John Roberts’ Birthright Citizenship Hubris

 by Mark Pulliam

John Roberts wants to be remembered as the opposite of Roger Taney; instead, he will be compared to Harry Blackmun, the author of Roe v. Wade.

Thanks to Power Line and Real Clear Policy (here)!

Last week’s release of the final batch of SCOTUS decisions produced one blockbuster that dominated the conversation: Trump v. Barbara, dealing with birthright citizenship. The result was not a surprise to me; I had predicted that the Court would rule against President Trump’s executive order. But I was disappointed in the rationale that the majority, in an opinion written by Chief Justice John Roberts, chose to employ. The decision deserves sustained criticism, much in the way that Roe v. Wade deserved—and received—such criticism. The existence of sustained public outrage is necessary for the Court to re-visit a precedent. Our goal must be for a future Supreme Court to overrule Trump v. Barbara, just as Dobbs overruled Roe v. Wade. Only we can’t afford to wait nearly 50 years for that to happen!

But let’s not fall into the trap of blaming the current Court, or John Roberts personally, or Amy Coney Barrett (who provided the fifth vote) entirely for a decision we don’t like. All Roberts’ opinion did was follow a prior precedent, albeit an ancient one from 1898, interpreting the muddled language drafted by the 39th Congress, which framed the 14th Amendment. Until President Trump issued the executive order at issue, 128 years passed since the Court’s ruling in Wong Kim Ark (1898). In that time, as untold millions of babies were awarded citizenship despite their parents’ status as non-citizens, Congress did not lift a finger to fix birthright citizenship, no one successfully waged a campaign to amend the Constitution, and no President showed any initiative to do what President Trump did. There is plenty of blame to go around.

As a result of a century-plus of acquiescence, interrupted only by President Trump’s MAGA insistence that controlling the nation’s borders meant taking citizenship seriously, John Roberts mistook the moment as a replay of Dred Scott v. Sandford (1857)–which is correctly viewed by historians as a misstep that may have pushed the nation toward Civil War—and in melodramatic fashion made a show of demonstrating that he is not Roger Taney, the Chief Justice who succeeded John Marshall only to earn eternal ignominy as the author of the worst decision in SCOTUS history.

That’s how we got the decision in Trump v. Barbara. Justice Alito’s dissenting opinion began with these words:

This is one of the most important decisions in the history of the Court, and in my judgment, the Court has made a serious mistake.  

Let’s unpack it.  

What did Trump do, and why: The problem was misinterpretation of the poorly-drafted Citizenship Clause of the 14th Amendment, ratified in 1868. This problem did not arise overnight; it has been around for over a hundred years and will take sustained effort to fix.

The Citizenship Clause is like one of the ink blots in a Rorschach test: “born in the United States and subject to the jurisdiction thereof” is an opaque formulation. The 14th Amendment was intended to “constitutionalize” the Civil Rights Act of 1866, which used a slightly different phrasing: The Civil Rights Act made citizens of “all persons born in the United States and not subject to any foreign power.” The Citizenship Clause means different things to different people, and the varied interpretations tell you something about the observers’ personalities—and priorities.

Based on an old case (United States v. Wong Kim Ark, 169 U. S. 649 [1898]), in Barbara the Supreme Court embraced an expansive reading of “subject to the jurisdiction thereof,” which conferred automatic citizenship on all those born on American soil. This included illegal aliens popping out “anchor babies” (at the rate of 250,000-300,000 per year) and birth tourists from China and elsewhere (CIS estimates 33,000 per year). Wong Kim Ark was controversial even in its day; Chief Justice Melville Fuller and Justice John Harlan (who also dissented in Plessy v. Ferguson in 1896) dissented. But eventually it was accepted as gospel, with only a few dissident legal scholars complaining. But this was before the era of mass migration and open borders.

In recent decades, with the advent of inter-continental air travel and mass illegal immigration, a growing body of scholars believed that birthright citizenship could and should be reined in. Legislation has been (unsuccessfully) proposed in Congress to deal with this going back 30 years or more, with bipartisan support. Sen. Harry Reid (D-NV) once sponsored such a bill. To no avail.

Critics believe that the 14th Amendment was intended only to overturn Dred Scott v. Sandford (1857) and grant citizenship and legal rights to the freed slaves.

Congress passed a statute, 8 U.S.C. section 1401(a), mirroring the Citizenship Clause, as interpreted by the Court. The statute was originally enacted in 1940 and re-adopted in 1952.

