The grace period is over. Enforcement begins now.

If that sounds obvious, it’s worth remembering that healthcare price transparency almost never happened at all.

There was a time when the idea that patients should know what medical care costs before receiving it was considered anti-capitalist, controversial, politically dangerous, and economically suspect.

I know because I was there. Here’s how it all went down.

(This story was originally published November 24, 2025)

Inside the White House War Over Ending Secret Health Care Prices

The first-hand play-by-play of how price transparency almost died in the cradle.

Price transparency is working. Not how most people expected. Better actually.

But I’ll have much more to say about that soon.

In the meantime, let me explain how it all kicked off with this price transparency business.

Back in the day, there were only a few supporters for ending secret health care prices inside the first Trump administration.

And I mean a VERY few (like count-on-one-hand few).

My first boss in the White House, and his boss, the president, were all in on price transparency.

They knew it was a bipartisan, 90 percent polling issue (that’s what we call #winning in politics). It also happened to be the right policy for reasons I’ll get to below. But, as it happens, my first boss abandoned me to become a fancy ambassador to… somewhere. Wherever. Not in the White House, having my back.

His successor, unfortunately, insisted that I convince a group of naysayers from various quarters within the building and from other agencies.

That group included a handful of free-marketeer bros with PhDs in economics, who looked pretty askance at this non-PhD, non-economist, must-be-a-lib chick. I had already earned their scorn the prior year by hand-wringing about the mid-term politics of trying to burn down the ACA.

We met weekly to discuss the academic literature about whether or not health care was the unicorn industry that would disprove the normally ironclad rule of economics: price competition lowers prices.

It felt silly — like trying to convince physicists that gravity is a thing.

Nevertheless, apparently this was controversial and the meetings dragged on, with the clock ticking loudly on the president’s term (little did we know just how short the window would be, with COVID-apalooza about to eat all other policy agendas).

I realized that something had to give, because I was outnumbered and the policy was stalling out.

Political appointees at the Department of Health and Human Services (HHS) had written a memo about why a price transparency Executive Order was crazy-talk.

Since my supportive boss left, the policy was on life support.

There was also this one study that kept coming up in the journal club and of course, in the hostile media, such as the Pharma-shilling Wall Street Journal. It was a study of the Danish cement industry — yes, Danish cement — that showed that when the government forced price transparency into the industry, prices for cement actually went up.

My allies on the Senate committee that oversees public health were so annoyed by the repeated and desperate citing of the stupid Danish cement canard that they had t-shirts made and sent one over to me, their sister in eye-rolling.

Given the aforementioned New, Less-Supportive Boss (NLSB), I knew my time was not much longer in the White House and things had to get rolling on this Executive Order. Despite the navel-gazing journal club and the WSJ industry shillery, I already knew the president loved the policy, and decided to make an end-run to get it into the State of the Union speech.

My thinking was that his word would be final and would put an end to the palace intrigue.

I managed to get a few paragraphs inserted into the draft a few days before the speech, announcing the policy, and arranged for an amazing guest to be acknowledged during the speech.

Her name was Wanda Brooks.

Wanda was a nursing home employee whose surprise $8,000 ER bill at Mary Washington Hospital in Fredericksburg, Va, had become a case study in predatory hospital billing. Wanda’s story was brought to my attention by Dr. Marty Makary (then Johns Hopkins surgeon and policy researcher and 2nd Trump term FDA Commissioner, now, regrettably, former Commissioner).

Unfortunately, the next draft of the speech that I saw had stripped all the price transparency stuff out — likely the work of the NLSB and the aforementioned economist caucus (I’m guessing, anyway).

Game on.

At that point, I put out the bat-signal for Cynthia Fisher.

Side-note about Cynthia Fisher, the zillionaire owner of Boston Beer Company, health care CEO, and fearless transparency advocate. Cynthia was the one who actually got me to take price transparency off the To-Do-At-Some-Point list and onto the Do-Right-Now list. Knowing how hard it was to get frenzied, over-scheduled staff to take a meeting, she played hard-ball. She brought my former boss, the incomparable Senator Tom Coburn, MD, then-retired but still feisty, to the party, knowing there was no way I’d be able to say no to him. When I worked for him, we had bickered like an old married couple, but the mutual affection and loyalty was unbreakable.

I spent the first half of the meeting doing what all staff always do in every meeting - I mentally rehearsed how I’d say no to the ask. The perennial problem of having way too much on our plate means we almost always say no to even the best ideas.

Then, halfway through the meeting, some switch inside my head flipped, and I said to myself: “You know this is the right thing to do. Why don’t you stop saying no and figure out how to get to a yes?”

And we were off to the races. Cynthia was and is a force of nature.

Cross her and she will bombard your email, your constituents, and the billboards in your Congressional district with compelling pro-transparency advertising, replete with Hollywood A-listers and heartbreaking stories from patients done dirty by surprise medical bills.

She never gave up — to this day — and she often seemed to have the president on speed-dial. She was FAFO before FAFO was a thing, and always with a winsome smile.

After HHS sent their price-transparency-is-stupid memo over to the White House, Cynthia found herself invited to an intimate dinner for business leaders with the president. When her turn to speak came up, she went all in on ending secret health care prices. The president, as we knew he would, loved it and told his team to get it done. Gladly! (What an amazing idea!)

So that’s why, months later, when I saw that my detailed take-down of secret health care prices and my call-out to Wanda had been stripped from the speech draft, I pulled out all the stops — Cynthia was my first call. I knew that her rolodex was more powerful than mine.

For my own part, I ran around the West Wing, cozying up to the more politically savvy types who understood the populist appeal of ending secret health care prices, like Kellyanne Conway and Mercedes Schlapp.

The speechwriters were holed up with the president, inaccessible to my harassment. So I pleaded with Derek Lyons, who wielded incredible power as Staff Secretary, possibly the littlest-known, most powerful role in the White House. The Staff Secretary’s office controls the flow of paper (including speeches) in the building and synthesizes all the edits everyone makes to that paper before it goes to the president or the public.

If Derek was persuaded, he could put his thumb on the scale in the draft.

Meanwhile, the New, Less Supportive Boss kept walking by these offices I was in (the building is much smaller than most people realize). He would do a double-take as he saw me, probably wondering what I was up to.

I waved and pretended to be casually chit-chatting.

There was no callout to Wanda and no fiery diatribe about the Health Care Swamp — but it was enough.

I knew that ONE sentence by the president of the United States would be powerful enough to move mountains, and would put an end to (at least the overt) internal opposition to price transparency going forward.

Not for nothing, a grateful nation should truly honor Cynthia for her heroic efforts, along with Dr. Marty Makary.

Marty’s book, The Price We Pay, is a classic for anyone learning the basics of health insurance and its actual impact on real people, the perverse incentives it creates and potential hacks of the corrupt system.

I sent all the naysaying political appointees around the government a copy of the book, which laid out — in the plainest English — the problems in our current insurance system — the so-called “free market” that Republicans thought existed, but didn’t.

A lot of their attitudes softened toward price transparency and the rest of the president’s populist health agenda after that.

As I had predicted, the president’s speech mention was the jet fuel the policy needed.

I eventually left the White House later that year, and to their everlasting credit, the colleagues I left behind, including the previous naysayers, were the ones who pulled price transparency over the finish line.

Policy, like politics, is a team sport.

We did it.

You’re welcome, America.

*****Fair warning: this one isn’t about your health (well, it’s about the health of the Republic, so perhaps that counts…). Jason and I worked together in the U.S. Senate, and what happened last week was too unhinged to leave unremarked. More health and health policy next week - PROMISE! - Katy*****

Last week’s collective freakout over the recently announced Anti-Weaponization Fund illustrates how divorced from reality partisan politics has become in the DC bubble.

As professionals who spent most of our careers advising legislators and leading oversight investigations in the U.S. Senate, it was bizarre and perplexing to watch this unhinged, uninformed bipartisan hysteria drive GOP leadership to send everyone home rather than quell the Republican bed-wetting and beat back the Democrat nonsense.

This is the biggest fracas over nothing that we’ve seen in a long time, and that’s saying something. If you’re interested in understanding what actually happened, here’s an explainer.

First, some context Congress would rather you forget

When it comes to enforcing immigration law, Congress has refused to fund certain segments of the federal government (ICE and Border Patrol). Those agencies have thus been living off a surplus from last year’s One Big Beautiful Bill, affectionately called the Big Beauty, rather than their normal annual appropriations.

When it comes to funding the Justice Department’s ability to settle any legal claim for any amount of money, Congress long ago put that on autopilot, using what’s called a “permanent, indefinite appropriation”- in other words, an unending supply of blank checks. It started like most government programs do, as something a little less crazy.

The Judgment Fund, as originally designed in 1956, was meant to allow the Department of Justice (DOJ) to pay damages of less than $100,000 when ordered by a court - without having to seek budget authority from Congress each time. So, at first, it was an unending supply of blank checks – but only up to $100,000 each. Makes sense, right? Why require an act of Congress every time a court orders the government to pay damages to a citizen it has wronged?

But in 1961, Congress amended the law to let DOJ use the Judgment Fund for more than just paying judgments. It granted authority to also pay for settlement agreements in pending, or even potential legal cases. The $100,000 cap still applied, though. It didn’t get really bonkers until 1977, when Congress eliminated the cap altogether – unlimited bonanza!

Administrations of both parties have tapped the Judgment Fund routinely since then, mostly for legitimate purposes to avoid or cut short costly litigation and remedy government wrongdoing (there’s been plenty to remedy).

The Fund was the logical necessity of a regulatory state run amok - extending its tentacles further into our daily lives every year, with the brute force, incompetence, and injustice that too often accompanies government action. Naturally, there would be citizen victims - those whose lives, livelihoods, and reputations were damaged by government malfeasance. When they understandably sought redress by suing the federal government, of course it’s DOJ serving as the government’s lawyers. As such, DOJ had to decide whether to settle the case by paying damages or go to court, where the government could lose, or be subject to, shall we say, an awkward discovery process.

However necessary the authority to settle cases may be, without any guardrails or upper limits other than the “good judgment” of government bureaucrats pressured by politically-appointed leadership, it will also naturally become subject to abuse and controversy without oversight.

Enter: The 1776 Fund™

Fast-forward to last week. The Senate got its knickers in a twist and fled town over an “unprecedented slush fund” - supposedly created by settling the case President Trump filed against the IRS for illegally leaking his tax returns along with the confidential returns of thousands of other citizens’ to ProPublica and The New York Times.

Unprecedented, they said - except it was Congress itself that created the mother of all slush funds.

Through the Judgment Fund (and the removal of the cap), Congress is to blame for giving DOJ unlimited spending authority in the first place - long before anyone had ever heard of the Trump-IRS settlement.

