Minnesota Lt. Gov. Peggy Flanagan (D), now running for U.S. Senate, promised a Somali audience in 2023 to seek funding for “culturally relevant treatments and care” and support multifamily housing.
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Today's guest is Mark Cuban, the billionaire entrepreneur and former Shark Tank star who is now on a mission to reform the American healthcare system. Through his companies, Cost Plus Drugs and Cost Plus Wellness, Cuban is trying to make healthcare more affordable by cutting out middlemen and making pricing more transparent. But he argues that fixing America's healthcare system will require breaking up massive conglomerates that wield enormous power over pricing and competition, often at the expense of patients.
Nick Gillespie talks with Cuban about why he supports bipartisan legislation from Elizabeth Warren and Josh Hawley to break up Big Medicine. Cuban explains how artificial intelligence can expose hidden costs in health insurance contracts and transform the way doctors diagnose and treat patients. They also discuss Cuban's support for Texas Democrat James Talarico and his belief that political parties have outlived their usefulness. The billionaire entrepreneur makes the case for restricting social media algorithms for children under 16 and discusses why he isn't particularly worried about socialism's growing popularity among young people. Finally, Cuban reflects on how Ayn Rand's The Fountainhead shaped his understanding of capitalism and why he believes helping others is part of being a successful entrepreneur.
0:00—James Talarico and the Break Up Big Medicine Act
4:13—Healthcare conglomerates and "contractual terrorism"
15:39—Drug pricing and pharmacy benefit managers
26:58—How AI will transform healthcare
33:04—The Trump administration's policy reforms
34:22—How does Cost Plus Drugs work?
43:08—The backlash against billionaires
47:52—Political parties and Texas governance
51:50—The rise of support for socialism among Gen Z
55:11—Would Cuban back a social media ban for minors?
55:50—The influence of Ayn Rand
Producer: Paul Alexander
Audio Engineer: Ian Keyser
This is an AI-generated transcript. Check all quotes against the audio for accuracy.
Nick Gillespie: This is The Reason Interview With Nick Gillespie. Thanks for listening, watching, however you're consuming this. My guest today is Mark Cuban, the former majority owner of the Mavericks, now a minority owner, if memory serves. And that's partly because you're going all in on Cost Plus Drugs, a company and a business model about prescription drugs and, more broadly, wellness and health care. We're going to talk about that in a little bit, but right now, you have recently in a very tight Texas Senate race, you've endorsed James Talarico, or you're speaking with him, partly because he has talked about coming up with a health care plan that you think will reduce health care costs. Can you talk a little about the Talarico plan and why that was so important for you in terms of signing on to appear with him?
Mark Cuban: I mean, really, what we agreed on is that we need to pass Elizabeth Warren's and Josh Hawley's Break Up Big Medicine Bill. And that was the fundamental reason why I supported him. I mean, there are other reasons as well, but I think that as long as we have these huge conglomerates that dominate the economics and provision of health care, the system's not ever gonna work, and we're gonna get what we have right now.
So, identify what is the main problem with health care right now? Is it just that everything costs too much, and that's because of the big conglomerates? Or is it that the quality of care is no good, the rate of innovation is dying?
What's the main problem with health care?
It's the economic side. I mean, the U.S. has the best health care in the world. It's not even close. The problem is, it's not accessible to everybody, but it's not affordable to most. And that is underpinned by how the biggest conglomerates in the country, that do hundreds of billions of dollars each in revenue each year, dominate the economics of health care.
So how is the Break Up Big Medicine Act or bill how is that gonna actually reduce costs? Because I know in the past you've talked about being a small-l libertarian. You're obviously very much in favor of capitalism. You don't hate billionaires. You don't like wealth taxes. You like free markets. How is the Break Up Big Medicine Act gonna work? Because one of the reasons we're where we are now is because of all of the past government intrusions into the market or structuring of the market. I mean—
No, that's wrong…OK, let's just…
I mean, the government already spends about 50 cents of every dollar in the healthcare ecosystem. So it's not like this is a market, right?
Well, it's not a market. You're correct though. Right? But in order to have an efficient market, you have to have price discovery. In order to have price discovery, you can't have gag clauses in every single contract that every single health care—you can't have gag clauses in every single health care benefits contract that's signed. Period. End of story.
And who commands those gag clauses? The big companies that need to be broken up. And it's not an issue of what the government is doing. It's specifically an issue of the choices that are being made by the CEOs and C-suites of those companies.
You look at the largest vertically integrated health care companies: 3,000-plus subsidiaries, $150 billion in intercompany transfers. That's more than the GDP of 13 states. And so they literally dominate the economics. And that's just one company.
If you go to the top three, the point of this is, the leverage is not with the federal government in this particular case. The definitions, the relationships, the pricing, the rules are being set by these big conglomerates. And if you were to break them up, it would change.
Ok, so we can work through a more specific example. What's the worst conglomerate, then, or the biggest healthcare—vertically integrated provider? And how are they bilking everybody—customers, doctors, hospitals, unless they own the hospital system? Who's the worst, and how is that working?
UnitedHealthcare. They're the ones that have thousands of subsidiaries, $150 billion, $160 billion in intercompany transfers. They either contract or employ more than 10 percent of the doctors in this country.
Out of those 3,000 subsidiaries, they own pharmacy benefit managers, they own health care providers, they own what they call ASOs, third-party administrators that administrate care. They own Medicare, Medicaid, MCOs that manage Medicaid for states. There's just—I can't even begin to start to list all the different things that they control.
So one of the ideas behind a vertically integrated company is that they— if you are sourcing your own cost inputs, you can do things more efficiently, and you pass that on to the customers. So McDonald's grows its own potatoes because—
Sure, I know I get it. I know the potential benefit. Yeah.
Oh, no, no. I know that. So explain—
It's also a choice. So, here's the choice. You can pass it on and say, "Look, we're going to be more efficient and pass on the benefit of our efficiency." And the easy way to understand whether that's occurring—there are two easy ways.
One, to ask anybody who uses their services or any of their peers, and just ask them: Have you felt like you've been the beneficiary of their scale?
Based on the polls going around for these midterms, right, the number one issue is affordability, and the number one underpinning of that affordability is the cost of health care.
Number two, being a healthcare geek, I will read the transcripts of their quarterly earnings conference calls. The one thing I have yet to ever hear them say over the past four or five years is that, "Based on this investment, based on this new technology, based on this acquisition, we are going to be able to reduce the cost of care or services to patients that receive that care." Not one.
So patients just don't show up in the way you're talking about it? It's like…
Not at all.
We've streamlined like our costs—
Right. Well, not even necessarily streamline our costs, but what does show up is: "We are going to be able to increase our earnings along with our previous trend. We are going to be able to increase our margins and our revenue for specialty medications," right? There's just a long list of things that they are pushing.
And the bottom line of this—and every capitalist, every CEO has to decide who they're responsible to. Typically, in a public company, which all of these are, they're responsible to shareholders. And that's not necessarily a bad thing if they're aligned also with their customers, their ultimate customers. It may not be the direct customer, but the ultimate customer, which is a patient.
They are not aligned. Not only are they not aligned with the patients, they're not aligned with any other stakeholders.
When you talk to corporations, big or small, a solo entrepreneur, 100 employees, 100,000 employees, and you say, "How are your health care costs doing these days? Are they going down? Are they going up?" And obviously, the response is they're going up.
And you talk to their members, their employees, their families: Are your deductibles and premiums going up or down?
And so the proof is in the pudding that they're aligned with their shareholders, but they are not aligned with their ultimate customers. And that creates a disconnect. And those are the decisions that they've made. In one case, with a tragic outcome, unfortunately.
And so going back to the Break Up Big Medicine Bill and the outcome, when you have somebody who is that big and has that much control and that much regulatory capture, it's AT&T time. It's Standard Oil time, again.
Yeah, I mean, but then it gets complicated. And I don't want to spend too much time on this, but in the sense that when Standard Oil got broken up, they were actually charging the least for their products in their history.
This should be easier then, right? Because now these guys are charging the most.
No, no. Well, I'm saying it gets complicated because you mentioned regulatory capture, and this is part of the problem. Like, if UHC, if UnitedHealthcare is so bad, why do companies keep using them as a benefit?
I'm so glad you asked that. Why do they keep on buying from them, right? Why do they keep on doing business with them? Right?
Right.
So I spend most of my days going to CEOs and explaining to them how they're getting ripped off and how they are getting worse outcomes by dealing with these big conglomerates. Almost all my days. And what I can tell you—
I'm sorry to interrupt, just real quick, because just to get you on the record on this. You're not against bigness per se…
No!
Right? Big conglomerates—because people like Elizabeth Warren often are like, if it's a big company, break it up, right?
Not the issue to me at all.
If I were running that company, I'd be like, "We are so efficient. We are so good at what we do. We use AI and technology better than anybody, so good that we're pushing prices down." And because of that, we'll make more money.
And you know what? Even if we don't make more money, we'll make enough to keep our shareholders happy. But you know what? I'd rather be a great citizen of this amazing country of ours, and if that means better health care at less cost, and our P/E ratio needs to be a little higher to get that stock price where we want it, I'm good with that.
That's how I would—so I have no problem with scale.
The problem I have, like when you talk to people who work for these companies, when they say, "Yeah, I work for whoever," the first thing they say to me is, "I'm sorry. I need the job."
It's not like they're proud. It's not like, "Hey, we're doing such amazing things." And so that's the underpinning of all of this.
So go back to your point on why do companies hire them, right?
I spend so much of my time—literally before this call, I dealt with a group of people who were HR representatives and buyers of these services. And I said, "Do you like these companies that you're dealing with?"
They refer to the big insurance companies as the BUCAs, right? Blue Cross Blue Shield, United, Cigna, etc.
And they're like, "No, we don't like dealing with them."
I'm like, "Why do you?"
"Well, because our CEO just doesn't understand health care costs and health care benefits. And they may know somebody or do business with them."
Like, I've literally talked to humongous banks who have said that we're not going to switch because we'll lose their deposits and banking relationships.
Ok, that happens. So let's put them out.
So now I was talking to this group today, and I started giving examples of places where those big companies were taking advantage of them. And I went directly to contracts because most of the contracts are comparable.
So I call them contractual terrorism.
The city of Dallas, we'll use them as an example. Their pharmacy benefit manager contract: 1,300 pages. There's no human or humans or enough coffee on the planet.
I don't even know if the AIs are capable of scanning that.
Well, the AIs are capable of doing it, right? You kind of got ahead of me there, because before they were able to push things through.
So, like, for pharmacy benefits, there are these things called rebates, where the manufacturers give money back to the pharmacy benefit managers, and they have the choice of how to distribute it from there depending on the contracts, right?
And one of the biggest sources of rebates is something called specialty drugs. They're supposed to be more complicated drugs. Just as often, they're not, but they call them specialty.
But in these contracts, and I literally asked the question of this group who has a good understanding of their contract, I said, "How many of you have a clause in your contract that says specialty rebates, specialty medications either get a flat rebate or no rebate?"
They all raised their hands.
And then I said, "In that contract, doesn't it also say that that PBM owned by that big BUCA—"
That's the pharmacy benefit—
Benefit manager, right, gets to determine what is a specialty drug or not. So in some cases, it could be generic, it could be a little pill, and they call it a specialty drug so that they get to arbitrage the rebate or to retain the rebates instead of sharing them.
So going back to the question of why would a company do this, and it's even worse on the medical side. That's the pharmacy side.
There's no company that, if you work for a company that's self-insured, and God forbid you need to get some major surgery, and so they send you a bill, not even specifically to you, but for the whole company every week or every month, right? And the company just writes the check for the bill, and they may or may not even get examples of the claims so they can reconcile them to what was actually charged or paid to the hospital.
So you have these huge companies that have no way of reconciling whether or not what they were charged is what was paid to the hospital or doctor or provider.
So I was like, why do you do this? Why are you letting yourselves be taken advantage of? And it's because, "Well, it's just happened, it's changed so rapidly, and the prices have gone up so rapidly. We're still in the contract. We're still doing it."
And I'm like, so let me give you the way to resolve this. And this goes back to AI.
So what I've done, and I've done it for my companies, I've helped other companies do the same, I've helped states do the same. Now, with AI where it is, and it's only recently capable of doing this, you can take a 1,300-page contract. You can take a 600-page contract, and I tell them, take the PDF file of all of your health benefits contracts and put them into your favorite large language model and just use this prompt: "Where are they ripping us off?"
And within five minutes, you'll see, boom, boom, boom, boom, boom. Because it's contractual terrorism. They only have to squeeze through a couple of things that the lawyers don't see, and that changes the whole contract, and everything economically references the contract.
So part of, I mean, in any kind of market that's not working well, price signals are arbitrary or buried. There's a lack of transparency. People don't know what they're paying for, what all of the benefits are, how much they cost, and things like that.
There's also, and I know you've talked and written about this, where it's exacerbated by the fact that the company, I mean, a health benefit, it's not what your main company is doing. They're offering it for a variety of reasons. And this goes back to World War II or wage and price controls and things like that.
