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

Hmmm.

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

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

Here’s the 411.

Bottom Line

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

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

Definitions, in Plain English

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

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

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

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

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

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

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

What Happened

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

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

What the Hell Is the Window?

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

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

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

Why Scentsy Was Mad

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

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

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

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

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

Read more

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

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

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

Dear Dr. Oz:

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

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

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

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

What The 340B Fracas is All About

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

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

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

What CMS Has Proposed, and Why

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

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

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

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

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

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

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

Not for Medicare.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Good.

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

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

Finalize It

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

Specifically, I’d urge CMS to:

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

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

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

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

Respectfully submitted,

Katy Talento, ND, ScM

CEO, AllBetter Health

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

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

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

You guys. This is a good one.

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

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

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

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

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

Most doctors don’t even think so.

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

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

Cliff’s Notes on the Suit

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

So CPT is, functionally, the law.

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

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

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

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

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

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

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

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

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

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

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

The cartel takes any threats to its racket seriously.

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

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

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

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

Same playbook, hospital edition.

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

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

It doesn’t have to work this way

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

Also, completely free.

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

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

One Final Argument

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

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

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

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

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

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

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

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

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

Why This Costs You

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

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

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

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

You don’t hate these two groups enough.

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

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

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

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

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

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

Congress is Coming for Your Health Plan

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

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

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

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

Where Do We Even Start?

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

Oh wait…

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

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

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

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

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

What Coverage Actually Buys

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

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

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

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

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

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

Motherless and Fatherless By Design

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

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

The Egg Market

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

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

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

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

The Sperm Market

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

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

Surrogacy and the Farms

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

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

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

Thailand banned commercial surrogacy for foreign clients that same year.

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

Nobody Checks Who’s Buying

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

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

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

Legal quagmires, even for the normal couples

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

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

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

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

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

Whose Money, Whose Conscience

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

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

The Employer Checklist

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

Who gets the benefit?

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

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

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

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

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

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

Third parties

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

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

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

Embryos

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

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

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

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

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

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

Procedure coverage

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

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

Conscientious objectors

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

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

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

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

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

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

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

Back to the Question

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

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

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

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

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

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

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

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

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

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

Ask me how I know

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

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

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

Herding cats doesn’t begin to cover it.

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

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

So, What Actually Is a Health Care Sharing Ministry?

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

Not “insure.” Help pay.

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

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

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

Congress weighed in

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

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

That last part is the whole ballgame, legally speaking.

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

Can This Actually Get Me Out of My ACA Premium?

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

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

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

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

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

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

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

This may sound risky to those outside the fold.

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

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

Which brings us to the actual point of this article.

The Four Kinds of Sharing (Not All Involve Jesus)

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

Jesus in Action

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

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

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

Jesus-Adjacent

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

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

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

Jesus, Inc.

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

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

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

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

Jesus Front Groups

And then there’s outright fraud.

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

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

So How Do You Tell the Difference?

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

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

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

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

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

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

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

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

What are the Blaring Red Flags?

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

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

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

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

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

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

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

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

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

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

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

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

I Want to Offer This for My Employees!

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

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

Being Different is Worth It

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

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

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

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

So yeah, I believe in this model.

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

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

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

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

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

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

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

So I washed out. The breakup was entirely amicable.

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

What I never managed to escape was their health plan.

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

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

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

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

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

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

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

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

We Fired Everybody

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

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

No matter.

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

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

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

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

Gob-Smacking

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

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

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

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

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

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

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

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

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

It Wasn’t Easy

This hasn’t been a cake-walk.

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

That’s the easier problem.

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

We’ve had our horror stories.

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

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

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

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

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

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

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

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

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

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

Hospital Charity Programs Can Work for Your Employer Plan Too

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

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

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

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

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

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

What Does All This Mean for Me?

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

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

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

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

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

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

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

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

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

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

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

And every bit counts.

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

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

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

Be the change!

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

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

It was my first year on the Domestic Policy Council (DPC), and we ran the smoothest, most harmonious policy process of my entire career.

Every single agency with a stake in the outcome - and there were an absurd number of them - agreed. Completely. Unanimously. With no disputes to escalate, no fights to referee, nobody storming into a room to announce “this is bullshit” (that’s a different story).

It was about marijuana. And it went absolutely nowhere.

Some Background

A little Senate enthusiasm for legalizing marijuana was bubbling up in early 2017, and the White House Office of National Drug Control Policy (ONDCP) came looking for direction. What’s the president’s position?

I wasn’t aware he had one, and I didn’t have one to hand him either - which, if you know me, is… unusual. I show up to a policy meeting with a clear agenda and limited patience for dissent. But on the question of weed, I genuinely saw both sides. (That was then. Soon after, my kids became teenagers and my usual dogmatism came roaring back.)

So I asked the obvious question: what does the data say?

Nothing. We didn’t have any. ONDCP told me, kind of sheepishly, that Obama’s team had ordered federal agencies to stop collecting data on marijuana’s health effects. There was no current science on an increasingly popular drug. Super.

With nothing but vibes to work from, I convened a Policy Coordinating Committee and invited everyone with an “equity” in the outcome (White House lingo for a reason to care and the standing to make your life difficult if you leave them out).

I expected Health and Human Services (HHS) to have thoughts, and Department of Education. I did not expect nearly every agency in the federal government to raise its hand with a marijuana problem I’d never heard about.

State showed up to warn that going soft on marijuana would violate the international narcotics treaty - we were, in their words, “the last country holding the whole thing together.” Is that what you want, Katy? No. I hadn’t previously considered that legalizing a plant might unravel international law.

Treasury arrived with a story about Suspicious Activity Reports - paperwork banks must keep filing, every 90 days, for any account tied to the illegal drug trade. Since, it’s still federally illegal to sell cannabis, regardless of what Colorado said, that now meant that the HVAC guy in Oregon who services a dispensary, or the janitorial company that cleans one, get tagged as colluding with cartels. Banks were just closing their accounts instead of doing the filings. What do you want us to do, Katy?

Interior had cartels running illegal weed grows inside national parks - guys with Uzis, occasionally shooting a hiker who stumbled onto them. Clear them out and risk a shootout? Burn the crops? Airdrop pesticides on them? Fish and Wildlife, meanwhile, wants to know who’s cleaning up the pesticide runoff those same grows dump into the water table. I did not have strong opinions on any of it, but setting fires or dumping toxins in national parks didn’t seem awesome.

Customs and Border Patrol pointed out that hemp and marijuana are genetically the same plant, one just bred with less THC - so if the Senate legalized hemp (Senate Majority Leader McConnell was pushing hard for his state’s farmers), every truck carrying the plant over the border would need stopping and testing to prove it wasn’t carrying the illegal version. Congress solving one problem was about to hand CBP a much bigger one.

Transportation, which sets drug testing standards for bus drivers nationwide, wanted to know whether Colorado’s late-night party-bus drivers should get a pass for testing positive off insane amounts of secondhand smoke, or keep the current standard - screwing up non-using drivers’ records.

