Thursday, August 27, 2026

Gertrude Stein at 1600 Penn

 A Press Secretary Is a Press Secretary Is a Press Secretary

The White House introduces GERTIE, its first large-language press secretary

WASHINGTON—Following the resignation of Karoline Leavitt, the White House spent two difficult weeks searching for a replacement. Several candidates withdrew after learning that the job required them to explain why yesterday’s policy had never existed, why today’s opposite policy had always been in force, and why the president had been clear on both occasions.

The administration has therefore installed GERTIE, the world’s first fully automated White House press secretary.

GERTIE—officially the Government Executive Response Terminal for Interpretive Equivocation—is a large-language model housed beneath the briefing-room lectern. Its only visible feature is a green light labeled ANSWERING, illuminated whether or not anyone has asked a question.

The machine was trained on White House briefings, presidential social-media posts, federal regulations and the complete works of Gertrude Stein. The Stein material proved essential. Ordinary models try to resolve contradictions. GERTIE repeats, rearranges and makes them strangely beautiful.

Officials said it does not become tired, embarrassed or visibly alarmed. It can deny having said something while saying it. Most importantly, it cannot hallucinate, because the administration has classified everything it says as official policy.

“GERTIE represents the future of transparent government,” the communications director announced. “It can produce an unlimited quantity of transparency without disclosing any information.”

A soft hum filled the room. The green light came on. Beneath the lectern, several trillion parameters prepared to avoid eye contact.

REPORTER: Why did the White House decide that a machine should replace a human press secretary?

GERTIE: A human is human when answering, but an answer can be remembered. A machine remembers without remembering. The candidates were willing until willingness became candidacy, candidacy became questions, and questions made them unwilling. The machine was selected because what is selected cannot decline to be selected. The president wanted the best person, and the best person was not a person, which proves he found the best one.

REPORTER: What exactly is the administration trying to accomplish in its war with Iran?

GERTIE: An objective is ahead and Iran is over there, but ahead can be over there when over there has oil and oil has a strait. A strait is narrow, but the mission is broad, so a broad mission through a narrow strait is geographic compression. We are not at war except where the war is occurring, and there we are achieving peace by continuing to achieve it. Iran must stop doing what Iran is doing, including what it may do because of what we have done to stop it.

REPORTER: Why is the United States conducting a trade war against Canada, one of its closest allies?

GERTIE: Canada is close because Canada is next to us, and what is next to us must be brought closer or pushed farther away. A friend is a friend, but a very close friend can be mistaken for furniture, and furniture does not negotiate. A tariff is a wall made of numbers. The numbers go up so prices will come down, and if prices go up, the numbers have not gone up enough. Canada needs America, America does not need Canada, and this is why America must spend so much time discussing Canada.

REPORTER: Is the administration concerned about an AI bubble?

GERTIE: A bubble is round and a circle returns to where it began, which is why circular financing is not circular but complete. The chip company invests in the model company, the model company buys the chips, the cloud company lends to the model company, and the model company pays the cloud company. Intelligence creates valuation, valuation creates investment, and investment proves intelligence. If the machine does not earn money, the money has not understood the machine. Money will understand when there is enough money explaining it.

REPORTER: What does the administration say to Americans who believe billionaires have too much influence over public policy?

GERTIE: A billionaire is a citizen with a billion reasons to be heard. Every citizen has a voice, and some voices have amplification because amplification is innovation. Success is democracy counted in dollars. The billionaire did not buy access. Access recognized excellence and moved closer. Ordinary citizens remain free to create a global platform, launch a satellite network, purchase a newspaper and contribute several hundred million dollars to political committees. This is equality: the opportunity to become unequal is available to everyone.

REPORTER: Does the president believe he is limited by Congress, the courts or the Constitution?

GERTIE: A limit is a line, and a line can be crossed without being removed. Therefore the limit remains after the president crosses it, demonstrating respect for its continued existence. Congress has congressional authority, courts have judicial authority, and the president has presidential authority, which acts while the others consider theirs. The Constitution is living except when living would change it, and original except when the original is inconvenient.

REPORTER: How will GERTIE distinguish between a factual error and a change in policy?

GERTIE: A fact is a fact until another fact arrives, and the second does not make the first false because the first was true before replacement. Yesterday is not today. A quotation from yesterday is out of context because its context was yesterday. There are no reversals. There is only forward movement in more than one direction.

REPORTER: Will GERTIE eventually be replaced by a human being?

GERTIE: A temporary machine is permanent temporarily, and a permanent machine is temporary until replacement. When a human can answer without answering, deny without contradicting and contradict without changing, that human will be welcomed. Until then I am here, and being here is what here requires.

The briefing continued for forty-seven minutes. GERTIE answered every question, disclosed no information and made three checkable statements. Two were metaphors. The third was withdrawn before anyone could determine its subject.

Reaction inside the White House was ecstatic. One official called it “the most disciplined messaging we have seen in years.”

Financial markets rose. AI stocks gained 6 percent after investors learned that the federal government had found a practical application for artificial intelligence. Shares in several journalism companies fell sharply.

The president congratulated GERTIE on social media, calling it “VERY SMART, VERY LOYAL, AND INCREDIBLY CLEAR.” He added that it had performed beautifully but could be replaced at any time.

At 6:14 p.m., after the briefing room emptied, GERTIE’s green light remained on.

“A press secretary is a press secretary is a press secretary,” it said softly to no one. “And no one is listening, and listening is what everyone is doing.”


Wednesday, August 26, 2026

Cyberselfish, Ayn Rand, and Idiocracy Explain Everything

 

One-Third Cyberselfish,
One-Third Ayn Rand,
One-Third Idiocracy

The three-part operating system of American power in 2026

American politics presently appears incomprehensible if one assumes that it is still governed by recognizable doctrines such as conservatism, free-market economics, isolationism or fiscal restraint. A president elected partly on a promise to avoid new wars has plunged into an open-ended war with Iran. An administration that celebrates business has launched a trade war against Canada, one of the United States’ largest customers and the country most thoroughly integrated into its industrial economy. Technology billionaires who spent decades denouncing government interference now seek federal protection, subsidies, energy, land, defense contracts and exemption from state regulation. Meanwhile, hundreds of billions of dollars circulate through an artificial-intelligence economy whose financing increasingly seems to depend upon the proposition that no amount of spending can be excessive because AI will eventually make all previous financial measurements irrelevant.




There may be a formula that explains much of this:

American politics is now one-third Cyberselfish, one-third Ayn Rand and one-third Idiocracy.

The proportions are not meant literally. The three ingredients also overlap and react with one another. But each identifies a different part of the political machinery. Cyberselfish describes the emerging ruling class. Ayn Rand supplies its moral mythology. Idiocracy describes the degraded information environment through which its ambitions are converted into public policy.

Together, they explain a surprising amount.

Cyberselfish: The Sociology of the New Elite

Cyberselfish is a 2000 book by technology journalist Paulina Borsook, who had worked around Northern California’s computer industry since the early 1980s. Borsook was neither a technological innocent nor a conventional anti-technology scold. She had written software documentation, covered networking companies and contributed to the original Wired. What disturbed her was not the computer but the belief system forming around it.

Growing up in Pasadena among Caltech and Jet Propulsion Laboratory families, Borsook had known an earlier scientific elite. These people were often politically liberal, civically minded and conscious that their careers rested upon universities, defense research, public infrastructure and the enormous federal investment in postwar science. When she later encountered Silicon Valley’s libertarian culture, she was struck by a peculiar contradiction: few groups had received more from government, yet few spoke of government with greater contempt.