You know, whatever my company…I don't even know what my—Reason Foundation, the nonprofit that publishes this podcast, I don't know what they pay monthly for my premium. And I barely know what my premium is.
And do you know what your deductible is? Do you know?
Yes, I do indeed. And I had a kid last year, so I'm always hap—
Let me ask you a question, over $1,500 a year?
Yes, for the overall, it's like $6,000.
OK, so $6,000. Have you ever been prescribed, or has anybody in your family been prescribed, a brand medication?
No, I gave up on brand medications a while ago. I always go for the—but what's your point?
No, my point is that brand medications without generics, right?
Right. Yeah, yeah.
So let's just take a drug like Xarelto. The list price of Xarelto, sold by J&J, is $600. The way the system is structured by these big BUCAs and their pharmacy benefit managers is such that during your deductible phase, you and pretty much everybody else, unless your company negotiated something different, have to pay the full retail list price for that medication.
That's insane. Now the question becomes, why does that happen?
And I'm going to explain to you, and this is way inside baseball, how pricing for brand medications is done in the United States of America.
We'll, excuse me, we'll take a drug like Xarelto because it's easy to understand and use. $600 list price. When J&J sells that to one of the three big wholesalers—there's three of them that control 95 percent of the pharmaceutical transactions—when they sell to that wholesaler, you know what they sell it to them for? List price, $600.
Sounds crazy. If they came on Shark Tank, Kevin would probably say, "Take them out behind the barn and shoot them," because it makes no sense that multihundred-billion-dollar companies don't negotiate a discount.
But they're lucky in that the brands will give them 5 percent back if they prompt pay and give them some data.
So now let's just say 5 percent from a $600 drug means the net cost to the wholesaler is $570. That sets the floor for what they can charge pharmacies because they're not going to sell it for less than they pay.
Now what happens next, then, is now a pharmacy has paid $570 for that drug. When you walk in, or any of your family members walk in, or anybody who works for the foundation walks in who has a comparable deductible, the pharmacy can't sell it to you for less than $570 because that's the charge.
Now that's ridiculous in and of itself because you know how much J&J actually nets, give or take, for that medication? It's not $570. It's about $300.
Their yield, their net revenue is about half of the list price. And so where does that delta, the $570 minus $300, where does that go? That goes to the pharmacy benefit manager.
Now, if this was a real market where they didn't have control because of their control of formularies and lives covered, then J&J and all the other brands in the same situation would then sell to the wholesaler at $310. Remember, their net yield was $300, so they'd make $10 more.
And remember, the wholesaler was selling to the pharmacy for no markup. They make their money on generics, right? So they could sell it for $320 to the pharmacy, and they'd make more. And then the pharmacy could sell it for $325 to you and your family or any underinsured or uninsured patient, and they'd make more.
So everybody would make more, but more importantly, more people would be able to afford their medications, and more people would be able to adhere.
So the question becomes, why does it not happen that way? Because in a capitalist society, people are going to act in their own self-interest. That's the beauty of capitalism.
People are always going to find shortcuts and disrupt so that I can get you something…
Right, wherever they can. So I'm going to tell you why it doesn't happen, right? Because those big PBMs owned by the big BUCAs, they control these things called formularies, and they control the formularies for 85 percent of people who receive pharmacy benefits.
And the formularies are the drugs that are covered by a particular plan?
Correct, correct.
And if your medication is not on that formulary or it's on a low tier, because you know in your tiers for your own health care, right, you might pay zero, $10, $50, coinsurance, whatever it may be.
Well, so these PBMs are saying to the brand manufacturer, they've told me this, that if they don't play the game this way, sell at list price and only give a 5 percent, don't do it at net, if they don't play the game that way, they will diminish their positioning on that formulary, not just for that drug, but for their entire portfolio.
It's the same reason Cost Plus Drugs doesn't have a lot of brands, because they've said the same thing: If you work with Cost Plus, then we will diminish your position on the formulary.
So two quick questions that I think will clarify what you're talking about. One is, where did the pharmacy benefit managers come from? They weren't always part of vertically integrated institutions, well let's start with that. PBMs have been around at least since the '60s, and the whole idea, and it makes sense, is like, we're going to arbitrage a lot of possibilities, and we'll sell more drugs for the people who are making them, and we'll sell them cheaper to the people who are buying them.
But really just processing claims. Right? Somebody, there's a prescription, and you have insurance—
Yeah, how do we go from there to, I mean, PBMs in a lot of ways, those are your white whale, right? That's what Cost Plus Drugs is going after. That's where you tend to—
The whole thing. They're not a unique company. They're part of these vertically integrated companies, right? So culturally, they are the same, right? Optum Rx has the same organizational culture as United, CVS, etc.
So how did they get there? Vertical integration.
And once an insurance company who already had X number of plans that they control now buys a PBM, what they say to the employer and Medicare Advantage plans, they'll say, well, let's just start with employers, right?
Self-insured employers. Sixty-seven percent of people who get insurance through their company get it through a self-insured employer. That's about 150 million, 160 million people, right? And so those all go through a PBM at some level.
And by being able to control that, plus Medicare Advantage plans, plus Part D plans for Medicare, they have such market dominance. It's like they have more customers than Amazon does.
And just imagine Amazon saying, "If you don't do business the A, B, or C way that I demand, we're not going to allow you to sell on Amazon. Or we're going to make it so that somebody has to make 15 searches to find you."
That's the equivalent of what these vertically integrated companies are using their PBMs to do.
Yeah, how does the Break Up Big Medicine Act specifically address this issue of vertical integration?
Well, it's breaking them up by definition, right?
I mean…
So then what's the benefit. Right, how do we get the lower prices and all that, right?
And so without having the market dominance to define and threaten, to say, "Look, we're not going to work with you unless you do it our way. And if you don't do it our way, you're going to lose access to 180 million customers," it ends that.
Yeah. And it says things like, if you are a medical provider, you cannot own this type of company. So, I mean—
So then we can talk about medical loss ratio and all that.
It tries to end vertical integration or limit vertical integration.
Limit vertical integration, right. Because once you get market—and there's another part that we haven't talked about that goes hand in hand with doing capitalism the right way.
So in order to have an efficient market, and you mentioned this, you have to have price discovery. In order to have price discovery, you have to have price transparency and some level of contractual transparency. Because if the prices are in the contract, then you have to have some transparency there.
You know the old Fight Club thing? The number one rule of Fight Club is you can't talk about Fight Club. The number one rule of pharmacy benefit manager and ASO and other contracts from these vertically integrated companies, their number one rule is you can't talk about them. They have complete gag clauses.
So they literally say that—well, I'll give you a better example.
TRICARE, that offers all the pharmacy benefits for all the people serving in the military, retirees as well, right? They have their plans and everything. And for certain of their plans, particularly if you're a retiree who lives off base, you don't live on a military base, then you have to order certain generics from Express Scripts slash TRICARE, and the copay is like $16.
Well, it's cheaper in many of those cases to buy from Cost Plus Drugs. Just proving the point that it's not necessarily getting the best price dealing with a bigger company.
But that's not the bad part. That's not the bad.
We still have no idea, none, zero, how much taxpayers pay for those same drugs because they prevent everybody from seeing it.
Elizabeth Warren said she was willing to go and sit in a SCIF in order to be able to look at those prices, and they refused to allow it.
And a SCIF is a secret room where you can read super top-secret documents.
Yes, right. And they still wouldn't show them to her.
And so here we are taking taxpayer money. And if they're doing such a great job, you would think they'd be proud of their pricing.
"Mark Cuban, you can't touch our pricing with Cost Plus. We want everybody to see that. We'll put you out of business"
Yeah. So, I mean, part of the idea is, like, if you introduce transparency into more markets and people understand what other people are paying, you get a more informed market, and innovation is going to happen, prices will probably come down.
What you're talking about, like if you're going to the city of Dallas and you're saying, "Hey, here's a way for you to push back on your benefits provider and maybe to shop for better things." Part of it is information, part of it is regulation, and something—when I think of two people I hate for different reasons, but with almost equal ferocity, it's Josh Hawley and Elizabeth Warren. Most of the time when they're talking, I'm like, "Hey, all I know is my freedom is going to end up on the cutting room floor," right?
But there's regulation, and then there is the ability of individuals to make choices, meaningful choices.
I guess you talk a lot about AI in very positive terms, and you've laid out one way in which AI might help by just making people capable of understanding documents, contracts that they're about to sign.
In this particular case, absolutely.
Yeah, what are the other ways that you think AI is going to transform and improve the quality and quantity of medicine and health care?
One is drug discovery.
We'll get to the point, I don't know when, where we'll be able to take genetic information about ourselves, if we choose to, and make that available to far more advanced artificial intelligence than we see today, and say, "Analyze this. Tell me what I should be concerned about." Or, "Here's everybody in my family. Let's compare it and look for deltas and see how we can use AI to improve our health or wellness."
Make, like, personalized medicine.
Yeah, I'll give you a perfect example, right?
I have to take Synthroid for a thyroid scenario. And I was taking iron supplements because I work out and I sweat a lot, and my iron levels were low. I had no idea you couldn't take them at the same time. None. My doctor didn't know because you can't remember everything. And so I put it into Claude, and boom, I found out you've got to take them at least four or five hours apart.
Simple, simple, simple example.
We're all using Dr. ChatGPT and Dr. Claude to a certain extent. Doesn't make them perfect, doesn't make them accurate in all cases, but it gives us access to this information we otherwise didn't have.
But to go back to your question, as AI gets more advanced, not only will we be able to use it for personalized medicine, but it's capable of memorizing everything.
Now, AIs don't know the consequences of their actions. AIs don't have ethics, right? AIs are not smart. They're just able to combine things in ways that they've seen before or ways that you tell them to do. But within that constraint, doctors will be able to use them to more efficiently and effectively make determinations about somebody's health. So I see it as a big positive as long as we all understand that there are certain things that they can't do.
I'll give you one more example.
The minute an AI is released, we're done training and it's made available to the world, it's out of date.
This brilliant conversation you and I are having right now, no AI knows about. And even if it's published, unless you publish a transcript along with it, it has no way to consume the video itself.
So there's always built-in latency. And so because of that, it's always going to be behind.
And you talk about a capitalistic system and how people adapt. Well, researchers and doctors who publish are recognizing that, "Hey, maybe it's smarter that I don't publish, I don't try to patent this particular device or approach to solving a health care problem. Instead, I'll just keep it to myself and either sell it to a company that can benefit from it or put it in my own model."
And so that means you're going to have disparate information in different models.
AI is probabilistic. It's not deterministic. You're not going to ever get a scenario where you put something in four different models and you get the exact same answer.
So within health care, we have to understand those constraints. And by understanding those constraints, we can use the tools to our benefit. And I think that improves health care in a thousand different ways.
Let's talk a little bit about the regulatory framework. Donald Trump and Robert Kennedy, secretary of Health and Human Services, talked, particularly for round two, or the second term for Trump, talked a really big game about changing the regulatory apparatus at places like the FDA.
It costs anywhere from a billion to several billion dollars, might take more than 10 years, to bring a drug to market. By the time it comes to market, part of its patent life is already over, et cetera, and things like that.
Are there regulations, are there policy changes that the Trump administration has made that you're bullish on, that you think were in a right direction?
I think with things like biosimilars, which are effectively injectable generics, they removed one of the steps, which I thought was smart. Because having that, I forget the exact terminology, my partner knows this stuff better than I do, but having that third-tier trial to confirm what you already know is going to happen, and there haven't been any exceptions to prove that you need it, I thought that was really smart.
But I don't get involved in the FDA side in depth as much as I do on the commercial side.
Right. Well, let's talk about Cost Plus Drugs and explain the mechanics. Before this, I went to—and of course, because he has to put his name on everything, Trump started a prescription program online, TrumpRx. It's a government program where you can get coupons, basically, for things.
One of the drugs that I take is an off-patent statin, and it used to be known as Crestor, right, when it was on patent. And I looked up on the TrumpRx plan, it would cost me $8.60. And then I went to Cost Plus, and it said it would be $5.66. This is for a 30-day supply, 10 milligrams. And then I'm on Cigna, and it costs me zero when I fill that prescription.
But it doesn't cost you zero, right? You're paying it.
Yeah, absolutely right. And unfortunately, it costs my colleagues something. They chip in a little bit as well. But how does Cost Plus— how does it work? If you go there and you already have insurance, how do you use it in a way that you know what you're going to pay for a drug, and it's probably going to be cheaper?
So two different paths, right?
So if you have insurance, then if you work with one of the big PBMs, the big three PBMs, you're not going to be able to use your insurance with Cost Plus Drugs.
There are about 35, give or take, pass-through PBMs that we partner with. So if you have insurance cards from them, you just go in there and click on insurance, and you put in the card ID, and you get the benefit. It's probably going to be a zero copay, but we'll ship it to you, right? Because that's the benefit of sorts.
If you happen to be somebody who is on a Medicare Advantage plan and are prescribed a drug that's not covered, it's not on your formulary, or there's a high copay or high coinsurance, that's a perfect customer for us because you can come to us. We're far less expensive, including shipping and handling and everything, and you use us to save money.
