Ron DeSantis appointed all five members of the Florida Public Service Commission. In November 2025, those five commissioners approved a $6.9 billion rate hike for Florida Power & Light, widely described as the largest for a single utility in American history. Twelve million Floridians will pay an average of $175 more per year starting in January 2026, climbing to $289 more by 2028. The Office of Public Counsel (the state’s official consumer advocate) opposed FPL’s proposal and was excluded from the final settlement. Twenty-nine elected officials from both parties wrote a letter asking DeSantis to intervene. He did not.

Gavin Newsom appointed all five members of the California Public Utilities Commission. In July 2019, those five commissioners watched him sign Assembly Bill 1054, creating a $21 billion wildfire liability fund for investor-owned utilities, including PG&E, which was in bankruptcy at the time for killing 85 people. The law changed the liability standard so that utilities are presumed to have acted responsibly after obtaining a safety certificate. Ratepayers pay $10.5 billion of that fund through monthly surcharges. In 2022, state regulators approved PG&E’s safety certification. PG&E then accessed over $609 million from the ratepayer-funded wildfire fund to cover damages from the Dixie Fire, which PG&E’s own equipment had started.

One is a Republican in Florida. The other is a Democrat in California. They agree on one thing that neither will say out loud: the governor appoints the regulators, and the regulated pay the governor.

DeSantis received over $3 million from FPL and a network of business front groups and dark money nonprofits that FPL helps fund, per the investigative newsletter Seeking Rents. FPL’s parent company, NextEra Energy, and its subsidiaries poured nearly $6 million into Florida state campaigns during the 2022 cycle alone, per the Energy and Policy Institute. Before the rate hike, DeSantis signed legislation that forced the resignation of J.R. Kelly, the longtime head of the Office of Public Counsel who had fought previous FPL increases. Kelly’s replacement was a former utility lobbyist. DeSantis also signed a bill granting FPL permission to charge customers tens of billions for burying power lines, signed legislation preventing local gas bans that benefited FPL’s sister company Florida City Gas, and gave the company $2.75 million in tax breaks on speculative green hydrogen projects.

Four years before the $6.9 billion approval, DeSantis’s PSC approved a separate $5 billion rate hike for FPL. All four of his appointees voted for the deal. Consumer groups appealed to the Florida Supreme Court. FPL’s lawyers argued the deal should stand because the Office of Public Counsel supported it. The same Office of Public Counsel whose director DeSantis had replaced.

Newsom’s utility math runs through his wife. PG&E’s corporate foundation donated $358,000 to Jennifer Siebel Newsom’s nonprofit, The Representation Project, between 2011 and 2018. The Washington Post found that Newsom, his wife, and various political causes received upward of $700,000 from PG&E over approximately two decades. The most recent cycle added another $700,000 through direct contributions and funding for Siebel Newsom’s film ventures, per California Courier News. PG&E employees gave $58,400 directly to his 2018 campaign. Blue Shield of California gave nearly $23 million to his campaigns and associated causes over sixteen years, per California Healthline.

In 2018, 979 state vendors gave Newsom $10.5 million in campaign donations across his various election cycles. Those same companies received $6.2 billion in state payments. Open the Books, the nonprofit that compiled the data after filing 442 public records requests, noted that pay-to-play is legal in California because no statewide prohibition exists.

The governor appoints the regulators. The regulated pay the governor. The mechanism does not require a party.

Both governors married well for the job.

Casey DeSantis founded the Hope Florida initiative, a welfare program operating through the Florida Department of Children and Families. The Hope Florida Foundation, its fundraising arm, received $10 million from Centene Corporation in September 2024. Centene is Florida’s largest Medicaid managed care contractor, operating under state contracts worth hundreds of millions.

Within days, the Foundation granted $5 million each to two 501(c)(4) dark money organizations. Both organizations had submitted grant proposals promising the money would not be used for political activity. Both redistributed the funds to Keep Florida Clean, a political committee chaired by James Uthmeier, DeSantis’s Chief of Staff. Keep Florida Clean sent $10.5 million to the Republican Party of Florida and $1.1 million to the Florida Freedom Fund, DeSantis’s personal PAC. Uthmeier chaired both.

DeSantis had also made Hope Florida a condition for Medicaid managed care operators selected to receive over $165 billion in contracts, the largest procurement in Florida history, per Politico. If you wanted one of those contracts, supporting the First Lady’s initiative was part of the application.

A Republican state representative, Alex Andrade of Pensacola, stated publicly that he was firmly convinced Uthmeier and Foundation attorney Jeff Aaron engaged in a conspiracy to commit money laundering and wire fraud. A Florida grand jury heard evidence in October 2025. The Florida House investigation halted after the Foundation refused to cooperate. The Republican-controlled legislature defunded Hope Florida in June 2025.

Jennifer Siebel Newsom runs The Representation Project, a nonprofit, and Girls Club Entertainment, a for-profit film production company. The nonprofit has paid the for-profit $1.64 million since 2012 for film production and licensing rights, disclosed as related-party transactions on IRS Form 990 filings. California public schools have paid approximately $1.5 million in licensing fees for her documentaries. The standard license is $270.

The shared donors between Newsom’s campaigns and his wife’s nonprofit include AT&T, Comcast, PG&E, and Kaiser Permanente. Companies regulated by agencies whose commissioners the governor appoints, donating to the governor’s wife’s organization, which then pays the governor’s wife’s company.

Nobody has been charged in either state. Everything documented here was legal at the time it happened.

Both governors also picked a fight they could not lose.

DeSantis went to war with Disney over the company’s criticism of the Parental Rights in Education Act. He signed legislation revoking Disney’s self-governing status in the Reedy Creek Improvement District, appointed a new oversight board, and spent over a year in litigation. The board budgeted $4.5 million for legal fees in 2024 alone. Disney canceled a planned $1 billion employee campus in Orlando.

Then it ended. Disney settled in March 2024, conceding the old development agreements were null and void. DeSantis replaced two Disney critics on the board with Disney supporters the day before the settlement. The Parental Rights Act had already been largely overturned by a court two weeks earlier. The fight was over. The fundraising content it generated was permanent.

DeSantis’s 2022 reelection raised $166.5 million. The culture war machinery, including the Disney fight, drove small-dollar contributions and Republican Governors Association transfers totaling $14.35 million. The fight did not cost him Disney’s money. Lodging and tourism remained his second largest contributing sector at $10.3 million in 2022, behind only Republican ideological organizations.

Newsom campaigned for governor on single-payer healthcare. The California Nurses Association endorsed him. They toured the state with a bus bearing his image and the slogan “Nurses Trust Newsom.” In January 2022, Assemblymember Ash Kalra introduced AB 1400, the California Guaranteed Health Care for All Act. The bill cleared the Assembly Health Committee 10 to 1. Then it died without a floor vote.

Newsom told reporters the bill had not been presented to him. CalMatters reported that as the bill marched toward defeat, the governor remained mum.

Blue Shield of California, which had given nearly $23 million to Newsom’s campaigns and causes over sixteen years, had $27.4 billion in annual revenue. A single-payer system would restructure every dollar of it. Every major health insurer with a California Medicaid contract had donated to Newsom. Centene gave $121,600 in 2018. UnitedHealth gave $63,400 plus subsequent contributions. The industry that would be eliminated by the policy Newsom promised spent millions ensuring he stayed in office. The bill never reached his desk. He expressed no objection to that outcome.

The fight he could not lose was the fight he never had. Disney cost DeSantis a year of litigation and a billion-dollar campus cancellation. Single-payer cost Newsom nothing. He kept the campaign promise on his website and the industry contributions in his account, and the bill died in a chamber his party controlled by a supermajority.

DeSantis wears Fighter Identity armor. The permanent appearance of combat. If you are always at war with Disney, nobody asks about the $6.9 billion rate hike his appointees approved five months later. The fight absorbs the attention. The utility math happens in the background.

Newsom wears Business Credential armor. PlumpJack, the wine empire co-founded with a billionaire heir, is estimated at over $400 million by Forbes. The blind trust. The $13 million reelection. The “pro-business progressive” who signs 31 housing bills and launches a state-branded insulin program. The credential makes the donor alignment sound like competence rather than capture. “I believe in markets AND government” is unfalsifiable, even when 979 vendors have receipts.

Both governors have done real things that cut against the money.

DeSantis fought Disney when the donor class wanted him to stop. Republican senators confirmed his PSC picks 40-0 and 36-0 and 35-1, but the Disney battle drew open criticism from members of his own party and from Trump’s campaign operation. He spent political capital on a culture war fight that his donor base in lodging and tourism had every reason to oppose. The fight was real, even if it was also useful.

Newsom launched CalRx and released state-branded insulin at $11 per pen, bypassing commercial pharmaceutical supply chains. He signed an oil well setback law banning new drilling within 3,200 feet of homes and schools. The oil industry spent over $20 million on a referendum to repeal it. They withdrew before voters could decide. He expanded Medi-Cal to cover 1.6 million undocumented immigrants at a cost of $9.5 billion per year, a program commercial health insurers had financial reason to oppose. He signed the most aggressive corporate climate disclosure laws in the country, covering over 5,300 companies, including many of his own donors.

The mechanism is not total capture. Governors retain selective independence. They choose which fights to have, and the selection is not random. DeSantis picks culture wars. Newsom picks consumer-facing policy with his name on it. The fights they choose are visible. The fights they avoid are where the money sits.

A $6.9 billion rate hike does not fit on a bumper sticker. A dead single-payer bill does not make the highlight reel. A $21 billion wildfire fund with $10.5 billion in ratepayer surcharges does not generate small-dollar donations. A First Lady’s charity routing $10 million through dark money organizations does not trend on the same timeline as a Disney lawsuit.

The things they agree on are the things neither one talks about.

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SOURCES

DeSantis PSC/FPL: Florida Phoenix, November 2025 (PSC approval of $6.9B rate hike). Food & Water Watch, November 2025. Jason Garcia/Seeking Rents, September 2022 ($3M+ from FPL network, $5B rate hike, all DeSantis appointees voted yes, Public Counsel replacement). Energy and Policy Institute, 2022 (~$6M NextEra state-level contributions). Florida Phoenix, February 2026 (new PSC commissioners, $945M base-rate increase 2026). Food & Water Watch, April 2026 (PSC denied reconsideration, case to FL Supreme Court). WUSF, November 2025.

Casey DeSantis/Hope Florida: Tampa Bay Times/Miami Herald campaign finance records review, April 2025 ($10M flow). NYT, April and October 2025 (investigation, grand jury). Politico, April 2025 (Medicaid settlement origin, $165B contract condition). CBS Miami (House investigation halted, Andrade quote). WUSF (timeline). ProPublica Nonprofit Explorer (Foundation Form 990). Florida Politics (defunding).

Newsom CPUC/PG&E: Washington Post, November 2019 ($700K over two decades). California Courier News, 2025 ($700K recent cycle). OpenSecrets, 2018 ($58,400 direct). California Healthline, March 2021 (Blue Shield $23M over 16 years). Open the Books/Substack ($10.5M from 979 vendors, $6.2B in state payments, 442 CPRA requests). Nossaman law firm analysis, July 2019 (AB 1054 structure). KQED, August 2019. PG&E Application No. A.2511001/CPUC filing, November 2025 ($609M Wildfire Fund reimbursements for Dixie Fire). Office of Energy Infrastructure Safety, December 2022 (2022 safety certification).

Siebel Newsom: IRS Form 990 filings via Open the Books ($1.64M to Girls Club Entertainment, $150K salary). Washington Post ($358K PG&E Foundation donations). L.A. Times (shared donors).

DeSantis/Disney: Wikipedia/Disney v. DeSantis (timeline, settlement March 2024). CNBC, April-May 2023 (lawsuit filing, expansion). AllEars, September 2023 ($4.5M litigation budget). NPR, March 2024 (settlement). Axios, November 2023 ($40.3B economic impact). Transparency USA ($166.5M raised, $10.3M lodging/tourism 2022).

Newsom/single-payer: CalMatters (AB 1400 timeline, “governor remained mum”). NYT, 2018 (campaign positioning). California Healthline (CNA endorsement, bus tour). OpenSecrets (Centene $121,600, UnitedHealth $63,400).

Newsom counter-evidence: Governor’s office/Civica Rx, October 2025 (CalRx $11 insulin). CalMatters (oil industry withdrew $20M referendum). Governor’s office, 2022 (Medi-Cal expansion, 1.6M covered, $9.5B/year). Crowell & Moring analysis (SB 253, SB 261 climate disclosure). Forbes, October 2025 (PlumpJack valuation).

DeSantis counter-evidence: Disney fight drew intra-party criticism. Lodging/tourism sector continued donating ($10.3M, 2022). AP News, March 2024 (settlement terms).

The armor takes different forms. Some wear plate mail: ancient, visible, heavy. Everyone can see it. Nobody dares swing at it. Some wear a bulletproof vest under the suit: invisible until you check the filings. Some wear chain mail: flexible, layered, shifting to fit whatever shape the news cycle demands. Some wear camouflage: you cannot target what you cannot distinguish from the noise.

Here is the catalog.

Image: Equipment Manifest. Armor illustrations generated with AI. All data from public records.

The Faith Shield (Plate Mail)

This is the one that locks the door.

Mike Johnson told reporters that if they wanted to understand his worldview, they should pick up a Bible. His oil and gas contributions are the largest of any sector in his portfolio. His lifetime League of Conservation Voters score is 2 percent. [1] He is also the Speaker of the House. Nothing reaches the floor without his consent. His Super PAC, the Congressional Leadership Fund, has received more than $10 million from fossil fuel interests, including Chevron, Valero, Koch Industries, Occidental Petroleum, ConocoPhillips, Devon Energy, and the American Petroleum Institute. [2] His first act as Speaker included cutting energy efficiency rebates from the Inflation Reduction Act.

When a reporter asks why a bill died or why a vote was never scheduled, the available answer is not “because his top donors fund the fossil fuel industry.” The available answer is that the Speaker prays on these decisions. Johnson described himself as a “reluctant” Speaker, placed in the role by God’s design. [3] The gavel and the Bible occupy the same hand. If the Speaker was placed there by divine authority, opposing his agenda requires opposing God’s plan.

The shield works across the aisle. It works across religions.

Hakeem Jeffries is the House Democratic Leader. First Black person to hold the top leadership position in either chamber. Lead Democratic sponsor of the First Step Act. AFL-CIO score: 100 percent. [23] That is the armor.

His top career contributor is AIPAC, at $933,415. [24] Career total from pro-Israel organizations: $1.74 million, among the highest of any current House member. [25] Career total from securities and investment: $3 million. He told a WNYC radio host that AIPAC “can contribute, in a given election cycle, $5,000 or $10,000 per cycle, that’s it.” [27] That was the direct PAC maximum. It did not account for the conduit operation: AIPAC’s earmarking website has delivered more than $1 million to his campaign through donations that appear in FEC filings as individual contributions. [26]

He rejected calls for a ceasefire in November 2023. He voted for the $26.38 billion Israel military supplemental and the IHRA antisemitism definition in April 2024. [28] He met with Netanyahu in April 2025. Palestinian activists confronted him at Harvard in June. By July, he called for restoration of the Biden ceasefire deal. By August, he accepted a J Street endorsement for the first time. The contributions came first. The positions shifted after the protests. He met with Progressive Caucus leaders who asked him to keep AIPAC out of Democratic primaries. He took no action afterward. Johnson’s shield is Scripture. Jeffries’s shield is that the question sounds like something an antisemite would ask. Different material. Same function.

He broke with AIPAC once, on the Iran nuclear deal in 2015. That was eleven years ago. His pro-Israel contributions have more than tripled since. The $26.38 billion military supplemental vote came nine years later. The armor does not require total capture. It requires that the question cannot be asked without triggering a defense that has nothing to do with the money.

Bob Menendez tried the same shield in front of a federal courthouse. He told reporters he had faith in God and the jury. Menendez was not widely known for public displays of faith before the indictment. He found God around the same time investigators found the gold bars and the cash in the jacket. To be fair, his situation may have genuinely required divine intervention. The jury was not moved. Sixteen counts. Eleven years. [4] Johnson faces an electorate that already agrees with the Bible. Lucky for Menendez, the courts moved past the Old Testament.

The Populist Brand (Chain Mail)

The outsider identity that absorbs financial scrutiny by redirecting it. “I fight the system” is the brand. The money comes from the system.

JD Vance wrote a memoir about poverty in Appalachia. It became a bestseller, then a movie. The memoir is the armor. Underneath it: Vance co-founded Narya Capital, a venture firm backed by Peter Thiel, and retains 56.4 percent carried interest rights on the fund’s first $7 million in profits. [5] That is the same carried interest loophole this series has tracked across three articles. Thiel invested $15 million in Vance’s 2022 Senate campaign, the largest individual contribution to any Senate race that cycle. [6] Thiel also co-founded Palantir Technologies. When the Trump-Vance administration took office, Palantir was worth approximately $170 billion. By April 2026, it had grown past $350 billion, driven by expanding federal contracts in defense, immigration enforcement, and AI. [7]

The memoir is on the bookshelf. The carried interest is in the financial disclosure. The Palantir contracts are in the federal procurement database. All three are public. The memoir is the one people have read.

The Fighter Identity (Camouflage)

A variant of the populist brand, stripped down to pure combativeness. The fighter does not need a cause. The fighter needs a camera.

Jim Jordan received $1.89 million from the Republican/Conservative ideological sector in a single cycle without chairing a committee with jurisdiction over any industry that benefits from a specific vote. [8] Chip Roy holds a 98 percent lifetime score from Heritage Action while Americans for Prosperity defended his seat in a competitive primary. [9] Lauren Boebert received $236,895 from oil and gas and introduced a bill to block BLM lease reforms on federal land. [10] Three members. Three different funding structures. The same armor: if you are always fighting on camera, nobody stops to read the donor filings.

The Business Credential (Bulletproof Vest)

“I vote my principles, not my donors” is the defense. The principles happen to align perfectly with the donor portfolio.

Ted Cruz of Texas has received $6.5 million in career contributions from the securities and investment sector and $5.5 million from oil and gas. His wife, Heidi Cruz, is a managing director at Goldman Sachs. [11]

In 2024, Cruz led the Congressional Review Act resolution to overturn the Department of Energy’s energy efficiency standards for residential gas furnaces. The standards, finalized in 2023, would have cut household utility costs by an estimated $1.5 billion annually and $24.8 billion over 30 years, according to the DOE. The Senate passed the resolution 50 to 45. The American Gas Association and the gas appliance manufacturing lobby supported the rollback. Cruz framed it as protecting consumer choice. [12]

The business credential makes the alignment sound like philosophy. “I believe in free markets” is unfalsifiable as a motive claim even when the PAC money is documented and the wife works at the investment bank. The $5.5 million from oil and gas is Texas. Nobody blinks. It is so expected it functions as camouflage for the $6.5 million from securities and investment, which is the sector his wife’s employer belongs to. Both numbers are public record. One of them is a bumper sticker. The other one requires a search on OpenSecrets.

The Catalog (Deflector Shield)

Johnson quoted Scripture while his Super PAC cashed checks from Chevron. Jeffries told a radio host AIPAC can only give $10,000 while FEC records show a million. Menendez invoked God outside the courthouse. Vance holds 56.4 percent carried interest from the fund that made him. Cruz’s wife works at Goldman while he campaigns against Wall Street elites. Jordan’s top donor category is ideology itself. Tuberville missed 130 disclosure deadlines and called restrictions “ridiculous.” Booker reversed on pharma. Sinema removed the carried interest fix and left. Hawley published the op-ed seven weeks before the vote. Tauzin collected $11.6 million to defend the law he wrote. Toomey, Bayh, and Manchin all landed at Apollo. Gottlieb joined Pfizer’s board 83 days after leaving the FDA.

Thirty-three names across four articles. Both parties.

