Tag Archives: Health

Healthcare Is Still on the Ballot. But the Debate Has Changed.

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment
https://www.medpagetoday.com/opinion/second-opinions/123447?xid=nl_mpt_DHE_2026-10-18&mh=30d2d79f4357232a6a1236c866c0fe17&zdee=gAAAAABm4wli3fIz03mrmvZ196IZ7qiXDICmUr2x_v5Bie-ZePJsrTmL8XrZU6B1xohljjXg8La69mMLVEUrDycj0GAGgW4UPILdjxfuDCWMMIvHim5oQBk%3D&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%20Evening%20-%20Randomized%202026-10-18&utm_term=NL_Daily_DHE_dual-gmail-definition&lctg=5e4a6afa7e553f502501e525

As medical students in New York City, we spend our days witnessing firsthand how economics shapes patient care. Patients struggle to afford needed medications, battle insurance requirements, and wait months for specialty appointments. Rotating from Upper East Side hospitals to public safety nets in Queens, we also see how the precarious state of hospital finances makes care more difficult. So, as a consequential midterm election approaches, we’ve been following the news closely.

Since the 1990s, healthcare has been among the most important electoral issues. President Clinton proposed an ambitious restructuring of the system in the 1990s, Medicare Part D was born under President George W. Bush, and then came President Obama’s Affordable Care Act (ACA). In perhaps the most analogous election, healthcare became a top issue in the 2018 midterms during the first Trump administration, following dramatic “repeal and replace” efforts led by Republicans. Most recently, in 2020, “Medicare for All” was compared to a public option or the expansion of the ACA. These past policies differed tremendously, but they all asked a version of the same fundamental question: how should American healthcare be organized and provided?

Yet, in 2026, as we watch the midterms take shape, something seems different. Healthcare has hardly disappeared from American politics. But instead of grand structural reforms, candidates are particularly focused on individual affordability. The change may have more to do with voters than with politicians.

Healthcare affordability has become increasingly salient over the last few years: In 2024, when KFF asked voters about rising household expenses, food and grocery costs were the main concern. In January 2026, healthcare costs were voters’ top economic concern, with 31% saying they were “very worried.” Concern persisted across parties: 33% of Democrats, 36% of Independents, and 25% of Republicans were “very worried.” On top of that, 58% of voters said they expected healthcare to become less affordable next year.

While the issue is the same, the major parties are taking different approaches. Republicans are championing the Trump administration’s push for “most favored nation” drug pricing, reducing waste and fraud, and calling for direct subsidies for some Americans to purchase insurance. Democrats like Sen. Elizabeth Warren (D-Mass.) and Rep. Alexandria Ocasio-Cortez (D-N.Y.) have introduced a bill to make it illegal “for private equity funds, insurance companies, and other for-profit corporations to own or control medical practices,” with a co-sponsor, Sen. Ron Wyden (D-Ore.), saying explicitly in the bill’s announcement that “corporate medicine is making health care more expensive for everyone.” House Democrats have also created a “Cost of Living Healthcare Working Group” to highlight this issue as a campaign topic, alongside other household budget woes.

But these policies do not mean healthcare reform has stalled. Drug pricing, restricting corporate ownership, and shining a spotlight on the price of healthcare are themselves important reforms. What has changed is how both parties frame them: as solutions to the high cost of living.

Clearly affordability matters. However, from inside the hospital, we cannot help but wonder if something is lost when healthcare debates evolve into purely an affordability crisis. Healthcare is both a consumer expenditure and a social good — its success cannot only be measured by its price. As medical students, we see problems that don’t fit neatly into costs: avoidable cancer diagnoses due to shortages of primary care physicians, emergency departments overwhelmed with boarded patients, people in need of mental healthcare discharged to the streets, and re-emergence of infections due to eroding trust in public institutions.

Increasingly, clinicians themselves are left to compensate for these problems of healthcare delivery. When patients wait months to see a specialist, primary care physicians wind up managing niche, complex conditions. When beds are unavailable, emergency physicians care for chronically ill patients for days. When outpatient services are inaccessible, hospitals, like those we have rotated through, become the safety net instead. Patient care suffers.

Naturally, even those problems have financial roots, and prices are easy targets for politicians. Yet, while an insurance premium or prescription price can decrease, improvements in continuity, trust, and ultimately clinical outcomes are much harder to measure. And unfortunately, they may be even more difficult to campaign on in 2026.

Healthcare has not vanished from the midterms. Voters are increasingly concerned, candidates campaign on it, and parties disagree about how the government should address these issues. Yet, the foundation of the debate has changed. Increasingly the question is not how we should re-engineer the system, but rather, how we should make the system that we already have less expensive. In other words, instead of asking what kind of care Americans deserve, the 2026 debate is increasingly asking what Americans can afford.

Maybe that change is overdue. However, as medical students entering a system that these debates will shape, we hope that by confronting what healthcare costs, we do not stop asking what — and for whom — healthcare is for.

Health System Reform: The Two Areas where Support is Strongest

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment
Health System Reform: The Two Areas where Support is Strongest

As campaign 2026 nears its end in 15 days, polls show the potential for some surprising results and political pundits are already speculating about what to expect in the lame duck session and 120th Congress that convenes in January.

For healthcare, the realities are these:

  • Healthcare will be on local, state and national ballots in the context of affordability and costs of living. It’s a top-of-mind concern to voters along with housing, gas prices and groceries. A fourth of the population has an unpaid medical bill, and the majority worry about a surprise medical bill that could wipe them out.
  • Healthcare has lost much of the trust and confidence it enjoyed for decades. It has failed to navigate its positioning with voters because it lost control of its narrative. Among majorities of elected officials and voters across partisan aisles, the “system” is viewed as big businesses that put profits above all else. Reform is desirable to outside stakeholders but there’s no consensus about a ‘future state’ destination.
  • Healthcare is structurally flawed. Its tribalism is reinforced by laws and regulations that protect its status quo. Primary and preventive health is subordinated. For-profit and non-profit distinctions are artificial. Value is not defined. Business practices are opaque.