On the surface, the terms of the settlement require a formal apology and authorize the creation of an “Anti-Weaponization Fund” at DOJ. No dollar amount is specified in the agreement, but DOJ later announced it was carving out $1.776 billion (get it?) from the Judgment Fund to pay claims of damages from the abuse of government power to target political enemies through lawfare and weaponization. The 1776 Fund™ does have a better ring to it than “Anti-Weaponization,” so that’s what we’ll call it.

But don’t be fooled, this is all smoke and mirrors. The Judgment Fund itself has no cap. It’s a permanent appropriation - meaning it’s automatically funded, no annual Congressional funding vote required. So this isn’t some brand-new “slush fund.” It’s simply DOJ using the already-unlimited blank check authority Congress surrendered half a century ago. It’s the same unlimited money with a different label on part of it.

In other words, this is nothing more than a marketing tactic.

The 1776 Fund™ is just a public invitation for victims of political weaponization to sue (or threaten to sue) and settle with the Federal government. The announcement was nothing more than a DOJ press release.

To punctuate the earlier point: DOJ already had all the statutory authority it needed to remedy what the settlement calls “misuse of government power for improper political, personal, or ideological reasons” without carving out a special sub-account in the Judgment Fund. And if there were ever a misuse of government power for ideological reasons, illegally stealing and leaking thousands of Americans’ tax returns in an effort to embarrass the most prominent of those Americans, Donald Trump, certainly qualifies.

The Biden DOJ let the supposed lone criminal leaker, Charles Littlejohn, off with a slap on the wrist, allowing him to plead guilty to just a single count of unauthorized disclosure of tax returns, even though he admitted to stealing and leaking thousands of them. Isn’t that convenient? No messy trial that might risk exposure of more senior government bureaucratic negligence or complicity. And no remedy for the victims.

Whatever damages you think might be appropriate in this or similar cases, nearly 50 years before the Trump-IRS “settlement,” Congress had already removed monetary limits on DOJ’s settlement authority. The $1.776 billion number makes for cute marketing, but wasn’t actually specified in the settlement agreement itself and, of course, DOJ could have carved out any amount imaginable from the literally infinite pot of money Congress authorized.

The only brake on the process under current law is that settlement payouts from the Fund must only be for controversies that could have been litigated and could have resulted in a payable judgment. Since The 1776 Fund™ is simply a logo slapped on a portion of the Judgment Fund, that means it is also subject to these minimal requirements needed to tap the Judgment Fund - it’s not like DOJ can just start handing out checks like Oprah handing out cars to her audience.

Nevertheless, this is far from the first time that use of the Judgment Fund has seemed dubious to outside observers, though the real innovators here were Presidents Obama and Biden.

For example, in 2010 the DOJ Civil Rights Division tapped the Judgment Fund for $680 million to settle a single class-action discrimination lawsuit broadly alleging bias in farm loan programs from 1981–1999. The Obama administration set aside that pot of money to compensate victims, but when no more victims could be found, it still had more than $300 million to play with. So, rather than returning the money to the Treasury, it sent the leftover funds to politically aligned nonprofits that had filed no claims. Critics said the total funds far exceeded the real “litigation value” of any potential claims, but were distributed anyway.

Also brought to you by The Judgment Fund, Peter Strzok ($1.2 million), Lisa Page ($800,000), and Andrew McCabe ($700,000+), 3 senior FBI officials publicly exposed for chicanery that included leaking to the press and trying to impact the 2016 election. They later filed claims alleging violation of their privacy and wrongful termination, which the Biden DOJ settled and paid.

So, nothing about the current controversy is new or unprecedented. Unfortunately, neither side has enough incentive, self-awareness, or understanding to tell you the truth: this whole brouhaha is a nothing-burger.

Democrats howl that The 1776 Fund™ means there is a massive new pile of your money that the Trump administration has stolen through a corrupt, illegal and unconstitutional bargain in order to reward violent January 6^th insurgents - the game of “Demagogue It” that regular readers will recognize.

Because the legacy media can still amplify that message often and loudly, some weak-kneed or shockingly uninformed GOP Senators may even believe it’s true. And, no doubt some hard core MAGA-faithful will want to brag that it’s a brilliant 4-D chess move Trump invented to own the libs so hard you’ll be tired of winning.

It’s neither.

Far from a new or unique form of cronyism-by-settlement, it’s just DOJ announcing an intent to keep using those blank checks Congress handed out to settle whatever claims it wants to pay. According to the announcement, the Acting Attorney General will delegate this pre-existing authority to five other people who will sort through the merits of each case. But that delegation could have occurred before the Trump-IRS “settlement” and relies on zero new authority from that agreement.

One of us (Foster) has direct experience with DOJ’s statutory authority to pay damages to remedy political weaponization, having founded a nonprofit representing whistleblower clients who settled claims during both the Biden and Trump administrations. That organization, Empower Oversight, has negotiated settlements for clients, including non-political career government employees with personal beliefs across the political spectrum - including Democrats, Republicans and Independents. These clients were targeted for their beliefs or for objecting to the targeting of others. Most of their ordeals began after they sought religious exemptions from the COVID-19 vaccine mandate or after they made legally protected whistleblower disclosures about politics improperly affecting law enforcement decisions.

Even though these settlements occurred quite publicly between June 2024 and August 2025, House Judiciary Democrats waited until just before The 1776 Fund™ announcement to suddenly “launch an investigation” into rumors about it, lying about Empower Oversight’s clients as well as complaining about other settlements entered before the announcement, including with former National Security Advisor Michael Flynn and former Trump campaign advisor Carter Page.

Ironically, that illustrates our point.

Settlements already can and do happen routinely with the blank checks Congress handed over 50 years ago. The 1776 Fund™ doesn’t change that. Controversial settlements have occurred before and will continue to occur under administrations of both parties unless and until Congress amends its permanent and indefinite appropriation to the Judgment Fund to restore some limits on how it can be used.

Which brings us back to what happened last week

Instead of looking in the mirror and taking responsibility for what it has done, Congress freaked out and the Senate left town - another episode in the Senate’s ongoing insistence on doing nothing. By “insistence,” we mean an obsessive, compulsive, pathological, and scandalous commitment to doing nothing.

For those of you fortunate enough to live outside the Beltway and its psychosis, let’s bring you up to speed as to where things stand procedurally.

Congress was on track to appropriate funding for ICE and CBP, as well as some Secret Service security beef-ups. (It’s not like anyone has tried to kill the president, right?) Also included were some DOJ-related immigration court and counterterrorism efforts - all as part of a “skinny” reconciliation package. Regular readers will recall previous posts complaining that a “skinny” bill was a grotesque waste of an opportunity to address the affordability crisis prioritized by voters, such as with health care reform or other issues like housing and energy costs.

Reconciliation is a type of bill, designed to be part of the budget process, that allows for certain fiscal measures to be moved in the Senate under privilege, with only 51 votes rather than the usual process that requires 60 votes to end debate and move to final vote (aka the “filibuster”). The majority party of either stripe will frequently use reconciliation to get through legislation that doesn’t have bipartisan support, such as Obamacare, or the “Big Beauty.”

But of course, Congress is so dysfunctional these days that even their most basic job - funding the various departments of the executive branch - has turned into a hyper-partisan affair. The shutdown showdown earlier this year was eventually overcome (well into the fiscal year to which the funding was supposed to apply, sigh), except for one unresolved dispute: ICE and CBP.

Democrats have refused to fund these agencies and pay those federal workers, in order to spite the president over his deployment of ICE and Border Patrol agents to enforce the law. In case you’ve forgotten Schoolhouse Rock, those laws are passed by Congress.

In any case, now that we are already nine months into the fiscal year in question, the Congress finally had a plan to fund the agencies. The reconciliation bill was on track for a vote in the Senate, imminently. And then the DOJ made its seemingly unrelated announcement about the Trump-IRS “settlement” and The 1776 Fund™.

Cue the Senate’s nuclear meltdown

If you read the legacy press, you’ll hear melodramatic accounts of Republican freakout in closed session with Acting Attorney General Todd Blanche, summoned to explain this crime against humanity.

Apparently, Republican Senators are so aggrieved about this policy that Majority Leader Thune has suspended consideration of the reconciliation bill funding ICE and CBP and sent his colleagues home for the week.

What, you might ask, does The 1776 Fund™, whatever its merits, have to do with paying the salaries of ICE agents and CBP officers who risk their lives to enforce the laws passed by Congress?

Nothing. Sort of.

We say “sort of” because Democrats are using the opportunity of the reconciliation bill as a moving vehicle to amend it to exclude anyone with a claim related to January 6th from eligibility for any settlements. Some weak-kneed Republicans could help the Democrats to derail the entire funding bill over this political sideshow. This is the vote that some Republicans are so afraid of that they fled the city just to avoid it.

Why are they so afraid?

The political dilemma is supposedly that Republicans who vote no would be painted as supportive of “violent J6 insurrectionists”- not a good look in some swingier states. Republicans who vote yes would be bucking the president, and could be painted as weak on fighting the Democrats’ lawfare - politically risky in redder states, where voters were rightly (in our view) alarmed by the Biden administration’s unprecedented use of DOJ to persecute Biden’s political enemies while protecting his family and political allies.

On the one hand, it is understandable that Senators might be annoyed at the White House for putting them in that position by announcing The 1776 Fund™ just prior to the vote.

On the other hand, life is “nasty, brutish, and short.” We all have to pay taxes (except Hunter Biden, apparently), and most Americans expect their Senators to take a tough vote once in a while, especially if it’s necessary to keep paying those in law enforcement who risk everything to keep us safe. On this one, you can count us in this latter camp.

But that’s actually not why this whole kerfuffle is legislative and political malpractice.

We are, of course, cognizant of the stereotype of crusty Senate veterans sneering down our noses at the “kids today” making a mockery of the very important work we once loved. But last week, we asked each other, “wait, are we the only ones who see the obvious?”

As we’ve explained, the 1776 Fund™ is just a White House branding exercise on a power Congress handed over decades ago.

So, why is Congress shocked? The Judgment Fund is their program - their decision, supported by all of them for decades. And why are some GOP Senators so afraid of the Democrats’ and their media allies’ dishonest framing that they ran away rather than stand and fight back with facts?

Aggrieved Senators would argue (and ARE arguing) that DOJ didn’t have to wave the blood-red J6 flag in front of Democrats right before the reconciliation bill was up for a vote, taunting them into filing amendments that would prohibit their J6 boogeymen from getting access to the Judgment Fund through the newly announced carve-out fund.

But the talking points and strategies to beat back such an amendment are not that hard.

