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Health Insurance Cancel Culture

By MATTHEW HOLT

Strap in for a dramatic tale in which our hero battles bureaucracy and logic to try to get his health insurance back.

About 20 years ago lots of Americans, especially Californians who bought health insurance from Blue Shield of California, found that their coverage was cancelled without them knowing about it. That practice called “recission” got lots of attention during the run up to the ACA, and was banned by it. Now if you want to buy insurance and you pay for it, the insurance company has to sell it to you and can’t cancel it after the fact.

Or so I thought.

Post ACA most people who don’t get their insurance through an employer, or Medicare or Medicaid, now buy it via a very regulated “individual market” on a state-based or Federal exchange. Generally, the insurance they buy is heavily standardized (with bronze, silver or gold levels) and what they pay for insurance is heavily subsidized based on income. It’s those subsidies that were increased in the pandemic and extended in the Inflation Reduction Act (IRA) during the Biden administration. The subsidies were the topic–still unresolved–of the latest government shutdown. (Yes, yes, I know the shutdown is over—for now).

It’s pretty much impossible to buy individual insurance outside the exchange, although if you have Scott Galloway levels of wealth you can avoid buying insurance altogether and pay cash and you might be better off, or you can join some quasi-religious health share organization and take your chance. But for most people you are way better off buying on the exchange because that’s the only way you can get those subsidies.

I live in California and remain an under-employed blogger, and a few times in my recent life I have not been married to someone with health insurance provided by their employer. It happened in 2016-17 and again two years ago. No, not what you’re thinking. I didn’t get kicked to the curb by my wife, but in 2022 she got laid off by her employer and decided not to get another job. For the first year of that period (2023) we did not buy via the exchange, but used COBRA. That means we bought into her previous company’s insurance using our own money because it was cheaper than buying on the exchange. Two reasons for this. First, she got a severance package that made our combined incomes too high to get a subsidy and secondly, the ACA plans charge by age, whereas employers pay a flat fee for all employees. That made the exchange plan more expensive than the employer plan. (No prizes for guessing who in our family is old and expensive!)

But COBRA only lasts a year, and then it was time to head back to Covered California.

This starts a process where you try to figure out which plan offered is the cheapest, yet includes your and your family’s doctors, and which one has the lowest associated fees for the stuff you use the most (usually pediatric visits in our case). Turns out that in our case is the Blue Shield Trio 73 HMO. My inability to understand why it’s called Trio 73 reveals why no one calls me a marketing genius.

The other thing you have to figure out is what level of subsidy you get. As mentioned, the IRA passed in 2022 extended the pandemic emergency increase in subsidies for people with higher incomes. But then again, you have to figure out what your income will be when you sign up. Like the audience laughing at an obvious punch line a comedian hasn’t gotten to yet, those of you running ahead of me will have worked out a slight problem here.

I was signing up for a 2024 health plan in 2023. But I had to guess what my 2024 taxable income would be. Like many self-employed people with extremely variable income I had no idea what that final income would be until I filed my 2024 taxes in October 2025 (given I take the IRS extension). In other words, almost two years after I chose the plan. It turns out that in California, the people who track your income are not your health plan, nor the exchange but instead your local county health department. So in November 2023 I guessed my 2024 income and had to tell the local county what that guess is via some affidavit. The county health department actually called me to check that my estimate was correct. Or at least was what I told them it was.  Remember this for later.

Meanwhile I sign up on what I regard to be a very complex web site run by Covered California, and select the aforementioned Blue Shield HMO. It covers One Medical and UCSF theoretically via the Brown & Toland IPA, and leads to lots of fun and games in terms generating much content for me on this blog and Linkedin.

As it turns out, I was sent for an echocardiogram by my primary care doctor this past summer to check if I had a heart. While many of you were surprised at the answer (yes, I do), apparently it’s got a congenital disorder that needs a little help.

This gets us to November 2025 (last month!) with your brave hero going back onto the Covered California exchange trying to figure out whether the cardiologist recommended by my primary care doc is covered by the 2026 version of the Blue Shield plan I am on, or whether I need to switch. I could now digress and tell you the late Ian Morrison’s formula for choosing a health plan but I will hold that for the next telenovela article as of course that process is a fricking mess too!

In order to try to do that I login to the Covered California site and see I have a notice that I am not eligible for health insurance. I am confused.