As a result, the industry will operate in limbo in the immediate future. Structural change is unlikely. For the near term, states will be the labs for healthcare innovation, and large (non- healthcare) employers might force a needed national discussion. Thus, in the 119th Congress’ lame duck session and 120th Congress next year, public policies in healthcare will center on low-risk efforts in two domains that enjoy widespread, Bipartisan support among elected officials and voters:

Program integrity: Fraud, waste and abuse in the U.S. health system is a soft target. According to CMS’ 2025 Improper Payment data, improper payments in Medicare, Medicaid, CHIP and other programs amounted to amounted to $96.16 billion. The largest categories include:

  • Medicare Fee‑for‑Service (FFS): 6.55% (≈ $28.83B)
  • Medicare Part C (Medicare Advantage): 6.09% (≈ $23.67B)
  • Medicare Part D: 4.00% (≈ $4.23B)
  • Medicaid overall: 6.12% (≈ $37.39B)
  • Children’s Health Insurance Program (CHIP): 7.05% ($1.37B)
  • Advance payment of the Premium Tax Credit (APTC) program: 0.89% ($657.46M).

It includes enrollees or actions for which the DOJ, FTC, FBI or HHS-OIG may seek redress on behalf of the public:

  • Billing for services not provided
  • Upcoding or unbundling
  • Billing for medically unnecessary services
  • Kickbacks or inducements
  • Duplicate billing
  • DME schemes (back braces, wheelchairs) — a high‑risk category highlighted by FTC.

Elected officials and the majority of voters support intensification of policies that reduce FWA spending.

Price transparency: Polls show large majorities of voters want unfettered access to accurate prices for the services they receive from doctors, hospitals, insurers, prescription drugs and everything else. They reject insider reasoning they’re not available today due to complexity and believe most price estimator tools currently in use of limited help to consumers. They believe of willful avoidance of price transparency is a calculated business strategy to protect margins, executive compensation and revenue growth.

There’s no doubt healthcare will significantly impact the results of the November 3 vote. There’s no doubt it will be a major focus in the 120th Congress. The major unknowns are (1) how states and federal policymakers will address the realities noted above, (2) how large employers and community leaders will participate (or not) in the design of a reformed system of health and (3) how voters will decipher reforms that promise offer accessibility, affordability and effectiveness.

Game on.

P.S. I grew up watching ABC’s Wide World of Sports that opened with Jim McKay’s infamous call “The thrill of victory, the agony of defeat”. Last week, we felt both. Pope Leo’s successful lung surgery was the victory; the mass murder of 3 kids and a teacher at Silver Rail Elementary the defeat. Our nation’s psyche is on edge along with many of the 8 billion inhabitants of planet earth. We need hope. We need victories. We need a break from bad news. I’m just sayin’.

ProPublica Wants to Hear About Your Prior Authorization Denial

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment
https://healthcareuncovered.substack.com/p/propublica-wants-to-hear-about-your?utm_source=post-email-title&publication_id=255152&post_id=222201228&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

Insurers promised to cut back on prior authorization. Now, ProPublica wants to know whether patients are still being denied or delayed care – and they need your help.

Last year, many of the country’s biggest health insurers promised to cut back on prior authorization. That’s the extra approval step insurers require before they’ll pay for a treatment, test, drug or piece of medical equipment. The pledge came after years of anger from patients, doctors and lawmakers in both parties.

I was skeptical then and I’m skeptical now. Prior authorization makes money for insurers. Every delay and every denial can mean care that never gets paid for. Companies don’t easily give up tools that pad their bottom line.

ProPublica is now trying to find out whether the promises meant anything. Reporters Max Blau and Brandon Roberts are investigating how insurers’ continued use of prior authorization is affecting patients. They want to know if people are still facing delayed or missed care.

I’m delighted they’re doing this. ProPublica can do the kind of reporting my small team can’t do yet – and they need your help.

If you’re covered by Medicaid, CHIP, an ACA marketplace plan or Medicare, and you’ve had a prior authorization request delayed or denied, they want to hear from you. That includes people in Medicare Advantage plans, where prior authorization is especially prevalent. It also includes people in traditional Medicare, where it has been rare until very recently.

The Trump administration is testing a program called WISeR that brings prior authorization into traditional Medicare for certain services in several states. Private tech companies are doing the reviews. As we have reported previously, this could be the start of turning traditional Medicare into something that looks a lot more like Medicare Advantage. If you’re in traditional Medicare and have run into WISeR, ProPublica wants to hear about it.

The reporters also want to hear from people who see the process from the inside. That includes doctors, nurses and office staff who fight these battles every day. It also includes regulators and people who work for insurance companies.

That last group matters. I know from my own years in the industry how much insiders know that the public never sees. If you work at an insurer and you’ve seen how prior authorization really works, please consider reaching out.

ProPublica says it will read everything submitted and won’t publish anything without your consent.

You can share your story here.

Why workers are giving up health insurance

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment
https://time.com/article/2026/10/22/us-health-care-costs-becoming-unsustainable/?utm_source=beehiiv&utm_medium=email&utm_campaign=newsletter-health-matters&_bhlid=c45aa2147e9223ce0a6186db43d0349c7193b7a1

Amber Kostka, who owns The Stockpot restaurant in Hampton Roads, Va., says she has tried to do right by her employees by offering them health insurance, alongside good wages and a 401k.

But as costs have risen—premiums have roughly tripled since the company first started offering health insurance in 2018—her employees are increasingly telling her they can’t afford health insurance. That’s even though she splits the cost of premiums with employees, which are roughly $400 a month.

Instead, employees are dropping out of the plan and going uninsured, she says. About 35% of her eligible employees now buy the employer-sponsored health insurance, she says, down from 50% prior to COVID. She wants to warn them about the risks of going without insurance, she says, but also knows their finances are extremely tight. “It’s just a cost thing, at the end of the day,” she says. “You can’t stop paying for groceries.”

Her employees aren’t alone. The share of working-age U.S. adults without health insurance rose to 11.2% in 2026, up from 8.9% in 2024, according to new research from the Commonwealth Fund. People don’t have health insurance because the costs of everything—including gasoline, housing, and food—are rising, and they’re deciding they can’t afford to pay for even employer-sponsored plans like Kostka’s. “The whole system just seems like a complete gamble with people’s lives,” she says.

Some people are looking at the price of plans on the Affordable Care Act marketplace and deciding they can’t afford health insurance. Premiums on the ACA marketplaces increased by an average of 58% in 2026 after Congress decided last year not to renew expiring subsidies.

Ironically, these uninsured Americans may be helping drive the cost of health care even higher, fueling a cycle in which health insurance gets more expensive, forcing more people to drop coverage. As hospitals field more uninsured patients, they have to pass the costs of uncompensated care onto someone. “When providers have to provide a lot of uncompensated care, how do they make themselves whole? They raise prices,” says Beth Umland, director of employer research for Marsh, the health benefits consultant company formerly known as Mercer.