And if you're in one of eight states, Tennessee, Texas, and a few others, then you can also count that against your deductible.
If you're completely uninsured, then we're a godsend for you, particularly if it's an expensive medication, and particularly now with biosimilars. So now there's a biosimilar for Humira. There's a biosimilar for Stelara. Last year, Stelara would have cost you or your employer or somebody $127,000. Now our cost is $365 plus shipping.
Yeah. What limits the types of drugs that you offer? Because I noticed, I think when I looked today, there were no GLP-1s, right? You don't do things like Adderall or the generic versions of Adderall. Explain why those are—
On controlled substances, we just don't want to fight the battle, right? Because there are just too many risks, and we wanted to make sure that we weren't in a position of contributing in ways we didn't want to contribute.
In terms of GLP-1s and brand medications and specialty medications, as I referred to earlier, the big PBMs have gone to the brand manufacturers, specialty manufacturers, and told them, "If you deal with Cost Plus Drugs, we will diminish your positioning on our formulary."
Now the question becomes, why? Why do these huge conglomerates care about us?
Well, there's a study that's getting ready to come out that says every area of health care costs has gone up over the past 30 years, except starting in 2022, the cost of generics started to level off and then started going down.
That's when we launched, January of 2022.
And the reason that happened, and the reason these big PBMs and conglomerates are afraid of us, is because when you go to Cost Plus, you put in your statin, right? And we showed you our actual cost, and then we showed you our markup was only 15 percent.
And so if we were to do the same thing with brand drugs, all of a sudden, all that premium, remember we talked about the pricing of brand medications, all that premium margin that is going to PBMs to keep or distribute would be gone.
Because everybody would finally know the actual cost, just like they know the actual cost of biosimilars and specialty generics and general generics, like you saw.
Do you think, in a market sense, is the function of Cost Plus, obviously, is to sell drugs or deliver them to people who need them at prices they're willing to pay or want or can afford, but is part of it also that it disciplines the big guys? Because if what you're saying is true, they're going to have to start taking into account that if we keep squeezing this stone—
So then where are the limits of that effectiveness? When I mentioned Standard Oil, at its peak market share, was selling its products for the least amount. It was because they had a monopoly. They had over 90 percent of market share in home heating oil and lighting and things like that. But they acted as if they were constantly about to be…
Go out of business.Yeah, yeah…
Right. So, I mean, where are the other places in the medical industry? In recent essays, and preparing for this, you said, well, it's not the pharmaceutical companies, because they're often—
They're not innocent, but they're not the worst—
Yeah, ok. It's not the doctors. It's not the government. But when I look at it, it's like the American Medical Association and other groups that govern the number of medical licenses that get issued every year or the number of resident beds that are available. They're not doing anything to increase supply.
No, I agree. I'm not saying I agree with that, right? But the AMA is not a government entity either.
Well, it's quasi, right? Because you have to show—but I'm saying, how do you bring that same kind of market force, that kind of comp….This is like real competition to say, "You know what? My competitor, who's got 90 percent market share, is selling something for $10 a unit. I'm going to sell it for $8 a unit, and I'm still doing well, and you're making out better, and they're going to have to change." How do you bring that to bear on the larger healthcare system?
Because what it's missing is not only price, but trust. Nobody trusts the economic side of health care. You don't. I don't care who you are, right? Every poll, everything says…right.
I look at trust as a formula: Trust equals transparency divided by self-interest.
We're completely transparent. We show our costs. We're still the only pharmacy that publishes a price list. We have a programming interface where anybody can pull down our pricing anytime they want.
So we're completely transparent there, and we only mark up 15 percent. So that's fair, right?
And so that's what differentiates us to start, right? So people can work with us, and they trust our pricing. They know what it is.
We charge the same price to everybody, no matter who you are, where you are, what time of day it is. It doesn't matter.
When our volumes go up, like with TrumpRx, it's a portal. As you saw, you can come find your way to us. Our volumes went up. Our costs went down.
At Cost Plus, we pass those cost cuts on to our patients. We were able to lower the price of 190 more drugs. And so we're able to start with these drugs, right? We're also getting involved with manufacturing. We manufacture drugs that are sterile injectables that are on the FDA short supply list.
We also have used AI and used robotics to shrink the size of our initial manufacturing plant from football-field size, so about 5,000 square feet. And over the last five years, we've been able to shrink that into the size of a tractor-trailer.
We call them pods. And these pods are going to be our biggest business. They're our most disruptive business because we've been able to combine AI and technology so that we can take these little things, tractor-trailer size, and ship them anywhere.
Ecological disaster, weather disaster, God forbid, war disaster, we can put them there and, depending on what kind of pod it is, make any kind of drugs.
And because we can daisy-chain these things together, we're able to manufacture in volume so that we can manufacture generic tablets cheaper than we can buy them from India.
So then let me, and this might seem like a leap, but in what you just described, and particularly the trust divided by self-interest, all of what you're talking about, all this innovation, why do people—or let me say this: If there's anything that's less popular than data centers and AI, it's billionaires like yourself.
What you just gave is a riff that is, if you believe in free minds and free markets, that's been Reason's catchphrase for decades, this is beautiful. And you're describing exactly how the system should work.
But we have, in contemporary America, people, including people like Elizabeth Warren, the governor of California, who want billionaire taxes. There are members of Congress who have staff members who say every billionaire is a policy failure.
Where is the anger? And when I say people like you, there aren't that many billionaires, but in terms of economic innovation and people doing well, it seems like it's worse now.
If you can't pay your rent, if you can't pay for your medications, if you can't pay for daycare, if you can't pay for food, you're just mad.
And when you're mad, you're not looking to say, "Ok, let me find a logical construct to define why I should be mad or why I'm in these circumstances." You're just mad.
And when you're mad like that, and I've been broke, right? Six guys living in a three-bedroom apartment, et cetera, no money in the bank. You're just mad at whoever is a convenient target.
And so I don't begrudge them. Hopefully, they'll eat me last.
I understand why politicians say billionaires are a policy failure because we're an easy target. I don't blame them for doing it that way. But as an entrepreneur, I'm still going to do what entrepreneurs do. It's why I did Shark Tank for 15 years, because I wanted people to be excited about being an entrepreneur. I wanted them to see, when they watched the show and somebody walked in on that carpet from Idaho or Iowa or wherever with nothing, they had a chance for their American dream to come true.
And if they can do it, I wanted them to think, "I can do it."
And so do you feel like that dream is still alive? Or is it, because when people talk about, ok, it's hard to make rent, it's hard to do this, it's hard to do that. All of this struggle is always real. But is it just that that's the struggle? I mean, are things worse now than they used to be?
No, they're not necessarily worse, right? But we communicate differently now than we did before. Each of us is on social media at some level, whether we know it or like it or not. And each of us gets our own unique feed on social media.
There's no more Walter Cronkite. There's no more Dan Rather, where we all have communal shows that we all watched and basically understood and agreed on some level.
And there's a reason why, right? I mean, those disappeared partly because they weren't really giving people what they wanted, right?
Regardless of what it was, technology is technology. It's going to find its place, right?
I mean, I started the very first streaming company because people didn't have access to, in my case, Indiana basketball or music or whatever it may be, shows.
So people want more, but what's changed dramatically is how algorithms distribute content to each of us individually.
We all get our own individual feed on each of our social media platforms. Mine's not like yours, and they're like snowflakes. No two are alike.
And because of that, engagement increases with anger. And so every one of those algorithms has an incentive to make us mad.
Because the madder we get, the more we consume. The more we consume, the more ads that are sold. The more ads that are sold, the more subscriptions that are bought, et cetera, et cetera.
And because of that, if I'm mad about not being able to afford my rent, I'm mad about the cockroaches in the kitchen, I'm mad about the cost of beef, whatever it may be, you better damn well believe I'm getting a lot of that in my social media feed.
And if someone comes along and in that feed says it's this billionaire's or that billionaire's fault, what do you think I'm going to believe if that's 30 percent of the content I consume in any given day?
That's what's changed dramatically. And I say this all the time: Whoever controls the algorithm controls a lot of people.
Yeah. You have, in the 2024 election, I believe you're a political independent, but you came out and talked about how you wanted Kamala Harris to win. You were backing her. You're backing Talarico against Ken Paxton, the Republican Senate candidate. There's, of course, Ted Brown, the Libertarian candidate, who looks like he's going to cover the spread in Texas.
But I guess in terms of politics, at the state level, there's a real experiment going on. I'm talking to you from New York. New York City, New York state, and California are pursuing one model of governance, it seems, which is high tax, high regulation, high social services, or this is what they claim.
And then you have places like Texas and Florida that are saying we're going to do less tax, less regulation, we're going to give less services.
How do you feel about being in Texas? You've been there for decades now. It's your home place. Is Texas a better model compared to, say, California and New York state? Or how do you gauge that?
It's the ultimate capitalist decision, right? I mean.
Where you live.
Yeah, where do you live. And politicians, they sell what people will buy, what voters will buy.
And in terms of how I feel about Texas, when I got here, it was pretty much blue, and then it was purple, and then it was red, and it'll change again, just like multiple states, right?
What a conservative is today is far different than it was 11 years ago, you know? And the parties are completely different. If it were up to me, I'd get rid of all political parties. I think they've outlived their usefulness. They're just a way to raise money and to try to aggregate power as opposed to the power of ideas.
I don't give to politicians. I don't give a penny to politicians. Either you agree with what I have to say and you think it's of value to you, or you don't. And I have no intent of changing that.
Either my ideas stand up on their own, or they don't.
And in terms of my own philosophy here in Dallas, I'm an entrepreneur. And Dallas has been, Texas has been, great for me as an entrepreneur, been great for my family. I owe a lot to the city and the state, but it's changed radically, to use that term, over the years that I've been here.
Do you feel like it's getting better, getting worse, or it's just—
No, it's going to change no matter what.
The only constant is change.
My dad used to say, "You don't live in the world you were born into," you know? And it's the same thing here, where especially now with AI, I mean, there's always, like my kids, one was born before the iPhone, two weren't. Shit's going to change.
And so I don't look at it and say, "Well, pick this point in time, is it good? Is it bad?"
I look at it and say, "What can I do to make the world better?"
Look, I'm one lucky guy, right? My life is so much different than I ever possibly imagined.
And as an empathetic capitalist, right, as a compassionate capitalist, I want to give something back. My next dollar won't change my life, but it can change somebody else's life.
And when I talk to people about capitalism, that's the message I want to convey.
Now, if I was 25 again or 35 again and in healthcare, I'm sure I'd be trying to build as huge a company as I possibly could and sell it for as much money as I could because the one thing that I would want, the one thing I valued most, is time.
And the best way to gain control of your time is through your personal economics.
And so everybody's going to have their different perspective on where they live, how it's doing for them, what comes next. All I can do is try to help where I can help.
You mentioned being 25 again. Does the popularity or the kind of embrace of the idea of socialism, or the term socialism, concern you, particularly among Gen Z?
No.
Explain that, because a lot of people are like, when you hear capitalism is at a kind of historic low in terms of positive feelings, socialism in America is at a historic high, why doesn't that concern you?
So I'll go back to the algorithms and social media again, right?
When I talk to—I have three kids who are now 17, 20, and 23. And I talk to them and their friends, and a couple of them are entrepreneurial.
And their friends will come on and give me all these ideas that they think are great businesses. And I've heard them all, right? You know, shoe drops, dropships. And I'm like, these are old, tired.
Where did you get these? Social media.
How do you understand how to run this business? Social media.
Where did you watch anything? YouTube, right? Or I saw it on Instagram.
So if you take that same concept toward business, the same thing is going to work when it comes to understanding political systems and politics in general.
Kids are getting short sound bites. And if somebody who's popular and goes viral says, "Hey, I just started this business. We're going to be selling widgets at 100 percent markup. That's socialism. I hate capitalism, but I do socialism business the right way," that's the way they're going to convey how they understand something.
We don't live in a world—if I have a problem with Gen Z, it's that they don't read books.
And it's not that they can't learn because AI can be a great democratizer of information. You can ask AI to teach you anything, and like a teacher, it's not always going to be right, but you have that opportunity to learn.
It's just we don't read and consume information the way we used to. And I think that makes it harder for kids to discern between fact and fiction, information and misinformation.
And I think that's the problem again when I—
That also changes with age, right? I mean, like—
Yeah, of course.
You start to figure things out.
Yeah, hopefully, right?
But we don't know, really, because Friendster was 2006 or whatever it was, and then Instagram became popular in 2011 with Snapchat, right?
So that's only 15 years of history, really. YouTube's been around longer, but the algorithms themselves really only started to hit in 2012.
And so we only have about 13, 14 years of history. So we don't know how kids are going to evolve through this period in their lives as they become older. We have no idea.
And so when I see Australia say, "Ok, 16 and under, ehh, no social media." Some people might say, "Well, that's wrong. We don't want government involved. Let the chips fall where they may."
