By MIKE MAGEE

When I asked my brilliant literary agent, Jill Kneerim, when I would know that my book proposal  was ready for submission, she replied directly, “It will be ready when I say it is ready.” Eleven months later, in April, 2018, she finally green lit the project, and two weeks after that, in an orchestrated two-round public auction, it “sold” to Grove/Atlantic Press.

I passed over the highest bidder in choosing to earn the opportunity to be associated with a literary and cultural publication – The Atlantic Monthly– that dates back to November, 1857, when it “quickly became known for the quality of its fiction and general articles, contributed by a long line of distinguished editors and authors that includes James Russell Lowell, Ralph Waldo Emerson, Henry Wadsworth Longfellow, and Oliver Wendell Holmes.”

Their book publishing arm, the Atlantic Monthly Press, was incorporated in 1917. A merger in 1993 with Grove Press gave birth to Grove/Atlantic. Grove was no slouch when it came to social activism. Founded in 1951, it purposefully republished D. H. Lawrence’s Lady Chatterley’s Lover: Complete and Unexpurgated, and Henry Miller’s Tropic of Cancer as a challenge to U.S. obscenity laws at the time. And in 1965, they were the original and first publisher of The Autobiography of Malcolm X.

The Atlantic Monthly’s name change to The Atlantic officially occurred in 2007 and signaled a broader and more modern editorial platform, a digital presence and engagement with multi-platform modern media. At around this time, corporate offices were moved to Washington, D.C., and the magazine focused down on politics featuring a longtime journalist, Jeffrey Goldberg. A decade later, noted philanthropist, Laurene Powell Jobs, purchased a majority stake in the growing empire, and Goldberg was elevated to editor-in-chief.

Now a decade later, with America’s 250th birthday upon us, the very same Jeffrey Goldberg penned an opening editorial – “America’s Promise” – in the July, 2026 edition. Meant to provoke, it opens with “It is quite interesting, and somewhat chastening, to realize that the most important piece of journalism published across the 169-year history of this magazine was not journalism at all, but a poem…”

That poem appeared on page 10 of Vol. IX – February, 1862. -No. LII. It had five stanzas, and no title when it was submitted. The author, an abolitionist poet and pacifist, Julia Ward Howe was a contributor and friend to then editor, James J. Fields. In November, 1861, while visiting Washington, D.C. with her husband Samuel, she was drawn to a group of Union soldiers who had joined voices to sing a familiar tune titled “John Brown’s Body” with the original hymn credited to John William Steffe, a South Carolina born Philadelphia bookkeeper in 1856, and lyrics added five years later by Mass 2nd Infantry Battalion.

Howe was not so impressed by the lyrics which she knew well, but rather by the enthusiasm of the soldiers who clearly loved the tune. And she wondered, what if I were to write different lyrics? Might the soldiers take them up as their own and pass them along to others?

As she slept on the idea, she was awakened by the tune in her head in the early morning hours, and rushed to a side desk to jot down the lyrics that had appeared spontaneously before they were lost.

The words are recognizable as poet-generated and religiously inspired. For example: “I have seen Him in the watch-fires of a hundred circling camps; They have builded Him an altar in the evening dews and damps: I can read His righteous sentence by the dim and flaring lamps: His day is marching on.”

Julia Ward Howe wasn’t certain what she had in her hands. But she took a chance and delivered the words to her friend and editor James T. Fields. Her note to Field’s revealed her ambivalence: “Fields! Do you want this, and do you like it, and have you room for it in January number? I am sad and spleeny…Isn’t this a melancholy view of things? But it is a vale you know. When will the world come to an end?” The rest, as they say, is history. It made that issue on page 10 of the February, 1862 issue, with no byline “as was then the custom.” She was paid $5. Field is credited with adding the “grand, martial, and commanding title.”

Historians say that President Abraham Lincoln wept whenever he heard the song. And it traveled well, far and wide, reappearing over a century later on April 3, 1968 at the Mason Temple Memphis, Tennessee in Martin Luther King’s final speech “I’ve Been to the Mountaintop” the night before his assassination.

Goldberg shares his discussion with The Atlantic historian, Jake Lundberg, on the significance of Howe’s effort. In his words, “By the time of the Great Depression, the ‘Battle Hymn’ had achieved a truly national character. The song’s stature is such that it can be used to make a statement in a way that the official anthem (The Star Spangled Banner) never can.”

It is said that every half century since America was born (1826, 1876, 1926, 1976, 2026) we as a nation have been forced to debate anew the steep chasm between our highest ideals as originally expressed in the Constitution, and the reality which is often brutal and disheartening. And yet, in the process, whether during the years of Reconstruction, the Robber Barons, Watergate, and now Trumpism, we are asked to recommit to the possibility that we meant what we said.

We often fall back on competing images to gauge our progress toward goodness; asked this July 4th to somehow see and interpret our reflection in a now non-reflecting pool. We are, and have always been, imperfect.

And yet, we are also the heirs of Julia Ward Howe, and her final words in stanza 5 of her original title less poem – “As he died to make men holy, let us die to make men free, While God is marching on.”

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/Atlantic, 2020)

This was such a great discussion I wanted to publish the transcript. The way I do that is to copy the Youtube generated transcript and drop it into Claude to smooth it over. I then read it and if I think it’s made an error, dip back into the video and listen to what actually happened and make a correction. This is all code therefore for me saying I think this transcript is pretty accurate but it might have a bunch of AI and human generated mistakes.

THCB Spotlight: Warris Bokhari, CEO of Claimable

Matthew: Matthew Holt here with The Health Care Blog. Another THCB Spotlight and I’m thrilled to be talking with Warris Bokhari. Warris is the CEO of Claimable and not so very long ago I had his co-founder Alicia Graham on a panel at ViVE, where she was faced up with at least one senior executive of a big health plan — although the other one didn’t show up because apparently my questions weren’t going to be nice or something like that. [laughter] So if you’ve seen Warris around on LinkedIn, you know that Claimable has certain loud points of view. But Warris, why don’t we start with what Claimable does. We’ll get into a little bit about what you’ve been doing before that and then we’ll probably — the most of this conversation is how do we fix American healthcare, because that’s what two British guys, as we both are, should be discussing. 

Warris: I also — much to the annoyance of Anthem’s PR person — would like to talk about that panel as well. I don’t know if that’s off limits, but we’re [laughter] happy to talk about it. The good news is I remember what actually happened on it. [laughter]

Matthew: And I think the only person who’s ever found a recording of it was you,

Warris: Why don’t we start with — as you suggested — what Claimable is and does. The broad problem is: we’ve in this country — and you and I, by the way, are not from here, but we live here, and I think that makes us…. 

Matthew:I’m old, so I’ve lived here more than I lived in England; I’ve lived essentially my entire adult life here — 

Warris : depending on when you consider me to have become an adult the same could be said for me. [laughter] So the broad problem is that every year in the US there are about a billion denied claims across the entire healthcare system. That’s when you think about Medicare Advantage, when you think about commercial — which includes self-insured and fully insured plans — the ACA exchange, which we’ve been busy trying to kill (which is ill-advised), and Medicare, Medicaid, etc. So across all of those plans there’s a billion denials out of the 5 billion claims filed every year, and really only about 1 million appeals ever get filed. Now when you think about how many humans this affects — obviously there aren’t a billion humans in the United States, there are 300 million insured people — if you look at the latest data from the Commonwealth Fund, it backs into like a 1-in-5 denial rate, but that’s as high as 1 in 3 if you have a chronic disease. So a third of America — quite a lot of Americans — have a chronic disease and they’re battling denials. 50% of these denials are medication denials. And if you think about the few modes of health care — there’s the stay-well mode, which is manage chronic disease well, and then there’s get-care, which is normally when someone’s acutely decompensated and needs to end up in a clinic or an emergency room — we’re biasing toward people needing more expensive care because we’re restricting access to things that keep them healthy, and those are medications that keep chronic diseases controlled. So we built a TurboTax of appeals, basically, for medications. So far –  it will be expanding to include investigations like MRIs and PET scans specifically for oncology pretty soon. And we’re going to keep moving down the field. We beat around 80% of denials — I think the exact number across our entire platform is closer to 74%. But when you look in biologics, which are the expensive medications that are often restricted, we’re beating well over 80% of those cases. There are a number of ways that patients can use us. First of all there’s a direct-to-consumer door which will never go away, and that’s particularly because most providers give up and don’t appeal. And then there’s also a door where we work with manufacturers and we support their patient assistance programs — where effectively we’ve transferred the economic loss from the insurer (who’s getting the premiums and should be paying for the care) to the patient, who then has to seek subsidy from a pharma company. But effectively the payer should be paying for it at least 80% of the time. And then we’re increasingly starting to work with health systems. So those are the ways in which we work today.

Matthew: And then for the actual consumer experience — I have a problem, I don’t have anybody else to help me. I’ve seen you appealing for people on LinkedIn on behalf of people and I know Mark Cuban is an investor and he joins sometimes. But let’s say it’s all normal. I come to the Claimable website and what do I do?

Warris: Yeah, so there’s a finite number of things that we support today, just to be very clear. We get people who come to us looking for all sorts of things which we don’t cover. We cover a lot of therapeutics. Sometimes — like last week I had a mom reach out whose kid has osteosarcoma, which is a terrible bone cancer effectively, and the insurer’s answer was: hey, amputate the leg versus get surgery at Memorial Sloan Kettering. And that was one which I did on the side. So we run a for-profit AI-forward SaaS company effectively on one side, and on the other side I run a pretty much 24/7 advocacy business where I figure out how to help as many people as I can in the background whilst we’re closing the gap on all the things we can automate responsibly. But say for example you’re denied — a common example would be Zepbound, right? We get a lot of patients who are denied GLP-1s. They’re extremely helpful drugs and they’ve now been approved for more and more indications, including MASH — metabolic-associated steatohepatitis — which my dad died from. So the idea that there’s a medication that actually could have prevented cirrhotic liver through that would have been very useful say 10 years ago. But like here we are. So you could appeal for that. We take you through a very simple Q&A of what you’ve tried before — lifestyle measures, etc. — and then we’ll ask you questions about how your disease affects you.

 Because Matthew, the dirty secret is that insurers don’t think of you as a person. They think of you as a membership card and a membership ID number. You’re really a passive premium payer to them. But when you have a problem, there’s no way that you can reach them. They sure as hell don’t want you to appeal, because they never actually want to know what it’s like for a patient to suffer from a disease. So we capture the information about — for example — ‘I have severe rheumatoid arthritis. I used to be the person who did the cooking for my family on a Sunday and now I don’t see my family because my disease has decompensated so much that I’m in so much pain I can’t sleep. I sleep upright in a chair in my living room every night.’ And so patients become progressively socially isolated. We narrate that story in the patient’s words back to the insurer, and then we combine it with the clinical evidence — the peer-reviewed studies, the clinical practice guidelines, and also cases where the insurer has been beaten before — to show them: hey, your decisions seem inconsistent with these other decisions that have been made for cases just like mine. Oh, and by the way, here are all the laws that mean that what you’re doing to me is probably illegal. And we’re going to send this to the CEO of a self-funded plan, because they’re actually the fiduciary and they probably have no idea what you’re doing. We’re going to send it to the Department of Labor. We’re going to send it to the C-suite of this plan to make it extremely clear that this is a real person with real needs.

Matthew: So they are coming on board, they’re getting some AI assistance. I mean — let me ask the scalability question. How are they — I know there are very few appeals — that very few denials that get appealed. I don’t know how many are being appealed now and how many are you responsible for? Are you a significant part of the market now?

Warris: Not yet.

Matthew: As you said, the numbers globally — denials that get overturned on appeal is actually pretty high.So I don’t know how good 80% is or 75% is compared to the average.

Warris: The average from the Kaiser Family Foundation data is 44%. So across all — yeah. We’re significantly better than that. I think currently —

Matthew: I assume these are coming from providers doing appeals or is it direct?

Warris: If you look across the country, around 75% of appeals today come from the provider. The issue is — and this is the thing that people don’t understand — the provider actually has no statutory rights to appeal. They actually borrow their rights from the patient. So providers have contractual rights with United and whoever, but the patient has federally protected rights under ERISA, which was the 1974 law that was set up to make sure that employers couldn’t gamble away pension funds and things, but got extended into health benefits. And ERISA was built on top of — and this is probably more Chris Deacon’s area — but was built on top of, for the Affordable Care Act in 2010, which basically stood on those provisions and extended them to include consistent rights of independent review, which basically every state other than Alabama follows. 