None of them broke a law.

You have read that sentence three times now. It has not stopped being true.

Two questions belong at the end of every armor assessment. They were banked at the start of this series. Here they are.

What would have to be true for this to be wrong?

For the armor to be genuine rather than functional, every financial relationship would have to be coincidental. Every contribution that matched a committee assignment. Every post-office hire that matched a regulatory portfolio. Every carried interest provision that survived every Congress. The $11.6 million Tauzin earned at PhRMA would have to be unrelated to the law he wrote. The $15 million from Thiel would have to be philanthropy. The $10 million in CLF oil money would have to be unrelated to the Speaker’s floor schedule. The $933,415 from AIPAC would have to be unrelated to the $26.38 billion supplemental vote. All of it. Every time.

Has this person ever paid a price for being wrong?

Menendez got 11 years. One name out of thirty-three. Tauzin was never charged. Daschle was never penalized. Gottlieb joined two boards. Toomey got $750,000 in his first year. Sinema left without registering as a lobbyist. Tuberville’s 130 violations produced no removal, no fine, no committee reassignment. Bresch retired with $18.9 million after the $465 million settlement. Scott ran for Senate after the largest healthcare fraud in American history.

One out of thirty-three paid a price. And the price required gold bars in a jacket.

Four articles. Three types of money: contributions before the vote, compensation after the exit, and personal financial interests during the term. Thirty-three names. Both parties. Same mechanism.

The system does not need villains. It needs participants. It needs the armor to be real, because real armor is the kind you cannot take off someone else.

The behavior is documented, the incentive structure is visible, and the mechanism now has a name.

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SOURCES

[1] League of Conservation Voters, Lifetime National Environmental Scorecard, Mike Johnson (R-LA), 2% lifetime score. https://www.lcv.org/moc/mike-johnson/

[2] Congressional Leadership Fund FEC filings, confirmed via Sludge (February 2024) and Pennsylvania Independent (May 2024). Chevron ($1.5M), Valero ($1.25M), Koch Industries ($1.25M), Occidental ($1M), ConocoPhillips ($1M), Devon Energy ($1M), API ($1M). https://readsludge.com/2024/02/01/oil-and-gas-companies-donate-big-to-gop-super-pacs/

[3] Associated Press, October 2023. Johnson first press conference as Speaker, divine design remarks. https://apnews.com/article/mike-johnson-house-speaker

[4] DOJ conviction, United States v. Robert Menendez (S.D.N.Y., 2024). 16 counts. 11 years. https://www.justice.gov/usao-sdny/pr/senator-robert-menendez-found-guilty

[5] Vice Presidential financial disclosure, 2025. 56.4% carried interest, Narya Capital.

https://www.oge.gov/

[6] FEC filings, 2022. Thiel $15M to Protect Ohio Values PAC. https://www.politico.com/news/2022/05/03/jd-vance-win-ohio-primary-00029881

[7] Palantir market cap: ~$170B January 2025 (StockAnalysis year-end 2024: $172.29B); ~$355B April 2026. U.S. Army $10B Vantage contract. https://stockanalysis.com/stocks/pltr/market-cap/ and https://public.com/stocks/pltr/market-cap

[8] OpenSecrets, Jim Jordan 2024 cycle, Republican/Conservative sector ($1,894,802). https://www.opensecrets.org/members-of-congress/jim-jordan/industries?cid=N00029020&cycle=2024

[9] Heritage Action scorecard, Chip Roy (TX-21), 98% lifetime. https://heritageaction.com/scorecard/members/R000614

[10] OpenSecrets, Lauren Boebert career oil and gas ($236,895). H.R. 6009 via govinfo.gov. https://www.opensecrets.org/members-of-congress/lauren-boebert/industries?cid=N00044720&cycle=CAREER

[11] OpenSecrets, Ted Cruz career: securities/investment ($6.5M), oil and gas ($5.5M). https://www.opensecrets.org/members-of-congress/ted-cruz/industries?cid=N00033085&cycle=CAREER

[12] DOE, “Energy Efficiency Standards for Residential Furnaces,” September 29, 2023. $1.5B annual, $24.8B over 30 years. Senate vote S.J. Res. 58: 50-45, May 21, 2024. https://www.energy.gov/articles/doe-finalizes-energy-efficiency-standards-residential-furnaces

[23] AFL-CIO scorecard, Hakeem Jeffries: 100% (2023). First Step Act (Public Law 115-391), lead Democratic sponsor. https://aflcio.org/scorecard/legislators/hakeem-jeffries

[24] OpenSecrets, Hakeem Jeffries career 2011-2024. AIPAC: $933,415 (top contributor). Securities/Investment: $3,000,052. https://www.opensecrets.org/members-of-congress/hakeem-jeffries/summary?cid=N00033640&cycle=CAREER

[25] OpenSecrets, pro-Israel industry all-time recipients, 1990-2024. Jeffries: $1,742,105. https://www.opensecrets.org/industries/recips?cycle=Career&ind=Q05

[26] Sludge, Q1 2025 FEC filing analysis. Jeffries Victory Fund ~$1.2M from hedge fund/PE donors. Henry Laufer (Renaissance Technologies): $300,700.

https://readsludge.com/

[27] Sludge, November 25, 2025. Jeffries WNYC statement on AIPAC limits. AIPAC conduit via Democracy Engine, $1M+ earmarked. https://readsludge.com/2025/11/25/jeffries-misleads-on-aipac-pac-money/

[28] House Clerk Roll Call 152, April 20, 2024 (H.R. 8034, $26.38B, 366-58). House Clerk Roll Call 172, May 1, 2024 (H.R. 6090, 320-91). Ceasefire rejected November 9, 2023 (Wikipedia, multiple outlets). Met Netanyahu April 24, 2025 (ABC News). Harvard protest June 16, 2025 (Mass Peace Action). Ceasefire call July 25, 2025 (jeffries.house.gov official statement). J Street endorsement August 2025 (Wikipedia, J Street). JCPOA counter-evidence 2015. https://clerk.house.gov/Votes and https://jeffries.house.gov/2025/07/25/leader-jeffries-statement-on-the-humanitarian-crisis-in-gaza/

The last article followed the people. Where they went after they left office. Who hired them. What they were paid. This one follows the money in the other direction. Not what happens after. What happens before.

The check arrives before the vote. You can look it up. It is a filing.

Brett Guthrie represents Kentucky’s Second District. He has served in Congress since 2009. For most of that time, nobody outside of Bowling Green had heard of him. He did not generate headlines. He did not appear on cable news. He did not tweet anything that went viral.

What he did was climb the committee ladder.

Guthrie joined the House Energy and Commerce Committee. He became chair of the Health Subcommittee. In January 2025, he became chair of the full committee. Energy and Commerce oversees pharmaceutical regulation, Medicare, Medicaid, and drug pricing. It is the committee that decides which bills reach the floor and which die in markup.

His pharmaceutical industry contributions tracked almost exactly with each step up.

As a backbencher, the numbers were modest. As Health Subcommittee chair, they grew. As full committee chair, they reached $507,000 from pharmaceutical and health product interests in a single cycle. His career total from the sector now exceeds $1.8 million, among the highest of any currently serving Republican House member. [1]

His first major act as chair was introducing H.R. 7174, the Ensuring Pathways to Innovative Cures Act. The name alone is doing a lot of heavy lifting. The bill would extend the exclusion period for small-molecule drugs from Medicare price negotiation, pushing it from 7 years to 11. If it had been in effect when the Inflation Reduction Act passed, more than half the drugs currently being negotiated would not have been eligible. CMS projected the negotiation program would save Medicare beneficiaries billions in 2026 alone, with additional multi-billion-dollar savings from the next round of negotiations in 2027. [2]

PhRMA lists that timeline extension as a lobbying priority. The man who chairs the committee that controls the bill received more pharmaceutical PAC money than anyone else in Congress that cycle. [3]

The money does not follow the vote. The money finds the committee seat, and the vote follows.

This is not one party’s problem.

In the 2024 election cycle, the pharmaceutical and health products industry gave $82.83 million in political contributions. The split: 57.88 percent to Democrats. 41.45 percent to Republicans. [4]

The American Hospital Association spent $32 million on lobbying in 2025. The American Medical Association spent $24.8 million. PhRMA spent $27.5 million. [6] Their priorities do not always overlap, but their method is identical: fund the committee members who control your legislation, and fund them proportionally to their influence over your bottom line.

The industry does not pick sides. It picks committee chairs. It picks swing votes. It picks the person whose signature appears on the markup. And when that person moves to a new committee, the money adjusts.

Scott Peters, a Democrat from California, sat on the Energy and Commerce Committee. In the 2023-2024 cycle, he received $343,640 from pharmaceutical and health product interests. He co-wrote a letter with Guthrie warning against the most aggressive drug pricing provisions in H.R. 3. He co-sponsored the MINI Act, which would delay certain drug negotiations. [5]

A Republican and a Democrat on the same committee, co-signing the same letter, funded by the same industry.

Max Baucus chaired the Senate Finance Committee during the Affordable Care Act negotiations. From 2003 to 2008, his health and insurance sector contributions totaled $3.4 million, nearly one-fourth of everything he raised during that period. [7] That part of the story was told in the last article. Here is the part that was not.

As a senior Finance Committee staffer, Forbes worked on the 2003 Medicare Part D legislation that included the provision banning Medicare from negotiating drug prices. Forbes left the Senate and registered as a lobbyist for PhRMA. During the 2009 ACA debate, he lobbied to defend the very provision he had helped write. [8]

A Sunlight Foundation investigation found that 37 former Baucus staffers had become lobbyists, second only to Mitch McConnell’s office. Five of them represented 27 health and insurance organizations during the ACA negotiations. None appeared on Baucus’s official meeting schedule. [9] They did not need to. They operated through their client organizations’ CEOs, who did. You could sit in the hearing room and watch the senators ask questions that their former employees had written the talking points for, on the other side of the table.

The staff member writes the provision. The chairman collects the contributions. The staffer crosses over to defend the provision from the industry side. The chairman moves on. The provision remains.

Marsha Blackburn of Tennessee introduced a bill in 2016 that the DEA’s own chief administrative law judge later warned would weaken enforcement against drug distributors. The agency’s internal assessment described it as the greatest reduction in the Attorney General’s drug enforcement authority in decades. The bill passed both chambers unanimously. President Obama signed it without a photo op. [10]

Blackburn had received $1.38 million from pharmaceutical interests over her career. An additional $120,000 came specifically from opioid manufacturers and distributors between 2013 and 2017, including McKesson, Cardinal Health, and AmerisourceBergen. [11]

When asked whether she would return the money, she called the suggestion “completely absurd.” To be fair, $120,000 spread across four years is not a lot of money for a law that reshaped federal drug enforcement. If anything, it was a bargain.

The bill was bipartisan. Democrats co-sponsored it. Nobody voted against it. The only people who objected were the DEA agents who could no longer use their primary enforcement tool. Their objection was documented in an internal memo. The memo was leaked to the Washington Post and 60 Minutes. Congress did not revisit the law.

Pat Tiberi served as a Republican congressman from Ohio for 17 years. He sat on the House Ways and Means Committee, where he chaired both the Health Subcommittee and the Tax Policy Subcommittee. In October 2017, he resigned from Congress. His last legislative act was helping pass the Tax Cuts and Jobs Act. [12]

By January 2018, he was President and CEO of the Ohio Business Roundtable, an advocacy organization representing Ohio’s largest corporate CEOs. His 2023 compensation, per the organization’s Form 990: $979,304 in base salary, $1,033,835 total. [13] Down to the dollar. On a form anyone can download from the IRS. In 2024, he publicly urged Ohio’s congressional delegation to extend the tax provisions he had helped write. [14]

The tax-writing committee member now runs the organization that lobbies the tax-writing committee.

Collin Peterson served as a Democratic congressman from Minnesota for 30 years. He chaired the House Agriculture Committee. After losing his seat in 2020, he started the Peterson Group, his own consulting and lobbying firm. He also joined Combest, Sell and Associates, the largest agriculture lobbying operation in Washington. [15]

Peterson told the Red River Farm Network: “I’m not wild about being a lobbyist. I will be giving them strategies and consulting with them on ideas.” [16] By 2025, OpenSecrets listed him as a registered lobbyist with nine clients. He named the firm after himself.

Two committee chairs. Two parties. One designed the tax code, the other regulated the farm bill. Both now work for the industries their committees oversaw.

This is what the pipeline produces. Not corruption in the traditional sense. Nobody passes an envelope under a table. The contribution is filed with the FEC. The vote is recorded in the Congressional Record. The committee assignment is posted on the House website. The lobbying registration is searchable on OpenSecrets. Every piece of it operates in daylight, and you can pull the receipts from your phone while you are standing in line at the grocery store.

The system still produces the same outcome every time: the industry that funds the committee chair gets the legislation the committee chair controls. Nothing that happened was illegal. The rules were written to make sure of that.

The next article is about who writes the rules.

The final article in this series catalogs the armor. Every shield. Every pattern. Every mechanism that protects the people who built this system from the people who pay for it.

SOURCES

[1] OpenSecrets, Brett Guthrie career contributions, pharmaceutical and health products industry. STAT News, February 2025. Sludge, December 2024. $507,000 figure represents 2024 cycle total from pharma/health products PACs.

[2] Families USA analysis of H.R. 7174 impact. CMS estimates for Medicare Drug Price Negotiation Program savings, 2026-2027. Guthrie press office, H.R. 7174 text.

[3] STAT News, “Claims of Pharma PAC Contributions to Sanders, Warren Overblown,” February 2025. PhRMA lobbying disclosure filings.

[4] OpenSecrets, pharmaceutical and health products industry contributions, 2024 cycle. Split: 57.88% Democratic, 41.45% Republican.

[5] OpenSecrets, Scott Peters (D-CA) contributions 2023-2024. Jacobin, March 2024. Peters-Guthrie joint letter on H.R. 3 pricing provisions.

[6] OpenSecrets, lobbying spending totals 2025. AHA $32M, AMA $24.8M, PhRMA $27.5M.

[7] Montana Standard, June 2009 (Lee Newspapers State Bureau, sourced from Center for Responsive Politics / OpenSecrets). Democracy Now, June 16, 2009. Figure covers Baucus campaign committee and Glacier PAC, January 2003 through 2008. Breakdown: $853,000 pharma, $851,000 health professionals, $784,000 insurance, $467,000 hospitals/nursing homes, $466,000 health services/HMOs.

[8] Sunlight Foundation, “The Legacy of Billy Tauzin,” February 2010. ProPublica, “Medicare Drug Planners Now Lobbyists,” October 2009. Forbes registration as PhRMA lobbyist confirmed via OpenSecrets and National Review.

[9] Sunlight Foundation, June and July 2009. OpenSecrets, April 2013 (37 Baucus staffers became lobbyists). Meeting schedule analysis confirmed five named staffers absent from official logs.

[10] Washington Post / 60 Minutes joint investigation, October 2017. DEA internal assessment. Congressional Record (unanimous passage).

[11] Washington Post / 60 Minutes joint investigation, October 15, 2017. Blackburn donations from opioid industry 2013 to June 2017: $120,000. OpenSecrets, Marsha Blackburn career pharmaceutical contributions ($1.38M). Individual confirmed figures: $17,500 from Cardinal Health, $15,000 from McKesson (American Bridge PAC / USA Today reporting, 2018).

[12] Wikipedia, Pat Tiberi. Ballotpedia. Governor’s Office of Workforce Transformation biography.

[13] ProPublica Nonprofit Explorer, Ohio Business Roundtable Form 990, filed November 2024 (2023 fiscal year). CEO compensation: $979,304 base, $1,033,835 total.

[14] Ohio Business Roundtable press release, “Pat Tiberi Urges Ohio Congressional Delegation to Support Bipartisan Tax Package,” January 2024.

[15] Agri-Pulse, “Peterson joins Combest Sell firm,” March 2021. Park Rapids Enterprise, March 2021. The Peterson Group website.

[16] Red River Farm Network, March 2021. Park Rapids Enterprise, March 2021.

[17] OpenSecrets, Collin Peterson lobbying profile, 2025. Nine clients listed.

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The last article asked why we do not chase villains. This one shows where the villains go after they leave.

Not to jail. Not to retirement. To the industry they just finished regulating.

The path is so well worn it has a name. Washington calls it the revolving door. That makes it sound like an accident, like somebody got turned around on their way out. Nobody gets lost. They leave through the front door with a job offer in hand.

Washington calls it public service. K Street just calls it onboarding.

---

Billy Tauzin represented Louisiana’s Third Congressional District for 25 years. In his final term, he chaired the House Energy and Commerce Committee. That committee wrote Medicare Part D, the prescription drug benefit that passed in 2003. Built into the law was a single provision that would shape pharmaceutical pricing for the next two decades: Section 1860D-11, which prohibited Medicare from negotiating drug prices. [1]

The Congressional Budget Office later estimated that allowing Medicare to negotiate would have saved more than $450 billion over ten years. [2]

Tauzin left Congress in January 2005. The same day his term ended, he started his new job as president and CEO of PhRMA, the pharmaceutical industry’s trade association. [3] His salary was reported at $2 million per year. In 2010, his final year at PhRMA, his compensation reached $11.6 million. Bloomberg confirmed it made him the highest-paid lobbyist among groups involved in the healthcare debate. [4]

Between those two jobs, Tauzin brokered one more deal. During the 2009 Affordable Care Act negotiations, he sat across from White House Deputy Chief of Staff Jim Messina and secured a cap: the pharmaceutical industry would contribute $80 billion in cost reductions to the ACA. In exchange, two provisions would stay off the table. Drug reimportation from Canada. And Medicare price negotiation. [5]

The man who wrote the law banning negotiation became the man who defended it. And he was paid $11.6 million in a single year to do so.

They are not selling access. They are selling memory. Committee memory. Regulatory memory. All the phone numbers you collect in the name of serving the public.

---

That is one door. Here is a hallway full of them.

Don Nickles served as a Republican senator from Oklahoma for 24 years. He sat on the Senate Finance Committee. He helped shape Medicare Part D alongside Tauzin. After leaving the Senate in 2005, he founded the Nickles Group, a lobbying firm. Its clients include pharmaceutical companies. Between 2018 and 2025, the firm reported $59.2 million in total lobbying income, with $7.87 million in 2023 alone. [6]

John Breaux served as a Democratic senator from Louisiana. He also sat on the Finance Committee. He also helped shape Part D. He also left the Senate and became a lobbyist. His firm, the Breaux Lott Leadership Group, received $300,000 from pharmaceutical clients in 2009 while lobbying on the Affordable Care Act. ProPublica documented that at least 25 former members or staffers who helped write Part D later registered to lobby for the pharmaceutical industry during the ACA debate. [7]

Two parties. Same committee. Same law. Same exit.

Richard Burr served as a Republican senator from North Carolina for nearly 28 years. For much of that time he sat as either Chair or Ranking Member of the Senate Health, Education, Labor, and Pensions Committee: the committee that controls pharmaceutical and healthcare legislation. Burr left the Senate in January 2023. By February, he was at DLA Piper as Principal Policy Adviser and Chair of their Health Policy Strategic Consulting Practice. [20] DLA Piper’s confirmed healthcare clients include Genentech, Braun Medical, Biohaven, and Intra-Cellular Therapies. He is barred from lobbying his former colleagues for two years. He does not actually need to. “Strategic consulting” on health policy for pharmaceutical clients is not lobbying. It is the same expertise with a different business card. The Washington Examiner called it the Great 2023 Cashout. [21]

Louisiana sent four members through the door in one decade. Tauzin, Breaux, Landrieu, Vitter. Both parties. Both chambers. Pharma, energy, environment, finance. Louisiana ranks near the bottom in education, healthcare, and median income. It currently holds both the Speaker of the House and the Majority Leader. In most states that record would be a scandal. In Louisiana it is a parade. Huey Long said every man a king. He was off by one word. Every chairman a consultant.