No matter your views on J6, certain core, neutral principles remain the same. The Judgment Fund was established precisely to compensate people who were harmed by government overreach. Someone has to decide whether to litigate or settle each individual claim on the merits, and Congress cannot do that. That is an Executive Branch function. Congress can, however, write into law basic guardrails to govern the process, and maybe it should. But is a budget reconciliation bill the proper way to do that? Or should there be committee hearings, study, and deliberation on exactly how to write thoughtful rules that place reasonable limits on how DOJ exercises this authority?

This is precisely the sort of talking point that should resonate with the Susan Collinses and the Thom Tillises of the world and which they could adopt in this case, to justify opposing a Democrat amendment aimed at killing what’s really an immigration spending bill.

The Byrd rule in the Senate reconciliation process requires amendments to be primarily fiscal in effect rather than policy-oriented. Serious reform of the Judgment Fund might be a good idea, but that’s definitively a policy-oriented legislative task, not just a funding measure. But if a Democrat amendment miraculously survived the Byrd rule (or the 60-vote point of order to waive such a rule), then two can play this game.

Republicans could force Democrats to vote against some of their own sacred cows.

This happens all the time as a tactic to get the original amendment withdrawn. GOP Senators could file a separate amendment similar to the Democrat one being contemplated to prohibit certain people from receiving settlement payments.

For example, GOP amendments could describe categories designed to block settlements for a long parade of partisans who might line-up for payouts from a future Democrat Attorney General - including such supposed “victims” as Hunter Biden, James Comey, Dr. Tony Fauci and his deputy David Morens, John Brennan, John Kerry (remember those retaliatory Logan Act violations?), and Federal Reserve Governor (and alleged mortgage fraudster) Lisa Cook.

Categories could include foreign pro-Hamas activists targeting Jewish students, officials in sanctuary cities who defy federal law, and activists who obstructed, violently resisted, or threatened ICE agents conducting lawful enforcement operations.

Any number of amendments could be drafted to illustrate the folly of placing politically targeted limits on the government’s ability to settle legal claims. We’re old enough to remember when, instead of crying and refusing to take painful votes, some in the GOP Senate (including Senate legends we worked for like Tom Coburn and Chuck Grassley) would fight back.

You want to politicize the Judgment Fund? Game on.

Let’s show you how ugly that could get. Then maybe cooler heads will prevail, and we can talk later about serious Judgment Fund reform that reasonable people on both sides could support, such as monetary caps and enhanced oversight.

In other words, there is no cause for hysterics, shutting down the Senate floor, burning down the budget process, or blocking funding for immigration enforcement and security beef-ups over this big fat nothing-burger.

Memo to the Senate: stop the madness and get back to work.

Paid subscribers get access to the actual document we’re putting in the hands of congressional staffers right now. It gets a little technical - statutory frameworks, certification requirements, the works. If you want to understand why the Congressional freakout is unwarranted as a legal matter, it’s all in there.

• Congressional staffers or members of Congress interested in this document, DM us with your government email and we’ll send it to you for free.

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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.

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.

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 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.

Read more

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.

I was about to fire another vendor.

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

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

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

The Holy Trinity of Vendor Firings

I helped the sisters:

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

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

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

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

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

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

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

The Part They Don’t Put On The Sales Slide

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

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

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

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

• Confirm eligibility/coverage when providers call

• Get prior auths done quickly and correctly

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

• Receive bills and reprice them against Medicare-based terms

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

• Pay the repriced amount and any negotiated resolution amount

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

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

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

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

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

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

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

• running procurement,

• negotiating contracts,

• integrating vendors,

• building workflows,

• enforcing performance,

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

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

We All Need an Honest Coach

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

It wasn’t pretty: industry shillery.

No chance.

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

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

She listened. Patiently.

Then she said:

“The problem is you.”

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

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

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

Generous mentors are gold in this business.

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

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

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

I like sleeping at night.

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

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

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

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

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

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

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

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

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

Maddening.

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

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

But times have changed.

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

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

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

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

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

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

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

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

Paid subscribers get the inside scoop.

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

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

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

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

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

She would need to be strong to get through that.

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

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

The inpatient admission was largely a fail.

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

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

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

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

I didn’t buy it.

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

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

What happened next was the worst night of my life.

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

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

To say the transition went badly would be an understatement.

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

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

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

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

None of it made a damned bit of difference.

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

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

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

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

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

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

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

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

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

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

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

“It’s protocol.”

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

Blank stare. “It’s protocol.”

What if she refuses?

“She can’t. It’s protocol.”

No really, what if she refuses?

“She can’t deliver here.”

So she can just walk out of here?

“Well, we’d have to call CPS.”

Ah yes, the CPS card.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• Death-by-hospital:

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

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

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

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

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

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

There is an important caveat here: mechanics.

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

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

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

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

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

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

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

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

Not to mention the cost.

What cannot be sustained will not be.

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

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

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

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

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

Policy-makers will need to decide what that means.

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

This transformation can’t happen fast enough.

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

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

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

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

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

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

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

All Soviet empires must fall.

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A quick note before we get into it.

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

This one is for everyone else.

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

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

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

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

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

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

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

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

No one is immune.

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

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

Here’s how they run their scheme:

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

Then you sign. Of course you sign.

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

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

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

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

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

Before You Walk In: Know More than They Do

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

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

Yeah, no.

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

Get the billing codes

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

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

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

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

See how much Medicare would pay for each code

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

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

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

Crunch the numbers.

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

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

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

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

• A predatory price is anything above 250%.

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

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

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

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

Ask about “site of care.”

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

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

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

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

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

Find out how many people are going to bill you.

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

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

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

Get a Good Faith Estimate.

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

Compare the cash price.

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

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

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

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

That usually recalibrates things.

And follow up with HR.

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

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

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

A few special cases to consider:

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

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

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

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

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

The Day Of Service: How to Evade Their Trap

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

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

Ask for paper forms.

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

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

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

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

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

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

How you handle them depends on where you are.

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

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

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

(Are we having fun yet?)

After: When the Bills Start Rolling In

Never pay the first bill.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

One last note on collections.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Federal Government is Dropping Thermonuclear Bombs

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

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

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

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

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

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

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

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

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

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

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

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

That’s wrong.

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

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

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

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

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

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

• Knowingly lie on these new proposed PBM disclosures

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

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

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

• Mislead auditors or regulators.

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

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

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

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

Read more

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

It’s your paycheck.

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

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

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

Awkward Silence.

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

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

This is a hard and heartbreaking truth.

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

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

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

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

How Abortion Became A Tax Deduction

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

That means that:

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

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

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

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

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

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

There Has to Be a Catch

But HSAs are also tied to this IRS abortion ruling.

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

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

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

Unelected. Unaccountable. Effective.

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

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

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

Or for every coverage-expanding law in between.

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

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

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

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

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

Compliance Theater

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

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

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

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

That concern is understandable. But it is also incomplete.

They’re the same cause.

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

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

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

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

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

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

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

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

It is pro-life work.

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

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

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

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

Speaking of Steaming Piles of…

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

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

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

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

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

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

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

Principalities and Powers

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

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

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

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

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

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

That is Why I’m Calling This Family Meeting

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

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

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

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

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

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

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

But there are more abortions today than ever before.

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

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

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

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

But Doing Nothing Does Things

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

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

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

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

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

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

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

But only as tactical flexibility, not as surrender.

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

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

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

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

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

One Last Thing (Before the Dems Come Back In)

The president could do this by executive action - today.

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

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

Whaddya say we ask him to use it?

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

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

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

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

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

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

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

How Health Care Became the Hostage

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

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

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

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

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

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

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

The Shutdown Hoe-down

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

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

Democrats refused.

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

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

Because bipartisan health care breakthroughs happen a lot.

Oh wait.

No they don’t.

The Hostage Exchange

No deal was reached before the holidays.

I know – you’re shocked.

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

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

Reportedly, Democrats would get:

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

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

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

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

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

Behold, Budget Reconciliation

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

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

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

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

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

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

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

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

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

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

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

Real Reform Worth Fighting For

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

Rumor has it the package will likely include:

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

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

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

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

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

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

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

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

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

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

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

But, wait.

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

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

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

HSA expansion? Dead.

Subsidy reform? Dead.

Tax deductions for innovations? Dead.

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

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

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

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

(My last article explained the problem Republicans face in trying to fix health care. This post focuses on the solution.)

We can’t afford not to have insurance because the prices are so high. But we also can’t afford insurance because the premiums are so high.

Which is why almost every American requires a significant subsidy from someone else in order to afford insurance – whether it’s government ACA subsidies, employer subsidies, or government-run Medicare, Medicaid and other programs.

With the COVID-era expanded subsidies for people on the ACA exchanges about to expire in a few days, there’s a growing panic among policy-makers about what to do.

You may have noticed that I’ve been warning Republicans in recent articles about the pitfalls of the various proposals reportedly under consideration. Their response back is understandable:

So what's the plan?

This article is my answer to that question.

My proposal is the same as the president’s.

(But not the weak-sauce version being kicked around by some in Congress.)

So what details would put flesh on the bones of the president’s all-caps social media screeds against insurers?

Is there hope for a bill that can pass – satisfying both the moderates and the conservatives in the party, without screwing over voters and losing elections?

Answer: YES.

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One of the problems with most Republican proposals is that they are only targeting the small fraction of Americans on the ACA exchanges. That’s 23 million people – a lot, to be sure. But 180 million Americans – almost 54 percent – get their insurance on the job, nine times more than ACA enrollees.

That said, we still have to have a solution for the affordability problem for those 23 million currently on ACA plans. Because the premiums are so astronomical, almost all (92%) of those people are receiving free or heavily subsidized coverage, paid for by you and me.

That government cash goes straight from the Treasury to the deep pockets of the “money-sucking insurance companies,” to quote President Trump (he’s not wrong!).

As I’ve mentioned in previous articles, if we take money away from people who are currently getting subsidies, we will lose the mid-terms, period. We lost the 2018 mid-terms just for trying.

No amount of wailing and gnashing of teeth from conservatives will change this. I wish it weren’t true, because it’s extortion. But it is true.

If we lose the mid-terms, Democrats will come in and make things even more impossible the next time we’re up at bat for a chance to fix this.

So here’s my four-point plan, or rather, what I think the president might have meant with his social media posts.

Let’s start with the executive summary, followed by a deeper dive for the bravest among you.

1. School choice for health care: ACA Market edition

Convert all subsidies currently going to insurers on behalf of ACA exchange enrollees into dollars put in a tax-advantaged Health Freedom Account, or “Health Wallet,” “Care Fund,” “MediStack,” “Trump Card,” whatever branding you choose. It’s an account owned by the enrollee. For now we’ll call it an HFA.