I'm like, no. I really believe that people don't understand how algorithms work, and they don't understand how detrimental they are not only to a kid's mental health, but their ability to learn and how they perceive the world.
I think that's a real problem. Like when you see—
Would you back a law in America, in the U.S.? Say you would be in favor of a—
16 and under. 16 and under.
I wouldn't say ban them from social media, but I would say ban them from algorithmic access.
Now there's a problem because Section 230, on Instagram an algorithm is just as protected as any other website, right? So it's a challenge.
But if I could overturn that, or at least modify it, in a heartbeat.
Ok, so then final question. You mentioned reading books, being younger. You mention Ayn Rand a fair amount, or—
Howard Roark, baby. Howard Roark's my guy.
All right, yes. So then I'm wondering how Ayn Rand would think about the idea of the government saying, "Ok, here's an arbitrary age level that you can access information or not." But beyond that, talk a little bit about how you came to know Ayn Rand's work and why it was so important to you.
Oh, my mom. My mom was a housewife who had every odd job you can imagine, went through every pop psychology you can imagine.
And what did they call the people who followed Ayn Rand? I forget the name they gave.
Objectivists.
The Objectivists, right? So we used to get the Objectivism newsletter. There was a guy named Nathaniel Branden who was big in Objectivism, and he would have records, and my mom would play the records.
And so I would have all that just around me all the time. And she was a Democrat, a hard-core Democrat, by the way.
But at the same time, I remember reading The Fountainhead and just connecting to Howard Roark.
And then I remember reading The Virtue of Selfishness and thinking to myself, you know what? To me, being selfish means helping people because that's what makes me feel best. And that's what being selfish is all about, doing what makes you feel best.
And I didn't take it as, "Ok, laissez faire ideology is strategy in life." I took it as being an individual and finding your way and work your ass off. There's going to be issues, but respect other people who may not have the same opportunities that you do.
And it's not like I grew up with a silver spoon. My dad did upholstery on cars, never made more than $40,000, etc.
But I always looked at it as I can find the motivation in Howard Roark. I can't tell you how many times I read that book. I had to stop reading the book because I would get so fired up that people didn't like it.
You're going to blow up a building somewhere.
No, not like that, right? But for business, right? Because I get so intense when it comes to learning things for a new business, like with health care, whatever it may be, that people have to slow me down.
And so I literally had to stop reading The Fountainhead over and over again.
Wow, that's a great story. We're going to leave it there. Mark Cuban, thank you so much for talking to Reason. And I know I, for one, will keep looking at Cost Plus Drugs.
Please do. costplusdrugs.com.
Yeah, when it's cheaper, I'm going to be there.
Thanks for having me on. I really enjoyed it.
Thank you so much, Mark.
The post Mark Cuban: 'I'd Get Rid of All Political Parties' appeared first on Reason Magazine.
© Illustration: Fatima Ruiz
If a treatment can improve your health, does that give the government the right to force it onto you? Should the state compel people with diabetes to take insulin, patients with hypertension to take their medications, or people with obesity to lose weight?
Most Americans would recoil at such proposals. Yet when it comes to people diagnosed with psychiatric disorders, many people seem willing to make an exception.
A physician who administers treatment to a competent adult against the patient's will violates one of medicine's most fundamental ethical principles: informed consent. Why should that principle carry less weight when the doctor is a psychiatrist? Yet in a recent City Journal article, Stephen Eide and Valerie Franchitti of the Manhattan Institute argue that public support for involuntary psychiatric treatment reflects a welcome recognition of its potential benefits.
Strangely, the article entirely avoids the concept of informed consent. Where it acknowledges any limitations to involuntary treatment at all, it considers only the possibility that coercive treatment may increase stigma against mental illness.
But the more fundamental objection is liberty. A psychiatric diagnosis does not extinguish your right to control your body. Competent adults have the right to decide what substances they consume, which medical treatments they accept, and what risks they take, even when others consider their choices unwise or self-destructive. As the psychiatrist Thomas Szasz wrote in 1997, "I oppose involuntary psychiatric interventions not because I believe that they are necessarily 'bad' for patients but because I oppose using the coercive apparatus of the state to impose psychiatric relations on persons against their will."
Eide and Franchitti write, "The public is right to suspect that involuntary treatment can be effective." They cite data from the New York State Office of Mental Health showing substantial reductions in hospitalization, incarceration, homelessness, substance abuse, and suicide attempts following enrollment under Kendra's Law, which mandates outpatient psychiatric treatment. Yet these data do not establish that coercion caused those improvements. Participants also received increased access to psychiatric services, case management, and other support. Without adequately separating the effects of those services from the effects of coercion itself, the reported improvements cannot establish that compulsory treatment was responsible.
The authors also justify involuntary psychiatric treatment by citing subway attacks, mass shootings, and other violent incidents. But there is a fundamental difference between holding people accountable for violating others' rights and confining them because they might become dangerous. Communities can enforce laws against assault, trespassing, and public nuisance without criminalizing homelessness or mental illness.
Moreover, involuntary commitment to a psychiatric hospital or rehabilitation facility—sometimes for prolonged periods—deprives people of their liberty without a criminal conviction. Although civil commitment involves judicial procedures and opportunities for review, continued confinement may depend heavily on mental health professionals' assessments of whether patients meet release criteria. As Szasz warned, coercive psychiatrists can thus function as "judges and jailers not physicians and healers."
Severe mental illness can impair decision-making, sometimes profoundly, but diagnosis and incapacity are not the same. Even among psychiatric inpatients housed for severe mental illness, a meta-review of the research at BMC Psychiatry shows, most retain the capacity to make treatment decisions. Outside of hospitalized patients, decision-making capacity is even higher.
The legal scholar Elyn Saks, who has lived with schizophrenia, brings both personal experience and academic expertise to the debate over involuntary psychiatric treatment. Having experienced involuntary hospitalization, physical restraints, and forced medication, Saks has questioned the assumption that mental illness justifies overriding patients' wishes. In her book Refusing Care she examines the ethical and legal problems posed by involuntary hospitalization, forced medication, and physical restraints. Saks and the psychiatrist Dilip Jeste have also reviewed empirical research on decision-making capacity among people with psychiatric and substance use disorders, analyzing how capacity varies among individuals and how clinicians can assess and enhance patients' ability to make informed decisions.
Though the medical field has developed structured interviews with standardized scores for mental incapacity, doctors can disagree on assessment. Mental capacity is also decision-specific and time-specific, not a permanent status attached to a diagnosis. That same BMC Psychiatry review of the literature describes the impairments seen in psychosis as "temporal, identifiable, and responsive to interventions," such as presenting information in simpler terms.
Even when incapacity can be established, we must adhere to the principle of least restrictive intervention. Any intervention must be justified by the circumstances, limited to what is necessary, and designed to preserve as much individual freedom as possible. Compulsory treatment takes different forms, each imposing distinct restrictions on individual liberty. Assisted outpatient treatment allows people to remain in the community but subjects them to a court order governing treatment. Involuntary inpatient commitment deprives people of their physical liberty through hospitalization, while forced medication goes further by overriding bodily autonomy. So impaired decision-making capacity does not automatically justify confinement, let alone forced medication.
Medication can reduce psychotic symptoms, and some psychiatric patients who initially refuse treatment later believe it helped them. But evidence that medication works is not the same as evidence that compulsion produces better outcomes than voluntary treatment, particularly when a person's decision-making capacity may improve as an acute episode subsides.
In 2024, a scoping review in the journal Psychiatry, Psychology and Law found mixed evidence of benefits and harms from involuntary inpatient treatment. Patients admitted involuntarily often experienced improvements in symptoms and functioning, but they also tended to enter treatment with more severe illness, making it difficult to determine how much of the improvement resulted from compulsory intervention itself. Involuntary admission was also associated with higher financial costs and worse patient experiences, including feelings of coercion, loss of freedom, and lower satisfaction. In 2018, The Canadian Journal of Psychiatry published a systematic review of coercive measures; it found that patient experiences were predominantly negative and frequently involved adverse consequences. Overall, no consistent evidence shows that involuntary treatment itself causally improves outcomes, although it unquestionably restricts patients' freedom and imposes costs on taxpayers.
These concerns are compounded by a health care system that financially incentivizes psychiatric overdiagnosis and overmedication, regardless of whether additional interventions yield commensurate benefits for patients.
The difficult case arises when a person genuinely cannot reason about treatment options or communicate an informed choice, and when delaying intervention creates an immediate risk of harm. In such cases, the ethical principle should be the same as elsewhere in medicine: Temporary treatment may be justified when informed consent cannot be obtained, using an advance directive or surrogate when available, and only to the minimal extent necessary to manage the emergency and restore the patient's ability to decide. A credible, imminent threat to another person presents a separate public-safety justification for state intervention. But even support for those types of emergency interventions is not the same as support for broad, long-term involuntary psychiatric treatment based on supposed mental incapacity.
City Journal frequently advocates free markets, individual liberty, and limits on government intervention. Yet these writers appear willing to grant the state considerable authority over people's medical decisions without adequately distinguishing those who lack decision-making capacity from those who retain it. If we distrust government officials to make economic decisions for us, why should we trust them to make decisions about our bodies and medical care?
The post Mental Illness Doesn't Cancel Your Right to Say No appeared first on Reason Magazine.
On August 27, registered nurses, patients, and community allies rallied and stopped traffic in cities around the US to demand that hospitals and elected officials cut all ties with artificial intelligence giant Palantir. In this episode of Working People, we speak with a panel of registered nurses—Kelli Brennan (Portland, Maine), Lee Barker (Kansas City, Missouri), and Kiera Arbour (Chicago, Illinois)—about National Nurses United’s “Purge Palantir!” campaign, and about the disturbing creep of Big Tech and Big Brother into a US healthcare system that is already in crisis.
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The following is a rushed transcript and may contain errors. It will be updated.
Maximillian Alvarez:
Alright. Welcome everyone to Working People, a podcast about the lives, jobs, dreams, and struggles of the working class today. My name is Maximillian Alvarez, and today we are speaking with union nurses who are speaking out against big tech and big brother, sneaking more of their tentacles into our healthcare system and into our lives. They and their union, National Nurses United, participated in a National Day of Action on August 27th, which brought together hundreds of registered nurses, patients, and community allies in cities around the country to demand that hospitals and elected officials cut all ties with artificial intelligence giant Palantir. As a press release from NNU lays out, “The nurses who are members of National Nurses United, the nation’s largest union of registered nurses, stop traffic in an act of civil disobedience in eight cities, Palo Alto, California, Los Angeles, California, Chicago, Illinois, Washington DC, Portland, Maine, Asheville, North Carolina, Austin, Texas, and New Orleans, Louisiana.
Union nurses cannot be silent when our most vulnerable people, babies and children are being detained by federal immigration agents,” said NNU President Jamie Brown. “While our patients and neighbors are living in fear of immigration raids enabled by Palantir, our hospitals are facing huge cuts and our patients are facing mounting healthcare costs because of H.R.1. Nurses aren’t just saying no to Palantir, but we’re calling for our public resources to go toward the benefit of working people, not billionaires and their corporations. “The press release continues. From 2009 to 2025, Palantir received $2.5 billion in federal government funding, but this number has grown tremendously in just the past year. Last July, the Department of Defense announced a $10 billion agreement with Palantir to use its technology to share data across federal agencies, enabling unprecedented surveillance power. This followed a $30 million contract awarded to Palantir by the Department of Homeland Security to build an AI-powered system that would identify immigrants for deportation.
In February of 2026, the Department of Homeland Security and Palantir signed a $1 billion contract. In the hospital industry already, Palantir manages more than one fifth of US hospital beds. For nurses, this marks a dangerous threat to their nursing profession, which is seeing a glut of untested and unregulated technology introduced into patient care settings.” All right, so we got a lot to talk about here, and to talk about all of this, I am really grateful to be joined on the show today by three guests who are all registered nurses, all members of National Nurses United. Thank you all so much for joining me today. I really appreciate it. Please introduce yourselves to our listeners.
Kiera Arbour, RN:
My name’s Kiera Arbour. I’m a registered nurse from Chicago, Illinois.
Kelli Brennan, RN:
My name’s Kelli Brennan . I’m a registered nurse from Portland, Maine.
Lee Barker, RN:
I’m Lee Barker. I’m a registered nurse in Kansas City, Missouri.
Maximillian Alvarez:
Well, again, thank you all so much for joining me today. I really, really appreciate having you all three here to talk about this because there’s so much here that I didn’t even know before I saw the day of action and started digging into this. So before we really get into Palantir and all this AI stuff, I want to start at the shop floor worker’s eye level, and I want listeners to get to know more about you all and to have y’all give us more of a lay of the land here. So could you start by telling us more about the jobs that you do, the hospitals that you work at, the kind of patients that you care for? And I guess could we talk a bit about all the non-AI workplace issues that you and your coworkers are already dealing with on a daily basis?
