New episode — NYT’s Ron Lieber: “These people are not going to win”

Hey there—

What’s scarier than major surgery? How about getting a letter from your insurance company less than two days before surgery, saying they’re not paying the bill?

Oh, and the letter arrives on Saturday. You’ve been out all day, so you get it Saturday night. Surgery’s scheduled for first thing Monday. You can try making calls on a Sunday to get this resolved, but nobody’s gonna pick up.

That’s what happened to New York Times personal finance columnist Ron Lieber and his family in late 2024. Ron’s wife was the patient.

In today’s new podcast episode Ron tells the story of how his family navigated that scary dilemma — and what he did afterwards, to help other folks avoid getting caught in the same terrifying spot.

Spoiler: Ron didn’t set out to solve the problem of random insurance-company denials. He’s a personal-finance columnist, not Superman.

But he did aim to help folks avoid getting stuck with a denial at the last minute, with no idea where to turn or what to do next.

Ron drafted a guide to “pre-authorization” that providers could give patients — the kind he wished docs had given his family — and published it in the Times.

The gist: Hey, sometimes insurance companies don’t want to pay for the care we recommend. It can be frustrating, but if anything like that happens, here’s how we — you and our team — can work together to (hopefully) solve the problem.

Then, readers wrote in with smart critiques and suggestions, so Ron published a revised version as The Health Insurance Prior Authorization Memo That You Helped Write.

It’s good! Check it out, and please pass it around — especially to providers (or folks who work with them).

The link above is a “gift link”: It’ll open for anybody, no subscription or registration necessary — but only for the next 30 days, so please don’t wait to spread it around.

And in any case, I hope you’ll enjoy today’s episode. Ron’s a terrific storyteller, and the tale has some twists that I haven’t spoiled here.

Congress and the feds try to make drugs more affordable

Three new things, all this week. Some sound big. Will any of them work?

First: A new law just passed.

When Congress passed a spending package to end a short government shutdown this week — with questions about ICE funding deferred for a little while — lawmakers tucked something else into the budget bills.

New restrictions on pharmacy benefit managers — PBMs for short.

PBMs are powerful middleman companies that set the out-of-pocket prices we pay for prescription drugs, and often set those prices out of reach.

An estimated 80 percent of all prescriptions get run through three giant PBMs.

If you want a review, or a primer on PBMs — how they make money, and their role in making drugs less affordable — we’ve got a podcast episode for you.

Of course, drugmakers play a big role in drug prices too. The two sides love to fight over which is the bigger villain. And as we’ve reported, they’re both sharks, fighting over who gets to take the biggest bite out of us.

It’s impossible to know for sure how big a difference this new law will make for most of us.

The NYT’s story quotes one observer noting that the PBMs show “tremendous resilience in the face of policy reform,” and a Politico story quotes an industry spokesman calling the law “tolerable.”

Second: The Federal Trade Commission just announced a settlement with one of the three big PBMs.

Under then-President Joe Biden, the FTC sued the big three PBMs in 2024. This week, the FTC announced a settlement with one of them, Express Scripts.

One of the best-informed analysts, Adam Fein, writes that the agreement has “completely … dismantled the existing PBM business model” — and that the agreement’s impact will hit the other two big PBMs, even though they’re not party to the settlement.

Which sounds … good? (Honestly, I’m just starting to wade through all this. Hey, we published an episode on an entirely different topic today.)

I can’t help but note that the CEO of Express Scripts’ parent company, Cigna, reportedly doesn’t expect any of this to affect the PBM’s profit margins.

Third: TrumpRx

The Trump administration has negotiated deals with 16 drugmakers to sell certain meds at discounted prices directly to consumers. A full list hasn’t been made public, and neither have the prices.

But the administration says they’ll all be available via links from a new federal website, TrumpRx, that’s scheduled to go live tonight at 7pm ET.

As NBC News reports, the site may have limited impacts on out-of-pocket costs for most people. Purchases through these links won’t be covered by insurance, and for lots of us, the prices we pay with insurance will be lower.

But if your insurance doesn’t cover the meds you actually need, or doesn’t make them affordable, it’ll probably be worth adding “check TrumpRx” to the Prescription Drug Playbook we outlined last year.

We’ll be watching all of this.

Meanwhile, let us know what you think! Just hit “reply” — or, for anything you want to share, there’s always the contact form on our site. It goes directly to my inbox, and Emily’s and Claire’s.

Catch you next week!

— Dan