They can use the money to buy the same plan they’re on now, a different plan, a plan off the exchange, a membership like a health care sharing ministry or direct primary care, or just cash-paid care.

Trust them to choose their own health expenses, including holistic care, without the government dictating what medical care is or should be.

Let anyone else contribute to it as well, up to the max subsidy amount available for an ACA silver plan, or whatever cap above that Congress decides on (see below).

2. School choice for health care: for everyone else

Allow everyone in America to have an HFA - including employees of businesses. That way, employers who want to provide financial support for their people – but don’t want to be in the health care business, having to manage a complex group health plan for their workers – still can provide robust health benefits. By contributing to their workers’ HFA, businesses could free up employees to make their own health choices rather than having their bosses make those choices for them.

3. Cut out the middlemen between buyers and sellers of care

• Require doctors and hospitals to publicly post and accept a cash price for all services that is equal to or lower than the lowest carrier rate.

• End discrimination against uninsured patients by requiring providers to treat cash-paying patients the same way they would patients using insurance.

• Prohibit insurance contracts from banning employers or doctors from cutting out the insurer and negotiating a better deal directly between themselves, or simply transacting in cash on behalf of patients.

• Prohibit state/local laws from banning new hospitals and repeal federal law prescribing who can own hospitals, like doctors.

• Require pharmacy benefit managers and third party plan administrators to assume fiduciary obligations to the plans and enrollees they serve.

4. End secret health care prices

• Codify the first-term Trump price transparency rules and supercharge them with more details, more ease of access, and excruciating penalties for noncompliance.

• Entitle all buyers of health care to have full access to their claims data, including individual patients, employers, unions, and governments, again, with excruciating penalties for non-compliance.

That’s it, that’s the plan.

You’ll note that I’m proposing to extend a form of the COVID subsidies.

Conservatives don’t want to do this. I know. I hear you. I don’t want to either.

But I like winning elections, and I know you do too. We have no margin in the House – every moderate in a swingy, unsafe seat has to vote for a package in order for it to pass.

Moderates are currently signing up for a totally clean (i.e. reform-free) three-year extension of the subsidies right now. That would get us all the current costs and no policy wins in return, enshrining the premium-spiking death spiral we’re in now.

Moderates have rightly figured out that they have to extend the subsidies or they’ll lose their seats. I don’t want them to lose. Do you want them to lose?

Conservatives in safe seats have to sacrifice our principles more than moderates do, when margins are this tight. I’m sorry. I wish it weren’t so.

However, if it’s any consolation, this is one of the only proposals that actually would lower costs throughout the entire commercial market (not just the ACA exchanges), because it would facilitate actual price competition and greater efficiencies through cash/direct-pay and direct contracts between employers and hospitals.

I urge you to consider that, if prices come down through these reforms, premiums would come down too, including the silver benchmark plan premium that subsidies are tied to. In this way, there’s a path for the extended subsidies in this proposal to actually pay for themselves in lower health costs nationwide.

Moderates, you get to say you took nothing away from anyone and you gave them more options, more control over their own destiny, and more affordability.

Conservatives, setting cost aside, you’d be getting all your health policy hopes and dreams.

Conservatives have long wanted to move subsidies into private accounts, to give people choices away from the limited government-approved options in Obamacare, and to move employers away from defined benefit health coverage towards defined contribution coverage. This proposal would do all of those things.

My experience is that you can actually get big policy reforms done in Washington. But you always have to buy them. Meaning, you have to spend more than you’re comfortable spending. That’s usually the compromise, and I’ve found that it’s generally worth it, if your policies are the right ones.

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So that’s my pitch. And now here’s the deep dive.

If you want to look under the hood a bit more...

1. SCHOOL CHOICE FOR HEALTH CARE - ACA market edition

All current subsidies going to anyone on the ACA exchanges will continue flowing, but they will be given to the people themselves, not the insurers, so that the people can buy whatever health care or coverage that they want.

Put all subsidies that any American qualifies for today (including base ACA subsidies, COVID expansion subsidies and Cost-Sharing subsidies) into an HFA.

The amount that goes in is the exact amount of the max subsidy that the person would qualify for today under the ACA for an average silver plan. This amount changes every year based on the rate of inflation or some other standard index, rather than just a blank check covering whatever insurers feel like charging.

HFAs can be used, tax-free, for:

• Insurance premiums for ACA exchange plans (people can buy the same plan they’re currently on if they want)

• Insurance premiums for off-exchange insurance plans

• Membership fees for Health Care Sharing Ministries

• Membership fees for Direct Primary Care

• Out-of-pocket insurance-related expenses such as deductibles, coinsurance, copays

• All other qualified medical expenses under Sec 213(d) of the tax code, EXCEPT abortion or sex-rejecting (transgender) procedures.

No one loses a single dollar that they currently are getting in subsidies (i.e. it’s an extension of the COVID subsidies, only through a different mechanism).

If you are on an ACA Blue Cross plan today and Blue Cross is receiving your subsidies, you will now get those subsidies in your HFA. You can take that money and give it right back to Blue Cross to buy your same plan. You lose NOTHING.

But if you want a different plan, like say, an off-exchange plan or a health care sharing ministry membership, you can use your subsidy money to buy that instead, and keep whatever’s left over in your HFA for other medical expenses.

NOTE: If Republicans insist on ending the expanded (COVID-era) subsidies, I recommend that they only do so for the richest people. Pick a threshold that everyday Americans would all agree is “rich” (and therefore, fair), say, above $150,000 or $175,000.

ANOTHER NOTE: Ok, ok, what about phasing down the COVID-era subsidies after a few years? You could maybe get them down to pre-COVID era – or even lower over time. Unlike most reform plans, this one actually rescues the rest of the commercial market and not just the ACA – that means that underlying prices will now be subject to competition at scale. That could lower premiums and save money in the end by lowering the indexed subsidy amount allowed in the HFAs each year.

AND YET ANOTHER NOTE: It’s important – both politically and morally – to prohibit HFAs from being used to pay for stuff that is violent toward self and others like abortion and sex-rejecting procedures like cutting the breasts off little girls. That’s not health care – conventional, holistic, woo-woo or otherwise. Sorry, not sorry.

Goodies for MAHA

Little-known fact – you could use the HFA for MAHA tax breaks.

HFAs could be used, not just for insurance premiums or membership fees, but for “qualified medical expenses,” as defined by the tax code. That means it could also include expenses that help you live like a human, like physical training, visits with an acupuncturist, Traditional Chinese Medicine practitioner, a functional nutrition expert, a fertility health coach, and so forth.

BUT here’s the proviso – to comply with current IRS rules, you would need to get a licensed clinician to write a letter of medical necessity saying that the clinician is prescribing these less-conventional services or equipment in order to treat a specific diagnosed condition like obesity, depression, lower back pain, infertility, and so forth.

In other words, tax breaks for MAHA.

This policy would make things a lot more fair for people like me, who are more woo-woo, and don’t want insurance at all.

More and more Americans are extracting ourselves from the white-coat religious cult and would prefer to treat with time-tested home remedies, and pay cash if we need to set a bone or get an x-ray.

But since catastrophic care is still so unaffordable, maybe we join a health care sharing ministry in case we’re attacked by radicals on a college campus and need a burn unit or ICU.

Further, why not let us donate unused money in our own HFA to someone else’s health care whose costs exceed their HFA limit?

2. SCHOOL CHOICE FOR HEALTH CARE – for Everyone Else

Why not open up HFAs to all Americans, not just those currently getting ACA subsidies?

Remember those 180 million Americans getting their insurance on the job? This has turned every company into a health care business – whether they want to be or not. What if they could get out of that business and focus on their core competency, while still helping their workers afford health expenses?

HFAs would not only be available to people getting subsidies today. HFAs would be available to anyone else (only without the government pre-funding).

This would build on a policy created by President Trump in the first term where employers were allowed to set aside money for workers to buy their own coverage rather than buying it for them.

Anyone could contribute private money to the HFA – tax free to them and tax free to the account-holder – up to a cap equivalent to the amount most people would use for an insurance premium and out-of-pocket costs. Another cap could be used instead, such as the maximum ACA subsidy amount.

That private money can be contributed by the account owners themselves, or anyone else on behalf of the account owner, including employers, health care sharing ministries and other charities, crowd-funding sites, churches, or family members.

Employer-sponsored health benefits are already tax free, so putting that same money into a worker’s HFA won’t drain the Treasury - well, not anymore than it’s already drained.

3. CUT OUT THE MIDDLEMEN BETWEEN DOCTORS AND PATIENTS

There’s a hostage crisis in the 180 million-person employer market. Secret contracts with middlemen keep prices high for ALL Americans by prohibiting buyers and sellers from making better deals with each other - directly.

America’s health care system is full of good doctors, nurses, and (a few) hospitals. American businesses want to do the right thing by their employees, but they’re drowning in double-digit rate hikes year over year, threatening their ability to survive in the economy and compete with foreign companies.

Charities, churches and health care ministries just want to help patients get care at affordable rates.

But one group quietly controls the entire system: health insurance companies.

Insurance contracts hold every stakeholder hostage.

Behind the scenes, insurers use their contracts to lock up doctors, hospitals, employers, ministries and patients – all to block competition.

And if you’re wondering exactly how they carry out their dirty work, these contracts:

✘ Stop hospitals and doctors from accepting fair, lower direct-pay prices from patients:

Even when a doctor wants to accept a lower direct price for someone paying cash, the insurer contract often forbids it.

When patients who are enrolled in one of my employer-client’s plans show up at a doctor’s office, they are asked to present their ID card. If that ID card has a carrier logo on it, then that doctor isn’t allowed to accept cash from us for a lower price. He has to send the bill to the insurance company and charge us those predatory rates. And we’re not supposed to even offer cash in that situation either, because of our own contract with the carrier.

We’re all held hostage to this middleman.

✘ Stop doctors and hospitals from giving employers a better deal without the insurance network.

If a local employer wants to contract directly with a hospital for lower prices, insurers often ban the hospital from saying yes. Employers are hostage to the insurer’s deal—even when everyone knows the insurer negotiated a terrible one.

My employer-clients often want to do a deal with their local hospital. But both my client and the hospital have their own separate contracts with, say, Cigna. We have to get permission from Cigna to do that deal. If the deal is too likely to disrupt Cigna’s profiteering, they veto the arrangement and we’re both out of luck.

✘ Stop patients from getting appointments unless they have the “right” insurance.

One of my employer-clients isn’t an employer at all, they’re a religious order of Catholic nuns.

They wanted a health plan without a carrier network so that they were free to pay cash directly to doctors or hospitals, or to negotiate their own contract.

