The Exposed
72 senators. $700 million in lobbying. The names behind the healthcare monopoly.
In every empire, there are gatekeepers.
Not the ones who build.
The ones who block.
In American healthcare, they don’t wear white coats.
They wear flag pins.
They sit on committees.
They cash checks from the same systems they’re supposed to regulate.
THE NUMBER
72.
72 of 100 sitting U.S. senators accepted $10,000 or more from pharmaceutical and health product PACs in 2024.
35 of those seats are on the ballot next November.
They voted to keep the physician ownership ban, written by health system lobbyists in 2010.
They killed site-neutral payment reform, protecting the facility fee markup.
They defended Certificate of Need laws in their home states, where health systems literally vote on whether competitors can exist.
This is the list.
THE SCORECARD
We graded every senator on four pro-competition reforms:
Section 6001 Repeal
Lifts ban on physician-owned hospitals10 senators (all R)American Hospital Association
PBM Reform
Transparency for pharmacy benefit managers21 senators (bipartisan)AHIP (insurers)
Site-Neutral Payments
Same price for same service, any setting3 senators (bipartisan)American Hospital Association
Price Transparency
Hospitals must post real prices14 senators (bipartisan)American Hospital Association
Notice the pattern.
The American Hospital Association opposes three of the four reforms. They’re the primary obstacle to competition in American healthcare.
9 senators scored 2 or higher out of 4.
91 senators scored 1 or lower.
That’s your Senate.
THE NINE
These are the Free Market Champions.
They’ve taken concrete action on at least two of the four reforms.
Roger Marshall - R Kansas
3/4 Section 6001, PBM, Price Transparency
Maggie Hassan - D New Hampshire
3/4 PBM, Site-Neutral, Price Transparency
Bill Cassidy -R Louisiana
3/4 Section 6001, PBM, Site-Neutral
Chuck Grassley - R Iowa
2/4 PBM, Price Transparency
Thom Tillis - R North Carolina
2/4 Section 6001, PBM
James Lankford - R Oklahoma
2/4Section 6001, PBM
John Cornyn - R Texas
2/4 Section 6001, PBM
Tammy Baldwin - D Wisconsin
2/4 PBM, Price Transparency
John Barrasso - R Wyoming
2/4 Section 6001, PBM
7 Republicans. 2 Democrats.
The hospital lobby donates to both parties.
Most senators accept it.
These nine didn’t fold.
THE SECTION 6001 TEN
Only 10 senators have cosponsored S.1390, the Physician Led and Rural Access to Quality Care Act, to repeal the ban on physician-owned hospitals.
All 10 are Republicans:
James Lankford - OK - Has CON laws
Roger Marshall - KS No CON laws
Bill Cassidy - LA CON-like laws
Thom Tillis - NC Has CON (strictest)
John Cornyn - TX No CON
Markwayne Mullin - OK Has CON
John Boozman - AR Has CON
John Barrasso - WY No CON
Ted Budd - NC Has CON (strictest)
Jim Justice- WV Has CON
Notice something?
7 of 10 represent states WITH Certificate of Need laws.
They’re fighting against the monopolies in their own backyards. That takes spine.
Where are the other 43 Republican senators?
Where are ALL 47 Democrats?
THE EXPOSED
The Leadership
Mitch McConnell (R-KY) Lobby money from top 4 healthcare groups: $51,500.
Reform score: 0/4.
Kentucky is a CON state.
The Senate Minority Leader. Four decades in Washington.
Over $2 million career in healthcare.
He has supported zero of the four pro-competition reforms.
Zero.
Chuck Schumer (D-NY) Lobby money from top 4 healthcare groups: $25,500.
Reform score: 0/4.
New York has one of the strictest CON regimes in America.
The Senate Majority Leader. Represents the largest healthcare market in the country.
Northwell, Mount Sinai, NYU Langone, NewYork-Presbyterian, they all win.
New Yorkers lose.
He has supported zero of the four reforms.
Patty Murray (D-WA): Lobbying money from the top 4 healthcare groups: $30,500. Reform score: 0/4. Washington is a CON state.
Former Chair of the HELP Committee, the committee that oversees healthcare policy.
Providence, MultiCare, and UW Medicine control her state.
She held the gavel. She did nothing.
The “Progressives”
Elizabeth Warren (D-MA) Career: healthcare industry total: $1,222,965. Reform score: 0/4. Massachusetts is a CON state.
She’s built a career fighting monopolies. Banks. Tech. Airlines.
Mass General Brigham dominates Boston healthcare.