This was the pre-MAGA tableau. President Trump was the first President in my lifetime to take concrete action to fix this anomaly, via executive order. The executive order that was challenged is E.O. 14160, issued on January 20, 2025. (It was not limited to “birth tourism”; it went for the whole enchilada. Not that this would have made a difference, as some have contended.)

President Trump’s goal: Eliminate the broad reading to deny automatic citizenship “to persons born in the United States:  (1) when that person’s mother was unlawfully present in the United States and the father was not a United States citizen or lawful permanent resident at the time of said person’s birth [i.e., anchor babies], or (2) when that person’s mother’s presence in the United States at the time of said person’s birth was lawful but temporary (such as, but not limited to, visiting the United States under the auspices of the Visa Waiver Program or visiting on a student, work, or tourist visa) and the father was not a United States citizen or lawful permanent resident at the time of said person’s birth [i.e., birth tourism].”

The E.O. was facially challenged. The ACLU filed Barbara v. Trump asking the U.S District Court for the District of New Hampshire to grant a class-wide injunction covering those who would not qualify for birthright citizenship under the executive order. The representative plaintiff, Barbara, a Honduran citizen, is only known by her first name because she fears for her and her family’s safety.

In December 2025, the Supreme Court granted certiorari before judgment as permitted by its procedures “upon a showing that the case is of such imperative public importance as to justify deviation from normal appellate practice and to require immediate determination.”

The question to be decided was “whether the Executive Order complies on its face with the Citizenship Clause and with 8 U.S.C. § 1401(a), which codifies that Clause.”

Barbara was argued on April 1, 2026 and decided on June 30, 2026. The Court’s various decisions (majority, concurring, and dissenting) were almost 200 pages long!

Decision(s) in Trump v. Barbara:

The majority opinion was written by Chief Justice John Roberts. It is a major disappointment, in the alignment, holding, and reasoning. The Court could have ruled—as I had hoped–simply that Trump cannot alter a statute (8 U.S.C. section 1401) by executive order. Especially since this was a facial challenge with no factual record. This would have left a role for Congress, and possibly put pressure on Congress to act. Instead, the majority reached the merits—and botched them.

Technically 6-3, the decision was really 5-4, with only Barrett and the three liberals joining Roberts’ decision on the constitutionality. Kavanaugh agreed with the result, on narrow technical grounds, but indicated that in his view Congress could eliminate birthright citizenship by statute.

The majority opinion said that the Citizenship Clause of the 14th Amendment requires birthright citizenship, leaving no role for Congress. This was particularly inappropriate in a facial challenge.

So Roberts’ opinion (26 pages) was not only wrong, it was gratuitously—and ostentatiously—wrong. He reached issues that were unnecessary to address. He foreclosed a legislative solution, at least with the current composition of the Court. However, since the constitutional holding was 5-4, it would require only one seat to flip.

This should be a GOP priority.

What did the Court say? Roberts adopted the ancient English common law rule of jus soli—”right of the soil”—hook, line, and sinker. This rule derives from the monarchy in England, where people were regarded as “subjects” of the King, not self-governing citizens with inalienable rights who are sovereign. With the Declaration of Independence, 250 years ago we rejected the notion of being a “subject” of the King! “Subjects” are not the same as “citizens.” Roberts was so concerned to distance himself from Roger Taney’s opinion in Dred Scott (which he denounced as “odious”) that he took the extreme opposite position. Grooming himself for history, at the expense of the nation’s future. This is pure jurisprudential vanity, topping his Obamacare rescue.

What did the majority get wrong? The 39th Congress’s drafting of the 14th Amendment was messy, sloppy, and confusing. The Citizenship Clause could have been interpreted in a common-sense manner. Wong Kim Ark  could easily have been distinguished or overruled. The lengthy dissents by Justice Clarence Thomas (91 pages) and Justice Samuel Alito (39 pages) showed the way. If the Citizenship Clause commands jus soli, how do you explain the exclusion of American Indians from birthright citizenship following ratification of the 14th Amendment (fixed by statute in 1924)? Or the continued recognition of the “legal fiction” that other nations’ ambassadors and diplomatic corps based in the U.S. are not subject to jus soli? You can’t.

Ironically, Roberts enshrines English common law (jus soli) in our 14th Amendment even though, as Alito pointed out in dissent, “the United Kingdom has abandoned [it], as have other countries whose legal systems share the same pedigree.” Because common sense prevails elsewhere. Not in Roberts’ majority opinion, however.