Kiera Arbour, RN:
This is Kira. I am a nurse in the neurosurgical ICU at Stroger Hospital of Cook County. We are one of the largest safety net hospitals in the United States. So I am just finishing up my first year as a nurse. Just graduated from my nurse residency program last week, came to nursing late in life. I took my licensing exam the day after I turned 50. For me, I think the thing that has really been the most challenging part of my first year of practice as a nurse is the patient population that we serve at Stroger Hospital as a safety net hospital in the third largest city in the country is just all of the poverty related, social determinants of health related illnesses. So in the neurosurg ICU, anybody who’s a gunshot wound to the head comes to us, blunt force trauma to the head, two gunshots to the head on the unit last night, one blunt force trauma, and then a whole bunch of people who have had strokes because they live in food deserts, they don’t have access to healthy things to eat or they don’t know how to manage chronic conditions like diabetes and high blood pressure.
And as somebody who grew up pretty privileged and whose parents are heading into their 80s over the next year and a half or so, I see my amount of death play golf every day. They go swimming with their grandkids every day because they grew up middle class, they grew up with money. And then I see people 20 years younger than them who are looking at end of life type of illnesses in our hospital. And it has really kind of overwhelmed me emotionally just because we live in a system that doesn’t do a very good job of allocating resources to folks. And so I’m watching people be very sick and eventually die from very preventable diseases and things that are associated with poverty. Violence is associated with poverty.
Kelli Brennan, RN:
I’m Kelly. I’m at Portland, Maine. Similar to Kara, I also work in neurosurgery, neurotrauma. My background is in stroke. I’ve been a nurse for a little over 17 years from Boston and then I moved to Georgia. I was a director of neurosciences in Georgia, so I was in management, left management to come back to the bedside and be a union nurse and use everything I learned as a manager now for the good of the union. So happy to be here. I’ve been at MaineMed for about five years. I was a member of the original facility bargaining committee when we were organizing for our union. And when I got here, I was coming from Georgia right after COVID and COVID in Georgia was awful, made me realize I needed to go back to New England. So I left the South, came back to New England, wanted to be near family.
So I came to Maine and just wanted to work at the bedside, work my three 12s, get my shifts done and go home and not have twenty four seven responsibility. Now I’m in the union and I have a different kind of twenty four seven responsibility, but I love it. So I started and when I got to the hospital in Maine, I was almost like, well, this is compared to where I came from in Georgia, I was like, “Well, this is pretty nice.What are you guys all upset about?” And started talking to the staff and learning things. And then I shifted my thinking and I was like, “I just came from a really bad situation. Things aren’t that bad up here in Maine, but I know that the way healthcare works, because what I saw in Georgia was consolidation of healthcare systems, lots of financial issues, lots of layoffs and closures and all that kind of stuff.
I didn’t want any of that bad healthcare to come up to this hospital.” So I was like, “You know what? The best thing is to start a union and to lock it in what we have now so that it can’t get taken away because we know the turnover in the C-suite is every five years. These people are not dedicated to the communities. They’re not dedicated to the hospital. They are there for five years just to make a resume, just to go on to the next place.” So I got all in with the union. I’m a charge nurse, I’m a steward, I’m chair of our professional practice committee, and I’m co-president of the Maine State Nurses Association. Yeah, I’m all in. And the things that we’re working on now outside of AI is staffing. There’s this huge misconception or this though process that there’s a nursing shortage.
And we’ve been saying for years there’s not a nursing shortage. There’s a shortage of nurses willing to work in unsafe conditions at the bedside. And that’s why I went into management when I did because the working conditions at the bedside suck and nobody wants to work every weekend. Nobody wants to work every holidays. You can go to management and have your weekends off, have your holidays off, get paid more. So you see the shift of people leaving the bedside because the work is just unmanageable. The working conditions aren’t safe. The patients are sicker, more complex. Our nursing turnover is super high. The years of experience on the floor are low. When I work, there’s a lot of times I’m the most experienced nurse on my unit by 15 years. So it’s a lot of challenges in that, and there’s no focus on nurse retention. They just let one go and then just hire a traveler or temporary staff and we try to make the best of it.
I was at my professional practice committee meeting this morning and it was all about staffing. The hospital has budgets and staffing grids and plans, but they fall through. They don’t hold themselves accountable.
Lee Barker, RN:
Just wanting to build off of what Kelly said, staffing is also an issue at the hospital that I work at research in Kansas City, Missouri. I work specifically in our inpatient psychiatric population. Our staffing grids call for one nurse to every eight patients. That’s already an unsafe ratio and our management likes to push us to one to nine, one to 10. I’ve seen 11 and 12 as well. And like Kelly said, it’s not that there’s a nursing shortage in this country. There’s a shortage of nurses that are willing to work in the unsafe conditions that the hospitals push on us. At research, I mean, we used to have, I think, 800 nurses when we were fully staffed up. Currently we have like 550 and we just can’t. The hospital doesn’t care to retain nurses. Somebody leaves and, oh, we can hire in a new grad and they’ll stay for their two years, get their experience and leave and well, we’ll just hire another new grad.
Maximillian Alvarez:
Well, and it’s like, I hate to make light of all the incredibly serious and important stuff that y’all just laid out, but in 2026, hearing all this, my mind is imagining the Pawn Stars meme of like, “Hey, hospitals, can you fix any of these problems?” And the response is, “No, the best I can do is nothing, and I’m going to add Palantir to your list of things to be worried about now.” So that’s the kind of upside down, topsy-turvy nightmare reality that we’re living in right now, but it is what it is and we got to deal with it.
I’m so grateful to all of you for laying that out for folks because it’s such important context for everyone to understand even though we’re all focused on AI and Palantir right now, let’s not lose sight of the forest from the trees here. There’s so many other systemic issues that are running workers into the ground and screwing over patients and all of us for the benefit of a few. Those sorts of dynamics are already at work in the stories you’ve been hearing on this show about the working conditions for healthcare workers around the country. We’ve been covering it for years, but now we got to worry about ICE coming into hospitals. We got to worry about these truly super villain-esque big tech oligarchs putting their AI into our most sensitive and private systems and information. So let’s talk about this gang, because I need your help unpacking this for myself and for our listeners.
So I want to stay in the world of healthcare right now, and I want to ask if you could sort of lay out for us how is AI in general and Palantir specifically seeping into your workplaces and your work lives?What are nurses seeing here that perhaps the average patient is not?
Lee Barker, RN:
So the hospital that I work at is owned by HCA or the Healthcare Corporation of America, and what HCA has done in their partnering with Palantir is to build an AI scheduler called Timpani. We don’t really know how it works. It’s like a black box. We put our preferred days of working in. Timpani spits out a schedule that’s allegedly balanced, so we have enough nurses working throughout the week. They’re supposed to also balance our level of experience so we don’t have a unit full of new grads and then all of the experienced nurses are working different shifts. These were the promises that we were made. And unfortunately, at the end of the day, Palantir is giving us a shitty product. Aside from all of the moral reasons that Palantir sucks, they can’t even provide us again with the product that meets the promises that they told us, which is that it would take the burden of scheduling off of our managers.
And now our managers in the building don’t have any way to adjust our schedules. So when the AI inevitably screws up, puts out a bad schedule, nobody in the building has any way to fix the schedule unless it’s, I think, within 24 or 48 hours of the shift beginning, which is ridiculous. Part of what Timpani does as well is HCA is using it to push short staffing. Allegedly, our understanding of how Timpani works is that it somehow looks at the average daily census on the unit and decides, “Oh, for 16 patients on this psych unit, we need two nurses every shift.” What Timpani doesn’t see is that that unit can hold up to 24 patients, and frequently we are trying to fill it up to 24. Timpani will schedule only two nurses and management will say, “Well, really, we could admit a couple more patients.
We’ll push you guys up to one nurse can take 10 patients instead of one to eight.” And so they’ll sneak in and just ask us to do more and more with less and less.
Kelli Brennan, RN:
So at MainMed or Maine Health, we have Palantir in our hospitals through their application called Foundry. When we first heard about the potential, we asked the hospital or MaineHealth to let us know what they were using it for. And at first they told us it wasn’t really any of our business. We further pushed, sent letters to the board asking what’s going on, what’s it for? And their response was that they’re using it for insurance denials. So they’re using it. So say a patient comes in and they have pneumonia and the doctor doesn’t write the details of the pneumonia clearly. The insurance company will deny the claim and say that there’s lacking documentation for payments or whatever. So the hospital or MaineHealth’s idea is that Palantir’s AI software will look at these denials and claims and figure out what the letter or what the documentation needs to be in order for the claim to get approved.
So this requires us, Maine Health, sharing information with Palantir of our patient’s information.
Maximillian Alvarez:
I’m sorry. So was our whole system of already not approving so many prescriptions and surgeries in our American healthcare system, was that all not bad enough that now we need a fucking AI bot denying us as well? I can’t believe that that is actually happening.
Kelli Brennan, RN:
It’s very much crazy. The argument is that the return on investment is already better than projected, so the hospital will be gaining so much money, but they’re claiming that they’re losing money because the insurance company is denying it because the insurance company changes the rules 15,000 times a year. It has no obligation to tell the hospitals, so that’s why they’re getting denied. So instead of holding the insurance companies accountable, now we’re introducing Palantir to help solve it. That’s the solution. It doesn’t make any sense, and it just makes us complicit in this whole thing.
Kiera Arbour, RN:
Thankfully, in Chicago, we don’t have Palantir software anywhere near our patient’s information. Our action was based on the fact that our pension fund has $28 million invested in Palantir. That includes all county employees, not just nurses. So everybody who works for Cook County, which is where Chicago is, including all the people who work at the hospital, the doctors, the administrators, the nurses, the PCTs, the environmental service people, the folks who work in the cafeteria, the people who work in the forest preserves of Cook County, where I like to ride my mountain bike. All these people unknowingly have their pension funds, A, invested in a company that’s heavily aligned with the current administration and could potentially go, if Democrats screw his spine, could go belly up in a couple years. And then B, is doing some pretty nefarious stuff, is collaborating with ICE and making it so.
Kellyann mentioned that the patients are getting sicker and sicker. One of the reasons the patients are getting sicker and sicker is because they know that they have the potential to get arrested if they come seek healthcare. So they delay and defer care and then they come to us and they’re a lot of times near death. I took care of somebody last night who intubated completely unconscious body full of ammonia because their liver had failed and they had deferred care. And I couldn’t get this person’s story because obviously they were intubated and in a coma, but judging from this person’s last name, they very easily could have been somebody who was undocumented. But for us, for me, for the nurses at Cook County, we became nurses because it sounds cheesy, but it is a calling. I walked away from a six-figure career in supply chain and logistics management to come do this with the rest of my life because I felt a calling to do so because in 2020, I was at the George Floyd protest.
I said, “Wow, I’m actually the baddie and I need to get my life right.” And so I was feeling really good about what I was doing every day, taking care of some of the sickest people, the poorest people, the least fortunate people in my community and serving my community. And then I find out the thing that I’m relying on for my retirement is heavily invested in a company that’s collaborating with ICE, that is writing software for the IDF, that is tracking kids home from school in Gaza so that the Israeli Defense Force can send a bomb to this person’s house because there’s a one in two million chance that this kid’s dad is part of Hamas. And so that doesn’t align in any way with my values. And so we felt the need to step up and demand that our pension board divest itself from Palantir, and we were kind of blown off.
So I am looking to put together a run to be part of the pension board in the next few months. So that’s where our involvement with Palantir is.
Maximillian Alvarez:
Hell yeah. Well, I want to keep going in the direction that y’all are leading us to. I want to keep zooming out here and take this discussion beyond the world of healthcare, but I think it bears repeating or reminding all of us who and what we’re talking about here. I mean, if you’re still asking yourself or you listen to this and you’re saying, “Well, why is Palantir so bad? Who are they?” They’re telling us who they are. They published a whole batshit manifesto about their evil vision of and for the world. Their CEO, Alex Karp is constantly saying super villain type stuff about the kind of future he imagines with AI. And there’s a piece that we’ll link to in the show notes from The Guardian that is literally titled Palantir Manifesto described as Ramblings of a Super Villain Amid UK Contract Fears. And in that article, here’s a quote that says, “Palantir’s manifesto, which embraces AI state surveillance of citizens along with national service in the USA is either a parody of a Robocop film or a disturbing narcissistic rant from an arrogant organization.” And that was actually from a liberal Democrat MP in the UK.
But read that, read the manifesto. They are telling us who they are and we should believe them. I don’t want this creep carp near my healthcare or my information or any of my government data. I don’t want them near anything having to do with the administration of our society or what remains of it these days. And yet they are getting in there in our government. The data centers that are popping up everywhere. They’re tied up in all of that too. So I wanted to ask y’all to sort of zoom out and keep talking about that bigger picture. And I wanted to ask why you and your union are demanding that not only hospitals, but elected officials cut ties with Palantir. Why is it important for you to speak out against this kind of larger onslaught of big tech and to speak out as union nurses to stop it?
