Disruptive Dialogue with Chuck Melendi

Amendment 3 is on every Florida ballot this Tuesday, November 3, and it’s being marketed as property tax relief. Chuck talks with Holly Bullard of the Florida Policy Institute about what the amendment actually does, who stands to gain the most from it, and what it could cost local communities. The conversation focuses heavily on healthcare, because property taxes help fund county health services, hospital districts, EMS and safety net care that people depend on whether they realize it or not.

Floridians, and anyone who wants to understand how tax breaks and funding cuts get sold as smaller government, should give this a listen before Tuesday. You can look up the estimated impact on your own county or ZIP code with FPI’s calculator at amendment3.floridapolicyinstitute.org.

Part one was the diagnosis, and this one is about what is working. Ann Kempski returns to take a  closer look at Maryland, the only state that regulates hospital prices. Everyone pays the same rate and hospital budgets are set in advance instead of rising with volume.

We also take on nonprofit status, which covers 58% of community hospitals and close to seven in ten private ones. Ann argues it should be earned each year rather than granted for good, and we get into the Super Bowl ads, the war chests funding hospital venture capital arms, the boards stocked with bankers instead of clinicians, and the $25.8 million paid to one nonprofit system’s CEO after a 49% raise. Then she lays out what you can do close to home – addressing community health needs assessments, county hearings, and the certificate of need laws that mostly protect the incumbent.

Links: hscrc.maryland.gov · thepcc.org/profiles/ann-kempski

Chapter list

1. Global budgets and breaking the link to volume
2. What Maryland pays for together, and what it costs
3. The office that looks independent and bills like a hospital
4. What to ask before any appointment that isn’t an emergency
5. How HMOs taught us to stop asking what things cost
6. Nonprofit status and what it should have to buy
7. Super Bowl ads, lobby sculptures, and land off the tax rolls
8. War chests, venture arms, and squeezing out the independents
9. CEO pay, and boards full of bankers
10. Community Health Needs Assessments and county hearings
11. Certificate of need and the incumbents it protects
12. Eight patients for the price of one, and how to make that case

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Hospitals count for about 31% of everything this country spends on healthcare, and that number hasn't moved in forty years. My guest is Ann Kempski, an independent health policy consultant who has led health policy work at SEIU, the Permanente Federation of Kaiser Permanente, and the Delaware Health Care Commission.

We start in Pittsburgh, where UPMC controls 71% of hospital beds inside the city, employs 76% of hospital workers, and sells its own insurance. Ann explains how the balance of power quietly shifted from insurers to hospitals, why the employers and workers footing the bill are never at the negotiating table, and how the same MRI costs $400 at an independent center and $4,000 across the street. We also get into what employers and unions are actually doing about it, and the contract clauses hospitals use to shut those efforts down.

This is part one of two. Part two covers solutions, including Maryland's all-payer hospital rate setting.

Chapters:

1. Pittsburgh and what near-monopoly actually looks like
2. The corporatization of the community hospital
3. No margin, no mission, and the limits of that argument
4. Innovation moved care out of the hospital. Spending never followed.
5. Empire building, branding, and buying the practices
6. How the power shifted from insurers to hospitals
7. The people paying the bills aren't at the table
8. Primary care as a feeder system
9. The $400 MRI and the $4,000 MRI
10. What employers and unions are actually trying
11. Price transparency data and who can use it
12. Anti-tiering, anti-steering, and the antitrust openings
13. Coming in part two: how Maryland does it

Ann Kempski is an independent health policy consultant with more than 25 years of experience as an analyst, advocate, and strategist, currently advising primary care advocates and coalitions working to contain healthcare costs. She served as Executive Director of the Delaware Health Care Commission, was Director of Policy for the Permanente Federation of Kaiser Permanente from 2010 to 2017, and led health policy for SEIU from 2000 to 2010, where her team played a central role in the passage of the Affordable Care Act. She holds a BA in economics from the College of William & Mary and a master's in industrial and labor relations from Cornell.

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Hospitals drive close to a third of all healthcare spending in this country, and today we turn the focus there. My guest is Brian Reid, author of the daily Cost Curve newsletter and a former Bloomberg and Washington Post health policy reporter.

We dig into 340B, a drug discount program written as a two-page law in 1992 that now moves more than $100 billion a year, and Brian lays out who really collects the discount and what employers are losing in the process. Then we get into what happens to prices when hospitals buy up independent physician practices, and why he says the best thing you can do is be skeptical of size.