Kevin Brady chaired the House Ways and Means Committee for six years. In that role, he was the chief architect of the 2017 Tax Cuts and Jobs Act, the first major rewrite of the federal tax code since 1986. [27] The law cut the corporate tax rate from 35 percent to 21 percent, restructured the treatment of pass-through income, and created new deductions for specific industries. Many of its provisions were written with built-in expiration dates, set to sunset in 2025. Brady left Congress in January 2023. In May 2024, Akin Gump announced he was joining as a Senior Consultant in their Lobbying and Public Policy practice. [28] His focus: advising clients on the extension and modification of the tax law he wrote. The Hill called the hire a strategic move “ahead of the tax fight.” [29] The man who designed the expiration dates is now paid to influence what replaces them.

The Lobbying Disclosure Act was supposed to slow this down. It requires registration for anyone who spends more than 20 percent of their time on lobbying activities. The result was not compliance. The result was “strategic adviser.” Tom Daschle, the former Senate Majority Leader, proved how well the workaround works. After losing his seat in 2004, he joined Alston and Bird at $2.1 million per year and advised healthcare companies for eleven years without registering as a lobbyist. The loophole became so notorious that Politico ended up naming it after him: the Daschle Loophole. [8] [9] Burr uses it. Sinema uses it. Manchin uses it. The title changes. The function does not.

---

Sometimes they write the law and cash out. Sometimes they skip the word “lobbyist” and cash out anyway. Sometimes they regulated the industry for two years and joined the board before the chair was cold.

Now watch what happens when the door swings from the regulatory side.

Scott Gottlieb led the Food and Drug Administration for two years, from May 2017 to April 2019. During that time, the FDA regulated every major pharmaceutical manufacturer in the country. Eighty-three days after leaving the agency, Gottlieb joined Pfizer’s board of directors. [11]

In November 2025, he joined UnitedHealth Group’s board as well. The nation’s largest health insurer. A former drug regulator now sits on the boards of both a pharmaceutical manufacturer and a health insurance company. [12]

Evan Bayh served as a Democratic senator from Indiana. He sat on the Banking, Housing, and Urban Affairs Committee and the Armed Services Committee. In the Senate, he voted against a procedural motion to advance carried interest reform. Seven months later, he joined Apollo Global Management as a senior adviser. [13]

Apollo, through its LifePoint and ScionHealth platforms, controls approximately 71 rural hospitals.

Pat Toomey served as a Republican senator from Pennsylvania. He sat on the Banking and Finance Committees. During the 2017 Tax Cuts and Jobs Act negotiations, Toomey helped preserve the carried interest loophole. Industry lobbyists called him an “all-star” in that fight. [14] In February 2023, less than a month after leaving the Senate, Toomey joined the board of Apollo Global Management. His first-year compensation included $600,000 in restricted stock and a $150,000 cash retainer. [15]

Joe Manchin served as a Democrat, then an independent senator from West Virginia. He chaired the Senate Energy and Natural Resources Committee. He left the Senate in January 2025. On February 6, Apollo announced that Manchin would serve as an adviser to the firm and join the board of Athene Holding, Apollo’s insurance subsidiary. [30] His advisory focus: energy markets. While Manchin was in the Senate, his daughter Heather Bresch was CEO of Mylan Pharmaceuticals. Between 2007 and 2016, Mylan raised the price of the EpiPen from roughly $100 to more than $600. Bresch’s compensation rose from $2.4 million to $18.9 million over the same period. [24] Manchin received $127,000 in campaign contributions from Mylan executives. [25] His wife, Gayle Manchin, led the National Association of State Boards of Education and pushed to require schools to stock EpiPens. [26] Manchin sat on committees with jurisdiction over pharmaceutical pricing. He did not move to cap the price. Mylan later paid $465 million to settle federal claims that it had overcharged Medicaid by $1.27 billion. Nobody went to jail. Bresch retired in 2020. Manchin left the Senate in 2025 and joined Apollo.

Three senators. Three different political affiliations. The same firm. Bayh arrived in 2016. Toomey in 2023. Manchin in 2025. Apollo does not have a political preference. It has a hiring pattern.

---

Eric Cantor served as House Majority Leader from 2011 to 2014, the second-ranking position in the House. He controlled which legislation reached the floor: financial reform bills, derivative regulations, capital rules. What advanced and what died quietly in committee was, for years, largely his call. Cantor lost his primary in June 2014 and left Congress on August 18th. Within weeks, Moelis and Company announced he was joining as Vice Chairman and Managing Director. His package: a $400,000 base salary, a $400,000 signing bonus, $1 million in stock options, a minimum $1.2 million cash incentive in year two, and a New York City apartment paid for by the firm. Reported total: $3.4 million. [22] Dennis Kelleher, CEO of financial reform group Better Markets, said Cantor would now be fighting against the same capital rules and carried interest reforms he had helped block in Congress. [23] Cantor did not object. He took the job.

Kyrsten Sinema of Arizona left the Senate in January 2025. By March, she was a senior adviser at Hogan Lovells, a global law firm with $2.96 billion in annual revenue. She does not register as a lobbyist. Emails subsequently surfaced showing local lobbying activity for an AI data center in Chandler, Arizona. Her former Senate aide, Daniel Winkler, registered as a lobbyist at the same firm. [16]

The door swings both directions. And nobody bothers to lock it behind them.

---

Public Citizen studied the 115th Congress. They found that nearly two-thirds of former members who took private sector jobs went into roles designed to influence federal policy. [19] The revolving door is not an individual scandal. It is a staffing pipeline. The system trains people in government, seasons them with committee assignments and regulatory knowledge, and then the private sector comes back to hire them for exactly the expertise they picked up on the public payroll.

This is not corruption after the fact. It is deferred compensation.

That is why your pharmacy bill survives every election. Why the tax loophole outlasts the congressman who wrote it. The staff changes. The incentive package does not.

The problem is not that the door exists. Every democracy has people who move between public and private life. The problem is that the door is the compensation plan. The congressional salary is the internship. The real paycheck comes after.

Tauzin: $11.6 million. Brady: hired to lobby on the tax law he wrote. Toomey: $750,000 in his first year at Apollo. Cantor: $3.4 million before the first performance review. Gottlieb: board seats at Pfizer and UnitedHealth. Bresch: $18.9 million in the same year her father’s committees declined to act.

These are not exceptions. These are the top performers.

---

They do not leave government despite what they did there. They leave, very specifically, because of it.

The next article in this series follows the money from the other direction: the contributions that arrive before the votes, the committee assignments that determine who gets paid, and the legislative pipeline that connects the check to the chairmanship.

---

**SOURCES**

[1] Social Security Act, Section 1860D-11(i): “the Secretary may not interfere with the negotiations between drug manufacturers and pharmacies and PDP sponsors.” Medicare Modernization Act of 2003.

[2] Congressional Budget Office, H.R. 3 (Elijah E. Cummings Lower Drug Costs Now Act) scoring, December 2019. Projected $456 billion in savings over 10 years.

[3] Sunlight Foundation, “The Legacy of Billy Tauzin: The White House-PhRMA Deal,” February 12, 2010. OpenSecrets Revolving Door profile.

[4] Bloomberg, “Tauzin’s $11.6 Million Made Him Highest-Paid Health-Law Lobbyist,” November 29, 2011.

[5] Sunlight Foundation, February 2010. Bill Moyers, “The Lobbyist Who Made You Pay More at the Drugstore,” March 2016. ProPublica, “Obama’s Deal,” 2009.

[6] OpenLobby, Nickles Group annual revenue 2018-2025. CBS News, “Health Care Lobbyists’ Rise to Power,” 2009.

[7] ProPublica, “Medicare Drug Planners Now Lobbyists, With Billions at Stake,” October 19, 2009. Breaux Lott Leadership Group pharmaceutical client revenue.

[8] Center for Public Integrity, 2009 ($2.1M, Alston and Bird). Tom Daschle financial disclosure filings, 2008.

[9] Politico, “Tom Daschle finally registers as a lobbyist,” March 2016. Public Citizen, “Revolving Congress,” June 2019.

[11] CNBC, “Former FDA Commissioner Scott Gottlieb joins Pfizer’s board of directors,” June 27, 2019. FDA departure: April 5, 2019. Pfizer board: June 27, 2019. 83 days.

[12] Healthcare Dive / Fierce Pharma, November 2025. UnitedHealth Group board appointment.

[13] Associated Press, October 2016. Mother Jones, May 2022. Politico, September 2016. OpenSecrets, Bayh revolving door profile.

[14] The Lever, “Private Equity’s Senator Gets Big Payout,” February 22, 2023.

[15] Jacobin, “Former Senator Pat Toomey Has Walked Through the Revolving Door,” February 27, 2023. Bloomberg, Apollo director compensation structure.

[16] Reuters/Politico, 2025. AZFreeNews, 2025. Hogan Lovells 2024 revenue: $2.96 billion.

[19] Public Citizen, “Revolving Congress: The Revolving Door Class of 2019 Flocks to K Street,” June 2019.

[20] Bloomberg Law, “Ex-Senator Richard Burr Joins DLA Piper as Health Policy Leader,” February 2023. DLA Piper press release, February 7, 2023. STAT News, “Richard Burr to join health care practice at law and lobbying firm,” February 7, 2023.

[21] Washington Examiner, “The Great 2023 Cashout begins with Richard Burr joining lobbying giant DLA Piper,” February 2023.

[22] TIME, “Eric Cantor Joins Wall Street Investment Bank Moelis and Company,” September 2014. Newsweek, “Eric Cantor Lands $3.4 Million Investment Banking Job,” September 2014.

[23] Fortune, “What’s really outrageous about Eric Cantor’s Wall Street gig,” September 4, 2014.

[24] Washington Post, “Senator’s daughter who raised price of EpiPen got paid $19 million salary, perks in 2015,” August 24, 2016. NBC News, “Mylan CEO’s Pay Rose Over 600 Percent as EpiPen Price Rose 400 Percent,” August 2016.

[25] The Intercept, “Heather Bresch, Joe Manchin’s Daughter, Played Direct Part in EpiPen Price Inflation Scandal,” September 7, 2021. NRSC, “Mylan executives open up wallets for Manchin,” April 2018.

[26] The Intercept, September 7, 2021. Washington Free Beacon, “Government Funds to Mylan Spiked After Manchin’s Daughter Became CEO.”

[27] Tax Foundation, “The Tax Cuts and Jobs Act,” December 2017. Joint Committee on Taxation scoring.

[28] Akin Gump press release, “Former Ways and Means Committee Chairman Kevin Brady Joins Akin’s Lobbying and Public Policy Practice,” May 2024.

[29] The Hill, “Lobbying World: Akin snags former Ways and Means chair ahead of tax fight,” May 2024.

[30] Athene Holding / GlobeNewsWire, “Former U.S. Senator Joe Manchin to Serve as Adviser to Apollo and Appointed to Athene Board of Directors,” February 6, 2025.

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Every time you read something, or hear someone make an argument, there is a set of questions running underneath it whether you realize it or not. Who is this person. What do they actually believe. Who do they work for. Why are they saying this now. What are they really trying to accomplish. Who benefits from you believing it. And what are they not saying.

Those seven questions are the only tools that matter. Every con, every extraction system, every political maneuver that has ever worked on a large number of people worked because it interrupted that sequence before question three.

The interruption has a name. Call it armor.

It does not have to be false. That is the part that takes a minute to sit with. The church attendance is real. The philanthropy is documented. The op-ed was published. The reversal was genuine. None of that matters for the mechanism. Armor only has to answer question one loudly enough that questions three through seven never get asked.

In 1993, Bain Capital acquired a steel mill in Kansas City, Missouri, for $8.3 million. [1] The firm merged it with another plant to form GS Industries, loaded the new company with debt, and began collecting consulting fees. Over the life of the deal, Bain pulled in more than $4.5 million in fees alone. When the company filed for bankruptcy in 2001, 750 workers lost their jobs, their severance was denied, their health insurance disappeared, and the pension fund came up $44 million short — covered in the end by the federal Pension Benefit Guaranty Corporation. [2]

Bain still made money. The firm received $12 million on its $8.3 million investment, plus the consulting fees. The workers received a federal bailout of the pension their employer had underfunded while paying advisory fees to the firm that owned it.

At the time of the acquisition, Mitt Romney was running Bain Capital.

After leaving Bain, Romney ran the Salt Lake City Olympics, became governor of Massachusetts, ran for president twice, won the Republican nomination, and served in the United States Senate. His tax returns along the way showed he gave $7 million to charity over two years, roughly $4.1 million of it to the Church of Jesus Christ of Latter-day Saints. [3] Over a twelve-year period, more than $9 million went to the church. He tithed at or above the expected 10 percent, established a charitable foundation bearing his family’s name, and gave $1 million to Brigham Young University to create an institute of public management named after his father. [4]

None of that is fake. The giving is real. The faith is documented. The foundation files its taxes.

And none of it changes what happened at the steel mill. But it changes whether anyone can make the steel mill stick. That is the function of armor. Not to disprove the record. To make it irrelevant.

Some armor goes further. Speaker Mike Johnson has stated publicly that the Bible is his worldview and that he runs legislative decisions through Scripture. Oil and gas has been his top contributing industry since he entered Congress, and his lifetime League of Conservation Voters score is 2 percent. [24] When his constituents ask why he votes the way he does, the answer available to them is God. Technically, God did create the oil. Bob Menendez stood outside a Manhattan federal courthouse in July 2024, while a jury deliberated on 16 counts of bribery, extortion, and obstruction, and told reporters: “I have faith in God and the jury.” He was convicted on all 16 counts and sentenced to 11 years. [25] The armor did not prevent the verdict. That is not what armor is for. It is for the people who were never going to read the indictment anyway.

In May 2025, Senator Josh Hawley of Missouri published an opinion piece in the New York Times under the headline “Don’t Cut Medicaid.” He argued that slashing health coverage for the working poor was “both morally wrong and politically suicidal,” and he called on Republicans to ignore the Wall Street wing of the party pushing for cuts. [26]

Seven weeks later, Hawley voted for the One Big Beautiful Bill Act.

The Congressional Budget Office estimated the bill would cut federal Medicaid spending by $1.02 trillion over ten years, the largest rollback of the program in its history. [27] Two weeks after casting that vote, Hawley introduced legislation to undo some of the Medicaid cuts he had just helped pass. [28]

The op-ed is still on the Times website. The vote is in the congressional record. Both exist simultaneously because they serve different audiences. His career total from the Republican and conservative ideological donor network is $5.8 million. [20]

The op-ed and the vote do not contradict each other. They complete each other.

Now do the same exercise on the other side of the aisle.

In January 2017, Senator Cory Booker of New Jersey voted against an amendment co-sponsored by Bernie Sanders and Amy Klobuchar that would have allowed Americans to import prescription drugs from Canada. [5] The amendment failed.

Booker’s stated reason was safety concerns about imported pharmaceuticals. It was the same argument the Pharmaceutical Research and Manufacturers of America had been making for years.

Over the six years before that vote, Booker received $267,338 from pharmaceutical manufacturing companies, more than any other Democratic senator who voted against the amendment. [6] His career total from pharmaceutical and health product interests, including his leadership PAC, reached approximately $468,000. [7]

That is the behavior. Here is the armor.

Booker later reversed his position, co-sponsored a drug reimportation bill with Sanders, and stopped accepting pharmaceutical PAC money. In 2019, during a presidential debate, he claimed he did not take money from the pharmaceutical industry. When it surfaced that he had recently accepted a donation from a pharma executive, he returned it on the spot. [8]

The reversal itself became the shield. He listened. He evolved. He grew. That is the language his supporters used, and it worked. The vote was reframed as a learning moment, not a data point. The $267,338 became backstory. The new position became the story.

You can prove the math. You can prove the behavior. You can prove the incentive structure. What you cannot do is get past the personal brand someone has built to insulate themselves from accountability. The church attendance. The philanthropy. The foundation with their name on it. The public evolution. That is armor. And the system is designed so that proving motive does not matter anyway, because everything they did was technically legal, technically rational, technically within the rules of the game they wrote.

You do not have to believe that Romney wanted 750 steelworkers to lose their pensions. You do not have to believe that Hawley published a piece calling Medicaid cuts morally wrong and then voted for them anyway because the donor math said to. You do not have to believe that Booker voted against drug importation because a pharmaceutical company wrote him a check.

Motive is speculation. Behavior is documented.

Romney’s firm collected consulting fees from a company while its pension went unfunded. Hawley wrote in the New York Times that cutting Medicaid was morally wrong, then voted to cut it by a trillion dollars seven weeks later. Booker voted the same way as the industry that paid him more than any other Democrat in the room. Three documented records. Three different armor types. The same result each time.

Neither of them broke a law. Neither of them violated a rule. The rules were already written to make what they did legal. That is the system working as designed.

If you need proof that this is not about individuals, look at the one tax loophole that connects both sides of this equation.

Carried interest is the provision that allows private equity managers to pay capital gains tax rates on their income instead of ordinary income rates. Three presidents promised to close it. Barack Obama called it a loophole. Donald Trump called it unfair. Joe Biden put it in his budget proposal. [9]

It survived all three.

In 2017, Senate Republicans passed the Tax Cuts and Jobs Act. Senator Pat Toomey of Pennsylvania helped preserve the carried interest provision during negotiations, with private equity lobbyists calling him an “all-star” in that fight. [10] Less than a month after leaving the Senate, in February 2023, he joined the board of Apollo Global Management, with first-year compensation that included $600,000 in restricted stock and a $150,000 cash retainer. [11]

In 2022, the Inflation Reduction Act included a partial fix. Senator Kyrsten Sinema of Arizona removed it from the bill during final negotiations, having received more than $500,000 from private equity interests that cycle. Senate Majority Leader Chuck Schumer, who said there was “no choice” but to accept the change, had received $1.2 million from the same sector. [12]

In the years before all of this, Senator Evan Bayh of Indiana voted against a procedural motion on carried interest reform, then joined Apollo Global Management as a senior advisor seven months later. [13]

Two senators. Two parties. The same firm.

Private equity firms gave $83 million to Democrats and $62 million to Republicans over two election cycles. [14] When House Republicans wrote their reconciliation bill in 2025, they left carried interest untouched as well. [15]

Three presidents. Both parties. Two decades. The loophole outlasted every one of them.

Apollo Global Management, through its LifePoint and ScionHealth platforms, controls approximately 71 rural hospitals. You have been reading about those hospitals for three articles.

And those hospitals are one thread. The system is the whole cloth.

Scott Gottlieb spent two years as FDA Commissioner, regulating every major drug company in the country, then joined Pfizer’s board 83 days after his last day in office. [16] Rick Scott ran the hospital chain that committed the largest healthcare fraud in American history: $1.7 billion in fines, $9.88 million in personal severance, and 75 invocations of the Fifth Amendment in a civil deposition, before going on to serve as governor of Florida and then as a United States senator who votes on healthcare legislation. [17]

Joe Manchin of West Virginia blocked drug pricing reform in the Senate while his daughter, as CEO of Mylan, oversaw a 400 percent increase in the price of the EpiPen. Mylan settled with the Department of Justice for $465 million. [18] Marsha Blackburn of Tennessee introduced a bill in 2016 that the DEA’s own internal memo called the greatest reduction in the Attorney General’s drug enforcement authority since 1970, having received $1.38 million from pharmaceutical interests over her career. [19]

Max Baucus of Montana chaired the committee that shaped the Affordable Care Act while collecting $3.4 million from the health and insurance sector. His former staffer Jeff Forbes helped write the provision banning Medicare from negotiating drug prices, then registered as a lobbyist for PhRMA and defended it. [20]

Five names. Both parties. Not one of them broke a law.

This is why we do not chase villains.

