The Charlie Kirk Show - The Minneapolis Mogadishu Looting Operation

Episode Date: November 21, 2025

Minnesota has gone all-in on importing huge numbers of Somalis from the Horn of Africa. Now, a new report exposes how billions of dollars have been stolen from the state's welfare programs, especially through organized Somali efforts that have funneled money all the way to Islamic terror groups. Ryan Thorpe explains how the scams have worked. Plus, data expert Cremieux explains how America can reform its health care system to fix the problems with Obamacare. Watch every episode ad-free on members.charliekirk.com!    Get new merch at charliekirkstore.com!Support the show: http://www.charliekirk.com/supportSee omnystudio.com/listener for privacy information.

My name is Charlie Kirk. I run the largest pro-American student organization in the country fighting for the future of our republic. My call is to fight evil and to proclaim truth. If the most important thing for you is just feeling good, you're going to end up miserable. But if the most important thing is doing good, you will end up purposeful. College is a scam, everybody. You've got to stop sending your kids to college. You should get married as young as possible and have as much.

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Lord, use me. Buckle up, everybody. Here we go. The Charlie Kirk Show is proudly sponsored by Preserve Gold. Leading gold and silver experts and the only precious metals company I recommend to my family, friends, and viewers. All right. Welcome to Our Two of the Charlie Kirk Show. I'm Andrew Colvin, executive producer of this show, along with Blake Neff. Really exciting hour, too, actually. We're going to get a little deeper, more, I don't want to say philosophical, but this is going to be a smart elevated hour because we're talking about some of these themes in American life, especially the modern American life, that kind of go under the radar.

but they're having a profound impact on your taxes, the way your government spend money, some of the fraud that's happening. We just had a congresswoman out of Florida who was a grand jury returned an indictment charging her for stealing $5 million of COVID funds. So this is kind of a story in that realm. We're going to welcome Ryan Thorpe. He's an investigative journalist with Manhattan Institute. It's got a new piece he co-authored with Chris Rufo at The City Journal. And it's entitled The Largest Funder of Al-Shabaab is the Minnesota taxpayer. Al-Shabaab, of course, is a radical Islamic terrorist group in Somalia.

Somalia. We have a lot of Somalis in Minnesota, and we've hit this beat a few times that there's a lot of fraud of various kinds that goes on because it's an insular community. But this piece really lays out how a lot of it works. So, Ryan, are you there? I am. It's a pleasure to be here. Thank you very much. So, Ryan, how about you just dive into it? Al-Shabab, largest funder, Minnesota taxpayer. What do you mean? by that? Well, so what we're seeing in Minnesota is that there's billions of dollars of fraud going on, particularly targeting government welfare programs. The fraud has gotten so bad that the U.S. Attorney's Office has indicated that there are entire government welfare programs

where the fraud outstrips the legitimate claims. These large-scale fraud rings to date have largely been concentrated in Minnesota's Somali community. But this is an inconvenient fact that progressive politicians in Minnesota, and I would also say the mainstream media, has been unwilling or unable to acknowledge. And over the course of our investigation for City Journal, we developed several counterterrorism sources, law enforcement sources, who confirmed to us that some of these stolen funds, millions of dollars, are being sent abroad through Huala networks, which are informal money transfer networks that are popular in Islamic countries. This money has then gone overseas, and some of that money has ended up in

the hands of al-Shabaab to the point that one of our sources said the largest funder of al-Shabaab is the Minnesota taxpayer. Well, can I just read? I just want to give you some kudos here, right? Because this is, you're opening, you had me at hello kind of moment. You're opening to this article is just so blunt and to the point, I love it. I have to read it. Minnesota is drowning in fraud. Billions in taxpayer dollars have been stolen during the administration of Governor Tim Waltz alone. Democrat state officials overseeing one of the most generous welfare regimes in the country are asleep at the switch. And the media duty bound by progressive pieties refused to connect the dots. I mean, it's just really direct. I want to flag the numbers on here. So this is so incredible.

we're having Kramu on next to talk about health care. And when he came out on the show with Charlie a few months ago, one of the things he said is he's like, he says, I think the growth of autism in America is overstated because they overdiagnose it. And the example he said is he said, in Minnesota, Somalis are just scamming the autism system

to get a ton of money. And this is a quote, I want to read this. So like with another program, autism claims to Medicaid in Minnesota have skyrocketed from $3 million in 2018, 3 million to, I'm going to abbreviate it, $399,000,000 in 2023.

