Workforce committee. They dream about Ways & Means, or Senate Finance. So that’s where they go. Because, for decades, that’s where the health care fights happen.

And that’s why we end up fighting forever over the 20 million people in the ACA exchanges while 160 million Americans on employer-sponsored plans get fleeced by PBMs, carriers, Big Pharma and fake-charity hospitals - and nobody in this town lifts a finger for them.

Then, when a new administration shows up and needs political appointees, they go to the committees where the staffers are, and stack HHS with people who have never done serious policy work for employer-sponsored market.

Nick Solheim at American Moment had me on the Moment of Truth podcast this week and we went through all of it.

• How I watched us try to do Repeal and Replace in 2017 with a Congress that hadn’t written a replace bill (and then watched the Frankenstein that came out of that process die in the Senate - and thank God it did).

• Why price transparency actually got done (the internal fight with our own libertarian wing was brutal).

• Why insurance is now more expensive than paying cash most of the time.

• Why every time Bobby Kennedy or Marty Makary tries to do the job we hired them for, our own side lets them get torched — when what we should be doing is laying our bodies on the train tracks for them, the way the other team does for their own.

Also, the apology email I wrote to Bobby Kennedy after I helped run him out of the first Trump White House. He was gracious. I self-flagellated. You can tell I’m Catholic.

Give it a listen. Let me know what you think.

We interrupt our more poetic topics on femininity and radical agency in healing, or our more technical paywalled pieces on health care mechanics, to bring you this rant on the epic fecklessness of the Republican Congress.

You can usually count on Congress to do exactly nothing. But the nothing that is on the table for the next few months is nothing short of political malpractice.

As I’ve described elsewhere, the reconciliation process is how a party, when it controls both chambers of Congress, can enact policies with only 51 votes - rather than having to overcome the filibuster in the Senate with 60 votes. Given that Republicans may lose the House (and Senate) in November, the president may insist on a productive lame duck session after the elections to get whatever pieces of his agenda through before the more hostile Congress starts in January.

There is another option of course. Congressional leadership could try to, you know, not lose the elections.

That would require passing legislation that reflects the urgent priorities of the voters, like the affordability of health care, housing, and fuel.

Doing hard stuff because the people are counting on them is not exactly politicians’ strength, to be sure, but it’s not impossible, especially with the reconciliation process allowing for simple majority votes without a filibuster.

But if things continue as they are, your elected “representatives” have crafted a political suicide pact guaranteed to generate maximum voter fury - right before the election.

A reconciliation bill is apparently being planned - GREAT!

It’s going to have nothing but middle fingers to voters in it - wait, what?

Senate Majority Leader Thune has signaled that he doesn’t want to do health care or any of the other affordability issues like energy or housing that matter to the American people. Instead, he wants to just fund the Department of Homeland Security (DHS), including ICE and Border Patrol, which have been subject to a shutdown showdown that has defunded these functions and the federal workers that carry them out for months.

This would be the most colossal stupidity I have ever heard in my 25-year policy career, and that is truly saying something.

To carry out this epic face-plant, I have it on good authority that he has instructed Budget Committee chairman Senator Lindsey Graham to leave all committees out of the reconciliation bill that his committee is drafting except the one committee with jurisdiction over DHS. This would make it impossible for provisions on health care, housing, or energy to be included in reconciliation.

Apparently Thune and others in leadership are shaking in their boots about Minority Leader Schumer offering some amendment restoring Medicaid funding that was cut in the One Big Beautiful Bill last year (like kicking the illegals, millionaires and Somali fraudsters off the program). Because of that, they think that a “skinny” reconciliation bill will preclude painful amendment votes forced by Democrats. That’s because those amendments would be ruled out of order for reason of not being germane to the bill. The bigger the bill, the more you can amend it.

But this is crazy talk.

Of course, Schumer and anyone else can simply offer their amendment, it’ll get ruled non-germane and subject to a point of order, and then the amendment sponsor will call for a vote to waive the point of order. If they get 60 votes needed to waive, their amendment will still pass. If they don’t, they still get the campaign ads of Republicans voting against the measure. Thune knows this. He knows, because Republicans will also offer non-germane amendments and call for the waive-the-point-of-order vote to make Dems vote on stuff for campaign ads too.

So this can’t be the real reason to have a “skinny” bill with nothing in it for the voters.

And why even bother doing reconciliation, which takes weeks of “vote-a-ramas” with unlimited amendments on the floor, if you’re not doing anything useful? Most parties that control both chambers can’t wait to use the reconciliation process to swing for the fences - get as much of their agenda done as possible without having to face a Senate filibuster. That’s what the One Big Beauty was all about last year - when Republicans delivered Americans significant tax relief.

What’s more, using reconciliation to only fund DHS appropriations is catastrophically stupid because it will remind the voters that Congress didn’t do its most basic job - pay the guys keeping the bombs off planes and the narcoterrorists from crossing the border. While Congress has been cashing its own inflated paychecks, the guys in uniforms who have to hide their faces to keep their families from being assaulted are taking loans out to get through the week. But hey, let them eat cake.

What makes this even more inane, if that were possible, is that DHS funding doesn’t require reconciliation. It is already “paid for” by being included in the budget baseline. That means that Republicans are including measures that don’t need to be in reconciliation because they’re not costing or saving money. And instead, they’re leaving provisions out of reconciliation that do save money that could be used to address urgent voter concerns.

