Dec. 12, 2025

Pills, Profits, and Promises: How Hospital and Pharma Subsidies Save Lives—and Get Hijacked

Pills, Profits, and Promises: How Hospital and Pharma Subsidies Save Lives—and Get Hijacked
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Most subsidies in America started with good intentions: to help people through hard times and get them back on their feet. They were built for the couple who just found out they’re having a baby and are terrified of the hospital bill. They were built for the parent who just lost a job and is scrambling to keep health coverage. They were built for the grandparent whose body can’t do it anymore after forty years of work. They were built for the person who just heard the word “cancer” and now needs help paying for food, childcare, and gas to get to chemo. They were not built so hospital CEOs and their minions could turn compassion into a business model. In this fiery World of Payne deep dive, Tanner pulls the curtain back on how hospitals and pharmaceutical companies use government subsidies like 340B drug discounts, Disproportionate Share Hospital (DSH) payments, NIH research funding, rural hospital support programs, and nonprofit tax breaks. On paper, these subsidies are supposed to keep safety-net hospitals alive, expand access for low-income patients, fund breakthrough research, and keep rural ERs from going dark. In reality, many have been quietly hijacked and turned into profit engines that inflate costs, drive consolidation, and enrich executive teams while families drown in medical debt. Tanner breaks down how 340B really works in the wild—hospitals buying drugs at steep discounts, billing full price, and pocketing the spread with almost zero transparency about how much actually reaches poor patients. He exposes how nonprofit hospitals collect tax exemptions and DSH dollars in the name of charity while still suing low-income families, garnishing wages, and slapping liens on homes. He walks through NIH funding and overhead, showing how universities and health systems can treat taxpayer-funded research as a revenue stream while labs fight for scraps. He takes you into rural America, where nearly 200 rural hospitals have closed in two decades, almost half of those left are losing money, and one closure can turn a 10-minute ambulance ride into a 45-minute gamble. This isn’t just a rant—it’s a conservative blueprint for reform. Tanner lays out how to force radical transparency on subsidies, tie nonprofit and 340B privileges to real charity care and clear patient benefits, cap and expose NIH overhead bloat, and make rural support money follow actual access instead of political connections. He argues for a “subsidy-light” future where we attack the root price disease—insane hospital facility fees, opaque drug pricing, rigged contracts, and monopoly power—so we can shrink and sharpen subsidies instead of endlessly throwing more money at a broken system. If you’re tired of being told “healthcare is complicated, just trust us,” this episode gives you the receipts and the language to start asking the questions no one in power wants to answer. It’s unapologetically conservative, fiercely compassionate toward patients and families, and absolutely ruthless toward the hospital systems, pharma giants, and academic empires that have turned safety-net programs into cash machines. “Pills, Profits, and Promises” will leave you informed, fired up, and ready to demand a healthcare system where compassion isn’t a marketing slogan—it’s the standard.

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WEBVTT

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Hello, everyone to Welcome to the World of Pain podcast. Tonight,

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we're going to continue our deep dive into subsidization and

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the programs of which the United States government spends money

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to help subsidize. And I mean, really, before we get

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lost in the acronyms and the policy and all the

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mess of all the other programs, I want to unwind

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why most subsidies even exist in the first place. Because

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they weren't built for CEOs. They weren't built for hospital boards.

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They weren't built for consultants and suits who know how

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to squeeze one more percentage point out of a reimbursement line.

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They were built for people whose lives got turned upside down.

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Think about a couple who just found out they're having

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a baby. One minute, they're staring at two pink lines

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or two blue ones, depending on the test, scared and

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excited and hopeful. The next minute, they're looking at the

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cost of pre needle care, ultrasounds, delivery, maybe a nick

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use day if something goes wrong, and realizing we can't

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afford this if anything goes off. Script programs were created

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so that people could walk into a hospital and not

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be told you're on your own good luck. Medicaid for pregnancies,

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hospital subsidies, rural maternity supports. Those things were supposed to

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be there so a child doesn't come into the world

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already buried under a stack of unpaid bills. Think about

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a parent who loses their job out of nowhere. One friday,

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they're clocking out planning the weekend. The next friday, they're

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staring at a layoff notice and wondering how they're going

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to pay rent, gas, groceries and still keep their children insured.

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Subsidies were created so that one bad month, one factory closing,

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one downturn doesn't mean you don't get to see a

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doctor anymore. They built bridges so people could cross a valley,

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not fall into it, and stay there forever. Think about

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the grandparent whose body can't do it no more. They

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worked hard for forty fifty years. Their back is shot,

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their knees are gone, their heart isn't what it used

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to be. They're not lazy, they're just spent. Our US

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economy has milked every tax dollar out of them. They can.

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They're that phase of life where they should be able

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to just step back, hold grandkids, attend ball games, enjoy

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a few quiet mornings without wondering which joint is going

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to give out next, Medicare, social Security support for seniors,

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love them or hate the way they're run. Those things

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come out of a very basic conviction. When someone has

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carried their share and their body taps out, we're not

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going to leave them to rot in the dark. And

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then there's the brutal one, the person who just heard

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the word cancer. One phone call, one biopsy result, and

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everything changes. Now it's chemo radiation, surgery, months of appointments, days,

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you just can't get off the couch, weeks where the

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idea of working full time is a joke. If they

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have kids, they still need childcare. If they have a mortgage,

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the bank still wants their money. If they want to

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keep eating halfway decent food while the drugs are wrecking

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their appetite and their energy, that costs too. Subsidies, drug

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discount programs, hospital payments, disability benefits. These things were built

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so that one life hits like that, the verdict isn't

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you get You can just get treated, or you can

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feed your family. You can only pick one. Those are

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the people. These things were meant for the expecting parent,

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praying for the delivery and that it goes well. The

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laid off worker trying not to panic in front of

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their kids. The worn out grandparent who gave everything they

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had and just wants to finish with dignity. The cancer

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patient who suddenly has to choose between showing up for

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treatment and showing up for a shift. Most of these

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programs didn't start with politicians sneering about handouts. They started

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because someone was looking at the stories like that and saying,

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we can't just shrug and walk away. Whatever else you

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think about government, that instinct to stop a family from

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being wiped out by something they didn't ask for isn't evil.

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It's human. But here's where my blood starts to boil.

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Those bridges, those safety nets, those lifelines were never supposed

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to be turned into personal ATMs for executives and their

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armies of middle managers. They were not created so a

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hospital CEO can pocket a seven figure bonus while his

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nonprofit system sues a laid off dad over a broken leg.

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They were not created so a giant health system can

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use a drug discount program to buy Chemo at a

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bargain build full price, and then never tell the single

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mom in the infusion chair that her hospital just made

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a fat margin off of her treatment. They were not

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created so some VP of revenue cycles could figure out

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how to code an er visit a little higher and

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squeeze a little bit more out of Medicaid, then turn

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around and complain that these programs are unsustainable. When people

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hijack subsidies, they don't just steal money, They poison the

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entire well. They take something that was built for the

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scared expecting parent, for the unemployed worker, for the broken

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down grandparent, for the chemo patient trying to keep their

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kids fed, and they twist it into a revenue stream.

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They turn compassion into a business strategy, and the fallout

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hits everyone. The people in the programs are the ones

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who get blamed and shamed for the abuse they did

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not even commit, and the people paying for the programs

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who understandably look at the whole mess and say, I'm done,

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burn it down. That's the tragedy. The bad actors. They

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give ammunition to the folks who want to tear the

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whole thing out by the roots. They make it easier

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for politicians to stand up and say, see, it's all

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the waste and the fraud while never admitting it's their donors,

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the hospital systems, the drug companies, the big nonprofits, nonprofits,

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and air quotes doing most of the hijacking. They make

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it harder to defend the bridge, even for people like

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me who think some kind of bridge needs to exist.

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So as we get ready to talk about hospitals, pharmaceutical companies,

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research institutions, and all these government subsidies that touch almost

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every life in this country, I want you to hold

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this in your mind. These things were meant to keep

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the bottom from falling out under real people. If we

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let CEOs and their minions keep turning those lifelines in

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the profit machines, we're not just losing money, we're betraying

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the very people these programs were created to protect. That's

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the fight we're walking into tonight. Not a fight against

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the mom, the dad, the grandparent, the cancer patient just

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trying to hang on a fight against the people who

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look at these stories and see the pain, not duty,

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but opportunity. Those are the people that we fight. And

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I'm a believer that there is certain things that still

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need to stay and a lot of these programs that

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I talk about when they talk about subsidies are programs

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that are needed because they were there for an original

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reason and now they're just rampant with fraud. A lot

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of these programs should stay, but there needs to be

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tightening the ropes to help bring some of this stuff

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back into the original reason they were implemented in the

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first place. We're gonna talk about these and we're gonna

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dive into them because I believe our country can do

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better because money taken away from a struggling father, a

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struggling mother, a struggling patient of any kind, and using

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just those people as dollar signs in a system that

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is funded by taxpayers is a double edged sword because

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not only are they taking from them in their care,

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but they're also taking from them on the back end

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when those people are paying taxes, paying high your taxes,

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because we have to be able to afford in front

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these programs. We're going to dive into this really in depth,

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and it all starts here on the World of Paying podcast. Okay,

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our opening was more about programs as a whole and

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subsidies as a whole, but we're gonna give you some

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actual circumstances that actually happen with people due to the

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subsidies we're gonna talk about these episodes. Picture a mom

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sitting there after midnight. The kids are asleep in the

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next room. On the table in front of her a

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stack of envelopes with little plastic windows, a shot off

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notice from the power company, and two prescription bottles, one

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for her, one for a sick kid. She works, She's exhausted,

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She is not lazy, she is not some villain in

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a talking point. She's one bad week away from everything unraveling.

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She has no idea what three forty B means. She

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couldn't tell you what a DSH payment is. She couldn't

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she's never even read a single line of a federal register.

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But somewhere in the mess of programs and subsidies, a

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hospital drug discount, or a Medicaid supplemental payment or a

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charity care policy she's never heard of is the only

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reason one of these bottles was affordable this month, and

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the only reason her kid isn't on a waiting list.

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The picture of a dad sitting next to a hospital bed.

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There are tubes everywhere, monitors beeping, a nurse moving quickly

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in the half light. His kid is fighting for their life.

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That dad doesn't know what a nonprofit tax exemption is

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he doesn't care how the hospital booked its DSH revenue.

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He is not thinking about NIH grant codes or how

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many dollars came out of which CMS rule. He just

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heard a doctor say we're going to do everything we can,

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and he's praying they mean it. Somewhere in the background,

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a tangle of government subsidies and special payment rules and

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tax breaks is what kept that ICU open and staffed

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and stocked with the machines currently keeping his child alive.

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He's not a data point. He's the reason this conversation matters. Now.

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Picture a grandmother in a rural town, the kind of

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place that shows up on the national news only when

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a tornado hits. She doesn't watch c SPAN, she doesn't

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read policy briefs. She just knows that out by the

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highway there is or was a small hospital with a

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glowing red emergency sign. She's driven by it a thousand times,

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and every time she feels a little safer because of

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her chest titans at midnight, or she falls alone at home,

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there is somewhere to go. That hospital might be hanging

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on because of a critical access designation, rural support grants,

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or cost based Medicare reimbursement words she's never heard of.

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But she doesn't call that a subsidy. She calls it

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the reason I'm not totally alone out here when we

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say subsidy. Washington hears budget lines and CBO scores and

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program acronyms, cable news hears talking points and attack ads.

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But the country experiences subsidies as something much simpler. We

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had somewhere to go, the drug existed, the hospital was

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still open. They didn't throw us out because we were broke.

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It is very easily, especially from a conservative perspective that

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values live in a government, to let anger at bloated

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programs calcify into contempt for the people who are actually

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dependent on them. I want no part of that. If

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you're listening to this and you are a medicaid or

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your chemo runs through a three point forty B clinic,

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or your rural hospital survives because of special Medicare rules,

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I am not your enemy. You didn't create this mess,

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you are surviving in it. My anger is aimed at

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somewhere else. I am furious with the way that the hospitals,

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pharmaceutical companies, giant non profits. If you want to even

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consider them that, and captured agencies have learned to turn

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these lifelines into profit centers. I am furious at the

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way that they stand behind the sick and the poor

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like human shields, while they quietly arbitrage discounts, pocket tax breaks,

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and build empires. I am furious at the way both

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parties in Washington still pound the table about protecting patients

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and then go to meetings with hospital lobbyists and big

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pharma to make sure that the gravy keeps flowing. I'm

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furious that we built safety nets in the name of

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compassion and then looked away while most of the most

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powerful institutions in America use those nets as hammocks. So

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this episode is going to be a contradiction on purpose.

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I'm going to defend the existence of some of these

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subsidies and absolutely torch the way that they're being used.

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I'm going to say, without apology, that programs like three

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point forty B, disproportionate share hospital payments, NIH research funding,

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rural hospital supports, and nonprofit tax exemptions can embody the

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best of us, our willingness to say we're not going

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to let people die just because the market doesn't care

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about them, and at the same time say that they

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have been hijacked, gamed, and twisted in ways that and

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should discuss anybody who still believes in basic fais. We

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are going to dig into how these subsidies are supposed

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to work, how they actually function on the ground, how

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hospitals and drug companies and big systems are gaming them,

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and what it would look like to clean this up

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without collapsing fragile safety net hospitals or starving out life

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saving research. We're going to talk about fraud and arbitrage,

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but we're also going to talk about the nurse in

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the safety net er who's burning out, the oncologists trap

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between what's best for the patient and what's best for

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hospitals spreadsheet, the rural EMS crew that just lost the

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only er in their county, and the families who do

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everything right and still end up crushed by nonprofit medical bills.