Kavanaugh’s dissenting opinion (10 pages) stated that:

That decision [United States v. Wong Kim Ark, 169 U. S. 649] adopted a general rule of birthright citizenship for those born in the United States—with four disparate exceptions for “children of foreign sovereigns or their ministers, or born on foreign public ships, or of enemies within and during a hostile occupation of part of our territory” and “children of members of the Indian tribes.” Id., at 693.

Why these four exceptions? The Citizenship Clause does not contain any exceptions. Why only these four exceptions? As Kavanaugh pointed out, the Court could have updated the holding of Wong Kim Ark to reflect the changed circumstances in the U.S. since 1898, or entertained the possibility that Congress could do so. Kavanaugh said that

If Congress amends §1401(a) or otherwise enacts a statute creating new exceptions along the lines of the Executive Order for children born to foreign citizens unlawfully or temporarily in the country, such a statute, as I see it, would pass constitutional muster…. Consistent with the Fourteenth Amendment, Congress could amend §1401(a) or otherwise enact new legislation establishing exceptions to birthright citizenship for children born to foreign citizens unlawfully or temporarily in the country.  (Emphasis added.)

Instead, Roberts’ majority decision slammed the door shut. Roberts’ opinion holds that the 14th Amendment “put the ‘great question of citizenship’ ‘beyond the legislative power’ altogether, to settle the issue once and for all.” Thus, Congress is helpless to fix the problems of anchor babies and birth tourism. The door will remain shut absent constitutional amendment (nearly impossible) or until Trump v. Barbara is overruled. The dissents by Thomas, Alito, Kavanaugh, and Gorsuch point the way for a future majority to overrule Trump v. Barbara. As one non-MAGA legal scholar said, “In the end, an opinion meant to settle the debate over birthright citizenship may have instead kindled a new one.”

Thomas dismantled Roberts’ (and the majority’s) adoption of the feudal doctrine of jus soli. Thomas (and Gorsuch) reasoned that birthright citizenship requires more than geographic presence; it also requires allegiance to the U.S. in the form of domicile, which means the legal home of the parents. Foreign nationals—citizens of another country—cannot be deemed to be “domiciled” in a country they entered illegally or which they are only temporarily visiting. Illegal aliens and birth tourists would not qualify. Alito used a slightly different formulation, focusing on whether the non-citizen parents of a child born in the U.S. are “subject to a foreign power,” which entails an inquiry into the rules of citizenship in their home country. He said: “the Fourteenth Amendment confers citizenship on only those children who, at birth, owe allegiance solely to this country.” (Emphasis added.) In many cases, this would preclude citizenship for anchor babies and birth tourists.

Trump v. Barbara was a terrible blunder. Here are the follow-up questions and considerations:

(1) What should the Court have done? Roberts should have done what Kavanaugh did. With one more vote, the dissenters could have punted the decision to Congress with a strong suggestion that it codify the provisions of President Trump’s E.O.

(2) How bad is the majority decision? Worse than Roe v. Wade? Worse than Plessy v. Ferguson? Worse than Dred Scott? It was pretty bad, even though technically it did not change the law. Affirming Wong Kim Ark in 2026 amounts to turning the Constitution into a borderline “suicide pact.” I would compare it to Obergefell in terms of misguided sanctimony, but with far greater consequences. We need to stay mad about it, just as the pro-life community did with Roe v. Wade.

(3) It is appropriate to criticize Barbara as a mistake and an abomination, but we have to maintain some perspective. How has the conservative community reacted? Not with one voice, but generally with extreme disappointment. I don’t fault criticism of the decision itself, but it is wrong to condemn the justices (at least ACB) as a “mistake.” Every one of Trump’s appointments is better than other GOP appointment in my lifetime, excepting only Rehnquist, Scalia (who could be quirky: supported Chevron; held flag burning is protected speech), Thomas, and Alito. Judges aren’t robots.

(4) What are the potential solutions? Long-term: Amend the Constitution (not likely).

Are there any solutions short of constitutional amendment?

A later Court could overrule this with a single switched vote. John Roberts should retire and let President Trump appoint his successor. Future GOP nominees should face a litmus test: “Trump v. Barbara must act as a litmus test for every future conservative nominee.” Amen.

Congress could fix this by statute (per Kavanaugh dissent), but only if Trump v. Barbara is overruled. Section 5 of the 14th Amendment says that Congress “shall have power to enforce this article by appropriate legislation.” This is how American Indians were granted birthright citizenship in 1924.

In the meantime, we must continue with mass deportations (for the illegal aliens already here) and restrict entry for pregnant visitors to curb “birth tourism.” Administrative measures and enhanced enforcement could reduce or prevent abuse. But this will vary depending on who controls the executive branch.

