Twenty-Two Billion

Congress passed a law so the ER bill would stop surprising you. Georgetown just counted what that law costs now. Twenty-two point four billion dollars. Four years of arbitration between doctors and insurers. You were not in the room.

Sixteen point six of that twenty-two landed in 2025 alone. Providers won about 85 percent of the fights. The median award was more than four times the in-network rate. The patient does not get the surprise bill anymore. The shop gets the surprise premium.

UnitedHealthcare told investors the process is adding two to six percent to commercial premium expenses. New York's state-employee plan called two hundred million in extra claim payments a primary reason its 2025 rates jumped nearly ten percent. That is not a better ER. That is last year's argument, priced into this year's renewal.

I am not anti-insurance. Keep a policy for the wreck. I am anti a fight nobody can shop. We take care of patients for a flat monthly fee. No claim. No arbitrator. The number on the door is the number you pay.

Twenty-two billion is a price. It just never showed up on the bill you were supposed to be protected from.

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.