Not because there are no bad actors. There are. Not because accountability does not matter. It does. But because the system does not need villains to function. It needs participants. It needs consulting fees that are legal. Votes that are funded. Tax provisions that survive every election. It needs the armor to be real, because real armor is the kind you cannot take off someone else.

The receipts do not require you to prove that anyone meant to do what they did. They require you to document that they did it, that it was legal, and that the rules were written to make it that way.

The behavior is documented. The incentive structure is visible. The mechanism has a name now.

That is what this publication does. Not chase the people who play the game. Map the game. Name the interruption. And give you back the seven questions armor is designed to stop you from asking.

The next article in this series follows the political money directly: who funded the campaigns, who wrote the legislation, and what the legislation did to the hospitals in the districts of the people who voted for it.

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SOURCES

[1] Reuters, “Special Report: Romney’s steel skeleton in the Bain closet,” January 2012. Washington Post, “Romney’s Bain Capital record shows mixed record on bankruptcies,” 2011. American Bridge PAC compiled court documents and SEC filings.

[2] Reuters, January 2012. Federal Pension Benefit Guaranty Corporation records. PolitiFact fact-check of Obama campaign ad, May 2012.

[3] TIME, “Tax Returns and Tithing: How Mitt Romney Gives Away 16% of His Income,” January 2012. Christian Science Monitor, January 2012.

[4] Boston Globe, “For Mitt Romney, charity centers on Mormon church,” February 2012. Inside Philanthropy, Romney profile. Huffington Post review of IRS documents.

[5] The Intercept, “Cory Booker Joins Senate Republicans to Kill Measure to Import Cheaper Medicine from Canada,” January 2017.

[6] The Intercept, January 2017. MapLight, pharmaceutical manufacturing industry contributions to Booker, 2011-2016.

[7] OpenSecrets, Cory Booker career contributions from pharmaceutical and health product interests, including leadership PAC ($411,948 direct + $56,000 leadership PAC).

[8] PolitiFact, The Hill, ABC News. Coverage of Booker’s reversal on reimportation, pharma PAC decision, and 2019 debate exchange.

[9] CNBC, NPR, NBC News. Coverage of Obama, Trump, and Biden proposals on carried interest.

[10] The Lever, “Private Equity’s Senator Gets Big Payout,” February 22, 2023. Industry lobbyist quote on Toomey as “all-star” in carried interest fight.

[11] Jacobin, “Former Senator Pat Toomey Has Walked Through the Revolving Door,” February 27, 2023. Bloomberg reporting on Apollo director compensation structure.

[12] Jacobin, “Kyrsten Sinema Got $500K From Private Equity, Then Killed the Carried Interest Tax,” August 2022. OpenSecrets, Sinema and Schumer PE contributions. Truthout, August 2022.

[13] Associated Press, October 2016 (Bayh vote record and Apollo timeline). Mother Jones, May 2022. Politico, September 2016. OpenSecrets, Bayh revolving door profile.

[14] OpenSecrets, private equity industry contributions across 2020 and 2022 election cycles.

[15] NOTUS, May 2025. Reporting on House Republican reconciliation bill omitting carried interest reform.

[16] CNBC, “Former FDA Commissioner Scott Gottlieb joins Pfizer’s board of directors,” June 27, 2019. FDA departure date April 5, 2019; Pfizer board appointment June 27, 2019 (83 days). Pfizer press release, June 27, 2019.

[17] DOJ press release, December 14, 2000 ($840M settlement). DOJ press release, June 26, 2003 ($631M second settlement; total $1.7B confirmed). PolitiFact, “Rick Scott took the 5th Amendment 75 times,” June 2014 (75 invocations confirmed, Nevada Communications Corp. civil deposition, July 27, 2000). Wikipedia/settlement records ($9.88M severance per board settlement).

[18] Truthout/The Intercept, 2021 (Manchin/Mylan connection). DOJ settlement ($465M). Congressional testimony, Heather Bresch.

[19] Washington Post / 60 Minutes, October 2017 (DEA internal memo). OpenSecrets, Blackburn career pharma contributions ($1.38M). USA Today, October 2017.

[20] Montana Standard, June 2009 ($3.4M health/insurance sector). Sunlight Foundation (Forbes/PhRMA lobbying registration). Democracy Now, 2009.

[24] League of Conservation Voters, Mike Johnson member page (2% lifetime score confirmed): https://www.lcv.org/moc/mike-johnson/. Inside Climate News, “League of Conservation Voters’ Take on Speaker Mike Johnson’s Voting Record,” November 4, 2023 (LCV official confirms 2% lifetime score, 4 pro-environment votes out of 160+). OpenSecrets, Mike Johnson career industry contributions (oil and gas top industry): https://www.opensecrets.org/members-of-congress/mike-johnson/industries?cid=N00039106&cycle=CAREER. E&E News, “Republican speaker candidates flush with fossil fuel cash,” October 2023.

[25] New York Post, “Sen. Bob Menendez ‘has faith’ as jurors deliberate,” July 12, 2024. Wikipedia, Bob Menendez conviction and sentencing. [SOURCE VERIFIED — Florida Phoenix and Common Dreams both confirm quote and outcome]

[26] Hawley, Josh. “Don’t Cut Medicaid.” The New York Times, May 12, 2025. Hawley.senate.gov press release, same date.

[27] Center for American Progress, “The Truth About the One Big Beautiful Bill Act’s Cuts to Medicaid and Medicare,” July 2025. CBO, “Estimated Budgetary Effects of Public Law 119-21,” July 21, 2025 ($1.02T confirmed). Signed into law July 4, 2025.

[28] MSNBC/MaddowBlog, “GOP’s Josh Hawley pushes to undo the Medicaid cuts he just voted for,” July 16, 2025. NBC News reporting on Hawley legislation introduced July 15, 2025.

Health sector PACs gave $27 million to Republicans and $25 million to Democrats in the 2023-2024 election cycle. [1] That is not a typo. The split is 52 to 48. In an industry that depends on federal reimbursement rates set by Congress, the money does not pick a side. It picks both sides. Evenly. On purpose.

The American Hospital Association spent $32 million lobbying Congress in 2025. [2] Over the prior twelve months, 18 rural hospitals closed or converted. I am not saying those two numbers are related. I am saying they exist in the same sentence and nobody in Washington seems to find that interesting.

Medicare pays hospitals 83 cents for every dollar it costs to treat a patient. Medicaid pays 88 cents. Rural hospitals see more of those patients than anyone else, and they lose money on nearly all of them. Private equity bought the struggling ones, extracted hundreds of millions, and left the debt behind. More than 200 rural hospitals have closed or converted since 2010. The math was broken. The investors monetized the break. Nobody in Washington fixed either one.

This article is about why.

The easiest version of this story is the one where you blame one party. It is also the wrong one.

Start with the states that refused Medicaid expansion. Seventy-four percent of all rural hospital closures between 2010 and 2021 occurred in states that had not expanded Medicaid or had expanded it for less than a year. [3] Texas leads the nation with 27 closures or conversions. Tennessee, Oklahoma, Mississippi, Alabama, Kansas. The pattern is not subtle.

In Tennessee, there was a plan. Governor Bill Haslam, a Republican, proposed Insure Tennessee in 2014. It was designed for a conservative state. It included work requirements. It had an off-ramp if federal matching funds dropped below a threshold. The state’s hospital associations backed it and agreed to finance the state’s share through an assessment, because they saw it as essential to survival. [4]

Americans for Prosperity spent approximately $300,000 on advertising, town halls, door-to-door canvassing, and phone banking to kill it. Their messaging tied the plan to President Obama and accused Republican lawmakers of breaking their promise to oppose the Affordable Care Act. The plan died in committee. [4]

Tennessee had already lost multiple rural hospitals. By 2018, nine had closed. [4] AFP spent $300,000 to block a plan designed to keep hospitals open. The hospitals closed. The money came from out of state. The closures did not.

In Texas, Governor Greg Abbott rejected Medicaid expansion entirely, calling it a “massive expansion of an already broken and bloated Medicaid program.” [5] Texas built a waiver system instead, one that funds uncompensated emergency care using local hospital district taxes to draw down federal dollars. The structure works for urban hospitals with strong tax bases. Rural districts with weak tax bases got the 83-cent math, plus nothing. Texas has lost more rural hospitals than any state in the country.

The metaphor stayed dry. The counties did not.

Now here is where someone is going to sort this into a partisan bucket and feel finished. Do not get comfortable.

The Affordable Care Act expanded Medicaid coverage. It did not fix the reimbursement rate. Medicare still pays 83 cents. Medicaid still pays 88 cents. No administration, Democratic or Republican, has fixed the underlying gap. The ACA turned zero-dollar patients into 88-cent patients. That is an improvement. It is not a solution. In expansion states, 35 percent of rural hospitals are still operating at a loss. [3]

Massachusetts expanded Medicaid. Massachusetts has a Democratic governor, a Democratic legislature, a Democratic attorney general, and a city council that voted 12 to 0 to try to save Carney Hospital. Carney closed anyway. The coverage was there. The building was not. The reimbursement math does not check voter registration.

The rate is the constant. Expansion is one variable. One side refused the variable and made the math worse. The other side accepted the variable and called it a fix. The math kept running.

One side can refuse Medicaid expansion and make the hole deeper. The other side can preserve the hole and call it a compromise. The hole appreciates the nuance.

This past July, the One Big Beautiful Bill became law. The Congressional Budget Office estimates it cuts Medicaid and ACA spending by more than $1 trillion over ten years and leaves approximately 10 million more people uninsured. [6]

The same law includes a $50 billion Rural Health Transformation Program. Five years of funding. Ten billion a year. On paper, that sounds like an offset. It is not.

The NRHA and Manatt Health project that rural hospitals will lose approximately 21 cents of every Medicaid dollar they currently receive. [7] The fund does not cover the cuts it was designed to offset. They named it after the thing it does not do.

States can only devote 15 percent of RHTP funds to direct patient care payments. The rest must go to “innovative projects and technologies.” Rural hospital associations in Colorado, Michigan, and Nebraska stated publicly that the program will not save a single hospital. [8] Transformation is a lovely word when you are trying not to say subtraction.

The fund was not enough. Then it got conditions.

By December 2025, the administration began distributing RHTP funds with conditions. Twelve billion dollars of the five-year total is tied to whether states implement health policies aligned with the Make America Healthy Again initiative, including banning the use of SNAP benefits for certain foods and requiring schools to participate in the Presidential Fitness Test. The administration can claw back funds annually if states do not deliver on promised policies. [9]

The rural hospital fund is now a policy lever. The hospitals are the collateral.

And it is already happening. In northeast Georgia, a hospital closed its maternity ward. In rural New Hampshire, a community health center shuttered. In Iowa, a Des Moines hospital system laid off employees and closed a clinic. Hospitals are not waiting for the Medicaid provisions to take full effect. They are cutting now, because the math is already moving. [10]

Rep. Jodey Arrington of Texas is the House Budget Committee chair. The Texas Observer calls him the “House architect” of the One Big Beautiful Bill. [11]

Arrington’s district covers rural West Texas. It contains 25 rural hospitals. Six of those hospitals are categorized as at risk of closing. [11]

He received $13,000 from AHA-linked sources in the 2024 cycle while designing the bill. [11] Thirteen thousand dollars. That is not a bribe. That is a rounding error in a PAC budget. And it did not need to be more than that, because the system does not run on bribes. It runs on access. The money does not buy the vote. It buys the meeting. The meeting is where the math gets set.

Down in Alabama, ALEC published an op-ed in Yellowhammer News arguing that Medicaid expansion is a “mirage” that will not save the state’s rural hospitals. [12] Alabama has had five or more rural hospital closures since 2010. Alabama still has not expanded Medicaid. Peer-reviewed studies consistently find that expansion improves rural hospital finances and reduces closure probability.

They called the solution a mirage in the state that most needs the water.

I want to be precise about what this article is saying, because it would be easy to read it as “both sides are the same” and move on. That is not the claim.

The states that refused expansion made the crisis measurably worse. That is documented. Seventy-four percent of closures in non-expansion states is not a coincidence. AFP spending $300,000 to kill a plan that Tennessee hospitals said would keep them alive is not a policy disagreement. It is a receipt.

But the reimbursement rate that makes rural hospitals structurally unprofitable has survived every administration since it was set. Democratic congresses have not raised it. Republican congresses have not raised it. The AHA has spent over $90 million lobbying in the last three years and the rate has not moved. [2] The PAC money flows to both parties because the system serves both parties. Not as a conspiracy. As an equilibrium.

Health sector PACs gave $25 million to Democrats and $27 million to Republicans. [1] That is not conviction. That is portfolio management.

The country argues red versus blue while the money behaves like beige.

This is the last of four articles I wrote about why rural hospitals close. The reimbursement math. The private equity extraction. A specific hospital in a specific neighborhood. And now the political money that keeps all of it in place.

The mechanism does not have a party. It has a payment rate, a lobbying budget, and a PAC split that covers its bets. One side can refuse to expand coverage and accelerate the closures. The other side can expand coverage and leave the rate untouched. The hospital closes either way. The paperwork just changes accents.

417 rural hospitals are flagged as financially vulnerable right now. [3] The number has not gotten smaller in a decade. The reimbursement rate has not gotten higher. The lobbying spend has not gotten lower. The PAC split has not gotten less even.

If you are waiting for me to tell you whose fault this is, I cannot do that. Not because I do not have opinions. Because the receipts do not support a clean answer. The receipts support a system. The system does not need a villain. It needs both teams to keep playing, and both teams keep showing up, and the check clears either way.

The math was not designed to close rural hospitals. It was designed for a system where someone else would cover the difference. In a rural county where the median age is 58 and the largest employer left in 2009, there is no one else.

In Washington, where the PAC checks arrive on time and the lobbying meetings stay on the calendar, there is everyone else. They just have somewhere else to be.

SOURCES

[1] OpenSecrets: Health Sector PAC Contributions, 2023-2024 Cycle. Total: $52.2 million. Democrats: $25.0 million. Republicans: $27.0 million.

[2] OpenSecrets: American Hospital Association Federal Lobbying. 2023: $30.2 million. 2024: $29.0 million. 2025: $32.0 million.

[3] Chartis Center for Rural Health: 2026 State of the State. 417 vulnerable rural hospitals. In non-expansion states: 52.2% operating at a loss. In expansion states: 34.9% operating at a loss. 74% of closures in non-expansion states, 2010-2021 (AHA fact sheet). Texas: 27 closures or conversions.

[4] NBC News: Koch Group Shows Its Power in Tennessee, February 2015. AJMC: Why Did Tennessee’s Medicaid Expansion Plan Fail?. Tennessee hospital closure data from UNC Sheps Center.

[5] Texas Tribune: Abbott Holds Firm Against Medicaid Expansion, April 2015. Texas Tribune/Public Health Watch: Why Do Texas Republicans Still Oppose Medicaid Expansion?, November 2022.

[6] KFF: Health Provisions in the 2025 Federal Budget Reconciliation Law. CBO: One Big Beautiful Bill Act Analysis. CBO projects $1+ trillion in Medicaid/ACA spending reductions and 10 million increase in uninsured by 2034.

[7] NRHA and Manatt Health: H.R. 1 and RHTP Advocacy. Rural hospitals projected to lose 21 cents of every Medicaid dollar. NC Health News: Rural Health Transformation Program Won’t Make Up for Federal Budget Cuts.

[8] KFF Health News: Lawmakers, Health Groups Resist State Rural Health Fund Plans, March 2026. CBS News: State Rural Health Transformation Plans. 15% direct patient care cap per RHTP statute.

[9] PBS NewsHour: Trump Administration Rolls Out Rural Health Funding, With Strings Attached, December 29, 2025. $12 billion of RHTP tied to MAHA policy priorities. Annual recalculation with clawback authority.

[10] CNN: Hospitals Are Making Cuts After ‘Big Beautiful Bill,’ Fueling Midterm Fears, March 2, 2026. Georgia maternity ward closure, New Hampshire health center closure, Iowa layoffs and clinic closure.

[11] Texas Observer: West Texas Congressman’s ‘Big Beautiful’ Cuts Could Harm Rural Hospitals in His District, September 2025. OpenSecrets FEC data. Sheps Center analysis. Rep. Jodey Arrington (R-TX-19): 25 rural hospitals in district, 6 at risk. $13,000 from AHA-linked sources, 2024 cycle.

[12] Yellowhammer News: Alabama’s Hospital Crisis and The Medicaid Expansion Mirage, April 2024. ALEC op-ed by Brooklyn Roberts and Rep. Arnold Mooney. Georgetown CCF and Health Affairs studies on expansion and rural hospital financial performance.

This was a four-part series on why rural hospitals close. Part 1: the reimbursement math. Part 2: private equity extraction. Part 3: Carney Hospital. Part 4: the political money.

Every stat is sourced. Every claim is documented. If you want the full research, subscribe. The dossier drops with the show.

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Carney Hospital opened on June 9, 1863, during the Civil War. Its first patients were soldiers. The Daughters of Charity of Saint Vincent de Paul ran it for over a century. A Carney team performed the first abdominal surgery in Boston, and the first plastic hip operation in the United States happened inside that building. For 161 consecutive years, it served the people who walked through its doors.

It closed on a Saturday. August 31, 2024. No ceremony. No buyer. The emergency department shut down the night before. The last patients were transferred. The sign stayed up.

The building is still there.

Carney sat at 2100 Dorchester Avenue, on a 12.7-acre campus in Lower Mills. It was a teaching hospital and a Primary Stroke Service facility, with 122 licensed beds, 50 of them psychiatric, serving adolescent, adult, and geriatric patients. It ran a Clozapine Clinic, one of very few in the area, for patients with severe and persistent mental illness who needed weekly blood draws and close monitoring. It ran a 200-language interpreter service where the top patient languages were Vietnamese, Spanish, Haitian Creole, Cape Verdean Creole, and Cantonese. [1]

Thirty thousand people came through that emergency department every year, the sixth-highest volume ED in Boston. [2] Two hundred and four thousand outpatient visits annually, nearly a thousand of them psychiatric admissions. [1]

The neighborhood it served, Dorchester and Mattapan combined, has 167,000 people. [2] The population is predominantly Black and Latino. Median income is below the Boston average. Premature mortality, deaths before 65, runs double the rate of wealthier neighborhoods. Mattapan has the lowest life expectancy in the city. [2]

Seventy-four percent of Carney’s revenue came from Medicare and Medicaid. [1] This is a safety-net hospital by every definition that exists. The payer mix alone tells you it was never going to generate the margins a private equity firm needs to service debt.

And yet.

Cerberus Capital Management acquired Carney in 2010 as part of the Caritas Christi deal. I covered the acquisition in Article 2. What I did not cover is what happened to Carney inside the system.

The ICU had 16 beds when Steward took over. By the time of closure, it had 4. [3] A recovery nurse who had worked at Carney for 48 years watched the count drop year by year. Four beds. In an ICU! Serving a neighborhood where premature death is twice the city rate.

On June 2, 2021, a 31-year-old man named Gilberto Melendez-Brancaccio was in Carney’s emergency department. He was in a behavioral health crisis, chemically and physically restrained, and having trouble breathing. His doctors ordered continuous one-on-one monitoring.

One sitter was watching three patients. [4]

Gilberto went into respiratory arrest, and nobody was in the room. Federal investigators found that inadequate training and staffing were reasonable contributing factors to his death. [4]

An internal nurse email from September 2023, two years later and nothing fixed, described arriving for a shift to find four nurses for 25 patients. [5] The email said this is seriously dangerous and no one should be expected to work like this.

The hospital was not failing because the community did not need it. Thirty thousand ER visits a year. The hospital was failing because the financial structure it had been placed inside was not designed to keep it open. The 2016 sale-leaseback with Medical Properties Trust sold the Carney property for $263 million. Steward had paid $12.5 million for the same building less than a decade earlier. [6] The money from the sale went to investors, and the rent stayed with the hospital. The payer mix that was nearly three quarters government-funded was now also carrying a lease it could never cover.