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The goal is to not rip the parachute off mid flight.

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The goal is to stop pretending the parachute isn't full

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of holes, and to stop tolerating executives and politicians who

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are perfectly happy to let those holes grow as long

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as the money keeps flowing. We're going to walk through

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the promise, the corruption, the reforms, and then ask the

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big question conservatives should be asking. Is there a way

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to move forward and toward a more competitive, transparent, subsidy

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light healthcare system without knowing and throwing the most vulnerable

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people in this country off a cliff? And if so,

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what would it really take. Let's start with a beautiful theory,

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the version of these programs that's written in brochures. If

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you only listen to the official descriptions, you'd think we

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built something close to genius. Take three forty B. In

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nineteen ninety two, Congress looked at the safety net hospitals

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and clinics drowning under the cost of treating poor and

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uninsured patients and decided, instead of just throwing more tax

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dollars at this, let's force drug manufacturers to sell outpatient

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drugs at steep discounts to these providers in return for

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access to the huge Medicaid and federal purchasing markets. Pharma

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companies have to provide those discounts to covered entities like

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disproportionate share hospitals, children's hospitals, referral rural referral centers, counity

254
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health centers and specialized clinics. The goal, in hrssay's own language,

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is to help these providers stretch scarce federal resources as

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far as possible, reaching more eligible patients, and providing more

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comprehensive services. On paper, this is elegant. The hospital or

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clinic pays a much lower price for certain outpatient drugs,

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cancer infusions, HIV medications, insulin, you name it. If a

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drug would normally cost ten thousand dollars at wholesale acquisition cost,

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the three forty B pricing might be closer to six

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thousand or less. The idea is that the provider can

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use that discount to keep oncology clinics, open fund pharmacy

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assistant programs, and make sure a patient's zip code doesn't

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decide whether they treatment. Over time, regulators even allowed contract pharmacies,

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so hospitals and clinics could partner with retail chains and

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local pharmacies to dispense three forty B drugs closer to

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where patients live, especially in rural and underserved areas. Then

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there are the disproportionate share hospital payments. If you have

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a hospital where a huge share of inpatient days are

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paid by medicaid or uncompensated. Altogether, the basic Medicare and

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Medicaid rates won't cover the reality on their ground. DSH

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is supposed to be the hazard pay for that mission.

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The federal government kicks in extra payments to hospitals that

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serve a disproportionate share of low income patients, acknowledging that

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if we treated them like a suburban surgical center, they'd die.

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The moral logic is clear. If you carry the heaviest load,

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we'll help you shoulder the weight. Now we're going to

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layer on NIH research funding. Every year. NIH now controls

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on the order of forty seven to forty nine billion

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dollars of budget authority, making it one of the biggest

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science funders on Earth. That money does not just fund

283
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shiny cancer centers. It funds thousands of labs doing basic

284
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and translational research on everything from rare genetic syndromes to

285
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long term effects of infections. That money helped build the

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scaffolding behind the HIV drugs, mRNA vaccines, targeted cancer therapies,

287
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and diagnostics. It underwrites clinical trials that private industry wouldn't

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touch on its own because the market is too small

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or the payback too slow. If you're conservative and you

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care about national strength, there is a strong argument that

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this kind of public investment in science is one of

292
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the few things the government should actually be doing now.

293
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Look at rural hospital supports. Between two thousand and five

294
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and twenty twenty three, at least one hundred and forty

295
00:20:15.400 --> 00:20:20.720
six hospitals in a rural US counties either close completely

296
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or stopped offering acute inpatient care. Over a longer stretch,

297
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nearly two hundred rural hospitals have closed, and nearly half

298
00:20:30.160 --> 00:20:34.839
of those are operating at a loss, with hundreds more

299
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at risk. If you live in a big metro area,

300
00:20:37.799 --> 00:20:41.119
you can drive past three ers and five minutes, and

301
00:20:41.559 --> 00:20:44.599
around fifteen minutes if you live in a rural county.

302
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One hospital closure can turn a ten minute ambulance ride

303
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into a forty five minute gamble. So policymakers created special

304
00:20:52.279 --> 00:20:57.079
categories like critical Access hospitals, which get cost based Medicare

305
00:20:57.119 --> 00:21:01.960
reimbursements up to a cap instead of just the usual

306
00:21:02.039 --> 00:21:08.039
DRG payments. In newer rural emergency hospitals models that pay

307
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facilities to maintain twenty four to seven emergency and outpatient

308
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care even if they shut down in patient beds. The

309
00:21:15.200 --> 00:21:19.519
goal is not academic, it is life and death. The

310
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federal government basically saying we will bend the rules so

311
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you don't have to shut off that red emergency sign. Finally,

312
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the nonprofit tax deal. Most large health systems claim nonprofit status.

313
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In return, they get federal income tax exemption, big breaks

314
00:21:38.319 --> 00:21:42.319
on state and local taxes, including property taxes on extremely

315
00:21:42.440 --> 00:21:45.920
valuable real estate, and the ability to borrow through tax

316
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exempt bonds at lower rates. In exchange, they're supposed to

317
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behave more like charities than corporations. That means offering charity

318
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care to patients who genuinely cannot pay, maintaining clear financial

319
00:22:00.039 --> 00:22:05.079
assistance policies, investing in community benefit programs like free screenings

320
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and outreach, and generally acting as if the community is

321
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something more than a customer base. Taken together, the theory

322
00:22:13.960 --> 00:22:19.160
is almost inspiring. Drug companies eat discounts so safety net

323
00:22:19.240 --> 00:22:24.079
hospitals can keep their doors open. Dsh and special rural

324
00:22:24.599 --> 00:22:29.480
payments make sure hospitals serving the poor and isolated don't collapse.

325
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NIH funding drives science that becomes tomorrow's cures. Nonprofit tax

326
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breaks encourage hospitals to be true community anchors instead of

327
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revenue machines and the glossy version subsidies are targeted, efficient

328
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and compassionate. They take a healthcare market that naturally ignores

329
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the poor, the rural, and the long term and force

330
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it to pay attention. If that were all happening, this

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episode would just be a love letter to smart policy

332
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and we could all go home or to shut off

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the podcast. But good intentions plus huge sums of opaque

334
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money plus concentrated power is how you get exactly the

335
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kind of corruption, gaming, and quiet exploitation conservatives worn't about.

336
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So let's flip the board over and talk about these

337
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payments and what they really look like up close. Starting

338
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with on the surface, three forty B is simple hospitals

339
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and clinics that qualify by certain outpatient drugs at steeply

340
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discounter prices. They then bill insures, Medicare, Medicaid, managed care,

341
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or commercial plans, whatever their contract says. The gap between

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what they paid under three forty B and what they

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collect is the spread between imagine a big oncology and

344
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fusion and then world the hospital might pay something close

345
00:24:02.200 --> 00:24:06.079
to ten thousand dollars wholesale and build a payer something

346
00:24:06.160 --> 00:24:11.000
a little higher or lower depending on contracts. Under three

347
00:24:11.000 --> 00:24:13.640
point forty B, that same drug might cost the hospital

348
00:24:13.680 --> 00:24:18.720
around six thousand dollars or less. The insurer's allowed amount

349
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often doesn't care about that discount. It's still based on

350
00:24:23.480 --> 00:24:29.559
list price, negotiated rates, or average sales price benchmarks. So

351
00:24:29.599 --> 00:24:32.960
the hospital gets paid, say ten thousand dollars, but only

352
00:24:33.039 --> 00:24:37.799
laid out six thousand. That four thousand dollars difference is

353
00:24:37.839 --> 00:24:42.839
peer three forty B margin. Multiply that across thousands of

354
00:24:42.920 --> 00:24:49.359
high cost drug encounters on when you're talking about incology, rheumatology, GI, neurology,

355
00:24:49.680 --> 00:24:53.160
HIV clinics, and so on, and suddenly you are not

356
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talking about charity. You're talking about a silent profit engine.

357
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HRSA and GAO openly acknowledge this reality. Covered entities can

358
00:25:04.799 --> 00:25:08.400
generate revenue under three forty B when reimbursement exceeds their

359
00:25:08.400 --> 00:25:12.200
three forty B purchase price, and that revenue can be

360
00:25:12.319 --> 00:25:18.039
used to expand services the General the Government Accountability Office.

361
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In the storybook version, every dollar of that spread is

362
00:25:23.000 --> 00:25:28.119
channeled into free meds, enhanced clinics, social workers, and charity care.

363
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In the real version, some of it goes to that

364
00:25:32.039 --> 00:25:36.160
good work, but some of it subsidizes the unrelated projects,

365
00:25:36.599 --> 00:25:42.000
and some of it simply flattens and fattens the bottom line.

366
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The scale is stunning. Hr Essay's own data shows that

367
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three forty B covered entities purchase sixty six point three

368
00:25:54.480 --> 00:25:58.599
billion dollars and outpatient drugs at three forty B prices

369
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in twenty twenty three, a roughly twenty four percent jump

370
00:26:02.720 --> 00:26:08.720
over the year before. Equivia estimates that if you measure

371
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at a wholesale acquisition cost three forty B prices rough

372
00:26:15.119 --> 00:26:18.799
or roughly one hundred and twenty four billion dollars in

373
00:26:18.880 --> 00:26:21.319
twenty twenty three, and have grown more than one hundred

374
00:26:21.319 --> 00:26:25.960
and twenty percent over the last five years, far outpacing

375
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non three forty B drug sales. This is not a

376
00:26:30.599 --> 00:26:36.359
niche side program anymore. It is becoming a gargantuan shadow

377
00:26:36.400 --> 00:26:40.480
market where discounted purchases alone are larger than what Medicaid

378
00:26:40.720 --> 00:26:45.160
spends on drugs across the entire country. Once you understand that,

379
00:26:45.599 --> 00:26:48.559
you start to see why large hospital systems chase three

380
00:26:48.640 --> 00:26:53.000
forty B volume like oxygen. The financial incentive is not

381
00:26:53.240 --> 00:26:56.240
serve as many poor people as possible it's run as

382
00:26:56.279 --> 00:26:59.839
many expensive outpatient drugs as possible through your three forty

383
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b be eligible sites. That leads to quiet but powerful

384
00:27:05.680 --> 00:27:11.119
shifts and behavior. Systems buy up independent oncology practices and

385
00:27:11.240 --> 00:27:16.119
specialty clinics and reflag them as hospital outpatient departments. They

386
00:27:16.119 --> 00:27:20.279
move infusions out of privately owned offices and into hospital

387
00:27:20.319 --> 00:27:24.759
based units. They steer referrals to the places that are

388
00:27:24.960 --> 00:27:28.400
inside their three pin forty b umbrella, not because it's

389
00:27:28.480 --> 00:27:31.400
cheaper for the patient, but because it's more lucrative for

390
00:27:31.440 --> 00:27:35.599
the system. If you're conservative watching this, this is exactly

391
00:27:35.640 --> 00:27:37.960
the kind of distortion you'd expect when you create a

392
00:27:38.000 --> 00:27:43.880
giant pot of hidden subsidies. Institutions with lawyers and consultants

393
00:27:43.920 --> 00:27:50.000
adapt to maximize the subsidy, not necessarily the mission. The

394
00:27:50.039 --> 00:27:53.119
incentive is to not think how do we pass this

395
00:27:53.240 --> 00:27:56.559
discount to the patient at the counter. The incentive is

396
00:27:56.599 --> 00:28:00.119
to think, how do we capture the spread on as

397
00:27:59.880 --> 00:28:03.960
many well insured patients as possible and then tell regulators

398
00:28:04.200 --> 00:28:08.839
were helping the poor system wide. Then there are the

399
00:28:08.880 --> 00:28:13.799
contract pharmacies. HRSA opened the door to multiple contract pharmacies

400
00:28:13.920 --> 00:28:18.799
per covered entity, and hospitals ran through that door like

401
00:28:18.839 --> 00:28:23.079
it was Black Friday. The number of contract pharmacy arrangements

402
00:28:23.119 --> 00:28:29.599
exploded as covered entities partnered with big nationals like CVS, Walgreens,

403
00:28:29.680 --> 00:28:34.680
and specialty mail order shops. Those pharmacies dispense drugs to patients,

404
00:28:35.519 --> 00:28:38.799
the covered entity claims the three forty B discount, and

405
00:28:38.839 --> 00:28:43.640
the two parties share the margin under confidential contracts. In theory,

406
00:28:43.759 --> 00:28:47.200
this expands access. In practice, it creates a labyrinth of

407
00:28:47.279 --> 00:28:53.079
data and claims where diversion drugs going to a non

408
00:28:53.079 --> 00:28:58.000
eligible prescriptions and duplicate discounts where a drug gets both

409
00:28:58.039 --> 00:29:02.599
a three forty B price and a medicaid rebate they're

410
00:29:02.599 --> 00:29:08.039
the real risks. Hr Essay has tried to strengthen audits

411
00:29:08.079 --> 00:29:14.240
and internal control expectations, and some recent audit data shows

412
00:29:15.519 --> 00:29:20.519
fewer diversion and duplicate discount findings than in those early days,

413
00:29:21.200 --> 00:29:25.640
which defenders point to as evidence of better compliance. But

414
00:29:25.880 --> 00:29:29.000
at this scale, with this many players, it is naive

415
00:29:29.079 --> 00:29:31.880
to think that all the gaming is gone. In the fights,

416
00:29:31.920 --> 00:29:35.720
we see manufactures imposing limits on shipment of three forty

417
00:29:35.759 --> 00:29:41.960
B drugs to contract pharmacy stales passing laws to protect

418
00:29:42.000 --> 00:29:46.039
three forty B arrangements. Lawsuits flying in both directions tell

419
00:29:46.079 --> 00:29:49.720
you exactly how much money is at stake. The most

420
00:29:49.720 --> 00:29:54.359
infigurating part is that the costs and benefits are not symmetrical.