Roberts botched it, but it is not the end of the world. In a self-governing republic, concerned citizens can unite to solve almost any problem. (Or at least Americans used to be able to do so.) Trump v. Barbara should be overruled, as soon as possible. All it would take is a single switched vote.

https://misruleoflaw.com/2026/07/05/john-roberts-birthright-citizenship-hubris/

The Headache of Hospital Pricing

 

Some of the most persistent problems in American healthcare can be traced to structural features that conceal economic realities from patients, providers, and policymakers. The tax preference for employer-sponsored insurance is one. Over-reliance on third-party payment is another. These features have dulled price sensitivity, inflated spending, and caused patients to disengage from the economic realities of the care they consume. Another such defect that deserves more attention is the extent to which we have normalized internal cross-subsidization across different services, particularly within the hospital context.

It sounds technical, but put simply, hospitals have come to depend on an internal financial arrangement in which some lines of business are reliably profitable while others are chronic money losers. For example, elective, specialized, and outpatient-oriented services such as orthopedics, cardiology, and imaging often generate substantial margins. By contrast, emergency care, psychiatric services, obstetrics, and pediatrics are often financially weak or negative. This arrangement is causing problems, especially for anyone trying to introduce competition, transparency, or lower prices into healthcare.

This is not the same type of cross-subsidization that you might have heard about in which private payers are said to subsidize public programs by paying more for the same healthcare services than payers such as Medicare and Medicaid. That issue is important, too, but somewhat murky. In that debate, the facts are hard to pin down, and nobody has access to all the data. Talk to a C-suite hospital person, and they will assure you that cross-subsidization between private and public payers is real. Check the literature from the academic health economists, and some of them will claim that it’s not.

The issue of internal cross-subsidies is different: it is about some hospital departments being used to prop up others. This situation holds back progress because once one part of the system starts to depend on hidden internal subsidies, every effort to introduce change through competition or lower prices in another high-profit area is met with outsized resistance. One service can be shown to be wildly overpriced, but the response is, “Yes, but that’s what keeps the emergency department open.”

How This Plays Out

Consider imaging, which is a service category that tends to be highly profitable, in part because Certificate-of-Need (CON) laws keep new competitors from moving in and bringing prices down. Free-market health policy advocates can push for repeal of CON laws, but part of what makes it possible for incumbents to push back is the argument that over at the big hospital in town, those big margins are often needed to support some other service, perhaps labor and delivery. Or take another profitable service: orthopedic surgery. Some of those expensive surgeries could be provided at lower prices in new direct-pay (i.e., cash-only) ambulatory centers, but legislative efforts that would allow the licensing of direct-pay facilities attract pushback from incumbent hospitals that, once again, need those profits to sustain other unprofitable parts of their mission.

In American twentieth-century history, airlines and railroads both went through phases of cross-subsidization. As Dwayne Banks et al. note, “First, airlines cross-subsidized shorter-haul and lower-density traffic with profits from longer-haul, higher-density traffic. Second, railroads (at least until the creation of Amtrak in 1971) cross-subsidized money-losing passenger service with profits from freight.” But these arrangements tend to be unstable over time. Once competition emerges, the cross-subsidy gets exposed and becomes harder to maintain. Incumbents need to become increasingly political in order to fend off competitors who want to break into certain market segments. This is how we get incumbents making allegations of “cream skimming.”

Cross-subsidization across hospital services is not what one would normally expect to see in a free and properly functioning market. In most industries, each product or service is expected to stand largely on its own. Usually when a business continually loses money on one service or product line, it responds by raising prices, cutting costs, finding a more efficient delivery model, or shutting down that product or service altogether.

Hospitals operate differently because our public policy choices have made them operate differently. The clearest example is emergency care. Under the Emergency Medical Treatment and Active Labor Act (EMTALA), hospitals must provide emergency care and stabilizing treatment regardless of a patient’s ability to pay. Whatever one thinks of that obligation, we have never paired it with a transparent financing mechanism. Instead, it basically functions as an unfunded mandate, which forces hospitals to figure out ways to recover the money elsewhere.

Another cause is the general reliance of hospitals on government payers that pay administered rates instead of actual market prices. Medicare’s Prospective Payment System (PPS) and Medicaid’s cost‑plus reimbursement formulas lock hospitals into fixed rates for inpatient and emergency services, while private insurers negotiate separately for high‑margin procedures. These formulas are decided on by a committee, not through a market process. As such, it is possible for public payment rates to bear little relationship to local supply, demand, or actual costs of delivering care, creating some “misses” that are high and some that are low.