So they went up more than 100 times over in five years, and it mentions the number of autism providers went from 41 to 328, and then it says the Somali community has established autism treatment centers for culturally appropriate programming. One in 16 Somali four-year-olds has reportedly been diagnosed with autism. Are they just letting anything happen and they're not doing any policing whatsoever, Ryan? Well, it's very clear with these government programs that there weren't many checks and balances that were built into the system and that this was done by design. I mean, this was done purposely to help facilitate money going out the door ostensibly to people in need.

And what's interesting about the autism fraud case, the first indictment that's come down, the U.S. Attorney's Office indicates that more indictments will be. coming is that it is very clear the extent to which this fraud scheme penetrated the wider smally community so this wasn't just a bad apple the woman accused in this case would approach members of the smally community in minnesota who had children she would sign them up for autism services if the child wasn't autistic she would get them a fraudulent diagnosis and then kickbacks would be paid to Somali parents in the state who had signed up their children for fraudulent autism services. And the U.S. Attorney's Office noted that if the kickbacks were too low, the parents would threaten to pull their child from one provider and take them over to a different

fraudulent provider in order to get more money that was being stolen from taxpayers through this scheme. So that's, that's, the autism was an example. Can you also describe this, uh, this homelessness one, the Medicaid Housing Stabilization Service, can you explain how that fraud worked as well? And any others that come to mind? Yeah, the housing stabilization services program was quite interesting because if you were to design a government program specifically to facilitate fraud fraudulent claims, it would probably look a lot like this program was designed. There were almost no checks and balances baked into this system. It was launched in 2020 with I would say a fairly noble goal. It was seeking to get people who are struggling with drug and

alcohol addiction, mental illness, people with disabilities to help them find and secure housing. The U.S. Attorney's Office claims that, you know, fraudulent companies were set up. They were operating out of, you know, dilapidated storefronts. They would target people that were exiting drug and drug rehabs. They would sign them up for Medicaid services. that, you know, they had no intention of providing, and then they would simply pocket the money. And yet again, we've seen the claims under this program absolutely skyrocket. When it was launched in 2020, government officials estimated it would cost about $2.6 million a year. By 2024, it cost $104 million.

And in the first six months of this year alone, claims were $61 million. At that point, the state stepped in and shuttered the program, because, they realized that, you know, they had a significant problem on their hands in regards to fraud. And the U.S. Attorney's Office has indicated in a press conference that he, the U.S. attorney at the time, he believed there were more, there was more fraudulent activity in this program than there were legitimate claims. There have been eight indictments to date for HSS fraud. Six of the eight men who have been accused were of Somali heritage. Two were Nigerian. of Nigerian heritage. And they're accused of defrauding millions of dollars from this government

welfare program. And yet again, it's been indicated that more charges will be coming. Is it as simple as it looks where I guess the stereotype would be, it's Minnesota. You've got a lot of Swedes, Norwegians, sort of Nordic, high trust people, very used to doing pro-social behaviors. And it's almost like they're like an animal on an island that has no predators. So the thought that someone would just fleece a program or just lie about it is so alien. They just have no defenses against this sort of behavior. Is it that simple? Is there any interest in fixing this other than arresting people occasionally?

Well, you know, I think that's a really good point. I think that does help explain some of what's going on. As I was reporting this piece out, the picture that was emerging was really of a perfect storm in Minnesota to facilitate fraud on a massive scale. You have a sizable small community that comes from a tribal clan-based society, and it has proven itself willing to cynically deploy accusations of racism as a shield in order to help cover up criminal behavior. You have a very generous, very progressive welfare state, and in many of these programs, checks and balances, they were specifically designed with very few in place. and then you have a progressive political establishment that is terrified of being seen as politically incorrect and also worried about alienating the Somali community, which is a sizable voting

block in the state and has also established significant political connections. And so when those three things kind of collide, this is what you get. This is Lane Schoenberger, Chief Investment Officer and Founding. partner of Y-ReFi. It has been an honor and a privilege to partner with Turning Point and for Charlie to endorse us. His endorsement means the world to us, and we look forward to continuing our partnership with Turning Point for years to come. Now, hear Charlie in his own words tell you about Y-R-R-R-R-E-F-Y-F-I. I'm going to tell you guys about Y-Refi.com. That is Y-R-E-F-Y-F-F-Y-Fi is incredible. Private Student Loan debt in America totals about $300 billion. Why-refi is