421
00:29:55.559 --> 00:30:00.799
Benefits of three forty B spread pricing a crue to

422
00:30:00.880 --> 00:30:05.680
the specific hospitals, chains and systems that are savvy enough

423
00:30:05.720 --> 00:30:08.519
to capture them. The costs are pushed out into the

424
00:30:08.559 --> 00:30:14.279
broader system. Drug manufacturers respond to deep mandatory discounts by

425
00:30:14.519 --> 00:30:19.640
raising list prices where they can. Medicaid, Medicare and commercial

426
00:30:19.640 --> 00:30:23.799
plans end up absorbing higher gross prices and then negotiate

427
00:30:23.839 --> 00:30:27.519
rebates or cost sharing arrangements that ultimately land on the

428
00:30:27.720 --> 00:30:32.960
employers and families your premiums, your deductibles, the copey at

429
00:30:33.000 --> 00:30:37.160
the pharmacy, the tax dollars going to Medicare. That's or

430
00:30:37.200 --> 00:30:39.640
the other side of this no cost to taxpayer fairy

431
00:30:39.640 --> 00:30:43.960
tale lands. So once again we have to hold both truths.

432
00:30:44.799 --> 00:30:47.720
There are clinics and hospitals using three P forty b

433
00:30:48.160 --> 00:30:51.519
as intended buying at a discount, and using the difference

434
00:30:51.559 --> 00:30:56.039
to run free or low cost pharmacies and expand services

435
00:30:56.319 --> 00:31:02.119
in poor neighborhoods and keep fragile alive, and there are

436
00:31:02.160 --> 00:31:05.759
giant hospital systems quietly using three forty B spreads as

437
00:31:05.759 --> 00:31:12.480
a revenue system to fuel their expansion, acquisitions, and executive compensation,

438
00:31:13.799 --> 00:31:16.920
all while the average patient never sees a line on

439
00:31:17.000 --> 00:31:19.680
their bill that says we passed your three forty B

440
00:31:19.880 --> 00:31:25.039
savings onto you. The program was sold as a lifeline

441
00:31:25.359 --> 00:31:29.279
in far too many boardrooms, it's treated like a Now

442
00:31:29.359 --> 00:31:32.440
take everything we just said about three forty B and

443
00:31:32.480 --> 00:31:36.519
stack it on top of DSH and nonprofit tax status.

444
00:31:37.839 --> 00:31:41.400
In the best case scenario, DSH dollars are exactly what

445
00:31:41.440 --> 00:31:44.799
they're advertised to be, targeted support to hospitals that are

446
00:31:44.799 --> 00:31:50.279
truly drowning in uncompensated care and Medicaid shortfalls. In big

447
00:31:50.359 --> 00:31:55.480
public safety net hospitals and shaky rural facilities, DSH funds

448
00:31:55.559 --> 00:31:59.480
are the margin between staying open and shutting down. But

449
00:31:59.559 --> 00:32:04.519
the formula is that governed. DSH eligibility and amounts are complex,

450
00:32:05.440 --> 00:32:11.640
and they're layered with state discretion, historical baselines, and definitions

451
00:32:11.680 --> 00:32:16.960
that can be stretched. A hospital that looks poor on

452
00:32:17.079 --> 00:32:22.680
paper can be part of a much larger, financially strong system.

453
00:32:23.880 --> 00:32:28.359
A system can optimize its cost reporting in patient classification

454
00:32:28.599 --> 00:32:37.160
to maximize DSH receipts, consultants build businesses around enhancing supplemental payments.

455
00:32:38.359 --> 00:32:42.440
At the same time, the nonprofit halo does enormous political

456
00:32:42.480 --> 00:32:47.400
and financial work. When people hear nonprofit hospitals, they picture charity,

457
00:32:47.880 --> 00:32:51.480
They picture missions. They picture the sisters of Mercy, not

458
00:32:51.559 --> 00:32:56.559
a Wall Street firm. The perception justifies massive tax breaks,

459
00:32:57.119 --> 00:33:02.119
but reporting on charity care and community benefit has repeatedly

460
00:33:02.200 --> 00:33:05.799
shown that some large non profit systems provide levels of

461
00:33:05.920 --> 00:33:09.440
free and discounted care that are shockingly low compared to

462
00:33:09.480 --> 00:33:15.119
the value of their tax exemptions. In some markets, analysis

463
00:33:16.759 --> 00:33:22.240
have found that a hospital's avoided taxes are greater than

464
00:33:22.279 --> 00:33:26.359
the dollar value of its charity care. The community is

465
00:33:26.400 --> 00:33:30.359
effectively paying them to act like a charity and getting

466
00:33:30.359 --> 00:33:35.079
a mediocre return on that investment. Even worse, many of

467
00:33:35.160 --> 00:33:39.119
these same nonprofits turn around and play legal hardball with

468
00:33:39.319 --> 00:33:43.359
poor and working class patients. They send aggressive bills, they

469
00:33:43.359 --> 00:33:47.960
slap leans on homes, They garnish wages. They sue patients

470
00:33:48.000 --> 00:33:51.200
for a few thousand dollars that those patients will never

471
00:33:51.319 --> 00:33:55.839
realistically be able to pay. They sell bad debt to

472
00:33:55.920 --> 00:33:59.200
collectors who hound people for years and at the same

473
00:33:59.279 --> 00:34:04.160
time and the same annual reports they proudly count community

474
00:34:04.200 --> 00:34:09.719
benefit that includes everything from unpaid Medicaid shortfalls to physician

475
00:34:09.800 --> 00:34:16.360
training and marketing flavored outreach. From a conservative lens, the

476
00:34:16.480 --> 00:34:22.239
hypocrisy is staggering. These are organizations that argue they should

477
00:34:22.239 --> 00:34:26.239
not pay taxes like normal businesses because they are inherently charitable,

478
00:34:27.480 --> 00:34:30.599
but then they behave in ways that would make a

479
00:34:30.599 --> 00:34:37.400
credit card collections department blush. They get DSH payments because

480
00:34:37.400 --> 00:34:41.559
they are poor three point forty B spread because of

481
00:34:41.559 --> 00:34:45.679
their patient mix, and tax exemptions because they are nonprofit,

482
00:34:46.320 --> 00:34:48.960
but then use the stack of subsidies to build new

483
00:34:49.039 --> 00:34:53.760
towers and affluent suburbs, buy up independent practices, and invest

484
00:34:53.960 --> 00:34:59.639
like any other large corporation. That stack of subsidies. It's

485
00:34:59.719 --> 00:35:04.360
part of what powers the consolidation machine. When a large

486
00:35:04.360 --> 00:35:08.159
system with DSH revenue, three forty B margins and tax

487
00:35:08.199 --> 00:35:12.000
advantages looks at a map and sees a struggling independent hospital,

488
00:35:12.440 --> 00:35:17.840
a small cardiology practice, a community and cology clinic, it

489
00:35:17.960 --> 00:35:23.239
sees opportunity. It can offer a buyout, promis stability, fold

490
00:35:23.239 --> 00:35:26.679
those providers under its non profit umbrella, and then shift

491
00:35:26.719 --> 00:35:32.159
profitable service lines into hospital based higher price settings. It

492
00:35:32.239 --> 00:35:36.400
can use its scale to demand higher commercial rates, then

493
00:35:36.480 --> 00:35:41.360
point to thin system margins as justification for further growth,

494
00:35:42.159 --> 00:35:46.280
while individual facilities within the system drowning overhead they do

495
00:35:46.400 --> 00:35:50.679
not choose. What started as hazard pay for serving poor

496
00:35:51.599 --> 00:35:59.719
becomes fuel for creating regional monopolies. The nonprofit tax code

497
00:36:00.199 --> 00:36:05.840
to encourage altruism becomes a blunt weapon that lets a

498
00:36:05.960 --> 00:36:11.599
massive system avoid taxes while squeezing competitors and patients. Three

499
00:36:11.719 --> 00:36:15.119
forty B spreads meant to keep oncology clinics open for

500
00:36:15.199 --> 00:36:19.000
the poor become a factor in closing or absorbing independent

501
00:36:19.079 --> 00:36:24.159
practices and moving care into hospital at two, three, or

502
00:36:24.199 --> 00:36:29.519
five times the price. The result is exactly the opposite

503
00:36:29.559 --> 00:36:32.440
of what conservatives want to see in any market. Instead

504
00:36:32.440 --> 00:36:35.199
of lots of competing providers, you get a handful of

505
00:36:35.199 --> 00:36:38.400
giant systems that can set prices in rules. Instead of

506
00:36:38.400 --> 00:36:43.400
transparent prices, you get opaque charge masters and negotiated rates

507
00:36:43.400 --> 00:36:47.880
that nobody outside the C suite understands. Instead of personal

508
00:36:48.039 --> 00:36:53.039
responsibility supported by fair rules, you get families going doing

509
00:36:53.079 --> 00:36:57.960
everything right and still ending up with medical debt they

510
00:36:57.960 --> 00:37:01.320
can't escape because they had fortune of getting sick in

511
00:37:01.360 --> 00:37:04.880
a hospital whose building department is more aggressive than a

512
00:37:04.960 --> 00:37:10.559
charity office. From the left, you should be furious as well,

513
00:37:11.519 --> 00:37:15.360
because this is not universal care, its corporate capture of

514
00:37:15.440 --> 00:37:20.719
public compassion. From the right, you should be incandescent because

515
00:37:20.719 --> 00:37:25.239
this is not a free enterprise. It's a web of subsidies, regulations,

516
00:37:25.239 --> 00:37:31.400
and special tax statuses being used to enrich people who

517
00:37:31.440 --> 00:37:34.159
are very good at working the system while hiding behind

518
00:37:34.159 --> 00:37:38.079
the words mission and community. And we haven't even touched

519
00:37:38.760 --> 00:37:43.079
the nih overhead games or the slow motion disaster of

520
00:37:43.159 --> 00:37:47.719
rural hospital closures. Yet. The non profit halo is one

521
00:37:47.719 --> 00:37:52.119
of the most powerful shields in American healthcare. When a

522
00:37:52.119 --> 00:37:58.119
hospital calls itself a nonprofit, people instinctively assume that it

523
00:37:58.159 --> 00:38:02.599
is different from a corporation. They imagine charity, They imagine

524
00:38:02.599 --> 00:38:06.719
a mission. They imagine that, yes, the hospital has to

525
00:38:06.840 --> 00:38:10.800
keep the lights on, but fundamentally it exists to serve

526
00:38:10.880 --> 00:38:15.679
the community, not to squeeze it. In exchange for that expectation,

527
00:38:16.239 --> 00:38:21.920
we give these institutions enormous tax benefits. Nationally, private non

528
00:38:21.960 --> 00:38:27.159
profit hospitals are exempt from most federal, state, and local taxes,

529
00:38:27.719 --> 00:38:32.159
a benefit estimated at somewhere roughly between twenty four and

530
00:38:32.239 --> 00:38:36.360
sixty billion dollars a year. That is money that does

531
00:38:36.400 --> 00:38:41.519
not go to schools, roads, public safety, or debt reduction.

532
00:38:42.599 --> 00:38:46.119
It is money we intentionally leave on the table because

533
00:38:46.159 --> 00:38:51.440
we are told hospital gives that value back in the

534
00:38:51.480 --> 00:38:56.679
form of charity care and community benefits. When researchers actually

535
00:38:56.679 --> 00:39:01.599
compare the value of those tax exemptions to what hospitals

536
00:39:01.679 --> 00:39:06.559
give back, the picture is not nearly as flattering as

537
00:39:06.599 --> 00:39:11.159
the marketing bushers. A recent study found that, on average,

538
00:39:11.199 --> 00:39:15.800
nonprofit hospitals allocate about eight point eight percent of their

539
00:39:15.840 --> 00:39:21.320
total expenses roughly thirty three million dollars per hospital to

540
00:39:21.480 --> 00:39:29.239
things they label community benefits, including Medicaid shortfalls, charity care,

541
00:39:29.800 --> 00:39:36.280
and unreimbursed education. But nearly a quarter of nonprofit hospitals

542
00:39:36.519 --> 00:39:40.159
received more in tax benefits than they spent on community

543
00:39:40.199 --> 00:39:46.440
benefits at all. In other words, for a sizeable chunk

544
00:39:46.519 --> 00:39:50.360
of these so called charities, that community is a bad investor.

