Worst first. Then the fix.
The goal is an efficient, high-quality system that is fair. Fair means one stay, one rate, whoever pays, and a vial that is not four times a peer list. Efficient means a posted number, the same service at the same site rate, no rebate theater. High quality means a global budget so the hospital cannot make it up on volume, and a real emergency department that stays open — not a monopoly license to bill 3×. Coverage is not on this list. ACA already did coverage. This is the invoice. The political action page is the rulebook. This is the order to unwind it.
The door is the Senate · 1. The commercial night is 2–3× · 2. Brand drugs are ~4× a peer list · 3. Must-have systems after the merger · 4. The same service, a hospital extra · 5. A rebate off a high list is not a price · 6. 340B as a hospital revenue line · 7. Twelve years, then a thicket · 8. A file dump is not a cash menu
Fair: the night and the vial do not depend on who holds the card. Efficient: a cash menu, site-neutral, a national list instead of a rebate. Quality: do not close the only emergency department in the county, and do not pay extra for the same chair because the sign says hospital. Rank is by how much of the 5% it moves — hospital pile first, then the brand, then the machines that keep both legal.
Congress already prices Medicare. Maryland already prices the commercial night as one state. The Inflation Reduction Act is a statute — the drug-makers’ lobby (PhRMA) sued, and the ten drugs are still law. The American Hospital Association sued the transparency rule and lost. What a judge actually enjoined was a CMS memo that tried to do H.R. 3 without 60 votes: most-favored-nation never paid a claim. H.R. 3 and site-neutral died in the Senate, not in a courtroom. The missing commercial hospital rate is a bill nobody passed, not a court that said no. A rule is not a right. A statute is. That is why this plan is a statute, not another file.
What they tried · H.R. 3 — Senate · Most-favored-nation — enjoined · Inflation Reduction Act — still law · American Hospital Association sued and lost · The missing rate
1 · hospital · sourced
Hospital care is the biggest slice of the 5%. The job-plan night is a secret multiple, not a tariff.
ProblemCongress set Medicare IPPS/OPPS. It never set the job-plan night. A must-have emergency department extracts 2–3× Medicare (RAND). The plan does not invent that multiple. It passes it through. Same stay, three prices: Medicare, Medicaid, commercial. That is not fair. It is also not efficient — the tower bills the book that cannot walk.
SolutionOne stay, one rate, whoever pays. A federal all-payer hospital tariff, with a global budget so the hospital cannot make it up on volume. Carve out true rural emergency departments so the only door in the county does not close. Medicare is not ‘true worth.’ It is the posted public rate. All-payer can sit near a blended number, like Maryland, instead of a skinny take-it-or-leave fee plus a 3× private contract.
ProofMaryland HSCRC + TCOC waiver: one rate, global budget. Live US proof on this site’s hospital table. Peers pay a national tariff. Walking off the network is not a strategy. The network is the country.
Who blocksThe American Hospital Association, the Federation of American Hospitals, and state hospital associations. A bill nobody passed. Every other state’s lobby, the day someone copies Maryland.
2 · drugs · sourced
The other half of the 5%. Same molecule, four times the sticker. People ration and die on a century-old hormone.
ProblemUntil the Inflation Reduction Act, Medicare was forbidden to bargain Part D (non-interference). The rest of the formulary still is. The manufacturer wants a high list. The PBM wants a rebate that looks like work. Nobody bargains as a country. US brands sit ~4× a peer national list (RAND). Insulin $35 is Medicare only. Alec was 26 with a job.
SolutionBargain as a country. A national list — H.R. 3’s basket and international-reference cap, or most-favored-nation as a statute that can survive court. Expand the Inflation Reduction Act past ten drugs and onto the commercial book. A posted list makes the rebate theater pointless. Quality is not ‘skip the next drug.’ It is stop treating a 1921 molecule like a launch-year brand.
ProofVA already bargains. Peers post a national list. The Inflation Reduction Act punched a hole for ten drugs; Peterson-Kaiser Family Foundation still has those ten at ~2.8× OECD. The House passed H.R. 3. The Senate did not take it up.
Who blocksThe drug-makers’ lobby (PhRMA), the biotech lobby (BIO), and the PBM lobby (PCMA). The Senate door. Courts over the ten that did pass.
Why US brands are ~4× · H.R. 3 · Non-interference · Patient voices
3 · hospital · sourced
The 2–3× is what a must-have extracts. Stop the merger or you are arguing about the contract after the door is the only door.
Problem1,600 hospital mergers. 90% of metro markets concentrated. A third of doctors hospital-employed. The job plan cannot drop the emergency department. After the merger there is nowhere else to send the night. COPA statutes shielded some deals. FTC under-enforced cross-market systems for a long stretch.
SolutionStop anti-competitive hospital and physician-practice deals before they close. Hart-Scott reporting for the small buy-ups that currently skip the agencies. Repeal or tightly condition COPAs. You cannot un-merge a system with a press release, so this is the brake, not the rewind. Rural emergency departments stay open as a public door, not a monopoly license to bill 3×.