Finally, as already mentioned, CON laws and other entry barriers protect incumbent hospitals from competition in many of their most profitable service lines. This helps preserve the profit pools that make internal cross-subsidization a workable kludge, but also sets up the tensions that emerge when reformers ask to expose those services to competition.

What Prices Tell Us

Prices convey important information. They tell producers where demand is strong, where efficiency gains are possible, and where resources should flow. High profits attract more suppliers, which has the effect of driving prices down in the long run. Low profits are often a signal that prices are too low; let prices rise, and more suppliers will eagerly provide that service. But in American healthcare, those signals get blurred and suppressed. If a knee replacement or MRI carries a large markup not because it is especially costly to provide, but because it is silently financing some worthy but underfunded activity elsewhere, then the posted price is not providing a useful market signal.

That is not how most sectors of the economy work. In normal businesses, each department or service is roughly sustainable on its own terms. Walmart does not run a business model in which one of its product categories must earn extraordinary margins in order to offset permanent losses in another. It doesn’t “make bank” on sporting goods and lawn and garden while losing its shirt, so to speak, on home goods and health and beauty. Profitability may vary across departments, and occasionally a department might struggle and even make a temporary loss, but rare is the business that intentionally maintains or tolerates extreme cross-subsidization across basic lines of operation. And, crucially, businesses like Walmart don’t use cross-subsidization to justify getting politically involved in blocking new entrants and innovators. They just focus on competing.

Granted, hospitals face challenges and obligations that ordinary retailers do not. But we pay for those obligations dearly when we incentivize hospitals to go to great lengths to protect profitable service lines from competition. The hospital industry spends hundreds of millions of dollars on state and federal lobbying annually. A significant portion of this spending goes toward protecting highly profitable service lines, such as surgery, imaging, and oncology, from competitors like Ambulatory Surgery Centers (ASCs) and independent imaging centers. That makes all of healthcare a little less functional.

When you think about internal cross-subsidization alongside other generally recognized structural problems (e.g., the tax exclusion for employer-sponsored insurance and the overreliance on third-party payers), you can see some parallels. All three are features that impair price formation and sever the connection between value and payment. All three make healthcare less legible to ordinary people. And all three make reform harder because they create webs of dependency that defenders of the status quo can invoke whenever change is proposed. We do not need to pick which is the worst distortion. It is enough to think of all of them as things worth fixing.

Could Things Be Different?

None of this is intended to be an attack on these less profitable services as such. Emergency departments, psychiatric care, maternity wards, and other such services are all important parts of healthcare. It is possible for a service to be important and socially valuable but commercially unviable or just hard to keep afloat. For instance, emergency departments must be available 24/7 whether or not patients are coming in for care. Maintaining readiness is expensive. But for these categories of services, instead of camouflaging the subsidy the way we currently do in healthcare, we could at least have a more open and honest conversation about whether and how to make these services viable.

Reform could begin by insisting on clearer accounting and greater transparency around service lines. Patients receiving one service shouldn’t be unknowingly charged higher prices in order to finance other services, and the public should have a clearer picture of which service lines generate surpluses and which require support. To bring the highly profitable services back to a “normal” level of profit, we should repeal CON laws so that low-cost providers can enter any market where demand exists and drive prices down. As for bringing the current money-losing services into the black, greater transparency and honesty about the true cost of these services would provide justification and cover for these services to raise their prices, which might be what is needed in order to bring the system into balance. All of this happening simultaneously (i.e., price decreases for some services and price increases for other services) might mean that insurance premiums could actually stay level.

A separate reform idea is to revise the prospective payment system used by the Center for Medicare and Medicaid Services (CMS) to incorporate price signals from comparable private‑payer transactions. This could enable hospitals to get paid prices that are more market-like, although it should be emphasized that annually reviewing rates and changing them by a rulemaking process is not the same as following freely fluctuating market prices. Administrative pricing cannot fully replicate a market, but it can be improved.

In summary, a better healthcare system should have more respect for prices, profits, and losses. If American healthcare is ever to become more transparent and less resistant to change, we will need to confront the hidden structures that keep it so rigid. We can’t make tradeoffs disappear, but we can make them more visible, and if we’ve forced hospitals to take on unfunded mandates, we should be more open and honest about it so that the public isn’t left with the impression that it is getting a benefit without a cost. A first step in that direction is to recognize the tensions that cross-subsidization within hospitals presents. Then we can start approaching some reforms.