545
00:39:51.000 --> 00:39:54.280
We give more and foregone tax revenue than we get

546
00:39:54.360 --> 00:39:59.639
back in tangible public good. It would be one thing

547
00:39:59.639 --> 00:40:02.480
if the show shortfall were an honest mistake and the

548
00:40:02.559 --> 00:40:06.480
hospitals were otherwise bending over backwards to protect vulnerable patients,

549
00:40:06.840 --> 00:40:11.360
but investigative reporting has shown a very different pattern. A

550
00:40:11.440 --> 00:40:17.239
Kaiser Health News investigation documented that hundreds of hospitals across

551
00:40:17.280 --> 00:40:24.679
the United States, public, private, nonprofit, academic maintained policies aggressively

552
00:40:24.760 --> 00:40:31.920
pursue patients for unpaid bills, including lawsuits, selling debt to collectors,

553
00:40:32.280 --> 00:40:36.719
and reporting people to credit bureaus, even when those patients

554
00:40:36.719 --> 00:40:40.880
are low income. In North Carolina alone, researchers found that

555
00:40:40.960 --> 00:40:45.119
hospitals filed nearly six thousand lawsuits against more than seventy

556
00:40:45.119 --> 00:40:48.719
five hundred patients and family members between twenty seventeen and

557
00:40:48.840 --> 00:40:53.960
mid twenty twenty two, witting judgments that averaged over sixteen

558
00:40:54.079 --> 00:40:59.159
thousand dollars each. The Minnesota Attorney General forced Mayo Clinic

559
00:40:59.480 --> 00:41:03.159
into asses settle after finding that its hospitals had sued

560
00:41:03.199 --> 00:41:07.920
patients who probably qualified for charity care while maintaining charity

561
00:41:07.960 --> 00:41:14.800
policies that created barriers and engaging in aggressive collection practices

562
00:41:15.679 --> 00:41:22.400
that flatly contradicted its mission statement. This is not a

563
00:41:22.440 --> 00:41:26.280
stray bad actor, this is a pattern. Meanwhile, the law

564
00:41:26.400 --> 00:41:31.199
already says nonprofit hospitals have to have clear financial assistance

565
00:41:31.519 --> 00:41:36.519
policies it make reasonable efforts to determine whether a patient

566
00:41:36.599 --> 00:41:43.519
qualifies before using extraordinary collection actions like lawsuits and wage guarnishment.

567
00:41:44.440 --> 00:41:48.679
When hospitals blow past these obligations, they are not skating

568
00:41:48.880 --> 00:41:52.760
through some loophole. They are breaking both the spirit and

569
00:41:52.960 --> 00:41:56.400
arguably the letter of the deal that they that had

570
00:41:56.440 --> 00:42:03.719
earned them that tax except status place. From a conservative standpoint,

571
00:42:04.159 --> 00:42:08.199
this looks like less charity and more like subsidized corporate behavior.

572
00:42:09.159 --> 00:42:14.239
We give them enormous tax favors, supplemental payments, and legal privileges,

573
00:42:14.519 --> 00:42:17.400
and they turn around and behave in ways that would

574
00:42:17.400 --> 00:42:21.400
get any normal church run charity shredded in the press

575
00:42:22.199 --> 00:42:27.280
and if it tried the same tax now layer DSH

576
00:42:27.360 --> 00:42:30.760
and three forty B. On top of that, many large

577
00:42:30.800 --> 00:42:35.119
nonprofit systems collect DSH payments because somewhere in their footprint

578
00:42:35.199 --> 00:42:39.079
they take on enough medicaid and uninsured volume to qualify.

579
00:42:40.960 --> 00:42:45.239
They collect three forty B spreads because their payer mix

580
00:42:45.599 --> 00:42:50.719
meets those thresholds as well. They collect tax exemptions because

581
00:42:50.760 --> 00:42:56.079
they're technically not for profit. Then they use that stacked

582
00:42:56.159 --> 00:43:02.599
advantage extra federal dollars, extra drug marginans, and tax savings

583
00:43:02.639 --> 00:43:07.559
to consolidate smaller hospitals buy up physician practices and dominate

584
00:43:07.719 --> 00:43:13.599
regional markets. And once they dominate, they negotiate higher commercial rates,

585
00:43:15.039 --> 00:43:19.079
tack on more facility fees, and push prices up for

586
00:43:19.199 --> 00:43:25.079
employers and families who have no real alternative. What you

587
00:43:25.199 --> 00:43:28.599
end up with are local and regional hospital monopolies that

588
00:43:28.719 --> 00:43:34.679
look act in charge like for profit conglomerates, but enjoy

589
00:43:34.760 --> 00:43:38.800
the legal and tax privileges of charities. Research presented to

590
00:43:38.840 --> 00:43:43.159
Congress this year points out that many nonprofit hospitals spend

591
00:43:43.239 --> 00:43:47.719
less on charity care, then the public is effectively paying

592
00:43:47.760 --> 00:43:53.320
them in tax subsidies while still maintaining high prices and

593
00:43:53.400 --> 00:43:58.079
aggressive collection strategies. That is not a safety net. That

594
00:43:58.159 --> 00:44:04.360
is rent seeking a conservative angle. It is infuriating. This

595
00:44:04.840 --> 00:44:07.880
is the worst of both worlds. We don't get the

596
00:44:08.599 --> 00:44:12.559
discipline of the real market competition, and we don't get

597
00:44:12.559 --> 00:44:17.960
the integrity of genuine charity. We get a cartel of

598
00:44:18.039 --> 00:44:22.000
subsidized giants that can point to a few community programs

599
00:44:22.079 --> 00:44:24.880
and then tell anyone who questions their behavior that is

600
00:44:24.960 --> 00:44:28.320
attacking them that it is an attack on the poor.

601
00:44:30.199 --> 00:44:38.239
They hide behind very few people and use them as shields.

602
00:44:39.440 --> 00:44:41.719
And these are the very same people that they are

603
00:44:41.760 --> 00:44:45.760
supposed to serve. And yet as angry as we should be,

604
00:44:46.039 --> 00:44:50.039
we can't just rip out the support beams tomorrow, because

605
00:44:50.079 --> 00:44:53.519
buried inside those same systems are trauma centers, nick us,

606
00:44:53.719 --> 00:45:00.360
burn units, transplant programs, and safety net clinics that really

607
00:45:00.400 --> 00:45:05.400
actually do serve the people no one else will touch.

608
00:45:06.679 --> 00:45:10.280
The task is to separate the mission from the machine

609
00:45:11.079 --> 00:45:19.719
without collapsing the parts that actually save lives. That's the

610
00:45:19.800 --> 00:45:23.840
same tension we find when we turn hospitals, when we

611
00:45:23.880 --> 00:45:27.280
turn from hospitals. If you want to see a place

612
00:45:27.320 --> 00:45:31.599
where subsidies can be both unquestionably good and quietly abused

613
00:45:31.639 --> 00:45:35.079
at the same time, look at the National Institutes of

614
00:45:35.119 --> 00:45:40.519
Health and Fiscal year twenty twenty four, NIH's total program

615
00:45:40.599 --> 00:45:45.880
level was about forty seven point three billion dollars, making

616
00:45:46.000 --> 00:45:49.679
one of the largest public research funders on Earth. Roughly

617
00:45:49.800 --> 00:45:52.840
ninety five percent of that money flows back out of

618
00:45:55.280 --> 00:46:02.960
the pool in a form of research boards, centers, programs,

619
00:46:03.000 --> 00:46:06.480
and contracts at more than twenty five hundred research institutions,

620
00:46:06.760 --> 00:46:12.840
supporting hundreds of thousands of jobs and generating nearly ninety

621
00:46:12.880 --> 00:46:19.280
five billion dollars in economic activity. According to one research analysis,

622
00:46:21.280 --> 00:46:24.000
If you're looking for a place where government spending actually

623
00:46:24.039 --> 00:46:27.880
does create long term value, NIH is one of the

624
00:46:27.880 --> 00:46:31.519
better candidates. It is not an exaggeration to say that

625
00:46:31.559 --> 00:46:35.960
modern medicine is built on NIH's back. The basic science

626
00:46:36.039 --> 00:46:40.920
that underpinned HIV treatment came from decades of publicly funded work.

627
00:46:41.280 --> 00:46:48.360
A huge amount of the virology, immunology, and mRNA platform

628
00:46:48.440 --> 00:46:52.119
research that make COVID nineteen vaccines possible was funded by

629
00:46:52.280 --> 00:46:57.360
NIH grants long before any company saw profit potential. Thousands

630
00:46:57.400 --> 00:47:02.559
of cancer, neurology and rare disease trials would simply not

631
00:47:02.679 --> 00:47:07.679
exist without NIH money. No serious conservatives should pretend that

632
00:47:07.719 --> 00:47:12.559
this has been wasted. It has saved lives and strengthened

633
00:47:12.599 --> 00:47:17.719
the country, but inside that success is a structural problem.

634
00:47:17.880 --> 00:47:22.920
Conservatives should care about the way the money flows creates

635
00:47:23.039 --> 00:47:27.599
a constant temptation to treat NIH not as a research engine,

636
00:47:27.880 --> 00:47:32.679
but as a quasi revenue source for large universities and

637
00:47:32.760 --> 00:47:37.000
medical centers. The core distinction is between direct costs and

638
00:47:37.119 --> 00:47:40.360
indirect costs. Direct costs are what people imagine when you

639
00:47:40.400 --> 00:47:44.800
say research funding. The salaries of lab staff, the equipment,

640
00:47:45.280 --> 00:47:50.000
the reagents, the animal models, the imaging time, the storage

641
00:47:50.000 --> 00:47:53.679
and analysis of data, the stipends for patients and clinical trials.

642
00:47:55.599 --> 00:48:02.559
Indirect costs often labeled facilities and administration FNA. They cover

643
00:48:02.639 --> 00:48:06.159
the overhead that institutions say they need to support the

644
00:48:06.239 --> 00:48:14.840
research buildings, utilities, IT, compliance officers, HR, animal care security,

645
00:48:15.159 --> 00:48:19.679
and the layers of bureaucracy that handle grant management. Institutions

646
00:48:19.719 --> 00:48:23.440
negotiate indirect cost rates with a federal government, and those

647
00:48:23.519 --> 00:48:29.320
rates can easily run forty fifty or even more of

648
00:48:29.400 --> 00:48:33.360
the direct costs. That means a million dollar grant might

649
00:48:33.440 --> 00:48:37.440
bring another four or five hundred thousand dollars in overhead.

650
00:48:38.239 --> 00:48:43.880
That overhead in theory tied to real expenses, but it

651
00:48:44.000 --> 00:48:50.199
also becomes a powerful incentive. The more nah dollars your

652
00:48:50.440 --> 00:48:54.920
facility brings in, the more indirect dollars your institution harvests.

653
00:48:55.679 --> 00:49:00.920
You don't need a conspiratorial mind to see what happens next.

654
00:49:01.320 --> 00:49:05.039
Universities in big health systems invest heavily in grant capture.

655
00:49:05.360 --> 00:49:10.280
They build gleaming research towers. They expand administrative offices. They

656
00:49:10.360 --> 00:49:16.159
hire layers of compliance, research development, air quotes in internal

657
00:49:16.199 --> 00:49:20.039
grant support staff. Some of this is necessary. It is

658
00:49:20.079 --> 00:49:24.360
impossible to run modern biomedical research out of a garage.

659
00:49:24.559 --> 00:49:27.000
But at some point the tale starts to wag the dog.

660
00:49:27.400 --> 00:49:31.719
Instead of we have overhead so we can support the science,

661
00:49:32.400 --> 00:49:35.360
the unspoken reality becomes we need more science so we

662
00:49:35.400 --> 00:49:39.000
can support the overhead. From the outside. Taxpayers see a

663
00:49:39.239 --> 00:49:44.079
forty seven billion dollar research budget and imagine forty seven

664
00:49:44.199 --> 00:49:47.599
billion dollars of benchwork and clinical trials from the inside.

665
00:49:47.599 --> 00:49:51.320
Administrators see the overhead slice and start quietly treating it

666
00:49:51.400 --> 00:49:56.679
like a funding stream that they need to defend. When

667
00:49:57.000 --> 00:50:00.400
lawmakers float the idea of capping indirect cost rates or

668
00:50:00.440 --> 00:50:05.119
tightening oversight, universities and medical centers scream that science will collapse.

669
00:50:05.840 --> 00:50:09.440
The message is always the same. Any attempt to discipline

670
00:50:09.519 --> 00:50:13.960
overhead is framed as an attack on research and patients,

671
00:50:14.280 --> 00:50:18.400
even when the proposed reforms are aimed squarely at the bureaucracy,

672
00:50:18.920 --> 00:50:25.440
not the bench. Recent trends should worry anyone who cares

673
00:50:25.440 --> 00:50:32.159
about value. While the top line NIH programs has stayed

674
00:50:32.199 --> 00:50:36.960
relatively flat or grown modestly, reports now show NIH awarding

675
00:50:37.079 --> 00:50:40.239
fewer new and competing grants in twenty twenty five than

676
00:50:40.280 --> 00:50:43.800
twenty twenty four and tightening pay lines as inflation eats

677
00:50:43.800 --> 00:50:47.039
away at purchasing power. In other words, more of the

678
00:50:47.079 --> 00:50:51.159
budget goes to maintaining existing commitments and overhead, while the

679
00:50:51.199 --> 00:50:54.920
pipeline of new science gets choked. At the same time,

680
00:50:55.039 --> 00:50:59.719
institutions continue to add admin staff faster than they add

681
00:50:59.719 --> 00:51:06.679
principle investigators. The risk is obvious nah becomes a way

682
00:51:06.719 --> 00:51:11.000
to maintain sprawling research bureaucracies rather than primarily a way

683
00:51:11.119 --> 00:51:14.280
to fuel discovery. The human side of this and pain

684
00:51:14.440 --> 00:51:19.719
is very painful. There are scientists out there who want

685
00:51:20.039 --> 00:51:26.559
into this field to solve real problems and now spend

686
00:51:26.599 --> 00:51:29.960
over half of their lives writing and rewriting grant applications

687
00:51:30.000 --> 00:51:32.840
because their institution needs them to keep the money flowing.