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piece about Mogadishu, Minnesota. And I want to get into this, Ryan, because how much of this is essentially Western culture confronting, I mean, let's just be honest, a very backwards, tribalistic African culture that has been imported into our country, and they're just colliding and they don't understand each other. Or, I mean, Somali seem to understand us. They're taking advantage of Minnesota nice. How much of it is a cultural breakdown, though, where Americans in Minnesota, they simply cannot fathom the cynical nature of these schemes and these cons? Well, I would say that sources I've spoken to in Minnesota have indicated that as a significant contributing factor in regards to these large-scale fraud rings that we're seeing. There is a

cultural component here. When you're talking about people of Smalley Heritage that have landed in Minnesota, these are people that come from a very tribal, clan-based society. They have likely spent time in a refugee camp prior to arriving in America, where I would imagine you have to be pretty resourceful in order to get by. They then come to a traditionally very high trust state with significant welfare programs, perhaps the most generous in the country. And quite clearly, by the criminal indictments that have been coming down, many people in the Somali community have figured out how to fraudulently obtain significant amounts of money. We're talking about billions of taxpayer dollars here that have stolen, fraud rings that run to hundreds of millions of dollars

alone. So I don't think you can discount that clash of cultures as a major factor and what we're seeing that's going on. Well, listen to this. This is a quote from your piece. What we are seeing, what we see are schemes stacked upon schemes, draining resources meant for those in need. It feels never ending. I've spent my career, this is this guy named Thompson, as a fraud prosecutor, the depth of the fraud in Minnesota takes my breath away. What can be done? Like, if you are going to, I mean, is there a significant move to actually denaturalized, to deport some of these people that are here on protected status or on a temporary status of some nature? Is there a way that you would dismantle this that would actually fix the problem? Or it feels like we're just going to be playing whack a mole for years

here in Minnesota? Well, the sources that I've spoken to, these are political people, law enforcement, counterterrorism folks. I put this question to them, you know, what needs to happen here? You know, they don't discount the fact that there is a role for law enforcement to play. They have been cracking down on many of these major fraud rings. There's more work to be done. More indictments will be coming. But pretty much across the board, people that I spoke to said there really isn't a law enforcement solution to this problem.

As you said, that's simply playing whack-a-mole. People pretty consistently told me that, you know, there needs to be a policy change here. And there clearly needs to be more accountability from the state government in Minnesota, which under Tim Walts has been overseeing fraud after fraud to the point where the fraud has taken over entire government programs. So there has to be a policy solution here. Simply hoping for law enforcement to clean the mess up is naive. yeah it really is a striking case the most extreme thing of when you bring in people from a different culture you bring in a different culture and it really manifests the way that it's so large and so many people are involved like we didn't even talk about the feeding our future scam another scam they did during COVID where they were pretending to feed thousands and thousands of kids got millions of dollars and it was I think one white Lutheran woman at the top of it and then 50 plus people from the Somali community doing the rest of it that it really is just who you have any moral relationship to as people in your, you know, extended family, people in your clan, people in that community, and you have no moral relationship

or otherwise with the government, with wider society. You've basically brought a people within, a separate group of people who just don't feel any obligation to the rest of the citizenry, and they think it's totally valid to just loot that community for everything they have. And I think the only way, yeah, the only way you can deal with that is, You basically need to impose far higher standards for any benefits you're going to dole out. Or you also have to say, frankly, why are we doing this in the first place? Why have we imported an alien culture that thinks it's their duty to just loot us?

Now, with Trump's travel restrictions, because we had this in Trump 1.0, now 2.0. What's the status of immigration from Somalia right now? To be honest, I haven't looked into that, so I would not be a person to ask for that. Yeah, I'm pretty sure Somalia's on the no track. So I don't know if we're making this problem worse right now or if we've sort of stopped the bleeding or if there's backdoor ways for chain migration and family reunification. Before we close it up, I want to throw it up.

Put up 298. It's the social contract in Minnesota. You have only 30 years old and all of his money is going to El Shabab, defeating our future, to cause more chaos in Somalia so that more migrants move in to Minnesota so that they can give more money to them. I wanted to share that one. Ryan, great job, really good reporting.