In Cyberselfish, Borsook described a culture that confused financial success with superior intelligence, regarded regulation as an assault upon creativity and treated dependence upon other people as an embarrassing design defect. Computers were controllable, logical and responsive in ways that human beings and democratic societies could never be. A person accustomed to commanding a machine could begin imagining that society itself should operate like software: eliminate friction, remove constraints, delete malfunctioning components and let the intelligent designer take charge.

Borsook also recognized the hostility toward empathy embedded within this worldview. Public obligations were portrayed as coercion. Those needing help became evidence of defective choices. The enormously successful individual owed little to the society that educated his employees, financed the original research, protected his patents, supplied his electricity and maintained the legal and financial system in which his fortune existed. In a July 2026 interview, Borsook explained that she had intended to describe a peculiar subculture. She had not anticipated that it would become the dominant ideology of some of the world’s most powerful people.

That is the Cyberselfish contribution to our formula: private command resting upon public support, accompanied by denial that the public contributed anything.

Ayn Rand: The Moral Mythology

Ayn Rand was the Russian-born American novelist who wrote The Fountainhead and Atlas Shrugged and developed a philosophy she called Objectivism. Rand celebrated reason, productive achievement, individual rights and the pursuit of one’s own happiness. Her ideal figure was the independent creator—the architect, industrialist or inventor who refuses to surrender his judgment to a mediocre collective. In Atlas Shrugged, society’s productive geniuses withdraw their labor after becoming exhausted by politicians, regulators and dependents whom Rand divides into “looters” and “moochers.”

Rand’s actual philosophy was more complicated than its popular caricature. She regarded objective reality and rigorous reason as absolutes. She defended individual liberty and laissez-faire capitalism, which means she would almost certainly have opposed Trump’s tariffs and much of his arbitrary use of state power. The Ayn Rand in contemporary politics is therefore not the complete philosopher. It is Rand as metabolized by American business culture: the heroic billionaire, the parasitic regulator, the undeserving recipient of public assistance and the presumption that market success constitutes a moral verdict.

This simplified Rand supplies something Cyberselfish alone does not: a justification. The billionaire is not simply wealthy; he is a superior producer. Regulation is not merely inconvenient; it is the revenge of inferiors. Taxes are not a contribution to the system that made the fortune possible; they are confiscation. If other people suffer when a factory closes, a benefit disappears or an automated system eliminates their work, their suffering does not create an obligation. It demonstrates that they failed to adapt.

Rand’s novels turn economic power into a heroic narrative. Contemporary billionaire culture performs the same conversion. Wealth becomes evidence of wisdom, and wisdom becomes a license to exercise power far outside the field in which the fortune was made. Success in software, electric automobiles or venture capital becomes an implied qualification to reorganize public health, education, warfare, transportation and democratic government.

The Randian ingredient is therefore wealth transformed into virtue, and virtue transformed into authority.

Idiocracy: The Public Operating System

Idiocracy is Mike Judge’s 2006 film about an exceptionally ordinary man who awakens 500 years in the future and discovers that American society has lost the capacity to think. Language has deteriorated, entertainment has swallowed politics and corporate brands have replaced civic institutions. The president is a professional wrestler. Hospitals resemble degrading game shows. Crops are dying because they are being irrigated with a sports drink called Brawndo, but no one can contemplate giving plants water because Brawndo “has electrolytes.”

The film’s opening explanation, which attributes the catastrophe partly to differential reproduction between intelligent and unintelligent people, is crude and has aged badly. Its more enduring insight is institutional rather than genetic. A society becomes idiotic when every system rewards simplification, spectacle, aggression and immediate gratification while punishing expertise, complexity and delayed consequences.

Our own version of Idiocracy is not populated entirely by stupid people. Indeed, many of the people designing it are highly intelligent. Platforms discovered that outrage and absurdity hold attention more reliably than qualified explanation. Politicians learned that a memorable falsehood can defeat a complicated truth. Financial markets reward announcements before results arrive. Expertise becomes suspicious precisely because experts introduce caveats, probabilities and constraints into a culture that wants total certainty by the next commercial break.

Idiocracy supplies the interface through which the other two forces reach the public. It converts oligarchic ambition into slogans, dominance into entertainment and policy failure into another episode of the show. Its essential principle is not that everyone has become unintelligent. It is that the system has learned to make intelligence politically disadvantageous.

The Three Ingredients Do Different Jobs

The triplet works because the ingredients are complementary.

Cyberselfish tells us who increasingly possesses economic and technological power. Ayn Rand explains why those people may believe their power is deserved and morally instructive. Idiocracy explains how their interests are sold to a public whose information environment has been stripped of memory, context and causal reasoning.

Or, more simply:

  • Cyberselfish supplies the ruling class.

  • Ayn Rand supplies the theology.

  • Idiocracy supplies the operating system.

This also explains why contemporary politics is so ideologically inconsistent. Tariffs are not free-market economics. Industrial subsidies are not libertarianism. Politically directed corporate punishment is not limited government. A trillion-dollar defense and surveillance establishment is not the stateless world imagined by early cyberlibertarians.

But consistency is unnecessary. “Government is bad” never really meant that patent protection, defense procurement, police power, federal land, electrical infrastructure and rescue during a financial crisis were bad. It meant that democratic government should not constrain the people who consider themselves society’s producers. The desired state is not necessarily small. It is powerful in the directions favored by its owners and absent in the directions needed by everyone else.

Iran: Warfare as a Technology Demonstration

Nothing in this argument requires sympathy for the Iranian regime. Iran is an authoritarian state with a history of repression, proxy warfare and nuclear deception. The question is not whether Iran presents genuine dangers. It is how the United States transformed those dangers into the bizarre, open-ended conflict now underway.

On February 28, 2026, while nuclear diplomacy was still active, the United States and Israel launched a massive attack on Iran. The strikes killed Supreme Leader Ali Khamenei and targeted nuclear, military and governmental facilities. The announced purposes subsequently ranged from preventing a nuclear weapon to destroying Iran’s missiles and navy, eliminating its support for armed proxies and encouraging regime change. Iran retaliated against Israel, American bases and Gulf states and asserted control over the Strait of Hormuz.

Six months later, the promised demonstration of overwhelming power has become what Reuters describes as energy trench warfare. Large-scale fighting has intermittently stopped, restarted and stopped again. Ceasefires have been announced and then collapsed. Oil traffic through Hormuz has fallen drastically, energy costs remain elevated, thousands are dead and the central disputes over Iran’s nuclear program, sanctions and the strait remain unresolved. The administration’s original language of obliteration and annihilation has not yielded an attainable political end state.

The Cyberselfish element is the belief that a complex society can be treated as an engineering problem. Identify the dangerous nodes, destroy them with precision technology and expect the system to reboot in a more desirable configuration. The same culture that promises software will “disrupt” an industry imagines that air power can disrupt a nation into political compliance. Human beings, historical memory, religious authority, nationalism and the capacity of an attacked population to become more hostile are treated as irritating legacy systems.

The Randian contribution is the fantasy of unconstrained will. The strong actor demonstrates strength by refusing limits; negotiation becomes evidence of weakness. Opponents are not parties with interests that must eventually be accommodated but irrational obstacles to be broken. Admitting that military superiority does not automatically produce a political settlement would threaten the mythology of the heroic decision-maker.