And then there was National Institutes of Health (NIH), which runs the sole government-sanctioned research weed farm in America, at Ole Miss. It’s the only legal source of marijuana for researchers in the country, and the product is derived from the weed on the street in the 1970s, so weak and outdated compared to what’s on the street today that studying it is basically studying a different drug. Worse, the hoops to get any of it are so brutal most researchers gave up, which is part of why we still didn’t have great data.

The hits kept coming, a dozen agencies deep.

And Then, a Miracle

We took all these normally warring fiefdoms - DEA, FDA, CDC, NIH, State, Treasury, Interior, Fish and Wildlife, Customs, DOD - through a set of policy recommendations, without having to escalate once from our level to the Cabinet-level people above us, and they agreed. On everything. Every single agency signed off.

So, we picked our moment. Kellyanne Conway (who was crushing it on the president’s combating opioid addiction initiative), as well as my DPC colleague who covered law enforcement, and I would brief the president, hopefully get his blessing, and hand the agencies the clarity they’d been begging for.

The meeting got scheduled. Then, it vanished off the calendar. “Scheduling conflict.” Ok, the president is a busy guy. Then, again. And again. For months.

Eventually I found out why.

Someone very close to the president - someone with one of those vague, ad hoc titles that were created outside the more formal org chart in the White House - had an equity we never knew about, and simply made the meeting disappear. Had we known, we’d have put them at the table and fought it out like men. Instead, it just died.

I never briefed the president on marijuana policy. Near as I can tell, nobody ever did. The most harmonious policy process of my career produced an airtight, unanimous consensus that went straight into a black hole.

So what does this have to do with why things aren’t happening on health care?

I used to tell that story as a fluke, the one time an unlisted stakeholder short-circuited an otherwise working process. But that process isn’t working anymore.

Inside every White House, and every agency’s political staff, there are two groups of staff, and which kind is driving the bus can change things quite a bit.

There are policy people - the subject matter experts (supposedly, LOL) who build the substantive case, weigh who wins and loses, and land on a recommendation. And there are relationship people - Communications, Political Affairs, Public Liaison, Intergovernmental Affairs, Legislative Affairs - whose job is to flag possible outside relationship threats posed by a policy and, once a policy is set, to sell it, rally the winners, and absorb the fury from whoever lost.

Policy people historically have led the process in every other administration, including the first Trump term. But the portfolio is so enormous, and the affected interests so numerous, that no policy shop can field every hysterical call alone - and if you leave the relationship managers out of the team, something you never saw coming could run you over. Policy, like politics, is a team sport.

The White House Org Chart

Every White House in recent decades has three policy councils: Domestic Policy (DPC - maybe a dozen people), the National Economic Council (NEC - about the same size), and the National Security Council, which dwarfs the other two combined - 300 to 400 people, roughly 80 percent detailees on loan from every foreign policy agency in government, maybe 40 to 50 political appointees mixed in.

Somehow DPC and NEC, in charge of the issues touching American voters most directly, each get an eighth of a hallway on one floor, while NSC occupies two (three?) entire floors of the Old Executive Office Building. Still aggrieved about this, apparently, ten years later!

Two more offices round out the building. The Office of Management and Budget (OMB) prices out the president’s agenda and approves every agency’s spending, and somehow manages to be despised by literally everyone else in government, usually (though not always) through no fault of their own.

White House Counsel tells you all the ways you can’t do what you’re trying to do. If they are sharp and aligned, they’re worth their weight in gold. If they’re bureaucratic or not aligned, a nightmare. Most of them are fast talkers, logical thinkers, and some of my most favorite people, who always helped us lawfully get to “yes” on the president’s priorities.

The Relationship Offices

Each manages exactly one type of outside constituency.

Public Liaison runs the outside groups - trade associations, pharma, hospitals, pro-lifers, farm bureaus. Need doctors and patients filling chairs at a Rose Garden event? OPL finds them. First Lady wants to visit a school? OPL picks the perfect setting.

Political Affairs handles donors, campaigns, and pollsters, and is one of the only offices allowed to be openly partisan on the clock, since the Hatch Act bans it for most others. Give enough money to the re-elect or inaugural committee, and this office might return your panicky call about a policy rumor coming out of HHS. They can also poll an idea for the president when he wants the politics, not just the substance, which sometimes helps your case and sometimes kills it.

Legislative Affairs babysits all 535 wild-eyed egos, committee by committee, usually staffed by former Hill aides who already know the players. Any Senator with a gripe usually calls their OLA contact first, not the policy person, since OLA juggles that member’s whole relationship with the White House, not just on one issue. Sometimes they might call the policy people directly, or the policy people might call them directly. OLA hates when this happens because you might blow up some unrelated ask the White House is already working with that Senator, mid-flight. Ask me how I know.

Intergovernmental Affairs liaises with the governors of both blue and red states, mitigating various state funding grievances, disaster declarations, supply chain problems and other important situations.

Communications counts as a relationship office too since the media can kill a policy before it’s ever formally voted on, just by drowning it in hostile coverage before rollout.

You want every one of these people at the table when policy is being made. Not necessarily for a vote, but for the early-warning radar about any restless natives or grassroots insurgency popping off outside the building.

The Hierarchy, and How Fights Climb the Ladder

The org chart undergirding this whole circus - the people heading each council or relationship office - are Assistants to the President, APs - cabinet secretary rank, no Senate confirmation required. Under them, Deputy Assistants, DAPs - deputy secretary rank. Under them, Special Assistants, SAPs - assistant secretary rank, and the designated subject matter experts. That was me: SAP for health care at DPC. Which meant, on my plate: all of HHS, social issues, and any cross-agency issues where health or social questions arose. Not to mention that NSC never staffed global health with a political appointee, so whatever health questions their people couldn’t answer landed on my desk to.

APs, DAPs, and SAPs, and their counterpart Secretaries, Dep Secs and Senate-confirmed Assistant Secretaries at the federal departments, are what are called “commissioned officers,” as identified in Article II of the Constitution, holding the only default seats in the formal policy making process. Which means, at some point, a fancy calligrapher (actual job at the White House) writes up your commission for the president to sign.

The policy process and the White House hierarchy are structured around the layers of commissioned officers. Everyone else gets invited at the discretion of whoever’s running it. Then there are the ad hoc, extra-special jobs every president gives to his closest advisors - various czars, “Counselors to the President” like Kellyanne, or the president’s own daughter and son-in-law - who are often important to have at the table, have invaluable feedback, or have equities and interests that will get shared with the president if you don’t accommodate them in the meeting.

The formal process is a Policy Coordinating Committee, starting at the SAP level: policy people from the White House offices, and the federal departments, as well as the relationship managers, counsel’s office, and OMB. Disagreement escalates one rung at a time - SAPs to DAPs, DAPs to APs, and if even that fails, straight to the president. That’s the theory - and, not coincidentally, the structure of my weed story, except it worked flawlessly and the result still got lost in space, because somebody entirely outside it had an equity we hadn’t realized.