Of course, having more uninsured Americans isn’t the only reason costs are rising. A Marsh survey of employers recently found that they expected total health benefit costs per employee to rise 8.2% in 2027, the highest increase since 2003. One reason was that the consolidation of health systems was leading to higher prices, as some systems had monopolies in certain markets. Another was that lower government spending for public health programs was leading to higher costs for private sector plans.

“This is starting to feel—’unsustainable’ is the word you hear,” she says.

Many of the reasons why health care costs are rising may seem minimal until you start adding them up, Umland says. For example, more doctors are using AI scribes in care, which are helping them bill for more services, making care more expensive, she says. A clause of the No Surprises Act, which was passed by Congress in 2020 to protect patients from surprise medical bills but which allows disputes to be settled by arbitration, has also added billions to costs, she says.

There are also increasingly more treatments available for patients, and those treatments are more expensive than the ones they’re replacing, she says. One example: GLP-1s, which may save insurers money in the long run on health costs but which are expensive upfront. “That’s just a whole new category of expense that didn’t exist before,” she says.

In its survey, Marsh found that many employers were planning to pass costs onto employees after years of trying not to do so.

Overall, workers are paying on average about $7,471 annually towards premiums for employer-sponsored family health benefits this year, up 9% from 2025, according to a new employer health benefits survey from KFF. Workers at small firms with less than 200 employees—like Kostka’s—are especially hard hit, paying about $9,687 towards family coverage: $2,847 more than workers in larger firms.

And even as they pay more for health care, the plans available to them are getting costlier to use. The average deductible for employer sponsored plans has increased 34% over the last 10 years, according to KFF.

What employers are doing

Kostka says there have recently been fewer health insurers in her area to choose from. Two years ago, she switched from just buying insurance outright for her employees, which many small businesses do, to self-funding the plan. She was able to do this because her employees are relatively young and healthy, she says, making her risk of incurring big medical costs for cancer or a catastrophic illness relatively low.

But she knows she’s just a major diagnosis away from being dropped from the self-funded plan, she says. “It’s a little bit of a gamble right now,” she says.

There are some things employers can do to push back against high health care costs, says Jim Winkler, chief strategy of the Business Group on Health, which published its own recent survey of employers which projected health care costs to rise 9% in 2027, the highest forecast the group has ever recorded.

Some employers are dropping coverage for GLP-1s for weight loss to save money, he says. Others are trying to drive employees toward what are called Centers of Excellence—essentially hospitals or medical practices with high ratings that may save money in the long-term since employees won’t need to return again and again for care. Some employers are also telling employees to try to find cheap, legitimate medications where they can—from sites like GoodRx, for example—and reimbursing them, rather than getting medications from a pharmacy benefit manager.

“We’re just painting a really challenging picture for health care costs,” he says, “which leads employers down the path of needing to find things to do to take action to mitigate them.”

A small number of employers are deciding not to offer health care at all and are instead offering employees cash to buy their own plans through the ACA marketplace. This option, called an ICHRA (Individual Coverage Health Reimbursement Arrangement) is pushed by Republicans, Winkler says, and was introduced during the first Trump Administration.

Small employers, though, often can only choose from available plans, and if there aren’t many, they don’t have much room to negotiate.

It’s a problem facing Mas Torito, owner of Kokoro restaurant in Denver. He spent close to $150,000 in premium payments for his employees in 2025 and is on track to spend $200,000 in 2026. That’s about 2.7% of revenues; most restaurants only have margins of 2-3%.

“Really since COVID, every single year feels like there are these extra pressures on us,” he says.

Kokoro has been in business for 40 years, and some of Torito’s employees have been working at the restaurant the whole time. He suspects that having an older pool of employees is part of what’s driving his health care costs up every year.

“I think they see the number of claims and costs every year going up,” he says, “and that translates into higher premiums.”

Like Kostka, Torito is committed to offering health insurance for his employees, even as his own costs rise. And like Kostka, he’s hearing from more employees that they can’t afford it. Now, only about 40% of his employees buy the insurance, he says.

“I get it,” he says. “The deductible keeps going up every year, the insurance keeps going up. It’s enough where people are really thinking, ‘Hey, do I want insurance or not?’”

Three Structural Changes Necessary to Health System Sustainability

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment
Three Structural Changes Necessary to Health System Sustainability

Last Friday, I had the honor of meeting with Fellows in the Milbank Memorial Fund program where top state health department and elected leaders discuss policy issues facing their states. Their issues are mounting and complicated. Their role and the scope of their responsibilities are expanding. Per the National Association of State Budget Officers, health programs accounted for 31% of the average state’s budget in FY2025 though what’s included and how it’s spent varies widely by state.

Most are compensated below their private sector peers.  All work long days. All share similar challenges:

  • State legislatures are asking for simple answers to complex problems about costs, coverage and services.
  • Governors are asking for solutions to politically-sensitive problems that don’t disturb voter confidence.
  • Program leads in state health agencies want increased funding and less administrative oversight.
  • Healthcare trade associations are amping-up their advocacy machinery to protect their interests and fend off election-year losses.
  • And federal policies, rules and guidelines from HHS, CMS, VA, CDC, DOD, FDA, DOA et al are changing almost daily prompting court actions and regulatory chaos. In tandem. funding cuts via the One Big Beautiful Bill, uncertainty about programs like Rural Health Transformation and vaccine policy, and endless directives paralyze state health leader effectiveness.

The federal government played a back seat to states until the modern era. That changed as Medicare and Medicaid became the primary banks for healthcare. By design, states oversaw the delivery and financing of healthcare services within their borders, often experimenting with innovations in coverage to address growing access issues in underserved populations.

Today, states have a full plate: control licensing and scope of practice, insurer solvency and coverage requirements, retail pharmacies, public health programs, competition, price transparency, facility adequacy and safety (hospitals, nursing homes et al) and many much more. Since the conservative leaning Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization (2022), tricky issues like abortion rights and others have defaulted to states to adjudicate further taxing the state’s healthcare leadership and resources.

The road ahead for state healthcare regulators will be harder regardless of the state’s population, partisan leaning and resources. Spending levels are not sustainable, dissatisfaction with the health system is at an all-time high and neither political party has advanced solutions that achieve the triple aim: better care, lower cost and universal access.  Reality:

  • The healthcare industry changes faster than its laws and regs. As a result, policy changes are primarily focus on corrections to known flaws rather than systemic reforms that enable sustainability long-term.
  • Short-term opportunities for healthcare investors benefit from the dysfunction. Winners in the industry leverage regs and rules that favor specialty care, consolidation, cost+ business models and profit maximization. Non-profit status protects favorable tax treatment at local, state and federal levels while day to day operations is indistinguishable from investor-owned competitors.