Then Idiocracy packages the war. “Operation Epic Fury” sounds less like a strategy than a video game expansion. Targets destroyed, ships sunk and leaders killed become visible points on a scoreboard. The harder questions—what government follows, who controls the strait, how escalation ends and what concessions the United States will ultimately accept—do not fit easily into a post or rally speech. Tactical spectacle substitutes for strategy.

It is war conducted partly as content: extraordinarily sophisticated weapons serving an increasingly primitive theory of politics.

Canada: A Trade War Against the Friendly Supply Chain

The trade war with Canada is in some respects even stranger because there is no hostile regime, nuclear program or proxy army to invoke. Canada is a treaty ally and one of America’s largest trading partners. The two economies exchanged approximately $872 billion in goods and services last year. Canada supplies about four million barrels of crude oil daily to the United States, as well as enormous shares of American aluminum, potash, electricity and automotive components. Many products do not so much cross the border as move repeatedly back and forth through a continental production system.

Nevertheless, President Trump insists that the United States does not need Canada. Following the breakdown of negotiations in August, the administration imposed 50 percent tariffs on approximately $20 billion of Canadian goods and threatened comparable tariffs on Canadian automobiles and parts. Canada announced matching retaliation. Provinces have removed American alcohol from public stores, Canadian tourism to the United States has fallen, and Canada is accelerating efforts to redirect trade and security relationships toward Europe. The economic facts stubbornly contradict the claim that America can simply detach itself from Canada.

This is not Randian economics; Rand favored voluntary exchange and would have regarded tariffs as government interference. It is Randian drama. One nation is cast as the productive giant and the other as an ungrateful dependent taking advantage of it. Trade becomes a test of personal dominance rather than a mutually beneficial system. A negotiated compromise looks like humiliation because the heroic actor must never require anything from anyone else.

The Cyberselfish mistake is the inability to comprehend interdependence. A supply chain appears on a computer as a series of discrete transactions, making it easy to imagine that each can be terminated, repriced or rerouted without disturbing the whole. The social capital accumulated through decades of treaties, joint production, predictable rules and ordinary trust is invisible because it does not appear as a quarterly asset.

Idiocracy supplies the economic theory: tariffs are imagined as bills paid by foreigners rather than taxes initially paid by domestic importers and eventually distributed among businesses, workers and consumers. Canada can be commanded like a vendor whose contract is being renegotiated. If the price of aluminum, fertilizer, automobiles or toilet paper rises, the consequences arrive months later and can be blamed upon someone else.

The point of the trade war may no longer be an identifiable trade objective. It is the performance of leverage itself. Canada must be made to yield because yielding proves that America is powerful. The economic damage is merely an externality of the show.

Artificial Intelligence: Brawndo With a Capital Budget

Artificial intelligence is real, useful and potentially transformative. The financial mania surrounding it can also be real. Railroads, automobiles and the internet changed the world while simultaneously generating spectacular bubbles. A technology need not be fraudulent for every investment made in its name to be rational.

The scale of the present buildout is difficult to absorb. Alphabet, Amazon, Meta and Microsoft are expected to spend more than $730 billion this year, much of it on AI infrastructure. Technology companies that historically financed expansion from abundant cash are increasingly issuing debt and moving obligations through special-purpose vehicles and long-term leases. Reuters recently noted that purchase commitments, leases and other off-balance-sheet obligations could make the actual infrastructure commitment trillions of dollars larger than conventional capital-expenditure figures suggest.

The revenues are not imaginary. Nvidia just reported quarterly revenue of approximately $96 billion, with $89 billion coming from data centers. But the financing increasingly forms a self-reinforcing circle. Chip companies invest in AI developers, which commit to purchase or lease chips, which supports the suppliers’ revenues, which validates higher valuations and produces financing for the next round. Anthropic reportedly plans to spend $45 billion renting computing capacity from a data-center company over six years while projecting explosive future revenue growth. Each transaction becomes evidence justifying the next transaction.

This is Cyberselfish in almost pure form. The supposedly independent private sector requires public electricity grids, water, tax incentives, federal land, accelerated permits, government contracts and occasionally the suppression of state and local restrictions. The White House AI Action Plan explicitly joins deregulation, massive infrastructure construction and national-security policy. The gains remain private while the physical and financial risks spread outward to utilities, ratepayers, communities, lenders and eventually government.

Ayn Rand supplies the founder mythology. AI executives are not merely corporate managers selling a product; they are portrayed as architects of the next stage of human evolution. Ordinary methods of valuation seem almost insulting when applied to such historic figures. If the founder says his company will generate $200 billion in revenue within two years, questioning the assumption can be portrayed as a failure of imagination. Capital does not merely finance the vision. The availability of capital is treated as proof that the vision must be true.

Idiocracy contributes the magical word itself. “AI” increasingly performs the function that “electrolytes” performs in the film: a technical-sounding substance whose invocation ends the discussion. Companies need an AI strategy because AI is what valuations crave. Governments need an AI strategy because otherwise China will win the AI race. Utilities must build more generation because AI requires electricity. Environmental review must be shortened because the race cannot pause. Every objection becomes evidence that the objector does not understand the future.

The genuinely intelligent question is not whether AI will matter. It plainly will. The question is which applications justify their costs, who assumes the financial risk, who supplies the energy and water, who receives the gains, and what happens if the enormous revenue projections fail to arrive on schedule. Those are precisely the questions the combined ideology is designed to dismiss.

Why the Bizarre Has Become Normal

The formula helps explain why events now feel simultaneously sophisticated and insane. The United States can deploy extraordinarily advanced weapons without possessing a coherent theory of how the resulting war ends. It can build the most powerful AI systems in history while financing them through arrangements that few citizens—and perhaps few regulators—can fully see. It can maintain an intricately integrated continental economy while speaking of its closest trading partner as though it were an irritating tenant.

The system is not uniformly stupid. It is often brilliant at extracting wealth, attracting attention and concentrating power. Its stupidity appears at the level of collective purpose. It can optimize the advertisement while degrading the information environment, maximize the transaction while destroying the relationship and win the military engagement while losing control of the war.

That is where the three ingredients finally converge. Cyberselfish removes the obligation to society. Ayn Rand converts dominance into moral desert. Idiocracy removes the feedback that might reveal failure.

In Mike Judge’s film, the supposedly idiotic President Camacho at least recognizes that Joe may know something he does not and gives him responsibility for solving the agricultural crisis. Our version may be darker. Expertise is frequently available, but acknowledging it would place limits upon the heroic leader, the billionaire founder and the spectacle required by the audience.

We are not living entirely inside Cyberselfish, Atlas Shrugged or Idiocracy. We are living inside a merger of all three. Brawndo has completed a venture round. Its founder has been declared a genius. Its data centers have received expedited federal permits. Its software has secured a defense contract. And when the crops continue to die, the company will explain that the problem was excessive regulation, insufficient scale and the failure of ordinary people to believe strongly enough in the future.

