A bureaucracy can function like a tumor. It disguises itself from the "immune system" of public accountability by using noble language ("it's for the kids"). It then redirects resources (funding) to ensure its own growth, even if it's harming the larger organism of society.

Despite possessing immense wealth that provides insulation ('F You money'), many business leaders avoid criticizing the administration. They fear becoming a target, a risk that ordinary citizens like activist Renee Good take while billionaires do not.

The Centers for Medicare & Medicaid (CMS) avoids cracking down on high-cost oncology drugs because they represent a critical profit center for otherwise low-margin hospitals. Hospitals lobby behind the scenes, arguing that reducing these reimbursements would create systemic issues in the healthcare system, creating a regulatory moat.

At the J.P. Morgan conference, nonprofit hospitals abandoned talk of growth and expansion, focusing instead on "stability" and "consistency." This defensive pivot reflects deep concern over looming financial threats like federal Medicaid cuts and the loss of ACA subsidies, which could cripple their thin operating margins.

Pfizer's CEO was named a "Best CEO" not for pipeline success but for effectively managing political pressure from the Trump administration. He made deals that appeased the White House on drug pricing without harming shareholder value, highlighting how a modern pharma CEO's job now heavily involves navigating the political landscape.

When facing government pressure for deals that border on state capitalism, a single CEO gains little by taking a principled stand. Resisting alone will likely lead to their company being punished while competitors comply. The pragmatic move is to play along to ensure long-term survival, despite potential negative effects for the broader economy.

While federal law mandates hospitals treat all emergency patients, financial strain's real impact on patient access is the elimination of less profitable but essential services. Hospitals are cutting rural labor and delivery units, pediatric specialties, and psychiatric services, rather than turning patients away from the ER.

When an institution is under political attack, leaders can follow Jerome Powell's model: remain calm and steady publicly, articulate the facts of the situation clearly, and privately leverage relationships with allies to build a wall of support.

CEOs are in an awkward position, supporting the administration in public but asking Congress not to codify the Most Favored Nation drug pricing policy. They fear legislation would create a permanent, stricter, and more broadly applied version than their private deals with the White House.