The hospital was counting down. The neighborhood just did not know the number yet.

On May 6, 2024, Steward filed for Chapter 11 bankruptcy. Nine billion dollars in debt. [7] The company ran a sale process for its eight Massachusetts hospitals, and Steward’s attorneys said they contacted hundreds of potential buyers.

On July 26, Steward announced that Carney and Nashoba Valley Medical Center in Ayer had received no qualified bids. Both would close by the end of August. [8]

I want to unpack “no qualified bid” because the phrase sounds like nobody showed up. Somebody showed up.

Insight Health System, a physician-owned company from Michigan that runs hospitals for low-income patients, bid on all of Steward’s Massachusetts hospitals, including Carney. Steward rejected it. The company said Insight lacked the financial capacity to actually operate the hospitals. [9] Two people briefed on the process told the Globe that Insight offered virtually no money for operations. Just an agreement to assume the lease payments. [10]

The real obstacle was the building. Apollo Global Management held the mortgage on the property. The campus was assessed at $76 million. Any buyer of the hospital’s operations would still owe rent to Apollo’s real estate structure. For a hospital where nearly three quarters of the revenue comes from government payers that reimburse below cost, there is no business model that covers that rent. The math from Article 1 and the structure from Article 2 arrived at the same address and produced the same answer. [11]

A bankruptcy judge in Houston named Christopher Lopez approved the closure on July 31. He called it painful, said keeping the hospitals open would threaten the entire hospital system in Massachusetts. [12]

A bankruptcy judge in Houston decided whether Dorchester keeps its hospital. I am going to leave that sentence where it is.

Massachusetts state law requires 120 days’ notice before an essential hospital service can close. Steward announced July 26. It closed August 31. That is 36 days. [8]

Federal bankruptcy law overrode the state requirement. Massachusetts officials acknowledged they could not compel Steward to comply. The Attorney General, Andrea Campbell, lives blocks from Carney, and her old city council district included it. She wrote to Steward reaffirming its obligations but did not take enforcement action to compel the hospital to stay open. [13]

The Department of Public Health held a hearing at Florian Hall in Dorchester on August 13. Hundreds showed up. The Steward representative was booed off the podium. [14] The DPH Commissioner told the room the closure feels unfair, then said DPH cannot legally require a hospital to keep a service open to the public. [14]

The Boston City Council voted 12 to 1 for eminent domain. [15] Governor Healey did use eminent domain, but not for Carney. She used it for St. Elizabeth’s Medical Center in Brighton, offering $4.5 million against Apollo’s $200 million assessment. [16] For Carney, she said no qualified operator had stepped forward. The state could seize the property but could not force someone to run a hospital inside it. [17]

So. A 161-year-old hospital with 50 psychiatric beds in a state that already has a psychiatric bed shortage. That hospital closed because a private equity firm loaded it with debt, sold the building, went bankrupt, and no one who could afford the rent wanted to run a safety-net hospital at a loss. The state could not force it to stay open. The city could not force it to stay open. The bankruptcy court in Houston said go ahead and close it.

The market did what markets do. It left.

Here is what the market left behind.

753 people lost their jobs [18], 448 full-time, 131 part-time, 174 per diem. Combined with Nashoba, 1,243 jobs gone.

Boston EMS documented a 20 percent increase in transport times for former Carney-area patients. [2] The nearest ER, Beth Israel Deaconess Hospital-Milton, is 2.2 miles away and 6 minutes off-peak, fourteen minutes in traffic. Boston Medical Center, the next major ER, is 6.1 miles and 31 minutes in Boston traffic. [1]

For patients who take the bus, BID-Milton is an 8-minute ride from the Ashmont T stop. The bus runs every 30 minutes.

Brigham and Women’s Faulkner Hospital, five miles northwest, went from 8 patients per night in hallway beds to 20 per night within three months of Carney’s closure. [19] That is not a statistic. That is a hallway.

Codman Square Health Center in Dorchester started seeing patients arrive sicker than usual. The CEO said the level of acuity is elevating in our urgent care practice. [20] New patients at Codman now wait 4.5 months for a primary care appointment. [2] Urgent care volume at Codman jumped 12 percent. [2]

Fifty psychiatric beds disappeared from a city that already did not have enough. Eliza Williamson of NAMI Massachusetts said during the closure proceedings that even if there was a place for these patients to go, transfers would be deeply challenging. But there is nowhere for people to go. [21]

The Clozapine Clinic was supposed to continue in an adjacent office building, but without hospital infrastructure, continuity for complex patients was not guaranteed. [1] Eighteen months later, the behavioral health gap remains. [22]

A social worker named Malaka Mims warned that without nearby psychiatric access, people in crisis would turn to police rather than hospitals. And that, she said, can be problematic in so many ways. [20]

She is being generous with the word problematic.

I said in Article 1 that the mechanism does not care what state you are in. Here is the proof.

Massachusetts expanded Medicaid. Carney’s catchment area had 65 to 74 percent MassHealth enrollment. [2] The coverage was there. The patients were insured. The hospital still closed.

Not because of a coverage gap. Not because a red-state governor blocked expansion. Not because rural voters elected someone who defunded their hospital. Massachusetts is as blue as a state gets. The governor is a Democrat. The AG is a Democrat. The city council voted 12 to 1 to try to save it. They still lost.

Carney closed because coverage does not fix the reimbursement rate. Medicaid was paying. It was paying roughly 88 cents on the dollar of actual cost. Medicare was paying 83 cents. [24] And nearly three quarters of Carney’s patients were on one or the other. The coverage was in place. The math still did not work. And when you layer a sale-leaseback and $9 billion in bankruptcy debt on top of that math, the coverage is not even the conversation anymore.

If you read Article 1 and thought this is a red-state problem, Carney is the receipt that says no. The mechanism does not have a party. It has a payment rate.

The Carney campus is vacant. Twelve point seven acres. Nearly 730,000 square feet of building. Apollo Global Management holds it through a subsidiary called Silver Carney Dorchester LLC. Assessed at $76 million. [2]

In October 2025, HYM Investment Group signed an agreement with Apollo. HYM is led by Thomas O’Brien, the former director of Boston’s own redevelopment authority. As of March 2026, the proposal is 500 residential units, a 350,000-square-foot healthcare facility with no operator secured, and ground-floor retail. [23]

Mayor Wu has said the city will oppose any effort to rezone the property for uses other than healthcare. [11]

As of right now, the building where 30,000 people a year went to the emergency room, where 161 years of continuous hospital care was delivered, where a Clozapine Clinic monitored the most vulnerable psychiatric patients in the neighborhood, where Vietnamese and Haitian Creole and Cape Verdean Creole speakers found interpreters who could explain what was wrong. That building is a vacant lot with a development proposal and no healthcare operator.

When a hospital closes, the building is still there for a while. People drive past it. The sign stays up. The parking lot empties slowly. The community loses the thing before the building confirms it.

Dorchester lost Carney Hospital on a Saturday. The building has not confirmed it yet. But the hallways at Faulkner have. And the wait list at Codman has. And the behavioral health gap that is still open eighteen months later has.

The next article is not about a hospital. It is about a question I keep getting asked. Why don’t you name the villain? Why don’t you pick a side? Because everything that happened to Carney was technically legal, technically rational, technically within the rules of the game. Chasing motive is a trap. The next piece explains why this series works the way it does.

SOURCES

[1] Steward Carney Hospital Transition and Closure Plan, submitted to Massachusetts DPH, August 12, 2024. 122 licensed beds, 81 staffed, 50 psychiatric beds, 31,090 ED visits (Q3 2023-Q2 2024), outpatient volumes, interpreter utilization, employee counts. https://www.mass.gov/doc/carney-closure-plan-pdf/download

[2] Dorchester Health Planning Working Group Report, April 22, 2025. 167,276 catchment population, 28,136 FY23 ED visits (sixth-highest volume in Boston), 204,061 outpatient visits, 65-74% MassHealth enrollment, demographic and health outcome data, 20% EMS transport time increase, 12% urgent care volume increase at Codman, 4.5-month primary care wait. https://www.boston.gov/sites/default/files/file/2025/04/Dorchester%20Working%20Group%20Report%204.22.2025.pdf

[3] Dorchester Reporter, “Simply unsafe -- pols, advocates mount urgent push to save Carney,” August 11, 2024. Recovery nurse testimony: ICU reduced from 16 beds to 4 under Steward. https://www.dotnews.com/2024/08/12/simply-unsafe-pols-advocates-make-final-push-save-carney/

[4] Boston Globe Spotlight Team, “People died as Steward executives enriched themselves,” September 6, 2024. Gilberto Melendez-Brancaccio death at Carney, June 2, 2021. Federal investigation findings. Boston Globe Spotlight timeline. https://apps.bostonglobe.com/metro/investigations/spotlight/2024/09/steward-hospitals/timeline/

[5] Boston Globe Spotlight Team, September 2024 investigation. Internal Carney nurse email, September 2023: four nurses for 25 patients.

[6] OCCRP investigation, “How Private Equity and an Ambitious Landlord Put Steward Healthcare on Life Support,” October 8, 2024. MPT paid $263 million for Carney property in 2016 sale-leaseback. Steward had paid $12.5 million for the same property. Private Equity Stakeholder Project, “The Pillaging of Steward Health Care,” June 2024. https://www.occrp.org/en/investigation/how-private-equity-and-an-ambitious-landlord-put-steward-healthcare-on-life-support

[7] Steward Health Care Chapter 11 bankruptcy filing, May 6, 2024. Approximately $9 billion in debt.

[8] CommonWealth Beacon, “Steward to close hospitals in Dorchester, Ayer,” July 30, 2024. GBH News, “Carney Hospital and Nashoba Valley Medical Center to be closed,” July 26, 2024. 36-day timeline vs. 120-day state law requirement.

[9] WBUR, “A Michigan company wanted to buy all of Steward’s Mass. hospitals,” August 5, 2024. Insight Health System bid and Steward’s rejection. https://www.wbur.org/news/2024/08/05/insight-steward-health-care-bankruptcy

[10] Boston Globe reporting on Insight bid details, August 2024.

[11] Dorchester Reporter, “US judge okays Carney closing on ‘a final basis,’” August 6, 2024. Senator Nick Collins on property valuation obstacle. Mayor Wu letter to Apollo. https://www.dotnews.com/2024/08/06/city-council-weigh-emergency-resolution-aimed-carney-crisis/

[12] Fierce Healthcare, “Steward Health Care plans to close 2 Massachusetts hospitals,” July 2024. Judge Christopher Lopez approval, July 31, 2024.

[13] Dorchester Reporter, “AG’s office will seek ‘accountability,’” February 2024. AG Campbell’s response and proximity to Carney. https://www.dotnews.com/2024/02/27/campbell-ag-s-office-will-seek-accountability-hospitals-crisis/

[14] WBUR, “Employees, residents plead for Carney at closure hearing,” August 13, 2024. Florian Hall hearing, DPH Commissioner Goldstein testimony. https://www.wbur.org/news/2024/08/14/carney-hospital-dorchester-steward-closure-hearing

[15] GBH News, “Boston City Council proposes taking over Carney Hospital by eminent domain,” August 7, 2024. 12-1 vote. https://www.wgbh.org/news/politics/2024-08-07/boston-city-council-proposes-taking-over-carney-hospital-by-eminent-domain

[16] WBUR, “Why Mass. is seizing one formerly Steward-owned hospital,” August 19, 2024. Eminent domain for St. Elizabeth’s, $4.5 million offer, Apollo $200 million+ assessment. https://www.wbur.org/news/2024/08/19/eminent-domain-steward-hospitals-st-elizabeths-carney-nashoba-valley-massachusetts

[17] GBH News, “1 year since Carney and Nashoba closures, gaps in service are clear,” August 28, 2025. DPH Commissioner Goldstein: “the state isn’t in the business of running hospitals.” https://www.wgbh.org/news/local/2025-08-29/1-year-since-carney-and-nashoba-closures-gaps-in-service-are-clear

[18] Boston.com, “Here’s how many employees are slated to lose their jobs,” August 5, 2024. WARN notice: 753 employees. https://www.boston.com/news/local-news/2024/08/05/heres-how-many-employees-are-slated-to-lose-their-jobs-in-latest-steward-closure

[19] Boston Globe, “Steward closures are worsening Massachusetts ER overcrowding,” November 25, 2024. Faulkner: 8 hallway patients to 20 per night. https://www.bostonglobe.com/2024/11/25/metro/steward-carney-nashoba-valley-emergency-department-crowding/

[20] Bay State Banner, “Health centers see influx of patients, longer wait times since Carney closure,” October 1, 2024. Codman CEO Dr. Guy Fish on rising acuity. Social worker Malaka Mims quote. https://baystatebanner.com/2024/10/02/health-centers-see-influx-of-patients-longer-wait-times-since-carney-closure/

[21] WBUR, “Judge approves Carney, Nashoba Valley closures,” July 31, 2024. Eliza Williamson / NAMI Massachusetts testimony on psychiatric bed shortage. https://www.wbur.org/news/2024/07/31/massachusetts-steward-hospitals-closing-hearing

[22] Dorchester Reporter, “The Carney shut down 18 months ago, but the behavioral health gap remains,” March 12, 2026. https://www.dotnews.com/2026/03/13/the-carney-shut-down-18-months-ago-but-the-behavioral-health-gap-remains/

[23] Dorchester Reporter, “Carney redevelopment plans could be filed within weeks,” March 11, 2026. HYM Investment Group / Thomas O’Brien proposal. ABG Realty/Boston Business Journal reporting. https://www.dotnews.com/2026/03/12/carney-redevelopment-plans-could-be-filed-within-weeks/

[24] American Hospital Association, “2024 Costs of Caring” report, April 2025. Medicare reimbursed hospitals at 83 cents on the dollar (2024 data). AHA January 2024 fact sheet: Medicaid pays approximately 88 cents on the dollar of actual hospital costs nationally. https://www.aha.org/costsofcaring

If your rural hospital closed, downgraded, or is at risk: I am collecting stories. Not for outrage. For documentation. What happened, when, what changed. Send it: stories@theranter.com. Your name stays out of it unless you say otherwise.

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When a hospital starts losing money, the board has limited options. Cut services. Defer maintenance. Pray that the next fiscal year looks different. Eventually someone at the table says the word “partner.”

Private equity firms are very good at arriving when that word gets said.

As of 2023, private equity firms owned at least 130 rural hospitals across the United States. [1] Apollo Global Management, through its LifePoint and ScionHealth platforms, controlled approximately 71 rural facilities. GoldenTree and Davidson Kempner held roughly 17 through Quorum Health. Sam Zell’s Equity Group Investments held about 15. By 2018, more than 8% of all private hospitals in the country were PE-owned. At least a quarter of those were rural.

The pitch sounds roughly the same every time. A distressed hospital gets an offer from a firm with real capital. Press conference. Promises about investment, jobs, keeping the doors open. The community board votes yes because the alternative is closing without a plan.

What happens next has now been documented across enough cases, by enough investigators, that it is not a theory. It is a receipt. So here is one.

Cerberus Capital Management created Steward Health Care in 2010 by acquiring the Caritas Christi hospital system in Massachusetts. Caritas was a nonprofit Catholic system. Cerberus was a private equity firm named, and I want to be clear that I am not making this up, after the three-headed dog that guards the gates of hell in Greek mythology.

Cerberus acquired Caritas with significant debt loaded at the operating company level. Not on the firm. On the hospitals. This matters for everything that follows.

In 2016, Steward sold its hospital real estate, the buildings, the land, to a real estate trust called Medical Properties Trust. [2] Cash from the sale went to the investors. What stayed behind was a long-term rent obligation. The hospitals no longer owned the buildings they operated in. They rented them.

The hospitals used to own the buildings. Then the buildings started charging the hospitals to be hospitals.

Steward expanded into multiple states, including rural parts of Texas and Ohio. Management fees flowed to affiliated entities that Cerberus also controlled. Staffing ratios dropped. Service lines that lost money (maternity, behavioral health, pediatrics) got cut. On paper the hospitals looked more profitable, because the costs went down. The community noticed slowly. Fewer nurses on the floor. Longer waits. OB units closed and nobody held a press conference about it.

By the time Steward filed for bankruptcy in 2024, the company owed $6.6 billion in long-term rent obligations. $1.2 billion in loans. Nearly $1 billion in unpaid vendor bills. [3] The hospitals did not run out of patients. They ran out of money to operate inside buildings that someone else now owned.

The closures included Carney Hospital in Dorchester, Massachusetts, and Nashoba Valley Medical Center in Ayer. Trumbull Regional Medical Center and Hillside Rehabilitation Hospital in Warren, Ohio. Others across the footprint. The Massachusetts government considered using eminent domain to prevent the closures. [3] When a governor starts talking about seizing a hospital to keep it open, the market is telling on itself.

The Senate Budget Committee documented this playbook in a January 2025 report. [2] Steward was one of two case studies. The other was Prospect Medical Holdings, and the math was worse.

Leonard Green and Partners acquired Prospect in 2010. Over the following decade, Leonard Green extracted between $400 million and $645 million from Prospect through dividends, management fees, and sale-leaseback transactions. [4] This money left the operating company. It went to investors. What stayed behind was debt.

When Leonard Green exited in 2021, Prospect had $3.1 billion in debt and unpaid obligations. [4]

In 2016, while the extraction was ongoing, Prospect acquired the Crozer Health system in Pennsylvania, a four-hospital nonprofit. Prospect made explicit commitments to keep those hospitals open for at least ten years.

By 2022, services were being cut. Maternity shut down. Residency accreditation was lost. In October 2024, the Pennsylvania Attorney General filed a civil lawsuit alleging that Prospect had violated the terms of its 2016 purchase agreement and asked a court to appoint a receiver. [5]

$645 million went out. $3.1 billion in debt stayed. The hospitals that were promised a decade got less than half of one before the math collapsed.

Quorum Health Corporation, controlled by creditors including Davidson Kempner, operated Martin General Hospital in Williamston, North Carolina. Quorum reported $30 million in cumulative losses since 2016. It missed financial reporting requirements to the state for five consecutive years. Then, in August 2023, Quorum closed Martin General. [6]

The nearest hospital is now 25 to 40 miles away. Martin County is small, rural, and aging. Martin General was one of its largest employers. The EMS system described severe strain from longer transport times.

Quorum missed its reporting to the state for five years and then acted surprised the math did not work. Nobody is surprised. The math was documented. The money was already gone.

Here is the part where I am supposed to say this is about greed. It is, partially. But it is also about structure.

If the playbook sounds familiar, it should. In 2005, KKR, Bain Capital, and Vornado Realty Trust acquired Toys “R” Us for $6.6 billion. They put up roughly $1.3 billion of their own money. The other $5 billion was debt, loaded onto the company, not onto the firms. [8] Toys “R” Us spent $450 to $500 million a year just servicing interest. It still controlled 20 percent of the U.S. toy market when it filed for bankruptcy. [8] The company did not fail because it ran out of customers. It failed because the debt was never designed to be survivable. 800 stores closed. 33,000 people lost their jobs. The firms collected roughly $200 million in advisory fees over the course of ownership. [9]

Debt loaded onto the target. Management fees extracted regardless of performance. Real estate separated from operations. Company still generating revenue when it collapsed. Buyers walked away whole.

Steward. Prospect. Quorum. Toys “R” Us. Same playbook.

The difference is what happens after. When Toys “R” Us closes, you drive to Target. When a rural hospital closes, you drive 25 to 40 miles to the nearest emergency room. If you make it.

The reimbursement math I described in the last article, the 83-cent problem, is what makes rural hospitals vulnerable to this playbook in the first place. A hospital losing money on every Medicare patient, with a shrinking commercial base, has no good options. The PE pitch arrives precisely because the math is broken. The firm does not cause the crisis. It monetizes the crisis. The difference matters, but the outcome does not change.