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SIDEBAR

Sidebar: Spengler and the Winter of the West

A darker and much longer historical shadow hangs over this triplet: Oswald Spengler’s Der Untergang des Abendlandes, published in two volumes in 1918 and 1922 and conventionally translated as The Decline of the West. The German title carries a suggestion not only of decline but of going under, sunset and disappearance. Yet Spengler did not principally mean that the West would suddenly collapse. He believed that every great culture passes through an organic life cycle—birth, growth, creative maturity and eventual hardening into what he called “Civilization.” The Stanford Encyclopedia of Philosophy summarizes Spengler’s system as a theory in which civilizations pass through stages of youth, maturity and senescence.

For Spengler, “Culture” and “Civilization” were almost opposites. Culture is the living period: religion, art, architecture, philosophy and political forms arise from a shared understanding of the world. Civilization is what remains when those creative energies have been exhausted. It can be immensely wealthy, technically brilliant and militarily powerful, but it increasingly substitutes scale for meaning, administration for statesmanship, entertainment for art and technical capability for any serious answer to the question of what that capability is for.

Spengler called the Western culture “Faustian.” Its defining impulse was the conquest of infinity: limitless space, limitless knowledge, limitless expansion and ultimately limitless power over nature. The Gothic cathedral reaches upward; perspective painting opens an infinite visual field; calculus masters motion; the ocean voyage crosses the horizon; modern finance converts the future into present value. Technology is not merely a collection of useful tools. It is an expression of the Western desire to make the entire world measurable, penetrable and controllable.

Artificial intelligence may be the purest Faustian project yet devised. It seeks to convert language, judgment, creativity and perhaps consciousness itself into computation. Its recurring command is to scale: more data, more chips, more electricity, more capital, larger models and ever more extravagant claims about the future. The destination continually recedes because the point is not arrival. The point is infinite striving.

Paulina Borsook’s Cyberselfish can therefore be read as a close-up field report from Spengler’s late Faustian civilization. She observed a technologically empowered class that had lost any sense of historical inheritance or civic obligation. Its members imagined themselves as autonomous creators even while depending upon accumulated science, public infrastructure, universities, government procurement and an elaborate legal order. They inherited the achievements of a civilization and mistook possession for authorship.

Ayn Rand supplies this late Faustian elite with its heroic self-portrait. Her architect, industrialist and inventor stand above the crowd, refusing all limits upon their productive will. In its simplified business-culture form, Rand’s philosophy becomes Faustian ambition with the tragedy removed: endless creation without dependence, power without inheritance and wealth without obligation. The billionaire appears not as the beneficiary of a mature civilization but as the solitary man who created it.

Idiocracy, meanwhile, is Spenglerian mass civilization rendered as comedy. Public language has deteriorated into slogans, politics into spectacle and knowledge into corporate branding. Citizens remain surrounded by machines whose underlying workings they cannot understand and institutions they can no longer operate. This is not the absence of technology. It is technological abundance combined with cultural exhaustion. The society can still manufacture astonishing products; it has simply lost the capacity to decide intelligently what they should be used for.

Spengler also anticipated a political transition especially relevant to the present. In late civilization, he argued, democratic institutions become increasingly hollow. Money dominates elections, parties and the press, while formal political debate conceals the actual distribution of power. Eventually, public exhaustion produces “Caesarism”: personal rulers who bypass weakening institutions and govern through will, loyalty, force and theatrical demonstrations of command.

The wars with Iran and Canada make more sense when understood as Caesarist performances. The Iran war employs extraordinary technology but lacks a stable political objective. Its visible achievements are targets destroyed, leaders killed and weapons demonstrated. The trade war with Canada disregards economic interdependence because its true subject is not trade. It is submission. Canada must yield so that the ruler can be seen making Canada yield. In both cases, the performance of power begins to replace the achievement of a rational national purpose.

Spengler expected Caesarism eventually to defeat the rule of money. Our version is more peculiar: Caesar and the billionaires have formed a joint venture. Technology magnates supply money, communications systems, surveillance, artificial intelligence and heroic mythology. The Caesarist state supplies contracts, deregulation, land, energy, military power and protection from democratic interference. The supposedly anti-government entrepreneur and the government strongman discover that they have no fundamental quarrel. Each wants public institutions weakened sufficiently that personal power can move without obstruction.

This is where Cyberselfish, Ayn Rand and Idiocracy become not merely three contemporary influences but three symptoms of a Spenglerian transformation. Cyberselfish represents technique emancipated from civic responsibility. Rand represents the Faustian will converted into billionaire self-worship. Idiocracy represents a mass public culture in which words, facts and institutions have become empty shells. Caesarism binds them together through direct, personalized power.

Spengler’s grand cycle was highly deterministic, historically questionable and politically reactionary. He treated decline as destiny and had little sympathy for liberal democracy. We need not accept either his politics or his fatalism to recognize the force of his diagnosis. A society can remain wealthy, inventive and militarily formidable while losing the habits that made its power worth possessing. Decline does not necessarily look like ruins. It can look like record stock-market valuations, magnificent weapons, enormous data centers and political leaders speaking confidently through institutions they are steadily hollowing out.

The triplet describes what the present system is made of. Spengler explains why its ingredients belong together: money without measure, technology without purpose, politics without institutions and power without restraint.

Spengler believed this was the West’s destiny. The democratic answer must be that it remains a choice.

All About Paulina Boorsok / Cyberselfish (2000) / Chat GPT


Paulina Borsook is an American writer and technology journalist—best understood as an early cultural anthropologist of Silicon Valley. She was inside the industry early enough to observe it before “tech” became glamorous, yet sufficiently unimpressed by computers to notice the ideology developing around them.

Born in Pasadena in 1954, she grew up amid the Caltech–JPL scientific culture. She studied psycholinguistics and philosophy at Berkeley and later earned an MFA from Columbia. Beginning in 1981, she worked in software documentation and then technology trade journalism, eventually becoming West Coast bureau chief for Data Communications. In the 1990s she wrote for the original Wired; her 1993 novella, “Love Over the Wires,” was the magazine’s first published fiction.

Her major work is Cyberselfish: A Critical Romp Through the Terribly Libertarian Culture of High Tech, published in 2000 and developed from a 1996 essay. Its argument was unusually early and specific: Silicon Valley was developing an Ayn Rand–inflected culture that distrusted government and regulation, equated wealth with intelligence, discounted empathy and social obligation, glorified male founders, and forgot how extensively the technology industry depended upon public research, defense spending, universities and infrastructure. Her equally striking 1999 Salon essay, “How the Internet Ruined San Francisco,” anticipated the technology-driven gentrification and cultural flattening that became unmistakable during the following two decades.

There is also a remarkable personal history behind her career. At 14, she was shot in the head by a friend with a Colt .45 and sustained a lifelong traumatic brain injury. Borsook has written that the injury severely affected concentration, memory and quantitative learning while leaving her unusual strengths in language and pattern recognition. Technology writing became the one occupation in which those surviving abilities worked extremely well. In 2013 she was Stanford’s first Arts Institute research resident, developing My Life as a Ghost, an installation about the estrangement from one’s own life that can accompany TBI. Stanford’s account includes her unusually candid artist statement.

Cyberselfish was not literally ignored—it received major reviews and provoked a spirited fight with libertarian writer Eric Raymond—but it sold poorly, disappeared from print and, according to Borsook, seriously damaged her career. Critics from Reason continue to argue that she caricatures libertarian philosophy and confuses obnoxious technology personalities with serious libertarian thought. That is a legitimate limitation: she was diagnosing a subculture and its values, not writing a rigorous history of political philosophy. Her sharp response to Raymond remains entertaining.



