Two Hundred Sixty Percent
Next Tuesday, Indiana puts a number on the hospital. Not a premium. A price.
Hospitals that are not already part of a giant nonprofit system have to offer employers a direct contract at no more than 260 percent of what Medicare pays. Miss it and the fine is ten thousand dollars a day. That is state law from last year, not a press release. The five big systems already had to do this last September. Next week the rest of the state’s hospitals join them.
That is not a Kansas figure. I will not pretend Wichita already has this statute. What travels is the distinction. A renewal letter is a percentage and a network. This is a contract that says what the hospital costs.
We have been saying this in clinic for years. Insurance is a tool for the wreck, not for the oil change. Primary care should never have been stuffed into a claims machine. Hospitals should never have been allowed to hide the invoice inside a network. Indiana just made the hospital name the price to the people who actually pay the bill.
The number is 260. The penalty is ten thousand a day. That is a price you can read before you get the bill.
The Hospital Chair Costs $102,680
I cannot unsee a number from this month’s Health Affairs.
They studied Keytruda, the cancer drug sitting at the top of a lot of employer pharmacy bills. Same vial. Same drip. And 340B hospitals booked $102,680 a year in insurer revenue for each of those patients. A community physician practice booked $3,094.
That is not the cost of the medicine. That is the cost of the chair.
Those hospitals buy the vial at a discount, then bill the plan as if the discount never happened. The markup over what they paid the manufacturer averaged 173 percent in 340B hospitals. In a regular doctor’s office it was 16 percent. Private insurers spent 142 percent more on Keytruda in 2024 than in 2020. The patient count did not grow that fast. The building did.
I do not hang that bag in a Wichita exam room. I do sit with shop owners who treat their premium like a second payroll. They are not buying extra oncology. They are buying a hospital’s right to charge a specialty price for a drug that already has a clinic price. Insurance belongs on the wreck. It does not belong on the chair.
Post the number. Buy the vial. Sit the patient down. Charge for the care, not the ZIP code of the recliner.
California Demands Affordable Care
One Hundred Twenty-Five Percent
One hundred twenty-five percent. That is the fine California’s health-affordability board may vote in on Wednesday. Hospitals, medical groups, and insurers that grow faster than the state’s cap could owe as much as 125 percent of whatever they spent over the line.
The line ramps to 3 percent a year by 2029. The earliest the fine can actually land is 2028. Two years of data. Then a performance-improvement plan. Then, maybe, a penalty.
I am not cheering a state board. I am looking at the calendar. A Wichita shop with forty people does not have two years. They get a renewal letter this fall. They need a price they can read before they get the bill, not a hearing in 2028 about last year’s overage.
KFF counted the last jump in national health spending: hospitals were 40 percent of it. Retail drugs were 11 percent. That is not a mystery. That is a price list nobody posted.
I am not anti-insurance. Keep a policy for the wreck. Primary care is not a wreck. We take care of patients for a flat monthly fee. No prior auth. No claim. The number on the door is the number you pay.
California can fine a hospital in 2028. We post the fee today.
Post a Fair Price...Not an Inflated Premium
Fourteen Percent Is the Insurance
KFF just counted the asks. Nearly 300 small-group insurers, every state, median proposed increase for 2027: 14 percent.
That is the number a Wichita shop with forty people is going to see on a renewal letter. Not because we got 14 percent better at a sore throat. Insurers told the states the usual story (hospital prices, physician fees, drugs, more utilization). Underneath that, the fully insured small-group pool has already shrunk from about 17 million people to about 10 million. Healthier groups leave. The ones who stay pay for the leaving.
I am not anti-insurance. I am anti using insurance for the work we do here. Primary care is a monthly relationship, not a claim. When a Kansas employer buys a 14 percent raise on a product that still makes the employee wait six weeks and then surprise-bills the deductible, they did not buy more health care. They bought more health insurance.
We take care of patients for a flat fee. No prior auth. No claim form. If you keep a policy, keep it for the wreck. The everyday stuff is cheaper when it never touches a payer.
Fourteen percent is a price. It is not a doctor.
Walking Toward the Mountains
“I know of no better life purpose than to perish in attempting the great and impossible.”
— Friedrich Nietzsche
There’s a short clip that’s been circulating for years: a lone penguin, waddling away from the safety of the colony, crossing miles of frozen nothingness, heading straight toward distant mountains.
No mates. No food. No obvious reason—at least none we can easily explain.
Just movement. Purpose. Direction.
Biologists don’t fully agree on why this happens. Some think it’s illness. Some think it’s a navigation error. Some suggest instinct misfiring. But anyone who watches the footage long enough feels the pull of a different explanation—one that isn’t scientific, but deeply human.
The penguin isn’t wandering.
It’s choosing something harder.
The Colony Is Safe. The Colony Is Also the Problem.
In nature, survival usually depends on conformity. Stay with the group. Follow the patterns. Don’t stand out.
Healthcare is no different.
For decades, the “colony” has been clear:
- Bill more.
- See patients faster.
- Add layers of administration.
- Accept that burnout is the cost of doing business.
- Accept that patients are confused, frustrated, and financially exposed.
Most doctors didn’t choose this system because they believed in it. They chose it because leaving it looked impossible.
And then some didn’t.
Direct Care Is the Walk Away From the Colony
Direct Care didn’t begin as a market strategy. It wasn’t a venture-backed disruption. It wasn’t born in boardrooms.
It began when individual physicians looked around and said:
This is not why I became a doctor.
So they stepped out.
No guarantees. No safety net. No roadmap. Often no encouragement—sometimes outright hostility.
They traded predictable paychecks for uncertain income, institutional protection for personal responsibility, and “this is how it’s done” for “let’s try something better.”
That decision looks irrational from inside the colony.
From the outside, it looks necessary.
Why the Walk Looks Like Failure (Until It Doesn’t)
That penguin doesn’t look heroic at first.
It looks wrong.
It looks like something is broken.
That’s how Direct Care has been labeled for years:
- “Not scalable”
- “Not real insurance”
- “Only for the healthy”
- “Too simple to work”
And yet—quietly, steadily—Direct Care physicians are spending more time with patients, restoring continuity and trust, slashing unnecessary costs, reducing burnout, and rebuilding medicine around relationships instead of codes.
The mountains don’t disappear just because the walk is lonely.
Attempting the Impossible Is the Point
Nietzsche wasn’t celebrating death. He was celebrating meaning.
Some things matter enough to fail at.
Some systems are broken enough that trying to fix them will look foolish before it looks inevitable.
Direct Care isn’t easy. It isn’t safe. It isn’t comfortable.
But neither is staying in a system that asks doctors to care less in order to survive more.
Why This Story Resonates
That lone penguin reminds us of something uncomfortable:
Progress rarely starts with consensus. It starts with someone willing to look wrong.
Direct Care is not the end of the story. It’s the walk toward the mountains.
And whether it succeeds or fails, it already proves something vital:
Medicine does not have to accept the world as it is.
Final Thought
Most people never leave the colony. Some do—and change the landscape forever.
If healthcare is going to be fixed, it won’t be because it was easy.
It will be because enough people believed the attempt was worth everything.