Jared Rhoads is the founder and executive director of the Center for Modern Health. He received his MPH degree from the Geisel School of Medicine at Dartmouth, and an MS degree from Bentley University. He also teaches health policy in the graduate public health program at Dartmouth, advising graduate students on their independent research projects. Before teaching, Rhoads worked in healthcare consulting in a role that handled policy and emerging practices.

https://lawliberty.org/the-headache-of-hospital-pricing/

Obamacare Fraud Is Worse Than You Think

 

Following the expiration of the Covid-era enhanced Obamacare subsidies at the end of last year, the corporate media have remained focused on how much Exchange enrollment might decline this year. But a new report issued by the Department of Health and Human Services (HHS) provides another perspective on the issue.

Official reports by the Congressional Budget Office and Government Accountability Office have previously examined how applicants misstate their income to qualify for subsidies and how Exchanges permitted enrollment of fictitious applicants. But the data HHS analyzed gives additional context and granular details surrounding improper enrollments into Exchange coverage. It provides yet another reminder that “success” should not merely consist of the number of people (real or otherwise) enrolled in government programs — and that Congress and the administration should take additional action to guard against fraud.

Individuals Removed

The report shows two facets of the same story: groups of individuals who have been disenrolled over the past year and additional groups still enrolled who show signs of questionable activity. The report reveals how the Centers for Medicare and Medicaid Services (CMS) removed enrollees over the second half of last year due to various program integrity efforts.

As the graphic below shows, two rounds of Medicaid periodic data matching (PDM in the chart) — i.e., removing people enrolled simultaneously in Medicaid and Exchange subsidies — culled the rolls by about 550,000. Likewise, CMS also removed approximately 665,000 enrollees who did not file federal taxes to reconcile the subsidies they received in prior years (which are based on projected income) with the subsidy amounts they should have received based on actual income (i.e., failure to reconcile, or FTR in the chart).

Additionally, the report notes that “27.8 percent of individuals in a plan where they pay no premiums whatsoever have canceled their plans through May 2026.” It would ordinarily make no sense for someone receiving “free” health coverage to disenroll from it — unless of course they were enrolled without their consent or are concerned about having to repay subsidies they do not qualify for.

The corporate media have focused on the 4 million decline in enrollment — i.e., the difference between the 23.1 million people who selected a plan during open enrollment (which ended in January) and the 19.2 million that the report says are paying premiums and currently enrolled. But if large percentages of people are canceling “free” coverage, that is a separate story in and of itself.

Continued Questionable Conduct

The report notes other potential flags that may indicate questionable enrollments of individuals who remain covered in Exchange plans. For instance, “CMS recently identified 1 million highly suspicious agent and broker assisted enrollments through Healthcare.gov with no social security number on their application who are also paying no premium.”

CMS would also like to remove an additional 300,000 people from subsidies for failing to file tax returns and therefore not reconciling their subsidy amounts for prior years. However, a federal judge has prohibited the administration from enforcing a rule issued last year that would require subsidy recipients to file taxes and reconcile past subsidies every year (as opposed to every two years under a Biden-era policy).

Questionable Value of Coverage

Finally, the report notes that more than half (55 percent) of enrollees who were in a zero-premium plan last year, but were enrolled in a plan that required a premium in 2026, had their enrollment canceled for failure to pay that premium. By contrast, from 2017-2022, only an average of 18 percent of enrollees had their plan canceled for not paying a premium after being enrolled in a zero-premium plan the prior year. 

The growth in the rate of individuals getting coverage canceled when faced with a premium could reflect improper enrollment. However, it could also mean that some enrollees just don’t value their coverage. They will stay signed up when the coverage is “free” (i.e., totally paid for by the federal government) but will drop their plan if required to pay even a nominal premium. 

Recall that a Brookings Institution study last year found that charging enrollees a de minimis premium of even $1 per month would cause nearly 1 million individuals to drop coverage. As I noted at the time, most Democrats would view this as a bug because people might become uninsured. But some conservatives might consider requiring everyone to pay something for their health coverage a feature, while asking a related question: If almost a million Americans won’t even pay $1 monthly to enroll in an Exchange plan, what does that say about how they perceive the value (or lack thereof) of Obamacare?

Affordability Debate

I won’t attempt to argue that the enhanced subsidies’ expiration had no effect. Near-retirees and households just above 400 percent of the poverty level (who became ineligible for subsidies) may face a substantial change in their out-of-pocket monthly costs for insurance. 

But the numerous signs of improper enrollment outlined in last week’s report — to say nothing of the myriad ones that preceded it — coupled with the federal government’s $39 trillion in debt, argue against spending another $350 billion (plus interest) to extend the enhanced subsidies. With fraud rampant and government spending stoking the rise in health care costs, such a measure would have only made both problems worse.

