FixCare!

Looks like we are going to need another "Affordable Care Act." Perhaps the next one will work better?

Armed guards at the door. Opioids offered on repeat. Apple Pay at my bedside. Welcome to the American Emergency Room. The French think it bankrupts you. Americans think France does it for free. I’ve been to the ER in both. Both are wrong. Mountain bike crash, dislocated and fractured shoulder. I’m French, I live in San Francisco, and I take slightly too many risks. Let’s compare. Security 🇺🇸 Kaiser in Marin. Three armed guards and a metal detector. My phone set it off, so with my shoulder out of its socket I walked through again. And again. Then a pat-down. 🇫🇷 A couple of unarmed guys with walkie-talkies. Still not sure what they’re for. Wait 🇺🇸 Three people in the waiting room. Seen in 15 to 30 minutes. 🇫🇷 Broken hand: packed room, 4 hours before anyone touched me. Records 🇺🇸 Kaiser is vertically integrated. Insurer, hospital, doctors: one system. They had my file before I sat down. 🇫🇷 Every new doctor is a fresh context window. Zero history, maybe a printout from last time. Infrastructure 🇺🇸 Small hospital, serious kit. Straight to the trauma bay: real bed, IV, vitals monitoring, ready for surgery if needed. All imaging on the spot. 🇫🇷 Broken hand: a plastic chair and a Doliprane. Drugs 🇺🇸 Strong opioids were the default offer. I said no. They insisted. The doctor came in personally, confused why someone in that much pain would refuse. I stuck to Tylenol, an anti-inflammatory, to put the shoulder back in. Yes, it hurt. No, I didn’t tap out. My mom is proud of me. 🇫🇷 Broken hand: Doliprane, opioids never mentioned. I have friends who got their shoulder popped back in with nothing at all. US default: opioids. French default: Doliprane. Bill 🇺🇸 Every nurse warned me: “You’re French, this bill is going to traumatize you.” Before discharge, someone came to my bed to collect payment. Apple Pay, from the hospital bed. $300. For everything. On a ~$500/month Kaiser plan. 🇫🇷 A flat ~€20 ER fee, usually reimbursed by your mutuelle. The real bill shows up later, on your payslip (see below) followup 🇺🇸 Kaiser called me right after to set up follow-up and physio, all in their system. So far, so good. 🇫🇷 Broken hand: discharged, figure it out yourself. A friend dislocated her finger. They put it back in wrong, sent her home with bad instructions, it locked up, and she needed surgery months later. Still not fixed. “Free healthcare” in France It’s not free when your marginal tax rate nears 70% with social charges. And if you want quality care fast, more and more people pay for private clinics anyway. Verdict One person, one data point. But the care was 10x better than anything I’ve had in France, for a price that’s completely fine. France has a lot to learn. And yes, I refused the narcotics to stay sharp enough to launch a NanoCorp from my hospital bed. Launch your first company run by an AI agent: nanocorp .so

You pay for health insurance. Then you find out the MRI costs $1,200 less without using it. Karim Wahib walks through an example: an imaging center charges $1,800 through insurance before you meet your deductible, versus $600 at the cash price. Same scan. Same center. Apparently, the insurance card needs a warning label: presenting this may increase your bill. @FixCareHealth

Wrong question: Why is healthcare expensive? Better question: Why do Americans accept buying healthcare without knowing the price first?

HHS Chief Economist: Health Care is Not Health

My wife and I own Forest Park Pharmacy, and we don't accept insurance. None of it. That decision is exactly why we could fix what happened to a patient today. A family came in wanting to transfer their kid's antibiotic to us. The child had already STARTED the course. Then, mid-treatment, the insurance company decided the last 14 tablets suddenly needed a "prior authorization" before the other pharmacy could hand them over. A sick kid, halfway through an antibiotic, and the answer was "please hold." The drug is linezolid. It's a generic. It's been generic for over a decade. It treats serious gram-positive infections — the kind you do NOT want to stop antibiotics in the middle of, because an interrupted course is how you breed resistant bugs and end up right back where you started. So why the hold-up on a cheap, common generic? Follow the fake math. Insurance and the PBMs behind them price drugs off a number called AWP — "Average Wholesale Price." People in my industry have another name for it: "Ain't What's Paid." It's a benchmark number, not a real-world cost. On paper, the AWP for just those last 14 tablets is about $2,500. My cash price for the same 14 tablets? $18. Read that again. The system that's supposedly "protecting" this family from cost is the same system that inflated an $18 medication into a $2,500 line item, then slapped a prior auth on it to "review the expense" THEY invented. They manufactured the problem, then billed everyone for the privilege of solving it — and made a sick kid wait while they did it. This is the whole game. When a drug is priced honestly, there's nothing to "manage." When it's priced off a fantasy benchmark, you get spread pricing, PA paperwork, pharmacy phone trees, and delayed treatment — all dressed up as cost control. Here's the part nobody tells you: roughly 90% of prescriptions are low-cost generics. For the vast majority of what people pick up every day, running it through insurance does two things — raises the real cost and risks delaying your care. That's it. That's the value-add. That's why we fired the insurance companies. No middleman deciding your kid can't finish their antibiotics on schedule. No fake prices. Just the real number, on the shelf, today. The medication was always cheap. The insurance was the expensive part.

I have asked Google, Meta, Amazon, Pinterest, and Shopify if physicians could sell actual medical services on their platforms. Lab tests. PT. CTs. MRIs. Consults. Their answer: “F-ck you. Go away.” You can buy almost anything online except healthcare at a transparent price. Tech used to be awesome because it was an active rebellion, today it protects the health systems and insurance companies.’ FYI, I have been actively on this path since 2014. And not once did I get more than a meeting.

DO NOT get sick in America y’all 💀

All doctors are underpaid.

I built direct contracting in New York and New Jersey first. The people who fought me hardest weren’t the insurers. They were the independent doctors I was trying to help. The model was simple: contract straight with self-insured employers and unions. Cut out Empire. Cut out Horizon. The physician gets paid more, the patient pays less, the middleman gets nothing. But it was new. It meant learning how employers actually buy healthcare. It meant a relationship that didn’t look like the one they’d had with the carriers their whole careers. So they said no. And went back to the system that was strangling them. The physicians are still telling me they have no relief. They’re right. They don’t. The relief was on the table. It just didn’t look familiar, so they didn’t reach for it. Here’s the uncomfortable part: the system doesn’t need to defeat you. It just needs the alternative to feel like extra work. Most people will choose a familiar cage over an unfamiliar door every time.