Most of the real work happens before a committee convenes - weeks or months talking to agency people, outside groups, and, of course, the lawyers about what the statute allows. These are the Super Bowl of policy jobs: you can call the best expert or biggest celebrity on earth on nearly any topic, and because the White House is calling, they pick up. The meetings stay pretty informal on the domestic side, unlike NSC’s memo-heavy choreography, since we don’t have the staff to maintain the rigid paper trail they do. Usually ninety percent of the paper is agreeable to everyone; it’s the one or two live disputes that need working out.

Escalating is slow and expensive. Regulation can take two years to finalize, longer if sued, and a term only has four years. Every level has an incentive to compromise rather than kick it upstairs.

This is roughly how it’s worked under Bush, Obama, Clinton, Biden and even the admittedly chaotic first Trump term, all of them - not because anybody would call it a good time, but because it’s the best mechanism anyone’s found for making sure the president gets the best, most expert and most vetted advice before he decides.

All of that was how things usually work. It does not seem to be how things are working right now.

At least that’s my working theory about why policy-making in this White House has felt so sideways, so inconsistent week to week, so contradictory - frankly so demoralizing, at least on the health issues I follow closely.

Everything you’ve read so far describes how a White House is designed to make decisions. But that’s not how this White House operates. In the paid section, I explain what has replaced the traditional policy process, who now drives decisions, why the normal checks have disappeared, and what that means for governing. If you’re not seeing the rest of the article, you’re missing out on the best part! Consider upgrading. The rest of you, let’s get to the good stuff.

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FDA has just tipped its hand on peptides, and the hand is a losing one for the hundreds of thousands of Americans who depend on naturally-occurring, non-patentable peptides to relieve pain, heal injury, speed recovery, and generally improve health.

The agency just released a briefing memo laying out its intention NOT to allow peptides to be authorized for sale by pharmacy compounders.

Despite the fact that there’s a critical meeting of the FDA’s Pharmacy Compounding Advisory Committee (PCAC) on July 23-24, and despite the fact that relevant evidence for that meeting isn’t due to be submitted by either proponents or opponents of peptides until July 9th, the FDA has pre-determined its decision.

Now, to be clear, FDA is not bound to take the advice of the committee.

Even if every health-optimized peptide enthusiast bikes, swims, or sprints to the meeting from across the country and storms the meeting in barefoot shoes and organic boxer shorts.

But it’s pretty defiant that the FDA didn’t even pretend to consider public input on the question before telling the world that they fully intend to deny Americans access to these peptides.

Sadly, it’s unusual for the agency to change its mind once they’ve committed pen to paper like this.

Even though they’re about to receive the data from three US-based randomized controlled trials showing flawless safety data on American study subjects. Even though the president’s pet pollster has made it abundantly clear that approving peptides polls at above 60% among Republicans, Democrats and Independents, especially among middle-aged women - a critically needed demographic.

Peptides Rv Survey Memo 6 29 2026

1.12MB ∙ PDF file

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Even though ground zero for peptide use and manufacture is in Texas, where Republican Senate candidate is in the race of his life and could use the help.

Nonetheless, I’m told by multiple sources that White House staffer Heidi Overton MD, a health advisor on the Domestic Policy Council, gave the green light to FDA on this position. Public release of the agency position - pushed by Pharma-friendly deep staters at the FDA - came as a shock to the (slightly) more MAHA-sensitive FDA political leadership.

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This seems like yet another gift to Big Pharma, who doesn’t want competition from compounding pharmacies creating useful products, based on natural substances, and selling them directly to consumers outside the insurance system.

Perhaps one explanation is that PhRMA - the industry’s powerhouse lobbying group - is apparently on the hunt for a new top lobbyist. Rumors are swirling that half the brain trust of the top health officials in the administration have applied for the $8 million a year job. Interviews start next week. Guess we’ll all have to sweat out the MAHA betrayals until the horse race is over. Sigh.

Right now - as in, at the very moment of publication - a group of economists and pharma-friendly policy types are sitting down to lunch, bankrolled by Pfizer (I was told privately), in Washington, D.C. to discuss a draft Executive Order (EO) that would hand the pharmaceutical industry everything it has ever wanted and then some.

I was invited to this lunch.

I sent my deepest regrets. I’m writing this instead.

The event is hosted by Unleash Prosperity Now, the think tank founded by Steve Forbes. The featured guests are Steve Moore (former presidential economic advisor) and Tomas Philipson (former Acting Chair of the Council of Economic Advisors, and apparently the academic health economist behind this draft EO).

Now you might be wondering why any of us should care what a roomful of think-tankers, Pharma bros and ex-Trump advisors say to each other over lunch on Pfizer’s dime.

The very real concern is that these aren’t cranks shouting into the void. The powerful people who show up in rooms like this are serious players with strong ties to senior officials at the White House, at HHS, and the president himself.

And those ties aren’t just hypothetical. A draft cooked up by outsiders becomes real policy when someone on the inside thinks it has merit, picks it up and runs with it. One day it’s being passed around a salon luncheon. The next, it’s got the president’s signature on it.

I know, because I have my own version of that story. It’s how price transparency came to be. Pointing out this method isn’t a knock on anyone. It’s how good policy gets made, too. The difference is what’s getting pushed. That one was a populist issue, despised by industry interests, that polled at 90 percent with voters. This one is a wish list for Big Pharma and Well-Connected Biotech. Paid for by Pfizer.

It’s billed as “an intimate salon luncheon” to discuss “the extraordinary economic promise of curing cancer” and “modernizing the FDA so that regulatory pathways keep pace with today’s scientific realities.” Who could be against curing cancer or keeping up with science? I know this language.

I’ve spoken this language. I know the free-marketeering policy that it is code for - which I very often have agreed with over the past couple decades in conservative policymaking. But the Shakespearean flaw of laissez-faire economics is its knee-jerk defense of private industry interests in health care - even when, as in the case of the past decade or so, that industry has become increasingly indefensible.

So I read what’s actually being proposed. Then I read it again, because I couldn’t believe my eyes.

And then I wrote 34 ranting comments in the margins.

The metadata of the draft EO lists Tomas as its author, which of course doesn’t mean he doesn’t have other collaborators. I worked alongside Tomas in the first Trump White House. He’s committed, credentialed, and about as laissez-faire as they come - a University of Chicago health economist who made his bones arguing for policies just like those in the draft EO - less and less FDA as the key to more and more Pharma products.

The draft EO was attached to the invitation to this lunch as the actual subject matter to be discussed. It has a name: Advancing Cost-Cutting Treatments and Diagnostics for Old-Age Populations through “Operation Warp Speed 2.0.”

(Paid subscribers can read it for yourselves here.)

Where to Even Begin

Before we get into the substance, the name alone will doom this proposal with public opinion.