And I’ve had significant arguments with the state of Alabama over their lack of compliance, as you might imagine. And so what we believe is that your first appeal is your best appeal. We try to put as much forward in the patient appeals as possible. The first battle was convincing anyone that this problem mattered. No one believed — three years ago, when I posited that this was a problem, no one believed me at all. And it wasn’t until after Brian Thompson died that suddenly the Overton window shifted. And initially it shifted in a really unhealthy way, which was a kind of morbid fascination about Luigi and other things. And then it shifted into like solutions — and I’m here for that, right? How do we get patients’ rights upheld? How do we get them access to care and not have them become progressively disabled? We’ve certainly had cases where we’ve intervened but it’s been too late. And pretty much nothing is more painful to us as a team than winning for a patient but it being a completely Pyrrhic victory — the patient dies or comes to significant harm. It’s probably happened four or five times this year.

Matthew: Yeah. So the majority of cases — you mentioned GLP-1s, but the majority of cases that you’re facing — how much of this is: people either change health plans or their health plan gets changed on them by their employer, and a new one has a PBM which doesn’t cover the drug that they spent years figuring out actually works for them? Or in some cases the PBM changed the formulary on the drug. And a lot of this is not necessarily massively expensive — not the hundreds-of-thousands-of-dollar biologics — but some of them are serious. And obviously because one drug can work for one patient and another drug may not work for that patient, that’s a big issue. We know the reasons why the PBMs are changing different brands for another, and even changing different generics for another. But give me a sense — how much of what you’re seeing is that? The other one that has raised a lot of hackles recently — a lot of news — is obviously the nursing home/SNF denials, rehab denials, especially in Medicare Advantage. How much of that are you seeing? Do you do that? Give me a sense of what’s going on out there in the wide world of denials and which ones you’re mostly picking up at Claimable.

Warris: Yeah, so in pretty much all therapeutics. I have done rehab denials, just FYI, and the provider can be as much to blame as the insurer in some of the cases I’ve seen. Some of that’s about DRGs — disease-related groups — and not wanting to split them. In fact, the first case we appealed was a stroke rehab patient, come to think of it, and the provider was afraid to appeal because they were worried about retaliation from the insurer. And we got that one overturned. And then there’ve been other ones. A friend of mine — her dad became quadriplegic after a fall and I had to intercede there because she was having a lot of issues getting his rehab paid for. But it was actually the hospital that didn’t want to fight, and that actually ended up getting escalated to Kathy Hochul as in the Governor of New York to tell off the hospital, and that got overturned. Those ones aren’t ones that we see commonly, but I see them and we’ll try and help where I can. On the therapeutic side, we see a lot of formulary changes — a lot of ‘if not Dupixent, then swallow this pack of steroids, good luck.’ We see a lot of ‘please don’t take this biologic, take this biosimilar,’ and the patient’s been stable on the branded biologic for 20 years, then they get switched to a biosimilar and they start to decompensate and now need a way back onto the originator compound. Now in England, the way I was taught — we never learned brand names in medical school, we were always taught the systematic name — you think of it as a drug, not a brand. The issue here is that not all of the biosimilars are exactly the same. Patients may respond to them quite differently, and if they’ve been stable. So there was a UC patient who was switched and ended up basically unable to eat, got admitted to the emergency room, needed feeding, needed a way back. There was another patient — a North Carolina patient, as I recall — a rheumatology patient who got switched from an originator to a biosimilar and developed rheumatoid lung, which is a really serious sign of not having control. I’ve got to caveat all of this by saying that we see a biased selection of patients who have been denied and have problems.

Matthew: just to interrupt — you are saying that some ‘generic’ biosimilar is not actually all that similar in some patients, right? 

Warris: for some patients — there’s a really good argument for saying that if you’re starting someone on a therapy you should start them on a biosimilar because it’s cheaper. Then the question becomes: cheaper for whom?

And it becomes cheaper for the plan, not for the patient, because they end up routing the patient through either a white bag — which is more expensive for them, because then it goes from a medical benefit to a pharmacy benefit, they pay more — or it could be that their infusion center won’t accept it because the infusion center’s buying it differently, and then they lose continuity of care. Maybe a hospital accepts it, then it moves from being a clinic visit to a hospital visit, so it goes from a $50 co-pay to a $2,000 hospital visit. The patient then abandons care. So ‘cheaper for whom’ is the first question. But if all things were equal and there wasn’t all of this chicanery, yes, it would be much easier to have patients on biosimilars to begin with.

Matthew: Yeah. And I think that’s one of the main ones. But there’s also a lot — you mentioned changing PBMs and formularies. I know that for instance Jen Horonjeff used to be Savvy Patient; now it’s Real Patients – she’s just gone through this where even though she’s as well known a patient as her, they changed a drug on her, formulary-changed, and she couldn’t get in, has to go through all the denial process, can’t get access, can’t get a human being to call her — only robocalls and that kind of stuff. You see way too much of that. And there’s now — a couple of things. One is that a lot of this is: who is to blame for the fact that these things cost so damn much money? [laughter] So let’s talk a bit about that, especially on the biologic side. There have clearly been a lot of biologics invented which do great stuff and change people’s lives, and there’s been a lot of biologics invented — especially in the oncology space, a lot of cancer drugs — that extend life a little bit for a huge amount of money. And then wrapped up in this is the fact that somehow Novo Nordisk can sell Ozempic for 80 bucks a month in Denmark and seem to make a decent amount of money on it, and why they have to sell it for 1,200 or 800 or 700 or 500 — whatever the number is — here. So how much of this is a problem with pricing of those drugs? How much of this is a fight between the PBMs and the drug companies over who gets what slice of the margin for the drugs? And then I guess the last question is: how do we get to your ideal — what’s the overall cost to the person who’s paying in the end?

Warris: Yeah. I mean there are way too many middlemen. If this business is ultimately successful, there’s no need for us. And that’s the future that we’re actually quite happy with as a business. If we can get to the utopia — it’s that the insurers realize that they can’t deny via AI because it becomes so ludicrously expensive for them to have all of these appeals reflected back at them. Now, the reason why they deny is because they’re looking for the more profitable route, which is either they don’t pay out, or they route it through their verticalized infrastructure — they own everything. Their own specialty pharmacy, their own PBM, their own retail pharmacy. They literally own it all. And then there’s an insurance company on the back of it that’s issuing the denial and collecting the premiums. So the vertical integration is for sure a big part of it, and a big part of the waste and inefficiency. The other issue is that you’ve got issues with how much the actual drug costs. Now, if you look at the dynamic — and I’m sure if you got David Joyner (note–CEO of CVS Health)  to put his hand on a Bible, he might tell you what’s really going on — I’ve had pharma manufacturers say to me that they would charge 5x less for a medication if the PBMs weren’t rate-setting a rebate. Whether that’s true or not, I couldn’t tell you. But the rebate determines market access because it determines the formulary position. And if you’re not on that list, your drug doesn’t exist, because there is no other way of accessing the market in an organized manner than through your insurance mechanism today. 

Matthew: Your argument is that it doesn’t really matter what the list price is — there has to be a big chunk rebated back by the manufacturer to the PBM, or else they won’t get on the formulary. 

Warris: It’s a mafia, right? They’re paying a vig to the PBM to basically be considered. ‘Nice drug you’ve got there. Be a shame if something happened to its formulary position.’ But ultimately the price does matter. And then your question also went to marginal benefit.

 Now in England — 

Matthew: before we leave that — I kind of joke that the biggest pharma innovation these days is in the legal department, trying to figure out how to extend patents.

Warris: Oh 100%, and the patent went on way way longer than it should have done because of all kinds of games played with formulation. I mean my inhaler — which is Symbicort — I think it was coming off patent and don’t quote me on this, but I think they did something to keep it on patent by changing the delivery mechanism. I can’t remember what it was, but it gave them another number of years. I mean there are generics for it, to be honest, but there are also FAERS reports with the FDA that say that Breo, for example, is ineffective — and that’s Aetna’s drug of choice for asthmatics like me, and they’ll continually try to steer me to it even though there are reports that say it doesn’t work, which is amazing.

So the price ultimately does matter. And all of these companies are ultimately answerable to their shareholders — that’s exactly what they’re solving for. It’s either volume of drug or unit cost. Now I think we can solve some of the toxicity if we actually were to clip the ability for these PBMs to earn rebates. There was a debate that went pretty viral between Mark Cuban and Patrick Conway — our neighborhood-friendly pediatrician as he describes himself — 

Matthew: who is I believe is the head of Optum altogether.

Warris:  I’ve had some pleasant emails with him where I’ve interceded for patients and he’s promised to look at things, and that’s been actually better than most, to give credit where credit is due. In that conversation you could see that Mark was visibly getting quite frustrated with the obfuscation of the answer to the question: what other charges are you not telling us about that you’re billing for? Because there are a lot of bundled charges and a lot of things that employers are buying that they probably don’t need, that are buried in the costs — including, you know, payers are starting to charge providers for challenging prior auth denials. So that gets passed on to the employer. There’s a lot of buried costs in there. It’s still non-transparent. And then there’s gross-to-net as well.

Matthew: Yeah. No, I think — AJ Loicano, who these days is at Capital Rx — I think Judi is the name of his PBM. He said to me at one point there were 27 or 25 different fee types attached by the PBM beyond the basics. And I think if you get rid of the rebate but you don’t fix the contracts — and this is what you mentioned Chris Deacon has a lot to say about contracts that don’t allow you to assess or audit the activity of the plan– f you put these people in the middle, they are going to figure out ways to charge you. 

It’s like buying a ticket for the World Cup and then the water costs you $19 or whatever. So where I’m going with this: I think the only way you get to fix this is essentially what the Brits have done — you do some kind of NICE (note: the UK’s National Institute for Clinical Excellence) thing and say yes, this is a clinically acceptable cost, this is not a clinically acceptable cost. And then you say we’re going to do price controls on all the drugs.

I think if you did that, you would do two things. One is you would get a lot of unnecessary cost out of the pharma business — they are still spending more money on non-R&D than on R&D, if you add in stock buybacks and the vast amount they pay their executives. It’s still an excessively lucrative business and they’ve spent a lot of time and effort funding people atTufts & elsewhere to persuade people that drugs really do cost $3 billion to get to the FDA. I’m not sure much of that is true. I think you can get prices down that way without impacting R&D. 

And I think we also need to figure out how to make R&D better because we’re spending more and more on R&D and getting essentially less and less valuable drugs out of it.

Warris: There are a couple of interesting things there. I think it’s easy to make a health economic argument for an expensive drug when the cost of all of the downstream care is even more expensive. And that’s also the problem, because then everything’s just really inflated. I was living in LA until quite recently and I remember getting into a punch-up with Cedars-Sinai for my neighbor who had been billed $70,000 as the total cost of an appendectomy — in a young, healthy person, uncomplicated basically appendectomy. The comparable cost was $10,000. So the question is: okay, they’re charging 7x, and then the percentage of that is being passed on to the patient. That starts adding up. It’s basically like having one gas station in a town — the price of gas is whatever they say it is. You have these monopoly providers, you’ve got monopoly insurers, the prices go up in step. And then when you look at what NICE does — when they start looking at does this drug truly extend life, is this drug truly different to other things on the market, is the evidence solid, is the study actually rigorous — those things have to matter and they don’t matter enough here.

We look at that. So if we’re going to work with a manufacturer — by the way we say no to people a lot — we actually look at the studies and whether they’ve been rigorously conducted and whether there’s a basis for this drug being on the market. We had a manufacturer with an absurdly inflated price — it was effectively a marginal benefit over a traditional steroid and only in one circumstance would it be considered actually appropriate — and we told them to pound sand. We’re not going to help ramp healthcare costs on the basis of this. It’s just too marginal. We see this from time to time and just say not for us. But where you get to biologics — take a rheumatology patient: I remember when Cosentyx was first coming out, there was a patient in Chicago who needed to be on it because she tried and failed everything else and had incredibly poorly controlled rheumatoid disease. For that kind of patient, yeah, it’s appropriate. And you know, that’s not where it is on the label anymore — it’s now approved earlier than that. The point is that yes, an expensive therapy could be justified if a patient’s gone through the requisite number of cheaper drugs. We saw this this morning on a new patient. A patient who had failed a medication previously, had been stable on another medication for 7 years, was then directed by CVS to go try the medication they had previously failed — again — and was now on six medications to control all of the side effects of the medication they’d been put on. At what point are we now doing more systematic harm?

