“You talk to the janitor or the field worker making hourly pay and looking at these figures, knowing we better stay healthy this year, because there’s no way we can afford this.” - Sebastian Sanchez, RHSB

In this episode of Last Month in Healthcare, Producer Nathaniel and I sat down with Sebastian Sanchez, benefits consultant at RHSB in Dallas, to break down the biggest healthcare news stories of October 2026.

We started with Mark Cuban’s argument in Fortune that healthcare costs, not AI, are the real job killer. His fix is to break up the vertically integrated insurers and make provider contracts public. Sebastian sees employers starting to revolt against the system from the ground up. My take is that both can be true: if you replace someone with an AI tool, you don’t have to pay for their health plan either.

We also dug into KFF’s annual survey. Family coverage now averages $28,303, up 5%, while the worker’s share rose 9% to $7,471. At firms with fewer than 200 employees, nearly a third of workers pay $12,000 or more in premiums alone. Sebastian explains what those numbers look like to an hourly employee.

Plus, Amazon, Google, Meta, Oracle, and Axon pledged to speed up electronic prior authorization. A new bill from Rep. Frank Pallone would scrap No Surprises Act arbitration, which researchers say has added more than $22 billion in costs since 2022. And doctors’ offices owned by hospital systems are billing routine visits at hospital rates, sometimes 10 times more for the same care.

To cap it off, we played a Halloween edition of our fewer-ingredients game, and I answered a listener question about how to tell a client their plan is fine without looking like you’re not doing your job.

Thank you to Walk-On Clinic for sponsoring this episode. Visit walkonclinic.com to learn more.

Chapters:

(00:00:00) Intro: Sebastian Sanchez and Walk-On Clinic
(00:01:52) Mark Cuban: Healthcare Costs, Not AI, Kill Jobs
(00:04:39) KFF Survey: The $28,303 Family Premium
(00:08:00) Big Tech’s Prior Authorization Pledge
(00:10:09) A Bill to Scrap No Surprises Arbitration
(00:13:30) Doctors’ Offices Billing as Hospitals
(00:17:05) Game: Halloween Candy, Fewer Ingredients
(00:23:38) Ask Spencer Anything: When the Plan Is Fine

“Rebates, I’ll go out on a limb and say, they’re almost inherently evil... Your sickest employees are paying for that rebate.” - Steve Ditto

PBM rebates are sold as savings. Steve Ditto argues they do the opposite. Manufacturers pay for rebates by raising list prices, and members’ copays and deductibles are based on those inflated prices. The employer cashes the rebate check while its sickest members cover the cost.

Steve spent 30 years as a healthcare consultant before the wrong $100,000 infusion put him in the ICU and made him a patient advocate. He explains why buying drugs on a lowest-net-cost basis beats chasing rebates, why the PBM is the easiest place for a self-funded employer to start, what to ask about an advisor’s compensation, and how Nautilus Health Institute’s free model contract language and Contract X-Ray tool help plans get a better deal.

His new book, The Middleman’s Cut, is available on Amazon.

If you’re advising self-funded employers on pharmacy, this is the episode for you. Tune in.

Thank you to our 2026 sponsors!

ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.

Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.

Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.

Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.

Chapters:

(00:00:00) Intro: Rebates Are Almost Inherently Evil

(00:00:16) From Consultant to Patient

(00:04:40) Jim, Maria, and Rationing Medications

(00:09:46) Why the Sickest Members Pay for Rebates

(00:17:09) Steve’s Path Through Healthcare Consulting

(00:19:40) Quality, Stop-Loss, and Specialty Drugs

(00:27:37) Nautilus and Free PBM Contract Tools

(00:32:54) Where Self-Funded Employers Should Start

(00:38:55) Direct Primary Care and Direct Contracting

(00:43:00) Navigation and the Right Diagnosis

(00:52:04) Are Carrier Networks Obsolete?

(00:56:51) Closing Thoughts

Key Links for Social:

@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded

Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02

Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286

Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/

Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

“The idea with WellGenie is, what if we can increase access and remove the cost burden? Then we give the opportunity for people to not delay care.” - Chris Mathew, WellGenie

Many employees have insurance they can’t afford to use. Every prescription, virtual visit, and specialist appointment costs them money, so they put off care until small problems become expensive ones.

Chris Mathew joined me this week to explain how WellGenie makes everyday care free for each employee and up to four family members: generic and brand medications, unlimited virtual and behavioral health care, same-day specialist access, and a personal health guide.

It runs alongside an employer’s existing carrier, TPA, and PBM, keeps those costs off the health plan, and refunds 40% of its fees if it doesn’t lower costs in the first year. Chris also shares why one state was told to walk away from $110 million in savings, and the thank-you bottle of wine he once sent a broker before learning how brokers get paid.

If your employees are insured but avoiding care, this is the episode for you. Tune in.

Thank you to our 2026 sponsors!

ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.

Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.

Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.

Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.

Chapters:

(00:00:00) Intro: Free Care, Lower Costs

(00:00:19) The State That Was Told to Stand Down

(00:05:00) Broker vs. Consultant

(00:07:10) The Thank-You Note to His Broker

(00:15:30) Catching Up With Chris

(00:20:53) Insured but Can’t Afford Care

(00:28:13) $0 Generics and Cheaper Brand Drugs

(00:33:38) Unlimited Virtual and Behavioral Care

(00:44:08) Same-Day Specialist Access

(00:46:42) The Personal Health Genie

(00:57:03) The Money-Back Guarantee

(01:11:59) Recap and Closing Thoughts

Key Links for Social:

@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded

Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02

Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286

Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/

Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/