The president gets booed at his own rallies, by his most diehard supporters, when he brings up Operation Warp Speed. There is no constituency in the United States - not Republican, not Democrat, not MAHA, not libertarian, not the guy who got the shot or the guy who didn’t - who is enthusiastic about resurrecting that program. Operation Warp Speed and all it delivered to the world is one of the most politically radioactive policy episodes of the last decade, and whoever suggested that branding either doesn’t read the news or wants the president’s polling to crater.

But the name is obviously just the first of many tone-deaf self-owns in this document. Let’s go section by section.

The Founding Myth

The EO’s opening premise is that medical innovation is the key to controlling the federal debt. If we just cure cancer and Alzheimer’s, the argument goes, we won’t have to cut Medicare - we’ll have a healthier population that doesn’t need as much of it.

This sounds good. And if we actually cured Alzheimer’s, cancer, and the other diseases consuming Medicare’s budget, it would be true. But pharmaceutical innovation and disease elimination are not the same thing.

We have had unfathomable medical innovation over the past century. More drugs, more devices, more diagnostics, more interventions than any previous civilization could have imagined. And what do we have to show for it on a population level? We are chronically sicker, fatter, more mentally ill, and more infertile than any previous generation in human history. The extinction-level chronic disease crisis that is actually bankrupting Medicare is not a failure of pharmaceutical innovation. It is the predictable outcome of dehumanized, unbiological lives - of industrial poisons masquerading as food, sedentary routines disconnected from nature, epidemic sleep deprivation, chemical exposures, and severed social bonds.

Medical innovation is not the answer to these problems. It is, at best, an increasingly expensive way to manage their consequences while the causes go unaddressed. Even if you concede that some drugs are keeping people with significant disease alive a little longer - which may be true - that would only perversely drive costs up, as these expensive new therapies generally manage or extend decline during the most expensive end-of-life years, but don’t cure.

And the dirty little secret is that “innovation” has become the industry’s word for obscene launch prices.

When a drug company insists that a new therapy deserves a $400,000 annual price tag, they justify it by saying - there was R&D involved, there were trials, there was a regulatory process. What they are not telling you is how much of that R&D was publicly funded, how taxpayers will be footing the bill for these products used by Medicare beneficiaries, and yet, how completely the profit is privatized once the product hits the market.

If the past is any preview of the future, there is no universe in which this dynamic controls the federal debt. It accelerates it.

The EO describes Operation Warp Speed (v.1.0) as an inspiration. I’d like to offer some alternative framings:

The tens of thousands of deaths attributed to the vaccines. The epidemic of myocarditis in young people. More than a million adverse events reported to government surveillance systems called V-safe and VAERS. The Pfizer trial in which there were more deaths in the vaccinated group than the unvaccinated group - and we approved the product anyway, because Warp Speed. The systematic delegitimization of existing treatments that might have helped people but were made of molecules too old to be profitable.

I’m not interested in re-litigating the entire COVID response here (though you can read more of my thoughts on it elsewhere). But if the lesson your team drew from that experience is “let’s do that again, but for cancer,” you’ve spent too much time in the faculty lounge.

The Structure - Who’s Running This Thing?

The EO would establish an Operation Warp Speed (OWS) 2.0 Steering Committee to be headed by Secretary Kennedy and his key agency heads.

Secretary Kennedy.

You know, Robert F. Kennedy, Jr.

Who literally wrote a book trashing OWS 1.0.

The Steering Committee gets better. It also explicitly includes pharmaceutical and biotechnology companies, among others, who would direct and oversee the OWS activities.

In other words, the regulated entities would sit on the committee telling the regulators what to do.

This isn’t a new idea. It is, in fact, the defining feature of regulatory capture - the thing that RFK Jr. has spent decades fighting, the thing that MAHA exists to dismantle, the thing that former Commissioner Marty Makary named as a foundational problem when he walked into the FDA, long before he was shown the door.

The EO summons another agency to the Steering Committee: BARDA, aka the Biomedical Advanced Research and Development Authority. You know, the shadowy, Pentagon-adjacent slush fund dressed up in public health clothing where sole-source contracts, guaranteed taxpayer pre-payment for unproven technologies, and relationships of unusual coziness with favored companies have determined who gets billions and who doesn’t.

What could possibly go wrong?

But the Operation Warp Speed (OWS) 2.0 Steering Committee isn’t the only committee this EO would establish.

The New “Advisory Committee on Expanding the FDA Mandate Beyond All Recognition”

Ok, that’s not really the name.

The EO would also create a permanent FDA Advisory Committee on Economic Innovation and Impact - a body of health economists, regulatory experts, industry representatives, biomedical entrepreneurs, and (for cover) patient advocates. The committee would be tasked with evaluating the economic consequences of FDA regulatory decisions and would require the FDA to respond in writing to any finding it declines to adopt.

Let me translate this: instead of asking whether a drug meets the scientific standard for approval, FDA would be pressured to ask whether enforcing that standard might hurt the industry’s (or anyone else’s) economic interests.

FDA’s statutory mandate from Congress is to protect the public from dangerous and ineffective products. Full stop. It is not to goose the GDP or pom-pom American biomedical competitiveness. It is not to weigh the complex economic ripple effects of its safety determinations. It is not to answer to industry representatives who are unhappy that their products didn’t get approved fast enough or that their garbage data were uncompelling.

The idea that an agency entirely organized around making scientific determinations about medical products has the institutional competence to accurately model all the downstream economic consequences of its licensure decisions is, charitably, delusional. No government agency could pull off such a sweeping set of mandates. And more to the point: we shouldn’t want it to try.

Picture the committee - stacked with regulated companies and their pals, now empowered to demand that their regulators consider the economic harm to their companies as part of the drug approval process. FDA’s independence has been in question for quite a while - in the last year, it’s been on life support. This would render it a complete fiction.

The draft EO reassures us that the committee members would be subject to “standard federal conflict-of-interest disclosure requirements.” But this is a joke - the committee is conflicted by design. The purpose of putting industry on the committee is to have industry’s interest overtly represented and to bully the FDA scientists with it.

Also worth imagining: this committee gets inherited by a future administration with completely different politics. Imagine President AOC, who decides that a drug’s anticipated launch price is itself grounds for withholding licensure. Because, economic impact. You’ve just built them the playbook - congratulations.

The Regulatory “Modernization” (Read: Weak-sauce Safety Trials)

Under the advice and oversight of all these committees, the draft EO would require:

• Creating fast-track pathways that cut development and approval costs by at least 50% while “maintaining standards of safety and efficacy.” You can’t cut the cost and time of safety evaluation by half and then claim you haven’t touched the standards. Sufficient follow-up time to detect safety signals IS the standard.

• Approving drugs that show “favorable safety with limited efficacy data” and then “further confirm safety and efficacy” later, by collecting more data after approval. But of course, shorter timelines make it less likely that we’ll know anything at all about safety, not more. This is the same trade the industry always wants: weaken and shorten pre-licensure requirements in exchange for post-licensure promises. Once a drug is on the market and a manufacturer blows off its post-market obligations, FDA is quite hamstrung in terms of what it can do without incurring the wrath of lawsuits and patient revolt. I don’t want to have to “further confirm” safety after licensure. I want safety fully confirmed before licensure. That used to be the whole point.