What PE adds to the equation is debt, lease obligations, and an exit timeline. A struggling hospital that stays independent loses money slowly. A struggling hospital that gets acquired by PE loses money according to someone else’s schedule, with someone else holding the building.

One more thing. This is the part nobody wants to hear.

Medical Properties Trust, the real estate trust that collected rent from Steward’s hospitals, is a publicly traded company. [7] If you have a 401(k) that tracks a broad index, or a target-date retirement fund that holds real estate investments, there is a decent chance you own a small piece of the company that collected rent from a hospital system while it was running out of money.

The system does not run on villains. It runs on ordinary financial instruments held by ordinary people in ordinary retirement accounts. The rent that helped bankrupt Steward was paid to a trust that pays dividends to shareholders. Some of those shareholders are index funds. Some of those index funds are in accounts with your name on them.

I am not saying that makes you complicit. I am saying the machine is bigger than the people you can see, and some of the gears are in your portfolio.

The next article is about Carney Hospital. It is about what happens to a specific building, in a specific neighborhood, when the math and the money and the structure I have been describing all arrive at the same address on the same Saturday.

SOURCES

[1] Private Equity Stakeholder Project (PESP), “Private Equity Descends on Rural Healthcare,” January 2023. Apollo Global Management/LifePoint/ScionHealth: ~71 rural facilities. GoldenTree/Davidson Kempner: ~17. Equity Group Investments: ~15. JAMA 2024 study on PE acquisitions confirmed 8%+ of private hospitals PE-owned by 2018.

• https://pestakeholder.org/news/pesp-releases-new-sweeping-report-on-pe-in-rural-healthcare/

• https://pestakeholder.org/private-equity-hospital-tracker/

[2] Senate Budget Committee bipartisan staff report, “Profits Over Patients: The Harmful Effects of Private Equity on the U.S. Health Care System,” January 2025. Documented PE acquisition playbook including debt-loading, sale-leaseback structures, management fee extraction, and service line cuts.

• https://www.budget.senate.gov/ranking-member/newsroom/press/private-equity-in-health-care-shown-to-harm-patients-degrade-care-and-drive-hospital-closures

• https://www.grassley.senate.gov/news/news-releases/private-equity-in-health-care-shown-to-harm-patients-degrade-care-and-drive-hospital-closures

[3] Boston Globe Spotlight Team, “Inside Steward Health Care,” 2024 investigation series. Steward bankruptcy filing: $6.6B rent obligations, $1.2B loans, ~$1B unpaid vendor bills. Cerberus Capital Management founded Steward via Caritas Christi acquisition, 2010. Sale-leaseback with Medical Properties Trust, 2016.

• https://apps.bostonglobe.com/metro/investigations/spotlight/2024/09/steward-hospitals/

• https://apps.bostonglobe.com/metro/investigations/spotlight/2024/09/steward-hospitals/steward-mpt/

[4] ProPublica, “Investors Extracted $400 Million From a Hospital Chain That Sometimes Couldn’t Pay for Medical Supplies or Gas for Ambulances,” September 2020. And “Rich Investors Stripped Millions From a Hospital Chain and Want to Leave It Behind,” February 2021. Senate Budget Committee report, January 2025. Leonard Green and Partners dividend and fee extraction from Prospect Medical Holdings: $400M-$645M over the 2010s. Prospect debt at Leonard Green exit (2021): $3.1B.

• https://www.propublica.org/article/investors-extracted-400-million-from-a-hospital-chain-that-sometimes-couldnt-pay-for-medical-supplies-or-gas-for-ambulances

• https://www.propublica.org/article/rich-investors-stripped-millions-from-a-hospital-chain-and-want-to-leave-it-behind-a-tiny-state-stands-in-their-way

[5] Pennsylvania Attorney General civil lawsuit against Prospect Medical Holdings, filed October 29, 2024, Delaware County Court of Common Pleas. Alleged violation of 2016 purchase agreement commitments for Crozer Health system.

• https://www.attorneygeneral.gov/taking-action/ag-henry-sues-prospect-medical-holdings-over-breach-of-contract-mismanagement-of-crozer-health-system-resulting-in-closures-disruptions-of-services/

• https://www.healthcaredive.com/news/pennsylvania-attorney-general-sues-prospect-medical-leonard-green/731555/

[6] UNC Cecil G. Sheps Center rural hospital closure database. Regional reporting on Quorum Health Corporation’s operation and closure of Martin General Hospital, Williamston, NC, August 2023. Quorum: $30M cumulative losses since 2016, $13M loss in 2022 alone, five years of missed state reporting.

• https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/

[7] Medical Properties Trust, Inc. NYSE: MPW. Publicly traded healthcare REIT. Collected rent from Steward Health Care facilities under long-term lease agreements executed via 2016 sale-leaseback transaction.

https://www.medicalpropertiestrust.com

[8] Private Equity Stakeholder Project, “KKR, Bain Capital, Vornado repeatedly rewarded themselves for adding debt to Toys ‘R’ Us,” 2018. $6.6B acquisition, $5B+ in debt loaded onto the company. $450-$500M annual interest payments. 20% U.S. toy market share at time of bankruptcy filing. The American Prospect, “Private Equity: Looting ‘R’ Us,” 2018.

• https://pestakeholder.org/news/kkr-bain-capital-vornado-repeatedly-rewarded-themselves-for-adding-debt-to-toys-r-us/

• https://prospect.org/2018/03/20/private-equity-looting-r-us/

[9] The Week, “How vulture capitalists ate Toys ‘R’ Us,” 2018. Bain, KKR, and Vornado extracted approximately $200M in advisory and management fees over course of ownership. 800 stores closed, 33,000 employees laid off. PitchBook, “Congress confronts Bain Capital, KKR over Toys R Us liquidation,” 2018.

• https://theweek.com/articles/761124/how-vulture-capitalists-ate-toys-r-r

• https://pitchbook.com/news/articles/congress-questions-bain-capital-kkr-over-toys-r-us-liquidation

If your rural hospital closed, downgraded, or is at risk: I am collecting stories. Not for outrage. For documentation. What happened, when, what changed. Send it: stories@theranter.com. Your name stays out of it unless you say otherwise.

Subscribe: TheRanterOfficial.substack.com

Main Site: TheRanter.com

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Before a closure, the average ambulance transport in a rural area takes 14.2 minutes. After the hospital shuts down, that number jumps to 25.1 minutes.^[1] Eleven extra minutes. During a stroke, brain cells die at roughly 1.9 million per minute, and every minute of delay shrinks the window for the one drug that can reverse it. During a car accident on a two-lane road at 11 PM, eleven minutes is the difference between an ER and a helicopter.

Since 2010, more than 200 rural hospitals have closed or converted to models that no longer include inpatient care.^[2] Not “are struggling.” Not “facing headwinds.” Closed. Doors locked. Signs dark. Ambulances rerouted. Eighteen of those closures or conversions happened in the last year alone. Another 417 are currently flagged as financially vulnerable.^[3] That is roughly one in four rural hospitals in the country sitting on a list that has not gotten shorter in a decade.

There is a version of this story that is about politics. This one is about the math that made the politics necessary.

The federal government pays hospitals for treating Medicare patients through something called the Prospective Payment System. In plain English: Medicare decides in advance what your appendix costs. If the actual cost of removing your appendix in a rural county with one surgeon, one anesthesiologist, and a supply chain that runs through a single distributor is higher than what Medicare decided, Medicare does not adjust. The price was set. You eat the difference.

Medicare pays hospitals 83 cents for every dollar it actually costs to treat a patient. Medicaid pays roughly 88 cents. In 2023, combined underpayment across all U.S. hospitals topped $130 billion.^[4]

That is not a rounding error. That is the system working the way it was built.

Now put that math inside a rural hospital. A typical rural facility sees a patient mix that looks something like this: 45% Medicare, 20% Medicaid, 25% commercial insurance, 10% uninsured. The commercial patients are the only ones who pay above cost. They subsidize the losses from everyone else. In a city hospital, that commercial share might be 40% or higher. Enough cushion to absorb the Medicare and Medicaid shortfall and still keep the lights on.

Rural hospitals do not have that cushion. The population is older, which means more Medicare. It is lower-income, which means more Medicaid. And the commercial base is small because the employers are small. You cannot negotiate higher commercial rates when you have no bargaining power, and you cannot raise volume when your population is shrinking.

Rural hospitals are not failing because nobody needs them. They are failing because the people who need them most are covered by programs that pay below cost, and the people with commercial insurance are too few to cover the gap. The math was always going to produce a loss.

Assume a cost of $2,000 per inpatient day. Apply the payer mix. Apply the reimbursement ratios. The expected revenue per day comes out to roughly $1,820.^[5]

That is a loss of about $180 per patient per day. Before capital costs. Before the roof repair. Before the MRI machine that needs replacing. Before the travel nurses you are paying a premium for because nobody wants to relocate to a county with one traffic light and a Dairy Queen.

More than 40% of rural hospitals are currently operating in the red.^[3] The question is not why so many are closing. The question is how any of them are still open.

There is a federal designation called Critical Access Hospital. It exists because someone in Washington looked at this math and realized it was going to kill rural hospitals. The fix: if your hospital has fewer than 25 inpatient beds, is more than 35 miles from the nearest other hospital, and keeps the average patient stay under 96 hours, you qualify. And if you qualify, Medicare pays you 101% of your actual costs instead of the standard rate.^[6]

There are about 1,350 hospitals with this designation. For them, the Medicare piece of the math is solved. Not generously. One percent above cost is not a windfall. But it stops the bleeding on the Medicare side. The other rural hospitals get 83 cents. Critical Access status pays 101 percent of cost for Medicare patients, which sounds generous until you notice how many hospitals are too close to qualify and too small to survive the regular formula.

Two problems.

First, not every rural hospital qualifies. If you are 20 miles from the next facility instead of 35, you are too close. You serve a town of 800 people with a median age of 58, and your ER handles everything from chest pain to farming accidents. But because there is another hospital 20 miles down the highway, you get the standard rate. 83 cents on the dollar. Congress noticed. A bipartisan bill in early 2026 proposed letting HHS grant cost-based reimbursement to hospitals that function as the sole provider for their community, regardless of the 35-mile rule.^[14] The map says you are close to another hospital. The road says otherwise.

Second, the 96-hour rule. Rural hospitals now manage more complex patients than they used to. The population is older. Chronic conditions are more common. Post-surgical recovery takes longer. But if the average patient stay goes over 96 hours, the hospital risks losing its CAH designation. So they transfer patients out. The policy designed to keep rural hospitals alive creates a rule that pushes patients away from them.

Here is where someone is going to sort this into a political bucket. Let them try.

Seventy-four percent of all rural hospital closures between 2010 and 2021 occurred in states that had not expanded Medicaid.^[7] Texas leads the nation with 27 closures or conversions. Tennessee has lost 18. Oklahoma, Mississippi, Kansas: a dozen or more each.^[2] These are states where the federal government offered to cover low-income adults at 90 cents on the federal dollar, and the state said no. The uninsured patients kept showing up. The hospital treated them and got paid nothing. In the states that still have not expanded, more than half of rural hospitals are operating in the red.^[3] Zero is worse than 88 cents.

That is a real and documented pattern. I am not going to pretend it is not there.

But the math underneath does not check voter registration.

Maine has the oldest population in the country: 23.5% of its residents are 65 or older.^[9] Vermont is second at 22.9%. New Hampshire is at 21.5%. These are not retirement states in the way Florida is a retirement state. These are states where people aged in place because nobody came to replace them. Younger workers left. The population got older. The payer mix followed.

When nearly a quarter of your patients are on Medicare, and Medicare pays 83 cents on the dollar, expansion does not fix that. You can expand Medicaid all day. Maine did, in 2019. Vermont and New Hampshire did in 2014. The uninsured rate dropped. And the hospitals kept losing money, because the problem was never only about who has insurance. The problem is what insurance pays.

In 2015, two Maine hospitals closed their inpatient units: Parkview Adventist in Brunswick and Southern Maine Health Care in Sanford.^[10] Both in an expansion state. Both with Medicaid on the books. Both unable to make the math work with a patient base that was old, publicly insured, and shrinking. In central Massachusetts, Baystate Mary Lane Hospital in Ware closed its inpatient services in 2016 and completed a years-long conversion to outpatient-only care.^[11] The inpatient census was too low to justify the overhead. The community did not lose a hospital to a political decision. They lost it to a spreadsheet.

Connecticut has three rural hospitals. All three are operating in the red.^[12] Zero closures. Not because the system is working. Because there are only three left to lose. You can hear the sentence breathing.

New Hampshire has not lost a rural hospital in two decades. But four are currently at risk, three at immediate risk.^[13] The state expanded Medicaid. The hospitals stayed open. And the math still does not work, because the payer mix is old and the reimbursement rate does not care what state you are in.

Expansion helps. It turns zero-dollar patients into 88-cent patients. But the reimbursement math was set before the expansion debate started. The states that refused expansion made the math worse. The states that accepted it did not make the math good. In expansion states, 35% of rural hospitals are still operating at a loss.^[3]

The 74% stat is real, and it matters. But if you look at it and think “this is a red state problem,” you have missed the mechanism. The mechanism is the payment rate. Expansion is one variable. The rate is the constant.

Rural hospital closures increase inpatient mortality by a relative 8.7% in the communities they leave behind.^[8] No comparable mortality effect in urban areas. The ambulance time is part of it. The loss of inpatient beds, surgery, maternity care, and behavioral health services is the rest. More than 300 rural hospitals have eliminated obstetric services in the last decade.^[3] When the nearest delivery room is an hour away, some women make it. The data says not all of them do.

I am going to leave that number where it is and not tell you how to feel about it.

This is the first of four articles. I started here because the math has to come first. If you do not understand the reimbursement structure, the rest of the story does not make sense. You will see greed, politics, and incompetence in what comes next, but they all sit on top of the same equation. Every hospital that closed, every investor who showed up with a rescue plan, every lobbyist who wrote a check: they all started with this math.

The math was not designed to close rural hospitals. It was designed for a system where someone else would cover the difference. In a rural county where the median age is 58 and the largest employer left in 2009, there is no one else. The math just runs.

The next article is about what happened when private investors showed up and offered to help.

SOURCES

[1] Troske, S., Davis, A.F. “Do Hospital Closures Affect Patient Time in an Ambulance?” Rural and Underserved Health Research Center, University of Kentucky, 2019. ruralhealthresearch.org

[2] Chartis Center for Rural Health. “2026 State of the State.” February 2026. 206 rural hospitals closed or converted since 2010. State-level closure/conversion counts: Texas (27), Tennessee (18), Oklahoma (13), Kansas (12), Mississippi (12). chartis.com

[3] Chartis Center for Rural Health. “2026 State of the State” and “2025 State of the State.” 417 vulnerable rural hospitals, 41.2% operating at a loss. In non-expansion states: 52.2%. In expansion states: 34.9%. More than 300 rural hospitals eliminated OB services between 2011 and 2024. chartis.com (2026) | chartis.com (2025)

[4] American Hospital Association. “The Cost of Caring,” April 2025 and March 2026 reports. Medicare 83 cents per dollar (2023 and 2024 data). Combined Medicare/Medicaid underpayment: $130 billion in 2023. aha.org (2025 report) | aha.org (infographic)

[5] Constructed from AHA payment-to-cost ratios and MACPAC rural hospital payer mix data. Updated with 2024 Medicare ratio (83 cents). Commercial rate multiplier (~1.44x cost) consistent with AHA survey averages for rural facilities.

[6] CMS Critical Access Hospital designation and eligibility requirements. HRSA CAH program. MedPAC March 2024 Report to Congress. cms.gov | ruralhealthinfo.org

[7] American Hospital Association. “Medicaid Coverage Supports Rural Patients, Hospitals, and Communities.” Fact sheet, March 2026. 74% of closures in non-expansion states, 2010-2021. aha.org

[8] Gujral, K. and Basu, A. “Impact of Rural and Urban Hospital Closures on Inpatient Mortality.” NBER Working Paper 26182, 2019. nber.org | cepr.org (summary)

[9] U.S. Census Bureau, 2024 Population Estimates. Maine: 23.5% age 65+ (highest nationally). Vermont: 22.9%. New Hampshire: 21.5%. census.gov

[10] UNC Cecil G. Sheps Center for Health Services Research. Rural Hospital Closures database. Parkview Adventist Medical Center (Brunswick, ME) and Southern Maine Health Care - Sanford: inpatient services ceased 2015. shepscenter.unc.edu

[11] Baystate Health / Mary Lane Hospital, Ware, MA. Inpatient services ceased 2016. Outpatient conversion completed; facility closed 2023. wwlp.com

[12] Chartis Center for Rural Health. “2025 State of the State.” Connecticut: 3 rural hospitals, all operating with negative margins. Confirmed in 2026 report. chartis.com

[13] Center for Healthcare Quality and Payment Reform (CHQPR). Rural hospitals at risk analysis, verified through December 2025. New Hampshire: 4 rural hospitals at risk, 3 at immediate risk. chqpr.org | beckershospitalreview.com

[14] Sustaining Rural Healthcare Act. H.R.7727, 119th Congress. Introduced February 2026. Bipartisan bill proposing cost-based reimbursement for hospitals functioning as sole community providers regardless of 35-mile distance rule. congress.gov

If your rural hospital closed, downgraded, or is at risk: I am collecting stories. Not for outrage. For documentation. What happened, when, what changed. Send it: stories@theranter.com. Your name stays out of it unless you say otherwise.

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That’s not a confession. It’s not bravado. It’s not me trying to sound like some edgy internet commenter who saw it coming. I didn’t see it coming. But when it came, the part of my brain that’s supposed to produce shock just... didn’t. It produced recognition. The same way you recognize a sound you’ve been hearing for years but never identified. Oh, that’s what that was.

A man walked up to the CEO of the largest health insurance company in America, shot him in the back outside a hotel in midtown Manhattan, and disappeared into the morning. December 4, 2024. Brian Thompson was on his way to an investor conference. The kind of event where executives present slides about revenue projections and analysts nod and the catering is fine. He never made it inside.

Five days later, Luigi Mangione was sitting in a McDonald’s in Altoona, Pennsylvania, eating, when another customer recognized him. He had a ghost gun in his backpack, fake IDs, and a red notebook. The notebook wasn’t rambling. It was focused. Three pages, clear handwriting, a specific thesis: the health insurance industry is parasitic, and he was the immune response. “I do apologize for any strife or trauma, but it had to be done. Frankly, these parasites simply had it coming.”

He’s 26 now. Ivy League. Wealthy family. Computer science degrees. Valedictorian of his prep school. He co-founded a game development company at Penn. He had chronic back pain that went undertreated. He read the Unabomber’s manifesto and found it persuasive. None of these facts fit together the way we want them to.

And then the internet happened.

Within hours, the jokes started. “Thoughts and prayers, pending prior authorization.” People asked if the hospital Thompson was taken to was in-network. Someone suggested his family should appeal the death. These weren’t coming from the fringes. They were everywhere. Mainstream platforms, group chats, comment sections on news articles from outlets that were still running the story straight.

Polling confirmed what the comments suggested. Among Americans aged 18 to 29, a significant plurality described the killing as “somewhat” or “completely” acceptable. [1] Not excusable. Not understandable. Acceptable. The NYPD’s own Intelligence and Counterterrorism Bureau assessed that Mangione could inspire copycats, that he was already being framed as a martyr.