Kiera Arbour, RN:
I would say first of all, we have our own manifesto. It’s called Vision for a Healthy Society, and it’s not super villainy. We want people to live happy, healthy, self-fulfilled, self-actualized lives where they have the resources they need to not just survive day-to-day, but to thrive as human beings in the way that human beings were meant to exist and to flourish, not to be beholden to these giant unelected powers, whether it’s Palantir, whether it’s Anthropic, who was just in the news yesterday because they have their own AI building dossiers on folks like us who are opposed to what they do, and nobody elected these people. They became billionaires because venture capitalists invested money in them, and now they call the shots. They own pretty much both parties. Shout out to Rokana for giving that money back from Palantir, but for the most part, they’re heavily invested in both Democrats and Republicans.
As far as union nurses, because we can’t, because our union has our backs, because they’re going to protect our free speech rights, they’re going to protect our right to go out there and say, “This is wrong. We don’t agree with it.” And they allow me, because they are themselves, my union is itself anti-colonial, anti-imperial. They stand up for these values that I try to model myself, and so I need to stand in solidarity with my working class siblings, and I need to work for the society that I think is going to allow human beings the best chance to live the lives they deserve.
Kelli Brennan, RN:
In Maine, in January, we had operation Catch of the Day, which Maine is one of the whitest states in the country. We have a Somali population. So for us to be targeted with this operation, it was devastating. It affected our community, it affected the hospital, our housekeeping workers, our transporters, our ancillary services, and all staff felt this. You could feel the emotions throughout the hospital as this was going on. About 30% of our housekeeping were calling out because they were afraid. We were picking up food because we had a food bank, but people were afraid to go to the food bank. So our C-suite was storing groceries, so we were bringing our immigrant vulnerable community members to get food. And then one of my coworkers, who’s of the vulnerable community, I offered to give her a ride into work because everything was so escalating. So I picked her up one morning and we were driving to the hospital to go to work, and it was about six o’clock in the morning.
It was dark out. We were driving down the street, and as we were driving, pulled up to what seemed to be ice activity. There was a bunch of unmarked cars, out-of-state license plates, just seemed suspicious. So I couldn’t just drive by. So I pulled into a parking lot across the street and started filming on my phone what these officers were doing, just trying to see if they had anybody, if anybody was in trouble. But I also had my friend in the car, so I didn’t want to draw too much attention, so I didn’t honk my horn. I didn’t get out. I didn’t yell. I just sat there with my phone on recording, and the officers saw me. They flashed their flashlight at me as to say, “Hey, we see you.” And then I saw them heading to their car. So at that point, I decided that this was not a safe situation and we should leave.
So we pulled out of the parking lot, carried on down the street, and realized that they were following us. So got to a red light, and they pulled up in the lane next to me, and I could feel them staring at me through the window. So I rolled my window down because I could see that they were wanting that, and they rolled down their window and they looked at me. It was a male and a female officer, and they said, “Can we help you?” I said, “Yeah.” I said, “You can get the fuck out of Maine.” To which they replied, “Oh, looks like we have another Karen here.” At this point, the light is still red, and I’m like, “Okay, this is going to escalate.” I was worried My friend. And so when the light turned green, they looked at me and they said, “I’m going to arrest three more people today just for you.
Ha ha ha ha ha.” And pulled out in front of me, did a U-turn and carried on down back to where they came from. I don’t think anybody was abducted that morning, but my friend and I continued to drive to work and it was just like I felt so awful. It was traumatizing. And so that right there for me was like, this isn’t okay. And so we went to work and then this was happening across our town and the hospital went through so much to help and support people. They changed where they were picking up employees so that the parking lot was gated so that there couldn’t be agents in there. And they did all these things. And then we find out that they have a contract with Palantir and it’s like, wait a minute, we just went through this in January. We felt the effects of this in the hospital.
So that’s where we all kind of started to get involved. And then fast forward through the summer, we get to July and we have the murder of Johan Sebastian Guerrero in Biddeford, which is three miles down the street from a Maine health facility. And at this point we are aware about the app called Elite that Palantir is using to target immigrants in our communities. So at this point, we’re concerned that this is really ramping up in our community. And then fast forward to August when our own nurse was abducted by ICE at an airport in Portland. And then to still find out that MaineHealth is still doubling down on their contract and Susan Collins is still holding onto her money, it’s just infuriating. And I think for us up here in Maine, you’re going to see us out and doing everything we can to try to tell the community that Palantir has no place in our hospitals, no place in our community.
And that if patients can’t trust the hospital, if they can’t trust where they’re going is safe, they’re not going to come and get care. And that’s not what we’re here for. Nurses are advocates first. We’re trained to advocate and to speak up when something is wrong and that’s what we’re doing.
Lee Barker, RN:
I mean, exactly. I think the biggest reason that union nurses are speaking out against Palantir is simply because we can. It’s the right thing to do. And like Kelly said, we’re advocates for our patients, we’re advocates for our communities.
Maximillian Alvarez:
Well, my God, thank you all so much for that. That was really, I think, important, really powerful. And I’m really grateful to y’all again for speaking out the way that you are and letting our listeners know why this is important. And I want to end on that and bring us back to where we started in the beginning where I learned about this Purge Palantir campaign from NNU because of the day of action in August. So I wanted to ask if you could tell folks more about now that we’ve thoroughly covered why we should all be invested in this and horrified that these tyrants and oligarchs and freaks and villains who want to control everything and everyone, why we should not just go quietly into that dark night and why people should stand up and fight back and that we can choose a different path. We don’t have to go down this path.
And that’s what I see all around me and in every kind of story we cover at The Real News. People around the country are pissed, they are fighting back, they are doing so wherever they can, however they can, whether it’s speaking out as union workers in mobilizations or it’s people in deep red, rural areas where there are data centers popping up or people here in quote unquote deep blue cities like Baltimore where data centers are also threatening to pop up. This is kind of forcing us all together and we’re going to need to work together to figure this out. And so in that spirit, I wanted to end by asking y’all if you could tell folks more about what NNU is doing to fight back and what people listening, what your message is to them about why they should get involved and what they could do to get involved.
And if you have any final words about what will happen to all of us if people don’t fight back against this now.
Kiera Arbour, RN:
So I would say that, and probably understanding that the demographic of your podcast are what we like to call fellow travelers. They’re socialist, anarchists, anti-capitalists, what have you. We need to get people off the sidelines. We’ll take care of our own business here in Chicago with this pension fund. What I would suggest that your listeners do is reach out to somebody who they would probably consider a liberal or a conservative and do something simple like, I don’t know, go take them to see the movie American Doctor. I don’t know if you’ve heard about that. It’s the story, it’s a documentary of people trying to go provide aid in Gaza in the midst of a genocide because I really feel like there is a large percentage of the population out there who just doesn’t really understand. It’s not that they don’t care, it’s just that A, they don’t understand what’s happening and B, they don’t know or don’t feel like they have any sort of political agency to change it.
And there are a lot of people who probably identify as neither any sort of political affiliation, and those are the people that we need to reach out to to let them know what’s happening around us. So go see something like American Doctor, which is really going to get you right here. Understand that Palantir and all these big tech companies played a very large part in all the horrible things that you’re going to see in that movie. And then wherever you live, I guarantee you there are people that there’s an anti-war committee. There are mutual aid groups who are going out every day and collecting donations and trying to feed the less fortunate in our community, the people who are undocumented, who are afraid to go to work. There’s so many opportunities to go out there and connect with the people in your community and that’s what’s going to make you feel safe and that’s what’s going to make you feel like you have power over this and that’s what’s going to make you feel like you have agency over this.
And that’s how we defeat this in solidarity together as working class human beings.
Kelli Brennan, RN:
I think it’s going to be really important that people get out and vote in November. I think it’s really going to be, we don’t know what the outcomes of the elections will be, but if they go the way we want them to go, there’s a chance that those results aren’t going to be accepted. So I think we have to prepare and organize and make sure that we’re getting everyone out to vote, making sure people are registered. I think there’s no hesitation on my mind about that we need a huge voter turnout this midterm. And I think if people aren’t involved, be a poll watcher, drive people to the polls, make sure your community members know if they’re registered, how to register, where the voting locations are, and notify your elected officials that you don’t approve of Palantir. Whenever I do stuff lobbying, one things that representatives in Congress or locally or wherever, they say that I don’t hear from my constituents.
No one’s called me to tell me about this. And that really matters. So I think it’s important for people to get out and vote. I think it’s important for people to join an organization, unionize. If you’re not in a union, join one, make one, connect with one because there’s so many resources. And if we’re all doing different things, we need to all do the same thing together at the same time. And we need to sustain organizing, sustain networking, talk to people that you don’t normally talk to. What I love is our candidate for Senate, Troy Jackson, one of his sayings I love is we’re not from the left, we’re not from the right, we’re from the bottom and we’re rising. This is a working class issue. They’re sayings that unions save the middle class, unions built the middle class. We’re going to have to do that again.
And even if you’re not in a union, you’ve got to link up with somebody because it’s going to take all of us to get through this. And nurses are first and foremost humanitarians, right? We’re the trusted profession over and over again. So we know what’s needed in healthcare. And as a nurse for 17 years, I’m so sick and tired of apologizing to my patients and their families on behalf of health insurance executives and hospital CEOs. So everyone get out and do something.
Lee Barker, RN:
Absolutely. Just to echo that, getting out to vote, reaching out to your elected representatives, telling them to purge Palantir. I’m going to put a couple links in the chat also. There’s a purgepalantir.com. You can get on there and find out what’s going on with the Purge Palantir campaign, Actions Near You. The other link I put in there is there’s a letter that people can fill out that will go to HCA specifically telling them to cut ties with Palantir. Anyone can sign that. Anyone can sign that. Anyone can find that.
Maximillian Alvarez:
All right gang, that’s going to wrap things up for us today. I want to thank our guests, Kelly Brennan, Lee Barker and Kira Arbour, all three registered nurses, all three members of National Nurses United, all participating in NNU’s Purge Palantir campaign. And you can learn more about that campaign in the links that we provided in the show notes for this episode. And of course, I want to thank you all for listening and I want to thank you for caring about this. We do this work for you, but we cannot do it without you. Working People is brought to you in partnership with In These Times Magazine and the Real News Network. This show is produced by the great Jules Taylor and is a proud member of the Labor Radio Podcast Network. We’ll see y’all back here next time for another episode of Working People. And in the meantime, go explore all the great work that we’re doing at the Real News Network, where we do grassroots reporting that lifts up the voices and stories from the front lines of struggle around the US and across the world.
Subscribe to our YouTube channel. Check out our great podcasts like Under the Shadow and the Mark Steiner Show and connect with us on social media and get updates on our reporting there and help us do more work like this by going to therealnews.com/donate and becoming a supporter today. I promise you guys, it really does make a difference. I’m Maximillian Alvarez. Take care of yourselves. Take care of each other. Solidarity forever.
This story originally appeared in Common Dreams on Aug. 19, 2026. It is shared here under a Creative Commons (CC BY-NC-ND 3.0) license.
The Teen Pregnancy Prevention program, first authorized through bipartisan legislation in 2009, has been credited with helping to dramatically reduce the number of American teenagers who have experienced unwanted pregnancies in the past decade and a half, dropping by more than 65% over 16 years, according to one congressional report.
Despite the best efforts of President Donald Trump and Health and Human Services Secretary Robert F. Kennedy Jr., a federal judge’s ruling on Wednesday sent the message that the push to reduce teen pregnancy in the US will continue, with the administration’s limits on the program’s federal grants paused.
Judge Christopher Cooper of the US District Court for the District of Columbia granted a preliminary injunction in the case of Hennepin County, Minnesota v. US Department of Health and Human Services, in which officials joined King County in Washington state, Planned Parenthood of the Heartland, and the Sexuality Information and Education Council of the United States (SIECUS) in challenging HHS’s changes to the program’s grant policy. The plaintiffs were represented by Public Citizen and Democracy Forward.
The changes, said Cooper, were “likely arbitrary and capricious.”
LAWSUIT WIN: The court blocked the Trump admin’s attempt to turn the Teen Pregnancy Prevention Program into an abstinence-only program.
— Public Citizen (@Public_Citizen) August 19, 2026
The court said the plan would seem to defy social reality, common sense, & scientific evidence alike.
A win for young Americans' wellbeing.
The new policy, announced in June, canceled 53 of 66 active grants that had gone to public universities, health departments, and nonprofits for programming related to sex education, including information that was given to teens on contraception and communication with sexual partners.
In Trump’s 2027 budget, the grants are described as promoting “radical leftist ideology,” and officials claim there is no evidence that teen pregnancy prevention programs that go beyond educating young people about abstinence have “contributed to the historic decline in teen pregnancy, which is now at an all-time low.”
Under new guidance issued in June, Teen Pregnancy Prevention (TPP) program grantees are required to focus lessons on abstinence, deemphasize contraception, and teach teens about fertility and “body literacy.”
“HHS is perfectly entitled to formulate its own views about how to stem teen pregnancy—or even whether it is worth preventing at all—and to pursue policy initiatives consistent with its viewpoint. But it is not at liberty, under the Administrative Procedure Act (APA), to impose conditions on grant recipients that Congress did not intend or that are unreasonable or unexplained. The preliminary record suggests that HHS has done just that,” wrote Cooper in the ruling.