• Establishing a quota: prioritize approval of at least three breakthrough therapeutics by June 2028. This is not how regulatory science is supposed to work. If products meet the statutory standard, they get approved. If they don’t, they don’t. Setting an approval quota in advance is just explicit pressure on regulators to cut corners to meet the number. If you don’t believe me, ask Drs. Marty Makary, Vinay Prasad, Tracy Beth Høeg, and every other FDA scientist who has faced industry pressure to lower their standards.

• Streamlining biomarker validation and surrogate endpoints for drug approvals. In other words, use change in some lab result as the outcome studied in the trial instead of, you know, actual improvement in health or mortality. I will be generous here: there are some biomarkers that are genuinely well-validated and useful as surrogate outcomes. But the track record on aggressive use of surrogates to speed approvals is not inspiring. Too many drugs approved this way improved the surrogate but were later discovered to have no impact on the clinical outcome (or to make it worse). Oncology drugs approved on progression-free survival that never demonstrated improved overall survival. The Aduhelm debacle for Alzheimer’s. The emerging scientific consensus - supported by decades of hard experience - is moving toward more rigor on surrogate validation, not less. This EO proposes to move in the opposite direction, and it does so, not because the science supports it, but because it lowers costs for drug makers.

Taxpayers as Insurance Policy and Piggy Bank

The EO directs NIH, BARDA, and the VA to use their contracting authority to “support late-stage trials and secure early access to promising candidates.”

If you don’t speak pharma gibberish, that means: transfer the financial risk of pharmaceutical R&D from private companies - who will capture all the profit - onto taxpayers, who will capture none of it. The companies bear the upside. The American public bears the downside. These frameworks have historically generated sole-source contracts, sweetheart deals for politically favored manufacturers, and guaranteed government pre-payment for unproven products.

As with so much else in this EO, we need less of this type of corruption, not more.

The Coverage Mandate

Buried in the coverage provisions is this: “CMS shall ensure that Medicare beneficiaries can access OWS 2.0-designated products within 30 days of FDA authorization.”

A drug gets FDA authorization under the accelerated approval pathway - meaning it has shown “favorable” safety (whatever that means) with limited efficacy data, remember - and within 30 days, Medicare must cover it. Before the “evidence development phase” tells us whether it actually works or has been followed long enough to be deemed safe.

This is guaranteed procurement by one of the planet’s largest single-payer systems, for under-scrutinized products at obscene launch prices, backed by the full faith and credit of the United States Treasury, with a 30-day clock that ensures there’s no time or leverage for the government to ask the hard questions or negotiate reasonable terms and conditions.

I’m old enough to remember when Republicans - especially Republican economists - argued that coverage mandates drive up the cost of health care.

And… Brace Yourself

Attention, MAHA: the draft EO calls for “ a rolling review process with clear timelines… similar to the Emergency Use Authorization (EUA) framework.”

I admit, I froze in horror and wrote “OMG” in the margins before I calmed down and read this part more carefully. Charitably, I think the EUA reference is really just about how the reviews of potential new products are scheduled (on a rolling basis to make the process more real-time and supposedly more efficient). I don’t think the EO is intending to use the EUA reference as a dog-whistle for a liability protection racket for industry here. But talk about tone-deaf! Between the OWS branding and the EUA shout-out, my MAHA moms are going to be calling their homeopaths for an acute PTSD remedy.

A Word for Our Friends Inside the Administration

I’m told that some people from HHS attended this Pfizer lunch. I hope it’s not true, or if it is true, that they’re using it as an opportunity to laugh this draft EO out of the room.

I have to believe that the few MAHA faithful who remain in the administration after the industry-instigated purge of the past year - Secretary Kennedy, NIH and CDC Director Jay Bhattacharya, and White House health advisor Calley Means - have not seen this document. These are people who have staked their careers and reputations on the proposition that the pharmaceutical-regulatory complex has been captured, that safety standards have been compromised by industry pressure, that the government has been de-risking pharma’s business model on the public’s dime, and that we need to fight all of that with everything we have.

This executive order is the enemy they’ve been fighting. It’s what they came to Washington to stop.

You can’t simultaneously lead a Make America Healthy Again movement and then go sign an executive order that puts pharmaceutical companies in charge of a new Operation Warp Speed designed to weaken safety and efficacy standards, mandate Medicare coverage of under-scrutinized drugs, and claim it’s all in the service of “lower costs” (LOL).

Those things can ‘t coexist, and the political base that elected this president knows it.

The Actual Answer

The draft EO closes with gestures toward lifestyle modification and AI tools for “personalized preventive guidance.”

It’s an afterthought.

The industry interests at the “intimate salon luncheon” going on right now will likely deflect attention from the four leading risk factors for preventable chronic disease - garbage food, physical inactivity, tobacco use, and excessive booze. These account for more than half of all preventable disease deaths in the United States across cancer, cardiovascular disease, chronic respiratory disease, and diabetes combined.

Folks, none of us suffers from an inborn pharmaceutical deficiency. What we suffer from is: not living like humans, for the past few generations.

Addressing these factors is hard. Much harder than turning a blind eye to unconvincing trial data and slapping an approval stamp on Pharma’s latest blockbuster. It requires taking on the food industry, the chemical industry, the seed oil lobby, the pharmaceutical companies that profit from managing the consequences of these diseases instead of preventing them. It requires telling Americans stuff that none of us wants to hear (You’re fat! Get off Diet Coke!). It requires regulators committed to protecting the public from misaligned industry interests rather than protecting industry from the public - public scrutiny, accountability and legal liability.

The cheapest disease to treat is the one that never develops in the first place. The biggest ROI is in prevention and lifestyle-mediated disease reversal, not weak-sauce symptom mitigation to manage and extend decline.

Nobody’s fooled by the pretense that this draft EO is about lowering costs for seniors and taxpayers. Throwing billions more at Pharma and transferring the R&D risk of drug development from them to us lowers nobody’s costs but Pharma’s.

The truth is that this policy is just craven regulatory capture and we have to make sure it never makes contact with the business end of President Trump’s pen.

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.

• Paid subscribers who want a copy, comment below or send a DM to and we’ll send it over.

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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.

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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.

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.

At a surface level, the problem looks like pricing. Employers are paying too much, and the obvious response is to look for cheaper alternatives: reference-based pricing, direct contracting, cash pay strategies, or some combination of the three.