In 2009 in preparation for the White House Office of Health Reform Affordable Care Act deliberations with industry groups, I examined the structures, financing and clinical results of health systems in developed economies (OECD) of the world. Each was unique, but all operated at lower cost than the U.S. and all produced population-based clinical results that rivaled the U.S. Of the 12 I studied closest, the U.S, ranked in the bottom 3 on almost every measure except one: cost.

No two countries are alike like no two states are alike, but three structural elements were apparent in every system that outperformed the U.S.:

  • Primary and Preventive Health Gatekeeping: Developed systems integrate public health (social determinants) with physical and mental health, nutrition, prophylactic dentistry and restrictive formularies. They enable primary care for all, and facilitate access to specialty services through gatekeeping for the substantial majority of citizens.
  • Clinical standardization based on evidence: Every system of the world that outperforms the U.S. operates an independent NGO whose purpose is to monitor science and align diagnostics and therapeutics with what is proven to work. As AI-enabled clinical directives become mainstream tools in the U.S. system, adherence to what works best in what order (step therapies) will enable reduction in unnecessary care and engagement of individuals in self-care.
  • Global budgets: Remarkably, countries that out-perform the U.S. set national budgets for their healthcare programs and ration care toward system-wide priorities. They spend 8-12% of the country’s total GDP (vs. 18% in the U.S.) and appropriate more resources to primary and public health and less to acute services proportionately.

The conundrum for Milbank Fellows is the obvious: big, structural changes like these require federal involvement. They’re common sense. They’re not about bad people; they’re about structural flaws in the status quo that need fixing.

It will require a thoughtful, national plan to transform the U.S. system. States can be the stimulus for change, especially through interstate initiatives and knowledge-sharing akin to the Milbank Fellows Program.

Ultimately, it will require a federal Manhattan Project that subordinates the proprietary wishes of the industry special interests and political gamesmanship by partisans to achieve a system that’s sustainable, effective, efficient and operates with and for the people served.

States are the frontline for system reform in U.S. healthcare.

Why Healthcare is on Defense

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment
Why Healthcare is on Defense

Last week was business as usual for the U.S. health system as other events grabbed the lion’s share of media attention:

  • Healthcare affordability and fraud were frequent mentions as GOP candidates railed against socialized medicine and industry’s lack of competition at the 2-day ‘Trumpalooza’ event in Dallas.
  • An apocalyptic prediction released on X by Evan Hubinger, a former Anthropic alignment lead, that ‘there’s a 10% chance that RSI (recursive self-improvement) AI could kill all humans in the next decade’ prompted social media frenzy and calls for AI regulation.
  • Wars in Iran and Ukraine continued.
  • The Jewish High Holy Days began with celebrations of Rosh Hashanah Friday just after 9-11 commemorations concluded across the land.
  • And the August CPI report from the Bureau of Labor Statistics showed prices elevated as the Iran war’s energy shock spiked an inflation and prompted concern the Fed might raise interest rates at its meeting this week.

With the exception of continued commentary about the Lindsay Clancy’s mistrial and post-partum psychosis defense, the healthcare system was virtually unscathed last week. For many in healthcare, ‘out of sight, out of mind’ is OK. It allows the system to operate without distraction from unwelcome criticism—disdain for media coverage has long been the preferred modus operandi in healthcare, preferring instead its own PR, ads and behind the scenes advocacy to keep things in order to its liking. It isn’t working.

Reality: The U.S. healthcare industry is not the crown jewel of our national pride. At the opening ceremony of the 2012 Olympic Games in London, the Danny Boyle-produced tribute to the National Health Service opened the games. A similar sentiment about the U.S. system is unimaginable. In its place, a dark cloud hovers above U.S. healthcare today. It is the industry’s biggest threat. The eminent cloud burst will wrack havoc on every provider, every investor, every user and every taxpayer in the U.S. unless preparedness is taken seriously.

It did not form overnight: it’s been building for 30 years but it darker and more threatening today than ever before. Here’s why:

  • Systemic arrogance: For decades, Americans have been told our health system is the envy of the world. We’ve embraced the industry hubris—the best doctors, the best hospitals. the newest drugs, the latest technology and most modern facilities and so on. But through these decades, costs have soared while population health and longevity have declined. Better ways to diagnose, treat, and deliver services are confined to privately-funded organizers whose shareholders see financial upside, while the less lucrative needs are left to public programs and do-gooders to bootstrap. Benign neglect for educating the U.S. population about how the health system works, how it’s organized and financed, how to use it is is the system’s original sin. It was designed so that dependence on the system via doctors, insurance, hospitals and drug companies was its foundational presumption. Evidence shows done right; it works. But it hasn’t. It declares its exceptionalism while hiding its business practices to avoid scrutiny. It rejects self-care deeming it only applicable to simple problems and presumes its concept of value always keeps ‘high quality’ distant from ‘low price’ in the public psyche. And it reinforces politics and policies that keep primary care, preventive health and social services for lower income and older populations subordinate to specialty services. Ironically, its workforce—25 million strong—that’s been warning of the cloud burst loudest. They think compensation for health executives is excessive, un-deserved and contributing to the storm.
  • Corporatization-driven wealth: The industry’s business practices have created massive wealth for some. 45 of the Fortune 500 companies is an investor-owned healthcare corporation. The industry’s executive class is among the highest paid compared to peers in other industries and the differential between the industry’s working class and its senior managers is the highest of all industries. Physicians have protected the profession’s distinction as the U.S. highest paid career even after accounting for the three-fold median gap between primary care and some surgical specialties. Polls show the majority of voters aren’t sure what ‘not-for-profit’ means or if it matters. Investing in healthcare is a safe bet, especially when overall market conditions are less welcoming. That’s the secret sauce that let’s the industry maintain prominence in wealth creation for risk takers, high compensation for its managers, executives and surgeons and carry grow in the aggregate faster than GDP and household wages. It’s a business, not a calling, for its management ranks, their advisors and private funders, because corporatization produces sizeable wealth for some.
  • Blame and Shame Advocacy: The major trade associations in healthcare have contributed to the cloud’s growing intensity. Protection of their members’ interests has takes precedent over the overall sustainability of the health system. That’s understandable: their Boards expect no less from their CEOs and teams. Thus, blame and shame advocacy is a priority over coalition building for systemic reform. But voters, employers and lawmakers increasingly recognize the obvious, no trade group in healthcare effectively represents the system as a whole. Short-term wins on proposed regulations, spending authorizations and policy shifts threatening to a specific tribe are their domain. It’s for others to fix the system even as the cloud gets darker.

