Decker Essential Services

10/15/2026

For two years, a nurses' station in Brownsville talked about me in Spanish. They were sure I couldn't understand. 👇

Travel assignment. Med-surg floor. A border town where Spanish comes first. They took one look and decided: white guy, no Spanish.

🏥 WHAT THEY DIDN'T ASK
🔹 I'd lived years in Guatemala, during the civil war
🔹 I learned my Spanish where the stakes were real
🔹 I never lied. I just never corrected them

🩺 TWO YEARS AT THE STATION
🔹 They translated my admissions, discharges and consents. Grumbling the whole way
🔹 And they talked. About me. About each other. The things you only say when nobody's listening
🔹 Then one day I was talking with a patient in Spanish, and the door was open

⚠️ To be fair: they weren't bad nurses. They were tired and they were certain. Certainty is the expensive part.

"How come you never told us?"
"You assumed I couldn't. So I let you."

I spent 25 years inside this system the same way. Quiet. Listening. Taking notes.

The quiet man in the room may be the only one who understands.

💬 Have you ever been underestimated and just let it ride? What happened when they found out?

Built, Not Given.

10/15/2026

The doctor shortage is not an accident. In 1997 Congress capped the residency slots Medicare would pay for. 👇

I sat down with Tim Harris on the Mad Metaphysician show. 25 years at the bedside, ER, ICU and managed care. Both sides of the fence. We started with why it takes so long to see a doctor.

📜 THE DECISION
🔹 1997: the Balanced Budget Act capped Medicare-funded residency slots at each teaching hospital at 1996 levels
🔹 For 24 years, Congress added no new Medicare-funded slots. The 2021 spending bill added 1,000, spread over five years
🔹 Since 1996, the country has added more than 70 million people

🩺 WHAT IT MEANS FOR YOU
🔹 A doctor is not trained in a classroom. They are trained in a residency. No slot, no doctor
🔹 Fewer doctors means longer waits, shorter visits and higher prices for the ones you can reach

⚠️ To be fair: the cap is on what Medicare pays for, not a ban. Hospitals kept adding residents on their own dime, about 17% more after the cap. Whether that kept pace with an aging country is still argued.

THE SUPPLY MACHINE. You cannot shop for a doctor who was never trained. Scarcity was written into the budget, and the waiting room is the receipt.

💬 How long did you wait for your last appointment? Weeks or months?

Built, Not Given.

10/14/2026

A surgery goes wrong. For a privately insured patient, the hospital's margin went up $39,017. 👇

Nobody plans a complication. I never met a nurse or a surgeon who wanted one. But somebody has to look at what the payment system rewards.

🩺 WHAT THE STUDY FOUND
🔹 JAMA, April 2013. 12 hospitals in one nonprofit system in the South. 34,256 surgical patients (2010)
🔹 Private insurance: contribution margin of $16,936 without a complication, $55,953 with one. +$39,017
🔹 Medicare: $1,880 without, $3,629 with. +$1,749
🔹 All payers: roughly $8,000 more per patient with a complication

📋 IN THEIR OWN WORDS
🔹 Lead author Sunil Eappen: reducing harm is "perversely penalized"
🔹 Funded in part by a hospital system, Texas Health Resources. The industry went looking for this itself.

⚠️ To be fair: the data is from 2010, from one system. For Medicaid and self-pay patients, complications cut the margin, so safety-net hospitals gain by preventing harm. The flaw is in how private and Medicare dollars pay, not in the people at the bedside.

THE PRICING MACHINE. The safer the surgery, the smaller the margin.

💬 Have you ever cleaned up after a complication, at the bedside or on the bill? What happened?

Built, Not Given.

10/13/2026

On a drug for cancer, MS or a transplant? The FTC opened the middlemen's books. $7.3 billion above what the drugs cost. 👇

Three companies sit between you and your prescription. The government finally counted what that seat is worth.

📋 THE REPORT
🔹 January 14, 2025: FTC second interim staff report on pharmacy benefit managers
🔹 The Big 3: Caremark (CVS), Express Scripts (Cigna), Optum Rx (UnitedHealth)
🔹 51 specialty generic drugs, including ones for leukemia, MS, kidney disease and transplant recipients

📊 THE MARKUP
🔹 Markups of hundreds and thousands of percent
🔹 More than $7.3 billion in dispensing revenue above estimated acquisition cost, 2017–2022
🔹 Top 10 drugs: $6.2 billion of it (85%)
🔹 Their affiliated pharmacies' share of specialty dispensing revenue: 54% in 2016, 68% in 2023

⚠️ To be fair: this is an interim staff report, not a court ruling. "Acquisition cost" is the FTC's estimate (the national NADAC benchmark), not each pharmacy's invoice.

THE PHARMA TRAIL. Not the pill. The toll between you and the pill.

💬 Is someone in your house on a specialty drug? What does it cost you a month, and has it gone up?

Built, Not Given.

10/13/2026

10/13/2026

Self-employed on a silver plan with a $4,500 deductible? Mark Cuban told Congress you pay full list price for months. 👇

Congressional testimony. October 22, 2025. The man who sells drugs at cost plus 15% walked the committee through where a $600 prescription goes.