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Use discount code Charlie. So order online at balance of nature.com. Use discount code Charlie. You have 35% off plus a free bottle of fiber and spice. We now have our next guest, Kramu. He's the author of the Kramu substack. And you can find him on X at Kramu. How do you pronounce that, Kramu?

Kramu, welcome to the show. Krami Rekai. We wanted to have you on because you're a big expert on health care. healthcare has totally taken over a lot of the discussion in the US as one of the biggest sources of rising costs in America people are

let's just play one of these clips actually I think that'll set it up nicely primer how about we do let's just do 263 going to hear horrible stories people are not going to be able to afford their insurance I don't think even with subsidies they're going to be able to

afford the premiums that are hiking up 100, 200 300%. Wasn't Obama? I was supposed to fix that? When people, no, well, not without the universal. I mean, there's a affordable care act. Affordable was the first birth. And I want to throw up this as the last primary here, Kramu, 279.

This is the average annual expenditures for health insurance per household consumer unit. And you can see that big jump there right when the Affordable Care Act was implemented into law. So health care is far outpacing the trend that we saw before the ACA was passed. so we call it the unaffordable care act, and that really is the foundation for our discussion. So, Kramu, what is going wrong with American health care? So I would qualify that last bit a little bit. I would say healthcare spending isn't really growing way over what you would expect before the ACA. We're looking at different metrics there, but if you use consistent ones, it looks pretty fine.

The bigger issue is that we have, it just shouldn't be growing this way in the first place. that like it is a completely broken system in the sense that we have created incentives that uh to make it worse so we have a lot of things in health care uh post aCA especially that are terrible uh in the sense that for example take the medical loss ratio requirement uh this is the requirement that health insurers have to spend 80 to 90 percent depending on the type of plan so 85 percent are there so of their premiums uh each year so if they charge their customers X amount, they have to spend 85% of X. And the fact that they have to spend that amount is effectively a profit gap. So they have to make profits in other ways. And to make those

profits, they look into other things like buying up the pharmacy benefit managers or buying up hospitals or sneakily changing the prices or even overpaying for drugs in order to meet the threshold of things they have to pay for. So you end up with costs just kind of running everywhere. You end up with incentives for vertical integration such that they're buying up everything else. And the number of competitors comes into the market is very, very small. Because again, who's going to invest in a company, a new company that has to spend 85% of its revenues every year? That's not a very good investment. But there's a lot of other issues. The ACA also, for example, had a lot of stuff that was informed by small kind of crappy

studies. So there was this idea that came about as an example of this where hospitals run by doctors would be lower performing. And the reality was they actually didn't be higher performing. But the ACA, when it was written, wasn't like, it wasn't based, this idea was not based on good empirical evidence. It was based on bad evidence. So they ended up banning doctors from establishing new, like, physician-run hospitals. Wow. They do, there's a lot of things in there that are just got a very bad. That just seems, but Kremu, that's seems like it should be illegal. How could you ban somebody from starting a business? I don't understand. Is this is just, is this like a real ban or you just can't get access to insurance

funds or something? No, it's a real ban. Unfortunately, you cannot start new one. There are some existing physician run hospitals that predate the ACA's ban going into effect, but you can't start new physician run hospitals. And that's a specific thing. So if you want to give up being a practicing physician, you can still start a hospital, but you can't both be a practicing physician and run the hospital. That's unfortunate. That's so interesting. So I, I guess just big picture. There's a lot of debate, you know, the GOP and Trump's first term tried to repeal and replace Obamacare. They failed, thanks to our late senator here. But I guess people talk a lot about rising costs, but if there were targeted reforms that the Republican Party could start

advocating, what do you think some of the best ones would be? Tons. So a lot of the problem is that we have good ideas that have been actually supposed to be put into effect. For example, Price transparency is the law of the land right now. If you go to a hospital, they are required to provide you with a credible list of all the prices. Before any operation is done in you, you are supposed to be given a price that is reasonable and that you will end up paying because once they put the number out there, they have to charge that for you, unless some reasonable complication comes up. But the law is not enforced. The regulation for price transparency was supposed to go into effect on October 1st. And I looked around at a sample of local hospitals. And I found, hey, you guys still aren't transparent about your prices. It's a lot of the issue with this stuff is that we don't actually enforce the rules, which is bizarre. I don't know. Like, what do you say about that at the end of the day? That sounds like a good chance to do populism, you know, have the Trump admin just sue a big hospital or like perpwalk some random, like, official at like a really big hospital.