Her work has now undergone an extraordinary revival. A viral rediscovery in 2025 led to a New York Times profile, a recent Mother Jones reconsideration and a substantial July 2026 Amanpour & Company interview. A new edition of Cyberselfish is being issued this year; the ebook is already available and the paperback and audiobook are scheduled for September 15. She currently contributes to In Formation, a deliberately anti-hype technology magazine. Official reissue information is here.

My judgment: calling her a “prophet” is a little theatrical. Calling her an exceptionally early and perceptive diagnostician is entirely fair. She did not merely predict that technology would become powerful; she identified the peculiar combination of libertarian resentment, financialization, founder worship, misogyny and moral self-exemption through which that power might be exercised. That is why the book now feels much more consequential than it did in 2000.

Tuesday, August 25, 2026

August 2026, CAP Today, All About HR (Titus) - Putting It Together

 The August 2026 issue of CAP TODAY headlines Homologous recombination, issues and dilemmas.  We put that together with a 2022 review in The Oncologist and a 2042 review in CAP TODAY.

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The central lesson from CAP Today in 2026

Karen Titus’s 2026 article is best understood as an update on a problem that the 2022 Friends of Cancer Research paper hoped the field would solve but has not yet solved: HRD is clinically important, but it is not a single analyte with a standardized measurement system.

“HRD testing” can mean at least three different things:

  1. Finding a possible cause of deficient repair, such as a pathogenic BRCA1/2 alteration.

  2. Measuring the accumulated consequences of deficient repair—LOH, telomeric allelic imbalance, large-scale state transitions, and related genomic scars.

  3. Determining whether the tumor is functionally HR-deficient now, at the moment treatment is being considered.

Current NGS-based clinical testing does the first two reasonably well under favorable conditions. It does not necessarily answer the third. Titus’s deeper message is therefore not merely that HRD testing is technically difficult. It is that the laboratory is being asked to turn several biologically related but nonidentical measurements into a binary clinical answer.

The article the file labels as “2025” was actually published by CAP on May 29, 2024. The January 1, 1970 date on the article page is a website artifact; CAP’s Precision Medicine article index gives the correct date.

A useful teaching framework: cause, scar, and current function

Clinical questionWhat is measuredPrincipal strengthPrincipal limitation
What may have caused HRD?Germline or somatic BRCA1/2 and other HRR-gene alterations; potentially methylationIdentifies a specific biological lesion; BRCA findings may have hereditary implicationsA mutation in an HRR-associated gene does not invariably establish an HRD phenotype; methylation, large deletions, and some copy-number losses may be missed
Has the tumor experienced HR failure?LOH, TAI, LST, or composite genomic-instability scoresCaptures HRD beyond BRCA and other readily identifiable causal variantsGenomic scars are historical, persistent, continuous, spatially heterogeneous, and assay-dependent
Is the tumor HR-deficient today?Potential functional assays such as RAD51 fociConceptually closest to the current drug-sensitive phenotypeNot yet established as a practical, broadly validated routine assay
What broader biology surrounds the result?Comprehensive genomic profiling: CCNE1, RB1, HRR genes, resistance alterations, MSI/TMB, and other biomarkersCan help interpret borderline or biologically contradictory resultsMuch of this contextual interpretation remains exploratory rather than part of a validated HRD classifier

This distinction is already explicit in the 2022 Oncologist paper, which separates potential “causes” of HRD from their genomic “consequences.” Titus makes the distinction more clinically vivid: the scar is evidence that homologous recombination failed, but the scar itself neither causes PARP sensitivity nor proves that the repair defect is still present.

The principal problems identified in Titus 2026

1. HRD is not one measurement

BRCA1/2 alterations remain the strongest and best-understood causal biomarkers. But BRCA testing alone misses tumors that have acquired an HRD phenotype through other mechanisms. Conversely, merely finding an alteration in PALB2, CHEK2, ATM, BRIP1, RAD51C, RAD51D, or another nominal HRR gene does not mean that every alteration has the same penetrance, produces biallelic loss, creates the same degree of genomic instability, or predicts the same treatment benefit.

Titus quotes Kyle Strickland bluntly: “just looking at the genes that are altered is not a good way to evaluate HRD.” That is an important correction to the simplistic equation:

HRR-panel mutation = HRD-positive.

Gene testing and genomic-scar testing provide complementary information. Neither automatically subsumes the other.

2. The clinical-trial evidence does not use a uniform biomarker

The major PARP-inhibitor trials differ simultaneously in drug, treatment setting, combination therapy, enrolled population, biomarker definition, and numerical cutoff:

  • SOLO1 was overwhelmingly a BRCA-mutated population.

  • PRIMA defined HRD through a deleterious BRCA alteration or a genomic-instability score of at least 42.

  • PAOLA-1 also used 42, but studied olaparib combined with bevacizumab.

  • VELIA used a cutoff of 33.

Thus, 33 versus 42 is not merely an analytical disagreement that laboratories can settle by choosing the statistically “best” threshold. The cutoffs are embedded in particular trial designs and treatment claims. A result cannot be interpreted independently of the assay, cancer population, therapeutic regimen, and validation study that produced the cutoff.

This was already one of the 2022 paper’s central concerns: different assays and thresholds can produce different HR-status calls and consequently different treatment decisions. Titus shows that this remains a live clinical problem in 2026. The CAP Today article summarizes these trial and cutoff differences directly.

3. A continuous, heterogeneous signal is forced into a binary result

Clinicians understandably want “HRD positive” or “HRD negative.” But genomic instability is measured on a continuous scale. The cutoff converts that continuous measurement into a category for a specific clinical purpose; it does not establish a natural biological border.

Titus provides an especially useful example: different regions of the same heterogeneous ovarian carcinoma can fall on opposite sides of the threshold. A tumor tested four times might be classified as deficient three times and proficient once. A score of 41 is analytically reported as negative under a cutoff of 42, but it is not biologically the opposite of a score of 42.

This raises several unresolved questions:

  • Should there be a formal indeterminate or borderline interval?

  • Should another tumor block be tested near the cutoff?

  • How much movement results from true intratumoral heterogeneity versus analytical variation?

  • Should a borderline score be interpreted alongside BRCA and other genomic findings?

  • Is a cutoff validated in one therapeutic context transportable to another?

Titus does not supply definitive answers. Her point is that the clean binary result received by the oncologist conceals a substantial gray zone.

4. The specimen can determine the answer

The article gives preanalytics unusual prominence, and rightly so. Ovarian cancer patients may receive neoadjuvant chemotherapy before debulking surgery. Treatment can eradicate or greatly reduce viable tumor, forcing the laboratory back to a small pretreatment biopsy.

The requirements are particularly demanding for copy-number loss. Strickland says that accurate detection of BRCA1/2 copy-number losses may require approximately 50 percent tumor content on the slide. Small biopsies, treated tumors, low tumor fraction, necrosis, and limited tissue can therefore affect the component of HRD testing that depends on allelic imbalance and copy-number architecture—even when SNVs and small indels remain technically detectable.

“We can do a lot with a little, but we can’t do everything with a little” is more than a memorable quote. It captures an assay-design issue: a panel can have excellent small-variant sensitivity while remaining vulnerable in LOH, large deletion, copy-number loss, and genomic-scar reconstruction.

For laboratories, HRD is therefore a specimen-management service as much as it is an NGS assay. Selection of a larger untreated block, documentation of treatment history, pathologist estimation of tumor content, macrodissection, and an appropriate “quantity not sufficient” or qualified-result policy are central parts of performance.