Call the Capitol switchboard at 202-224-3121 and tell your members that hospital pricing and 340B are on your ballot.

Links: reidstrategic.com/cost-curve · costcurve.beehiiv.com

Chapters:

-Meet Brian Reid and the Cost Curve newsletter
-Why the focus turns to hospitals this year
-340B in plain English, and the small problem it was written to solve
-How a safety-net program grew past $100 billion
-Who actually gets the discounted drug
-Charity care, nonprofit status, and the missing evidence
-Employers eat the duplicate discount
-Contract pharmacies and the PBM cut
-Why the same scan costs more once a hospital owns your doctor
-Be skeptical of size

Remember to subscribe to see what's next!

And together, #LetsFixHealthcare

Matt Zachary — brain cancer survivor at 21, founder of Stupid Cancer, and author of We the Patients — joins me to make the case that American healthcare isn't broken, it's finished. It was designed to move money, and denying your care is now more profitable than delivering it.

We cover how employer-based coverage and the 1973 HMO Act got us here, the billions insurers make by saying no on purpose, why Medicare Advantage is neither, and what AARP gets paid to lend its name to a UnitedHealth product.

Matt's answer isn't another awareness campaign. It's organizing patients into a bipartisan single-issue voter bloc big enough that state legislators have to hear us. We need “seatbelts” for patients, written into consumer protection law, and that means no denials, no delays for reasonable care, doctors decide, nobody goes bankrupt.

That only works if you're counted. Take the five-minute anonymous national poll at wethepatients.org, and call the congressional switchboard at 202-224-3121 to tell your representative that healthcare costs decide your vote. A hundred calls is a five-alarm fire in a state office.

LIKE this episode and SUBSCRIBE to keep it going!

Links:

www.disruptivedialogue.org

www.wethepatients.org

www.wethepatientsbook.com (buy indie) ·www.matthewzachary.com

www.siubfilm.com

Chapter list

-Meet Matt Zachary — 25 years of work, and the book that finally got himtaken seriously

-Not broken, built this way — employer coverage, the HMO Act, and theshift from service to product

-"What insurance do you have?" — the question that decides who lives

-The denial economy — how saying no on purpose became a profit center

-Medicare Advantage is neither Medicare nor an advantage

-The AARP card that isn't AARP — licensing a trusted name to seniors

-Rig it in your favor — what patients are forced to learn mid-diagnosis

-"Seatbelts" for cancer patients — borrowing Ralph Nader's playbook

-Why doctors can't fight back — moral injury, and the ban on organizing

-Building the voter bloc — why 10,000 people can speak for 20 million

-Go to the states — PBM reform, protection bills, and where they die

-How good laws get defanged — toothless fines and three-year delays

-Suck It Up, Buttercup (film)— burnout, private equity, and rural America

-Lightning round — the worst actors, and who's getting hurt most

-Your call to action — take the poll, call the switchboard, keep calling

Your pharmacist may be the last line of defense between you and a dangerous medication mistake — and the system is grinding them into the ground.

This week, Chuck talks with Todd Eury, founder of the Pharmacy Podcast Network and the original voice of pharmacy podcasting since 2009, about the forces hollowing out one of healthcare's most trusted professions.

With 17 years and more than 4,000 episodes behind him, Todd has watched PBMs evolve from a genuinely useful flat-fee service into multi-trillion-dollar middlemen that control which pharmacy you use, what you pay at the counter, and whether your neighborhood independent survives at all. He and Chuck get into the rebate shell game, the burnout crisis behind the pharmacy counter, and the landmark RICO lawsuit that could finally crack the whole thing open.

What You'll Learn

How PBMs started as a fair, flat-fee service and became some of the most powerful and least understood corporations in American healthcare.

Todd's two fixes for the system: banning insurers from owning pharmacies, and flat-rate pricing for anything funded by taxpayer dollars.

What the RICO class action against Express Scripts alleges, and why Chuck calls it a real tipping point.

How the rebate shell game works — and why employers getting "100% of rebates" are often getting 100% of a fraction.

Why Arkansas and Tennessee banned PBMs from owning pharmacies, and why senators from both parties want to break up the vertical integration.

Todd's new "evidence-based podcasting" standard: peer reviewed medical audio you can actually trust,

Take Action

📞 Call Congress directly at 202-224-3121 and tell your senators and representatives that healthcare needs the Ma Bell treatment — break up the vertical integration and restore real competition.