Just last month, NYU hospital (a so-called “charity” that doesn’t pay taxes) told a desperately sick nun, “sorry, we won’t let you in the door because your ID card doesn’t have a carrier logo on it. Even though your plan will pay. Even if one of our doctors very much wants to see you.” I had to use my fancy DC connections to get hold of an NYU executive, just to be allowed to pay cash at the door, before this poor sister could be seen. By the way, this sister would qualify for Medicaid and NYU’s financial assistance program. We actually wanted to PAY the hospital instead of going that route.

If you want to pay out of pocket — or if your employer or health care sharing ministry wants to pay on your behalf — you should be able to get the appointment.

✘ Punish doctors if they offer lower prices to anyone else. Insurers often include:

• “Most-favored-nation” (MFN) clauses – requiring the doctor or hospital to give the carrier the best price compared to any other purchaser, no matter what.

• “All-products” clauses – requiring doctors to participate in every network offered by the carrier if they want to participate in one.

• “Anti-steering” clauses – prohibiting employers from steering patients to doctors outside the network who are higher quality or lower cost.

• Outright bans on doctors or hospitals offering lower prices outside an insurance network.

These contract provisions block doctors and hospitals from giving anyone a better deal — patients, employers, even charities like my nuns.

Congress should make it explicitly illegal once and for all.

To put an end to these gangster tactics by insurers, Congress should:

✅ Require a direct-pay option for all care

Every health care provider must post and accept ONE single “direct-pay price” for each service – the same price for every patient, employer, or non-insurance payer willing to direct-pay, upfront and in full.

The published direct-pay price must be equal to or lower than the lowest commercial insurance rate accepted by the provider. Insurers lose the power to keep cash-paying customers or employers from getting a better deal. Being paid cash upfront and in full eliminates the need for pre-certification, eligibility checks, chasing patients for their cost-sharing obligations, sending claims, waiting around for payment while the insurer makes billions on the interest earned by delayed reimbursements, and collections efforts. That’s why it makes sense that the direct-pay price without all that bureaucracy and inefficiency should be equal to or lower than an insurance rate.

NOTE: Providers should still be allowed to negotiate a hardship discount between doctors and patients.

✅ End discrimination against cash-pay patients

Congress should ban the practice of turning away direct-pay patients, or otherwise discriminating against them, such as refusing to schedule, delaying an appointment, putting you at the back of the line, requiring you to use insurance if you have it, requiring you to submit claims to your insurance first, imposing any extra hoops or extra steps, simply because you (or someone paying on your behalf like your employer or a ministry) are willing to pay the posted direct-pay price.

✅ Establish a right to cut out the middleman between the buyers and sellers of care

Insurance contracts with health care providers (or employers) can no longer prohibit:

• Direct contracts with employers

• Direct contracts with health care sharing ministries

• Community-based arrangements between a local hospital that’s part of a giant conglomerate system and its surrounding community of employers or patients

• Lower-rate contracts outside insurance carriers

• New payment innovations that insurers historically block or control, such as subscription-based models or bonuses for achieving certain clinical outcomes.

Hospitals and doctors can finally say, “yes, we’ll give your business or your ministry a better deal than your insurer does.” Insurers lose their veto pen.

✅ Ban state “certificate of need” (CON) laws

CON laws are truly cons. They give state and local governments, as well as competitor incumbent hospitals, the power to ban new hospitals from being established in communities. These CON laws are anticompetitive clap-trap designed to protect predatory price-gougers from competition.

✅ Repeal the ACA’s ban on physician-owned hospitals

The Democrats who wrote the ACA thought that fat-cat MBA executives are somehow less self-interested than doctors would be when it comes to hospital revenue. This is crazy. Those of us trying to contract with doctors and hospitals on behalf of employers know that the very best facilities are the ones that are owned and run by the physicians who practice in them. They also happen to be the most willing to contract with employers, health care sharing ministries and cash-paying patients. I wonder why incumbent hospitals might not want that in their communities?

✅ Make PBMs and TPAs fiduciaries again

Middlemen often buy each other up to become bigger, grosser middlemen. This has happened with insurance companies buying up pharmacy benefit managers (PBMs) and vice versa. So then you have the situation where the profiteering gets even more opaque and harder for employers and other plan sponsors to see or avoid.

Insurance companies serving as third-party plan administrators (TPAs) might pretend to have low or transparent fees with their employer-clients. But they’re profiteering on the PBM side of the house and not telling you. They are driving up your costs and screwing you in more ways than a poor HR manager or even the best benefits advisor can suss out.

Worse, when employers do figure this out and then sue, too often they get told in court that these entities didn’t have to act as prudent fiduciaries — that was all on you, so too bad, keep paying them money to rape and pillage your workforce. These court cases have often been preempted in the first place by contract provisions forcing disputes into arbitration rather than the cold light of the court record.

It’s time to give guidance to courts who have been all over the place on this. Congress should set the record straight: make it clear that, when PBMs and TPAs exercise discretion that could help or harm plan beneficiaries, or when they act in their own interest rather than the plan’s, they’re fiduciaries and they can be sued like one. This will force the lawyers at these giant corporations to clean up their act and could bring sanity to the transactions and contracts that are bankrupting all Americans.

4. END SECRET HEALTH CARE PRICES

President Trump’s health care price transparency initiative, which we described in a previous article, required secret prices to be publicly available for the first time ever. Congress should enshrine those rules into law so that it’s harder for the industry special interests to undo them (they’re always trying!).

They should be beefed up even more, and enforcement penalties for noncompliance should be excruciating. Right now, penalties are basically a slap on a wrist or nominal fines.

What’s more, any purchaser of care – a patient, an employer, a union, or government program – should be provided the absolute right under the law to demand and receive all their claims data, every single raw data field, including the sticker price, the contracted rate (or the out-of-network allowable amount), the paid amount (including all extra fee shenanigans on top of contracted rates), rebates attributable to a given drug, and every single other data point associated with that claim.

This is essential so that the people that, you know, buy the stuff know what they’re paying so they can make sure they’re getting the best deal (SPOILER ALERT: they’re not!). Getting the best deal is actually required under the law for fiduciaries like employers but these middlemen are preventing them from complying.

More excruciating penalties should be imposed on any middleman holding claims data who does not turn it over within 24 business hours of the request.

I have had to get lawyers involved to get claims data out of these douche-bags for my employer-clients — and this protracted fight has taken — by design — months and months before the middlemen give in, and then they usually turn over garbage data, and well after it’s too late for the client to make the decision to fire them that year.

This chicanery should be illegal, immediately.

The Fifth Step of the Four-Step Plan

If you’ve made it this far, first of all, thank you for being a paid subscriber. Second, you obviously care deeply and so I’m going to ask you to, well… pray.

Health care is so personal, so intimate, so scary, so important. We have to get it right, and it’s so hard.

It’s a multi-trillion dollar industry, a fifth of the economy, and controlled by almost demonic forces profiteering off the suffering of the American people.

The expertise that’s necessary to understand it all is held by no one, nowhere, least of all in Washington.

So it’ll take divine intervention to redeem this industry and make health care great again.

Let’s bow our heads together.

I don’t want to be a patient in the U.S. health system. Ever. I’m not a fan, as any repeat reader will notice.

But all of us will be patients at some point. Many, if not most of us, already are.

Health care is a fraught issue, publicly, politically, personally.

As HHS Secretary Robert F. Kennedy Jr. has said, a healthy person has a thousand dreams for her life. A sick person only has one.

We have to get health reform right, period. We’re not there yet.

That’s why I still work on trying to fix the conventional “health” “care” system. It’s why I tried so hard, during long years in government, to make it incrementally better. It’s why I started working with employers to build health plans for their workers that are more human, less impoverishing, and less likely to lead to having the wrong knee replaced in the operating room.

It’s also why I’ve invested years running the Alliance of Health Care Sharing Ministries, in a fevered effort to protect people’s right to escape the insurance industry, if they want to.

The system comes for us all eventually, at some point. And if not us, then someone we dearly love.

It’s why this newsletter isn’t merely an escape-the-system manual, but also an improve-the-system manual.

And of course, it’s why I continue offering my former Republican colleagues unsolicited advice, derived from the PTSD and stripes on my back from years of trying (and often failing) to both improve the system and not lose elections.

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Yes, yes, I know what they’ll say: it was the Democrats who broke it with the not-so-Affordable, not-all-that-much-Care Act, and their policies are what drove up costs and government intervention and hooked tens of millions of Americans on government subsidies for their health coverage.

Got it. Stipulated.

But this isn’t about them. They’re not in charge.

This is an intervention for Republicans.

I say to my Republican colleagues what I say to my naturopath clients – if you’re focused on someone else as the source of your problems, you’ll never heal.

If Republicans keep blaming Democrats as the reason why they have to take stuff away from Americans — who very much feel they need that stuff — they’ll never win another election.

And let’s focus on our own responsibility here.

America didn’t kick us out of office and give both chambers of Congress and the presidency to Democrats in 2008 — who then passed Obamacare — because we had been doing such a bang-up job on health care.

I was there.

For most Americans under age 65, the most notable accomplishment delivered by Republicans before that was creating health savings accounts.

HSAs let you save for health expenses tax-free, but only a few thousand dollars a year (wiped out after the first overpriced MRI), and only if you have a stingy, high-deductible health plan with unaffordable out-of-pocket obligations.

I guess this was some sort of bribe to get you to buy crappy insurance that, if you get sick, will cost you way more than it’ll save you in taxes.

All to artificially prop up a market for crappy insurance that no one would otherwise want.

A note about Republican attachment to crappy insurance.

America, don’t hate us. There is a reason behind the madness. It’s not an excuse, but it is an explanation.

Republicans are convinced – not without economic reason – that insurance is unaffordable, in part, because people want too much of it – or the government wants too much of it on their behalf.

If everyone wants an iPhone, then Apple can charge $1,200 per, so the theory goes. So if governments would just stop demanding that insurance plans cover so darned much, then the prices would go down.

There is some truth to that. States that have the most mandates on what insurance must cover also have higher premiums, typically by a few percentage points.

Republicans are also not theoretically crazy to be pushing HSA+crappy-plan combos.

People with lower health costs (like under $5,000 or so per year) will break even or do better financially with a maxed-out HSA, coupled with a cheaper bronze plan.

Many people don’t know this and would prefer the gold plan, even if they’re generally healthy (of course, America is not generally healthy, but you get my point).

So, the problem is that nobody wants a bronze plan, where they have to max out an HSA, if they can afford a gold plan without an HSA.

One $10,000 ER visit could tip you over that break-even threshold and have you wishing you had a gold plan instead.

So while Republican economic theory might hold, voters aren’t buying what we’re selling.

Premiums are largely driven by the underlying prices of health care.