When was that law, when was that law passed into law? that was supposed to go into effect on October 1st. So that was a regulation. The law that provided the regulation with power is like very old, I think. It's like a decade old. Did that get caught up in like the government shutdown or something? I mean, or we're just... No, it predated it.

There's just not a mechanism to enforce it. Yeah, the president, the Trump administration should absolutely start ensuring this. Yeah. Yeah, what else though? Yeah, we cut you off there a bit. There are tons of things. So, for example, patients are actually entitled to all of your data. If a doctor generates some data and goes in your EHR, you are supposed to be able to get access to that.

You should be able to ask your physician and have your physician give that to you in some format that can be used by you, the patient. The same thing applies to the CMS's Kleea certified lab. So like IVF clinics, if a parent has some sequencing done in like one of their embryos, they should be able to get that data. But they don't. In fact, on I think it was September 14th, if I'm recalling the date correctly, RFK put it. out a little video saying that patients are entitled to their data. And at some date in the future, there'd be a little, not a hotline, but like a little form online that you can go fill out to report when data is not provided to you when you ask for it. And they just don't, they don't do

it. So it's like, it's not even things that are high costs that are being enforced. It's also things that are just good, like from a patient rights perspective that just nobody follows the rules because there are enforcement mechanisms, to be clear. CMS can run. really start hitting hospitals very hard. They can hit providers in ways that make their pocketbooks scream, but they don't. And that is the big issue at the end of the day is that they have enforcement mechanisms that they don't enforce them for all sorts of things. Another thing is, for example, site neutral payments. So if you are running a hospital chain and you buy up a clinic, you can charge hospital prices at that clinic location, even if they're totally separate.

You just bought the location. You didn't change any way it's run. But that allowed you to charge the hospital rates you're associated with the chain like that sort of thing should be outlawed and it was supposed to be outlawed on October 1st but guess what's still in effect non-neutral payments it's um it's absurd so so kramu it feels like you're sort of painting a picture that the health industry is plagued by death of a thousand cuts it there's maybe isn't one silver bullet but you know we we were talking about a thousand cuts it's so big it seems like they just feel that it's so big and so impenetrable they can just ignore they can just ignore but so we have to we have to that's right there has to be an initiative though from probably the highest levels of

our government to start enforcing some of these regulatory changes that are supposed to benefit the patients a lot of the problems in the country you could sort of trace back to illegal migration illegal immigrants how much of the rise in health care prices could you trace back to illegal immigrants on the dole or within the system or is that not a driver in your opinion not a big driver um the most liberal estimate that I've seen that's credible is about 0.9% and that's quite, that's stretching it honestly. I think it's not that much.

The main cost drivers have to do with old people. Old people are the biggest parts here. And the fact that we have bad incentives for cost control and we don't allow certain types of cost control to even be put into place. So the AMA is really your bigger problem here. Most of your growth is provider-side rents and that means the payments that go to doctors

that are way in excess of what the doctors, like the care of the providers, providing is worth. That's most of your issue. And we could lower provider side rents by allowing more physicians. But we have placed an effective cap on the rate of growth, not on the actual number of slots, but on the rate of growth in Medicare funding for residency slots. So the number of doctors who can actually come in and compete with the doctors and lower the rents and make it so they, you know, they're paid less, but they provide more, because they're going to be more of them, is limited. It's been limited since 1994. And we just don't care with such Congress. What happened in

94? What happened in 94? Oh, this is amazing. So the AMA argued there was going to be a surplus of doctors. There were going to be too many doctors and that this would cause a big problem. And you have to think, how can there be a surplus of doctors? Don't we always need more doctors? The answer is, yeah, of course. But they managed to somehow convince Congress this was an issue that would impact the quality of care when it makes no sense. And then they got these limits set in place. place. And now they argue, to get away from the fact that they did this, they argue, well, we don't limit the actual number of residency slots, but they ignore that, yes, there's still limitations on the growth in the number of slots and the funding mechanisms available to

create more slots outside of Medicare funding. So they created a broken system where we can't actually fix the issue with provider's side grants, which is roughly a third of all of the spending problem. holds so many memories. And I'm sure it's the same for you. Right now, there's a girl finding out she's pregnant. In the next couple of weeks, she's going to make a decision. And whatever decision she makes will become her memory of this Thanksgiving for the rest of her life. What will she be thankful for a year from now? You. She'll be thankful that you introduced her to her baby by providing a free ultrasound. And she'll be thankful that she chose life as she prepares for her baby's first