Political campaigns obscure facts and oversimplify solutions to complex challenges like fixing the health system. Protecting the status quo in healthcare is what its insiders want and it’s why they’re on defense. 

Paul

PS On 9/11/01, I was in Harry Jacobson’s conference room at Vanderbilt Medical Center discussing plans for our new Center for Integrative Health. The pictures of planes crashing into the World Trade Center, souls jumping to their deaths, fire-fighters running toward danger and dusty New Yorkers in zombi-like bewilderment are etched forever in my memory. It makes faith and family more meaningful and industry issues less. But in those days and after, our country seemed, if only for short while, united for a purpose. That spirit is needed for transformational change to the health system. It’s collapsing like the twin towers.

Is AHA Right to be Concerned?

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment
Is AHA Right to be Concerned?

Last week, the American Hospital Association released a study by Kaufman Hall, its preferred data vendor, that took issue with methodologies used by critics of hospital consolidation:

“These findings suggest that a more comprehensive analysis of hospital M&A transactions, one that considers impacts on all patients served, broadens the focus to impacts beyond pricing, and considers the consequences if an M&A transaction is not permitted to proceed, would ensure not only competitive but also healthy hospital markets that can continue to provide the fullest possible range of services.”

The report discusses how hospital merger reviews should look beyond the potential impact on commercial insurance prices and consider what proposed transactions mean for all patients, particularly the nearly 60% of hospital patient days attributable to Medicare, Medicaid and Medicare Advantage beneficiaries whose payment rates are largely set by government programs.” Drawing on analyses of challenged and canceled transactions, the report also finds that hospitals seeking partners often serve more vulnerable communities and face greater financial pressures, and that when proposed deals do not move forward, struggling hospitals can experience significant financial deterioration that threatens services, workforce stability and access to care.”

Kaufman Hall added this disclaimer: “The findings contained in this document may contain predictions based on current data and historical trends. Any such predictions are subject to inherent risks and uncertainties. Past performance is not necessarily indicative of future results. Kaufman Hall accepts no responsibility for actual results or future events.

Also last week, a Health Affairs commentary “In 2026, States Are Leading On Health Care Affordability” noted that “Research has consistently shown that hospital prices are the largest driver of commercial health care spending growth. Hospital markets are dominated by monopolies, which enable hospitals to charge higher prices without improving quality or outcomes. State policymakers are increasingly looking for options to limit excessive hospital prices. Our research shows that capping the highest, most egregious prices charged by hospitals can meaningfully improve health care affordability while still allowing hospitals to generate a healthy margin…

A key driver of rising health care prices is consolidation in health care systems, including through hospital acquisitions of physician practices. These acquisitions, which are a form of vertical integration, increase hospital prices by 3 to 5%. This can be attributed to greater bargaining power, more intensive coding practices, and hospitals charging facility fees at what were previously independent physician practices but are now treated as “hospital outpatient departments.” To address these issues, states are increasingly considering facility fee bans or “site-neutral” policies that would cap prices for certain routine hospital outpatient services that could be provided safely in an office setting.”

Both positions are defensible.

Not for profit and public hospitals are at a disadvantage in managing their finances because they’re obligated to serve entire communities without regard to local economies or population health. Investor-owned hospitals and insurance companies have fewer restrictions and can exit markets at will.

And almost every hospital is dependent on reimbursement from commercially insured patients to offset what is the widely-accepted calculus that Medicare and Medicaid reimbursement doesn’t cover the total cost of care provided enrollees. Thus, across the hospital industry, the playbook has been straightforward: to optimize hospital finances….

  • Maximize the attractiveness of hospital services that attract privately insured patients via contracting with private insurers.
  • Negotiate favorable rates with private insurers to enhance cost-shifting to Medicare and Medicaid by private plans.
  • Optimize leverage (scale) over insurers by consolidating hospitals, acquiring physician practices, expanding ancillary activities and deploying capital to potentially profitable ventures.
  • Advocate for state and federal laws that dissuade hospital price caps, 340B cuts, site-neutral payments, unreasonable price transparency requirements and limits on private-equity partnerships.
  • Assert that hospitals are efficient stewards of the public’s trust but disadvantaged by corporate insurers and drug companies that are allowed to enter and exit markets at will, price at “what the market will bear” and put shareholder profit above all else.

This scheme has worked for 40 years to enable hospitals to control at least 50% of total health spending: 31% for traditional hospital services, 12% of total physician services, and ventures, partnerships, ancillary services and post-acute services in addition. In the aggregate, hospitals are the most important cog in the healthcare wheel. They’re labor intense, capital intense, complicated businesses that enjoy public trust that’s slipping away, especially among the 25 million who work in the industry.  Complicating matters, distinctions between rural and government safety net hospitals and highly profitable investor-owned and not-for-profit systems are attracting unwanted scrutiny from regulators and in media coverage.

While Kaufman Hall raises legitimate questions about current methodologies used by state and federal regulators to assess consolidation, it does not answer the bigger question: what role should hospitals play in the U.S. system as AI-derived clinical innovation proliferates, labor and supply costs accelerate and fewer people can afford services?

It’s not clear.

  • Should “hospital services” be redefined bifurcating facility-dependent inpatient services (Part A) and an expanded set of services inclusive of self-care provided in homes, schools, workplaces and virtually?
  • Should “community-benefits” and “charity care” be redefined so that methodologies are consistent and gaming to receive tax benefits eliminated?
  • Should hospital clinical performance be linked to improved outcomes and lower costs (affordability)?
  • Should local primary care and preventive health services (inclusive of nutrition, physical and mental health, prophylactic dentistry) be integrated with hospital services to improve population health and control demand for hospital services?
  • Should specialized tertiary and quaternary hospital programs be rationalized to optimize outcomes and improve efficiency?
  • Should consolidated hospital systems disclose administrative costs, functions and allocation methodologies publicly?
  • Should hospital boards be required to conduct scenario planning that’s comprehensive?
  • Should hospital administrative services and costs be standardized to facilitate caps on spending and management performance comparisons?
  • Should physician ownership of hospitals be enabled to increase competition?

And many others.

The American Hospital Association is right to be concerned about how regulators are addressing hospital consolidation and its impact on prices. And they’re right to challenge methodologies applied to questions about hospital prices and competition. But they fall short in offering a vision for the future of the health system that’s plausible, affordable and compelling. Rather, they offer a hospital-centric vision based on suspect assumptions and inadequate sensitivity to market trends not directly associated with traditional health services.