💊 WHAT HE TESTIFIED
🔹 The biggest PBMs, owned by the biggest insurers, run drug benefits for about 270 million Americans
🔹 Their rebates and fees are a percentage of list price. The higher the list price, the more they make
🔹 On a hypothetical $600 brand drug: 50% rebate, 10% fees, manufacturer keeps $240
🔹 Uninsured patient pays $600. Insured patient who has not met the deductible also pays $600

🧮 THE DEDUCTIBLE MATH
🔹 His example: a drug like Eliquis lists around $600. A $4,500 silver plan deductible means about seven months at full price
🔹 The rebate on that $600 does not go to you. His words: it flows from your pocket to theirs

⚠️ To be fair: Cuban sells drugs that compete with this system, so he has a stake. And PBMs say the rebates hold premiums down. Your premium is not your deductible, though.

THE PBM MACHINE. The middleman is paid a percentage of the price. So nobody in the middle wants the price to fall. The patient with the deductible pays retail and gets none of the discount.

💬 Have you ever paid full price at the pharmacy counter with insurance in your wallet?

Built, Not Given.

10/12/2026

Self-employed and under 65? Your health plan isn't broken. You're just not in the plan. 👇

In 1954, Congress built a tax break around the employer plan. The self-employed waited 32 years for a piece of it. They still don't have all of it.

🏛️ THE LAW, IN THREE DATES
🔹 1954: Congress writes the employer exclusion into the tax code (IRC §106). Employer-provided coverage isn't income. No income tax. No payroll tax.
🔹 1986: The Tax Reform Act gives the self-employed a deduction. 25%.
🔹 2003: That deduction finally reaches 100% (IRS).

📊 WHAT IT STILL COSTS YOU
🔹 The deduction stops at income tax. It does not reduce self-employment tax (IRS Form 7206 instructions).
🔹 Self-employment tax is 15.3%: 12.4% Social Security + 2.9% Medicare (IRS).
🔹 On $10,000 of premium, that's up to about $1,413 a year in SE tax (10,000 × 92.35% × 15.3%, below the Social Security wage base).
🔹 Your neighbor with a W-2? Employer coverage is exempt from Social Security and Medicare tax (IRS Pub. 15-B).

⚠️ To be fair: employer coverage isn't free. It's part of that worker's pay. The difference is when it gets taxed. S-corp owners have their own rules, so ask your CPA.

THE DOUBLE STANDARD. It isn't broken. You're just not in the plan.

💬 If you work for yourself: what do you do for a living, and what did your renewal letter say this year? I read every one.

Built, Not Given.

#1099

10/11/2026

1967: the sugar industry paid Harvard scientists $6,500. Fat took the blame. Sugar walked. 👇

A review in the New England Journal of Medicine shaped how America ate for a generation. Nobody told the readers who paid for it.

📋 THE RECEIPT
🔹 July 1965: the Sugar Research Foundation agrees to pay Harvard scientists $6,500 (about $48,000 in 2016 dollars) for a review of heart-disease research
🔹 1967: the review runs in the New England Journal of Medicine. It plays down the sugar studies and names cutting fat and cholesterol as the only diet change that could prevent heart disease
🔹 The sugar funding was never disclosed

📅 WHAT CAME NEXT
🔹 2016: UCSF researchers publish the industry's own letters in JAMA Internal Medicine
🔹 One of the paid scientists, Mark Hegsted, went on to head nutrition at the USDA and in 1977 helped draft the forerunner to the federal dietary guidelines (New York Times)

⚠️ To be fair: the Sugar Association says the foundation "should have exercised greater transparency," and still maintains sugar has no unique role in heart disease. One review didn't set a nation's diet by itself. It just pointed everyone at the wrong suspect, and nobody knew who paid for the pointing.

THE FOOD MACHINE. Six thousand five hundred dollars bought a villain.

💬 Who in your family went fat-free in the '80s? What did they eat instead?

Built, Not Given.

10/10/2026

$2,294 a month. What COBRA can cost an average family — right after the paycheck stops. 👇

📬 THE LETTER, IN THREE NUMBERS
🔹 Average employer family plan: $26,993 a year (KFF 2025) — most of it paid by your employer
🔹 COBRA: up to 102% of full cost → about $2,294/mo for a family, $793 for one person
🔹 Usually 60 days to elect. Up to 18 months of coverage (U.S. DOL)

⏳ THE DATE
🔹 December 15 = deadline for coverage starting January 1

THE COBRA TRAP. The job ending was the first bill. The letter is the second.

The letter shows you one door. It is not the only door in the building.

🔗 Choosing next year's plan? Make it an informed decision — part of that is seeing what I use. Link in bio.

Built, Not Given.

10/09/2026

$3,786. The average you pay

before your marketplace plan pays a dime. Up $1,027 in one year. 👇

📊 LAST YEAR VS. THIS YEAR
🔹 2025 average deductible: $2,759
🔹 2026: $3,786
🔹 +37% — the steepest jump that market has ever recorded (KFF)

🚪 WHAT YOU BOUGHT
🔹 A premium every month, used or not
🔹 A door that stays shut until you've spent almost $4,000 yourself

It's not broken. You're just not in the plan.

🔗 Before you pick next year's plan, know what it costs to get inside. Make an informed decision — see what I use. Link in bio.

Built, Not Given.

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