🌐 Learn more about the Pharmacy Podcast Network at PharmacyPodcast.com

Disruptive Dialogue with Chuck Melendi — because the healthcare system isn't going to fix itself.

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In Part 1 of this series, Doug Griesenauer and I laid out the problem: 42% of American households are financially struggling right now, not because they aren't working, but because the federal poverty level — a formula built on 1955 grocery data — still determines who qualifies for help in 2026.

Now in Part 2, we get into what we actually do about it.

Doug returns to walk through the things that change practically and politically if policymakers adopt the ALICE threshold instead of the federal poverty level, and the difference is significant. Benefits phase out as families can genuinely afford to lose them instead of at an arbitrary cliff that punishes people for earning more. Financial stress drops. Workplace productivity rises. The math starts working for working families instead of against them.

We also go somewhere many policy conversations won't: a hard look at whether large corporations are deliberately relying on public assistance programs to offset wages they should be paying themselves. Doug lays out a clear framework: micro solutions at the business level, meso solutions at the community level, and macro solutions at the policy level. And he makes thecase that this is NOT a partisan issue, because when you strip away the labels, most Americans across the political spectrum agree that people who work hard should be able to get by.Key topics covered:

-What immediately improves for working families if ALICE replaces the federal poverty level

-Why financial stability helps workers but also makes businesses more productive and the broader economy stronger

-The uncomfortable question of whether corporations are subsidizing low wages with public benefits

-Matthew Desmond's research on the true cost of addressing poverty — and why it's a matter of will, not budget

-The two-path solution every American needs to understand: raise wages or update the support threshold OR both!

-Practical steps anyone can take, including the Volunteer Income Tax Assistance Program

This two-part series is essential listening for anyone who wants to understand why the American safety net fails working families, and what a better system looks like.

Guest: Doug Griesenauer, VP of Community Impact, United Way Suncoast
ALICE Research: unitedforalice.orgRecommended reading: Poverty by America by Matthew Desmond

Take action: Call 202-224-3121 to reach your congressional representatives and tell them that healthcare costs and reform to the outdated federal poverty level are priorities

If this series opened your eyes, please subscribe, share it with someone who needs to hear it, and leave us a review. Until next time — stay informed and take charge of your health.

Disruptive Dialogue is hosted by Chuck Melendi, a 35-year healthcare industry veteran committed to exposing the systems failing American patients.and the people working to change them. New episodes every two weeks.

Did you know that the federal poverty level was built on grocery price data from 1955 — and has never been updated to reflect how we live in America today?

In this episode, Chuck sits down with Doug Griesenauer, VP of Community Impact at United Way Suncoast in central Florida, to unpack one of the most overlooked crises in our country: the gap between who our safety net programs offer to help and who actually needs it.

They dig into ALICE — "Asset Limited, Income Constrained, Employed" — a research framework that reveals 55 million American households are financially struggling right now. Not because they're not working. Because the system wasn't built for how we actually live.

What you'll learn in this episode:

Why the federal poverty level is broken in three distinct ways — and why policymakers have known it since the 1960s

What ALICE is and why it's a far more accurate picture of financial hardship in America

The "fiscal cliff" (also known as the "valley of death") — why getting a raise or a promotion can actually leave working families worse off

How financial instability drives people straight into the most expensive healthcare settings: emergency rooms

Why 42% of America is struggling financially — and most of us never see it

This isn't a conversation about handouts. It's about hardworking people — single parents, dual-income families, people working two jobs — who are doing everything right and still can't afford housing, childcare, transportation, or healthcare. That's a policy failure, not a personal one.

This is Part 1 of a two-part series. Part 2 drops next week.

Subscribe so you don't miss Part 2

Like if this opened your eyes

Did any of these numbers surprise you? Take action: Call 202-224-3121 to reach your senators and representatives. Tell them healthcare costs and the outdated federal poverty level need to be addressed — now.

CHAPTERS

00:00 Introduction — The quiet gap in America

01:50 Meet Doug Griesenauer, United Way Suncoast

03:20 Financial health IS physical health — the dental divide

04:50 What is the federal poverty level and where did it come from?