Every stakeholder in the health system—including hospitals and physicians—face heightened pressure to eliminate unnecessary utilization and costs due to willful or unknowing fraud. Just as insurer prior authorization practices have been frustrating to providers, unnecessary care is confounding to regulators and employers. The use of agentic AI tools to examine appropriateness of tests, procedures, medications and visits will exponentially change how “quality of care” is defined and regulated, and how its delivered. It’s a big deal everywhere, especially in Medicaid programs.

Washington Wants AI Regulation. It Should Start With Health Insurers.

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment
https://healthcareuncovered.substack.com/p/washington-wants-ai-regulation-it?utm_source=substack&utm_medium=email

As lawmakers develop a national artificial intelligence framework, health insurers are already using automated decision-making tools to influence Americans’ access to care.

Barack Obama spent an hour last week telling House Minority Leader Hakeem Jeffries and a room of Democratic donors that artificial intelligence is “moving very fast in private hands” and that the party needs a real plan before it gets away from them entirely. He said a public framework on AI safety was urgently needed and that Democrats should make AI safety a “central agenda” in January when the next Congress is sworn in and when attention begins to shift to the 2028 elections.

Obama’s remarks were reported this past weekend alongside similar warnings and calls from AI industry leaders.

House Democrats apparently are working on the kind of “framework” Obama called for. Jeffries launched the House Democratic Commission on AI and the Innovation Economy last December, and the commission reportedly has a policy framework due this fall. That’s good news – and a good start. Rules governing how AI is built, tested and deployed will inevitably shape how health insurers can use it. But that framework also has to account for what happens when AI moves into high-stakes, industry-specific decisions. But if it doesn’t mention health insurance by name, it will have missed the industry that is already furthest along in using AI to make decisions about who lives, who dies, and who pays — with almost no oversight at all.

THE BOTTOM LINE: Health insurers are already using algorithms to influence coverage decisions. Any federal AI framework should require meaningful human review, clinician override authority, transparency and patient appeal rights.

This isn’t a hypothetical harm sitting somewhere out on the horizon, the way a lot of the AI safety conversation still is. It’s happening in claims systems right now. And the company doing it loudest and proudest is none other than the biggest and most profitable health insurance conglomerate, UnitedHealth.

UnitedHealth told shareholders and Wall Street financial analysts when it announced first quarter profits in April that it’s spending $1.5 billion on AI in 2026 alone, with executives promising a “conservative” 2-to-1 return within 12 to 18 months. A third of that money is going into new AI software products the company hopes to sell to other health systems. The other two-thirds is going into what Optum Insight’s CEO called “signature end-to-end processes” — the internal machinery of how the company handles care.

Some of that machinery is aimed at speeding up prior authorization decisions, and the company points to real numbers: turnaround times cut, call volumes down, a pharmacy tool that reportedly shrank prescription approval from eight hours to under 30 seconds. That’s good if true and the whole story. Nobody is nostalgic for eight-hour prior auth waits.

But the same earnings calls that tout faster prior auth decisions (denials as well as approvals) are the ones that tout a lower medical loss ratio — the industry’s term for the share of premium dollars that actually goes to patient care. UnitedHealth’s second-quarter medical care ratio fell 270 basis points this year, and executives credited the AI investment directly for that unexpectedly big decline in medical spending. When a company brags to Wall Street that artificial intelligence helped it spend less on medical care, that is not a customer-service story. It’s a story about how the company is boosting profit margins, and patients are the input being optimized.

The algorithms already have a body count

UnitedHealth and Humana are both being sued right now over their use of an algorithm called nH Predict, which families allege was used to cut off coverage for elderly and disabled patients in extended care — sometimes overriding the judgment of the company’s own medical staff — based on a tool plaintiffs say gets it wrong up to 90% of the time on appeal. Cigna is fighting a parallel case over its PxDx system, which ProPublica found had denied more than 300,000 payment requests in a two-month span, with a company doctor spending an average of 1.2 seconds per claim.

Both cases, which are still working their way through the courts, rest on the same basic allegation: that a health plan let software stand in for the individualized medical review its own policies promised. A federal judge has already allowed the Cigna case to move forward on exactly that theory.

Elizabeth Nicholas, writing in Vanity Fair last week about her own fight with her insurer during breast cancer treatment, put the trajectory more starkly than I have. Her argument is that the industry has already trained the humans who run it to set their humanity aside and act like machines — which is exactly what will make humans so easy to replace. (Several big insurers, including Cigna where I used to work, have said they are laying off thousands of workers this year.) Soon, she writes, “there won’t even be executives left to email; only code,” carrying out profit directives with no capacity for hesitation or mercy. Her essay’s whole premise was that she still had a CEO’s name to put in an email she sent begging the insurer to reverse a denial of a life-saving treatment. Take the human off both ends of that exchange and there’s no one left to shame, sue, or vote out.

A handful of states aren’t waiting for Congress. Colorado now requires bias audits and guaranteed appeal rights for AI-driven coverage decisions. But even bias audits raise a bigger question of what exactly counts as bias when an insurer builds these tools? An algorithm can pass checks for discrimination and still be designed to advance the insurer’s financial interests, including reducing spending on medical care. And as insurers increasingly build their tools on general-purpose AI models, biases embedded in those underlying systems can carry into whatever gets built on top of them.

California and Texas have both moved to require that a licensed physician, not an algorithm alone, sign off on any denial based on medical necessity. That’s real progress — and it’s also proof of how far behind federal policy is. Coverage decisions shouldn’t depend on which state you happen to live in.

Jeffries has already put two members of his caucus in charge of a group that presumably will come up with recommendations on health care reform priorities. Alexandria Ocasio-Cortez of New York and Terri Sewell of Alabama are co-conveners of House Democrats’ Cost of Living Healthcare Working Group, tasked with building out the party’s affordability agenda on health care. So far, the public framing of that group has been about premiums, Medicaid cuts, and ACA tax credits. None of that is wrong. But if AI’s growing role in coverage denials isn’t part of what Ocasio-Cortez and Sewell put forward, the working group will have missed the fastest-moving cost driver in the field they were assigned to cover. They’re the two members with the standing and the mandate to put specific, concrete AI proposals on the table — not vague concern, but actual legislative language on human review requirements, transparency, and audit rights. That’s the natural home for this work, and it shouldn’t wait for the broader framework Jeffries is still finishing.

Every argument Obama made to Jeffries about why Democrats need an AI framework applies with more force, not less, to health insurance. He talked about job displacement from AI — insurers are already using it to displace human medical judgment. He talked about AI moving fast in private hands — seven for-profit companies control most of the American health insurance market, and they answer to shareholders, not patients. He said he didn’t want to be a “doomer,” and neither am I. AI genuinely could help identify fraud, speed up legitimate approvals, and cut the paperwork that eats a doctor’s week. Nobody serious is arguing it should be banned from health care.