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Slaying The Dragon

By MIKE MAGEE

The date was June 9, 1954. This was over a year after Wisconsin Republican Senator Joseph R. McCarthy had assumed the chairmanship of the Senate Permanent Subcommittee on Investigations. The history shows that he had  “rocketed to public attention in 1950 with his allegations that hundreds of Communists had infiltrated the State Department and other federal agencies.” Clearly a psychopath, he escaped control of moderating voices, biting off ever larger targets, including now the U.S. Army.

“Judge, jury, prosecutor, castigator, and press agent, all in one”, was how Harvard law dean Ervin Griswold described him. In 1954, McCarthy accused the army of “lax security at its top-secret army facilities” which he claimed were infiltrated by communists. The army responded by hiring veteran Boston lawyer Joseph Welch to defend itself.

As documentarians reported, “Mothers who never watched TV during the day were glued to watching the Army-McCarthy hearings.” McCarthy’s right-hand chief council that day was lawyer Roy Marcus Cohn. Pragmatic, ruthless, and evil to the core, Cohn’s career was launched by McCarthy, and his tainted touch destroyed lives and weakened the U.S. government for three more decades, straight up to the moment of his death from HIV/AIDS in 1986.

His style and tactics are widely felt today to be the strategic scaffolding of our Executive Branch’s attempted takeover of the US government. Not surprisingly, a direct assault on the control functions, values, and traditions of the US Military are a leading wedge in these attacks.  They have literally exploded in the past week with revelations that Defense Secretary Pete Hegseth himself gave the go-ahead on a “kill them all” order that ultimately engulfed two survivors of a rocket attack on an alleged drug-transporting speed boat.

In a 5-minute summation of the televised events of June 9, 1954, you (along with our leaders) are able to witness the historic takedown of McCarthy by Welch (with Cohn as witness) – the “slaying of the dragon” that finally destroyed McCarthy once and for all.

Cohn had reached an agreement with Welch that McCarthy would avoid attacking one particular Army service man as a communist if Welch remained civil. But Welch had laid a trap, and purposefully needled McCarthy into loosing his temper, and on camera, violating the agreement and “attacking the good lad,”  who an outraged Welch tearfully defended in his historic and well-prepared retort.

As historian Thomas Doherty recalls, “It was as if the entire country had been waiting for somebody to finally say this line, ‘Have you no sense of decency.’” As Welch pounced on his victim, Cohn winces as his dragon is slain. To which Jelani Cobb adds, “At the end of it, all the illusions, the comfortable illusions that McCarthy had cultivated about himself, had effectively been dispelled.”

As Congress grapples with a situation that has veered dangerously out of control, we can only hope that this time “history will repeat.” Courage must be resourced from within. As Martin Luther King famously reminded: “In the end, we will remember not the words of our enemies, but the silence of our friends.”

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

Let’s Check the Math on Health Subsidies

By KIM BELLARD

It’s December 3, and, to no one’s surprise, Congress still has not acted on extending the expanded health care premium tax credits for ACA. To Congress, the subsidies don’t expire until the end of the year, so they figure they have until at least then to act, or maybe sometime after that, given the way they handled the recent government shutdown.

On the other hand, consumers who are renewing or shopping for ACA plans face a more immediate deadline; they have until December 15 to enroll for January 1st. They’re already seeing huge increases that result from a normal renewal increase plus the loss of the generous subsidies; Kaiser Family Foundation estimates that their premiums will more than double without them. They can’t wait while Congress plays politics.

There seems to be agreement that something will be done about the subsidies, but less clarity about what that something is. Some centrists argue to extend the enhanced subsidies but with some tweaks, such as lowering the upper income levels and/or requiring everyone to pay at least some minimum premium. To me, that’d be a reasonable compromise. But some Republicans, including President Trump, are calling for a more radical change: instead of giving the expanded premium tax subsidies to those “fat cat” insurers, give them directly to consumers through health savings accounts (HSAs). Put individuals over insurers, they argue. 

I’m here to tell you: the math does not work.

I am not an actuary, but long ago I was a group underwriter, setting rates for employer groups’ health insurance, and, also long ago, I was involved in the early days of so-called consumer directed health plans (CDHPs), including HSAs and high-deductible health plans. I don’t disagree that HSAs and high-deductible plans can play a role, but one has to understand the math that drives health care spending.