Matthew: That’s exactly the point. I mean there are two things going on. One is the issue we’ve talked about: how much damage do you cause by changing somebody’s medication? Not to mention the bureaucratic fight they’re having back and forth with CVS. You look at Jen Horonjeff and her attempt to get a human being to call her. And then the issue is: what’s the cost downstream? Now as you raised, the problem with the cost downstream is no one knows what the hell the cost downstream is, because it varies so much. And I’ve looked at my bills and said, you know, Blue Shield’s been paying a huge amount more for some providers than others. I’ve seen UC versus some private guy for the same thing. And you’ve got a lot of just not knowing. And I’m now at the point — policy-wise, not everyone’s agreeing with me — that you give a bunch of money to primary care doctors, tell them to look after people, and then everyone else gets a global budget and gets told to figure it out, or else a fixed price.

Warris: Look, I can give you a window into this. There’s a guy in Missouri, his name’s Ed Stratton, and we put his story on the front page of the Wall Street Journal — which I’m sure Anthem really loved, especially as I used to be an executive there, but oh well.

Matthew: You’re probably not going to be invited back.

Warris: Probably not. I actually had this idea of just applying for some really low-level role at Anthem — just doing it for a laugh. Like I wonder if I could get hired as a call center worker, or someone in med policy who just approves everything. But anyway — there’s this patient called Ed Stratton who had been denied a liver transplant. We’ve talked about this one quite a lot. But what was interesting is that we have his EOBs for all of the care he was getting whilst being denied his transplant, and it added up to hundreds of thousands of dollars over I think about 6 months, which his employer was paying for. Now if you think about the transplant, it probably costs a million dollars all in. If you were to just say, ‘Ed, you can’t have a transplant, you’re going to keep being admitted in and out of hospital for infections to your necrotic liver, and we’re going to keep having to drain this using CT-guided drainage, and he’s just going to continue to get worse’ — the employer’s on the hook for all of that. They’re going to pay way more over the odds than if he just had a transplant. Which he has now had, and to my knowledge he’s doing great. So that to me is where it starts becoming a false economy. Because palliative care in America — dying in America — is an extremely expensive proposition. It’s also not cheap. So if you’re going to die slowly from cancer in America, someone’s picking up that tab — either the family or the employer — and when you withhold treatment, that’s the only path you leave open.

Matthew: Yeah. And actually you go down that path —my favorite fact about American healthcare is that the biggest palliative care/hospice company is owned by the same company that owns Roto-Rooter.

Warris: [laughter] Right. Right. Right.

Matthew: And you know there’s been a lot of exposés about the hospice industry — poor care but also very expensive care out of that. Similar things are happening now in the home care industry. I’ve just run into this lately where there’s been an expansion in what home care should be paying for under Medicare, but in fact companies are not delivering that.

Everywhere you look there is some kind of — whether it’s for-profit or nonprofit — highly incented bad behavior. And I think the only way we get rid of that is to put a combination of patients and physicians back in charge.

Warris: I would agree.

Matthew:  I don’t think value-based care the way we do it works. Capitation — 

Warris: no, it’s nonsense.

Matthew:  I think Jeff Goldsmith, on The Health Care Blog, has said that we spent 40-50 years putting these controls in based on the fact that we thought physicians were cheating people, and the way you get rid of that is you get rid of fee-for-service and pay physicians a salary — and pay them a damn good salary, because they’re very expensive people who learned a lot, and by the way you’ve made them pay well over $300,000 to get through medical school and be bankrupted during residency and all that stuff. But that’s where I think you fix it.

Doesn’t get over some of these problems, right? What do you do about very expensive people? So let me slightly shift the conversation. At some point — we mentioned palliative care, we mentioned hospice — the argument about the denial is that if you get over the bit which is clearly ‘we put this other drug on formulary and we make more money if we steer it this way,’ which is BS — and if you get over the fact the drug costs too much — how often do you run into something where it looks like somebody is trying to do too much rather than letting patients die 

Warris: a quaternary prevention type situation? 

Matthew: I mean historically there’s a lot of ICU care of people who are going to die anyway. How much of that sort of comes into the claims?

Warris: I think most of it’s in hospitals. I rarely see it. On the therapeutic side, the patients who are appealing are really hurting. I’ve seen a couple of cases where families reached out looking for compassionate access to medications where there was no basis in science for the use of that medication in the therapeutic mechanism that would be understood for treating that cancer. And that’s one where you have to draw the line and say: I’m not sure you actually have a chance of getting this approved, and also you should probably talk to your physician because it sounds like there might be a misunderstanding and it would be good for you to understand what your options really are.

I’ve run into that maybe twice. And I’ve run into cases where physicians are adapting to step edits in maybe an overzealous way — trying to figure out the easiest way to get something approved by using a vague code, but then the patient doesn’t fit the criteria of that vague code, and that creates a problem for us because then we can’t support it. 

A vague code — like, we see this with PANS/PANDAS, which is a rare disease. The treatment is IVIG. It’s off-label. The American Academy of Pediatrics don’t believe in it, but there’s a lot of politics in how that clinical report got written, it’s a shit show –  and in the interim a lot of kids are in bad shape because they become acutely psychiatrically unwell and the insurers use the AAP report — which says it’s not a clinical guideline — to deny these patients. Every now and again what we see is providers who sometimes put the patient in as autoimmune encephalitis. And the problem is the patient often hasn’t had an EEG, hasn’t had an MRI or a lumbar puncture or the other things that would qualify them as actually having autoimmune encephalitis. And so then we can’t help them, because it’s not a true appeal. We only want to support cases where the evidence is really on the side of the patient.

Matthew: So yeah. It seems to me that what you’re saying though is: overall, if the doctor and the patient have followed the right protocol, most of the denials you’re seeing are not about end of life where the patient will die anyway. Most of them are about: can we pay once upfront for something which will save money later? Which by the way will save money for probably another insurance company later,

Warris: Yeah, totally. But there’s no collective action solution in this country. United is going to look 18 months into the future, which is the average time they’ll have a patient, and that’s how they set their actuarial payback. When we’re talking about whether GLP-1s are worth it and David Joyner is saying it’s not, that’s based on the price of a GLP-1 and then probably the downstream occurrence of an avoided cardiovascular event, which probably wouldn’t happen in 18 months but might happen in 5 years or 10 years depending on the average age of the person taking it. So you’re never going to see it. We’ve moved into a risk-shifting business, and people change employers regularly and change plans regularly.

Matthew: Absolutely. And even now in Medicare, right? You go into Medicare Advantage and people start to change plans. 

Warris:  And you know, the way I thought about this — I did Eisman’s podcast in December and I actually haven’t been back to rewatch that one because — 

Matthew: I saw it the other day, it was actually pretty interesting. This was Steve Eisman, the guy who was played by Steve Carell in The Big Short.

Warris: Yeah. I was super bummed because I had an Anthem patient who died a few days before — a transplant patient. The daughter of a liver patient reached out and said her mom needs help, she needs a transplant, and no one would accept Anthem’s Medicare Advantage contract in LA. This was a patient in a hospital in Orange County. I managed to get her accepted into a bed at UCSF, but by the time I got her accepted, she died. She had been languishing on that ward for about 10 days, and days really matter when you’re that sick. I was bummed. So if you watch it and I seem really depressed, that’s why — because I was really bothered and I hadn’t slept in about 3 days. And a lot of it was also just preparing to go up against Eisman because he’s so smart that you have to actually know your numbers.

Matthew: You don’t need to on this podcast!

Warris: Well you prepped me to be fair, so that’s helpful. But Steve has the recursive ‘why.’ And you have to have really thought about what you’re about to lay out.

And I put together a thesis of where this goes — I think these insurers are vulnerable, and they’re vulnerable in their insurance business. All of the other stuff, all of the unregulated revenue and that kind of thing, is going to start looking really attractive to split away from the insurance business over a period of time. Because if you look at the long history of conglomerates, it doesn’t end well. They will naturally want to unlock more value for shareholders by breaking them up. And so our incentive is to drive that narrative for activist investors to go into the boardrooms of these companies and actually break them apart. And then you’ve actually got a shot at free market behavior, if that’s actually the answer. Beyond that, what you need is a risk transfer mechanism from insurer to insurer, which solves this 18-month problem, which then allows people to actually take the bet on paying for more expensive care earlier — so then it isn’t futile. The other mechanism I’ve seen is manufacturer warranties for very expensive medications, which are starting to become a thing — where manufacturers say we’ll warranty some of the cost of this medication if survival isn’t XYZ months minimum. 

Matthew: Which is interesting, and it kind of goes against 200 years of drug company history. 

Warris: They’re taking bets on riskier disease, and if you go off those narrower indications, you have to be able to underwrite your benefit. I kind of like them having skin in the game there as well. And then the final thing is you just need an insurer of last resort, which is the federal government, who can take a longer horizon across everybody. Because ultimately we pay for this anyway. You stop working — guess who pays? The taxpayer pays.

Matthew: I mean, so you’re getting to where I’ve been for a little while. I used to think — you know, it’s America, you could figure out some kind of free market solution. I sat in front of Alain Enthoven in the early 90s figuring out how could you create five competitive Kaiser-type organizations and then have people buy into the more expensive plan if they wanted — with their own cash, therefore you drive the market down to a level, and then everyone does a sort of Kaiser-type thing where they figure the money internally. All sort of privatized British NHS.

Warris: Yeah.

Matthew: And great. My problem is that when you actually look at what happens in healthcare in America, there’s always some open field where someone can get away with something for a while. And then if you try to fix an individual thing — like out-of-network surprise billing — now there are people who’ve figured out how to game the arbitration system. If you put in a massive fee and choose the right arbitrators — I don’t know how the arbitrators have figured out that something should be $1,400 but they’re going to pay $28,000 or whatever — and now half the insurers are not paying up and there’s generalized chaos. Someone was complaining that Blue Cross of Texas wasn’t paying their arbitration bills and I said, ‘Well, is Blue Cross the only organization in Texas that has to obey the law?’ I didn’t understand.

Warris: [laughter] I mean they have the biggest penetration in Texas, I believe.Yeah, they’re the largest payer there

Matthew:. Anyway, just to finish my point: if you look at what the big players do — the pharma companies benefit from unregulated pricing. There’s some attempt at drug negotiation for Medicare, and there’s Medicaid and VA, but in general they can charge what they like here and charge way more than they do abroad. You could argue Europe should be paying more, but that’s a different argument. 

The hospitals have all consolidated and they’re all sitting on massive reserves and charging as much as they can. Dave Chase will go on about this — a big hospital system gets somewhere between 65 and 80% of its money from the government anyway. It might as well be a public utility. I don’t know why we’re paying the top 200 people at UPMC $500,000 a year plus, you know, $12 million to the CEO and $12 million to the former CEO who was still getting paid even though he left three years ago. 

The last group are insurers. A lot of their business comes direct from commercial employers, who are theoretically out of the tax base other than those employers are not paying tax on the benefits they’re giving their employees — that’s a massive subsidy from people who don’t get taxpayer-funded insurance to people who do. And then number two: their profits in recent years have all come from either Medicare or Medicaid. Some plans are entirely Medicare. That’s the taxpayer as well. So essentially this is all a wealth transfer to private healthcare companies. We should be able to do something about it.

Warris: But we’re seeing more and more of this. With ICHRs we’re basically shifting the risk back to individuals — ‘the employer’s going to give you a stipend, go buy a plan, but you probably can’t buy a plan that’s worth a damn for $500 or $300 a month.’ The president has mentioned getting rid of the ACA and is doing a good job of defunding it effectively.