And prices are being inflated and distorted by value-sucking middlemen between the creators of value (doctors/hospitals) and the buyers of value (you and me).

The real villains: middlemen

Republicans used to love them some insurance companies. But the romance is over.

They are now rightly calling out the middlemen in this business as the reason why premiums are so unaffordable – insurance companies that act like Bond villains.

Middlemen don’t want price competition because it doesn’t benefit them, but of course, they’re the ones setting the prices with the doctors and hospitals and drug makers.

As long as you’re paying for health care indirectly – through your insurance plan and their contracts with price-gouging, profiteering hospitals – using the prices they negotiated with each other and not with you, you’re getting screwed.

Republicans told you that your high deductible health plan and HSA would make you a price-sensitive shopper that would drive price competition and lower costs for everyone.

In fact, the insurance contract with your doctor actually prohibits you from being charged any other price, even if you both agreed on one.

So HSAs and high deductible health plans don’t facilitate the kind of price competition that results in lower prices, the way Republicans said they would back in 2003 when they created HSAs.

What’s more, the value prop of health insurance was that these insurers could get volume discounts that we couldn’t have gotten on our own. But study after study shows – and now the Trump price transparency regulations reveal that:

Also, middlemen don’t have the same goals as you do.

You want to be healthy and pay less when you do get sick. They profit when you’re sick and pay more to treat that sickness. They have no financial interest in improving your sleep, teaching you how to eat like a human, the value of sunlight or purpose or emotional healing.

This is not a match made in heaven.

Ironically though, in our current system, even if there were no middlemen, the incentives are still whacked. Doctors and hospitals, like car mechanics, only get paid when things break down. Their business model, even without middlemen, only works if enough of us are sick.

As most of us have learned the hard way, even if doctors instinctively understand the things that keep our bodies working well – sleep, real food, contact with nature, spiritual connection, and so forth – they’re not taught these principles in medical school. They might finger-wag a bit about your weight or stress, but they have no experience or expertise in how to practically support you in taking on those problems successfully – a process that is simple but by no means easy.

Health insurance fails spectacularly to either keep us healthy or to obtain lower prices for us than we could get without it.

In Part 2, I answer that question.

Read Part 2: The Prescription

Last week I shared three moments that should have told me our 2017 Obamacare repeal-and-replace effort was doomed:

• The Diet Coke button,

• Jared Kushner’s “this is bullshit” moment, and

• Panicky faces in the White House communications office.

[If you missed it catch it here.]

This week: what happened when we ignored all those warning signs.

So, once the bill had been introduced, Speaker Paul Ryan and the White House team were working hard to whip enough votes to pass it.

Democrats were slamming our guys with accusations of weakening protections for people with pre-existing conditions, including pregnant women. These assertions were somewhat unfair at best, and misleading demagoguery at worst, but I guess I would have done the same in their place.

We decided to buy the support of moderate Republicans - usually in unsafe, swing districts - by coughing up some sweeteners: $15 billion for people with pre-existing conditions, $45 billion to fight opioid addiction, and so forth.

When the fiscal conservatives – usually in safe, red districts – got wind of these inducements, they got jealous and insisted on some of their own priorities. These amendments made it into the bill as well and generally meant reducing requirements on ACA plans so as to make them more affordable.

And what happens when Republicans try to give America a big, fat federal program, but just a little less big and less fat than the Democrat version?

They lose elections, that’s what.

Which brings me to the last teaching moment from this dark episode of the first Trump term.

The Cabinet Room

Moderate Republicans were getting very nervous in advance of the House vote. Did I mention they were in unsafe, swingy districts?

Between the sweeteners thrown in for them, and the un-sweeteners thrown in for their conservative colleagues, the bill had become a Frankensteinian mess.

Our poor comms team was pretty much beside themselves.

So, the president did what only he can do. He summoned all the mods to the White House Cabinet Room and put the hard sell on.

He asked them politely for their vote. He didn’t try to sell them on the policy (how could he?).

He just used the power of the office to insist.

He went around the room, one by one, looking everyone in the eye and asking if they would be with him on the vote. My recollection is that every single one of them said some form of “you can count on me, Mr. President.”

Regardless of what they said that day, they all knew their districts well. The bill passed the House by only three votes, with 20 Republicans voting no.

The Rose Garden

After the vote, totally spontaneously, a bus was waiting outside the Capitol to shuttle a bunch of House Republicans over to the White House for a totally spontaneous victory lap — with totally spontaneous hors d’hoevres, and members of Congress lined up for exuberant one-on-one photos with the president to commemorate the occasion.

Then they all went out to the Rose Garden and staged a totally spontaneous public chest-beating, congratulating themselves on saving the American people from, well, a little more Obamacare than the Obamacare-lite in the bill.

Sitting in the totally spontaneously-arranged second row of the Rose Garden, I too shared their relief, after a lot of nail-biting. While simultaneously worrying about the Senate.

Which turned out to be a reasonable concern.

Still, I was surprised by Senator John McCain’s downturned thumb, the lethal third no vote in the Senate. There would actually end up being seven, but McCain gave permission to the subsequent four.

Frankenstein was taken out back and shot in the head.

I think I thought the power of the president’s personality and the momentum of House passage made Senate passage a surer thing that it geared up to be. It’s like I had forgotten every maddening lesson I’d ever learned about the upper chamber in my fifteen years, on-and-off, of working there.

Senators on both sides of the aisle are shrewd politicians who know their states. Even the Republicans in red states have to win in the face of viciously hostile local media, so they know what it takes.

Those seven no votes might just have saved the Senate majority.

The House wasn’t so lucky.

The Reckoning

The president demanded that House Republicans stick together and pass the bill. A year later, we lost the House in the mid-terms.

More than half of the 30 or so moderates who lost their seats had voted yes on the bill. More than half of all political ads that cycle were about health care. The party was so damaged reputationally that even moderates who voted no were bloodied up by the issue and lost anyway.

It didn’t help one bit that, right before the midterms, we doubled down on failure.

Texas was suing DOJ to bring down the pre-existing conditions protections in Obamacare, using a cute legal gimmick related to the tax package that had passed earlier in the year.

The question for the president was whether DOJ was going to defend the law in the case (which was their job, technically, but still awkward). The fiscal hawks – not the health team, notably – inside the administration argued that the conservative judge in the case was going to hand us a victory, and all we needed to do was nothing.

To be totally fair to this view – these were not evil people.

They wanted to take the mandates out of Obamacare plans that were making them unaffordable. They were just politically inept.

The sane caucus (which included my boss and DOJ) argued that the 5th Circuit would overturn the district judge and, if they didn’t, the Supreme Court would. The whole mess would extend the carnage we were already anticipating in the midterms into the 2024 re-elect, and we wouldn’t even get the policy in the end.

Which is exactly what happened when the fiscal hawks won the argument.

Why I’m Telling You This Now

If you’ve stuck with me this long, you’re either a devoted history buff, or you’ve got an inkling of where all this is going.

I’m panicking a little as I watch Team GOP go off the same Obamacare cliff, now eight years later. There’s been a ton of staff churn on the Hill. I can’t think of a single GOP staffer who is there now who went through the first go-round.

Not everyone from the first Trump health team would agree with my recommendations below. After all, there were a good number of street-fights among us. But most of us had way more in common than not, and really wanted to make health care great again.

So in that spirit, I offer the following painfully-acquired learnings to the next generation in Congress and the administration tasked with the Obamacare redux:

1. Don’t scare the voters. Americans know their insurance is garbage. They’ll tell you so at every town hall. But that doesn’t mean they don’t want as much of it as they can get. Health care prices are so high that the idea of facing a medical crisis without even garbage insurance is understandably terrifying. Fear is a powerful political force. If you get painted as the face of that fear, you will lose.

2. Understand where the political risk really lies: When compromises are needed to get to a winning vote – and, with a two or three-vote majority in the House, there will be a LOT of compromise – it must be the conservatives in safe seats who sacrifice their priorities more than the moderates in swing seats. Those moderates are the ones who’ll lose their jobs if this goes sideways. And then you lose your majority anyway.

3. Remember Reagan’s maxim: The closest thing to eternal life on earth is a government program. Voters always pick Santa Claus over the Grinch. Don’t get in an arms race with Democrats over who gives away the most government cheese, by offering less cheese and then trying to say you didn’t. They’ll win.

4. Stop letting the 20-million-person Obamacare program suck up all the oxygen. Rather than trying to eat away at the margins of Obamacare, focus on what you can do for the long-forgotten 160 million Americans covered by the rest of the commercial market. If you can lower their premiums, you’ll help the 20 million in Obamacare too.

5. It’s the prices, not the premiums. Focus on driving down what gets charged by the sellers of care. Only then will less insurance be politically acceptable to the buyers of care.

6. Define the right villain. Republicans too often demonize the government program that voters view as their safety net. But there are better villains to focus on, like the big, bad Bond villains in the health care industry driving up everyone’s costs. The president has already intuited this with his social media rants about taking money away from the insurers and giving it to the people. Follow his lead.

7. If you can’t say it in one simple phrase, you can’t legislate it:

   “End secret prices.”

   “School choice for health care.”

   “Cut out the middlemen.”

   “No tax on health care.”

   “Give the money to people, not Big Insurance.”

   “Make tax-exempt hospitals charitable again.”

   “Sell drugs cheap at TrumpRx.”

   “End surprise out-of-network billing.”

   “No more foreign free-riding on drug prices at America’s expense.”

A final note to my friends in the fiscal hawk community: Don’t take a dollar away from anyone who has that dollar now. Consider those dollars sunk costs of losing past elections. Instead, use them to buy the ROI of big policy reforms that lower costs for everyone.

And of course, never forget: If you’re explaining, you’re losing.

[We interrupt our previously scheduled series on ending secret prices in health care to bring you breaking news: Republicans Are About to Blow it Again on Obamacare.]

It was my first time in the Oval Office. I mean, with the president. I had once been given an after-hours tour with my family during the second Bush administration as a favor by my sweet friend whose unfortunate White House job was to “liaise” with (i.e. babysit) Senate health staffers.

It was just me in there with my boss, the head of the Domestic Policy Council (a brilliant, hilarious, passionate and ethical friend, who later became the U.S. ambassador to wherever and left me in the middle of the price transparency fight).

We were a few days into the new administration, January 2017, and health care was up at bat in the first inning.

Spoiler alert: Mistake #1. (Don’t do the hardest stuff first like health care – get some easy wins before you risk losing).

My boss reminded the president who I was (the health care girl on his team). The president, ever the charmer, was flattering and claimed that he’d been told (“many people are saying”) how amazing I was. This was definitely not true (neither how amazing I was, nor that he’d been told so by anyone), but it was adorable how he tried to make people feel like a million bucks.