What it Takes for an RBP Plan to Work

I already described the way hospitals and networks conspire to make RBP plans unworkable. While it’s theoretically possible to overcome these challenges and operate a successful RBP plan, it requires some pretty exceptional conditions to be met:

1. Localized employer in a non-gangster market. The employer plan sponsor must be localized in a market (not spread out all over multiple markets or nationwide) where there are multiple hospital systems, at least one of which chooses not to deploy the gangster playbook, and that has enough geographical spread and clinical quality to give most employees access to hospital care without unreasonable travel burden. That means they have quality care for admissions arising from acute cardiology, neurology, oncology, orthopedics, gastroenterology and so forth. They also need to be able to treat kids with acute specialty needs (including NICU/PICU), their labor and delivery care should be high-quality (good luck with that, LOL), their ER should be able to handle almost anything without transfer. If the employer’s workforce is spread out all over the place, many of them will be in markets dominated by gangsters.

2. Competent navigation vendor. You have a navigation vendor that is able to competently navigate members to providers who will accept the plan. That means the member has to contact the vendor, describe the need, and then the vendor has to contact an appropriate provider, and work with the provider to ensure that the plan will be accepted. That often requires getting a call back from the office manager or practice leadership, or hospital/facility management, which can take days (or weeks), teaching them about the plan, gauging their willingness, and then negotiating a rate, or a single case agreement just for that one patient, if they won’t accept the plan’s allowable rate more generally. Then the navigator has to let the patient know it’s ok to schedule. But often, the practice management that you worked things out with has not adequately communicated to the front desk schedulers when the patient calls, and this requires another go-round of communication from the navigators.

   In my experience, I have found not one vendor who is able to do this reliably well most of the time. I have worked with several myself for my little group of Catholic nuns. And I have surveyed every benefits advisor I can find who is running RBP plans, and they all complain too. Lots of good people working very hard, but even when they care as much as I do, many, many, many provider offices just won’t come around and play ball in a timely enough way for the patient’s need. The best advisors basically in-house this process and hire their own navigation staff, because it always seems like the vendor just doesn’t care about your clients the way you do. That can work better, but without other tools, like cash-pay options (more on this later), it’s still high-friction.

3. Patient education about the plan. All of them. That’s hard because, at best, the employees come to the open enrollment meetings where you do your best education, not their spouses and adult children - even if they’re invited. And even if you do additional education or contacts throughout the year, there’s only so much you can pack into a quick video, an email or flyer on the bulletin board.

   Patients aren’t really paying much attention until they need care. And then, they almost always have an idea of where they’d like to go for care and they bring that preference to the navigators, who will usually start trying to get that provider to accept the plan. Often these are the flagship hospitals or bougie practices in town, and they have zero incentive to play ball. So the navigators waste a lot of time trying to give the patient what they request before going back to them with alternate provider suggestions. Both the delay as well as the failure to get their preferred provider annoy patients. A lot. To them, it seems like normal, high-quality doctors that everyone else goes to won’t take their plan, so the plan must be cheap and crappy, and they get angry with their employer.

4. A balance billing vendor who is impeccable - and patients who are educated that they might get a balance bill, which they need to send to the plan immediately. Once they do, that vendor has to respond timely with outreach to the provider, and competently negotiate with them to an acceptable rate. Many providers make it intentionally impossible to talk to the right person about negotiating a bill - especially hospitals. At smaller practices, billing staff may not have the authority to just negotiate a bill downward and they refer you to the owners. So this process can go on for months, even years. The billing vendor has to have lawyers on hand as well, because the process gets nasty when the collections notices start coming. Most plans don’t let it get to that, often giving in and paying the occasional way-overpriced bill as the cost of doing business, trusting in the plan design to save enough elsewhere. But doctors who aren’t getting their bills fully paid will often cancel subsequent appointments for the patient or other patients on the plan and refuse to see them anymore or until the dispute is resolved. More friction that leads to angry calls to HR. I will say, however, that there are a few vendors out there who handle this problem reasonably well, so this challenge can usually be overcome.

5. A solution to reduce the traffic to specialists and acute care. This is usually accomplished by adding concierge primary care, preferably with a behavioral health solution included or bolted on as well. Direct primary care (membership-based with a monthly fee), provided free to patients, goes a long way here, since up to 80-90 percent of health care needs can be managed by a high-quality primary care doctor who is paid to keep people healthy and out of the system. The behavioral health piece is also essential because you’d be absolutely shocked at how much these costs drive overall spend these days. We’re all falling apart (see previous posts about our un-human lives).

Rarely are these ideal conditions all in place. Even employers who start out gung-ho get demoralized by all the friction, and have to continually remind their grumbling workforce about the savings generated by the plan and how they’re being used to lower premiums or cost-sharing, or increase wages, and so forth. There’s still a ton of friction around scheduling that requires dependence on navigation and negotiation vendors that must be absolute unicorns in order to work seamlessly almost all the time. Patients have to be educated about how to explain their plan to providers and why we’re doing all this. This education requires explaining a lot about health care to members who don’t really care. (You DO care, and it’s already taken me over 2,000 words to get us here.)

The RBP plans that last - meaning that the employers don’t give up from all the toil and trouble - eventually convert into something else over time: a custom network built on direct contracts. Most successful employers using this model make them sustainable by asking providers who agree to take the plan for a given patient if they’d be willing to paper up a direct contract for the whole group. Over time, this set of direct contracts turns into a custom network that requires less and less intense navigation work and education of patients. Patients get used to being sent to a certain set of providers. This promised land comes faster once a hospital system in the market agrees to a direct contract. That’s when the custom network starts to feel comprehensive to patients.

When this works, we call it a “community-owned health plan” - and the benefits advisors building these plans start offering this custom network and the plan design that steers patients to the custom network (usually at no or very low cost) to other employers in the community. Ideally, these plans bake in high-quality direct primary care as a way to limit the need for specialty and acute care as much as possible.

So yeah, RBP plans can work as transitional vehicles into community-owned health plans, but they are unicorns that require every almost-impossible condition above to be in place.

This is not a viable solution for the whole country.

Why Not Use a Network as a Backup Solution when a Provider Won’t Play Ball?

To a rational human, it might seem that the obvious solution to all the RBP challenges described above is to have claims sent from providers to the indie TPA first. Then, the TPA tries to get the provider to accept the RBP rate. But if that doesn’t work, then the TPA could send the claim to the network to apply its contracted rate with that provider. RBP is Plan A. Network is Plan B.

But health care doesn’t allow rational humans to prevail when revenue is on the line. Now that we’re past our earlier 101 on networks and discounts, it’s time to talk about how network contracts really work to box out rational alternatives.

Networks function through contracts not just with health care providers, but also with the plan sponsors, and their vendors. These contracts sit in three places simultaneously: between networks and providers, between networks and TPAs (if the network is not the same company as the TPA, which in the vast majority of cases, they are), and between networks (directly or indirectly) and plan sponsors.

These are not independent contractual relationships, negotiated separately. They reinforce each other in ways that make it extremely difficult for any one party to deviate without triggering consequences elsewhere.