Thanksgiving. Take a stand for life by providing an ultrasound with pre-born. When a young woman sees her baby on the ultrasound and hears her baby's heartbeat, she is twice as likely to choose life. Just $140 provides five ultrasounds that can save five babies. $280 saves 10 babies. A gift of $15,000 provides an ultrasound machine that can save thousands of babies for years to come. Call 833-850-229 or click on the pre-born banner at charley kirk.com today i just it's so it's so enraging that specific fact on that we basically intentionally capped the number of residences by extension caps the number of doctors we make in america and then we'll also say oh we need to import it's like part of the immigration hustle have lots of foreign doctors come in when just have more residency slots

have more people go to medical school in the u.s that will be more opportunities for Gen Z people who want to work hard and get a good job. Let the market work. Let the market work. I mean, but okay, now let's go back to ACA because you seem to think that maybe the ACA is not driving costs like the. No, no, no, no, no. Let me rephrase. The ACA is terrible. The biggest problem with the healthcare system is the medical loss ratio requirement. It is say that again, slow, slowly. Yes, yes, okay. Let me be slow here. So the ACA's medical loss ratio, the The MLR thing that I mentioned a moment ago where you have to spend 85% of your premiums leads to an enormous level of cost shifting.

It leads to vertical integration where insurers will buy up every other part of the medical space. It leads to, it prevents AI and healthcare from actually being useful. And it gives a lot of leverage to doctors and doctors cartels like the AMA and like the American Society of Anesthesiologists and all these other groups to continue to do. do things that increase costs. It's the worst thing on the books, and it can be fixed in two ways. So drug spending is like a problem in its own right. That's like 9% of the problem. But the ACA's medical loss ratio thing is a much, much larger portion of it. It's closer to 40% of the actual problem. And if you eliminated the problem, you could immediately start embarking on a massive wave of innovation in healthcare because you would allow AI stuff to be slotted in

to the prior off departments where insurers do the rejections or they accept a medical, you know, call by a doctor, but we don't allow this. We have effectively banned it. We've made there no incentives to do it. So just so I'm understanding, because I want to make sure I'm understanding exactly what you're saying, if we send a dollar, if we spend one dollar on health, care, 85% of that has to go to the actual treatments, meaning that the providers are only allowed to take 15% of, okay, okay, yeah. No, anything not administrative. So that 15% is whatever's left over.

And what that means is that in order to meet that level, like at the end of a billing cycle, what they'll do is they'll just pay more for stuff. So if a doctor says, like, I want to bill blah, blah, blah, blah, they'll get bill, blah, blah, they'll pay more for medication. they'll overpay for all sorts of things. They'll get wrong claims and just pay them because they have to meet this legal requirement. And in order to manage this fact,

they transfer large portions of their medical claim revenue to their PBMs, their subsidiaries that aren't regulated directly by this regulation. So Kramu, it sounds like you said that these two buckets, they essentially lead to 90% of the problems with the ACA. If you, so if you were consulting President Trump, J.D. Vance, would you just say deal with this 85% ratio issue and it sounds like one of the, I forget what the other one is. No. No. Okay. Um, so the, these issues are unfortunately statutory. There are, so statutory means that Congress is the reason for the issue. Congress has, uh, in the case of the MLR, the medical loss ratio requirement that drives so much of the spending issues and so much of the lack of AI related innovation and healthcare. The issue is, you know, was given, Congress gave the HHS the opportunity to write of the rules, and they gave them some limits. And they said, you have to write the rules a certain way, and these rules are

terrible. But in order to reform it, you can't just have the HHS rewrite the rules because of those limits put in place by Congress. If you actually wanted to fix this issue, you would have to, very likely, unless you can get some Democrats to agree, and I really doubt you could, you would very likely have to suspend the filibuster, which is what's something the Republican should be doing right now, and then go and get Congress to change it. So were I to offer this advice to Trump, I would say push on the filibuster, keep pushing, pushing, pushing. You have to get them to change the thing because you can't do it directly. But as president, you will be blamed for any sort of health care mishaps or just continuations of bad trends that we've had going on.