I was literally frozen and could barely speak. The past few days had been surreal.

I was a jaded former Hill staffer who had been in DC for almost twenty years at that point. It was quite hard to impress me with famous people or fancy buildings. But everything about that first week in the White House felt like I had landed on the moon.

On inauguration day, a little white bus drove the new Domestic Policy Council - about a half-dozen of us - over from the federal building a few blocks from the White House where the transition team had been holed up since the election.

As we went through a series of imposing gates groaning loudly as they opened, guarded by bomb-sniffing dogs and U.S. Secret Service inspections, the 18-acre complex unfolded before us.

We didn’t have any furniture or supplies. Although our boss, along with the heads of the NEC and NSC, worked in the West Wing – about the size of my Capitol Hill townhouse – the rest of us had managed to box out the speechwriters and scored the absolute best suite on the first floor of the Old Executive Office building, facing the West Wing. This was conveniently close to the entrance so that we could run back and forth between the two, fifty times a day (for all those very, very important meetings… well, and also, the 24/7, unlimited Diet Coke supply on the first floor).

I had picked out an office and could not believe my view.

So all that to say, I was exhausted, starstruck, and uncharacteristically tongue-tied, as I sat in front of the president at the Resolute Desk for the first time, about to brief him on the doomed Obamacare plan.

We began.

Thirty seconds later, he interrupted and said “you guys want to see something amazing?”

I very much did want to see something amazing.

He leaned over his desk with the excited expression of a 10-year old boy and, with his pointed index finger, pushed a big button on a little wooden box next to his phone.

We froze and waited. About five seconds later, a steward from the U.S. Navy came in and asked if we’d like anything to drink. The president said “you guys want a Diet Coke?”

I very much did want a Diet Coke.

But I demurred, because being served a Diet Coke – literally on a silver platter – by a member of the Armed Forces seemed decadent and weird (I eventually got less rattled by this as they serve at all the events and receptions on campus, but still). Also, we needed to get back to health care, since you never know how much time you’ll get in the Oval.

As we prepared to continue, the president interrupted us again.

“You wanna do it again?”

And again, the finger to the button, and the Navy steward coming in with the Diet Coke.

After he left, the president leaned in close and lowered his voice like he was letting us in on a secret.

“Can you believe this?” He whispered, incredulous. “Now, I’ve been in magnificent places, like the most beautiful and magnificent places. But this place is unbelievable! No wonder everybody wants this job!”

In other words, he was having the exact same reaction to being in the White House as I was.

And he shared my Diet Coke addiction.

I thought I loved the guy before, but this really sealed the deal.

We got about one or two more minutes of health care briefing before the NEC director and a couple others wandered in and started chit-chatting. He asked everyone if we wanted to take this party to the attached Map Room where the TV was and “watch Spicer.”

Yes, it was time for the daily press briefing by Press Secretary Sean Spicer, and the president loved seeing Sean mix it up with the hostiles.

We all sat around a conference table in the Map Room – of blue dress fame – and watched TV (a Samsung, reminding the president of the South Korean trade relationship, which diverted the conversation for a while).

And so it went for another hour or so and we never got back to health care.

That should have been my first clue.

Donald Trump, although extraordinary, is also totally normal in many ways.

And health policy makes normal people’s eyes glaze over. It’s way too convoluted and, when forced to focus on it, most people just get depressed and angry. Since the president doesn’t do depressed and angry, his cope was to change the subject.

It should have been a flashing red alert: “Danger! Danger! Voters will hate you for making them think about this!”

Understandably, they just want you to make it cheaper, like right now, and if you don’t, they’ll let you have it at the ballot box.

As the Reagan people used to say, “if you’re explaining, you’re losing.”

The second clue came a month later, at Mar-a-Lago

HHS Secretary Tom Price, MD, former US House Budget chairman – a lovely and affable man – got pushed out of office only a year in. The excuse was presumably because he flew too much on a government plane. This always seemed like a peccadillo that wouldn’t have taken anyone else out (at least not in a different administration). My theory is that he was the fall guy for our collective failure to get health care reform done. The president never got over it.

Anyway, speaking of that government plane…

The Secretary was summoned to Mar-a-Lago to have a health care meeting with the president and some of his top strategy advisors.

That meant I was summoned with him and we all jetted down on the (admittedly nice) plane, and took in the bright sun and gilded decor of the president’s over-the-top-beautiful coastal home.

At least for the five minutes we had to enjoy it going from the car to the meeting room and back.

Inside the ballroom, usually used for wedding receptions, were about a dozen people, including, if my memory serves, Stephen Miller, Jared Kushner — the president’s son-in-law, and Steve Bannon, lurking silently in the back of the room, as he customarily did.

They eagerly awaited the unveiling of the product of years of Congressional wrangling, conservative think-tanking and campaign promise-making.

The Secretary launched into the complex repeal-and-replace plan, replete with acronyms, formulas, pay-fors and a bunch of other voodoo that fewer than two dozen people in Washington probably understood (not always clear if I was one of them, to be honest).

Immediately, the barrage of questions came. There was a robust discussion, and Secretary Price, unlike most principals at his level, was knowledgeable enough to answer questions without needing anyone else. But still, he got flustered as the political peril of the whole enterprise was exposed by the discussion.

You see, the “replace” bucket in all Republican proposals over the years – including this one – was never quite as generous as what was in the “repeal” bucket. By design.

So, it wasn’t going well.

Again, normal people get depressed and angry when you make them focus on health policy. The president changed the subject. Jared stormed out of the room.

I don’t remember much else from that meeting. Jared’s understandable response to our hocus-pocus is seared in my memory as one of the defining moments of the entire repeal-and-replace process.

Probably because his one-word evaluation of the bill would be shared by the midterm voters.

If you’re explaining, you’re losing.

The third clue came from the White House communications team

We continued working with Congress on the bill, and the draft was repeatedly leaked, in every iteration, along the way.

As such, Democrats and the media (but I repeat myself) were in full attack mode.

The White House communications team, led by the heroic Sarah Huckabee Sanders (now Arkansas Governor, but who had then replaced Sean Spicer as Press Secretary), was treading water.

Because we hadn’t actually released the bill formally, no one had any communications products that are typically prepared to support a planned roll-out. So Sarah’s team was scrambling to respond to the hostile incoming without yet understanding all the details.

Eventually, though, they needed some reinforcements.

I was summoned to one of the regular meetings of a few dozen comms staffers in Sarah’s office. My charge was to explain to everyone what the bill did and why all the attacks were untrue or unfair.

I spent an hour in that interrogation, while the comms team kicked the tires on my messaging.

At the end of the hour, I had fast-talked my way through a zillion questions but the looks of continued confusion on the faces in the room are still as clear now as if it was yesterday.

This dog wouldn’t hunt. They knew it and they were starting to panic.

I realized it just took too many words, caveats, qualifiers, statistics, legal citations, and jargon to describe what the hell we were trying to do and why America was gonna love it.

If you’re explaining, you’re losing.

And I do mean losing.

That’s one of the reasons why I eventually fell in love with price transparency and other more populist reforms taking on the Bond villains in the health care industry.

It wasn’t over yet.

Next week: What happened when we ignored all these warning signs and pushed the bill through anyway.

Spoiler alert: We lost the House. And the argument.

Remember how my last post somewhat brashly asserted that the Trump price transparency policy — taking on secret prices in health care — was already working better than expected?

I know what some of you were thinking — especially those of you who work in the health care space.

Fair enough! That’s certainly what everyone said would happen back in the day when we were fighting with industry, academics, and yes, my naysaying colleagues in the first Trump administration.

Why Hospitals Said Price Transparency Would Crash Their Websites (LOL)

The hospitals, like many others, argued that price information was all SO darned complex that:

• It would be impossible to decipher even if it were public,

• If deciphered, it would be impossible to use, and

• If decipherable and usable, patients trapped in garbage insurance plans wouldn’t have the incentives to “shop” on price.

The hospitals caterwauled that they had so many different prices that the amount of data would literally crash their websites.

Because… insurers. Or something.

My initial response was:

Yes, pricing is complex, conveniently so. The incumbent actors (hospitals, insurers, and drug makers) weaponize pricing complexity against purchasers because it serves their bottom line to do so.

I argued that price transparency would one day expose this weapon for what it is and demand would begin to arise for the Holy Grail so many of us have been chasing in health policy: pricing SIMPLICITY.

The Real Audience Wasn’t Patients

The demand for pricing simplicity — a single, knowable-in-advance price for something, no matter who’s paying — wouldn’t come from patients shopping.

Patients are trapped in their aforementioned garbage insurance plans, which aren’t set up to reward price sensitivity.

The truth is: patients were never the real audience for transparent prices — at least not at first.

Pricing simplicity is a big and important goal, but it’s not sufficient. Markets need consumers who have the ability to pursue lower cost and higher quality.

You can have price simplicity, of course, in some situations.

Like Dr. Keith Smith’s Surgery Center of Oklahoma, where there’s one low, all-in cash price for each procedure, no matter who’s paying.

That’s pricing simplicity, par excellence.

But the problem is that the only consumers interested right now in that simple price is an individual consumer in the cash economy:

• Someone who has a health savings account and an exceptionally high deductible (higher than the cost of a surgery),

• A member of a health care sharing ministry that requires self-pay upfront before receiving financial support from the community afterwards, or

• A mogul, who can afford to pay cash for everything and risk being uninsured.

Apart from a small group of innovative employers (like my clients, just sayin’) working with physician-owned surgery centers, Dr. Smith’s solution isn’t scalable to all health care providers everywhere (yet), because most patients don’t fall in those categories.

Three Podcasts, Three Reasons To Smile

And that’s why I smiled at a few recent episodes of my favorite podcasts.

On the first one, An Arm and a Leg, host Dan Weissmann’s guest, the incomparable Dr. Vivian Ho of Rice University, laid out her research about how price transparency has exposed something — we have no way of knowing whether the prices posted are what are actually being charged.

In other words, the vendors, startups and employers who are trying to make use of the complex pricing data might not be getting the most actionable information to drive financial performance.

So what’s so great about that news? Two things:

1. People are starting to try to use the price information to do important things. And they’re having trouble because the data aren’t good enough.

2. It’s getting them mad. The hide-the-ball reindeer games that hospitals and insurers play — while pretending to comply with price transparency rules — are exposing just how much these special interests must have to hide.

Price transparency rules, even when badly complied with, are generating demand for price information, and anger when it’s not available.

The second podcast that made me smile was Relentless Health Value, where host Stacey Richter’s guests Dr. Sam Flanders and Shane Cerone laid out the problem: they took over a hospital and decided to make it great again. They brought the quality scores up from the basement to A+, and they restructured pricing to be more than 50 percent lower than what most hospitals charge. And then they waited for the stampede of patients, employers, insurers and other purchasers of care to come.