Start with the most visible network signal: the logo on the ID card. Most of us think this is just branding - but it’s actually a signal to the provider about where to send the claim and what options are off the table before the conversation even begins. If a provider is contracted with that carrier, the presence of the logo tells them that they are bound by their agreement with the carrier, which typically prohibits them from bypassing the network to accept a separate arrangement with the patient or the employer. They can’t simply decide to accept a cash payment in lieu of submitting a claim to the carrier, even if that cash payment would be faster, cleaner, and economically rational. The contract forbids it.

That same signal constrains the TPA, even if the TPA is independent (meaning the TPA is not the carrier/network) and the TPA is merely contracted with the carrier to offer options to employer clients to rent the carrier’s network. If the TPA has a network access agreement with the carrier, it is obligated to process claims in accordance with the carrier’s negotiated rates when a participating provider is involved. If the TPA attempts to deviate - by paying a different amount that the employer and provider have agreed to outside the network - it risks losing access to that network entirely. And losing access to the network is not a minor inconvenience for a TPA; it is an existential threat, because many of its clients insist on renting a carrier network. They don’t want an RBP/no-network plan, and they fire the TPA if they can’t rent a network for their plan. A good TPA I once worked with lost its main network contract because of these issues, and it declared bankruptcy a couple years later.

The plan sponsor is not exempt from these constraints. Even when using an independent TPA and merely renting network access, the employer is contractually bound to honor the carrier’s rates with providers. In some cases, the contract language goes even further, explicitly acknowledging that the contracted rate may exceed the sticker price that’s billed, and still requiring the plan to pay the higher contracted rate. I flat-out refused and got lawyers involved when a carrier rental contract came at my client with that language, and was told that Cigna would walk away - it was non-negotiable.

Similarly, the plan is often required to structure its benefits in a way that steers members toward participating providers and reinforces the network’s primacy. Some network access agreements allow for exceptions to this if you give them the list of direct contracts you may already have in place, or vendors for this or that type of service - but they have to approve them. When I’ve given them a vendor that is too big (like, say, for all imaging services), they have rejected those “exceptions” to their agreement, and that’s final.

Taken together, these provisions create a closed loop. The provider cannot accept an alternative payment. The TPA cannot facilitate one. The employer cannot direct one. And the carrier sits in the middle, enforcing the rules that keep all three aligned with the carrier’s interests.

Many times, I’ve asked the network: “you get paid your monthly access fee whether my client uses your network or not, so why do you care if we go around you?”

The answer: they recognize how threatened their business model is by allowing plan sponsors off the plantation, even a small percentage. The more that happens, the more employers and indie TPAs start building the underground railroad to a post-network world. And they can’t have that.

That is not a market. It’s the mafia.

Why You Cannot “Partially Escape” the Network

Employers don’t lack ideas or even willingness to embrace change. The system permits no incremental deviation. You can be inside the network, or you can attempt to operate entirely outside of it, but the middle ground - the place where you combine strategies and gradually build a better model - is where the contracts exert the most pressure.

This is why reference-based pricing, direct contracting, and cash pay all encounter similar limits, even though they appear, on the surface, to be very different approaches. Each one represents an attempt to create an alternative pathway for payment. Each one runs into constraints that were designed to keep everyone on the plantation.

It is also why the idea that employers can simply “fire the network” is misleading. Technically, they can. Practically, doing so exposes them to all of the access and operational challenges described earlier, without giving them the tools they would need to solve those challenges at scale. The system is designed so that leaving entirely is painful, but staying partially is prohibited.

You are allowed to exit. You are not allowed to compete.

Why Direct Contracting Is Not a Complete Solution

Direct contracting is often presented as the most promising alternative because it addresses one of the core problems of reference-based pricing: the absence of an agreement with the provider. By negotiating directly, the employer can establish a mutually agreed-upon rate, eliminate balance billing, and create a predictable payment structure.

You knew there was a “but” coming, right?

The first “but” is geographic reality. Employers rarely operate in a single, contained market. Employees travel. They relocate. They vacation, they work remotely. They have college kids all over the country. They live in areas where there may be only one viable provider. Even in a relatively concentrated workforce, the dispersion of care needs across different locations creates an immediate requirement for coverage beyond any single set of contracts. You can’t contract with all the providers in the country. So you’ll need some solution for the providers you don’t have a contract with.

The second “but” is that direct contracting takes time. You can’t just flip a switch and have a custom-built set of directly-contracted providers comprehensive enough to replace a network in a month or two. Even if you targeted one market alone, it would still take a year or more to get all the contracts in place. You need a solution during the transition.

The third “but” is provider willingness. Hospitals, in particular, are not uniformly interested in contracting directly with employers, especially smaller ones. I saw this firsthand when I tried to contract with El Camino Hospital in California, where my little group of nuns had a convent with about 10 sisters. The sisters had previously been going to Sutter Health, a gangster, Bond villain system, and I was looking for an alternative for hospital care. Direct contracting seemed like the best solution.

We did the work. We identified the right hospital executives, stalked them on LinkedIn until they agreed to meet, brought in the TPA and our legal and analytics partner to answer operational and data questions. We approached it seriously.

In the first five minutes of the meeting, they declared that they couldn’t contract with the sisters because their systems were not set up to accommodate a new payer in their scheduling and billing infrastructure. Specifically, they would need to modify the drop-down menus in their IT system.

I offered to pay for a coder. They thought I was joking. I wasn’t - the cost would have been trivial compared to the difference in rates.

They declined.

If a hospital can fill its beds with patients coming through carrier networks at rapey rates, there is no immediate incentive to do the back-office work of accommodating lower rates from a few Catholic nuns.

Direct contracting can work in specific circumstances, particularly where an employer has significant local leverage or can steer a meaningful volume of patients to the hospital in exchange for meaningful discounts. But those circumstances are the exception, not the rule. And even when they exist, they don’t eliminate the need for a broader solution to cover the rest of the system.

Cash Pay: Promising, but Not Yet Scaled

Cash pay introduces a different kind of possibility. In theory, it aligns incentives in a way that bypasses many of the inefficiencies embedded in the traditional claims process. Providers receive payment upfront, in full, without delay. They avoid the administrative cost of billing and collections, as well as the opportunity cost associated with waiting for reimbursement.

In many cases, those cash prices are indeed lower than carrier-negotiated rates.

The difference reflects the removal of billing bureaucracy, chasing patients for deductibles and copays, and the elimination of the opportunity cost of “the float” - the revenue accrued by the carrier due to interest earned on delayed payments to providers (who could have been investing that money themselves if they’d been paid timely).

That is the theory.

Operationally, most TPAs are not yet equipped to facilitate cash payments at the point of service in a way that integrates cleanly with plan administration. They can’t pay cash on behalf of a patient they don’t yet know is going to the doctor - they’re used to paying claims that are submitted after service.

So this requires the intervention of navigators who mediate between the TPA and the patient. Patients have to call the navigator, tell them when their appointment is, and then the navigator facilitates the payment to be made by the TPA - and that’s if the TPA has the capacity set up to even make that kind of payment, which most don’t. What’s more, the patient has to be educated by the navigator not to present their ID card with the carrier logo so that the provider has plausible deniability about his own carrier contract.