688
00:51:34.320 --> 00:51:37.840
There are junior investigators crushed by the pressure to land

689
00:51:37.880 --> 00:51:42.119
big grants in an environment where success rates are low

690
00:51:42.480 --> 00:51:46.639
and the overhead expectations are high. There are patients waiting

691
00:51:47.159 --> 00:51:52.800
and watching promising lines of research stall because funding is rationed,

692
00:51:53.599 --> 00:51:55.760
while they're being told there is no money, even as

693
00:51:55.800 --> 00:51:59.519
institutions put up new buildings. If you're conservative, the question

694
00:51:59.559 --> 00:52:01.880
is not should we fund science? The question is how

695
00:52:01.920 --> 00:52:05.760
do we ensure that when we fund science, the dollars

696
00:52:05.840 --> 00:52:11.800
actually reach labs? Trials in tangible progress, not just layers

697
00:52:11.800 --> 00:52:16.400
of administration and real estate projects. And the answer has

698
00:52:16.480 --> 00:52:21.840
to include transparency, caps and cultural shift in academia that

699
00:52:22.039 --> 00:52:25.800
remembers the mission is discovery and keeers, not empire building.

700
00:52:26.599 --> 00:52:28.960
The same kind of tension shows up when you zoom

701
00:52:29.000 --> 00:52:33.199
back out to rural America. When you look at a

702
00:52:33.239 --> 00:52:37.480
satellite map of the United States at night, you see

703
00:52:37.480 --> 00:52:40.000
bright webs of light where big cities are and long

704
00:52:40.159 --> 00:52:47.679
dark stretches where country stretches open. Those dark stretches are

705
00:52:47.679 --> 00:52:50.800
not empty. They're full of towns with two lane roads,

706
00:52:50.960 --> 00:52:55.280
grain elevators, gas stations, churches, schools, and one more thing

707
00:52:55.360 --> 00:52:57.960
that matters a lot more than the people in DC

708
00:52:58.360 --> 00:53:02.440
talking about rural issues seem to understand a small hospital

709
00:53:02.800 --> 00:53:06.880
with a red emergency sign. From twenty seventeen to twenty

710
00:53:06.880 --> 00:53:11.800
twenty four, alone, sixty two rural hospitals closed, while only

711
00:53:12.079 --> 00:53:16.079
ten opened, a net loss of over fifty two. Over

712
00:53:16.119 --> 00:53:18.480
the last twenty years, roughly one hundred and ninety three

713
00:53:18.559 --> 00:53:23.679
rural hospitals have shut down. By one count the USDA

714
00:53:24.119 --> 00:53:26.719
reports with that between two thousand and five and twenty

715
00:53:26.760 --> 00:53:29.760
twenty three, one hundred and forty six hospitals in rural

716
00:53:30.000 --> 00:53:35.920
US counties either closed completely or stopped providing acute impatient care,

717
00:53:36.320 --> 00:53:39.880
with eighty one of those shutting their doors all together.

718
00:53:40.440 --> 00:53:44.880
A recent analysis from the Chartist Center found that one

719
00:53:44.920 --> 00:53:49.480
hundred and eighty two rural hospitals have closed since twenty ten,

720
00:53:50.199 --> 00:53:52.880
and that forty six percent of the rural hospitals still

721
00:53:52.920 --> 00:53:56.119
standing are operating at a loss, with more than four

722
00:53:56.199 --> 00:54:01.679
hundred flagged as vulnerable. To now, I don't know about you,

723
00:54:02.039 --> 00:54:03.880
but to me, that is a big red flag going

724
00:54:03.920 --> 00:54:09.760
off in my head. Behind those numbers are brutal, brutal realities.

725
00:54:11.039 --> 00:54:14.239
In a city, if you have chest pain or your

726
00:54:14.320 --> 00:54:20.719
kid breaks an arm, there are usually multiple ers within

727
00:54:20.760 --> 00:54:24.599
twenty minutes. In a rural county, there might be one

728
00:54:24.719 --> 00:54:29.840
hospital for an area seventy or eighty miles across. When

729
00:54:29.840 --> 00:54:32.920
that hospital closes or converts to a bare bones clinic,

730
00:54:33.239 --> 00:54:37.679
the ambulance rides goes from ten minutes to forty five.

731
00:54:38.159 --> 00:54:41.079
For strokes and heart attacks, the distance is the difference

732
00:54:41.119 --> 00:54:44.239
between walking out of the hospital in a week and

733
00:54:44.320 --> 00:54:50.760
never speaking again, and in some cases that change in

734
00:54:50.880 --> 00:54:54.679
time can be the difference truly between life and death.

735
00:54:58.039 --> 00:55:01.039
It can be the difference between hug your family again

736
00:55:01.800 --> 00:55:05.679
or being buried by them. A Royal hospital is not

737
00:55:05.920 --> 00:55:08.239
just a health care facility. It is one of the

738
00:55:08.320 --> 00:55:11.440
largest employers in a town, an anchor for doctors and

739
00:55:11.519 --> 00:55:16.679
nurses and therapists, a reason for manufacturers considering locations. There

740
00:55:17.239 --> 00:55:21.559
a reassurance for retirees that they're not entirely on their own.

741
00:55:21.880 --> 00:55:27.440
When a hospital closes, jobs, vanish, young families leave, clinic struggle,

742
00:55:27.800 --> 00:55:32.280
and the community takes a psychological hit you cannot capture

743
00:55:32.360 --> 00:55:37.559
in a spreadsheet. It feels like the country has officially

744
00:55:37.599 --> 00:55:43.800
decided you are expendable. Rural subsidies and special payment rules

745
00:55:44.119 --> 00:55:47.679
are an attempt to acknowledge that the math doesn't work

746
00:55:47.679 --> 00:55:50.480
in these places, and if you apply the same formulas

747
00:55:50.480 --> 00:55:54.920
that use in dense metro areas. Critical access hospitals are

748
00:55:55.000 --> 00:56:00.159
allowed to get cost based Medicare reimbursement up to to

749
00:56:00.239 --> 00:56:05.639
a cap rather than the standard DRG rates. New rural

750
00:56:06.159 --> 00:56:10.679
emergency hospitals receive fixed monthly payments to maintain twenty four

751
00:56:10.679 --> 00:56:14.320
to seven emergency and outpatient services even if they no

752
00:56:14.400 --> 00:56:19.239
longer maintain in patient beds. There are grants for telehealth

753
00:56:19.239 --> 00:56:24.719
and infrastructure special designations for Medicare dependent hospitals and other

754
00:56:24.800 --> 00:56:28.960
acronyms meant to keep at least basic care within a

755
00:56:28.960 --> 00:56:34.760
reasonable drive, But even with those supports, the situation is precarious.

756
00:56:35.880 --> 00:56:40.039
A third or more of rural hospitals run on negative

757
00:56:40.079 --> 00:56:44.119
margins in some states. In any shock for Medicaid cuts,

758
00:56:44.400 --> 00:56:47.960
volume drop a bad payer mix here can push them

759
00:56:48.000 --> 00:56:54.360
over the edge. When lawmakers in Washington talk casually about

760
00:56:54.360 --> 00:56:57.800
slashing Medicaid funding by hundreds of billions of dollars over

761
00:56:57.840 --> 00:57:00.559
a decade to save money, what it means on the

762
00:57:00.599 --> 00:57:04.079
ground is that hospitals and places like Hondo, Texas or

763
00:57:04.239 --> 00:57:07.800
rural Iowa worry they will have to close maternity wards,

764
00:57:08.000 --> 00:57:12.679
shut down services, or close entirely. The same political movement

765
00:57:12.840 --> 00:57:16.599
that wraps itself in rural imagery and small town values

766
00:57:16.719 --> 00:57:19.199
is often willing to balance the budget on the backs

767
00:57:19.199 --> 00:57:21.719
of the very hospitals that keep those towns in their

768
00:57:21.800 --> 00:57:25.440
voters alive. From a conservative perspective, this is where the

769
00:57:25.559 --> 00:57:32.639
cut everything reflex runs directly into the obligation to preserve

770
00:57:32.719 --> 00:57:36.960
basic infrastructure. You cannot claim to back the heartland and

771
00:57:37.000 --> 00:57:40.400
then shrug when half of its hospitals are underwater. You

772
00:57:40.400 --> 00:57:45.920
cannot pretend that a town that is truly free if

773
00:57:45.960 --> 00:57:49.239
the nearest er is over an hour away. At the

774
00:57:49.320 --> 00:57:53.800
same time, you can't pretend that every small hospital can

775
00:57:53.960 --> 00:57:57.480
or should offer every service. We need a rural system

776
00:57:57.519 --> 00:58:03.159
that is smaller, smarter, and tightly integrated with regional hubs

777
00:58:03.360 --> 00:58:07.000
and supported by targeted, accountable subsidies, not a system where

778
00:58:07.000 --> 00:58:11.199
we keep zombie facilities shambling along with no plan. The

779
00:58:11.239 --> 00:58:14.920
stakes are not abstract. When the last rural hospital in

780
00:58:14.920 --> 00:58:18.559
a region goes dark, the next heart attack, the next stroke,

781
00:58:18.880 --> 00:58:23.519
the next complicated labor is erased against geography that a

782
00:58:23.559 --> 00:58:27.599
lot of people will lose. See at this point you

783
00:58:27.639 --> 00:58:30.039
should be able to start seeing the pattern. We've built

784
00:58:30.039 --> 00:58:33.840
programs that, on their best days, do real good three

785
00:58:33.840 --> 00:58:37.639
point forty b making drugs more affordable for safety net providers,

786
00:58:38.400 --> 00:58:42.519
DSH and rural subsidies, keeping hospitals open where they're needed,

787
00:58:42.519 --> 00:58:47.559
the most NAH funding, driving science that saves lives, nonprofit

788
00:58:47.639 --> 00:58:52.159
tax exemptions, encouraging mission driven care. But we also built

789
00:58:52.199 --> 00:58:56.159
them with enough complexity and enough money attached that they

790
00:58:56.199 --> 00:59:01.079
became magnets for gaming most of the abuse. This space

791
00:59:01.800 --> 00:59:06.239
does not look like a cartoon villain committing obvious crimes.

792
00:59:07.800 --> 00:59:14.679
It looks like a constant optimization, justified in soft, plausible language.

793
00:59:15.000 --> 00:59:18.320
Hospital leaders don't stand up and say, let's exploit three

794
00:59:18.440 --> 00:59:21.440
forty b to make a killing. They say, we're just

795
00:59:21.519 --> 00:59:25.079
capturing value to support our emission. They don't say, let's

796
00:59:25.079 --> 00:59:27.840
classify as much as we can as community benefits so

797
00:59:27.880 --> 00:59:32.239
we can justify our tax exemption. They say we're carefully

798
00:59:32.280 --> 00:59:36.280
accounting for the full scope of our contributions. They don't say,

799
00:59:36.360 --> 00:59:40.119
let's use our nonprofit HALO and DSH money to build

800
00:59:40.199 --> 00:59:45.280
a mini monopoly. They say we're creating integrated works networks

801
00:59:46.360 --> 00:59:51.920
to improve quality. Meanwhile, patients get crushed in very concrete ways.

802
00:59:52.880 --> 00:59:56.280
Medical debt is one of the leading sources of collection

803
00:59:56.360 --> 01:00:00.000
items on credit reports in this country. Hundreds of hospitals

804
01:00:00.239 --> 01:00:05.039
use lawsuits, garnishments, and credit reporting as standard tools to

805
01:00:05.079 --> 01:00:09.800
collect from patients, and far too many cases those patients

806
01:00:10.519 --> 01:00:14.079
would have qualified for financial assistance if the hospital had

807
01:00:14.119 --> 01:00:18.519
made it easy to apply or automatically screen them. Instead,

808
01:00:18.599 --> 01:00:21.400
they end up with their wages docked, their credit ruined,

809
01:00:21.679 --> 01:00:25.559
and their homes at risk, all while the hospital touts

810
01:00:25.639 --> 01:00:30.960
its community benefit and their totals and glossy reports to

811
01:00:31.159 --> 01:00:37.559
justify their tax breaks that dwarf what it actually spends on.

812
01:00:37.559 --> 01:00:41.039
On the billing side, fraud and abuse blended into creative

813
01:00:41.079 --> 01:00:47.760
coding upcoding billing a higher paying code than the service

814
01:00:47.800 --> 01:00:53.760
really justifies remains an ongoing concern. Hospitals and health systems

815
01:00:53.760 --> 01:00:58.280
invest heavily in revenue cycle optimization consultants who will walk

816
01:00:58.360 --> 01:01:03.320
them as close to the possible without tripping obvious fraud alarms.

817
01:01:03.920 --> 01:01:08.519
Documentation is tailored not just to reflect what happened, but

818
01:01:08.559 --> 01:01:14.679
to support the most lucrative code sets. Risk adjustment games

819
01:01:14.920 --> 01:01:20.119
and Medicare advantage, and certain Medicaid managed care settings inflate

820
01:01:20.880 --> 01:01:24.960
the apparent sickness of populations to increase payments. None of

821
01:01:25.000 --> 01:01:28.519
this is about improving care. It is about extracting more

822
01:01:28.719 --> 01:01:33.079
and more from public and private payers. In the three

823
01:01:33.199 --> 01:01:36.800
forty B world, you see diversion of discounted drugs to

824
01:01:36.880 --> 01:01:42.039
patients or payers who don't actually qualify, duplicate discounts when

825
01:01:42.079 --> 01:01:44.960
a drug is both purchased under three forty B and

826
01:01:45.079 --> 01:01:51.880
also generates a Medicaid rebate, in elaborate contract pharmacy arrangements

827
01:01:51.880 --> 01:01:56.119
that are hard to police even in NAH land. You

828
01:01:56.559 --> 01:01:59.360
see soft corruption in the form of institutions that build

829
01:01:59.440 --> 01:02:03.400
layers of admin funded by indirect cost recovery, and then

830
01:02:03.440 --> 01:02:06.079
fight tooth and nail against any attempt to cap those

831
01:02:06.079 --> 01:02:11.760
scrut or scrutinize those overhead rates. These systems are so

832
01:02:11.880 --> 01:02:16.440
complex that when someone from the outside questions them, insiders

833
01:02:16.440 --> 01:02:19.880
can always say, you don't understand how complicated this is.