And that is leading to patients going bare. I’ve had two patients in the last 2 weeks reach out. One is in a catastrophic amount of medical debt because they ended up uninsured and then got very sick. And then the other one did a health ministry, and the health ministry does not cover cancer within the first year of being in the plan — and unfortunately this person got cancer. So we’re going to see a lot more of this. 

And the other sort of wealth transfer is high-deductible plans, which also shifts the risk onto the patient. You’re covered but not covered. 

Matthew: And to give you a personal example: I’m about to have my knee surgery, as I think I mentioned the other day, and had I stayed on the exchange plan — and if my wife didn’t actually go out and get a job, which has its own problems, because she went out and got a job and was covered by Cigna, which is about to break up with UCSF.. So I had to have the date moved up so I’m in the coverage window, which is nuts, but there we go.

With Cigna the out-of-pocket max is going to be like $4,000 as opposed to I think it was going to be $14K or $12K on the exchange plan. And how many Americans who, by the way, are scraping together to get on the exchange in the first place, can afford $14,000 additional out of pocket? There’s no reason. We had this massive underinsured class, and the ACA was never supposed to be like that.

And don’t forget the ACA came from a huge amount of stories exactly like the ones we’re talking about — people who couldn’t get coverage, people who bought shoddy insurance that went away, people who couldn’t get insurance because they had pre-existing conditions or had their insurance taken away. All that was going on in California back in the 2000s. There was a term called rescission, where in fact Blue Shield was one of the worst offenders — ‘You didn’t check that box in the form and you did have this condition and therefore we’re taking it back.’ 

Warris: I’ve seen a rescission case in the last year where the patient was stuck with like a million dollars in retrospective claims. I mean, look — this system is a catastrophic mess. It is not fit for purpose. 

The problem is that everybody’s pretty much on the take. And as a result there’s low incentive to fix it. Right now we’re celebrating deregulation like it’s going out of business — you see whichever wearable executive posing with RFK and Marty Makary because they’ve decided they’re not going to weigh in on algorithms. But who bears the cost? The health systems do, when there’s all of this utilization full of false positives. It’s not going to be Oura or whoever else. Everybody’s just in it for themselves right now and nobody’s really thinking about the collective action problem we need to solve to make this system more sane. This is going to have some very negative effects in the coming years. I’m hoping for 2028 to restore some sanity. But who knows if that’s possible. And I really hope whoever runs actually understands that empowering Blue Cross or United or Cigna to go solve a problem on their own isn’t going to happen — unless there are real penalties that are enforced. They will never arrive at a solution themselves.

I very much doubt this solution is political. I really feel it’s going to be economic before it’s ever political. 

Matthew: Say one more thing about what you mean by that, because I actually think I’m about to disagree with you. What do you mean by economic?

Warris: Well, feel free to disagree. For the 2024 election, we decided to make an explorer for OpenSecrets to see who was actually taking money from PBMs and it was basically everyone — and it was really in local races. This had been on the back of a punch-up I was having with Blue Cross Blue Shield of Alabama over recovering a woman’s breast reconstruction, which they have a mandate to do on the state that this patient was on a union plan. And we actually ended up paying for it ourselves, because we were not going to let this woman suffer — it was before Christmas and we were feeling like we should. But the fact of the matter is everyone’s on the take. And when you look at how long it’s going to take to get beyond performative sessions in Congress where we sit all the executives up and make them answer awkward questions, followed by no change, no enforcement, no bills passed — that’s an extremely long arc.

Matthew: I don’t know if there’s an economic reform. People have talked for years — my friend Brian Klepper told me 25 years ago, ‘Don’t worry, employers are going to sort this out. They won’t put up with this much longer.’

Warris: That’s actually not what I mean. I mean that we are the economic reform. If we can get enough patients to appeal, we actually change the economics of these insurers. If we can stimulate this enough, it really impacts their bottom line, which actually impacts their top line. The revenue replacement is a real problem for them at that level. And then more patients get care and their model of denying by AI effectively becomes completely untenable because you start having investors really paying attention to the line item that’s failing.

Matthew: So that happens and the insurance companies get sort of sliced off by outside activist investors or hedge funds or whatever. Doesn’t that mean essentially — what’s left just becomes more expensive, more people become uninsured?

Warris: Not necessarily. I think what you do is you actually break up the verticalization. You allow more companies with a genuine value proposition into the market. The products are expensive because they have no idea how to price anything because there’s no collective action solution. But you allow new models to exist. And the other thing is you remove their bargaining power with the federal government to some extent because they’re far less powerful. They’d be diminished.

Matthew: Maybe. I have so many things I’m depressed about. One of them is I met with Natalie Davis from United States of Care, which is kind of supposed to be the moderate but sensible pressure group that Andy Slavitt set up some years ago. I talked to her about:, what are you pushing for in 2028? She told me  ‘I don’t think we can get anything done by 2028, but in 2032 we might be able to get — we’re going to be launching something which is going to help, hoping for more transparency in the system in general.’ I’m thinking: 2032 means it’ll get passed in 2033,which means something will happen in 2034. I’ll almost be dead by the time this problem gets addressed. 

And the other thing I see is: People are mad, but I don’t know how mad people are. I think we need a total revolution. Because if you do something that’s not a total revolution, you end up with somebody figuring out a way to make money out of every little piece. And the only way you can do it is to essentially abolish the insurance function.

Warris: Hey man, I’m there for it. Well, the point is the second you make these guys vulnerable, I think new solutions start presenting themselves. Some of it might be that it’s just cheaper to actually have the federal government pay for it — you actually shift the Overton window in that direction. Because it’s kind of what they’re doing in England. There’s a really great book by Walt Bogdanich called When McKinsey Comes to Town, and it is completely horrifying. It explains a lot of the crap I lived through when I was actually in the NHS — McKinsey were around like messing with the dials of how the NHS was running, and you’re like, ‘Oh, this is why it was all getting worse.’ And the idea has been to intentionally break the NHS and make it so unpalatable that people say, well, we would accept anything other than this model. Little do they know that a model like we have is unbearably worse. [laughter] 

I think people in England think it’s bad there, but until they’ve come here and had the pleasure of paying for private insurance that then denigrates you through denials, they haven’t lived it.

Matthew: You’re right. And by the way, that is an argument that gets used here all the time — how terrible it is in the NHS — whereas if you actually go to Japan, Germany, Holland, Spain, France, there are a bunch of perfectly acceptable healthcare systems out there which don’t tend to involve massive delays to get care or massive prices. I was talking to a shoulder surgeon in Japan last year and said, ‘If I hurt my shoulder, how long would it be before I got on your operating table?’ And he said four to six weeks — not so bad — and it would cost me essentially nothing. 

There are clearly American-specific issues: the level of violence, the level of addiction, maybe mental health. There’s a bunch of stuff going on here that’s different from other countries. But I think we could get to somewhere that’s rational and American — but it would require a kind of FDR-level New Deal hit. Unless you get — I don’t know — an AOC or whoever the guy from Maine is now called — you need a president who’s got the Donald Trump level of ‘I don’t give a damn’ but actually wants to enforce something good.

Warris: I know one guy but he says he’s not running.

Matthew: Who’s the guy that’s not running?

Warris: Mark Cuban said he’s not running.

Matthew: Oh, yeah, he would be great. Still — scratch him hard —he believes in a free market. He thinks if we got rid of all these conglomerates and got to real pricing and transparency, we would fix it.

Warris: I think it would certainly be more functional. 

Matthew: But the question — my point is that there are so many places you can’t see where somebody will pop up and start making a fortune in two years and then be gone. 

Warris: But the NHS — when I was in the NHS, blood services were privatized, so that was spun out. Hospitals used to manage their own transfusion services, that got spun out. Diagnostic testing used to be done in-house, that got subcontracted. Ambulance transfers, MRIs were all run by private companies and then leased back to the hospital, which is why the hospitals were in such a dire financial mess. You couldn’t get an MRI in daytime hours, you had  to transfer your patient across town. There were a lot of dreams of free market within the socialized model which actually broke the efficiency of that socialized model entirely. And then the constant pressure for ward closures as well, which endangered patients. I was there during Cameron but before that it was Gordon Brown. The same shit from prime minister to prime minister. So the idea made sense in the abstract — where it is today I don’t think necessarily makes sense because they’re trying to intentionally break it. And you’ve got people waiting in the wings like Optum and Cigna who are in the UK probably looking to pick up some type of contract somewhere. No doubt. But read the book — When McKinsey Comes to Town. It is interesting.

I would be remiss if we didn’t briefly touch on the panel.

Matthew:  All right. I’ve forgotten about the panel. Actually, I forgot about it three months ago. I’ve forgotten about it from the start of this hour.  OK, your complaint about it. I thought Alicia did a great job. Bunch of different issues and, to be fair, she did not get a lot of reply back.

Warris: No, she was basically like dealing with a mannequin who was preloaded with three PR-approved statements. Anthem’s chief digital officer — no matter what the question, he had to say one of three PR-approved talking points. And then the CVS person didn’t show up because I guess they were worried that anything they said could be used as evidence against them in a court of law.

Matthew: . The excuse they gave me was — and I’ll show you the correspondence, I may never be invited back to HLTH or ViVE again — I had a pre-chat with everyone’s PR agencies. They said to me, could you write up some questions? So I banged out a bunch. Normally I wouldn’t write out questions, or I’d use them and realize they were the stupid questions. But I banged out some questions and the CVS PR people — it wasn’t even CVS, it was their separate PR firm. And I forget who was the chief officer of Cigna — Michelle Gordine.I don’t know if she ever saw this, I don’t think it got as far as her.

Warris: Oh, I tagged her into my post-review of her non-performance.

Matthew: Well, what happened was that I wrote out these questions, which I thought were sensible real questions. I also said: ‘We’ve had a fee-for-service system forever in America and we can’t just do everything because we know what happens to medical inflation.’ And they came back to me and I said — if she doesn’t like that question, tell me and I won’t ask it — and they wrote back to HLTH and said ‘No, we don’t accept this, we are out.’ No discussion

Warris:  It’s because they can’t say anything real. If you’re in a large company, it’s actually quite hard to say anything that deviates from the company line and speak extemporaneously. They really don’t like you doing that. Which is why I was probably not allowed to speak on behalf of large companies for that reason. But it’s interesting. I would welcome a debate with them, because I think there’s a really good argument — for example, I spoke to one of the insurance execs afterwards and said: please stop denying cancer and transplant, and you guys will be heroes. Just remove prior auth in oncology and in transplant — things where patients really could come to harm or die. You’ll have far fewer angry patients and I guarantee you’ll save money. You’ll save money on the admin side and I think over time you’ll save money on the cost of care side. And the answer I got back was: ‘Who would pay for all of the additional care?’ And I’m like: there’s an inbuilt presumption there that the care is medically unnecessary. But if you think about what it takes to get approved for a transplant — these patients have been seen by a transplant ethics board, rigorously assessed, there’s a ton of imaging — on the oncology side, these patients are often desperate and increasingly they have curable disease if you get them early enough. The question is what care do you want to pay for versus are you going to pay for it? Because you are going to pay for it. Do you want to pay for something curative or something palliative? I would love to have that debate with them — genuinely in good faith, all day. And I would encourage them to ask the Wizard of Oz for some courage. 

Matthew: But they can’t do it, because by the time it gets to the court of public opinion via the Luigi situation and whatever’s happening — the answer is you’re cutting somebody off, you’re going to kill them. We had this with death panels back when the ACA debate was happening.

I think you were just arriving in the States at that point. Sarah Palin talked about death panels, and the US Preventive Services Task Force — USPSTF — was putting together at the time some completely apolitical thing about mammograms and got completely railroaded. ‘These are the death panels we’re going to have.’ And they’re now being shut down — I think RFK Jr. fired everybody on the panel and closed it down when it was trying to be an apolitical scientific body doing guideline treatments. It seems to me that as soon as you put the big insurers in that bucket, they cannot win in the court of public opinion 

Warris: because they’ve become the death panels. 

Matthew: Well, they’ve become the death panels and people are now noticing. And the reason I think there might be a big political shift in 2028 — I put it at maybe 2-3% probability that somebody would come along and say ‘I have a better way of doing this in healthcare.’ I mean 2028 is going to be so hard because it’s going to mean recovering from all the crap that Trump’s pulled. But at some point we’re going to have to get to healthcare and say this is an amazing show that we have to fix. And I think it has to be a radical fix. The ACA dont forget — massively fought over, a complete war about extending insurance to not very many people really — got us from like 84% to 93% insured, for 10% of the population. And we went to death wars about that forever. If you’re going to do something, you might as well do something big — say I’m here to take out the big four insurers, reconstitute how the big health systems behave, and price-control the drugs.