“Through the TPP, Congress sought to fund a range of evidence-based teen pregnancy prevention strategies, not just abstinence. According to unrebutted record evidence, programs that teach abstinence to the exclusion of all other approaches are ineffective in delaying sexual initiation and reducing adolescent pregnancy, at least as a general matter,” Cooper continued.
The judge took aim at the administration’s promotion of “body literacy,” which he called “a nebulous concept that appears to elevate fertility and marital procreation over well-tested forms of contraception and pregnancy prevention.”
Cooper also suggested that HHS had not bothered to find genuine evidence of its claims about “body literacy,” instead “remarkably” referencing “public health studies that appear either not to exist or not to support the propositions for which they are cited—a hallmark of AI-generated citations.”
The judge stopped short of reinstating the dozens of grants, amounting to about $67 million, that have been terminated, saying it was unclear whether he had the authority to do so.
The plaintiffs and other advocates of comprehensive sex education have called for a permanent injunction; Cooper called on both parties in the case to propose a schedule for next steps by September 1.
Callie Simon, executive director of SIECUS, said the group was “encouraged that the court has halted implementation of the new harmful policy” but emphasized that “the impacts of terminating existing grants remain.”
“Today’s decision sends a clear message that the Trump-Vance administration cannot replace the proven, bipartisan Teen Pregnancy Prevention program with an ideologically driven alternative that harms young people,” said Simon. “Communities across the country are still without the evidence-based programs they relied on, and we will continue fighting to ensure young people have access to the sex education they deserve.”
Sandra J. Valenciano, director and health officer for public health in Seattle and King counties, said local communities were facing a measurable loss due to HHS’ stripping of TPP grants
“This federal action threatened our ability to complete a study on a new science-based, community-informed sex education curriculum specifically for young men and boys,” said Valenciano. “This ruling gives us hope that we may still be able to get to the finish line with this study and ultimately empower more young people to build healthy families if, when, and how they choose.”
Ruth Richardson, president and CEO of Planned Parenthood North Central States, said the ruling “reaffirms the value of trusted, evidence-based education programs that help youth make informed choices and plan for their futures.”
“Attacks on the Teen Pregnancy Prevention program not only put young people at risk, they also risk increasing costs for taxpayers,” said Richardson. “No one benefits from these politically motivated attacks. It’s time for them to end.”
Frontline healthcare workers and the patients they serve are facing a major crisis at the University of Vermont Health network—the state’s leading healthcare provider. “In June, UVM Health eliminated over 140 positions across its network, a third of which were union positions,” Matt More reports at The Rake Vermont. “The cuts, which the hospital estimated will save $9.5 million, comes as the network faces a $300 million budget shortfall… Later that month, UVM Health handed down a speed-up order to its Medical Group, which includes outpatient clinics and more than 1,000 physicians, which practitioners say will result in briefer appointments with patients.”
How did Vermont’s flagship health network end up in this crisis? How is it affecting healthcare workers and their patients? And what can be done to fix it? In this episode of Working People, we speak with Melissa Lavallee, secretary of UVMMC Support Staff United and VP of healthcare for AFT-Vermont; and Teagan Cook, lead outpatient chemotherapy scheduler at her hospital and a chief steward in UVMMC Support Staff United.
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Maximillian Alvarez:
Alright. Welcome everyone to Working People, a podcast about the lives, jobs, dreams, and struggles of the working class today. Working People is a proud member of the Labor Radio Podcast Network and is brought to you in partnership with In These Times Magazine and The Real News Network. This show is produced by Jules Taylor and made possible by the support of listeners just like you. My name is Maximillian Alvarez, and today we are headed north to the state of Vermont, where frontline healthcare workers and the patients they serve are facing a major crisis at the University of Vermont Health Network, the state’s leading healthcare provider. In an article published in the Rake Vermont, which is an independent worker-owned news outlet based in Vermont, writer Matt Moore breaks down the situation like this. “In June, UVM Health eliminated over 140 positions across its network, a third of which were union positions, according to AFT Vermont, which represents workers there.
The cuts which the hospital estimated will save $9.5 million comes as the network faces a $300 million budget shortfall. Rules set by the Green Mountain Care Board, which regulates Vermont hospitals, will require UVM Health to cut expenses by that amount over the next three years. Later that month, UVM Health handed down a speed up order to its medical group, which includes outpatient clinics and more than a thousand physicians, which practitioners say will result in briefer appointments with patients. Owen Foster, the former chair of the Green Mountain Care Board, took aim at what he saw as the excesses of UVM Health in a board meeting last September. “It’s essentially an expensive and ineffective layer of overpriced and unnecessary corporate bureaucracy that has proven itself both physically and spiritually distant and unconnected from the mission of our flagship academic medical center and the needs of Vermonters,” Foster said.
Foster found that the surplus revenue earned by UVM Medical Center was being siphoned off by UVM Health to subsidize its hospitals in New York State that the network has been unable to manage profitably to the tune of over a hundred million dollars over the last several years. He noted that at the same time that UVM Health was shutting down kidney dialysis services in St. Alban’s, Rutland, and Newport, it was moving $10 million from UVMMC to its New York hospitals. Multiple executives, many of whom had received a combined $3 million in bonuses in 2024, were laid off in October of 2025 as part of a restructuring process. However, the most recent round of cuts and likely future cuts are aimed directly at the caregiver and support levels, leading to reductions in the quality of care for a majority of Vermonters.” To talk about all of this, I am really grateful to be joined on the show today by two guests.
Melissa Lavalle is secretary of UVMMC Support Staff United and VP of Healthcare for AFT Vermont. And Teagan Cook is lead outpatient chemotherapy scheduler at her hospital and a chief steward in UVMMC Support Staff United. Melissa Teagan, thank you both so much for joining me today. I really appreciate it. And I know we got a lot to dig into here, and I want to talk to you about everything that’s happening now at the UVM system with these devastating cuts or restructurings or whatever we’re calling them and the events that led to this point. But before we do that, I’d really love to start by getting to know more about you all and the work that you do. Every week we strive to remind listeners that there are flesh and blood human beings and fellow workers behind every name tag, every job title, and every one of us has a story worth telling.
So please tell us more about yourselves and how you got into this work and the kind of jobs that you do.
Melissa Lavalle:
Thank you so much for having us. I’m Melissa and I’ve lived in Vermont my whole life. I was born here. My family lives here. I was the kid that moved furthest away because I was 45 minutes from mom and dad. I’ve worked retail. I’ve been a grocery store clerk. I was a photographer inside a Kmart for Holy Mills. And when they were going to cut my health insurance, I decided it was time to get into a job line that would give me health insurance. And that’s what brought me to working in medical. I’ve been a medical assistant and I am currently the finance and admin assistant for the psychiatry and mental health departments. There’s a lot of backend bureaucratic needs, paperwork, vacation time, continuing education stuff. And so I am the department Santa. I love my job and love serving the folks that are giving wonderful and such needed mental health care to our community.
Teagan Cook:
Thank you so much for having us. I’m Teagan. Like you said, I’m the lead outpatient chemotherapy scheduler here at UVMMC. And I got into my job after previously working in law, which is where I have a degree. Not the one you can actually do something with, but still a degree in law. And the industry of law has just so many miserable soul-sucking problems without a lot of real emotional reward, at least that I was feeling. So I ended up moving into healthcare, which is a place where you can actually make a real difference to real people. And not all of it is couched in a bunch of pseudo-Latin nonsense. A lot of it is just making real connections with your patients, understanding what their daily lives look like. A lot of what my day-to-day looks like, if you came behind my computer, it would look like I was playing Tetris a lot of the day because I’ve got the blocks of each person’s treatment that we’re trying to all stack together to make fit to get as many people as possible safely treated in the amount of time and the amount of space that we have.
It’s very rewarding. I get to make contact with a lot of different people from across the state. I’ve got patients in New York, I’ve got patients in New Hampshire, I’ve got some patients in Canada. And working here has been really incredibly rewarding. But unfortunately, as time has gone on over just the past three years that I’ve been here, sometimes the stress and the weight has started to outweigh that reward in some ways that are really specifically related to the way that our labor as workers here is treated.
Maximillian Alvarez:
And I want to really talk to y’all about that at the shop floor day-to-day level. But I guess I need your help here because I want to talk about the crisis that is happening right now in the UVM Health Network. And first we need to help our listeners understand what is this crisis exactly? What do folks need to understand? Is it a budget crisis? Are you facing draconian cuts? Is it a shortfall? I guess we don’t have to get too far into the weeds that we lose sight of the whole plot, but help us understand what exactly the nature of the crisis that y’all are facing there at UVM is right now.
Melissa Lavalle:
It is incredibly complex, and I can kind of scratch the surface. For years, for decades, management at the top was kind of left alone to do what they want. And what they wanted to do was give incredible salaries to the folks at the very top. We went from being Fletcher Allen to University of Vermont Medical Center, and then the Health Network was formed. So now the network encompasses five hospitals in Vermont, and I think two or maybe three in Northern New York as well. So that necessitated an extra level of administrative folks at the top, and they’re not the ones making $20 an hour by any stretch of the imagination. Vermont’s really unique that we have what’s called the Green Mountain Care Board. It came out of the work of activists in 2011 in the passing of Act 48, which ostensibly created universal healthcare in Vermont.
We never had a governor that was able or willing to find funding for that. So instead this advisory board was created and yearly Green Mountain Care Board reviews and either approves or denies budgets for hospitals in the state. About three years ago, Green Mountain Care Board really put their foot down. Vermont is the most expensive state in the country to buy or get healthcare. And they said, “This is insane. UVM Health has an obvious monopoly on the state. You folks have been making way too much profit for too long, and now it’s going to be a cut.” So the budget, instead of having any growth to it, actually had a reduced amount of profit that was allowable. So now that they’re not able to charge the most exorbitant prices for literally everything, they are saying, “We’re losing money every day. Austerity measures need to go into place.” And what that looks like is those 140 cuts and staff just being overworked in almost all locations.
Teagan Cook:
Yeah, Melissa has a much more of a bird’s-eye view of it than I do because Melissa is much deeper into the daily goings on of the union. So she’s much more well-briefed than I am. But as far as how I’ve seen this in my day-to-day work, it’s been, for example, in my clinic, which is the outpatient cancer clinic at the flagship hospital in the network, the scheduling team is about three weeks behind at any given moment, which doesn’t necessarily sound like a big deal if what you’re generally familiar with as far as healthcare scheduling is just a primary care physician’s office. If you’re three weeks behind looking at that, generally it’s not going to be a huge deal for scheduling. But here in the outpatient cancer clinic, these are patients who are coming in twice a week or every single day, five days long once a month, or they’re coming in every other week, which means that if we get three weeks behind, we are operating so far behind the patient’s actual reality that it functionally doesn’t even make sense for us to be doing our jobs because we are working with outdated information that we then have to crosscheck with the more up-to-date information that we’re seeing in the chart.
Everything takes longer because we have to do that. We get further and further behind. Patient care falls further and further behind. And we’re all very concerned about the safety of the care that we’re able to deliver because of this. And this could be solved with safer, better staffing by increasing our numbers by just two or three more people. And we’ve been refused for months and months and months. Even while going through an official grievance process to try to address the issue, we have continued to be denied.
Maximillian Alvarez:
Well, I want to ask one more kind of clarifying question here because it seems like in all the kind of research I was able to do before we started recording this episode, there’s some competing narratives going on here, and that’s sort of muddling the picture and making it hard for folks to understand what’s going on here and why it’s so egregious. So I wanted to ask who is behind the narrative that this is a $300 million budget shortfall that requires squeezing people at the bedside level, people in the office level, and cutting back the most essential labor and piling more work onto the most essential workers?
Melissa Lavalle:
So there’s always yours, mine and theirs, but Green Mountain Care Boards saying, “You folks have made way too much money off of Vermonters for way too long. You need to lower your prices.” UVM Health is saying, “Oh my God, we used to make this much money, but now we’re only allowed to make this much money.” So normally in my mind, folks would lower the prices of things. What they’ve done instead is lower the number of available inpatient beds. So they’re seeing fewer patients, so therefore less money is getting made. And there was a law that went in that said they had to drop their prices on cancer infusion drugs because those were just astronomical through the roof. So care board says you’re making too much. Hospitals says we’re not making enough any longer. And from the union’s perspective, we’re saying this was poor management over decades and you’re now asking your lowest paid workers to bear that burden.
Maximillian Alvarez:
Well, let’s talk about that sort of how we got here question. Because sadly, this is a story that I have heard from healthcare workers across the country in different contexts. I’ve talked to workers on the picket line at a private Catholic hospital here in Baltimore saying very similar things. I’ve interviewed workers on strike at Kaiser Permanente in the Pacific Northwest saying similar things. Workers in Chicago at a university healthcare system there, very similar story. But the devil is also in the details and not every story’s the same. But it feels like the effects that people are feeling are very similar, which is that workers are being burnt out because they’re being asked to do more with less for less while either hedge fund type corporations are buying up their hospitals and forcing them to speed up production for the sake of more profits. Or you got a system like your guys’ system where you’re being forced to claw back your operations to sustain an unreasonably poorly managed from the top down system.