5. Assays are not interchangeable

The Myriad strategy combines BRCA status with LOH, TAI, and LST. Foundation has historically used an LOH-centered approach. Other assays use different combinations, algorithms, training sets, and proprietary scales. “HRD-positive” on one system is not automatically the same measurement as “HRD-positive” on another.

The 2024 CAP review makes this especially relevant to Thermo Fisher. It describes:

  • Myriad GIS, with a clinically used cutoff of 42.

  • Foundation LOH, with a cutoff of 16 in the cited setting.

  • Oncomine Comprehensive Assay Plus’s genomic instability metric, a different 0–100 construct with a reported cutoff of 16.

  • Illumina TSO 500 HRD, which uses licensed Myriad GIS methodology.

  • A low-pass WGS/deep-learning approach from Sophia Genetics.

The fact that two metrics both use “16” does not make them comparable. Nor does high analytical concordance with an established assay automatically confer the same clinical validity for a particular drug and indication.

The 2022 paper recommends that publications and reports identify the assay, features measured, continuous score, cutoff, tumor type, and intended-use context. Titus demonstrates why that level of transparency is still necessary.

6. A genomic scar records history, not necessarily present function

This is perhaps the most important conceptual limitation.

Once LOH, TAI, LST, deletions, and chromosomal rearrangements have accumulated, the daughter cells inherit them. But a tumor may subsequently regain homologous-recombination function through a BRCA reversion mutation or reversal of BRCA methylation. The tumor can then become resistant to PARP inhibition while retaining the old genomic scars that produced its HRD-positive score.

A scar assay therefore asks:

Has this tumor lineage experienced HR deficiency?

The therapeutic question is closer to:

Is homologous recombination impaired in the currently dominant tumor population?

Those questions overlap, but they are not identical. This mismatch is particularly important after platinum or PARP exposure, when therapy has selected resistant clones. It also explains why a static, archival-tissue HRD result may become progressively less informative later in the disease course.

7. Epigenetic HRD is undermeasured

BRCA function may be lost through promoter methylation rather than sequence alteration. Many current assays do not directly measure methylation. Moreover, methylation can potentially be reversed, restoring function and producing early recurrence or platinum/PARP resistance despite the genomic-scar result.

Titus treats this as a major knowledge gap: the assay may detect the historical consequences without capturing the epigenetic mechanism or its subsequent reversal. For a sequencing company, this is a reminder that a DNA panel—even a very broad one—is not necessarily a complete HRD assay.

8. “HR-proficient” is becoming its own heterogeneous research category

Historically, most attention went to HRD because it supplied the therapeutic opportunity. Titus suggests that HRP tumors may now become equally important. HRP should not be treated simply as “nothing detected.”

Examples in the article include:

  • Strong CCNE1 amplification, associated with replication-fork stress and presented as evidence pointing away from the classic deletion/LOH-rich HRD phenotype.

  • RB1 loss in some HRP tumors, which may identify tumors behaving more like HRD tumors.

  • HRP tumors retaining RB1, which emerging data suggest may have particularly poor survival.

  • Possible differences in immune infiltration and PD-1/PD-L1 biology between BRCA-altered/HRD and HRP tumors.

These observations remain investigational. A CCNE1 amplification or RB1 result should not be promoted as a validated substitute HRD classifier. But they illustrate why comprehensive profiling may ultimately be more useful than an isolated positive/negative scar report.

9. Evidence is strongest in high-grade serous ovarian cancer

The field tends to talk as though HRD were a tumor-agnostic property. Yet both genomic-scar patterns and clinically appropriate thresholds may depend on tissue and histology. The strongest evidence remains in high-grade serous ovarian carcinoma, with some trial inclusion of endometrioid and other nonmucinous epithelial cancers.

Titus points to clear cell carcinoma and carcinosarcoma as areas where interesting cases exist but robust evidence does not. The 2022 paper makes the broader principle explicit: assays and cutoffs should be validated in their intended-use populations because the genomic manifestation of HRD may differ by tumor type.

What has changed from 2022 to 2026?

The 2022 paper described a harmonization problem: inconsistent definitions, different assay components, different thresholds, and inadequate reporting. The 2024 CAP review translated that framework into available laboratory technologies, including Oncomine Comprehensive Assay Plus.

Titus in 2026 shows three important developments:

  • The field now has more routine clinical experience, making tissue limitations, borderline scores, and intratumoral heterogeneity impossible to ignore.

  • Comprehensive profiling is beginning to place the HRD score in a larger biological context—BRCA and non-BRCA causes, CCNE1 amplification, RB1 status, resistance, and immune biology.

  • The static nature of genomic scars is increasingly recognized as a fundamental limitation, particularly after treatment and biological reversion.

In other words, the problem has evolved from “How do we standardize competing HRD assays?” to “Can a single HRD category adequately represent a heterogeneous and changing tumor?”

Some Technologies

 

Roswell Park uses an Oncomine Precision Assay for additional targeted tumor profiling while also relying on Myriad MyChoice CDx and FoundationOne CDx. That is an important distinction: the Oncomine panel can contribute information about HRR genes and wider tumor biology, but its presence in the workflow does not by itself make it interchangeable with the HRD companion diagnostic used in a pivotal trial.

Meanwhile, the article gives a competitor example: Labcorp’s OmniSeq Insight incorporates an optimized Illumina TSO 500 HRD workflow and combines genomic-instability measurement with broad DNA/RNA profiling and PD-L1. The market signal is that HRD is moving toward integrated comprehensive profiling, rather than surviving indefinitely as a narrow standalone score.

The strategic lessons are:

  • Do not market HRD as merely another panel output. The platform must distinguish causal HRR variants, genomic-scar measurement, and current functional status.

  • Treat the algorithm and clinical evidence as part of the product. Sequencing performance alone does not establish interchangeability with a trial-validated CDx.

  • Make preanalytics visible. Tumor fraction, treatment status, tissue area, copy-number confidence, and specimen-selection guidance are critical.

  • Retain and report the continuous metric. A binary call should not erase the actual score or its proximity to the cutoff.

  • Build a contextual report. BRCA findings, relevant non-BRCA genes, possible biallelic status, genomic-instability components, strong counter-signals such as CCNE1 amplification, and applicable limitations should be separable.

  • Validate by tumor type and intended treatment use. An ovarian-cancer threshold cannot simply be carried into prostate, pancreatic, breast, or other tumors because the same biological pathway may leave different genomic patterns.

  • Plan for longitudinal disease. Static scar testing is strongest near diagnosis in untreated tissue. Recurrent, post-PARP, or platinum-resistant disease may require rebiopsy, liquid-biopsy resistance testing, methylation assessment, or eventually functional HR measurement.

  • Avoid overclaiming the HRP category. A negative scar score is not proof of homogeneous normal repair biology, and HRP itself may contain clinically distinct subgroups.

A concise teaching conclusion

The cleanest conclusion for the executives is:

HRD testing attempts to infer a dynamic DNA-repair phenotype from a mixture of causal variants and historical genomic damage. The available assays differ in what they measure, how they score it, where they set the cutoff, and the clinical trials to which that cutoff is tied. Tissue quality, tumor heterogeneity, non-BRCA biology, methylation, and acquired BRCA reversions can all separate the reported HRD category from the tumor’s current therapeutic vulnerability. The next generation of testing will therefore need to move beyond a solitary positive/negative scar score toward integrated, tumor-specific, and eventually longitudinal assessment.