They weren’t wrong about the martyr part. His legal defense fund on GiveSendGo has attracted well over a million dollars in donations. [2] His attorneys launched a public website because the “extraordinary volume of inquiries and outpouring of support” overwhelmed their office. In January 2026, someone tried to break him out of federal lockup in Brooklyn. The guy brought a barbecue fork and something that looked like a pizza cutter blade. That’s real. That happened. [3]

When the federal judge ruled that Mangione wouldn’t face the death penalty, a technical decision about whether stalking qualifies as a “crime of violence” under Supreme Court precedent, his lawyer called it an “incredible decision” and told reporters, “We’re all very relieved.” As officers escorted him from a later hearing where the state judge scheduled his trial for June 8, Mangione turned to the gallery and said: “It’s the same trial twice. One plus one is two. Double jeopardy by any commonsense definition.” [4]

He’s not acting like a man who thinks he lost.

I need to be careful here, because I can feel myself doing the thing. The thing where you lay out the facts so neatly that understanding starts to look like agreement. So let me say it plainly: I understand why this happened. I do not think it should have happened. Those are two different sentences and I need you to hold both of them at the same time, because the rest of this article won’t work if you drop either one.

I understand why someone with chronic pain, watching an industry post seventeen billion dollars in annual profit while denying claims in 1.2 seconds, might start circling a very dark conclusion. I understand the math that gets you there. That doesn’t make the math right.

But I also can’t pretend the public reaction was irrational. Tens of millions of Americans have been denied care they were promised. They’ve sat on hold. They’ve read letters that say “not medically necessary” about procedures their doctors ordered. They’ve watched family members get sicker during an appeal process designed to outlast their patience. When someone finally put a face on the facelessness of it all, they didn’t recoil. They recognized it.

Criminologists classified the shooting as a “symbolic takedown.” [5] Not random violence, not workplace revenge, not terrorism in the way we usually mean it. Political violence aimed at a specific node of power. It shares DNA with 19th-century anarchist assassinations, targeted acts meant to expose the vulnerability of systems that present themselves as invulnerable.

The system, for its part, did what systems do.

UnitedHealth Group opened at $611.02 on the morning of December 4, 2024. Brian Thompson had been dead for hours by the time the bell rang. The stock closed that day at $610.79. Flat. For much of the trading day, it was actually up. [6]

The market’s verdict: this changes nothing. The machine doesn’t need the man. The man was a component, and components are replaceable.

Day two, the stock dropped 5.2%. By the end of the first week, UnitedHealth had lost $41.6 billion in market cap. CVS fell 25%. Cigna dropped 20%. Humana, 19%. [6] The entire insurance sector bled, and for a few days it looked like the shooting had done something the appeals process never could, made the industry feel consequences.

It didn’t last. UnitedHealth posted better-than-expected Q4 earnings in January 2025. Revenue was up. Profits beat analyst estimates. The CFO opened the call by thanking people for their condolences about Brian. Then he read the numbers. [7]

The stock did eventually collapse. UNH is down roughly 50% from its highs as I write this. Almost none of that decline is about the shooting. In April 2025, the company reported that Medicare Advantage costs came in twice as high as expected, and the stock dropped 22% in a single day. [8] The CEO who replaced Thompson, Andrew Witty, resigned in May after five months. They brought back Stephen Hemsley, the CEO before the CEO before the one who got killed. He got on the earnings call and said, quote: “We apologize for that performance and we are humbly determined to earn back your trust and your confidence.” [9]

Your trust. Investors’ trust. Not yours, the person reading this. Not the family waiting on an appeal. The shareholders.

UnitedHealth’s full-year 2025 revenue was $447.6 billion. Up twelve percent from the year before. [9] The quarter Wall Street treated like a five-alarm fire? They made $113.2 billion. The “miss” that sent the stock into freefall was that they made $113.2 billion instead of $113.7 billion. They were off by half a billion on a hundred-billion-dollar quarter and analysts used the word “ominous.”

For 2026, they’re projecting revenue above $439 billion. [10] It would be their first revenue decline since the late 1980s. A two percent drop. Financial media is covering it like a corporate funeral. The stock dropped another 20% when CMS proposed a Medicare Advantage rate increase of 0.09% instead of the 6% analysts expected.

The company’s CFO told reporters: “We want to show that we can get back to the swagger the company once had.” [9]

Four hundred and thirty-nine billion dollars, and they’re talking about getting their swagger back. Meanwhile, the appeal rate is still under one percent. The algorithm still runs. nH Predict still tells nurses when to discharge your grandmother.

Wall Street didn’t punish UnitedHealth for how they treat patients. Wall Street punished them for how they treated shareholders. The suffering was always priced in. The suffering is the product. The stock price doesn’t measure how much they hurt you. It measures how much they promised to hurt you, and whether they delivered on schedule.

Here’s where I’m supposed to lose you.

My retirement account probably holds UNH stock. Most retirement accounts with index fund exposure do. Yours might too. We didn’t choose that. But we benefit from it, in some fractional, quarterly way. The same company that denies the claim pays into the fund that’s supposed to keep us alive when we stop working. And the fund managers who dumped twenty million shares of UNH in late 2025 didn’t dump them because they read about denied grandmothers. They dumped them because the earnings per share came in at $2.11 instead of $6.81. [8]

Members of Congress traded UNH stock twenty-one times in the last six months. Nine purchases. Twelve sales. [11] They are buying and selling shares of this company while debating healthcare policy. That’s not a conspiracy. That’s a filing. It’s public. You can look it up.

I don’t know what to do with any of this. I can document the mechanism. I can show you the exposed wiring of a system that absorbed a murder the same way it absorbs a denied claim, by processing the paperwork, adjusting the model, and continuing operations. I can tell you that Luigi Mangione’s trial starts this summer, and that major health insurers signed a voluntary pledge to reform prior authorization, and that the pledge has no enforcement mechanism, and that CMS Administrator Mehmet Oz, announcing that voluntary pledge, said the quiet part out loud: “There’s violence in the streets over these issues.” [12]

What I can’t tell you is that it worked.

The stock recovered from the shooting and then crashed for completely unrelated financial reasons. The voluntary reforms are voluntary. The algorithm is still a trade secret. The company that made $447.6 billion last year is apologizing, to its investors, for not making more.

The system’s response to being shot at is the same as its response to being appealed: run the numbers again, adjust the model, continue operations.

Luigi Mangione sits in a cell in Brooklyn with well over a million dollars in donations and a trial that threatens to put the entire industry in the dock beside him. He might be the most supported defendant in modern American history. And UnitedHealth is projecting $439 billion in revenue for the year his trial begins.

I wasn’t shocked when it happened. I’m not shocked by what happened after.

Sources & Notes

[1] Emerson College national poll, conducted December 11-13, 2024 (n=approx. 1,000 registered voters). Among voters aged 18-29, 41% described the killing as “somewhat” or “completely” acceptable vs. 40% unacceptable. Among all voters, 68% called it unacceptable and 17% acceptable.

https://thehill.com/policy/healthcare/5044269-poll-finds-41-percent-find-killing-unacceptable/

[2] GiveSendGo defense fund. Wikipedia cites over $1.4 million as of January 2026. CNBC confirmed the fund had surpassed $1 million in May 2025.

https://en.wikipedia.org/wiki/Luigi_Mangione

[3] Minnesota man Mark Anderson arrested January 28, 2026 at the Metropolitan Detention Center in Brooklyn after posing as an FBI agent with a court order to free Mangione. A barbecue fork and pizza cutter blade were found in his bag. Reported by ABC News and CNBC.

https://abcnews.go.com/US/man-allegedly-break-luigi-mangione-jail-impersonating-fbi/story?id=129679620

https://www.cnbc.com/2026/01/29/luigi-mangione-fbi-jail-murder-mark-anderson.html

[4] Federal Judge Margaret Garnett dismissed the death-eligible murder count on January 30, 2026, ruling that stalking does not qualify as a “crime of violence” under Supreme Court precedent. Federal prosecutors declined to appeal on February 27, 2026. State trial scheduled June 8, 2026.

https://www.nbcnews.com/news/us-news/luigi-mangione-will-not-face-death-penalty-judge-nixes-two-federal-cou-rcna256715

https://www.cbsnews.com/newyork/news/luigi-mangione-death-penalty-federal-prosecutors/

[5] Criminological framing of the shooting as a “symbolic takedown” -- political violence targeting a symbolic node of power rather than random or workplace violence. PBS NewsHour coverage and academic commentary, December 2024-January 2025.

https://www.pbs.org/newshour/health/unitedhealth-ceo-killing-latest-example-of-symbolic-takedown-experts-say

[6] UNH stock prices December 4-11, 2024. Sector declines (CVS -25%, Cigna -20%, Humana -19%) via CNBC and Yahoo Finance market data.

https://finance.yahoo.com/quote/UNH/history/

https://www.cnbc.com/quotes/UNH

[7] UnitedHealth Group Q4 2024 earnings call, January 16, 2025. Revenue beat; CFO opened by acknowledging Thompson’s death.

https://www.cnbc.com/2025/01/16/unitedhealth-unh-q4-2024-earnings.html

[8] UnitedHealth Group Q1 2025 earnings, April 2025. EPS reported at $2.11 vs. $6.81 analyst estimate. Stock fell 22% in a single session. Andrew Witty resigned as CEO May 2025.

https://fortune.com/2025/04/17/unitedhealth-earnings-q1-2025-stock-drop/

[9] Three sources for this footnote:

(a) Stephen Hemsley return and investor apology: UNH Q2 2025 earnings call, July 2025.

(b) Full-year 2025 revenue of $447.6 billion, up 12%: UNH Q4 FY2025 earnings call, January 27, 2026.

(c) “Swagger” quote: Wayne DeVeydt (CFO), speaking to reporters in November 2025 after joining as CFO from Elevance/Centene. Cited in Becker’s Payer Issues.

https://www.cnbc.com/2026/01/27/unitedhealth-group-unh-earnings-q4-2025.html

https://www.beckerspayer.com/payer/unitedhealths-new-cfo-details-plan-to-restore-swagger/

[10] UnitedHealth 2026 revenue guidance above $439 billion, representing the company’s first projected revenue decline since the late 1980s. CMS proposed a Medicare Advantage rate increase of 0.09% vs. the ~6% analysts had expected. UNH stock fell approximately 20% on the CMS announcement.

https://www.cnbc.com/2026/01/27/unitedhealth-group-unh-earnings-q4-2025.html

[11] Congressional trading data via Quiver Quantitative. UNH transactions September 10, 2025 through March 10, 2026: 21 total trades, 9 purchases, 12 sales across both parties.

https://www.quiverquant.com/congresstrading/UNH

[12] Mehmet Oz, CMS Administrator, press conference June 23, 2025, announcing a voluntary prior authorization pledge signed by major health insurers including Aetna, UnitedHealthcare, Cigna, Humana, and others. Quote confirmed by NPR, The Hill, CNN, and HHS.gov press release. The pledge carries no legal enforcement mechanism.

https://www.npr.org/sections/shots-health-news/2025/06/24/nx-s1-5442713/rfk-jr-dr-oz-health-insurance-prior-authorization

https://www.hhs.gov/press-room/kennedy-oz-cms-secure-healthcare-industry-pledge-to-fix-prior-authorization-system.html

Got a denial story? I’m collecting them. Not to publish without permission -- to document the pattern. One story is an anecdote. A hundred is evidence.

stories@theranter.com. Your name stays out of it unless you say otherwise.

TheRanter.com

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In 2022, a doctor at Cigna denied over 60,000 claims in a single month. ProPublica reported the average review time: 1.2 seconds per case.^[1] The doctor allegedly never opened the patient files. He didn’t need to. The algorithm had already decided, and he was just the signature.

That was the denial side. An AI scans your claim and flags it for rejection based on a procedure-to-diagnosis code match. Cigna calls this an “automated rules engine,” which is technically accurate the same way a vending machine is technically a nutritionist. Then a human rubber-stamps the pile. In bulk. Your entire medical history, reviewed by someone who was paid to stamp it, not read it.

Here is the full loop, in plain English. Your doctor orders a procedure. The insurer’s software checks whether your diagnosis code matches a pre-approved list. It doesn’t. The software flags the claim for denial. A medical director signs the rejection, sometimes without opening your file. You receive a letter. If you want to fight it, you have to locate the appeals process, gather your medical records, pull your policy documents, identify the specific clinical language the insurer used to deny you, find supporting medical literature, and submit a written response -- usually by fax, on a deadline that is not always clearly stated. At no point in this process is anyone on the insurer’s side being paid to ask whether your treatment is medically appropriate. Every step is about cost and documentation, and that is not an accident.

Now there’s an appeal side. And it’s also AI.

Welcome to the arms race nobody asked for, where robots are fighting robots over whether you deserve healthcare, and you’re standing in the middle holding a denial letter and a co-pay.

Part I

Holden Karau was a tech worker in San Francisco building search and recommendation tools. Early AI work, the kind that decides what shows up when you type something into a box. Then an SUV ran a left turn across four lanes of traffic and hit her Vespa. She survived. The paperwork almost killed her anyway.

“I’d had a number of denials before, but they were all sort of spaced out. When I got hit by a car, everything just happened all at once. And it was like, oh, this paperwork is insurmountable.”Holden Karau, Managed Healthcare Executive^[2]

She’s a computer scientist. She builds tools for a living. So in 2023, she built one: Fight Health Insurance. You upload your denial letter. The system scans it, identifies why you were denied, cross-references your situation against medical literature and common insurance policy language, and generates an appeal letter. Multiple versions, different angles, ready to submit. It’s free for individual patients. The company makes money selling an enterprise version called Fight Paperwork to medical practices and health systems. Because of course doctors need it too. They’re drowning in the same forms. That last part is the receipt: the paperwork problem is so severe that medical professionals with staff and resources are buying software to fight it alongside their patients.

Down in Research Triangle Park, North Carolina, a nonprofit called Counterforce Health built something similar. Their AI assistant analyzes your denial letter, pulls up your specific insurance policy, searches medical research for supporting evidence, and drafts a customized appeal. Also free for individuals. They charge hospitals and health systems for the professional version.^[3] Some Mayo Clinic physicians have recommended it to patients in educational presentations on fighting denials, alongside general-purpose AI tools. Doctors at the Mayo Clinic are telling patients to use chatbots to fight insurance companies. That’s where we are.

For coverage questions rather than active denials, there’s Sheer Health, which lets you connect your insurance account directly and ask plain questions about what you’re actually covered for. And for a full appeal from scratch, there’s Claimable, which charges around forty dollars to generate one from your information.^[4] A growing number of people are just going straight to the general AI chatbots. A KFF poll found that a quarter of adults under 30 have used an AI chatbot for health information or advice at least once a month.^[5] They’re not doing it for fun. They’re doing it because the system that’s supposed to help them is using the same technology against them.

Part II

The absurdity of this situation is hard to overstate, so let me try anyway.

The insurance industry spent years and billions of dollars developing AI tools to deny your claims faster, cheaper, and at greater scale than any human workforce could. They automated rejection. CVS projected $77.3 million in savings over three years from one AI denial program, far exceeding its original $10-15 million estimate.^[6] They modeled the denial of your treatment as a line item in a revenue projection.

And now, because those tools worked so well and pissed off so many people, a counter-industry has sprung up selling AI tools to fight the AI tools. The same underlying technology is now deployed on both sides of a denial letter. The insurance company’s AI reads your claim and generates a rejection. Your AI reads the rejection and generates an appeal. The insurance company’s AI reads your appeal and generates a response. Somewhere in this loop, a human being is supposed to be receiving medical care.

“We’re in an AI arms race where as consumers become more savvy and are more empowered by these tools to fight back, the insurers will just, you know, up the ante on their side with the AI.”Jennifer Oliva, Indiana University law professor, PBS NewsHour^[7]

She’s right. And she knows she’s right. And knowing doesn’t fix it.

Part III

Before you run off and upload your denial letter to the nearest chatbot (and I’m not saying don’t, because the data suggests you should fight), there are limits to what these tools can do.

Carmel Shachar at Harvard Law School has flagged the hallucination problem. AI generates text that sounds authoritative and confident, and most of the time the medical information in an appeal letter is accurate. But sometimes it isn’t. The AI might cite a study that doesn’t exist, or misstate a clinical guideline, or describe a drug interaction that’s plausible but wrong. If you’re a software engineer or a lawyer, you might catch it. If you’re a 67-year-old recovering from hip surgery and trying to keep your rehab coverage, you probably won’t.

“It can be difficult for a layperson to understand when AI is doing good work and when it is hallucinating or giving something that isn’t quite accurate.”Carmel Shachar, Harvard Law School, Stateline^[8]

An appeal letter with bad medical facts doesn’t just fail. It can actively hurt your case. The insurer’s reviewer, human or algorithmic, sees the error and uses it to dismiss the whole thing.

The other limit is structural. These tools help you fight individual denials. They do not change the denial rate. They do not change the algorithm. They do not change the business model that treats your claim as a cost to be minimized. If every denied patient in America used AI to generate appeals tomorrow, the insurance companies would adjust. They would add new criteria, build new filters, and design responses to counter what patients are filing. The arms race would escalate, and the patient would still be the one standing in the middle.

This is not an argument against using the tools. Use them. Seriously. The appeal rate in this country is a rounding error. When UnitedHealth’s nH Predict denials were appealed, plaintiffs allege that more than 90% were overturned.^[1] Ninety percent. They were wrong almost every time anyone checked. The win rate is embarrassingly high for the insurers because the denials were wrong in the first place, and they were profitable precisely because almost nobody fights. If an AI can cut the time it takes to write an appeal from eight hours to forty-five minutes, that changes who can afford to fight. A single parent with two jobs and a denied MRI just got a weapon she didn’t have last year. That matters. That’s real.

But the tools exist because the system is broken. Every successful AI-generated appeal is proof that the original denial should never have been issued. Using the counter-weapon is not the same thing as finding the cure.

Part IV

Insurance companies have started sending denial letters that explicitly state the claim was “reviewed by an AI program.” They’re telling you to your face. The rejection of your cancer screening, your child’s therapy, your spouse’s medication: processed by software. Not reviewed. Processed. The human name at the bottom of the letter is increasingly decorative.

And the response, from patients and startups and even Mayo Clinic doctors, is: fine, we’ll use software too. The system forced everyone into a language it invented, and now both sides are speaking it, and somewhere underneath all of it the actual medicine is waiting: the body, the pain, the diagnosis, the treatment that might help. Waiting for the robots to finish arguing.

The most human thing about this whole situation is Holden Karau getting hit by an SUV and realizing her computer science degree was about to become a survival skill. She didn’t build Fight Health Insurance because she saw a market opportunity. She built it because the paperwork was going to bury her, and she had the technical knowledge to dig herself out. Most people don’t have that.

That’s the gap the tools are trying to close. Not the gap between sick people and medicine. The gap between sick people and paperwork. The fact that we need AI to fill out forms to convince AI to let us see doctors is a documentation of failure. Every tool in this article exists because people had to build counter-systems just to access what they were already paying for.

Use the tools. Fight the denial. Win if you can. Don’t mistake the counter-weapon for the cure.

Tools Referenced

FightHealthInsurance.com. Free. Upload your denial, get draft appeal letters.

CounterforceHealth.org. Free. Nonprofit. Analyzes denial, pulls policy language, drafts appeal.

Sheer Health. App. Connect your insurance account. Ask plain questions about your coverage.

Claimable. ~$40 flat fee. Full appeal letter generated from your information.

General AI tools (Claude, Gemini, ChatGPT) can also draft appeal letters. Bring your denial letter, your policy documents, and your medical records. Review everything before you submit. The AI is a tool, not a doctor. Tip the publication at stories@theranter.com if you have a denial story worth documenting.

Sources

TheRanter.com | stories@theranter.com | @RanterMarkus

A drug company wants its $72,000 drug on the approved list. It pays the PBM a rebate -- a percentage of the list price -- for preferred placement. On a $72,000 drug, that rebate runs somewhere between $21,000 and $36,000. Per patient. Per year. And because the rebate is calculated off the LIST price, when the list price goes up, the PBM’s cut goes up too. Both sides make more money when the price is higher. The only person who loses is the one swallowing the pill. This is what happens when you let the bull write the safety manual.