The central fact of health care spending is that it isn’t evenly distributed. It is a perfect example of the Pareto principle: 80% of spending comes from 20% of people. The flip of that is that about 15% of people have no healthcare spending in any given year. What insurance does is take money from everyone and use it to fund the spending of the high cost people. That’s what all insurance does.

OK, I’ve avoided doing the math as long as I could, but here goes. One proposal has called for $2,000 to be deposited in each enrollee’s new HSA. Let’s keep it simple and say there are 1,000 such people, and that their average annual health care spending is $2,000 (which, of course, is way low). So we have 1,000 x $2,000 = $2 million in both subsidies and spending. It works out perfectly, right?

Not so fast.

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Farewell to Medicare Advantage

By JEFF GOLDSMITH

This morning, after twelve years, I dumped my Medicare Advantage plan and enrolled in a Medicare Supplement policy. My smoldering discontent finally boiled over and . . . I’m gone. It was a large network style national plan with zero premium.

My decision to enroll in MA was, in part, ideological. I liked the idea of a program design that rewarded healthy behavior. But I discovered that none of the alleged MA perks were actually reachable-my health club was out of network as was my dentist. When I got cancer in 2015, the plan did not give me attitude about my decision to fly 600 miles to the University of Chicago for my care. They merely paid the U of C about a third of what it cost them to rid me of my cancer. 

There was not a single denial of care during the entire twelve years. But they pestered my primary care doc mercilessly by insisting that he sign off on every single care decision made in my cancer fight or anywhere else I went- hours of needless “paperwork”. And I fended off sixteen offers of a “wellness visit”- a nurse coming to my house to upcode me. My relationship with the carrier was basically to be on the receiving end of hundreds of robo-calls.

I got little signs that their networks were withering. The University of Pennsylvania did not accept them, nor Cedars Sinai, nor the Hospital for Special Surgery. But when Mayo announced they were not accepting them, that was for me the last straw. Mayo is my “safety net” provider if my local Charlottesville folks are not able to meet my needs. 

From a policy standpoint, I think MA made sense when it was redesigned and rebranded in the early 2000’s. And if we had SCAN or even Kaiser here in my market, I would probably still be a member. Particularly for the multi-functionally impaired older folks or the dually eligible, thoughtful protocol driven care by a tightly linked multi-specialty medical group makes a great deal of sense. In this, my old friend George Halvorson and I agree.

But the idea that capitation or the newer version-micro-managed care run by a warm and fuzzy AI- is somehow a cure-all for what ails our society is increasingly questionable on its face. It isn’t about the incentives, folks. I ate the MA dog food for twelve years. It’s about the care system you rely on when things get scary. In twelve years, except for the frozen dinners they sent me after my cancer surgery, the carrier added no value whatsoever to my life. MA just wasn’t worth it, even if was free. 

Jeff Goldsmith is a veteran health care futurist, President of Health Futures Inc and regular THCB Contributor. This comes from his personal substack

Why Patients – And Many Innovative Doctors – Are Pursuing Health Outside the System

By DAVID SHAYWITZ

Our current system of delivering care is awful from the perspective of seemingly every stakeholder. It frustrates, enrages, saddens, and depletes patients and physicians alike. No one designed it this way. It evolved through a series of choices and contingencies that perhaps made sense at the time but now seem to have led us down an evolutionary dead end.

While there’s no shortage of examples, I was especially struck by an anecdote I heard in Dr. Lisa Rosenbaum’s brilliant “Not Otherwise Specified” podcast series for the NEJM. Her focus this season is primary care, and in one episode she speaks with a Denver family physician named Larry Green.

“I practiced in the oldest family practice in Denver, for years,” Green explains. “I was the chair of that department, I directed that residency, and I’m now a patient in that practice. I cannot call it. It’s impossible. Because when I call the practice, I get diverted to a call center…”

From the perspective of what he calls the “medical-industrial complex,” he says, longitudinal relationships are “totally unimportant in healthcare.”

Yet these relationships – developed with care over time – tend to be what many patients crave and what effective doctoring typically requires.

Green’s experience won’t surprise anyone who has tried to get care lately. In November 2023, Mass General Brigham announced it would not be accepting new primary care patients. At hospitals everywhere, it’s not unusual for patients to spend hours on gurneys in emergency-department hallways, waiting for an inpatient bed.

I don’t know many physicians who haven’t struggled to get care for themselves or a loved one – often at the very institutions where they trained and to which they’ve devoted years of their lives. If even insiders can’t reliably access timely, compassionate care, what chance does anyone else have?