Again, those are different situations, but the effect is very similar on the workers and the patients. But as you said, Melissa, that didn’t happen overnight. And so I wanted to ask how the hell did it happen? And how did you all as rank and file workers experience this over that time?
Melissa Lavalle:
A fact I heard once that really blew my mind was most hospitals used to be owned by the doctors. They were kind of co-ops that the doctors owned. And so if something terrible happened, you know whose door to knock on to complain. But letting hedge fund managers, letting private equity into healthcare. And even in Vermont, UVM Health is a nonprofit network, but letting business managers run health decisions does not work. And every other industrialized country in the world has figured it out that it’s most effective not to be paying these insurance middlemen to do nothing but mostly deny folks. Are governments capable of administering Medicare, which folks are generally happy with. With Medicaid, folks are generally happy with. And this introduction of the business element into health is where things went wrong, to be totally honest. Folks are making money off of something that should not be a money-making enterprise.
Teagan Cook:
I mean, I think what it boils down to, to your point, Melissa, is the fact that hedge fund managers, extremely well-paid executives in the healthcare industry, it’s kind of like the final frontier of late stage capitalism. This is the last way that you can profit off of not only your workforce, but the physical bodies of your workforce and the people around you. UVM Health has a monopoly on healthcare in Vermont, which means that all of their workers are here receiving care from them for the vast, vast majority, which means that not only are we struggling to get them to pay us wages that are meaningful in the economy of Vermont, which is total trash garbage right now, but there’s also the fact that we are functionally handcuffed to whatever decisions they’re making about what our healthcare is going to be like. I know, and I’m not alone in this, my fiance and I have been having to have really serious talks about when we get married, what’s going to happen to his healthcare?
Is it going to be worth it? Are we going to have to delay our wedding? I don’t know when I’m going to be getting married until we get a new contract for our union because I don’t know what my healthcare is going to look like. I don’t know what guarantees I’m going to have, and I’m not going to be able to get married if I have to pay $800 a month for me and my fiance to both have care as chronically ill people.
Maximillian Alvarez:
Jesus, man. I don’t know how people can hear stories like that from everybody everywhere all over the place. And we all just accept it as like, well, I guess that’s just the way things got to be, but that’s not the way things got to be. And I do want to talk about in the end, what can be done? What can folks listening do? But by way of getting there, I wanted to bring things back down to that worker and patient eye level. Can you tell us how, since those initial cuts, what this is translating to for frontline workers providing healthcare and for patients seeking healthcare?
Melissa Lavalle:
Patients seeking healthcare are definitely experiencing waits. They know it. They know why. When my husband goes to his primary care that’s part of the network, there’s one person to check in and check out folks in an office with 25 providers. You’re waiting longer when you call in to try to talk to a nurse to get a prescription refilled from your primary care. It’s just more work, more stress. You know that the cuts happened. And it’s so weird how they always seem to happen a couple of months before bargaining. So we have been in bargaining. And when we did our pre-bargaining survey, we’re doing combined bargaining between our support staff unit and the technical professionals unit of the VFNHP nurses union. So your radiologists, your respiratory therapists, those sort of folks.
But the layoffs really also energized our members to see that this is why we’re bargaining. And when we did our pre-bargaining survey, 3,300 members across the board, the priority was safe staffing. And our folks are not in great economic shape. We know wages are a thing, but we work in healthcare because we care about our patients and because we know we are the patients as well. And that was far and away what folks cared about, that when community members are coming to us, that we are safely staffed and they’re not going to get worse because they came to UVMC for care.
Teagan Cook:
Yeah, I think that the staffing is really the critical issue. And some of those layoffs did affect union members and some of them were non-unionized staff. For example, folks in IT, folks who were in MGET, which is medical group education and training. Those are the folks who train newly oncoming doctors how to use our health record system, which is byzantine and complex. So you know how it is. The money that the people at the top are getting is never going to trickle down, but the consequences that the people at the top impose trickles down. So it takes longer for these doctors to get appropriately onboarded. It takes longer for them to get the hang of how things are supposed to be done in these systems so that things are going through workflows correctly so that people like me are making sure that you are getting scheduled out for your treatments appropriately and safely.
People in IT getting laid off. I have had a ticket out for a fax machine that my unit uses to get looked at since April, and nothing has happened about it. And that doesn’t sound like a big deal except for the fact that not all outside facilities will accept electronic faxes. And that means that we are not able to, until that gets addressed, send imaging orders to those other hospitals because they won’t accept them because they’re only e-faxable right now because we don’t have a fax machine, which can result in patients getting delayed care in something as important as getting imaging done to figure out if their chemotherapy is working or not.
It’s difficult. The layoffs and the threat of more layoffs has created such an environment of paranoia and distrust, which is the exact opposite thing that anyone needs. We’re already all struggling enough, but it’s just created an incredibly difficult work environment from the things that are tangible, like the stupid fax machine, to wondering every day when you come into work, is this the day where I find out that I don’t have a job anymore and that my patients are going to call in and just end up waiting on the line for three hours to get a simple answer.
Maximillian Alvarez:
So where do things stand now and what can be done about this? And what can anyone who is listening to this conversation right now do to help?
Melissa Lavalle:
The base of the problem is the for-profit healthcare system. That just has to be the foundation that we’re working from. In our bargaining, like I said, priority safe staffing, we’re fighting for safe staffing committees. The hospital came proposing takebacks from our first contract. So that is one of the places where we’re kind of far apart. But one of the things we’re also doing on top of joint bargaining is a common good platform. We’re asking for protections for our immigrant coworkers. If they get detained, they don’t lose their jobs position, they don’t lose their health insurance. They get time off to go to these appointments when they need to, even if it’s short notice, like we know is happening more and more often. We’re asking the hospital to join our local community group as Migrant Justice, and they have a Milk with Dignity program to only source milk from farms in Vermont that treat their workers appropriately, give them safe housing, give them safe work conditions, pay them fairly.
And we are also saying that the hospital, in all its poverty, stop using its very high paid lobbyists and publicity folks to fight us in our plate for universal healthcare. Act 48 is on the books. We intend to get it funded and enforced. And every time we’ve tried in the past, the hospital, which is a huge economic driver in the state, has had their people at the state house pushing back, pushing back. And the time has come to stop. We cannot cut our way out of this. And I would encourage everybody listening, if they don’t have a union that they can get involved in and push them to fight for universal healthcare, get involved with a grassroots organization. They are just literally everywhere. Folks see this problem, and we know what the solution is. It’s a single-payer healthcare system.
Teagan Cook:
Yeah. I mean, what Melissa said, what it comes down to is that the for-profit healthcare system is functionally a vampire that is sucking us out of money without any real significant payoff. I don’t know anyone who has gone from being on Medicaid or Medicare to being on private health insurance and gone, wow, this is so much better.
Maximillian Alvarez:
All right, gang, that’s going to wrap things up for us today. I want to thank our guests, Melissa Lavalle, Secretary of UVMMC Support Staff United and VP of Healthcare for AFT Vermont, and Teagan Cook, lead outpatient chemotherapy scheduled at her hospital, and a chief steward in UVMMC Support Staff United. And of course, I want to thank you all for listening, and I want to thank you for caring. We’ll see y’all back here for another episode of Working People. And in the meantime, go explore all the great work that we’re doing at the Real News Network, where we do grassroots reporting that lifts up the voices and stories from the front lines of struggle. Check us out across our YouTube channel, our podcast feeds, our website, and our different social media pages, and help us do more work like this by going to therealnews.com/donate and becoming a supporter today.
I promise you guys, it really makes a difference. I’m Maximillian Alvarez. Take care of yourselves. Take care of each other. Solidarity forever.
A few weeks ago, we argued the Trump administration was seeking to invent new ways to punish Americans. The idea was that the authoritarian impulses of the MAGA-run government will need to dial up the cruelty in order to sow chaos and pave the way for a broader assault on democracy.
Well, this week a rule was issued by Medicare and Medicaid services that shows just how proficient the Trump administration is at inflicting pain. And the consequences for poor, seriously ill Americans could be devastating.
Before we explain the rule, it’s worth contemplating the often destructive role healthcare — both the lack of it and exorbitant costs associated with it — play in the lives of working-class Americans.
Poll after poll shows that working people rank anxiety over healthcare costs at the top of the list of high-priority concerns. Unpaid medical bills are the most likely cause of personal bankruptcy in the US. Unlike any other wealthy nation on earth, when Americans lose their jobs, they often lose access to a doctor as well.
The US healthcare system is already inherently extractive — making it even more prohibitively expensive means more people will suffer with diseases that can be cured and die from afflictions that would otherwise be treatable. All of this makes the working class vulnerable and likewise incapable of asserting their right to be healthy.
And that’s where the new rule comes in.
The government agency that administers Medicaid has created a new criterion, ‘medically frail,’ which must be met to qualify for the program without working — even if you only have weeks to live. It didn’t exist prior to the passage of the Big Beautiful Bill.
Before that landmark legislation was signed into law, Medicaid was primarily a means-tested program, accessible to those with low enough incomes to qualify. But the new rule means even if you have pancreatic cancer, HIV, or Parkinson’s, you will have to meet work requirements to maintain eligibility, or prove you are too sick to comply. Your doctor’s opinion won’t matter. It will be up to the bureaucrats.
Essentially, this amounts to navigating a process fashioned explicitly to kick people off the program. That means filling out forms and filing papers and hoping someone sitting at a desk determines you comply with a definition critics say is vaguely written and open to interpretation.
This is all part of a scheme hatched during the passage of the massively destructive Big Beautiful Bill last year. Trump and his MAGA cohorts wanted to give a trillion-dollar tax break to the top one percent. But the cuts were projected to add trillions to an already historically high federal debt.
The nonpartisan Congressional Budget Office projects the additional work rules will lead to 11.8 million people dropping Medicaid over the next decade — 7 million of whom they project will not find insurance elsewhere.
So, to conjure a so-called “pay for,” Republicans turned to Medicaid, the critical program that provides healthcare to the poorest Americans.
Simply slashing funding was politically unpalatable, even for the party best known for trying to dismantle Obamacare multiple times without providing a viable alternative. So Republicans came up with a workaround: make it more difficult to qualify.
In practice, that translated into the aforementioned new work requirements.
The medical frailty rule shows, in part, how this overarching plan will lead to fewer beneficiaries: create a complicated bureaucracy difficult to navigate, then cut people who can’t comply.
The nonpartisan Congressional Budget Office projects the additional work rules will lead to 11.8 million people dropping Medicaid over the next decade — 7 million of whom they project will not find insurance elsewhere.
And it won’t be millions of idle young men playing video games and refusing to work who are affected by the new rules, as House Speaker Mike Johnson suggested. Instead, as the CBO concludes, the burdensome paperwork and subjective standards will lead to most people simply dropping out, whether they qualify or not.
Democrats are pushing back hard against the regulation. In a letter to the Health and Human Services secretary, a group of Connecticut representatives argued that the rule exceeded the intent of the law.
“The overwhelming impact of this rule is that eligible citizens will be denied Medicaid coverage, states will expend unacceptable resources processing complex paperwork, safety-net providers will be further burdened, and population health will decline,” wrote Democratic Reps. John Larson, Joe Courtney, Rosa DeLauro, Jim Himes, and Jahana Hayes.
On the House floor, Courtney said vague standards and arbitrary rules would create confusion for critically ill people without care.
“The hope was that a medical diagnosis for cancer or HIV or other serious chronic conditions would qualify for protection. Instead the rule makes clear that a cancer diagnosis will not automatically qualify for an exception. Instead the patient will have to document that the disease actually impairs their ability to work,” he said.
“This rule will create chaos and dramatically increase the number of desperately ill people who will lose their coverage.”
We reached out to the Centers for Medicare and Medicaid Services, the agency that administers both programs. They have yet to respond.
In the meantime, if you’re skeptical that work requirements are mostly aimed at reducing the number of people on Medicaid, consider what’s happening with the federal government’s primary program for distributing food aid to low-income families.
The bureaucratic demands for SNAP are so extreme that some beneficiaries have been asked to provide documentation of money obtained from panhandling.
Known as SNAP, or Supplemental Nutrition Assistance Program, it’s been a frequent target for Republicans, who argue it’s rife with fraud and abuse. Those claims are exaggerated or unfounded — but, again, the Big Beautiful Bill imposed work requirements, and the consequences have been catastrophic.
A recent New York Times article reported that since the new paperwork requirements for SNAP were instituted in Arizona, nearly 440,000 recipients have lost assistance. The piece recounts how the bureaucratic demands are so extreme that some beneficiaries have been asked to provide documentation of money obtained from panhandling.
If this is what people receiving SNAP benefits have been subjected to, imagine what’s going to happen to people who will need to navigate the new Medicare requirements while struggling with a debilitating or terminal illness.
The point is that the same burdensome processes are combining to leave some of the poorest, sickest Americans facing death without care. That’s cruelty with a capital C. The frightening part is that it seems this administration is just getting started.
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