The argument is narrower than that: When an algorithm is making or heavily influencing a decision about whether a person gets the care their doctor ordered, someone accountable has to be able to explain why, a licensed clinician has to be able to overrule it, and the patient has to have a real path to appeal. Right now, in most of the country, none of that is guaranteed.

Any Democratic AI framework that talks about jobs, misinformation, and existential safety risk while staying silent on the algorithms already deciding who gets a breast cancer treatment, a hip replacement or a nursing home stay isn’t a serious framework. It’s an incomplete one. Jeffries has the chance to make sure it isn’t — and given that he reportedly brought up the resignation letter of an Anthropic employee warning about the dangers of AI development in his conversation with Obama, he’s clearly already thinking about where AI could do real damage. Health insurance should be at the top of that list, not an afterthought to it.

The Biggest Health Care Companies in America Don’t Treat Anyone

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment
https://healthcareuncovered.substack.com/p/the-biggest-health-care-companies?utm_source=post-email-title&publication_id=255152&post_id=217144235&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

It started as a simple question. Who are the biggest health care companies in the United States?

If you rank the ten largest health care companies in America by revenue, you will not find a single hospital system or drugmaker. Not Pfizer, not Eli Lilly, not the Mayo Clinic or HCA. Every company in the top ten is a middleman, and together they take in about $2.6 trillion a year.

Above is a list showing how much of every dollar of revenue each company keeps as net income. Then read about what these companies actually do.

Three of these companies are insurers that swallowed pharmacy benefit managers: UnitedHealth owns Optum Rx; CVS owns Caremark and Aetna; and Cigna owns Express Scripts. Three are drug distributors that move pills from the factory to the pharmacy and touch almost none of them. Three more are built on Medicare and Medicaid managed care. Every one of them sits between the people who deliver care and the money that pays for it.

McKesson, Cencora and Cardinal Health each keep somewhere between half a cent and a penny of profit on every dollar of revenue. Cencora reported $294 billion in sales in fiscal 2024 and $1.5 billion in profit. That is a rounding error as a margin. And yet all three rank among the thirty largest companies in the world.

No other rich country works this way

The sheer size of these companies is another distinctly American feature of the system. On the 2026 Fortune Global 500, UnitedHealth ranks fourth in the world, ahead of Apple; McKesson is seventh; CVS is ninth; and Cigna, where I worked for 15 years, ranks 14th in the U.S. and 21st in the world. Every health care company near the top of the global list is an American intermediary in one way or another. There is no foreign health care business of any nature that comes close.

The closest thing another country has to one of our giants is Allianz, in Germany. Allianz is the largest insurance company in Europe. But it is a general insurer built on property, life and asset management, and health is a minor line. Even at home, Allianz is only the third largest health insurer in Germany. There, roughly nine in ten people are covered by nonprofit sickness funds, which are barred by law from operating as for profit and must send any surplus in funds back into the system.

And then there are Britain’s National Health Service (NHS), which is funded by taxes; Canada’s single-payer system financed through the provinces; and Japan’s nonprofit insurance system based on a standardized national fee schedule.

None of these countries built the kind of for-profit middleman layer that exists in the U.S., where some of those companies have grown into the largest corporations in the world. Pharmacy benefit managers are also a uniquely American creation, which helps explain why that entire category of health care giant does not exist elsewhere.

What the middleman layer costs

The United States spent $5.3 trillion on health care in 2024. That was the first year the country ever crossed $5 trillion, and it is the most recent year with actual figures rather than projections. (The Centers for Medicare and Medicaid Services estimates total U.S. health spending will reach $6 trillion this year.)

A large share of that money never reaches care and instead is consumed by the U.S. health care system’s complicated administration and payment systems.

In 2021, the United States spent $925 per person on health administration, meaning the overhead of insurers and government programs. The average wealthy country spent $245. That gap of $680 a person accounts for about 12% of the entire difference between what America spends on health and what its peers spend. As a share of the total, administration eats about 7.6% of U.S. health spending against 3.8% across comparable nations. We devote twice the share of every health dollar to running our absurd machinery.

The $925 figure counts insurer and government overhead and does not include what hospitals and doctors spend on billing, coding and prior authorization just to get paid. When those costs are included, estimates put total administrative spending between 15% and 25% of all U.S. health care spending — or, based on 2024 spending, roughly $800 billion to $1.3 trillion a year.

The countries with the leanest administrative spending tend to be those (you guessed it!) with the fewest middlemen.

Middlemen spend to keep the status quo

I know how a system this profitable defends itself because I used to help do it. Back at my old gig at Cigna, my team and I wrote talking points for lobbyists to use with lawmakers, and we doled out campaign cash to candidates we liked.

The health sector spent $743.9 million lobbying the federal government in 2024, more than any other sector of the economy and the only one to clear $700 million. UnitedHealth alone spent $16.6 million in the 2024 election cycle. The insurance industry’s trade group, AHIP, and the biggest insurance conglomerates pour tens of millions more into the same effort year after year, and the pharmacy benefit managers keep their own operation running through another insurance industry funded trade group called the Pharmaceutical Care Management Association (PCMA), whose spending has roughly doubled since 2022.

That spending helps protect Medicare Advantage payments, fight efforts to rein in pharmacy benefit managers and oppose proposals that would move the country toward universal coverage. Compared with the $70 billion in combined profit of the seven biggest for-profit insurers last year, the lobbying bill is relatively small.

The price of “choice”

The industry says all of this is the price of “choice,” which they want folks to believe is sacred. It is the argument insurers and their allies reach for every time Congress looks at a single-payer bill or public option or any other approach, for that matter, that could move us closer to reining in the worst abuses of the industry.

Americans say they want to choose their own doctor and their own hospital, but that is exactly the kind of choice the middleman system can take away through narrow networks and prior authorization. What the industry defends instead is the choice among insurers. And for most working people, even that choice is made by an employer. We pay hundreds of billions of dollars a year to run a marketplace of middlemen, and in return we get narrower networks and more denials than patients face in the countries that never built the marketplace at all.

Depending on the results of the next two election cycles, Congress will almost certainly debate how to restructure health care again, with the familiar goals of lowering costs, expanding coverage and improving care. But any serious attempt to do that will have to confront the enormous middleman industry the current system has created and allowed to flourish.