834
01:02:20.360 --> 01:02:24.159
Complexity becomes a shield. It allows people to hide morally

835
01:02:24.239 --> 01:02:29.760
dubious choices behind jargon. And because these beneficiaries of the

836
01:02:29.800 --> 01:02:34.559
status quo are powerful, large systems, farmer giants, prestigious universities,

837
01:02:34.760 --> 01:02:38.320
politicians are often too scared or too bought to do

838
01:02:38.400 --> 01:02:41.199
more than nibble around the edges. The worst part is

839
01:02:41.199 --> 01:02:45.039
the moral language gets weaponized. If you say we should

840
01:02:45.320 --> 01:02:50.679
demand that nonprofit hospitals provide at least as much charity

841
01:02:50.719 --> 01:02:53.760
care as the value of their tax exemption, you're accused

842
01:02:53.760 --> 01:02:57.360
of trying to hurt the poor. If you say we

843
01:02:57.400 --> 01:03:01.000
should require three forty b hospitals to public report how

844
01:03:01.079 --> 01:03:04.199
much of their spread dollars go to direct patient relief,

845
01:03:04.679 --> 01:03:07.679
you're accused of carrying water for big pharma. If you

846
01:03:07.719 --> 01:03:11.880
say we should cap anih overhead and expose asmen at

847
01:03:11.920 --> 01:03:16.880
the admined bloat you're accused of being anti science. The

848
01:03:17.000 --> 01:03:20.159
faces of the sick, the poor, the rural, and the

849
01:03:20.239 --> 01:03:25.000
desperate are turned into rhetorical hostages to protect the revenue

850
01:03:25.039 --> 01:03:29.000
streams of the powerful. Conservatism at its best is supposed

851
01:03:29.039 --> 01:03:34.360
to be about ordered liberty and moral clarity, not blind

852
01:03:34.400 --> 01:03:38.079
trust in any institution that claims good intentions. You don't

853
01:03:38.199 --> 01:03:43.360
get moral clarity by shouting fraud at everything and cutting

854
01:03:43.400 --> 01:03:46.000
it all. You get it by telling the truth about

855
01:03:46.000 --> 01:03:48.880
who is helped, who is hurt, who is paying, and

856
01:03:48.920 --> 01:03:52.559
who is getting rich off the middle that's where they were.

857
01:03:54.639 --> 01:03:57.719
If this is just an hour or two rant, it's useless.

858
01:03:58.159 --> 01:04:01.679
The point is to not make you more sin. It's

859
01:04:01.719 --> 01:04:05.239
to make you more dangerous to the people who like

860
01:04:05.320 --> 01:04:09.840
things exactly the way they are. So, what would real

861
01:04:09.880 --> 01:04:14.039
world reform look like, Reform that protects the people who

862
01:04:14.079 --> 01:04:19.599
rely on these programs while putting an end to the games. Well, first,

863
01:04:20.000 --> 01:04:25.880
we would have to restore a simple erarchy patience first institutions. Second,

864
01:04:26.679 --> 01:04:33.079
every subsidy three point b dsh rural support, NIH grants,

865
01:04:33.440 --> 01:04:37.840
nonprofit tax exemptions should be judged by one primary question.

866
01:04:38.320 --> 01:04:42.599
Can we clearly see that this is benefiting actual patients

867
01:04:42.599 --> 01:04:47.280
in communities, not just being captured by executives and balance sheets.

868
01:04:47.800 --> 01:04:51.760
If the answer is no, or we don't know, then

869
01:04:51.800 --> 01:04:55.760
either the program is broken or the reporting is dishonest.

870
01:04:56.559 --> 01:05:00.679
That means radical transparency. Every hospital using three four should

871
01:05:00.679 --> 01:05:04.679
be required to publish in plain English how much it

872
01:05:04.760 --> 01:05:09.320
saved or earned via three point forty B and exactly

873
01:05:09.360 --> 01:05:13.760
how those dollars were used. Not vague phrases about supporting

874
01:05:13.760 --> 01:05:20.199
our mission, but numbers. How much when to direct patient discounts,

875
01:05:20.719 --> 01:05:24.119
how much to charity care, how much to staffing and

876
01:05:24.280 --> 01:05:29.000
underserved clinics, how much to service lines that would otherwise fold.

877
01:05:29.400 --> 01:05:33.920
Every nonprofit hospital should have to show, side by side

878
01:05:34.000 --> 01:05:36.599
what its tax exemptions are worth and how much it

879
01:05:36.679 --> 01:05:42.599
spends on true charity care and measurable community benefit. When

880
01:05:42.599 --> 01:05:46.239
a hospital sues patients or sends them to collections, it

881
01:05:46.320 --> 01:05:49.880
should have to disclose how many of those patients would

882
01:05:49.920 --> 01:05:55.440
have qualified for assistance under its own policies. DSH and

883
01:05:55.559 --> 01:06:01.280
rural subsidies should be tied tightly to documented uncompensated care,

884
01:06:02.119 --> 01:06:08.000
Medicaid shortfalls, and clear access metrics. If a hospital is

885
01:06:08.039 --> 01:06:12.000
taking in millions and extra payments while simultaneously spending more

886
01:06:12.000 --> 01:06:16.400
on executive compensation or expansion into affluent markets, then it

887
01:06:16.480 --> 01:06:20.480
spends on care for the poor. Taxpayers should see that

888
01:06:22.639 --> 01:06:28.800
NIH recipients should be required to be transparent with their

889
01:06:28.840 --> 01:06:35.079
breakdowns of direct versus indirect costs, ADMIN, headcount growth versus

890
01:06:35.199 --> 01:06:42.800
lab growth, and tangible output of big, long running grants. Second,

891
01:06:43.119 --> 01:06:47.519
we need to tie eligibility in scale to performance. If

892
01:06:47.559 --> 01:06:50.960
a hospital wants a nonprofit tax exemption worth tens of

893
01:06:51.280 --> 01:06:54.559
or hundreds of millions, it should be required to provide

894
01:06:54.719 --> 01:07:00.920
charity care and financial assistance of at least equal to

895
01:07:01.000 --> 01:07:04.719
a meaningful percentage of revenue or the value of that

896
01:07:04.880 --> 01:07:09.239
tax break. If a hospital wants broad three forty B privileges,

897
01:07:09.440 --> 01:07:14.719
it should have to require and maintain robust levels of

898
01:07:14.960 --> 01:07:19.239
care to low income and uninsured patients. If that care shrinks,

899
01:07:19.880 --> 01:07:23.920
so should its three forty BE privileges. If a system

900
01:07:24.039 --> 01:07:28.280
keeps suing poor patients despite having the money and obligation

901
01:07:28.440 --> 01:07:31.679
to forgive or reduce those bills, it should lose the

902
01:07:31.760 --> 01:07:34.679
right to call itself a charity and be taxed like

903
01:07:34.719 --> 01:07:43.039
a business is. For NAH, that means capping overhead at

904
01:07:43.079 --> 01:07:47.599
reasonable levels and rewarding institutions that keep admin lean and

905
01:07:47.679 --> 01:07:50.840
push most of the dollars into labs and trials For

906
01:07:50.960 --> 01:07:56.280
real support. It means funding specific access guarantees like no

907
01:07:56.440 --> 01:08:01.280
residence should be more than blank minutes from an emergency

908
01:08:01.320 --> 01:08:07.079
stabilization site, rather than propping up every legacy facility in

909
01:08:07.119 --> 01:08:10.639
its current form, where all subsidies should follow regional access

910
01:08:10.679 --> 01:08:16.560
plans that integrate ems, telehealth, local clinics, and referral centers

911
01:08:16.680 --> 01:08:21.000
into a coherent whole instead of throwing money at the

912
01:08:21.039 --> 01:08:26.680
loudest lobbyists. Third enforcement has to actually scare people right now.

913
01:08:26.720 --> 01:08:30.560
Too many organizations treat fines, settlements and clawbacks as a

914
01:08:30.600 --> 01:08:34.119
cost of doing business. That has to change. If an

915
01:08:34.119 --> 01:08:38.960
institution repeatedly abuses three P forty B or DSH and

916
01:08:39.039 --> 01:08:43.920
lies about the community benefit or disregards financial assistance obligations

917
01:08:44.079 --> 01:08:48.319
while aggressively collecting from poor patients, it should face suspension

918
01:08:48.399 --> 01:08:54.960
of its subsidies, loss of tax privileges, and in extreme cases,

919
01:08:55.319 --> 01:08:59.960
personal accountability for executives who authorized or concealed the behavior.

920
01:09:00.920 --> 01:09:06.000
Whistleblowers inside hospitals, universities, and pharma companies need strong enforced

921
01:09:06.000 --> 01:09:10.760
protections so that they can expose upcoding, diversion, duplicate billing,

922
01:09:11.000 --> 01:09:16.079
and misuse of funds without losing their careers. Fourth, the

923
01:09:16.199 --> 01:09:20.039
culture has to change. Board meetings and c suite huddles

924
01:09:21.159 --> 01:09:24.119
cannot just be about did we hit our revenue targets.

925
01:09:24.359 --> 01:09:26.960
They need to grapple with questions like how many medical

926
01:09:27.039 --> 01:09:31.000
debt lawsuits did we file and were they justified? How

927
01:09:31.000 --> 01:09:34.600
many patients actually got free or discounted care? How much

928
01:09:34.640 --> 01:09:37.119
of our three forty bter revenue went straight into helping

929
01:09:37.159 --> 01:09:40.760
low income patients at the point of sale? Are we

930
01:09:40.840 --> 01:09:47.760
building research capacity or admin empires? Real leaders, conservative, liberal, whatever,

931
01:09:48.399 --> 01:09:51.039
need to be willing to walk into rooms full of

932
01:09:51.119 --> 01:09:54.560
lawyers and consultants and say I don't care that this

933
01:09:54.720 --> 01:09:59.439
is legal, but is it right? Finally, politically, this is

934
01:09:59.439 --> 01:10:06.119
the only happens a voter. Stop accepting lazy slogans. You

935
01:10:06.199 --> 01:10:09.359
are allowed to say, I want to protect poor patients,

936
01:10:09.560 --> 01:10:14.079
preserve rural hospitals, and fund research and that's exactly why

937
01:10:14.119 --> 01:10:18.079
I want transparent, tighter rules and serious penalties for abuse.

938
01:10:18.520 --> 01:10:22.039
You are allowed to tell your representatives, don't you dare

939
01:10:22.159 --> 01:10:25.239
vote to cut safety net programs without a plan, and

940
01:10:25.399 --> 01:10:29.560
don't you dare keep running writing blake checks to institutions

941
01:10:29.760 --> 01:10:33.319
that can't show their work. All of that gets us

942
01:10:33.399 --> 01:10:37.439
to the last and hardest. Conservatives love to talk about

943
01:10:37.479 --> 01:10:42.039
small government. Liberals love to talk about strong safety nets.

944
01:10:43.199 --> 01:10:47.920
The reality is we've built a mutant hybrid, a massive, complicated,

945
01:10:48.079 --> 01:10:52.359
subsidies soak system that still leaves people bankrupt and afraid.

946
01:10:52.920 --> 01:10:55.680
The question is not whether we can snap our fingers

947
01:10:55.720 --> 01:10:58.880
and eliminate subsidies tomorrow, because we all know we cannot,

948
01:11:00.119 --> 01:11:05.079
and trying would be a straight act of cruelty. The

949
01:11:05.199 --> 01:11:08.359
question is whether we can build a path toward a

950
01:11:08.399 --> 01:11:12.720
world where we need less of the convoluted machinery because

951
01:11:12.760 --> 01:11:15.039
the base of the system is more honest and fair.

952
01:11:15.840 --> 01:11:20.640
Right now, we start with inflated prices, opaque contracts, rigged markets,

953
01:11:20.680 --> 01:11:26.279
and consolidation, then paper over the damage with subsidies. Hospitals

954
01:11:26.359 --> 01:11:30.920
charge wildly different amounts for the same services, depending on

955
01:11:30.960 --> 01:11:35.680
whether they can attach a hospital facility fee. Drug manufacturers

956
01:11:35.680 --> 01:11:39.039
play a game of high list prices, secret rebates, and

957
01:11:39.079 --> 01:11:45.000
differential discounts. Middlemen take their cut at every level, every

958
01:11:45.119 --> 01:11:51.680
level along the way. Then, when patients predictably cannot afford

959
01:11:51.720 --> 01:11:55.920
the fallout, we send in three pin forty b DSH

960
01:11:56.079 --> 01:12:02.600
and premium subsidies, as well as rural lifelines and charity

961
01:12:02.600 --> 01:12:07.199
policies to keep the whole mess from exploding. A subsidy

962
01:12:07.239 --> 01:12:11.439
light future is one where we flip that script. We

963
01:12:11.479 --> 01:12:15.319
attack the price disease at the roots, so we don't

964
01:12:15.640 --> 01:12:20.840
need as many band aids. That means real price transparency enforced,

965
01:12:21.079 --> 01:12:25.079
not optional, so hospitals and physicians have to post and

966
01:12:25.199 --> 01:12:30.800
honor usable prices, not meaningless charge masters. It means cite

967
01:12:30.840 --> 01:12:35.439
neutral payments wherever possible, so hospitals cannot charge five times

968
01:12:35.479 --> 01:12:38.479
more for the same MRI just because of a billing code.