That is the big tough question. We've talked about the filibuster a lot on this show, because Trump wanted to get rid of it to end the shutdown. And we've generally said, end the shutdown, but only, or end the filibuster, but only if you have a home run slate of legislation to pass. Otherwise, you're just going to do some lame thing and then fart around and then Democrats will have no filibuster to do

their agenda, which is a lot more clear cut on what they want to do. This is a lot scarier, too, by the way. There's popular aspects of ACA, right? It's the uninsurable people, right, that you couldn't have some very expensive treatment that you need for the rest of your life. The pre-existing condition. People like being on their parents.

insurance. And then being on your parents' issues, would your recommendation, just from a political standpoint, put your political hat on, would you say, let's keep those things in place and fix these underlying, I guess, statutory issues? I mean, you could, instead of replacing Obamacare, you pitch it as like, hey, these reforms would make it better. Yes, I absolutely would. So the big thing is, with respect to the preexisting condition requirement, it does add a lot of costs. I mean, it obviously does because you have suddenly people who are high costs being covered and you're in the same pool as them, and you've got to cover them. So that's a big issue.

But if you fix the medical loss ratio requirement and you allow health care provider, or not, sorry, if you allow health insurers to make better use of their prior authorization departments, you can minimize the downside of those people because you can offer them more tailored care. You can offer them, you can say, hey, your doctor called for this, but we actually think there's a better option here. You can figure out what is more optimal to give them in terms of care and save a lot of that money that you would have wasted anyway. But you're forced to spend it, so it doesn't matter.

At the moment, it becomes a bad thing in large part because there are no incentives to fix the issue from a technological perspective. Like, you can't go the technological route and minimize the issue the other way, which we totally could do if we fix this other issue. So I think keep that in place. It's fine. Because it's so popular, no one wants to touch it, and you really do still want these people to be covered somehow. Like, it's a, it's a humane issue.

At the end of the day, you want them to be covered in some way. That is it just like... So one last question I'm thinking. So you mentioned it's statutory issues on the biggest things. But what is the best thing you think the Trump administration could do right now just with its regulatory executive branch authority doesn't need Congress, which is its own big problem? What could they do tomorrow if they wanted to do? They could fix tons of the issues with CMS.

So like that site neutrality thing I mentioned before is totally able to be fixed. The issue is the enforcement there. They have that power to fix that issue and enforce it. And they've written up those rules and they have changed those rules and they have not enforced it. That is the big issue is enforcement. And there are tons of things like this. So they could get away with fixing a lot by just enforcing the rules and change. There are some things they can change too.

So they could be adventurous. There are some untested legal theories here. Like Section 804 is the thing that allows you states to sign up to start importing drugs. for their Medicare Medicaid programs from Canada at Canadian prices. If they were to be a little adventurous with this, they could expand that by changing two parts of the regulation so that states could import Canadian generics that don't yet have a generic equivalent in the U.S.,

thus lowering prescription drug prices a lot. It's totally on the table to do a lot of little fixes that are in untested legal territory, if they want to try that, and they could meaningfully lower the cost of health care, considerably beyond what they've done so far with the negotiations. Because the negotiations, they've actually been getting kind of duped on. Like, a lot of the Trump RX stuff that they've done where they've tried to directly go to Pfizer and tell them, give us most favored nation rates, that stuff doesn't really work to cut prices very much. Unfortunately, like you think there's a lot of room there, but the issue is those companies aren't really giving a great friend.

I was texting Blake that, you know, I assumed that it was the subsidy. for people who couldn't otherwise afford, or at least so they say, couldn't afford health care that was driving up the cost of health insurance for average American families. Yeah, like, we've all heard the story of the illegals who just go in to, for everything to the ER, causes overflow, causes all of this, these extra costs, and they never pay for any of it. It's all eaten by the taxpayer. But you say it's maybe 1% of total cost inflation. Poor Americans, working class Americans that qualify for the subsidy. So they get discounted insurance rates. So that's, the assumption is that's what's driving

most of the cost increase. Ah, that is, yeah, that assumption is very wrong. Health care is a $5 trillion industry. It is so much larger than these subsidies. And it's growing, it grows faster than the rate of inflation by a considerable margin, too. So the majority of the cost growth is just way away from these things. And it's, there's been no detectable change and trend related to the subsidies either in terms of like prices of drugs and whatnot. They're just negotiated on too like long term of scale and too large a scale for this stuff to really matter all that much. And the government has their rates they get with CMS stuff like Medicare and Medicaid that aren't going to be meaningfully changed if they get the subsidies. Like they're not going to lose negotiating leverage the

moment they start financing plans a different way. So ultimately this stuff doesn't make much of a difference. The big stuff is systemic like incentive related stuff that has been put in place for too long and needs to be changed at a more fundamental level. Yeah, I have an anecdote for you, and I wonder if there's a root cause that I'm not aware of. So, for example, Daisy is pregnant. She works here in the office. I've had three kids. I understand this process well.