When Insurance Says No, Some Patients Are Going Straight to the Top

Posted on by • Posted in Uncategorized • Tagged , , , • Leave a comment
https://healthcareuncovered.substack.com/p/when-insurance-says-no-some-patients?utm_source=post-email-title&publication_id=255152&post_id=218342648&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

After UnitedHealthcare denied his surgery, Donald Grant took his 11-page legal and medical appeal straight to UnitedHealth Group CEO Stephen Hemsley — and got his request approved.

Last month, Elizabeth Nicholas wrote in Vanity Fair about being diagnosed with breast cancer at 36 and then watching her insurer refuse to pay for a recommended course of chemotherapy. Her oncologist delivered the news. Nicholas’s response was to email the company’s CEO directly, laying out her case in plain, human terms rather than routing it through the black box of the standard appeals process.

I mentioned her essay briefly in the piece we published recently on artificial intelligence and health insurance denials. Since then, another case landed in my inbox that is worth looking at alongside hers. This patient fought back with an extraordinarily detailed appeal that shows just how sophisticated patients are becoming when an insurer denies critically important care.

You have to write a letter built to break through the corporate bureaucracy

On September 12, I was copied on an email from Donald E. Grant Jr., a 49-year-old industrial-organizational psychologist in Valley Village, California. It was addressed to UnitedHealth Group CEO Stephen Hemsley and copied to more than a dozen other people, including UnitedHealthcare executives, Optum’s chief medical officer, a California state senator, the lieutenant governor’s office, Attorney General Rob Bonta, and two health care reporters. Attached was Grant’s formal appeal, which runs eleven pages and cites the Code of Federal Regulations, ERISA case law and Department of Labor guidance, chapter and verse.

Grant’s situation was — and still is— serious and getting worse. A fall in August 2025 caused the sudden loss of sensation in his legs. Workup found severe congenital cervical stenosis. An in-network surgeon performed a two-level artificial disc replacement in December 2025, but it failed to adequately decompress his spinal cord. By March 2026, imaging showed new myelomalacia — scarring inside the cord itself that wasn’t there before surgery — spreading across four vertebral levels. He now has bilateral foot drop, no sensation in his lower legs, a hand going numb and weak, and new bowel and bladder problems. His surgeon, Dr. Hyun Bae at Cedars-Sinai, is a leading authority on multilevel cervical arthroplasty and its revision — one of the physicians who ran the original FDA trials for the very device implanted in Grant’s neck.

UnitedHealthcare has no in-network surgeon with comparable qualifications, and Grant argues none can safely operate within the window his deteriorating spinal cord allows. The surgery is scheduled for October 14. Everything but the surgeon himself — the hospital, the anesthesia team — is in network. He’s asking UnitedHealthcare to cover Dr. Bae at the in-network rate through a network exception.

What sets Grant’s letter apart isn’t the medicine. It’s the legal architecture around it, and that’s because he had help from Claimable, the AI-assisted appeal service founded by Warris Bokhari. The letter invokes the federal urgent-care claim regulation and its 72-hour decision clock. It demands that the reviewing physician be named, board-certified in the relevant specialty, and walled off from whoever issued the original denial — citing the exact subsection of the claims-procedure regulation that requires it. It requests the complete claim file and designated record set under both ERISA and HIPAA. It puts UnitedHealthcare on notice to preserve every internal record connected to the claim. And it names, as a co-recipient with real leverage, David Ellison — chairman and CEO of Paramount Skydance, the company whose self-funded plan is actually paying these claims, and therefore the ERISA plan administrator and fiduciary who can lean on UnitedHealthcare from above.

There’s also a section I want to draw special attention to, because it’s the clearest expression I’ve seen from a patient of a concern I’ve been raising for months: Grant explicitly demands that no algorithm, predictive model, or automated tool be used at any stage of deciding his appeal, and he wants written confirmation of that in the response. He backs the demand with a tight legal and factual history — ProPublica’s reporting on Cigna’s PXDX system, the nH Predict litigation against UnitedHealth, the Senate Permanent Subcommittee on Investigations’ 2024 report on Medicare Advantage denials, and California’s Physicians Make Decisions Act. His argument is that a federal regulation most patients have never heard of already requires what California’s algorithm-ban requires: a qualified human being in the relevant specialty, not a model trained on aggregate outcomes, deciding whether his particular spinal cord can wait.

The strategy worked. Grant told me this week that UnitedHealthcare has now approved both Dr. Bae and the procedure at the in-network rate, clearing the way for the October 14 surgery. And Grant was careful to give the insurer credit for how it handled the process once his appeal was underway. He said UnitedHealthcare employees were responsive and patient in helping him understand the approval and what he would owe out-of-pocket at the in-network rate.

“I realize this is not always the case,” Grant wrote, “but this time it worked out well.”

That’s an important part of this story too. The point isn’t that every appeal ends badly, or that an insurer can’t respond appropriately when a patient pushes back. Grant got the result he was asking for. But it took an eleven-page appeal, detailed medical and legal arguments, and an email that put executives, public officials and reporters on notice to get there. His case shows that patients can successfully challenge these decisions. It also raises a harder question: How many patients would have known how to mount the same fight?

The strategy patients weren’t supposed to have

I’ve been telling patients for years to do exactly what Nicholas and Grant did: If a denial threatens your life or your ability to function, don’t just work the internal appeals queue quietly. Go to the top. Email the CEO. Loop in the plan sponsor if you’re on an employer plan. Contact your state insurance commissioner or attorney general. Call your legislators. Talk to a reporter. Be the squeaky wheel. Insurers built the appeals system to be slow, opaque, and easy to lose interest in. They know that discourages patients to give up. Do not give up or even go through the normal bureaucratic nonsense if time is of the essence.

The nation’s largest health insurer says it is eliminating prior authorization requirements for 1,700 medical codes. Look under the hood and the announcement is considerably less impressive.

Nicholas didn’t have Grant’s legal scaffolding. She had her own voice and the reach of a national magazine. Grant has a documented clinical emergency, a sympathetic and well-known plan sponsor CEO, a growing list of public officials on notice, and — importantly — professional help translating his situation into the language ERISA regulators and general counsel offices actually respond to.

There’s a less comfortable layer here too. Grant had to do all of this — hire or enlist expert help, cite the C.F.R., demand a litigation hold on internal records — just to get the process ERISA already promises every plan member by law: a full and fair review, decided by someone qualified, free of algorithmic shortcuts. Most people denied a surgery their doctor says they need don’t know these regulations exist, let alone have the resources or stamina to invoke them. That gap is the real story underneath both of these cases. The system shouldn’t require this level of sophistication to work as designed. It just doesn’t work reliably without it.

II’ll be watching to see whether Grant actually gets his laminoplasty on October 14 with Dr. Bae in the room.