The miserableness of the system has been well documented, and physician burnout has sadly become a dog-bites-man story.

Applicants Are Still Flocking to Medical Schools

What’s perhaps more surprising is how many people are still desperate to enter the system and become physicians, fueling an application process that, as Drs. Rochelle and Loren Walensky have documented in The New England Journal of Medicine (NEJM), has become increasingly competitive, expensive, and time-consuming. Premed students routinely take an extra year (or more) to tick all the expected boxes and jump through the hoops that are perceived as mandatory.

This highlights something that’s easy to forget: the ideal of medicine remains deeply attractive. I wrote about this almost thirty years ago in a New York Times op-ed, and it’s still true today.

The notion of doctoring – of being trusted at the intersection of science and human stories – retains a powerful hold on young people. If only the actual experience could live up to the hope of these applicants, the well-worn quotes from Osler and Peabody, the promise of the profession, and the expectations of patients.

Searching For A Better Alternative

The idea that there must be a better alternative is at once familiar and evergreen.

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If You Could read My Mind – Wait, You Can?

By KIM BELLARD

Over the years, one area of tech/health tech I have avoided writing about are brain-computer interfaces (B.C.I.). In part, it was because I thought they were kind of creepy, and, in larger part, because I was increasing finding Elon Musk, whose Neuralink is one of the leaders in the field, even more creepy. But an article in The New York Times Magazine by Linda Kinstler rang alarm bells in my head – and I sure hope no one is listening to them.

Her article, Big Tech Wants Direct Access to Our Brains, doesn’t just discuss some of the technological advances in the field, which are, admittedly, quite impressive. No, what caught my attention was her larger point that it’s time – it’s past time – that we started taking the issue of the privacy of what goes on inside our heads very seriously.

Because we are at the point, or fast approaching it, when those private thoughts of ours are no longer private.

The ostensible purpose of B.C.I.s has usually been as for assistance to people with disabilities, such as people who are paralyzed. Being able to move a cursor or even a limb could change their lives. It might even allow some to speak or even see. All are great use cases, with some track record of successes.

B.C.I.s have tended to go down one of two paths. One uses external signals, such as through electroencephalography (EEG) and electrooculography (EOG), to try to decipher what your brain is doing. The other, as Neuralink uses, is an implant directly in your brain to sense and interrupt activity. The latter approach has the advantage of more specific readings, but has the obvious drawback of requiring surgery and wires in your brain.

There’s a competition held every four years called Cybathlon, sponsored by ETH Zurich, that “acts as a platform that challenges teams from all over the world to develop assistive technologies suitable for everyday use with and for people with disabilities.” A profile of it in NYT quoted the second place finisher, who uses the external signals approach but lost to a team using implants: “We weren’t in the same league as the Pittsburgh people. They’re playing chess and we’re playing checkers.”  He’s now considering implants.  

Fine, you say. I can protect my mental privacy simply by not getting implants, right?  Not so fast.

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Giving Thanks – Ken Burns “THE AMERICAN REVOLUTION”

By MIKE MAGEE

Give thanks for our America, blemishes and all. Ken Burns says as much, making it clear, we are a mess of contradictions, and that is (in part) what makes us a uniquely American.

Consider that in a single week, we have had to endure Trump’s “Things happen” as he defended the Saudi crown prince ordering the Khashoggi killing, while also rejoice in his smack-down THE HILL headlined, “The Epstein files are a turning point in the Trump presidency, but it’s not over yet.” Perhaps Marjorie Taylor Greene said it best for all of us, “I refuse to be a ‘battered wife’ hoping it all goes away and gets better.”

In the shadow of an autocratic assault unparalleled in our modern history, Americans are searching for a silver lining. Is it helpful to our Democracy to be stress tested and our Constitutional weaknesses revealed so that we might take corrective actions in the future? Should we accept some blame for supporting a culture rich in celebrity idolatry, and one tolerant of unsustainable levels of inequity? Hasn’t unbridled capitalism diminished solidarity and good government in equal measure?

It is heartening to see many of our public servants, several of whom are first generation immigrants, display their competence, professionalism and courage in support of these United States. Our citizens want to believe that they, rather than their DOJ inquisitors, represent us.

It’s encouraging that compassion, understanding, and partnership remain embedded in the caring citizens who say NO to kings, challenged mass ICE invaders, and (with the Catholic Church) lent a powerful voice to immigrants across our land.