Warris: And I’d love to pour energy into helping whoever comes up with that plan.

Matthew:  Right. Because I came up with this plan. I wrote it up. I’m very happy for AOC to plagiarize it with my name.

Give everyone fantastic primary care, give the primary care doctors a lot of money, and figure out a way to take it out of everybody else. We’re already spending 18% of GDP — 6% more than the Germans, the Japanese — 

Matthew: in England they had quality outcome frameworks, the QOF points. You might remember: docs were paid for asking about smoking cessation, blood pressure, etc. They actually improved outcomes. The problem was they made primary care relatively so well paid that people went into it for the wrong reasons. In my cohort, the people who went into it really didn’t go into it for the love of patients. They went into it because they didn’t want to be in a hospital doing on-calls for 72 hours across a weekend. You have to find a way of finding people who genuinely love working with patients and have a genuine sense of empathy. I don’t know how you select for that, but that’s really what you need. When I was practicing, 20 years ago — I was an ICU doctor, attracted to the fast-paced part of medicine. And now I spend all my time talking to patients; it’s basically like being in primary care. And I often do the thought experiment of: if I was to go back, would I go back to ICU? And I think the answer is I’d be a primary care doc, actually, because I care very much about that.

Matthew: You have to do some measurement but I don’t think you have to do the pay-for-performance measurement that the Brits introduced or that people tried to do here. I think you have to trust the doctors more. And in this country, the pediatricians and the primary care doctors, the family doctors — they make a pittance compared to the surgeons and the radiologists. And that’s why you don’t have enough people going into those residency programs. That’s also why all the prestige and money goes the other way.  You could fix that with money — just pay the primary care doctors more. You’d have to pay the other people less, but that’s not a big drain on the system. Where you’re going to save the money is on hospitals that are now incented to have primary care doctors referring people in for stuff that may be of marginal value.

It’s usually orthopedic surgery. [laughter] Speaking of the guy getting his knee replacement — If they have an incentive to fill hospital beds — and that’s why hospital systems across America have bought so many primary care docs. And you’ll see these big fights now and again with primary care groups that got bought by a hospital trying to get themselves out of it. 

Warris:  I just moved to Miami and two of our friends who are primary care docs quit taking insurance and now they are either concierge or DPC. 

Matthew: I’m fine with people going concierge and DPC. I think the government should pay for it. I think if you managed everyone through that — if you paid the concierge docs very well for 600 patients to manage their chronically ill patients — I would force everyone to go into it. I wouldn’t let people not have a primary care doc.

Warris: I would agree with that too.

Matthew: And then I think it would save so much money on the back end. 

Warris:  If you have a competent, incentivized primary care doctor it goes a long way. DPC can really work. Concierge — I have mixed opinions on, for reasons. There’s some quackery that gets stuck into high-price concierge 

Matthew:  It doesn’t have to be $20,000 or $50,000 or whatever private medical insurance is charging. You could do it because you could have a government-paid voucher which would be pretty decent — not that much. I was spending about 7-10% of the healthcare — the $15,000 per person — where I would spend 20%. It’ll be fine. 

Warris: Where I would have gone with that — I actually thought about this prior to starting this company — was to take a DPC chassis and power it with claims data. Then you’d know which services to put into DPC, and could pull clinic-based specialties that otherwise live in hospitals into kind of a multi-specialty clinic effectively. It’s really per-capita based on where you live. And you’d effectively have far less care going to hospitals because all of those specialties could manage things at the primary care level. 

Matthew:  There are bits I hadn’t figured out. I don’t quite know how you get mental health there. I don’t know what you do about dental — which seems to be a weird thing that’s excluded in most countries for no particular reason.Apparently your teeth are not part of your body.

Your brain and your teeth have nothing to do with your body, which is fine. But in the end you’ve got to say: how do I reliably manage the chronic disease of the massive population? That’s half of it. The other half is what do I do with very expensive people — which is what we’ve been discussing the whole time. And with both of them we are doing terribly. I don’t see any reason why not have a revolution.

Warris: Yeah, god-awful — I mean absolutely. I’m here for it. I want to see it happen. I want to have enough data on the bad behavior that we can drive that change. Maybe start working with some analysts to actually help them change their ratings on various insurers. I would love to be able to do that.

Matthew: Well, that maybe is where they end up. All right, so we’ve had a great chat. I’ve been talking with Warris Bohkari  He is the CEO of Claimable — Somewhere if you go back to the start of this conversation, we’re discussing what Claimable actually does in terms of helping people who are denied by insurers.And you can go to getclaimable.com. I assume, on the internet, if you have any issues with claims denials. And there is a policy where — is there a consumer fee? There is, right?

Warris: Yes, it’s $50. It’s getclaimable.com. And it’s $50 whether you win or lose. The idea was to charge a low flat fee — we’re not incentivized by what the care costs. It’s purely to allow anybody who has a denial the ability to come and appeal. 

Matthew: And then you’re making it up — hopefully — on the back end in work you’re doing with the patient access programs and others with the pharma companies.

 Check it out if you have any issues. And otherwise if it’s something urgent, reach out to Warris — turns out he’s very contactable. And you will find Warris on LinkedIn, almost all the time, lighting into some innocent insurance executive who’s giving their opinion about oncology in a bit.

Warris: [laughter] I was lighting into the SpaceX IPO yesterday. I’ll leave it there. 

Matthew: But I’m looking forward to almost all of my index fund being put in there. [laughter] And zero. But speaking of wealth transfer — as long as Elon Musk can get a bit richer off all our backs, I’m much happier.

Warris: It’s good to see you, man. All right. 

Matthew: Thank you, Warris. Great to catch up with you. Great discussion. I look forward to doing this again. And we will figure out how the two Brits are going to fix American healthcare eventually.

Warris: I love it. Take care. 

By MICHAEL MILLENSON

It took 129 years for the inalienable rights proclaimed in America’s Declaration of Independence to apply to the rights of patients in relationship to their doctors.

In 1905, an Illinois appellate court ruled in favor of a woman who’d sued her surgeon for performing a hysterectomy without disclosing in advance what procedure he was doing. The court declared in what became one of the foundational principles of informed consent that “under a free government,” all citizens had the right to know what a doctor planned to do to their body before he did it, no matter how “skillful or eminent” the physician.

Today, in the era of artificial intelligence chatbots and data democratization, the lessons of America’s 1776 political revolution continue to be reflected in the push for patient rights.

The most important lesson pertains to power. The American colonists learned from hard experience that those holding power rarely concede it voluntarily. Similarly, every advance in information sharing with patients can be linked to sustained economic or legal pressure.

Just as the British genuinely believed they practiced “benign colonialism,” the surgeon who performed a hysterectomy on 40-year Parmelia Davis to treat her epilepsy not only believed deceiving her was necessary for her health, but might also have cited as support the American Medical Association’s Code of Medical Ethics. Patients, the code then declared, should not allow their own ”crude opinions” to obstruct “prompt” obedience to the doctor.

Although that admonition was subsequently axed, patient rights remained minimal for decades.

It took a 1957 court ruling, in a suit by a 55-year-old man whose legs were left paralyzed following a hospital diagnostic procedure, to ensure that “informed consent” included disclosing a surgery’s risks as well as benefits. A requirement that the disclosure be in “plain language” took until 1972, in a court ruling related to a 19-year-old man left paralyzed after a laminectomy for back pain. The court specifically cited the right “of every human” to determine “what shall be done with his own body.”

In The Silent World of Doctor and Patient, the medical ethicist Dr. Jay Katz wrote, “Physicians have always maintained that patients are only in need of caring custody.” As Katz went on to criticize that view, he might have added that it conflicts with how Americans have seen themselves since the country’s beginnings.

In The Radicalism of the American Revolution, historian Gordon Wood wrote of the college president who in 1789, the year the U.S. Constitution became effective, huffed that American self-reliance was being taken to such an extreme that he soon expected to see books such as “Every Man His Own Lawyer” and “Every Man His Own Physician.”

Or “woman.” Like the self-reliant women who, after World War II, rejected pediatricians telling them when to feed their infants and, supported by the writings of the dissident Dr. Benjamin Spock, decided they were capable themselves of knowing when their babies were hungry. Or like the self-reliant Boston feminists of the late 1960s and early 1970s, chafing at a medical system that discouraged questions, who wrote a book of frank health information, Our Bodies, Ourselves, that eventually sold millions of copies. Or like the self-reliant women in the 1980s who demanded to be fully conscious during childbirth and, with their partner, make a shared decision with the doctor as to whether to continue natural breathing exercises or accept medical intervention.

There is a deeper similarity between the patient rights fight and broader American political struggles. Although the American revolution’s ideals were codified in the first ten amendments to the Constitution – known as the Bill of Rights – the rights guaranteed to all in theory were often absent in practice. In that same vein, the patient rights ideals of informed consent, patient-centered care and shared decision-making that have been codified in countless rules, regulations and ethics codes too often in actual practice remain euphemisms for getting the patient to do what the doctor wants.

One recent article described how distraught patients facing a medical procedure are often given scant time to consider a dense, informed consent form whose content may be intended more to protect the institution than the patient. That process, stripped to its essentials, isn’t really that different from the “prompt obedience” sought by 19^th century physicians.

The advent of the AI chatbot, with its personalized responses to even the most detailed medical questions, is rapidly changing the balance-of-power equation despite the technology’s known flaws. One in three adults used generative AI for health information and advice in the last year, according to both a KFF Tracking Poll and Rock Health’s Health AI Consumer Adoption Survey. More significantly, according to KFF four out of ten individuals using AI uploaded personal medical information such as test results or doctors’ notes. More significantly still, the latest Edelman Trust Barometer reported that 64 percent of respondents – including a majority of those over age 55 – said they believed consumers fluent with AI could do at least one task as well as, or better than, doctors.

Even greater change is on the way; e.g., patient-controlled AI agents, anyone? Just as the elite among the colonists came together to overturn the status quo, so, too are sophisticated patient activists interacting in the #PatientsUseAI Substack, launched by “participatory medicine” pioneer “ePatient Dave” deBronkart. For instance, efforts to institutionalize “patient-directed” health care include the Critical AI Health Literacy (CAIHL) initiative, from Hugo Campos and Liz Salmi, designed to help patients ask, “Who does this AI actually serve, and does it expand or constrain patient agency?” and the CLAIM initiative from Gilles Frydman (Contextual Literacy for AI in Medicine), which provides a structure for interrogating the AI’s answers and deciding what output applies to your actual situation. There is also the Patient AI Rights Initiative of The Light Collective.

A recent JAMA essay by medical ethicist Dr. John Lantos lamented “The Lost Aura of the Physician in the Age of Artificial Intelligence.” Wrote Lantos:

AI democratizes medical knowledge in a way no prior technology did. It is available to everyone, on their phones, without the expensive superstructure of a hospital…When a profession’s core competencies become reproducible, the central question is not whether it will disappear, but how its social role will be redefined.

The answer to that question lies in plain sight, if only physicians would refrain from hand-wringing and look, instead, to role models. My own list would include:

• Dr. Spock, who illustrated “patient empowerment” at its most elemental by telling a 1947 meeting of the AMA that “the baby will be a better judge than the mother or pediatrician of how much he needs at each feeding.”
• Dr. Sidney Wolfe, publishing the first consumer directory with physician information in 1974 as head of Ralph Nader’s Public Citizen Health Research Group and advocating for patients for decades afterwards.
• Drs. John Wennberg and Albert Mulley, pioneering the idea of shared decision-making in the 1980s with interactive tools intended to enable it.
• Dr. Tom Delbanco, coining the term “patient-centered care” in the 1990s and then providing years of guidance on how to accomplish it, including co-founding the OpenNotes movement.
• Dr. Donald Berwick, prompting the Institute of Medicine to declare patient-centered care a pillar of American medicine, helping popularize the phrase “Nothing about me, without me,” and so much else.
• Dr. Paul Batalden, forcefully advocating “co-production” of care.
• Dr. Tom Ferguson, a visionary far outside the medical establishment, grasping the potential of the digital information revolution in the early 1990s and inspiring the formation of the Society for Participatory Medicine.