Chris Jacobs is founder and CEO of Juniper Research Group and author of the book "The Case Against Single Payer." 

https://thefederalist.com/2026/07/06/report-shows-obamacare-fraud-is-worse-than-you-think/

Trump Administration Is Right to Target Abusive Hospital Contracts

 by James Capretta

Last month, the White House Council of Economic Advisors (CEA) published an analysis of the cost reductions which would occur if policymakers banned three abusive and common contracting terms used by hospitals to inflate their revenue. For elected leaders who profess to want to make healthcare more affordable, taking up this cause would be a good place to start.

Large hospital systems have strong incentives to prevent insurers, and the employers sponsoring most private-sector coverage, from directing plan enrollees to lower-priced care settings. Legacy facilities are typically capital-intensive and expensive to maintain and run. As ambulatory care options proliferate, hospitals have bought up some of their potential competitors. They then use the availability of their hospital-owned outpatient options to require insurers and employers to buy care from their entire service delivery networks or else risk losing access to the inpatient services all plans must include in their terms.

The strategy works because many of these systems have long existed in their communities and have loyal followings. Hospital leaders know that companies are reluctant to exclude these systems altogether from their preferred networks because doing so might displease some employees. Thus, those hospitals that can claim to offer a full range of inpatient and outpatient services can try to use the goodwill they enjoy in their markets to block a more a la carte approach to purchasing services. The result is needlessly high prices for many services that could be purchased less expensively from non-system providers, such as independent physician groups and free-standing surgical centers.

The most common contracting terms used by hospitals to block competition are:

• Anti-steering provisions. These contractual requirements restrict the use of financial incentives to direct patients toward lower-priced care options. For instance, insurers cannot offer lower cost-sharing to patients who opt to receive services from less expensive care providers. Creative insurance design strategies, such as reference-based pricing, are blocked by anti-steering terms.
• Anti-tiering provisions. Dominant hospital systems frequently insist that insurers designate them as preferred for all of the services they provide. These stipulations amplify the effects of anti-steering strategies and prevent insurers from favoring independent clinics and physician groups over hospital-owned options.
• All-or-nothing terms. These provisions prevent insurers and employers from contracting with dominant hospitals for inpatient services and independent entities for other services. Instead, insurers are forced to buy services from the full delivery networks owned by hospitals even when less expensive options are available.

CEA’s research complements the efforts of the Department of Justice (DOJ) to curtail healthcare contracting abuses through anti-trust litigation. OhioHealth, a large not-for-profit hospital system, recently settled a case with the DOJ by agreeing to remove provisions designed to suffocate its competitors from all current and future insurer contracts. DOJ is pursuing a similar case against New York-Presbyterian., which owns the largest not-for-profit hospital system in New York City. A second successful case would send a strong signal to other hospital systems that continuing with these practices is no longer risk-free.

The CEA study provides a range for the potential cost savings from applying the remedy imposed on OhioHealth in every jurisdiction.

• The estimates assume, based on hospital consolidation data in major market areas, that about 40 percent of enrollees in employer-sponsored insurance (ESI) live in areas which should allow plan design to achieve lower total costs, and that about 60 percent of the contracts in those markets restrict the ability of plan sponsors from gaining access to those providers charging lower prices. Thus, about one-quarter of the ESI market would be expected to see substantial cost reductions from a ban on abusive hospital contracting practices.
• Hospital prices are estimated to fall in the relevant markets by an average of 11 to 26 percent. The related premium savings for ESI would be about 6.5 percent annually. Lower ESI premiums would produce an increase in federal tax revenue as firms moved compensation out of tax-exempt health coverage and into taxable wages and salaries.

The provision of many services which used to require an inpatient stay, such as certain cancer treatments and common surgeries, are offered increasingly in less costly outpatient settings. Aggregate national health expenditure (NHE) data reflect the trend away from hospital-based care, with 31 percent of the total bill going to hospitals in 2024 compared to 40 percent in 1980. The downward trend in the reliance on hospitals is expected to continue in the coming years.

With less need for inpatient care, it should be possible to build insurance around service delivery in lightly-capitalized settings. That high-cost hospital systems are still dominant in many cities reflects the effectiveness of the strategies they developed to protect their positions. It is long past time to set patients free and relieve them of the burden of financing legacy institutions that were built for a different era.

https://www.aei.org/health-care/the-trump-administration-is-right-to-target-abusive-hospital-contracting-practices/

Sports related deals rising: Blair

Acquisitions in the sports industry are set to increase as investors leverage a slew of different approaches to the fast-growing sector, according to William Blair & Co.’s head of investment banking.