In times like these, I rely heavily on a book my son, Mike, published with the University of Alabama Press in 2004, titled, “Emancipating Pragmatism: Emerson, Jazz, and Experimental Writing”. The book derived from his PhD dissertation at the University of Pennsylvania, and extensively delved into the writings of both Ralph Waldo Ellison, author of “The Invisible Man”, and his namesake, Ralph Waldo Emerson.

So what did he say in his book that was so compelling that I turn to it today, on the eve of another Thanksgiving Celebration?

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Katie D’Amico, Carequest–Integrating Oral Health into Medical Care

Katie D‘Amico is the VP of Innovation at Carequest, a non-profit that supports oral health–she’s a big proponent on its integration with medical care. At HLTH in October 2025 she took me on a brief tour of innovation in dental care and oral health. We had a quick look at the ability to test collagen breakdown and how to use the dental office to refer to lab tests. I also had a brief chat with Dr Ashley Lerman from Firstgrin, which is helping kids take care of their teeth, and distributing her kits and apps via health plans and hospitals–Matthew Holt

When Drug Price Transparency Isn’t Enough

By KRISTINA SMITH & PHIYEN NGUYEN

Policymakers and advocates often promote drug price transparency to lower costs and improve equity. While transparency is an important first step toward accountability and informed public budgeting, it does not guarantee affordable prices or fair access to medicines.

Transparency Has Some Benefits

Drug price transparency helps show how and why medicines cost what they do along the supply chain (i.e., from the manufacturer to the pharmacy), which makes it easier to identify where costs can be reduced or better regulated. By making this information public, transparency allows patients, payers, and policymakers to make more informed decisions and encourage manufacturers to prices drugs more fairly. Ultimately, it supports a fairer system where patients can better afford and obtain the treatments they need, improving access to care.

States with Drug Transparency Laws

While federal policy to improve price transparency is lacking, the states have moved to make things clearer for patients and payers. Vermont was the first U.S. state to enact a drug price transparency law in 2016. Since then, many others have followed suit. At least 14 states have passed some version of transparency legislation, though the details and their enforcement of these laws differ widely.

For example, only Vermont and Maine require drug companies or insurers to disclose the actual prices paid after discounts (called the “net price”). Alternately, Oregon and Nevada require drug manufacturers to publicly report their profit to state government agencies. And Connecticut, Louisiana, and Nevada mandate pharmacy benefit managers (PBMs) to report the total rebates they receive, but not the amounts for each specific drug. Despite these efforts, no state has yet achieved full transparency across the entire drug supply chain.

Transparency is Not Enough

Even with clear pricing, Americans still pay about 2.6 times more for prescription drugs than people in other wealthy countries. Early evidence suggests that these laws have done little to curb drug prices. To date, only four states – California, Maine, Minnesota, and Oregon – have published analyses of their own laws. These reports share common concerns: difficulty tracking pricing across the supply chain and uncertainty about whether state agencies have the authority (or the will) to act when data is incomplete or unreliable. 

Most transparency laws fall short on requiring detailed cost or profit data, focusing instead on broad price trends. As a result, this narrow scope makes it difficult to identify the exact drivers of high drug prices. Even when transparency discourages manufacturers from raising prices, these policies do not directly control pricing or define what constitutes an ‘unjustified’ price increase. Manufacturers can simply adjust by setting higher launch prices or implementing smaller, more frequent increases to stay below reporting thresholds. Still, the result is a system where drug costs can vary by as much as $719 for the same 30-day prescription even when prices are publicly listed.

What can also be done?

Creating a consistent national framework could replace the current patchwork of state laws and improve oversight of how drugs are priced. For example, the Drug Price Transparency in Medicaid Act (H.R. 2450) could do just that: it would standardize reporting requirements and reveal how drug prices are set, rebated, and reimbursed. But transparency alone can’t lower costs—it only shows the problem.

To make transparency meaningful, policymakers must address the underlying contracts and incentives that drive high prices.

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Nabla — It’s been a rocketship

I met the Nabla management team two years ago. Two years later they have ridden the wave of AI scribing to be one of the leaders in the field. At HLTH this year, I caught up with CEO Alex Lebrun and COO Delphine Groll to check in on their growth (150 customers and 100K users) what the next little bit of ambient AI scribing will look like (more specialties, more integration) and whether they’re scared of Epic (no!).–Matthew Holt

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