While there are certainly other American physicians who might be on this list, I’d like to add a personal, non-American favorite. When I wrote a commentary a decade ago urging physicians to understand that digitized data meant their control of information was slipping away, it was summarily rejected by U.S. medical journals. The BMJ not only welcomed my essay, “When patient-centered isn’t enough,” which set out a “collaborative health” structure – one based on shared information, shared engagement and shared accountability – to replace the old hierarchy, but editor-in-chief Dr. Fiona Godlee designated it an “Editor’s Choice.”

On the eve of America’s birthday, it is ironic that the then-editor of the British Medical Society’s official journal appreciated patient autonomy better than many U.S. counterparts do even now. Unlike in 1776, the most avid activists don’t seek full independence – “Every Man His Own Physician.” They do insist, however, on a relationship that’s anchored in mutual respect and trust, not mere lip service. For their own sake, as well as the sake of their patients, doctors should listens.

As I concluded in my BMJ essay:

Accepting a less central role may feel at first as if collaborative health is shrinking the profession’s importance. In reality, accepting true partnership will profoundly expand the profession’s influence in the days to come.

Michael L. Millenson is president of Health Quality Advisors & a regular THCB Contributor.

By COLIN LAWLOR

A patient comes in for an ordinary primary care appointment. The nurse runs through the usual checklist: temperature, blood pressure, pulse, weight, sometimes pulse oximetry. Sleep probably won’t come up. If it does, it will be a side note, and if the patient says, “not great,” what often follows is a brief look of sympathy and the familiar advice to relax a bit before bed.

That is, more or less, what sleep looks like in the most common diagnostic interaction in American medicine. Don’t worry, it is not much, if any better in any other country. The other vitals get numbers, while sleep gets small talk. Calling this a minor gap misses the point.

What the Evidence Says

Sleep sits among the strongest behavioral and physiological predictors we have for chronic illness, cognitive decline, mental health outcomes, and burnout.

Work out of Stanford recently showed that just one night of sleep data (admittedly from a hospital sleep lab), processed by a foundation model called SleepFM, could flag elevated risk across 130 disease categories with high accuracy. The outcomes on that list are not trivial and include all-cause mortality, dementia, myocardial infarction, and heart failure.

A 2025 umbrella review that pooled 29 systematic reviews found two-way, physiologically mediated links between sleep and depression, anxiety, plus a long catalog of cardiometabolic conditions.

And researchers at Washington State University published what is, so far, the longest objective description of sleep in chronic insomnia. Eight weeks of continuous, in-home measurement pointed to something clinicians have struggled to capture for years: night-to-night swings in sleep efficiency, sleep latency, and intermittent wakefulness are central to the condition. Sleep diaries and one-night lab studies kept missing that pattern.

The clinical rationale for measuring sleep is settled, but what remains unclear is whether medicine intends to behave as if it believes its own evidence.

Look at the present setup. Obstructive sleep apnea affects an estimated 960 million people worldwide, and as much as 80 percent of moderate-to-severe cases are still undiagnosed. Chronic insomnia hits more than 800 million people worldwide. Both disorders feed into downstream consequences that are costly and common, like cardiovascular disease, depression, motor vehicle crashes, workplace injuries, dementia, and more. Both can be treated. Yet routine primary care generally does not screen for either.

The American College of Physicians has recommended cognitive behavioral therapy for insomnia as first-line treatment since 2016. Still, most people with chronic insomnia never receive CBT-I, partly because they are never identified in the first place. Clinicians cannot treat what they do not uncover, and they often do not even ask the questions that would surface it.

The Vacuum that Consumer Tech Filled

Talk to working professionals, parents of young kids, perimenopausal women, older adults, teenagers, almost anyone, and sleep comes up fast. People know it matters. They have read about it, they monitor it on a watch, they bring it to their doctor. And more and more, when the clinical system has nowhere to put that concern, they go looking elsewhere.

After more than 16 years in sleep science and health technology, the biggest shift I have watched is the change in what patients do when medicine leaves a gap.

Consumer tech moved into the space that healthcare left open. People measure their sleep, sometimes well, sometimes poorly, through wearables, phone apps, and bedside devices. Apple, Google, and the broader consumer market have helped make sleep feel “countable,” something worth paying attention to. That is genuine progress.

But the next step is where things break. If a patient sees a steady decline in deep sleep reported by their watch across six months, there is typically no clinical pathway for that signal. Most primary care practices are not designed to receive it. Physicians often have little training in interpreting it. Insurers are rarely arranged to pay for the time and work needed to investigate it.

The data is available, but what is missing is the machinery that turns data into insights and care.

So, patients end up doing the interpretation themselves, usually with mixed results, and often while surrounded by wellness content that ranges from thoughtful to careless. That gap is not a consumer problem. It is a medical one.

What Medicine Needs To Do

This case is more practical than it might sound. Medicine does not need to swallow the entire consumer wearable world to take sleep seriously. It needs to do four concrete things.

First, bring validated sleep measurement into routine primary care, right alongside the other vitals. At population scale, the tools already exist for smartphone-based measurement, clinical-grade bedside sensors, and standardized aggregation of wearable data that has been benchmarked against polysomnography. The science is not the bottleneck. Reimbursement, workflow, and training are.

Second, screen consistently for the three most common, most underdiagnosed sleep disorders, obstructive sleep apnea, chronic insomnia and Restless Legs Syndrome, especially in groups where prevalence is high. Primary care is an obvious home for this, but so are obesity medicine, cardiology, endocrinology, mental health, and women’s health. None of these areas do it reliably today.

Third, build a referral and treatment path that functions. When sleep measurement points toward a clinical problem, there has to be somewhere for a patient to go. That means more sleep medicine capacity, broader access to CBT-I, and tighter collaboration between sleep specialists and the rest of the care team. Right now, the route often runs through too few sleep labs and even fewer sleep doctors or behavioral sleep clinicians, which leaves patients waiting or never getting seen. Capacity needs to expand.

Fourth, treat the sleep data people already collect as a legitimate input. Tens of millions of Americans track sleep every night. The data quality varies, and the interpretation is often uncertain, yes. Still, the signal gets much clearer when you add validated measurement and clinical context. That is made easier through high-quality harmonization tools. When a patient walks into an appointment carrying months of self-collected data, they are doing work the system has not formally asked anyone to do. Medicine should take that seriously.

The science is sufficiently advanced. What is left is the operational work of sorting the wheat from the chaff, creating workflows, defending reimbursement, training clinicians, expanding capacity, and treating sleep with the same gravity we have given other vital signs for a century.

Sleep is also an obvious entry point to a larger question. How should medicine leverage the power of continuous physiological signals in everyday care? Sleep is becoming easier to measure, deeply consequential, felt personally, and it has one of the widest gaps between what we know and what we do.

If the healthcare system cannot figure out how to measure and respond to sleep—something universal, intuitive to patients, and supported by uncontested evidence—then the larger promise of preventive medicine driven by physiological data looks shaky. We are past arguing about whether sleep matters. We are past proving the technology can measure it. The question that remains is simpler, and harder: is medicine willing to treat sleep like the vital sign it is?

This one has been ‘slept on’ long enough.

Colin Lawlor is the founder and CEO of Sleep.ai, where he has spent more than a decade developing validated sleep measurement and intelligence technologies.

By MIKE MAGEE

Last week, policy wonks from the right and the left, finally found a topic they could agree on – Kids are no longer having (as many) kids.

Specifically, teen pregnancies dropped an additional 10% in the US in 2025. This is an acceleration of a trend which began two decades ago. Teen births peaked in America in 1991 with 62 births per 1000 girls/women age 15 to 19. In 2025, the rate was below 12 per 1000, a drop of 80%, with the majority of that (72%) occurring since the 2008 Great Recession.

Obviously, this is “good news” for these young women according to Congressional reports. And most agree the causes are multifactorial, and include gains in health education, declines in sexual activity in youth, access to contraception and the Plan B pill, and expanded economic and professional opportunities for women in society.

But for societies worldwide, leaders look on with angst as the birth rates in their nations have broken through the replacement line, with deaths exceeding births. This “replacement rate” is roughly 2.1 births per woman. The CDC recently reported that without immigration, the 2023 total fertility rate was only 1.6 births per woman (1,616 per 1000 women over a lifetime).

Since 2007, trend lines have pointed decidedly downward. In that year, there were 4,316,233 births in the U.S. In 2025, American women gave birth to only 3,606,400 newborns (a 23%) decline.

Demographers generally agree that the trend initially was most pronounced in young, college-bound girls/women. But it is now evident across all demographics, with concerns about jobs, housing, costs of child care, political instability and more causing prospective parents to wonder whether having children is a wise choice and economically attainable, segregating society into “fertility haves and have nots” according to UNC Sociologist Karen Benjamin Guzzo.

Culture warriors, like Katie Miller, texted away on X from the air conditioned comfort of her DC office, a safe distance from her own children.“Our biological destiny is to have babies — not slave behind desks chasing careers while our civilization dies.” But she’s fighting a downward trend.

About half of the nation’s 30-year-old women are now childless. In the immediate post-WWII era, total fertility rate was a remarkable 3.5. With the introduction of the Birth Control Pill, that number plummeted to 1.7 by 1976, and then slowly recovered. But by 2007, it had crossed the replacement figure of 2.1, and has moved steadily downward since then.

One countervailing trend is “delayed motherhood.” While birth rates under age 30 have collapsed, women over 30 are having more children, but not enough to make up the difference. Over the past three decades, birth rates in women 35-39 rose 71%, and doubled for women 40-44. But numbers remain small, and inadequate to cover the “postponement.”

As an expert report pointed out, education is having a dual impact. “The key insight: women aren’t just delaying childbearing—they’re having fewer children overall… American women with advanced degrees averaged 1.8 children, compared to 2.25 for women with high school diplomas and 2.7 for women without high school education.”

We’ve clearly entered an era where women think twice before becoming pregnant. The nation as a whole, compared to others, have done little to signal appreciation for the sacrifices required to select parenthood. In a country with problematic health coverage and services, a housing crisis, no subsidized child care, and a AI-shaken job market, why take the risk?

The “opportunity cost of child-rearing” has risen dramatically with women’s educational and career gains. Sociologists label this the success penalty. Interrupting a career is a derailment of opportunity growth including promotions, raises, and advances. And that’s without considering the direct costs associated with the care of a child, let alone the pressures of debt associated with housing and student loans. Not surprisingly, fertility rates have declined as housing costs and student debt have risen.

Economist Martha Bailey, who directs the California Center for Population Research at the UC, Los Angeles, doesn’t place the blame on women for protecting themselves. She summed up her feelings this way, “People are having the number of children they want and that they can afford at a time that makes the most sense for them. What I don’t think anyone is in favor of is a Handmaid’s Tale type policy regime, where we’re trying to talk families into having children they don’t want.”

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)

By KIM BELLARD

It probably didn’t show up on your calendar, but Monday was World Ocean Day. It’s a day meant to catalyze “collective action for a healthy ocean and a stable climate,” and has been around since 2002 (although the U.N. didn’t officially recognize it until 2008). Its website claims a network of over 2,000 organizations, in 180 countries.

I wish we had more to celebrate.

Many have recognized the irony of humans calling our planet “Earth,” when, in fact, 71% of its surface is covered with water. Even more amazing, oceans account for 99% of the biosphere. We come from the ocean and still owe much of our existence to it.

Unfortunately, these are not good times for oceans, and we’re to blame. The most recent World Ocean Assessment from the U.N. highlights:

• The ocean matters to everyone, everywhere;
• The ocean is under intensifying stress;
• Climate change is transforming conditions;
• Biodiversity is declining across nearly every marine habitat;
• Pollution is widespread and increasing;
• Ocean food systems are threatened.

The report concludes: “The coming decade is decisive: without rapid, coordinated global action, ocean health will continue to decline, threatening climate stability, biodiversity resilience, food security, livelihoods and the wellbeing of billions.”