Even if the TPA does have the ability to pay cash, they may run into a situation where the amount they paid upfront before the visit turns out to be wrong because additional services were offered during the patient visit (like a blood draw or a quick x-ray). They also may struggle to manually generate a corresponding claim record, and ensure that the transaction is captured for audit and reporting purposes.

This is all about to change. Quality companies ARE actively building solutions to overcome these challenges. Cash-pay is happening now, in some limited settings - but it still feels like a workaround, like an underground railroad, hiding ID cards - only with a few willing providers, not all claims - certainly not at scale yet. The partners helping make this happen are few in number right now, but I keep hearing about another one here popping up and another one there. So the logistical or technical barriers to cash pay are being broken down.

Another “but?” Yeah.

More fundamentally, providers have limited incentive to make their cash prices attractive. The self-pay market is relatively small - very few people can afford to pay cash at today’s rates. If providers were to offer materially lower cash prices and make them broadly accessible, they would risk undermining the higher rates they receive through carrier contracts without any corresponding competitive volume acquisition, because all that volume is still on the carrier plantation. As a result, many providers either don’t publish meaningful cash prices or publish figures that are closer to their sticker prices than to the actual discounted amounts they might accept in practice, when asked.

This leads to a situation in which the theoretical advantages of cash pay are real, and being realized in practice by a few unicorns, but the conditions required for those advantages to scale - transparent pricing, operational infrastructure, and provider participation - are not yet fully in place. Most importantly, the anticompetitive contract provisions shackling everyone from scaling this model have not yet been tackled by DOJ and the courts.

Networks are the Biggest Fraud Ever Perpetrated on the American People

Can we just stop for a moment and recognize the spectacular scam that is insurance networks? The whole sales pitch of carriers is that they negotiate better prices on behalf of employers than those employers could obtain on their own.

That is almost NEVER true. Instead, the carriers don’t let employers off the plantation to kick the tires on the pitch.

Hospitals are no less complicit - very few have any interest in arrangements that would expose them to direct price competition.

If employers were free to pay cash where it is cheaper, to contract directly where it is advantageous, and to use networks only as a fallback, someone might notice the truth about the carrier networks’ value prop.

The emperor has no clothes.

Enter DOJ (please)

What emerges from this structure isn’t just inefficiency, but a restriction on the ability of buyers and sellers to transact freely:

• Employers can’t offer to pay a provider less than the carrier rate, even if the provider would accept it, without risking the loss of network access.

• Providers can’t accept a lower price from an employer, even if it would be economically rational, without violating their agreements with the carrier.

• TPAs can’t facilitate alternative payment arrangements without jeopardizing their own contractual relationships.

• Patients can’t pay cash and providers can’t accept it if anyone displays an ID card with a network logo on it.

Each party is constrained, not by market forces, but by contractual provisions that align their behavior in favor of the status quo.

This is, at its core, a restraint on trade.

The Department of Justice has begun to address certain anticompetitive practices in provider contracts, and that is an important step, as I wrote about recently, regarding the OhioHealth lawsuit and a similar lawsuit just filed against Bondiest-of-all-Bond villains, New York Presbyterian. But the provisions that most directly prevent the emergence of a price-sensitive market are the ones that prevent the buyers and sellers of care from doing deals with each other.

Those provisions haven’t yet been the focus of enforcement. Paging DOJ Antitrust Division.

What Would Have to Change

If the goal is to move toward a system in which price competition can actually function, here are some ways government can intervene on behalf of you and me and and our post-network dream:

First, enforcement action should target the specific contract provisions that prevent employers and providers from entering into alternative payment arrangements. It’s not enough to address provider-side consolidation or all-or-nothing contracting if the mechanisms that enforce carrier dominance remain intact.

Second, Congress could outright ban these anticompetitive contract provisions. It’s possible that they’ve already been provided with the legislative text, wink wink. The groundwork for this has been laid in recent legislation, but it wasn’t as explicit as it needs to be.

Third, regulatory agencies, particularly the Department of Labor, could announce that these type of contract provisions are prohibited transactions under ERISA, in the same way they have begun to do with pharmacy benefit managers. The logic is similar: when an intermediary structures transactions in a way that benefits itself at the expense of the plan sponsor, that raises fiduciary concerns.

Now, providers could slow the cash-pay explosion by simply refusing to accept anything less than their sticker price in cash. That’s why another important policy would be for Congress or DOL to require providers to publish a single, all-in cash price for services and to accept that price from any willing payer, including employers and their TPAs. If that price were required to be no higher than the lowest negotiated rate, it would create a ceiling for competition that reflects the true cost of care without the added burden of billing infrastructure and delayed payment.

This requirement isn’t as price-fixey and communist as it sounds - it reflects the truth that negotiated contracted rates are based on having to submit claims after the fact and all the associated billing bureaucracy and delay. Starting your cash price at the lowest negotiated contract rate is actually probably too high, and could easily compete downward with the efficiency of the cash price process.

That kind of requirement would not be easy to implement, and it would be resisted. But without it, the transition to a price-competitive market will remain slow and uneven.

What the Transition Would Actually Look Like

If anticompetitive contract provisions were banned by either regulators, Congress, or both, as they are starting to be for PBMs (which are really just the same carriers), the system would not immediately flip into a post-network world. There would be a transition period, and it would likely be messy.

Employers would begin by using networks as a fallback while selectively deploying cash payments and direct contracts where they are advantageous. It still would likely require firing the carriers as plan administrators and using indie TPAs (unless carriers were required to let employers use direct contracts and cash rather than forcing their networks as the only option). Most employers are not using indie TPAs right now. Over time though - not as much time as you might think - as operational capabilities improve and providers respond to shifting demand, those alternative pathways would expand.

As more volume moves through those channels, the relative importance of carrier networks would diminish. Their role would shift from being the primary mechanism for accessing care to being a residual safety net.

At a certain point, that model becomes unstable. If enough employers are able to obtain better prices outside the network, the value proposition of maintaining the network erodes. Providers would have a ton of leverage in their communities to say to a carrier: “if you don’t agree to my terms, I’m going to go to the local Chamber of Commerce and offer direct contracts to all their member businesses.” Contracts are renegotiated. The system begins to reorient. The carriers would have to pay those providers more, which makes the carriers less competitive to employers, and the carrier death spiral begins in earnest.

That is how you get to a post-network world - not through a single decisive break, but a gradual shift at first, and then a sudden collapse.

The Walls Are Closing In.

None of this is inevitable. The current system is highly profitable for both the carriers and the gangster hospital systems, and they have both the incentive and the ability to defend it.

But the walls are closing in. Employers are finding escape routes. Startup vendor partners are emerging to help them, using price transparency reports, commercial claims data, and AI. The carrier network’s days are numbered.

A post-network world is not a utopian dream - it is simply a market.

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)

Read more

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.

Read more

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