969
01:12:39.000 --> 01:12:43.600
It means taking on pharmacy middlemen and rebate schemes so

970
01:12:43.720 --> 01:12:47.800
drug prices bear some resemblance to what patients and payers

971
01:12:47.960 --> 01:12:52.800
actually pay. It means serious anti trust enforcement that stops

972
01:12:52.800 --> 01:12:57.520
subsidized giants from gobbling up every independent practice and rural

973
01:12:57.520 --> 01:13:04.680
facility within fifty mile radius. It also means unleashing simpler,

974
01:13:05.359 --> 01:13:10.159
cheaper models of care, direct primary care, transparent cash pay clinics,

975
01:13:10.359 --> 01:13:15.359
telehealth services that don't require hospital overhead, independent imaging and

976
01:13:15.399 --> 01:13:20.039
surgery centers that can offer lower prices without facility fee bloat.

977
01:13:21.000 --> 01:13:25.640
When ordinary people can get primary and routine care without

978
01:13:25.760 --> 01:13:29.800
mortgaging their future, subsidies can retreat to where they belong

979
01:13:30.760 --> 01:13:36.399
catastrophic conditions, truly low income patients, and genuinely underserved regions,

980
01:13:38.199 --> 01:13:42.119
insurance can go back to looking like insurance protection against

981
01:13:42.439 --> 01:13:48.359
financial catastrophe rather than prepaid subscription for absolutely everything that

982
01:13:48.479 --> 01:13:53.239
has to be jerry rigged with subsidies because the sticker

983
01:13:53.279 --> 01:13:57.560
prices are insane. That doesn't mean no subsidies. It means fewer,

984
01:13:57.840 --> 01:14:01.560
sharper and more honest ones. Means means instead of fifteen

985
01:14:01.600 --> 01:14:05.960
overlapping programs and hidden across subsidies, we might have a

986
01:14:06.039 --> 01:14:11.680
handful of direct, tightly monitored supports, income based assistance that

987
01:14:11.840 --> 01:14:16.239
actually pays for necessary care instead of vanishing into hospitals

988
01:14:16.399 --> 01:14:22.239
balance sheets, tiding, rural access funds that guarantee emergency care

989
01:14:22.359 --> 01:14:26.840
within a certain drive, direct grants to research efforts that

990
01:14:26.880 --> 01:14:31.039
can show progress. It means we're honest about who gets what,

991
01:14:31.520 --> 01:14:35.199
who pays, and why getting there will not be fast.

992
01:14:35.479 --> 01:14:40.439
It will not fit neatly into a campaign slogan. It

993
01:14:40.479 --> 01:14:44.199
will require conservatives to admit that markets fail in healthcare

994
01:14:44.359 --> 01:14:48.079
when the rules are rigged, and it will require liberals

995
01:14:48.159 --> 01:14:51.680
to admit that writing bigger checks into corrupted structures is

996
01:14:51.880 --> 01:14:56.840
not compassion. Its complicity. It will require both sides to

997
01:14:56.880 --> 01:15:01.520
stand up to hospital lobbies, pharmaceutical giants, and university systems

998
01:15:01.640 --> 01:15:08.199
that have gotten very comfortable collecting public money without public scrutiny.

999
01:15:08.399 --> 01:15:12.079
But the alternative is to keep doing what we're doing,

1000
01:15:12.199 --> 01:15:16.560
letting the safety net fray, while telling ourselves that if

1001
01:15:16.600 --> 01:15:19.840
we just add one more program, one more subsidy, one

1002
01:15:19.840 --> 01:15:24.279
more acronym, one more form to fill out, somehow the

1003
01:15:24.359 --> 01:15:28.840
system will magically start caring about the people more than

1004
01:15:28.840 --> 01:15:32.119
they care about profit. I don't buy that. I don't

1005
01:15:32.119 --> 01:15:34.720
believe the richest company and the history of the world

1006
01:15:34.800 --> 01:15:37.199
has to choose between letting people die in the street

1007
01:15:37.239 --> 01:15:40.520
and letting nonprofit empires squeeze every last dollar out of

1008
01:15:40.520 --> 01:15:44.640
public compassion. I don't believe that the only way to

1009
01:15:44.920 --> 01:15:49.880
fund science is to keep feeding bloated bureaucracies. I don't

1010
01:15:49.920 --> 01:15:52.960
believe that the rural America has to become a healthcare

1011
01:15:53.039 --> 01:15:57.159
desert just so someone in Washington can claim a budget cut.

1012
01:15:57.680 --> 01:16:02.079
What I do believe is that we can insist on

1013
01:16:02.159 --> 01:16:05.439
two things at once. That we will not abandon the

1014
01:16:05.560 --> 01:16:08.720
mom at the kitchen table, the dad in the ICU,

1015
01:16:09.800 --> 01:16:12.720
the grandmother in the small town, the kid in the

1016
01:16:12.720 --> 01:16:16.640
clinical trial, and that we will no longer tolerate a

1017
01:16:16.720 --> 01:16:20.520
system that uses their stories as camouflage for greed. A

1018
01:16:20.560 --> 01:16:23.720
subsidy light future is not a future without mercy. It's

1019
01:16:23.760 --> 01:16:27.720
a future where mercy isn't a business model. It's a

1020
01:16:27.760 --> 01:16:31.359
future where safety net is strong, honest, and needed less

1021
01:16:31.880 --> 01:16:36.039
because the floor underneath the people is finally level. And

1022
01:16:36.119 --> 01:16:40.399
if that makes some hospital CEOs, some pharma executives and

1023
01:16:40.479 --> 01:16:45.560
some university administrator is nervous, good for once let them

1024
01:16:45.680 --> 01:16:49.119
feel what millions of families have felt for decades, a

1025
01:16:49.159 --> 01:16:54.439
little bit of pressure. The question now is whether we're

1026
01:16:54.439 --> 01:16:56.760
going to do anything about it, Whether we're going to

1027
01:16:56.840 --> 01:17:00.680
demand transparency and reform from the people who claim to

1028
01:17:00.720 --> 01:17:05.439
speak for us, whether we're going to let it's complicated

1029
01:17:05.800 --> 01:17:10.439
be an excuse any longer, whether we're going to build

1030
01:17:10.439 --> 01:17:13.720
a healthcare system where compassion is not measured by the

1031
01:17:13.760 --> 01:17:17.239
size of the subsidy, but by how directly it reaches

1032
01:17:17.279 --> 01:17:19.680
the people that it was meant to help. Because if

1033
01:17:19.720 --> 01:17:22.800
we don't, then all of this every subsidy, every program,

1034
01:17:22.840 --> 01:17:28.319
every acronym is just a very expensive way of pretending

1035
01:17:28.399 --> 01:17:31.479
that we care. And I think this country is better

1036
01:17:31.479 --> 01:17:34.560
than that. I want to land this where we started,

1037
01:17:34.880 --> 01:17:39.680
with people, not programs, Because after an episode like this,

1038
01:17:39.920 --> 01:17:42.439
it's easy to walk away drowning in acronyms three P

1039
01:17:42.560 --> 01:17:48.840
forty b dsh nih cah fn A, it's all alphabet soup.

1040
01:17:49.520 --> 01:17:51.359
It's easy to get lost in the corruption, in the

1041
01:17:51.399 --> 01:17:55.520
games and the numbers that you forget why any of

1042
01:17:55.560 --> 01:17:58.520
this matters. You forget why the mom at the kitchen table.

1043
01:17:59.199 --> 01:18:01.720
You forget about the dad in the ICU. You forget

1044
01:18:01.720 --> 01:18:05.600
about the mother driving past the red emergency sign and

1045
01:18:05.720 --> 01:18:08.439
her county and wondering if it'll still be there when

1046
01:18:08.479 --> 01:18:11.399
she needs it. I don't want you to walk away numb.

1047
01:18:11.399 --> 01:18:15.439
I don't want you to walk away mad I want

1048
01:18:15.479 --> 01:18:19.880
you to walk away wanting a change. I want you

1049
01:18:19.960 --> 01:18:26.079
to walk away with a clear mind and driven for change.

1050
01:18:26.239 --> 01:18:30.520
The system thrives on the fog. It thrives on complexity

1051
01:18:30.520 --> 01:18:34.000
and jargon and four hundred page rules written so densely

1052
01:18:34.720 --> 01:18:37.840
that almost no one outside the insiders can understand them.

1053
01:18:38.199 --> 01:18:41.199
It thrives on the idea that healthcare is too complicated

1054
01:18:41.239 --> 01:18:46.880
for normal people to question, That subsidies are too technical

1055
01:18:48.119 --> 01:18:51.479
for taxpayers to ask where the money went. That nonprofit

1056
01:18:51.520 --> 01:18:55.319
and research and rural access are magic words you're not

1057
01:18:55.399 --> 01:18:58.640
allowed to examine too closely. And here's what I'm telling

1058
01:18:58.640 --> 01:19:02.199
you tonight, that's a lie. You are absolutely allowed to

1059
01:19:02.239 --> 01:19:04.880
look at a hospital that calls itself a charity and

1060
01:19:04.880 --> 01:19:07.640
ask how many people did you sue last year. You

1061
01:19:07.680 --> 01:19:10.760
were absolutely allowed to look at a massive system swimming

1062
01:19:10.760 --> 01:19:15.279
in three forty B revenues and DSH money and tax breaks,

1063
01:19:15.319 --> 01:19:19.439
and ask how much did you actually do to help

1064
01:19:19.520 --> 01:19:22.600
reach the poor patients at the point of sale. You

1065
01:19:22.680 --> 01:19:25.399
were absolutely allowed to look at the universities bragging about

1066
01:19:25.520 --> 01:19:28.840
NIH awards and ask how much of that went into

1067
01:19:28.920 --> 01:19:31.880
labs and trials and how much w under your administration

1068
01:19:32.399 --> 01:19:35.359
and your glass towers. You were absolutely allowed to look

1069
01:19:35.399 --> 01:19:39.079
at the map of rural hospital closures and explain to me,

1070
01:19:39.159 --> 01:19:44.479
and ask them to explain to you, very slowly, how

1071
01:19:44.520 --> 01:19:47.560
you can send billions all over this sector and still

1072
01:19:48.039 --> 01:19:52.159
let entire counties lose their er. And if anybody tells

1073
01:19:52.199 --> 01:19:56.600
you that asking those questions makes you anti poor, anti science,

1074
01:19:56.680 --> 01:19:59.680
anti healthcare, I want you to remember exactly what's going on.

1075
01:20:00.039 --> 01:20:03.039
They're using the faces of the vulnerable as a human

1076
01:20:03.079 --> 01:20:05.840
shield to protect their revenue streams. I told you at

1077
01:20:05.880 --> 01:20:08.359
the beginning, and I'll say it again. My problem is

1078
01:20:08.399 --> 01:20:11.279
not with the people who rely on subsidies. My problem

1079
01:20:11.359 --> 01:20:16.159
is with the people who live off them. My problem

1080
01:20:16.319 --> 01:20:20.720
is with the executives sitting in offices calling themselves nonprofit

1081
01:20:20.760 --> 01:20:23.800
while they sign off on lawsuits against working families and

1082
01:20:23.840 --> 01:20:26.560
then fly to conferences to brag about their community benefit.

1083
01:20:27.039 --> 01:20:29.359
My problem is with the pharmaceutical giants that jack up

1084
01:20:29.359 --> 01:20:32.439
list prices and then pretend forced discounts are some kind

1085
01:20:32.439 --> 01:20:36.000
of act of charity. My problem is with the big

1086
01:20:36.039 --> 01:20:39.560
systems that buy up rural hospitals, pocket the subsidies, and

1087
01:20:39.720 --> 01:20:44.760
let and still let services with her. My problem is

1088
01:20:44.800 --> 01:20:48.119
with politicians who love to stand in front of the

1089
01:20:48.159 --> 01:20:50.800
camera and talk about protecting patients and then go to

1090
01:20:50.840 --> 01:20:54.520
fundraising dinners hosted by the very people who are gaming

1091
01:20:54.520 --> 01:21:00.000
these programs. I'll want you to understand something very clearly

1092
01:21:00.880 --> 01:21:03.680
that neither party will say out loud. They are afraid

1093
01:21:03.680 --> 01:21:07.760
of you becoming informed about this. They are fine with

1094
01:21:07.880 --> 01:21:12.840
you being angry in the abstract. They're fine with you

1095
01:21:12.880 --> 01:21:15.920
screaming about the system or healthcare or big farm on

1096
01:21:15.960 --> 01:21:19.159
social media. As long as you don't know how the

1097
01:21:19.239 --> 01:21:22.479
money actually moves. As long as you don't know what

1098
01:21:22.640 --> 01:21:25.800
three point forty b really does or how nonprofit tax

1099
01:21:25.840 --> 01:21:30.479
exemptions really work, you're safe to them. You're noise. The

1100
01:21:30.479 --> 01:21:33.359
most dangerous thing you can become is a voter who

1101
01:21:33.439 --> 01:21:38.399
knows enough to start asking specific questions. Not why is

1102
01:21:38.439 --> 01:21:43.119
healthcare so broken? That's too big and too easy to evade?

1103
01:21:43.680 --> 01:21:49.239
But why does our local nonprofit hospital provide less charity

1104
01:21:49.279 --> 01:21:52.560
care than the tax breaks it gets? Why doesn't our

1105
01:21:52.760 --> 01:21:59.720
hospitals automatically screen patients for financial assistance before it sues them?