For example, the tariffs have brought in a ton of money to the Treasury - between $300-400 billion. But it’s off-budget money because the tariffs were enacted administratively rather than legislatively. The budget score-keepers initially allowed the tariffs to count on-budget, but when the Supreme Court struck them down a few months ago, that giant pile of cash went “off-budget” again. This means that they’re not in the baseline and if you “authorize” - codify - them in a reconciliation bill, you can count their revenue as new, and use it to pay for a bunch of other priorities that cost money, like health care reform, tougher health care price transparency rules, or banning Blackrock from buying up all the housing in your town.

Some might argue that these reforms wouldn’t pass the “Byrd rule” - a rule that applies solely to the reconciliation process that requires all provisions to be primarily fiscal rather than simply policy changes. But you can draft all these reforms in ways that create fiscal impact. After all - the point is to make life more affordable for Americans, so of course the impact will be primarily fiscal. Health care reform redistributes tax subsidies. Banning Blackrock housing-grabs or Chinese farmland-grabs changes the economics of the housing or agriculture industries, including mortgage rates, mortgage tax deductions, and other financial impacts.

What’s more, let’s say you fail on the Byrd rule. Big deal - all that means is that you need 60 votes to waive the Byrd rule. There are lots of policies that should be bipartisan. And if not, at least force the Democrats to vote for Blackrock and secret medical prices and higher fuel costs.

There are two other health care related policies that, if included in reconciliation, would create savings that could be directed toward affordability measures.

1. Site neutrality policy that ends the ever-growing problem of hospitals charging you extra for stuff you’re getting done in an outpatient, non-hospital setting just because the hospital system slapped its logo on the outside of the building.

2. Tackle the hospitals using AI to automatically (and often fraudulently) inflate billing codes so Medicare (and everyone else) pays more.

If these policies were put into a reconciliation bill, Republicans would have about $70-400 billion over 10 years (depending on how far you go). Along with hundreds of billions more in tariff revenue, that could be used to pay for policies that make everyday life more affordable for Americans.

So, what they should actually do with all this money?

School Choice for Health Care: the president’s policy announcement of last Fall was that he wanted to take money from Big Insurance Companies and give it to the people. I consider this like vouchers for education - where parents get the amount that the government would have spent on their kid in public school and are allowed instead to use it for private school or homeschooling.

If we monetize what the government and employers are already spending on health care and put it in individual accounts instead and expand the ability of people to make their own coverage or cash-pay choices, it would be like school choice for health care.

To break it down:

1. Put every dollar that the government is currently giving to Big Insurance on behalf of patients and put it into the patient’s own tax-advantaged health savings account instead. This would be budget neutral because the government’s already spending it: ACA subsidies, Medicare Advantage, Medicaid Managed Care, etc.

2. Allow employers to put every dollar they currently spend on their workers’ health coverage into the worker’s own health savings account instead. This is also budget neutral because all this spending is currently tax-free today.

3. Medical freedom for how HSA funds are used, meaning that the money doesn’t have to be used solely for the limited tools of allopathic medicine: drugs or cutting. These funds could also be used for health promotion, disease prevention, nutrition, and fitness, including spending on regeneratively farmed food for metabolic disorder prevention, red light therapy for arthritis, removal of mercury fillings by biological dentists, removal of microplastics from your brain (now that the STOMP initiative has been announced by the Trump administration to try to develop such techniques), water filters in your house, and other MAHA initiatives. You could even clarify that HSAs can’t be used on inpatient hospital stays that involve serving ultra-processed food to patients.

4. Ending secret health care prices, such as with the bipartisan Patients Deserve Price Tags Act, so that doctors and hospitals can no longer hide their prices through weaponized complexity and billing bureaucracy. There is no free market without transparent price information.

5. Ending anticompetitive contracts between network carriers and hospitals that prevent you, me, your employer, or your union from getting a better deal with a doctor or hospital and cutting the network out.

As I’ve described elsewhere, these measures would unleash a much more competitive insurance market that would offer more affordable premiums for coverage, as well as a cash-pay market that would dramatically drive down prices for care through significant expansion of the consumer base for cash prices. To facilitate that cash-pay at scale, you’d also need to require cash prices to be posted and accepted by providers, regardless of coverage status, and that the cash price must be equal to or lower than the lowest negotiated contract rate with a carrier. This is fair because an all-in, upfront cash price eliminates the billing bureaucracy and delayed reimbursement so it’s far less costly for a provider than sending post hoc claims pursuant to a network contract. That’s how you drive prices down for everyone.

So what is the real reason why Congress is sticking it to the American people with their “skinny reconciliation?”

The only reason I can think of? The White House is weak.

It pains me to say it, but the White House policy shop should be running this show, and it appears that they’re not involved.

Congress is always lazy. Republican leaders always claim they can’t whip enough votes for a consensus package, especially with tight margins in their razor-thin majority.

In a normal administration, when the president goes public with a sweeping health policy agenda like he did last Fall - his team would develop the plan and then hold a gun to Congress’ head and make them negotiate something resembling it and pass it into law. That didn’t happen. I have many theories about why, but suffice it to say that the fruit of this inaction is likely to be catastrophic electoral losses.

Without the White House’s boot on Congress’ neck forcing them to swing for the fences on reconciliation, Republicans will always choose to do nothing rather than something big or hard.

Democrats do not suffer from this affliction - they always go balls-to-the-wall when they get the reins of power - which I suspect we’re about to see in technicolor, starting in January, if our current “leaders” don’t change course, stat.

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.