That’s in part as minority stakeholders in many professional teams look to exit, college athletic associations leverage so-called name, image and likeness agreements and parents spend more on their kids in youth sports, Matthew Zimmer said in a Bloomberg TV interview Monday.

https://www.bloomberg.com/news/articles/2026-07-06/sports-related-deals-on-the-rise-says-william-blair-s-ib-head

Israel-Lebanon talks to be held next week in Rome

 Israel's ambassador to the United States, Yechiel Leiter, announced during a meeting with the Council on Foreign Relations in Washington on Monday that the next round of negotiations between Israel and Lebanon will take place next week, on July 15 and 16, in Rome.

Leiter went on to state that Lebanese President Joseph Aoun will meet with US President Donald Trump on July 21 and that the meeting will take place at the ambassadorial level.

Furthermore, the official responded that his country opposes the sale of F-35 stealth fighter jets to Turkey "but will respect any American decision" when questioned about the US' potential sales of F-35 fighter jets to the country.

https://breakingthenews.net/Article/Israel-Lebanon-talks-to-be-held-next-week-in-Rome/66640886

Big Tech softens its AI jobs warning: Health system CIOs were already there

 For much of the past year, the loudest voices in tech warned that AI was coming for the workforce, The Wall Street Journal reported July 5. 

Anthropic CEO Dario Amodei said in May 2025 that AI could wipe out half of entry-level jobs. Ford CEO Jim Farley predicted AI would replace half of white-collar workers in the U.S. That tone has shifted.

According to the publication, OpenAI CEO Sam Altman recently told CNBC that the industry had underestimated how much it would be able to “keep people at the center of everything.” Mr. Amodei has since pointed to more optimistic scenarios for companies that adopt AI well, while Meta CEO Mark Zuckerberg and Amazon CEO Andy Jassy have both talked up AI’s job creating potential, even as their companies cut thousands of positions.

A May survey by EY-Parthenon found the share of CEOs who expect AI to cause significant headcount reductions fell from about 46% in January 2025 to 20% this May, per the Journal.

Health system CIOs speaking to Becker’s have told a more consistent story throughout, and it looks a lot like where Big Tech has landed: augmentation over replacement, with real caveats about which roles are exposed.

Lisa Stump, executive vice president and chief digital information officer of New York City-based Mount Sinai Health System, told Becker’s in June that her health system is using AI to expand IT capacity “without expanding headcount at the same rate,” pairing that with a larger hiring pool created by big tech layoffs.

Mouneer Odeh, chief data and artificial intelligence officer of Los Angeles-based Cedars-Sinai, told Becker’s in June that healthcare AI’s “second wave” is less about productivity gains and more about restructuring how work gets done.

“It’s changing the way we work and as a result, changing the jobs that we have,” he said.

Will Landry, senior vice president and CIO of Baton Rouge, La.-based FMOL Health, said in March that he doesn’t “think mass job replacement in healthcare is likely,” though he expects duties to shift from “back end” to “front end,” with more focus on patient experience and human connection. Reid Stephan, senior vice president and CIO of Boise, Idaho-based St. Luke’s Health System, pushed back on the popular idea that “AI won’t take your job, someone using AI will,” calling it the wrong mental model. Rather than simply making existing workers more productive, he said, AI is reshaping the systems those jobs sit inside, shifting where humans add the most value toward “care, judgment, and patient relationships.”

So far, healthcare has largely been spared the AI-linked layoffs hitting other sectors. Challenger, Gray & Christmas attributed 40% of the roughly 97,000 U.S. job cuts announced in May to AI, concentrated in tech. Healthcare job cuts were up 17% year over year through May, but hospitals and health systems have mostly pointed to state and federal funding reductions, not AI, as the driver.

Separate research covered by The Washington Post in March found healthcare has largely avoided AI driven job cuts to date, based on an analysis of task level AI exposure across more than 350 occupations.

Where Big Tech’s messaging has swung from doomsday predictions to reassurance in the space of about a year, healthcare’s IT leadership has held a steadier position: AI is already touching coding, documentation, scheduling and parts of diagnostics, hiring is shifting toward AI literate and cloud skilled staff, and most CIOs describe the goal as doing more with the same headcount rather than doing the same with less.

https://www.beckershospitalreview.com/healthcare-information-technology/ai/big-tech-softens-its-ai-jobs-warning-health-system-cios-were-already-there/