That’s the furnace. It runs the same in every house. Now let’s check who’s paying the heating bill.

Door #1: Your Company Is Self-Insured (And Probably Doesn’t Know It)

Your employer owns the house. They just hired someone else to manage it.

If you work for a company with more than 500 employees, there’s roughly a 65% chance your employer is self-insured. That means your company pays the actual medical bills. The name on your insurance card -- Blue Cross, Aetna, whoever -- that’s not your insurance company. That’s your property manager. They process the paperwork, print the cards, and handle the phone calls. Your employer writes the checks. And separately, a PBM handles the pharmacy side. Who keeps what is decided in contracts your employer usually can’t see.

Your doctor prescribes Humira. $72,000 a year. The claim gets approved. No prior authorization. No delay. The money comes out of your employer’s account.

Your employer sees a “negotiated discount” -- maybe 20% back. $14,400. They think somebody fought for them.

The actual rebate from the drug manufacturer to the PBM? Could be 30-50%. $21,000 to $36,000. Your insurer reports a fraction of it. The PBM keeps its cut. The exact split is in a contract your employer isn’t allowed to read. Trade secret.

Now a different doctor wants to run a $1,900 blood test. No rebate attached to a lab panel. No manufacturer paying a rebate for a diagnostic. Your insurer denies it. “Not medically necessary.”

They’re not paying either bill. It’s your employer’s money. They make more money approving the $72,000 drug -- which generates tens of thousands in rebates -- than approving the $1,900 test -- which generates nothing.

The property manager doesn’t care if the renovation is overpriced. The property manager gets a percentage of the contractor’s invoice.

Door #2: You Bought Your Plan on the ACA Marketplace

Different house. Here the insurer holds the deed. You bought a Silver plan, you pay your monthly premium, and when you file a $72,000 claim, the insurer writes the check. Their money. Not your employer’s.

So they should want to deny it. Right?

Two things stop them. The ACA says they can’t deny you for pre-existing conditions. And the Medical Loss Ratio rule says they must spend at least 80% of premiums on actual medical care. If they don’t, they owe you a refund.

So how does the $72,000 drug make them money?

Because the insurer owns the PBM. UnitedHealthcare pays $72,000 for your Humira. OptumRx -- which UnitedHealth also owns -- collects a $25,000-$36,000 rebate from the manufacturer. That money took the elevator from the sixth floor to the seventh. It never left the building.

And the MLR trick: payments to their own PBM subsidiary count as “medical expenses.” The $72,000 claim satisfies the 80% spending rule even though a massive chunk of it is circulating between departments on the same floor of the same building.

They’re paying themselves rent and calling it a housing expense. Your premium goes up next year -- not just yours, everyone’s in the risk pool. You’re not a cost to this system. You’re a revenue-generating node.

Door #3: Traditional Employer Plan (HMO/PPO Through Work)

You rent. Your employer picked the building. And the landlord already knows what you’re going to cost.

Your company picks an insurer. You split the premium -- employer pays maybe $27,000 a year, you pay $3,900 out of your paycheck. The insurer bears the risk. If you file a $72,000 claim, that’s their problem.

So they should want to keep costs low. They’re the ones paying.

Except the insurer set your employer’s premium LAST year knowing that a certain percentage of employees would end up on expensive drugs this year. Actuaries built that into the rate. Your $72,000 Humira isn’t a surprise. It’s a line item in a projection that was priced twelve months ago.

And the furnace still runs. The insurer contracts with a PBM -- maybe one they own, maybe a partner. The PBM collects $21,000-$36,000 in rebates from the manufacturer. If the insurer owns the PBM, the rebate stays in the family. Net cost after rebates: $36,000-$50,000. Not $72,000.

Next year, the insurer raises your employer’s premium. Your employer passes it to your paycheck. You don’t know why. HR sends an email about “rising healthcare costs.” Nobody mentions the word rebate.

Your rent went up. The landlord won’t show you the books. And every building on the block has the same landlord, could be Blue Cross, could be Aetna, could be United again, doesn’t matter, the furnace is the same.

Three Doors, Same House

Three doors. Different floor plans. Same furnace. Same plumbing. Same drain.

The Welcome Mat

My producer stopped me after I finished the three doors.

“They pay $200 a year toward my gym. $100 if I go to the doctor. $100 for the dentist. There’s a mental health line I can call at 3am. They send me emails about drinking water. They gave me a Fitbit. Are you saying that’s fake? Because it doesn’t feel fake.”

It’s not fake. That’s what makes it work.

Your employer pays the claims. A heart attack costs them $200,000 to $800,000. Your gym costs them $200. They want you healthy because you’re cheaper healthy. The gym is real. The checkup is real. Preventive care works. Nobody’s faking that part.

The part nobody mentions is who’s running the program.

Your wellness platform -- the app, the points, the biometric screening -- is usually operated by a subsidiary or partner of the same companies in the chain. Rally Health is UnitedHealth. Virgin Pulse -- now rebranded as Personify Health -- is owned by the same private equity firms that invest across the healthcare industry. Vitality partners with the insurers directly. You’ve probably used one of these platforms. Logged your steps, earned your points, collected your gift card. Did you ever check who was on the other side of the app?

And then think about what a checkup does inside this system. Doctor finds something. Refers you to a specialist. Specialist writes a prescription. Prescription flows through the PBM. The furnace kicks on. That $100 wellness visit that was supposed to keep you OFF medication just became the intake form that puts you ON a $72,000-a-year drug running through the same furnace.

Nobody designed the wellness program to be a funnel. But nobody designed it not to be one, either. The front door is real. The hallway it leads to is the same one behind every other door in this building.

My producer was quiet for a while after that. Then: “They gave me a Fitbit, Markus.”

Yeah. They gave you a pedometer and a pipeline. You just can’t see where the steps lead.

By the way -- UnitedHealthcare runs a program where your Fitbit data gets matched against your medical claims to build predictive health models. The Fitbit wasn’t free. You just didn’t pay for it in cash.

Why Nobody Gets Cured

A cured patient is a closed account. No refills. No rebates. No recurring revenue.

A chronic patient refills every month. Every refill runs through the PBM, generates a rebate, produces a spread. The $1,900 test that finds the real problem? Zero rebate. The system denies it because the test doesn’t pay it back.

A cure is a sale. You close once, the house is gone. A chronic prescription is a lease -- $72,000 a year, renewing automatically, with a landlord who never has to fix anything.

Somewhere around the third spreadsheet, I realized something a comedian figured out on a stage twenty-six years ago. There is no money in the cure. The money is in the medicine. The audience laughed because they recognized it. I’m not laughing. I’m showing you the receipt.

What You Can Actually Do

Door #1 (Self-insured): Ask HR if your company has audited its PBM contract. The DOL proposed a disclosure rule in January 2026. Most employers don’t know they can demand a full rebate audit.

Door #2 (ACA marketplace): Check your formulary. The “preferred” drugs generate the biggest rebates, not necessarily the cheapest. Ask your doctor about therapeutic equivalents off the preferred list.

Door #3 (Through work): When HR emails about “rising healthcare costs,” ask one question: has the company audited its PBM rebate pass-through rate? If the answer is “what’s a PBM,” you found the problem.

For everyone: The math is a trade secret. That’s not a conspiracy theory. That’s a filing system. The house is rigged. But you can still ask to see the blueprints.

SOURCES & RECEIPTS

[1] FTC Interim Report on PBMs (2024, 2025). Big Three control ~80% of prescriptions. Markups of hundreds to thousands of percent on specialty generics. https://www.ftc.gov/reports/pharmacy-benefit-managers-report

[2] Total manufacturer rebates to PBMs: $334 billion (2023). FTC / industry data.

[3] DOL Proposed Rule (January 2026). PBM disclosure for self-insured employers. Estimated savings: up to $1.1 billion annually.

[4] California SB 41 (October 2025). Fiduciary duty on PBMs, 100% rebate pass-through. Challenged in court by PBM industry, January 2026.

[5] KFF. ~30% of Americans skip doses due to cost. U.S. brand prices 422% of OECD peers (list), 308% (net).

[6] AbbVie/Humira: 247 patents. Manufacturing cost estimates under $1,000/year. USPTO / biosimilar industry analysis.

[7] Medical Loss Ratio (MLR) requirements: ACA Section 2718. 80% individual/small group, 85% large group.

[8] UnitedHealthcare/Fitbit data program: Fitbit data analyzed by Qualcomm Life, matched against medical claims to build predictive models. Up to $1,500/year incentive. (GovTech / The Conversation / U.S. News, 2017-2025).

[9] Rock, C. (1999). “Ain’t No Money in the Cure.” *Bigger & Blacker*, HBO. Recorded at the Apollo Theater, Harlem. Available on Max. *Yes, we cite standup specials. If the bit holds up after twenty-six years, it’s evidence.*

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**Next:** What happens when you fight back against a denial. And the AI that’s waiting for you when you do. Friday on The Ranter.

This is The Ranter. If you’ve ever had a claim denied, you already know the story. This is the part they didn’t tell you.

Your doctor said you need an MRI. Your doctor who went to medical school, did residency, spent a decade treating people exactly like you. They put it in writing and submitted it through the system your insurance company built and required your doctor to use.

Your insurance company said no.

Here’s the part that should make you throw something. Your doctor already knew they’d say that. The American Medical Association asked a thousand doctors about this in 2024. Ninety-four percent said insurance companies delay necessary care. [1] Not elective stuff. Not cosmetic. Necessary.

Your doctor is on your side. Has been. Doesn’t matter.

The Permission Slip

Here’s how it’s supposed to work. Doctor orders something. Insurance reviews it. If it’s genuinely not needed, they flag it. Quality control. Fine.

Here’s how it actually works.

Fifty million of these reviews got processed for Medicare alone in 2023. [2] (Quick sidebar for anyone under 65 who has never had to think about this: Medicare is government health insurance for seniors. “Medicare Advantage” is the private-company version. Moving on.) Fifty million permission slips for care doctors already ordered.

At Cigna, one medical director denied 60,000 claims in one month. [3] Average review time per claim: 1.2 seconds. A former employee described the process to ProPublica: “We literally click and submit.” No file opened. No chart read. Click, submit, next.

When they deny you, the math works in their favor immediately. Not because they’re right. Because fighting it takes time and energy that sick people don’t have.

Two-thirds of doctors don’t always bother fighting denials. [1] More than half said their patients can’t wait for the paperwork to play out. Doctor’s offices aren’t law firms. There are people in the waiting room.

But here’s the thing. When doctors DO fight? They win 80 to 90 percent of the time. [4] The government’s own investigators said the denials were wrong. [5] Not borderline. Wrong.

And fewer than one in nine people ever file that fight. [6]

I need you to sit with that for a second. The win rate is 80-plus percent. The fight rate is under twelve percent. That gap right there, that’s the business model. The machine doesn’t need to be right. It needs to be exhausting.

Joey

Joey works in facilities management. On his feet eight, ten hours a day on concrete floors. Hauls cleaning supplies, fixes whatever broke yesterday. July 2023, his feet start hurting. Not “long day” hurting. “I can’t do my job” hurting. He drops twenty pounds without trying. Can barely walk to his truck.

And here’s the part nobody thinks about. His job is how he keeps his insurance. The body that needs the coverage is the same body that has to keep showing up on concrete to keep the coverage. I’ll come back to that.

A specialist says rheumatoid arthritis. Puts him on prednisone, which is basically a steroid that tells your immune system to shut up for a while.

If you’ve never been on prednisone, Joey can’t explain it. Ten days. Everything stopped hurting. Everything. Joey came home after a 12-hour shift and cleaned the garage. Painted a room. Fixed the plumbing. His wife wanted to put it on a subscription. Ten days. The man was a terminator on facilities guy crack. After months of barely walking, he had his body back.

Then the prescription runs out. You taper off. Three pills for three days, two for three, one for four. Done. You feel it leaving. Every step down, more pain leaking back. And here’s the cruelty of it: before the prednisone, the pain was just your normal. Now you know what not hurting feels like. The drug didn’t fix you. It showed you what fixed feels like. Then it took it away.

Joey asked for another round. He was half-kidding. Then he heard himself say “Come on, doc. Ten more days. I’ll do anything.” And he stopped. Because he heard what that sounded like. Legal prescription from a licensed doctor, and he’s bargaining like someone who knows a guy in a parking lot.

The doctor’s chart said: “Patient responded. Diagnosis confirmed.” Next step: Humira. Seventy-two thousand dollars a year.

But, and this is the part that makes me want to break something. Prednisone doesn’t confirm anything. It suppresses your whole immune system. Arthritis? Feels better. Infection pretending to be arthritis? Also feels better. Prednisone doesn’t care what’s wrong with you. It just turns the volume down on everything. Joey wasn’t better. Joey was on mute. The system wrote “mute” down as “cured” and pointed him at the most expensive drug on the shelf.

Joey’s wife researched Humira. Her exact words: “No fucking way.” They never went back.

New doctor. New blood work. The basic panel, the one insurance covers, runs pass or fail. Like a pregnancy test for everything. Came back clean.

Joey was not clean. Joey was down twenty pounds and couldn’t close his fist.

So the doctor ordered better testing. The kind that shows values, not just pass or fail. Insurance denied it. “Not medically necessary.” The cheap test came back empty, so why pay for a better one? They bought the test that shows less. It found nothing. Then they used that nothing to block the test that shows more.

Joey paid $1,900 out of pocket. Nine of thirteen markers flagged for tick-borne infection. He never had arthritis.

The insurance company would have paid $72,000 a year for the wrong drug. It refused to pay $1,900 for the right test.

The Tumor Doesn’t Have a Hold Queue

What happens while a denial sits in a queue? Johns Hopkins tracked that question for over twenty years. [7] Diseases get worse. People end up in the hospital when they didn’t have to. In cancer cases, survival rates drop. Because when you delay cancer imaging, the tumor doesn’t wait for the paperwork. A few weeks is sometimes the whole distance between treatable and terminal.

Mental health might be worse. Insurance algorithms flag patients as “outliers” when therapy goes longer than the computer expects. [8] Not based on symptoms. Based on averages. When those cutoffs hit, self-harm risk goes up. The algorithm doesn’t know that. The algorithm doesn’t know anything. It counts.

And if the cutoff doesn’t get you, the phone book will. Senate investigators found that more than 80% of therapists listed in insurance directories weren’t actually available. [9] Wrong number. Retired. Dead. The listings stay up because every name counts toward a legal requirement on paper. They don’t deny you mental health care directly. They just make sure nobody picks up when you call.

$3.99 a Page

I can pay my credit card and it clears before midnight. I can split a dinner tab with four people in eight seconds on my phone. But a doctor’s visit takes 60 to 90 days to process, and you might need a fax machine. In 2026. A fax machine. The convenience store has one, $3.99 a page. I’m barely exaggerating. That’s the problem. I’m barely exaggerating and you’re not sure which part I made up.

This isn’t a technology problem. When a pharmacist tells you “$12.47,” that number was calculated against your specific plan in seconds. Visa processes 65,000 transactions per second. They could do this instantly. They choose not to.

Because delay is profitable. While your claim sits for 60 or 90 days, the premium you already paid is still in the insurance company’s account. Invested. Earning returns. Your money is working for them while your doctor waits to get paid.

And internally? UnitedHealth built an algorithm that scores employees on how closely they follow the computer’s denial recommendations. [8] Not on whether those recommendations are right. They called the score “fidelity.” Fidelity to the algorithm. Not to you. Not to accuracy. To the computer that says no.

Court filings from a real case revealed that UnitedHealth labeled expensive patients “High Dollar Accounts.” [10] Not “critically ill.” High. Dollar. Account. And in a recorded phone call that was never supposed to go public, an employee discussed the upcoming appeal for a dying college student and said: “We’re still gonna say no.” The appeal hadn’t happened yet. The outcome was already decided. I need to say that again. The appeal. Hadn’t. Happened. Yet.

Your Doctor Is Drowning Too

Here’s the part that should change how you think about your next appointment. Doctors say this system doesn’t even save money. [1] It creates more appointments because the first treatment gets denied and you have to come back. It forces worse treatment first.

That’s called “step therapy.” I’ll translate: try the thing your doctor knows won’t work, document that it didn’t, then ask permission for what your doctor wanted three months ago. Your body is the test subject. Your time is what they’re spending.

And there’s a pattern that might be the cruelest detail in all of this. Patient appeals a denial. Patient wins. Coverage restored. Then sometimes within days the insurance company runs the algorithm again on the same patient and issues a new denial. [8] Family appeals again. Might win again. Insurer runs it again. Near-constant battle. Winning rounds, losing the war.

Lawmakers had to ask the government to create a “grace period” before re-denial after a successful appeal. The fact that someone had to request that tells you the default setting: if the human overrides the computer, try the computer again.

Make Them Say No Twice

If they deny you, make them do it again. On paper.

Ask for the denial in writing with the exact reason. Not the form letter. Ask for the specific medical criteria they used. Request a peer-to-peer review. That means your doctor gets to talk to their doctor. File the appeal before the deadline, and put that deadline on your calendar in red because they are counting on you to miss it. If you’re on Medicare, you can request an independent outside review. If your employer runs its own plan ask HR, you might not know, there may be a second path nobody told you about.

None of this guarantees a yes. But every step forces a human to look at your file. That’s the one thing the system is built to prevent.

Write That Down

Next time you’re in that exam room and your doctor says “I’m going to order this for you,” understand what’s about to happen. The order goes into a system. The system asks one question. Not “does this person need this.” The question is: does the math work? Not for you. For them.

Ninety-four percent of doctors say the system delays care. More than eighty percent of denials get overturned when someone fights. Fewer than one in nine people fight.

The gap between those numbers is where the money lives.

Your doctor agrees with you. Write that down. You might need it for the appeal.

Sources & Notes

[1] American Medical Association, 2024 Prior Authorization Physician Survey. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf

[2] KFF, “Medicare Advantage Prior Authorization Determinations in 2023.” https://www.kff.org/medicare/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/

[3] ProPublica, “How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them” (2023). https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims

[4] KFF / JAMA Health Forum on appeal overturn rates. https://www.kff.org/tag/prior-authorization/

[5] HHS Office of Inspector General (April 2022). https://oig.hhs.gov/reports/all/2022/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/

[6] KFF analysis of Medicare Advantage appeal rates. https://www.kff.org/medicare/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/

[7] Johns Hopkins, “Adverse Effects of Prior Authorization on Clinical Effectiveness and Patient Outcomes” (2025). https://www.hopkinsmedicine.org/news/articles/2025/10/researchers-find-measurable-patient-harm-linked-to-prior-authorization

[8] STAT News investigation into UnitedHealth’s nH Predict algorithm (2023-2024). https://www.statnews.com/2023/11/14/unitedhealth-class-action-lawsuit-algorithm-medicare-advantage/

[9] Senate Finance Committee, “Barriers to Mental Health Care” (May 2023). https://www.finance.senate.gov/chairmans-news/wyden-calls-for-action-to-get-rid-of-ghost-networks-releases-secret-shopper-study

[10] Christopher McNaughton v. UnitedHealthcare. https://www.propublica.org/article/unitedhealth-insurance-denial-ulcerative-colitis

Got a denial story? I want to hear it. Not to publish without permission. To document the pattern. One story is an anecdote. A hundred is evidence. stories@theranter.com. Your name stays out of it unless you say otherwise.

Next time: why your insurance approved a $72,000 drug you didn’t need, and who got paid when it did.

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This is not medical or legal advice. If you’re navigating a denial, the Patient Advocate Foundation (patientadvocate.org, 800-532-5274) has free case managers. Your state may also have a Consumer Assistance Program -- find yours at healthcare.gov.

New articles publish on Tuesdays and Fridays.

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