1106
01:22:00.399 --> 01:22:03.359
How much three point forty bter revenue did our system

1107
01:22:03.439 --> 01:22:06.319
take in last year and how much of it showed

1108
01:22:07.079 --> 01:22:10.800
up as discounts at the pharmacy window? What's our royal

1109
01:22:10.920 --> 01:22:16.279
access plan if DR closes? Why is anih overhead at

1110
01:22:16.279 --> 01:22:20.479
this institution climbing faster than lab capacity. When you start

1111
01:22:20.520 --> 01:22:23.439
asking questions like that at town halls, board meetings, or

1112
01:22:23.479 --> 01:22:27.960
school boards and county boards and then the state House hearings,

1113
01:22:28.439 --> 01:22:31.479
you stop being a spectator and start becoming a problem

1114
01:22:31.760 --> 01:22:35.439
for the people who like the fog. Conservatism at its

1115
01:22:35.479 --> 01:22:38.600
core is not supposed to be blind obedience to big

1116
01:22:38.640 --> 01:22:41.840
business or big institutions. It is supposed to be a

1117
01:22:41.920 --> 01:22:46.000
deep belief that power, government power, in corporate power has

1118
01:22:46.039 --> 01:22:50.840
to be washed, checked and held accountable because human nature

1119
01:22:50.960 --> 01:22:55.239
is what it is. We believe in personal responsibility, yes,

1120
01:22:56.119 --> 01:23:00.039
but we also believe in stewardship, and we have We

1121
01:23:00.119 --> 01:23:06.359
have hospitals and drug companies and universities and politicians that

1122
01:23:06.399 --> 01:23:08.600
are supposed to be stewards of billions of dollars in

1123
01:23:08.680 --> 01:23:12.239
your name. It is not radical to say, prove you're

1124
01:23:12.279 --> 01:23:15.760
worthy of that trust. It is your duty. At the

1125
01:23:15.800 --> 01:23:19.880
same time, we cannot let good anger turn into cruel policy.

1126
01:23:20.039 --> 01:23:24.159
You will hear some voices say, just slash Medicaid, kill

1127
01:23:24.159 --> 01:23:27.319
these programs, wipe it all out. The market will fix it.

1128
01:23:27.760 --> 01:23:30.680
Those people have never driven forty five minutes behind an

1129
01:23:30.720 --> 01:23:33.880
ambulance praying that the er is still open. They've never

1130
01:23:33.960 --> 01:23:37.520
sat in a hospital or a clinic waiting to hear

1131
01:23:38.039 --> 01:23:41.279
if there will be a trial spot. They've never had

1132
01:23:41.319 --> 01:23:44.359
to call a social worker to find out if their

1133
01:23:44.439 --> 01:23:49.600
kids medication is covered this month. They'll treat subsidies as

1134
01:23:49.640 --> 01:23:52.760
an abstract cancer on the budget instead of a lifeline

1135
01:23:52.760 --> 01:23:56.840
that real people are clinging to. We don't get to

1136
01:23:56.960 --> 01:24:00.159
do that, not if we're serious about being a moral nation.

1137
01:24:00.840 --> 01:24:03.039
The answer is not to rip out the safety net

1138
01:24:03.039 --> 01:24:06.960
and pretend gravity doesn't exist. The answer is to reinforce

1139
01:24:07.000 --> 01:24:12.119
it where real human people hang from it, and cut

1140
01:24:14.399 --> 01:24:19.720
away the parts being used as a hammock by people

1141
01:24:19.720 --> 01:24:22.239
who could stand on their own two feet just fine.

1142
01:24:23.000 --> 01:24:26.079
The answer is not to scream socialism every time someone

1143
01:24:26.159 --> 01:24:30.199
questions a hospital's behavior. The answer is to act like adults,

1144
01:24:30.760 --> 01:24:33.760
look at the numbers, and demand every dollar spent in

1145
01:24:33.840 --> 01:24:37.039
the name of compassion actually works like the compassion when

1146
01:24:37.039 --> 01:24:41.560
it hits the ground. So what do you do when

1147
01:24:41.560 --> 01:24:45.279
this episode ends. You don't have to become a policy expert.

1148
01:24:45.640 --> 01:24:49.520
You don't have to memorize statute numbers, but you can

1149
01:24:49.560 --> 01:24:52.720
start local. If you live near a hospital, especially the

1150
01:24:52.760 --> 01:24:56.520
one that calls itself a nonprofit, go to their website

1151
01:24:56.560 --> 01:25:00.880
and find their financial assistance policy. Ask yourself what a scared,

1152
01:25:01.159 --> 01:25:04.960
stressed out patient working two jobs actually be able to

1153
01:25:05.039 --> 01:25:09.640
navigate this. Look up whether the hospital has been suing patients.

1154
01:25:10.359 --> 01:25:12.960
If it has, look at the income levels of these

1155
01:25:13.039 --> 01:25:16.640
of the people you're suing. If you've got a representative

1156
01:25:16.720 --> 01:25:18.880
or a state senator who loves to talk about roal

1157
01:25:18.960 --> 01:25:25.800
values while voting to get the very payments that keep

1158
01:25:25.880 --> 01:25:30.560
role facilities alive, call their office. Make them explain in

1159
01:25:30.640 --> 01:25:34.359
plain English, how they plan to keep your county from

1160
01:25:34.399 --> 01:25:38.399
becoming a healthcare dead zone. If you work inside the system,

1161
01:25:38.479 --> 01:25:41.399
if you're a nurse, a doctor, a pharmacist, attack a

1162
01:25:41.439 --> 01:25:44.800
bill or a coder, a researcher, you already know where

1163
01:25:44.800 --> 01:25:48.159
the bodies are buried. You know which programs are being

1164
01:25:48.279 --> 01:25:50.960
used the right way and which ones are used as games.

1165
01:25:51.560 --> 01:25:55.319
You know where patients are being failed. I'm asking you,

1166
01:25:55.399 --> 01:25:58.000
as someone on the outside, to find the courage to

1167
01:25:58.039 --> 01:26:01.680
talk about it. Maybe it's anonymous at first, Maybe it's

1168
01:26:01.720 --> 01:26:05.960
through whistleblower channels or journalists. Maybe it's refusing in the

1169
01:26:06.000 --> 01:26:09.840
small choices every day. So let that's how we do it.

1170
01:26:09.880 --> 01:26:14.000
Be the last word, and beyond all of that, I

1171
01:26:14.039 --> 01:26:16.640
want you to remember this. You are not crazy for

1172
01:26:16.680 --> 01:26:19.920
thinking the system is morally upside down, because it is.

1173
01:26:20.479 --> 01:26:22.600
You are not wrong to feel rage when you see

1174
01:26:22.640 --> 01:26:27.000
people bankrupted by charity hospitals. You are not wrong to

1175
01:26:27.039 --> 01:26:30.920
feel betrayed when you see billions in subsidies and still

1176
01:26:30.960 --> 01:26:35.800
watch ers die. You are not wrong to ask why

1177
01:26:36.000 --> 01:26:40.439
after decades of NIH budgets and hospital subsidies and tax

1178
01:26:40.479 --> 01:26:44.279
breaks and special programs, regular people still feel like the

1179
01:26:44.359 --> 01:26:48.920
system exists to extract from them, not protect them. That

1180
01:26:49.079 --> 01:26:52.600
anger is justified. The only question is what you do

1181
01:26:52.680 --> 01:26:57.199
with it. If you let it turn into pure cynicism,

1182
01:26:58.039 --> 01:27:01.359
they win. The people who profit off the fog loves

1183
01:27:01.399 --> 01:27:06.680
cynics because cinics don't organize, Cinics don't show up at hearings,

1184
01:27:06.880 --> 01:27:13.520
Cinics don't vote in primaries. Cinics don't ask questions specific

1185
01:27:14.439 --> 01:27:20.199
to the problems. Sinics just strug, just shrug and say

1186
01:27:20.399 --> 01:27:23.880
they're all corrupt, and go back to trying to survive

1187
01:27:23.920 --> 01:27:28.199
another year. That's exactly the attitude this machine is built

1188
01:27:28.319 --> 01:27:31.880
to create. If you let that anger turning into clarity

1189
01:27:31.960 --> 01:27:35.479
and courage, then something changes. Maybe not overnight, maybe not

1190
01:27:35.520 --> 01:27:38.359
in the next election cycle. But every time you refuse

1191
01:27:38.479 --> 01:27:42.760
to be gaslet by, it's complicated. Every time you push

1192
01:27:42.880 --> 01:27:45.920
back on trust us, we care. Every time you force

1193
01:27:45.960 --> 01:27:49.239
people in power to show their math, you chip away

1194
01:27:49.239 --> 01:27:52.199
at the moral fog that keeps the whole thing running.

1195
01:27:52.720 --> 01:27:56.640
I started tonight with the mom at the kitchen table,

1196
01:27:57.039 --> 01:28:00.479
the dad at the ICU, the grandmother passing the red

1197
01:28:00.560 --> 01:28:04.239
emergency sign. I want to end with them too, because

1198
01:28:04.239 --> 01:28:07.079
they are the measure of whether anything we do is

1199
01:28:07.119 --> 01:28:11.000
worth it. In five years from now, these people are

1200
01:28:11.039 --> 01:28:15.880
still sitting with the same fear, still getting crushed by

1201
01:28:15.880 --> 01:28:20.760
the same bills, still losing their hospital, and still being

1202
01:28:21.039 --> 01:28:24.760
used as props in the same speeches, then we have failed.

1203
01:28:25.560 --> 01:28:28.199
If five years from now we're looking at the system

1204
01:28:28.439 --> 01:28:31.520
that's at least a little more honest, a little more transparent,

1205
01:28:31.640 --> 01:28:34.920
a little less rigged, and a little more humane, then

1206
01:28:35.000 --> 01:28:38.199
maybe we can say we did something worthwhile. We cannot

1207
01:28:38.199 --> 01:28:41.119
build a perfect system, not in this world, not with

1208
01:28:41.279 --> 01:28:44.479
human nature, but we can build one that is less corrupt,

1209
01:28:44.960 --> 01:28:49.840
less captured, less cruel. We can build one where subsidies

1210
01:28:49.880 --> 01:28:52.840
are tools and not trophies. We can build one where

1211
01:28:52.840 --> 01:28:56.520
compassion has a backbone. That's the fight. And if you're

1212
01:28:56.560 --> 01:29:00.720
listening to this, whether you're left right or just exhausted,

1213
01:29:01.079 --> 01:29:05.239
you're invited because the one thing they're not prepared for

1214
01:29:05.600 --> 01:29:08.920
is a country that refuses to be confused anymore. Thank

1215
01:29:08.960 --> 01:29:12.279
you for listening. Now go ask somebody in power a

1216
01:29:12.359 --> 01:29:16.560
question that they don't want to answer. And also, don't

1217
01:29:16.560 --> 01:29:20.600
forget to share this with someone, whether it's your friend,

1218
01:29:20.640 --> 01:29:27.079
your family member, whoever it is. Because healthcare is complicated

1219
01:29:27.119 --> 01:29:28.920
for a reason, and I hope I did a good

1220
01:29:29.000 --> 01:29:32.199
enough job explaining to you some of the things that

1221
01:29:32.239 --> 01:29:37.960
are done and fraudulent about healthcare, and these last two podcasts.

1222
01:29:39.039 --> 01:29:44.159
Don't forget to leave a rating if you're listening on Spotify, leviraating,

1223
01:29:44.199 --> 01:29:48.159
if you're on Apple Podcasts Leviorating, if you're listening on Speaker,

1224
01:29:48.520 --> 01:29:54.079
any of those websites. Don't forget to follow our social

1225
01:29:54.079 --> 01:29:56.119
media as they should be the link below down the

1226
01:29:56.159 --> 01:29:59.880
show notes. But I want you, guys, if you can,

1227
01:30:00.079 --> 01:30:02.520
and please share this with a friend or family member

1228
01:30:02.720 --> 01:30:07.399
who does not understand where the fraud comes from. In

1229
01:30:07.560 --> 01:30:12.880
the healthcare sector. We touched in it's really been the

1230
01:30:12.960 --> 01:30:17.880
last three podcasts. We did the ACA tax credits, and

1231
01:30:17.920 --> 01:30:21.560
then we went into more of the Medicare Medicaid stuff,

1232
01:30:21.600 --> 01:30:23.520
and then then this one we actually tackled more of

1233
01:30:23.520 --> 01:30:25.279
the three point forty b and some of the other

1234
01:30:27.159 --> 01:30:31.920
fraud that happens within the hospitals in America. But please

1235
01:30:31.920 --> 01:30:34.920
share this out, share the share all three if you

1236
01:30:34.960 --> 01:30:38.279
want to, but don't forget to check out the socials,

1237
01:30:38.279 --> 01:30:42.079
don't forget to do all the things, leave comments on

1238
01:30:42.800 --> 01:30:45.239
the videos, and don't forget to share some of our

1239
01:30:45.640 --> 01:30:48.199
posts on social media, because we're trying to get this

1240
01:30:48.279 --> 01:30:52.640
information out there. Because the best way to compete with

1241
01:30:54.279 --> 01:30:59.000
people who want you ignorant to what they're doing is

1242
01:30:59.039 --> 01:31:03.960
by sharing this to everybody so people know what they

1243
01:31:03.960 --> 01:31:07.640
are doing. I appreciate you guys for listening. I hope

1244
01:31:07.680 --> 01:31:10.000
you guys have a good day, good night, whatever time

1245
01:31:10.000 --> 01:31:12.520
you listen to this, Share this