You get towards the end of your pregnancy, and the first time with your first kid, you're like really grateful for it. And you go to the OBGYN like every week in that final run up to having your baby. But then I'll baby two and three. You're like, I don't need to go every week. I know what we're doing. You not need to go over with the OBGYN is going to say, hey, you've got to come in every week. It's mandatory.

Stuff like that. Okay, maybe I'm not a doctor. Maybe that's really medically necessary. But for me and my wife, and I've heard this from other parents, like, you don't, like, I'm not going in again. Sorry, I'm just going to like skip that one. We're not doing it. You start taking control of your own health care a little bit. But the doctors, it occurs to me, are getting paid every time you're going in.

That's money. That's expense to the system. And here's what else they know is that you've already hit your $5,000 or $6,000, $8,000. deductible. And the incentive structure for the client, the patient in this case, is off because you know it's not going to cost you anything more out of pocket. The whole system just has to absorb this cost. What am I describing there and how do you fix it? What you're describing is actually related to the MLR issue again, the medical loss ratio thing. So medically necessary care is the majority of care, but it's a slim majority. 30 to 40% of the care, and I'm leaning more

towards the 40% side that we give out in this country just isn't necessary. So many things don't need to be done and we don't have the ability to say no to doctors in a very meaningful way because there's no incentive to. There are incentives to say yes to doctors to overpay for care. And they only recently added prior authorization. That's the rejection department basically to Medicare, fee for service plans. But they need to make that a more extensively used thing everywhere. They need to be able to say no more often. They need to be able to target care about it. They need to make individualized guidelines. And I don't mean in some hockey, personalized medicine sort of way. I mean in a, we need access to massive amounts of data

in order to properly tailor everything for individual patients in a way that like still provides them with all the care that they personally need without having them go over by like getting five times more well visits than they actually need or getting a mammogram when they're in the lowest decile of risk or something like that like it's that sort of thing is uh just far too common and it is the big issue and that is why if you were to fix that mLR requirement you would you would basically be able to start cutting back on medically unnecessary care and allocating care better and you'd be incentivized to figure out people who are currently underserved uh who you're not currently incentivized to go out and find and to bring them into the doctor's office so for example

There are a lot of young people these days, not a lot in absolute terms relative to the old, but like an increasing number of young people who get colorectal cancer. And we have wonderful algorithms for finding those people young. But nobody implements them in the prior authorization stage because there's no financial reason to. There are financial reasons not to, but no financial reason too. We have totally distorted the incentives away from promoting health for people and towards promoting costs because that's just how it is. I mean, that's just, we've made some very, very bad decisions in designing these systems. And we totally could fix them. But I always feel so much more optimistic because you're always like, oh, there's like all these big changes we could make.

And then you go back into politics and it's such a mess. But before we lose you, I want to congratulate you when you came out and you talked to Charlie. He loved it, by the way. He wanted to talk to you as long as he possibly could. One of his favorite segments of the past year, I think. So I wanted to thank you for that. But when we talked about autism, rising autism rates, one of the things you told us is you said, I think this is basically just, it's a matter of diagnosis. And one of the things you said was the Somali community in Minnesota is scamming the autism system, way inflating their rates to just scam everyone.

And our segment just before you was we were talking to Ryan Thorpe about the Somali scam, they're sending all the autism dollars to El Shabab in Somalia. So I wanted to congratulate you for calling that shot months. in advance. And I wanted to thank you again for coming on and giving us your time. Kramu, we got to get you in touch with some people that can actually implement some of this stuff. So we'll work on that too. But really, I mean, enlightening conversation. I hope people at home appreciate it just as much. So Kramu, thanks for making the time, my friend. And we'll see you again. I'm sure when the next hot topic comes up. Extremely complicated topic. Yeah, exactly. And you're looking at the macro data trends. So we appreciate it.

All right. Have a good one, guys. You too.