I think about this in light of last month’s announcement by the National Science Foundation that it was “descoping” the Ocean Observatories Initiative (OOI) Major Facility, beginning next week. That’s a $368 million deep-ocean observation system “that delivers real-time data from more than 900 instruments to address critical science questions regarding the world’s oceans.” Some 900 instruments will be removed, in both the Pacific and Atlantic oceans.

Michael England, a spokesman for the National Science Foundation, told Eric Niiler of The New York Times that the decision “aligns with N.S.F.’s wider strategy to have a nimbler approach to prioritizing support for evolving scientific priorities and emerging technologies as well as a deliberate approach to smart life cycle management within its portfolio of research infrastructure.”

In other words, we (the Trump Administration) didn’t invent it, and it relates to climate change, so we don’t want it.

Craig McLean, who was the acting chief scientist at the NOAA during the first Trump term, told Mr. Niiler: “This reflects the further lack of understanding that the current administration has of scientific value and scientific merit. By dismantling such a system, we push the United States back yet again into a rear seat in global scientific leadership.”

Scientists are aghast. Sabrina Speich, an expert in global ocean monitoring at the Ecole Normale Supérieure (ENS) in Paris and chair of the ocean expert panel of the Global Climate Observing System, told The Guardian: “Ocean heat content is the most robust indicator of climate change we have – not just of what is happening in the ocean, but of the entire climate system. Lose them, and you lose your ability to track not just ocean warming but the climate system as a whole – they are a proxy for variables that become unavailable the moment the observations stop.” 

John P Abraham, professor of engineering at the University of St Thomas, called the move “penny-wise, pound foolish,” adding: “The US government wants to save less than a billion in sensors, which are the eyes and ears of the ocean. We have hundreds of billions in climate costs per year. The cost of the observation system is a fraction of the climate costs from hurricanes and storms that hit the US.”

“Walking away from a $368-million investment in a state-of-the-art system, a feat of engineering already paid for by the American people, is absolutely myopic,” Chris Robbins, the associate director of scientific initiatives for Ocean Conservancy, a nonprofit group, complained to Mr. Niiler.

Democrats in Congress vow to fight the cuts, but lack the votes to do anything. The E.U. said it was stepping up its ocean monitoring efforts, independent of the U.S.’s action, with its OceanEye initiative, but that will be a long term process and won’t immediately offset the U.S. cuts.

Meanwhile, a new study has found that a “cold blob” in the Atlantic Meridional Overturning Circulation may suggest big changes ahead: “a further weakening of Atlantic heat transport in future climate change could lead to serious impacts on climate and weather conditions in Europe and other parts of the world.”

Sure doesn’t seem like a great time to lose our ocean monitoring abilities.

Even worse are the Trump Administration’s gung-ho attitude towards deep sea mining. It is well known that the ocean’s floor has lots of valuable minerals, and some mining companies are delirious at the prospect of strip mining them. The NOAA has started mapping some 30,000 square nautical miles off American Samoa, and the Bureau of Ocean Energy Management (BOEM) is investigating several other offshore areas, both with the intent of allowing deep sea mining.

The U.S. may even issue permits for seabeds not owned by the U.S., or any country.

“No one has done commercial-scale deep-sea mining,” said Becca Loomis, a staff attorney at the Natural Resources Defense Council, ““This would be brand new, and they’re kind of forging ahead. Rushing ahead with this industry is really scary for the ocean, the ocean ecosystem, for people who rely on fisheries.” 

A new review of existing studies found how relatively little we understand about the impacts of such mining, but what little we do know suggest there are large and longstanding impacts on biodiversity.

Just this week, a Greenpeace study found thriving new-to-us ecosystems in the Arctic Mid-Ocean Ridge “We barely understand how these communities function, which environmental factors influence their distribution, or how sensitive they are to human disturbances. Likewise, our discovery of several sponge species that are potentially new to science highlights how little is known about Arctic ecosystems, said Dr Julio A. Diaz, deep-sea researchers, Museum of Evolution at Uppsala University.

“The deep sea mining industry has not yet started to tear up the seabed, and we therefore have the opportunity to stop an environmental disaster before it happens.” said Dr. Sandra Schöttner, Chief Scientist, Greenpeace International.

One can imagine how little the Trump Administration – whose mantra is “drill, baby, drill” – cares about such impacts.

I’m thrilled that there is such a thing as World Ocean Day, but it’s hard to celebrate it in the midst of all that is happening to degrade and disrupt our oceans. I’m quite certain that the oceans will be around long after humans will be, but it’s unfathomable about how much damage we’ll do to them while we are.

By MIKE MAGEE

In a 1996  JAMA editorial Nobel Laureate Joshua Lederberg MD wrote “Our fight with microbes is far from over …odds are tipped in their favor…they outnumber us a billion fold, and mutate a billion times more quickly…pitted against microbial genes, we humans mainly have our wits.”

Now three decades later, our scientists remain in a “battle of wits” with this amazing viral foe, but even without a vaccine, have maintained a slide edge for humanity. Experts recently confirmed that we are unlikely to have a vaccine bullet by 2030. And it’s not because we haven’t tried. There have been more than 250 official HIV vaccine trials, with fewer than 10 making it past the safety threshold to test efficacy – and the best performer only had a moderate success rate in triggering some immunity in 31%.

HIV is just a bad actor according to Professor Anna Durbin at the Bloomberg School of Public Health at Johns Hopkins. To start with, it embeds its chemistry in the host’s DNA genome, blurring the boundaries between “self” and “non-self.” Most of our successful vaccines focus in on a protein portion of the virus envelop or capsule. But the HIV virus has a “glycan shield” – a protein envelope that incorporates around 95 different sugar molecules which shield or disguise the viral protein from detection by our immune system. As one expert described it, “The immune system’s antibodies approach the virus and effectively see a blurry cloud of sugars rather than the vulnerable protein underneath.”

The second problem is the virus’s “sloppy gene duplication” is riddles with mutations. This yields dozens of different versions each with endless subtype variations. This is not typical disciplined viral behavior. Today’s measles viral genome for example is nearly identical to its late 20th century version.

And finally, HIV’s favorite target for invasion is the CD4 lymphocyte, otherwise known as the “Helper T-cell.” That happens to be the cellular key that unlocks our entire immune apparatus. This virus effectively decapitates the lead generals of our defensive force. And yet, we’re gaining on the virus. How have we done it?

First, by focusing on two “work-arounds” that trigger “passive immunity” without the help of our own immune machinery. Three decades ago, breakthrough discoveries first offered a glimmer of hope in the form of antiretroviral medications. With a variety of different combined therapy approaches, HIV/AIDS emerged as “no longer a death sentence,” but a chronic disease, like diabetes, that could be managed. In the modern era, this effective approach has spawned PrEP, or “Pre-exposure Prophylaxis,” – a preventive regimen for HIV negative individuals who are at risk of contracting HIV.

This regimen, generally combining the two anti-HIV meds, tenofovir and emtricitabine, prevents HIV replication if an individual is exposed to the virus. This cut transmission through sexual contact by 99%, and from illicit dug injection by 74%. The challenge has been access – especially in under-developed countries. But las month, Gilead Pharmaceuticals, teaming up with The Global Fund and PEPFAR (President’s Emergency Plan for AIDS Relief) agreed to provide their new antiretroviral drug, lenacapavir (LEN) at cost. In trials, the drug was 99% effective in keeping individuals HIV negative. As important, it is a twice a year injectable that could make a world of difference in developing nations, especially when it comes to transmission of the virus from HIV+ mothers to newborns through pregnancy and breastfeeding.

Scientists have known for some time that this population is key to combating HIV/AIDS. The chances of a newborn contracting HIV from an infected mother are 1 in 2. Contrast that with unprotected sex (1 in 72) and IV drug use (1 in 158), and it was clear to policy makers where to focus. Three decades ago, 1 in 4 infants born in Uganda were HIV+. That translated into 32,000 HIV infected children per year. Today it is less than 5000. How? 1) All expectant parents are HIV tested. 2) If positive, they receive anti-retroviral meds.

The latest WHO stats show progress is indeed possible:

“At the end of 2024, 77% of people living with HIV were accessing antiretroviral therapy, up from 24% in 2010. Globally, there were 1.1 million pregnant women with HIV in 2024, of which an estimated 84% received antiretroviral drugs to prevent mother-to-child transmission. At the end of 2024, there were 1.4 million children aged 0–14 years living with HIV globally, down from 2.7 million in 2010.” Clearly there is still work to be done. One in six pregnant women with HIV is still not under treatment.

The second “work-around” is equally promising. It is what the NIH has labeled a “passive immunization strategy” – monoclonal antibodies. Research in animals, dating back to 2014, found that animals with long-standing HIV sometimes develop “broadly neutralizing antibodies” that effectively stop a whole range of different genetic subtypes of HIV. A decade later, synthetically engineered copies of these natural antibodies are being tested. Challenges remain, including the need for continued infusions, perhaps every six months, to keep formally HIV+ individuals in “permanent remission.” 

A summary report in Smithsonian magazine six months ago stated, “This year, researchers reported a breakthrough that suggests a ‘functional’ cure for HIV—a way to keep the virus under control long-term, without constant treatment—may indeed be possible. In two independent trials using infusions of engineered antibodies, some participants remained healthy without taking antiretrovirals, long after the interventions ended.”

The final word goes to Johns Hopkins Bloomberg School of Public Health’s Morgan Coulson, who recently wrote, “The history of HIV vaccine research is a long record of promising ideas that didn’t translate into protection in large trials. What makes the current moment different is that researchers have, for the first time, demonstrated they can deliberately guide the human immune system toward producing the kind of antibodies known to neutralize HIV broadly. Whether that initial success can be built into full protection is the central question for the next decade of research.”

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)

By MATTHEW ZACHARY

The American healthcare system behaves exactly as its incentives tell it to behave. That sentence sounds almost boring until you follow it to its logical conclusion.

Insurance companies now influence clinical decisions more aggressively than many physicians. They shape hospital consolidation. They determine startup viability. They influence venture capital allocation. They dictate which drugs succeed commercially. They pressure physician behavior through reimbursement design. They decide who accesses diagnostics, rehabilitation, home care, specialty drugs, imaging, mental health services, and sometimes whether a patient gets enough time left on Earth to watch their kid graduate college.

And somehow we still spend an astonishing amount of time talking about apps.

I have spent almost 30 years inside this machine as a brain cancer survivor, nonprofit founder, media mogul, healthcare conference producer, policy advocate, and accidental anthropologist of American institutional failure. I have watched every corner of healthcare promise transformation. Precision medicine. Digital therapeutics. Patient engagement. AI. Consumerism. Value based care. Coordinated care. Interoperability. Navigation. Ambient listening. Population health. Personalized medicine. Blah blah blah,.

Meanwhile millions of Americans spend their afternoons arguing with an insurance company employee named Chad who has never met them but somehow possesses the authority to overrule their oncologist.

At some point we need to admit the obvious. Innovation stopped driving healthcare years ago. Insurance drives healthcare now.

That realization sits underneath every chapter of my new book, We the Patients: Understanding, Navigating, and Surviving America’s Healthcare Nightmare. I wrote it because after decades inside the system I finally understood something uncomfortable. Americans think they are angry about healthcare costs, wait times, medical debt, or inaccessible care. They are. But underneath all of that sits a deeper fury most people struggle to articulate.

People understand, instinctively, that somebody they never elected now controls enormous portions of their lives during moments of maximum vulnerability.

That changes a country.

Healthcare executives still talk about “patient experience” like it is 2004 and somebody just discovered FourSquare recommendations. Venture backed startups still pitch friction reduction while prior authorization delays chemotherapy. Health systems launch innovation centers with reclaimed wood conference tables and espresso bars while patients crowdsource GoFundMe campaigns to afford deductibles larger than a used Volkswagen Scirocco.

Everybody inside healthcare knows this tension exists. Few people say it plainly because too many livelihoods depend on pretending the current arrangement remains sustainable.

The business incentives tell a clearer story than the public relations campaigns ever will.

UnitedHealthcare generated more than $400 billion in revenue last year. CVS Health topped $350 billion. Cigna approaches the GDP of mid sized nations.

Meanwhile independent physician practices collapse, rural hospitals disappear, oncology practices consolidate under private equity pressure, and patients navigate a reimbursement structure designed by people who appear to view Kafka novels as operational blueprints.