Where’s the same energy?
Bernie Sanders (I-VT) Career: healthcare industry total: $1,949,772. Reform score: 0/4. Vermont is a CON state.
The democratic socialist.
The anti-corporate crusader.
$1.95 million from the healthcare industry over his career.
UVM Medical Center controls Vermont. One state, one system. Senator Sanders, they’re not the revolution.
The Committee Chairs
Ron Wyden (D-OR) has received $1,214,999 from the healthcare industry. Reform score: 1/4 (PBM reform only). Oregon has CON laws.
Chair of the Senate Finance Committee. Oversees Medicare, Medicaid, and healthcare spending.
Credit where due: Wyden co-authored bipartisan PBM reform with Mike Crapo.
But: He chairs Finance. He represents a CON state. He’s taken $1.2 million from healthcare.
Where’s the site-neutral legislation? Where’s the Section 6001 support? Where’s the CON repeal push?
One reform out of four. From the man who controls the healthcare agenda.
The 2026 Class
These senators face voters in November 2026:
Susan Collins (R-ME) has received over $1,100,000 from the healthcare industry. Reform score: 0/4. Maine is a CON state.
The moderate. The reasonable voice.
MaineHealth and Northern Light have divided her state like feudal lords.
She protected the ACA. She never touched the consolidation that makes care unaffordable.
Protecting coverage is not protecting competition.
Jon Ossoff (D-GA) has received over $400,000 in contributions from the healthcare industry. Reform score: 0/4. Georgia is a CON state.
Piedmont, Wellstar, Emory, feudal territories.
He’s young. He’s supposed to be different.
Is he?
Shelley Moore Capito (R-WV) received $21,000 from top healthcare groups. Reform score: 0/4. West Virginia is a CON state.
One of the unhealthiest states in America. One of the most captured healthcare markets.
She’s taken the money. She’s supported none of the reforms.
THE CASSIDY CASE STUDY
Bill Cassidy (R-LA) breaks the pattern.
The Numbers:
Career pharmaceutical contributions: $1,267,596
Lobby money from top 4 groups: $6,500 (AdvaMed)
Reform score: 3/4
He should be captured. He’s not.
Why?
Look at WHERE his money comes from:
Individual physicians $958,000
Hospital PACs $102,000
He’s funded by physicians.
Not hospital systems.
What He’s Done:
Section 6001: Cosponsored bill to repeal physician-owned hospital ban
Site-Neutral Payments: Co-authored the Cassidy-Hassan framework with Democrat Maggie Hassan
PBM Reform: Active supporter of transparency legislation
340B Reform: Led Senate HELP Committee investigation, released a damning report on hospital abuse of the drug discount program
CPT Codes: Threatened to strip CPT code authority from the AMA — a direct shot at organized medicine’s monopoly on billing
Cassidy is a physician. He knows what these laws do to independent doctors.
He took the physician’s money and fought for physicians.
The other 72 took hospital money and protected hospitals.
The money matters. But WHERE it comes from matters more.
THE BIPARTISAN ANGLE: It’s important to recognize that support and opposition cross party lines.
Maggie Hassan (D-NH) scored 3/4 — tied for second place among all senators.
She co-authored site-neutral payment reform with Cassidy.
She supports PBM reform.
She supports price transparency.
New Hampshire has no CON laws. Maybe that’s why she can fight.
Tammy Baldwin (D-WI) scored 2/4.
She supports PBM reform and price transparency.
Wisconsin has no CON laws either.
The pattern: Senators from non-CON states are more likely to support competition reforms.
Senators from CON states are more likely to protect incumbents.
The hospital lobby has captured state legislatures AND federal senators.
THE CON CONNECTION
31 states plus D.C. have comprehensive Certificate of Need laws.
That’s 62 senators representing captured markets.
In CON states, hospitals vote on whether competitors can exist.
In CON states, physicians need government permission to buy an MRI machine.
In CON states, the incumbents write the rules.
And the senators from those states?
They take money. Protect the system. Score 0/4.
How did 31 states end up with the same anti-competitive law?
It wasn’t an accident.
In 1974, the federal government told states: adopt Certificate of Need or lose your federal funding.
The lion of the Senate himself pushed it through.
Tomorrow, we’ll tell that story.
WHAT THEY BLOCKED
The 72 captured senators killed or blocked:
1. Physician-Owned Hospital Ban Repeal Section 6001 of the ACA, written by hospital lobbyists in 2010, banned new physician-owned hospitals. Existing ones can’t expand.
