Mo Azam, MD, MBA

Simple heuristic. If big insurers and big hospital systems are both lobbying strongly for something, you should do the opposite if your goal is more affordable health care. Stop sending massive subsidies directly to health insurance companies. That will not work.

If you thought “You can keep your doctor” applied to the ACA, you are so 2010. Now it’s the Medicare Advantage lie. Before you sign up for Medicare Advantage in the next month , call your doctor and anyone you get care from and ask them to confirm they are in your Medicare Advantage plan. And remember. Original Medicare plans , plus Medigap, plus Part D may cost you a little more every month , but when you call your doctor to ask if they take original Medicare , the chances are really good they will be Don’t get skunked by zero premiums. Medicare Advantage has no Pre Authorization. Many Medicare Advantage plan specialize in it !

Mark’s right, insurers didn’t just “game” the ACA; they evolved around it. The Medical Loss Ratio rule was built for a world where payers and providers were separate. But over time, that world disappeared. 2010: The ACA assumes clean lines; insurers pay doctors, not themselves. 2015: Vertical integration begins; payers start buying PBMs, clinics, pharmacies. 2018: Megamergers like CVS-Aetna and Cigna-Express Scripts erase the distinction entirely. 2020s: “Medical spending” now flows inside the same corporate shell, where transfer prices can rise quietly and profits stay hidden. Regulators still see 85 cents on the dollar going to “care.” But when the insurer owns the doctor, the pharmacy, and the PBM, that 85 cents is just moving between pockets. Greed didn’t create the loophole, design did. But greed guaranteed it would be exploited. Because once profit can hide inside compliance, it will. Right now, the rules only look at where the money goes, not who owns the place it’s going to. So when an insurance company pays one of its own clinics or pharmacies, it still looks like “medical spending.” To fix that, regulators would have to track ownership links, not just cash flows, seeing whether the insurer and provider are really the same company. Until that happens, big systems will keep earning more by hiding profit inside their own walls instead of lowering costs for patients.