And they waited some more.

Weird, right?

I mean, markets reward lower prices and higher quality. I was reliably informed by all my free-marketeer colleagues inside the Trump administration that The Market™ was so amazing that it must not be micromanaged with silly price transparency rules.

I argued back: “there is no market in health care.”

To repeat louder for the back of the room:

Not only do we not have easily knowable-in-advance and accurate prices, but what the podcast guests described so well is that markets also require consumers who are both:

• Interested in, and

• Able to respond to price and quality.

What Dr. Flanders and Mr. Cerone explained is that insurers are able to respond but not interested (hurts their bottom line, counterintuitively).

And insured people might be interested, depending on the structure of their cost-sharing obligations, but they’re not (usually) able to respond collectively enough to lower prices at scale, since they don’t make the decisions about which providers to include in their plan’s network and what to pay them.

Uninsured rich people might be both interested and able to respond to price information, but there aren’t enough of them to move the needle.

Here’s some math for the STEM crowd:

Why This is Actually Good News (I Know, Weird)

So, again, why is this good news?

Because people have started to notice.

Not just wild-eyed Trump staffers in 2018 with theories about what a market is.

But lots of podcasters, hospital executives, health policy influencers and, most importantly, bulk purchasers such as employers, unions, governments and health care sharing ministries.

These are the only potential actors out there who are both interested in and able to respond to pricing information if they have it.

Until now, they haven’t been consumers of health care.

They’ve only been consumers of health insurance, quaintly assuming that health insurance was the way — the only way — to get lower cost health care.

And now, price transparency has exposed just how wrong they were — in the best way.

The third podcast that made me grin ear-to-ear was another Relentless Health Value episode featuring Elizabeth Mitchell. Elizabeth is helping jumbo employers — the bulkiest of bulk purchasers — use price transparency data combined with safety and quality data to shame their brokers and carriers, hopefully resulting in both being fired en masse.

They’ve realized they’ve been lied to. For decades.

The Holier Grail: When Bulk Purchasers Finally See the Scam

And that, my financially exploited friends, is the Holier Grail: getting bulk purchasers out of the market for health insurance because they can finally see how it fails them:

1. They pay more with insurance than without it (i.e. cash).

2. The network price at one hospital is often multiples more expensive than at the hospital down the street, for no discernible reason. Worse, employers’ contracts with their insurer bans them from doing anything about it (like steering patients away with plan design or negotiating their own, better contract with that hospital).

3. Network prices are usually all equally bad, net-net. Blue Cross is better at one hospital, United is better at the one down the street. But the variation is not systematic and it’s all a wash in the end, almost as if these networks were colluding to ensure that there was no meaningful price competition.

The prices are set by secret contracts between hospitals and insurers that they’re not party to, but which bind them and their workers, who bear the dire financial and medical consequences.

They recognize that insurers are just using them as dupes in a corrupt scheme to profiteer and prey upon the sickness of the American people and the asymmetry of knowledge between the sellers of insurance and the buyers of insurance.

When they finally see all this, they get mad enough to try some crazy ideas.

A subsequent article will outline what some of those crazy ideas should be (an even HOLIER Grail and eventually the Holiest Grail of all) and what it would take to really get there.

Price transparency was never intended to be the wholesale solution to a missing health care market.

It may not be the end of insurance and its fraudulent promise to get health care to people at lower cost, but it’s a long overdue beginning of the end.

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P.S. After you subscribe, come find me in the comments. I want to hear your price transparency horror stories. Or victory laps. Both are welcome here.

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And here are the links to the excellent podcast episodes referenced above:

1. An Arm and a Leg- DanWeissmann and guest Dr. Vivian Ho of Rice University.

2. Relentless Health Value - Stacey Richter and guests Dr. Sam Flanders & Shane Cerone.

3. Relentless Health Value Stacey Richter and guest Elizabeth Mitchell.

Price transparency is working. Not how most people expected. Better actually.

But I’ll have much more to say about that soon.

In the meantime, let me explain how it all kicked off with this price transparency business.

Back in the day, there were only a few supporters for ending secret health care prices inside the first Trump administration.

And I mean a VERY few (like count-on-one-hand few).

My first boss in the White House, and his boss, the president, were all in on price transparency.

They knew it was a bipartisan, 90 percent polling issue (that’s what we call #winning in politics). It also happened to be the right policy for reasons I’ll get to below. But, as it happens, my first boss abandoned me to become a fancy ambassador to… somewhere. Wherever. Not in the White House, having my back.

His successor, unfortunately, insisted that I convince a group of naysayers from various quarters within the building and from other agencies.

That group included a handful of free-marketeer bros with PhDs in economics, who looked pretty askance at this non-PhD, non-economist, must-be-a-lib chick. I had already earned their scorn the prior year by hand-wringing about the mid-term politics of trying to burn down the ACA.

We met weekly to discuss the academic literature about whether or not health care was the unicorn industry that would disprove the normally ironclad rule of economics: price competition lowers prices.

It felt silly — like trying to convince physicists that gravity is a thing.

Nevertheless, apparently this was controversial and the meetings dragged on, with the clock ticking loudly on the president’s term (little did we know just how short the window would be, with COVID-apalooza about to eat all other policy agendas).

I realized that something had to give, because I was outnumbered and the policy was stalling out.

Political appointees at the Department of Health and Human Services (HHS) had written a memo about why a price transparency Executive Order was crazy-talk.

Since my supportive boss left, the policy was on life support.

There was also this one study that kept coming up in the journal club and of course, in the hostile media, such as the Pharma-shilling Wall Street Journal. It was a study of the Danish cement industry — yes, Danish cement — that showed that when the government forced price transparency into the industry, prices for cement actually went up.

My allies on the Senate committee that oversees public health were so annoyed by the repeated and desperate citing of the stupid Danish cement canard that they had t-shirts made and sent one over to me, their sister in eye-rolling.

Given the aforementioned New, Less-Supportive Boss (NLSB), I knew my time was not much longer in the White House and things had to get rolling on this Executive Order. Despite the navel-gazing journal club and the WSJ industry shillery, I already knew the president loved the policy, and decided to make an end-run to get it into the State of the Union speech.

My thinking was that his word would be final and would put an end to the palace intrigue.

I managed to get a few paragraphs inserted into the draft a few days before the speech, announcing the policy, and arranged for an amazing guest to be acknowledged during the speech.

Her name was Wanda Brooks.

Wanda was a nursing home employee whose surprise $8,000 ER bill at Mary Washington Hospital in Fredericksburg, Va, had become a case study in predatory hospital billing. Wanda’s story was brought to my attention by Dr. Marty Makary (then Johns Hopkins surgeon and policy researcher and now FDA Commissioner).

Unfortunately, the next draft of the speech that I saw had stripped all the price transparency stuff out — likely the work of the NLSB and the aforementioned economist caucus (I’m guessing, anyway).

Game on.

At that point, I put out the bat-signal for Cynthia Fisher.

Side-note about Cynthia Fisher, the zillionaire owner of Boston Beer Company, health care CEO, and fearless transparency advocate. Cynthia was the one who actually got me to take price transparency off the To-Do-At-Some-Point list and onto the Do-Right-Now list. Knowing how hard it was to get frenzied, over-scheduled staff to take a meeting, she played hard-ball. She brought my former boss, the incomparable Senator Tom Coburn, MD, then-retired but still feisty, to the party, knowing there was no way I’d be able to say no to him. When I worked for him, we had bickered like an old married couple, but the mutual affection and loyalty was unbreakable.

I spent the first half of the meeting doing what all staff always do in every meeting - I mentally rehearsed how I’d say no to the ask. The perennial problem of having way too much on our plate means we almost always say no to even the best ideas.

Then, halfway through the meeting, some switch inside my head flipped, and I said to myself: “You know this is the right thing to do. Why don’t you stop saying no and figure out how to get to a yes?”

And we were off to the races. Cynthia was and is a force of nature.

Cross her and she will bombard your email, your constituents, and the billboards in your Congressional district with compelling pro-transparency advertising, replete with Hollywood A-listers and heartbreaking stories from patients done dirty by surprise medical bills.

She never gave up — to this day — and she often seemed to have the president on speed-dial. She was FAFO before FAFO was a thing, and always with a winsome smile.

After HHS sent their price-transparency-is-stupid memo over to the White House, Cynthia found herself invited to an intimate dinner for business leaders with the president. When her turn to speak came up, she went all in on ending secret health care prices. The president, as we knew he would, loved it and told his team to get it done. Gladly! (What an amazing idea!)

So that’s why, months later, when I saw that my detailed take-down of secret health care prices and my call-out to Wanda had been stripped from the speech draft, I pulled out all the stops — Cynthia was my first call. I knew that her rolodex was more powerful than mine.

For my own part, I ran around the West Wing, cozying up to the more politically savvy types who understood the populist appeal of ending secret health care prices, like Kellyanne Conway and Mercedes Schlapp.

The speechwriters were holed up with the president, inaccessible to my harassment. So I pleaded with Derek Lyons, who wielded incredible power as Staff Secretary, possibly the littlest-known, most powerful role in the White House. The Staff Secretary’s office controls the flow of paper (including speeches) in the building and synthesizes all the edits everyone makes to that paper before it goes to the president or the public.

If Derek was persuaded, he could put his thumb on the scale in the draft.

Meanwhile, the New, Less Supportive Boss kept walking by these offices I was in (the building is much smaller than most people realize). He would do a double-take as he saw me, probably wondering what I was up to.

I waved and pretended to be casually chit-chatting.

There was no callout to Wanda and no fiery diatribe about the Health Care Swamp — but it was enough.

I knew that ONE sentence by the president of the United States would be powerful enough to move mountains, and would put an end to (at least the overt) internal opposition to price transparency going forward.

Not for nothing, a grateful nation should truly honor Cynthia for her heroic efforts, along with Dr. Marty Makary.

Marty’s book, The Price We Pay, is a classic for anyone learning the basics of health insurance and its actual impact on real people, the perverse incentives it creates and potential hacks of the corrupt system.

I sent all the naysaying political appointees around the government a copy of the book, which laid out — in the plainest English — the problems in our current insurance system — the so-called ‘free market’ that Republicans thought existed, but didn’t.

A lot of their attitudes softened toward price transparency and the rest of the president’s populist health agenda after that.

As I had predicted, the president’s speech mention was the jet fuel the policy needed.

I eventually left the White House later that year, and to their everlasting credit, the colleagues I left behind, including the previous naysayers, were the ones who pulled price transparency over the finish line.

Policy, like politics, is a team sport.

We did it.

You’re welcome, America.

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