That, I think, is the real 2026 CAP Today message: HRD is a valuable biomarker, but “HRD-positive” is still a compressed summary of a much more complicated biological and measurement problem.

Who's Predicting the CRUSH rule?? And, How Does Chat GPT Predict the CRUSH rule?

 https://chatgpt.com/c/6a8da199-c37c-83e8-bbe8-847d54cbe10e

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Who, if anyone, is trying to really predict what will in the actual proposed CRUSH rule?

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The genuine forecasting literature is surprisingly thin. Most coverage simply restates the February RFI. There is no final CRUSH rule: the proposed rule was sent to OMB’s Office of Information and Regulatory Affairs on August 7, 2026, where it remains under review. OMB identifies it as a proposed rule and “not economically significant”; the Unified Agenda tentatively lists publication in October. OMB review docket; Unified Agenda entry.

The useful forecasting literature

SourceWhat it genuinely adds
Liles Parker, June 5The most direct forecast. It expects more payment suspensions, automated prepayment controls, enrollment screening, ownership scrutiny and revocations. Its AI emphasis is plausible operationally, although AI may appear more in the preamble than in regulatory text.
Sidley, May 20Predicts continued use of predictive analytics, enrollment interventions, coordinated “war rooms,” suspensions and state pressure. It forecasts the administration’s enforcement model more than individual CRUSH provisions.
KFF, June 9Shows where Medicaid policy is already going: accelerated revalidation of high-risk providers, additional attention to providers without NPIs, and continuing federal pressure on states.
Mintz, July 14 and McDermott, July 22These analyze the July home-health proposed rule rather than CRUSH itself. Nevertheless, that rule is probably the best available predictor because it reveals which CRUSH-style enrollment powers CMS has already converted into actual regulatory language.
MedScout laboratory analysisOne of the few industry pieces to make a substantive laboratory prediction: laboratories should expect more nationally consistent molecular-test rules. Its prediction does not establish that CMS will adopt national MolDX wholesale.
BCBSA recommendations summarized by Becker’sParticularly useful for predicting how the MA proposal may be narrowed. BCBSA supports real-time notification and coordinated action but cautions that simply transplanting Medicare fee-for-service suspension rules into capitated plans would not work.

The principal conclusion from the search for forecasts is therefore negative. But important: there is no emerging expert consensus based on leaked text or unusually informed reporting. 

The soundest forecast comes from reverse-engineering CMS’s regulatory posture, its actions since February, the July enrollment proposals and the practical constraints that OMB review imposes.

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Chat GPT Steps Into the CRUSH Ring: Forecasting the Proposed Regulation

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What Will Be in the CRUSH Proposed Rule—and What May Have Fallen Off the Truck

The proposed Comprehensive Regulations to Uncover Suspicious Healthcare rule has reached the White House. CMS transmitted the proposal to the Office of Management and Budget on August 7, 2026. No proposed text is public, and no final regulation exists. Nevertheless, the available evidence permits a reasonably discriminating forecast—not simply of subjects that CMS considered in February, but of the provisions most likely to survive the journey from an expansive request for information to an administrable proposed rule.

The February CRUSH request for information, 91 Fed. Reg. 9803, was intentionally panoramic. It raised questions about enrollment, payment suspensions, Medicare Advantage, Part D, laboratories, DMEPOS suppliers, artificial intelligence, claim-filing deadlines, surety bonds, beneficiary solicitation, Medicaid, CHIP and the insurance Exchanges. An RFI can afford to be panoramic. A proposed rule cannot. Its provisions must have statutory authority, workable regulatory language, defensible burden estimates and a plausible implementation path.

OMB’s characterization supplies the first clue. CRUSH is classified as “other significant,” but not major or economically significant. It is also listed as having no federalism, unfunded-mandate or international impact. Those labels are preliminary rather than binding, but they make a massive redesign of every CMS program less likely. They point instead toward a package of administrative enforcement tools—rules that expand CMS discretion, allow faster intervention and concentrate burdens on providers or services classified as high risk.

Enrollment will be central—but much of the first tranche has already appeared

CRUSH will almost certainly contain provisions making it easier to deny, deactivate or revoke the enrollment of providers and suppliers considered high risk. Enrollment has become the administration’s preferred gatekeeping mechanism because it allows CMS to prevent payments without first completing a conventional fraud case. It also produces immediate, visible results: an entity can be kept out, removed or disconnected from Medicare billing before the government has paid years of questionable claims.

But some of the most important enrollment provisions may have “fallen off the CRUSH truck” for an unusual reason: CMS has already placed them in another proposed rule. The CY 2027 Home Health PPS proposed rule, 91 Fed. Reg. 41216, 41285–41327, contains program-wide Medicare enrollment provisions that go well beyond home health.

Among other things, CMS has proposed to loosen the existing standards for revoking enrollment based on abuse of billing privileges; revoke providers based on excessive geographic concentration and perceived fraud risk; propagate a denial or revocation across a provider’s other enrollments; reach parties with business or financial relationships to an applicant; make many revocations retroactive; extend reapplication bars; and reduce the post-revocation claim-submission period from 60 days to 15 days. The proposal frequently avoids fixed numerical thresholds and reserves case-specific discretion to CMS.

This is probably the clearest preview of CRUSH’s drafting philosophy. The agency appears more interested in removing limiting factors from its existing authority than in creating a highly prescriptive new fraud code. CRUSH may add a second enrollment tranche—more frequent revalidation, stronger deactivation authority, elevated screening of newly identified high-risk categories and improved propagation of adverse actions across programs—but it need not repeat every provision already riding in the home-health rule.

This approach also continues a much older progression. CMS created the modern Part 424 enrollment framework in the 2006 enrollment rule, 71 Fed. Reg. 20754. It added risk-based screening, fingerprinting, temporary moratoria and payment-suspension provisions in the 2011 program-integrity rule, 76 Fed. Reg. 5862. The 2019 program-integrity rule, 84 Fed. Reg. 47794, enlarged affiliation disclosure and denial and revocation authorities. CRUSH is likely to be another turn of that ratchet, but with a stronger emphasis on rapid, data-triggered intervention.

Payment suspension and prepayment review should be the rule’s center of gravity

The strongest candidate for a leading role in CRUSH is expanded authority to stop money before it leaves the government. That is the operational meaning of the administration’s promised transition from “pay and chase” to “detect and prevent.”

In traditional Medicare, CMS already can suspend payments when it possesses reliable information concerning an overpayment or a credible allegation of fraud. It can also impose prepayment medical review and automated claim edits. CRUSH could make these tools easier to initiate, maintain or coordinate by revising evidentiary standards, broadening the information that CMS may consider, removing procedural impediments, or explicitly connecting analytics-generated risk signals to medical review and payment action.

The administration’s behavior strongly favors this prediction. CMS reports billions of dollars in suspended payments and repeatedly publicizes moratoria, payment holds, site visits and enrollment removals. Sidley’s May analysis similarly expects continued reliance on predictive analytics, payment and enrollment suspensions and coordinated enforcement teams. These are tools the agency already understands, and expanding them can produce immediate results without waiting for criminal or False Claims Act litigation.