ProofKlobuchar/Lee 2021 hearing, Arrington 2024, MedPAC, FTC hospital-merger literature. RAND’s multiple is the downstream.
Who blocksThe American Hospital Association on the Hill. State COPA bills. 2023 merger guidelines are a memo, not a statute.
Consolidation, then the 3× · Hospital voices · RAND hospitals
4 · hospital · sourced
Inefficient by design: buy the clinic, flip the sign, bill more for the same chair. Quality did not move. The site did.
ProblemA clinic visit, scan, or infusion pays more in a hospital outpatient department than in a physician office. Medicare wrote a site differential. Commercial copied it. Systems buy offices and flip them to HOPD. A freestanding emergency department can look like urgent care and bill $5,500 to walk in.
SolutionSite-neutral: same Medicare rate for the same service, office or hospital outpatient, except a true emergency department and rural carve-outs. House has passed slices (Lower Costs, More Transparency). Make it law. Then commercial stops copying the extra.
ProofMedPAC, year after year. CBO scores real money because the extra is the point. Arrington: it emanated with Obama; Republicans agreed.
Who blocksThe American Hospital Association. This is their federal hill. Rural and off-campus carve-outs sand the bill to nothing.
Site-neutral — House only · The outpatient extra · The $5,500 door
5 · drugs · sourced
The PBM product is the spread between list and net. That theater is why the sticker stays 4× after a ‘discount.’
ProblemAnti-Kickback safe harbors let a manufacturer pay a PBM a rebate off list. List stays high so the rebate looks large. Net is still ~3× other OECD after a US haircut (RAND). The person at the counter, or the deductible, meets the list.
SolutionA national list, first. Pass-through and spread bans are the consolation if the list does not move. Point-of-sale rebates so the deductible is net, not theater. A 50-state patchwork after Rutledge is not a country bargaining.
ProofPeers do not run this rebate machine. They post a list. The PBM lobby (PCMA) fights pass-through because the rebate is the product.
Who blocksThe PBM lobby (PCMA). Rebate-rule attempts die in court or the Federal Register.
6 · drugs · sourced
Charity ceiling on the buy. Job-plan sticker on the chair. The patient does not get the discount. Inefficient and unfair in the same infusion.
ProblemStatute: safety-net hospitals buy cheap. Practice: child sites and hospital-outpatient chairs. Buy at 340B, bill the job plan near ASP-plus. The spread is the product. The person in the chair is not the covered entity.
SolutionPass the 340B discount through to the patient, or bill the job plan the 340B price. Close the child-site map that turned a ceiling into a chain. Keep the original purpose: uninsured and safety-net, not a second commercial markup.
ProofThe chair is the evidence. Covered-entity growth is the American Hospital Association brief. The drug-makers’ lobby (PhRMA) sues to restrict 340B. Neither side is trying to make the job plan pay a national list.
Who blocksThe American Hospital Association defends the map. PhRMA restricts 340B. Reform stalls as ‘protect 340B’ vs ‘protect the manufacturer.’
7 · drugs · sourced
A fair system lets a biosimilar in when the statute said it would. A thicket on the pen is not R&D.
ProblemBPCIA: 12 years of biologic exclusivity. Hatch-Waxman 30-month stays and Orange Book listings on small molecules. Patents on the pen, the buffer, the schedule. Humira stayed the brand. Launch biosimilars take years the statute already paid for.
SolutionShorter exclusivity. Product-hop and thicket limits. Skinny labels that stick. The lab can still be paid. The calendar should not be the product.
ProofPorter’s Humira tape. Peers get biosimilars earlier. The 4× on a mature biologic is the thicket plus the US list.
Who blocksThe drug-makers’ lobby (PhRMA) and the biotech lobby (BIO). ACA created the biosimilar path and the 12-year wall in the same bill.
8 · hospital · sourced
Efficiency needs a number before the stay. Fairness needs the same number for cash and the plan. A secret contract is neither.
ProblemCMS made hospitals post machine-readable files. The American Hospital Association sued and lost. Most files are still not a shopper’s menu. Fines are small next to a 3× night. Cash can be cheaper than the insured allowed amount. Nobody can see that at the desk.
SolutionA posted cash menu — shoppable services as a package, like this site. Enforce the rule with fines that hurt. Require the same posted rate for the cash-pay and the job-plan shoppable, or the gap is the product. Transparency without a tariff is still a secret with extra steps.
ProofSurgery Center of Oklahoma posts a menu. This site models one. Maryland posts a rate. Files without a door price are the 2019 rule as lived.
Who blocksThe American Hospital Association’s second strategy is noncompliance. A shoppable package threatens the 2–3× book.
No Surprises stopped the ambush bill, not the 2–3× contract. The Inflation Reduction Act put Medicare in the room for a short list. Hospital price files exist and are not a cash menu. Those are real. They are not this plan. Do those first and you still have Alec’s vial and a must-have night.
The hallway: Political action · The 5% · Negotiation · Patient voices · National debt · Positioning · Flagship · The plant · Hostile world · Kill the monopoly · Mark · Evidence