Result: Hospitals eliminated their most efficient competitors.
Only 10 senators support repeal. 90 do not.
2. Site-Neutral Payment Reform Hospitals charge Medicare 2- 3x more than independent physicians for the same service. The “facility fee”, a markup for walking through a hospital door.
Site-neutral payments would end this arbitrage.
Save Medicare billions.
Lower premiums.
Only 3 senators actively support it. 97 do not.
3. Certificate of Need Repeal 31 states + DC require government permission to build healthcare facilities. Incumbent hospitals sit on the boards that approve competitors. They vote no.
Federal legislation could incentivize state repeal. Zero senators have introduced it.
4. 340B Transparency Hospitals buy drugs at massive discounts through the 340B program. They bill patients and insurers full price. They pocket the spread, billions annually.
No transparency required. Senator Cassidy released a damning report.
The other 99 senators have done nothing.
THE SUBSIDIES THEY PROTECT
These senators don’t just block reform. They actively protect the subsidy machine:
Medicare GME
$12.5 billion
Total Federal GME
$20 billion
340B Drug Discounts
$50+ billion
Tax Exemption
$30+ billion
Facility Fee Markup
$40+ billion
Over $150 billion in annual funding flows to hospital systems through these mechanisms.
The 72 captured senators protect every dollar.
THE THREE QUESTIONS
Before you vote in 2026, ask your senator:
1. Do you support site-neutral payments? Same service, same price — regardless of setting.
Only 3 senators have said yes.
2. Will you cosponsor S.1390 to repeal the physician-owned hospital ban? Let doctors own hospitals again.
Only 10 senators have said yes.
3. Do you support federal incentives for states to repeal Certificate of Need laws? Let competition exist.
Zero senators have introduced legislation.
If they won’t answer, they’ve already answered.
THE MATH: Here’s how Senate reform support and opposition break down numerically.
72 captured senators.
19 unknown, insufficient data, but likely captured.
35 seats on the ballot in 2026.
$29 million in AHA lobbying alone last year.
$700 million total healthcare lobbying.
$150+ billion in annual subsidies protected.
This isn’t influence.
It’s ownership.
WHAT YOU CAN DO
If you vote in a 2026 Senate race:
Look up your senator’s reform score (we’ll publish the full database for paid subscribers)
Find their healthcare industry contributions at OpenSecrets.org.
Ask the three questions, on camera, at town halls, in writing.
Share their answer. Or their silence.
If you’re a physician:
Stop donating to the AMA until they fight for you.
Support candidates who score 2/4 or higher
Donate to physician-aligned PACs, not hospital-aligned ones.
Testify at state CON hearings.
If you’re an employer:
Understand why your premiums rise 8% every year.
Ask your broker about direct contracting with independent physicians.
Demand price transparency from your health plan
Tell your lobbyist to support site-neutral payments.
THE BOTTOM LINE
9 senators are fighting for free-market healthcare.
72 are protecting the monopolies.
The battle lines are drawn.
November 2026 is coming.
TOMORROW
You’ve seen the map.
You’ve met the 25 systems.
You’ve seen the 72 senators who protect them.
Tomorrow, we go back to 1974.
The year the competition became illegal in American healthcare.
Day 4: The History of CON Laws
10 AM Central.
The Rojas Report is reader-supported. No pharma ads. No hospital sponsors. No conflicts.
Paid subscribers get the complete senator database with scores, contribution data, and state-by-state analysis.
SOURCES
Campaign Finance:
OpenSecrets.org, 2023-2024 election cycle (FEC data released February 2025)
KFF Health News Pharma Cash to Congress database
Senate Office of Public Records lobbying disclosures
Legislation:
Congress.gov — S.1390 Physician Led and Rural Access to Quality Care Act
Congress.gov — S.2973 PBM Transparency Act
Congress.gov — S.1629 Same Care, Lower Cost Act
Congress.gov — S.4159 Patients Deserve Price Tags Act
Policy Analysis:
Senate Finance Committee — Wyden-Crapo PBM legislation
Senate HELP Committee — Cassidy 340B Reform Report (April 2024)
Cassidy-Hassan Site-Neutral Policy Framework
Congressional Research Service — Federal GME Funding Report (August 2024)
CON Law Data:
National Conference of State Legislatures
Mercatus Center, George Mason University
National Academy for State Health Policy
Author’s Research:
30 years of direct engagement with healthcare policy
Interviews with physician practice owners
Analysis of hospital consolidation patterns
This is an awesome and terrifying report!
This is excellent.