The market consolidated exactly as incentives encouraged it to consolidate.

Insurance companies figured out something the rest of healthcare still struggles to admit. Whoever controls reimbursement controls the system itself.

That means every healthcare innovation eventually slams into the same wall. Reimbursement policy determines survival.

Founders know it. Hospital executives know it. Pharma knows it. Investors definitely know it.

You can build the greatest diagnostic AI platform in human history. If insurers refuse coverage or bury reimbursement under administrative complexity, congratulations on your beautiful science project.

You can build extraordinary survivorship programs. If insurance declines long term rehabilitation, fertility preservation, cognitive support, nutrition counseling, or mental health services, patients still absorb the damage alone.

You can launch patient navigation companies until every healthcare conference ballroom from San Diego to Orlando glows with backlit logos and optimism. If the underlying insurance architecture rewards denial, delay, and opacity, navigation simply becomes another coping mechanism layered on top of institutional dysfunction.

The healthcare industry increasingly resembles a city building flood mitigation kiosks while refusing to discuss the hurricane.

That hurricane carries a giant insurance company logo.

The irony here deserves attention. American healthcare still publicly frames itself around medicine. The system actually operates around financial risk management.

Insurance companies do not fundamentally exist to maximize health outcomes. They exist to manage financial exposure. Sometimes those goals align. Sometimes they violently diverge.

Every physician reading this knows exactly what I mean.

Every hospital CFO knows it too.

Every founder who quietly pivoted their startup because reimbursement codes changed knows it.

Every exhausted caregiver sitting on hold for 97 minutes while hearing a pan flute version of “Don’t Stop Believin’” knows it too.

The healthcare industry often defends itself by pointing to complexity. Healthcare involves regulation, compliance, clinical nuance, labor shortages, fragmented infrastructure, aging populations, and rising chronic disease burdens. All true.

But complexity became profitable.

That distinction changes everything.

Administrative complexity now functions as both operational reality and economic moat. Entire sectors profit from helping employers, providers, and patients navigate complexity created by other sectors profiting from complexity. We built trillion dollar ecosystems whose business models depend on translation services between fragmented bureaucracies.

At some point that stops looking accidental.

None of this means markets fail automatically or private sector participation inherently creates harm. The opposite argument deserves attention. Properly aligned incentives could produce extraordinary outcomes. Efficient reimbursement models, transparent pricing, aligned preventive care incentives, and rational risk pooling could dramatically improve patient protection while lowering long term system costs.

But current incentives reward scale, opacity, leverage, and administrative endurance.

Patients experience those incentives as exhaustion.

The healthcare industry still underestimates the political consequences of that exhaustion.

For years Americans compartmentalized healthcare suffering as individual misfortune. Cancer happened to somebody else. Bankruptcy happened somewhere else. Insurance denials belonged to another family. Then the system expanded its dysfunction into nearly every household in America.

Now everybody has a story.

• The delayed scan.
• The denied medication.
• The impossible bill.
• The out of network anesthesiologist.
• The prior authorization nightmare.
• The “we regret to inform you” letter.
• The 3 hour phone call transferred 6 times before disconnection.
• The family forced into amateur actuarial science while somebody they love sits in an ICU bed.
• Healthcare stopped feeling like civic infrastructure. It started feeling adversarial.

That erosion of trust carries enormous consequences for every institution attached to healthcare. Pharma wonders why public trust collapsed. Hospitals wonder why patient hostility increased. Insurers wonder why public rage escalates. Policymakers wonder why healthcare suddenly carries populist volatility across the political spectrum.

People eventually recognize when a system treats them like revenue extraction units wrapped in diagnostic codes.

The most dangerous mistake healthcare insiders still make involves assuming patients lack systemic awareness. Patients understand incentives far better than the industry gives them credit for. They may not speak in reimbursement terminology or regulatory language, but they understand outcomes.

They understand when nobody takes responsibility.

They understand when every institution redirects blame toward another institution.

They understand when “care coordination” means their exhausted spouse now functions as unpaid case manager, billing specialist, transportation coordinator, pharmacist, medical records clerk, and amateur attorney.

That awareness creates political energy.

Healthcare leaders should pay closer attention to what happens when millions of Americans across ideological lines begin reaching the same conclusion at the same time. The insurance architecture underpinning modern American healthcare increasingly shapes labor markets, household economics, disability, entrepreneurship, retirement timing, caregiving burdens, and social trust itself.

That reaches far beyond medicine.

The healthcare industry still behaves like patients remain fragmented consumers navigating isolated problems. Reality changed. Americans increasingly recognize shared structural exposure.

That realization explains why I wrote We the Patients.

I wanted to document the mechanics underneath the madness. I wanted readers to understand how incentives compound harm over time. I wanted healthcare insiders to confront the gap between what the system claims to deliver and what ordinary people actually experience after the MRI, after the diagnosis, after discharge papers land in their hands.

Most importantly, I wanted people to recognize their anger has a rational source.

Nothing destabilizes public trust faster than realizing your survival may depend less on medical science than on whether an insurance company decides your care fits an approved financial framework.

Once people see that clearly, they cannot unsee it.

That realization changes how people vote, organize, spend, work, retire, build companies, evaluate institutions, and understand power itself.

And frankly, after 30 years watching this system from every possible angle, I think healthcare insiders should spend a lot less time celebrating innovation theater and a lot more time asking a brutally simple question.

Who actually controls reality when a patient hears the word no?

Matthew Zachary is a 30-year brain cancer survivor & the co-founder of We The Patients, and the author of We the Patients: Understanding, Navigating, and Surviving America’s Healthcare Nightmare (Wiley, May 2026).

By TOMMY BEVERIDGE

Just like the Holy Roman Empire was none of those things, America’s health care system is neither health care, nor a system. Both are in fact decentralized commercial arrangements clothed in things that sound good, like Holy-Romanness, or Consumer-driven Health Care. Rather than health care, we have a patchwork of consumer products and government subsidies designed to pay a vast cadre of individuals and interests to perhaps incidentally provide health care. To even call it a system would imply something centrally coordinated, which no one in their right mind would do.

It feels hopeless. Health insurance is expensive, arbitrary, and capricious. It profits off of slices of an ever-growing pie, regardless of margins. The providers we cannot live without often charge whatever the market will bear. On top of this, the government, directed by laws written by politicians unwilling to upset powerful interests, has spent the past two decades pushing complex payment ideas with little result except a growing ecosystem of consultants specializing in gaming such incentives. Then there are the consultants— arms dealers in both sides of a war, selling hospital systems software that helps them bill as much as they can for their work, and health insurance companies software that helps them deny claims wherever they can.

We all know this. It’s the learned helplessness about it all that gets me. Sometimes a sob story about chemotherapy denied enters the zeitgeist, or the tale of a lone vigilante taking out a health care executive, but mostly we just take the 7 percent annual premium increases and deductible hikes with a stiff upper lip. Meanwhile, few of the players: payer, provider, government, or software slinger, put American’s health at the top of their agendas. Customer satisfaction? Maybe. Public ire? Occasionally. Shareholder value? Certainly. But our actual health?  

Something that isn’t health care or a system can’t be a health care system. Not when this how we pay for care:

People with steady work usually get employer-sponsored coverage. This is about 54 percent of America. These plans negotiate with providers in thousands of separate and discrete settings, with the natural incentive to maximize their own percentage in the deal. A family facing a surgery or cancer diagnosis can easily shell out $10k or more, on top of their growing monthly premiums.

Old people, and certain sick and disabled people get Medicare. That’s about 19 percent of America. It’s federally run and it’s a good deal, except that it covers only 80 percent of costs, and you need to buy a separate Medicare plan to cover prescription drugs whose prices are largely dictated by the sellers, plus a commercial plan that fills in all the gaps of its antiquated insurance coverage. Or a fully commercial Medicare Advantage plan that may or may not cover all your costs, but will make its money through a mix of annoying-to-lethal administrative frictions.

Poor people, certain sick people, and some lower-middle-class people get Medicaid. That’s about 18 percent of America. Low rates, coupled with the administrative headaches common to all health plans lead to considerably fewer providers taking Medicaid.

Ten percent of people buy individual coverage. All the claims of impending socialist doom, or a coming golden age sixteen years ago were about this sliver of the population. The problem is that it’s expensive, negotiates like employer-sponsored coverage (i.e., badly) and the government just cut subsidies for a lot of people. And the politics still burn.

People who are ineligible for coverage, can’t afford it, or don’t want it remain uninsured. This is about 8 percent of America (and growing, again). They show up at the ER and cost us all.

Then there’s the VA and Military Health System. About 1.2 percent of America is enrolled for health care with the VA. Active-duty military, their families, and retirees get TRICARE and the Military Health System. That’s about 2.8 percent of America. They both own large portions of the care delivery as well. These programs barely communicate with one another, and are perennial policy basket cases.

Each of these plan types have various subtypes, their own state and federal legal structure, their own billing and administrative procedures, and their own constantly churning client base. Each provider must individually contend with each of these complications with every claim or patient interaction. This is not a system, nor is it really health care. Against all this, how will small-ball, often voluntary payment reforms fix these problems?

Market utopians imagine that the right economic incentives will create the just and rational distribution of health resources. Some people even believe that health care will be better if we expose the patient to more costs— give them high deductibles and they’ll shop for care. I can’t believe that I would be a better buyer of chemotherapy than an expert who works on my behalf. But hey, what do I know?

This market conceit has been convenient for academics and politicians to dance around tough choices, hoping that the utopian’s light touch will be enough. Well-meaning economists thought up complex incentive structures like Accountable Care Organizations; where providers willingly enter contracts with insurance plans to pay them less. If I hear about one more clever economist’s approach to changing consumer or provider behavior, I’ll invoke the spirit of Uwe Reinhardt upon them. 

In the end, the only non-theoretical ways to control health care costs are things like negotiated fee schedules and global payments, and we still act as if they’re entirely novel. The only way to improve health is to restructure care towards prevention, but that’s a hard sell for committees of cardiologists and CEOs. The fact remains that market logic on its own has never and probably never will guarantee anything close to a “system,” where health care is delivered on behalf of people.

But there’s a lot of good too. There’s no better place on Earth for someone with a weird cancer or in need of a transplant (plus the money/coverage). Payers do good work too, when their incentives are aligned to helping the patient above all else. Medicaid managed care is a good example. Then there’s the drug industry, who does amazing things, but should be paid according to the marginal value of their new products, just like everyone else across the world does. Old power structures must be challenged, but they also need a role in the new order.

That’s a lot. Let’s think big again. Big and different. Medicare for All is a good slogan for a lot of different ideas. Taken literally, what you really get is a mid-1960s health plan design, some administrative simplicity, lower rates, and tremendous political baggage. Matthew’s Concierge Care for All concept offers a robust rubric for reform, reorganizing how both payer and provider operate in a thoughtful way; sort of a laissez faire NHS that takes advantage of what already works here in America. Agree or not, it’s an idea whose scale matches the challenge. Any way we do it, the road to reform is through prices and reorienting incentives away from hospitals, specialists, and pharma. The world is full of options:

• We could impose various forms of fee schedules and global budgets, reorienting providers to serve populations with heavy emphasis on primary care. That’s how much of Europe works.
• We could abolish most private insurance, directing the government to set prices and process claims, leaving the care to provincial and regional authorities. That’s how Canada works.
• We could change payer incentives so they’re more interested in collectively bargaining on our behalf instead of taking a percentage of the ever-growing pie. That’s how Japan works.
• We could attempt a consultant’s dream where heart surgery is just another consumer product. That’s the consensus of what entrenched interests think would work. 

Options abound, but no system will provide every service to everyone for cheap. Someone, whether it be government, a private insurance company, or ourselves, will need to judge that a particular back surgery is not necessary or too expensive for its value. The politics are dark and full of demagogues. But we can’t say we have health care, a system, or a healthy civil society until we look at the whole thing and make some fundamental changes. Bring your own ideas, and let’s get to work.  

Tommy Beveridge is a longtime health care policy wonk who has worked in the .org, .com, .edu, and .gov worlds. Due to present employment constraints, Tommy is sticking to a nom de plume. His picture above is actually Asclepius, the Greek god of medicine. Because why not?