05:15 Dr. Molly Orshansky and the 1955 grocery basket

08:30 Three ways the FPL is broken: food, geography, and household type

15:00 What ALICE is and how it was built

19:10 The ALICE numbers: what it actually costs to get by by state

21:35 42% of America — 55 million households — are struggling

22:30 Why wages haven't kept up and costs keep climbing

26:30 The fiscal cliff: why a raise can make you poorer

28:10 Refusing promotions might be the smart economic choice — and that's a system failure

30:32 Chuck's call to action

CONNECT & LEARN MORE

🌐 Disruptive Dialogue: www.disruptivedialogue.org

📊 ALICE Research: unitedforalice.org

Disruptive Dialogue is hosted by Chuck Melendi, a 35-year healthcare industry veteran on a mission to expose the systems failing American patients — and the people trying to fix them.

One in three Americans carries medical debt — and most of them have health insurance. In this episode, Chuck talks with Eva Marie Stahl of Undue Medical Debt about why insurance isn't protecting patients the way it should, what to do when the bills pile up, and how one nonprofit organization has abolished over $25 billion in medical debt for more than 14 million people.

Eva brings more than two decades of health policy experience and a front-row seat to stories that bring the statistics to life: a North Carolina man hit with nearly $10,000 in bills after a brain aneurysm, a Chicago woman with sickle cell anemia still paying off hospital bills from 2017 — both insured, both blindsided.

This episode covers the real drivers of medical debt, the little-known ways patients can fight back, and why medical debt reform is one of the few policy issues that polls above 80% across both political parties.

Listen and learn about:

• Why high-deductible health plans leave millions of insured Americans financially exposed — and why most people can't cover even a $500 surprise bill

• The critical difference between medical debt and consumer debt, and why it matters for your financial protections

• Practical survival tips: why you should never pay a medical bill with a credit card, how to apply for hospital financial assistance (even on a six-figure income), and how to negotiate your bill down

• How unpaid medical bills become a commodity — bought and sold in bulk on an open market — and how Undue Medical Debt purchases those portfolios and cancels the debt instead of collecting it

• What extraordinary collection actions (wage garnishment, property liens, lawsuits) are, and which states are moving to ban them

• Results from Undue Medical Debt's national survey: 94% of voters want interest rate caps on medical debt, 80%+ want it removed from credit reports — and these numbers hold across party lines

• How every $1 donated to Undue Medical Debt abolishes $100 in debt — and how you can be part of the solution

🌐 Visit UnduemedicalDebt.org to donate, learn, or find out if your community has been part of an abolishment campaign.

📞 Call Congress directly at 202-224-3121 and ask your senators and representatives to support medical debt protection legislation.

Disruptive Dialogue with Chuck Melendi — because the healthcare system isn't going to fix itself.

Subscribe, share, and leave a review! Together, #LetsFixHealthcare. Learn more at disruptivedialogue.org.

Private insurance companies are increasingly moving into veterans' healthcare and, according to health policy expert Dr. Rachel Madley, the consequences could reshape one of America’s most successful public healthcaresystems.

In this week’s episode, Chuck welcomes Dr. Madley to talk about about the growing privatization of the VA through the Veterans Community Care Program and the VA Mission Act.

They explore how companies like UnitedHealth Group and Optum Serve are gaining influence inside public healthcare programs, why many experts see concerning parallels with Medicare Advantage, and what this means for veterans, taxpayers, and the future of healthcare reform in the United States.

The conversation covers the economics of privatization, conflicts of interest in healthcare administration, the political influence of insurance lobbying, and why the VA often delivers better outcomes at lower cost than private systems.

Dr. Madley also explains why she believes reinvesting in VA facilities and staffing would strengthen care for veterans far more effectively than outsourcing administration to private insurers.

Topics include:

• The VA Mission Act and Community Care• Medicare Advantage and privatization trends in public care• Healthcare lobbying and political influence• Optum Serve and vertical integration concerns• Traditional Medicare versus private insurance administration• Why veterans’ care matters to all taxpayers

Our Guest

Dr. Rachel Madley is Executive Director of the Center for Health and Democracy, a nonpartisan nonprofit advancing policy reforms to lower health care costs and expand access to care. She brings a rare combination of scientific expertise, Capitol Hill experience, and personal perspective as someone living with Type 1 diabetes. Notably, she contributed to the passage of the Inflation Reduction Act as Health Policy Advisor to Congresswoman Pramila Jayapal.

Dr. Madley holds a PhD in Microbiology and Immunology from Columbia University and her work has been featured in The New York Times, Newsweek, and Business Insider.