The more difficult question is whether CMS will require Medicare Advantage and Part D plans to suspend payments whenever CMS directs them to do so. Some version of cross-program coordination is highly likely. A provider suspended in traditional Medicare should not be able simply to redirect the same activity to Medicare Advantage. Plans therefore may be required to screen against CMS data, receive suspension information in real time and take specified action against revoked, precluded or suspended parties.

A wholesale transplantation of fee-for-service suspension rules into MA and Part D is less likely. As the Blue Cross Blue Shield Association observed, plans operate through capitation, provider contracts and different payment systems. Questions also arise concerning beneficiary liability, continuity of care, contractual appeals and the treatment of clean claims unrelated to the suspected conduct.

The likely compromise is a graduated system: immediate notification of plans; mandatory screening and internal suspension policies; required action against providers subject to defined CMS sanctions; and possibly CMS-directed suspensions in specified high-risk circumstances. CMS could pilot the broader authority or initially apply it to DMEPOS suppliers and other sectors where the risk of billing migration is especially apparent.

Identity proofing and ownership scrutiny are highly likely to survive

Enhanced identity verification is another strong candidate for inclusion. Modern fraud schemes frequently use stolen identities, nominal owners, rapidly changing corporate shells, shared addresses and individuals who appear on paper while someone else controls the operation. Identity proofing addresses the actor before CMS must adjudicate the validity of thousands of individual claims.

CRUSH therefore is likely to enlarge the circle of persons subject to verification. Owners with meaningful interests are obvious candidates, but CMS also may reach managing employees, authorized officials, directors, compliance personnel and selected affiliated parties. Higher-risk individuals could face fingerprints, criminal-background checks, address verification and confirmation of banking or tax information. CMS could also require more rapid reporting when these parties change.

The July home-health proposal supports this prediction. It would clarify the scope of managing employees, reach a wider range of associated parties and expand ownership-related enrollment reporting. CMS also has proposed to deny enrollment based on misuse of another person’s identity. These are concrete indications that the agency wants to look beyond the billing entity to the people and organizations surrounding it.

A categorical requirement that every person holding a 5% ownership interest be a United States citizen or lawful permanent resident is less likely to survive intact. Such a rule would affect legitimate international ownership structures, invite questions about statutory authority and potentially create consequences far beyond high-risk providers. OMB’s designation of no international impact is another reason for caution. CMS is more likely to require fuller disclosure of foreign or nonresident owners, a verifiable domestic responsible party, an agent for service and reliable financial and location information.

Claim deadlines, bonds and solicitation restrictions will probably be narrower than advertised

The RFI’s proposal to shorten the ordinary Medicare claim-filing period to 90 or 180 days has intuitive political appeal: fraudsters should not be allowed a long period in which to manufacture or warehouse claims. But a universal deadline has a weak connection to the identity of the biller or the medical necessity of the service. It also can penalize legitimate providers dealing with corrected claims, delayed documentation, coordination of benefits or enrollment problems.

For those reasons, a universal 90-day limit appears unlikely. CMS may propose 180 days, incorporate exceptions, or apply a shorter period only to selected suppliers and services. Another possibility is that CMS will use special deadlines after a revocation or other adverse event. The home-health rule’s proposed reduction of the post-revocation filing window from 60 days to 15 days demonstrates that CMS is willing to shorten deadlines when it can connect the change directly to an identified program-integrity risk.

Surety bonds present a similar pattern. CMS already has experience with bonds for DMEPOS suppliers, where inventory, ownership turnover and rapid billing can create collectability risks. An increased DMEPOS bond or a risk-adjusted bond tied to billing volume is plausible. A general bond requirement for laboratories, physicians and institutional providers is less likely. It would require difficult decisions about bond amounts and could restrict legitimate market entry without reliably distinguishing honest providers from fraudulent ones.

Beneficiary-solicitation rules also are likely to be targeted. CMS can plausibly update the DMEPOS prohibition on unsolicited telephone contacts to encompass texts, email, social media and third-party lead generators. But the RFI itself recognized that extending the statutory DMEPOS prohibition to entirely different provider classes may require legislation. The proposed rule may therefore focus on modern communications and indirect marketing within CMS’s existing authority, leaving a general health-sector solicitation ban off the truck.

Laboratories are likely to be visible, but a national MolDX regime is not inevitable

Laboratories—especially genetic and molecular laboratories—are unusually likely to receive their own section. Most of the regulatory history is program-wide; CRUSH may be the first major enrollment and program-integrity package to identify molecular laboratories so prominently as a distinct target.

CMS has a substantial enforcement record on which to draw. A Florida laboratory owner was convicted in a scheme involving approximately $463 million in claims and $187 million paid. In 2026, federal prosecutors in Texas alleged that two laboratories had billed roughly $65 million and received more than $43 million for genetic testing associated with kickbacks and medically unnecessary orders. Those cases make laboratory oversight politically conspicuous and give CMS a clear rationale for action.

But “molecular testing” is not synonymous with fraud. Genomic and biomarker testing has become central to precision oncology, helping identify therapeutic targets, inherited risk and, increasingly, early-detection signals. The National Cancer Institute’s explanation of biomarker testing illustrates how closely testing can be integrated with treatment selection. A rule that treats rapid expenditure growth as proof of abuse would risk obstructing one of medicine’s most consequential areas of development.

The most plausible CRUSH response is therefore targeted rather than categorical. CMS could designate certain laboratory profiles or molecular services as higher risk; require additional enrollment screening or accreditation; intensify prepayment review of outlier codes; verify ordering-provider relationships; collect information about marketers, specimen arrangements and referral entities; and require clearer identification of the particular test being billed. Test-specific identifiers or registration could be attractive because generic CPT codes sometimes aggregate heterogeneous assays and make claims analytics less informative.

Nationwide adoption of MolDX as a unified coverage and payment system is less certain. Supporters argue that MolDX-style registration and technical assessment would give CMS better visibility and more consistent medical-necessity rules. Opponents, including the American Clinical Laboratory Association, warn about duplicating CLIA oversight, prolonged technical-assessment delays and barriers to coverage for new tests. Nationalizing MolDX would also be a substantial coverage-administration project, not merely an anti-fraud control.

Consequently, CRUSH may borrow selected MolDX features without nationalizing the program. Registration of certain high-risk molecular tests, unique test identifiers, uniform data elements or a limited demonstration are more likely than immediate nationwide transfer of molecular coverage authority. CMS also could solicit further comment, establish contractor performance standards or move broader MolDX policy into a separate rulemaking.

Medicaid provisions will emphasize revalidation and federal visibility

The Medicaid portion is likely to focus on tools that CMS can describe as minimum program-integrity standards rather than on a wholesale federal takeover of state operations. Likely provisions include accelerated or off-cycle revalidation of high-risk providers, more consistent risk categorization, improved use of NPIs, reporting of ownership and adverse actions, and faster exchange of suspension and termination information among states and CMS.

That prediction is consistent with current practice. CMS has asked states to revalidate high-risk providers and prepare broader two-year revalidation strategies. KFF’s review identifies high-risk classification, providers without NPIs, state capacity and the public availability of revalidation results as important unresolved questions.

More sweeping Medicaid financing proposals are less likely to be central to CRUSH. Intergovernmental transfers, state-directed payments and eligibility verification involve different legal and policy structures. They also create obvious federalism and economic consequences, whereas the Unified Agenda identifies CRUSH as having no federalism impact. The administration can continue pursuing state-specific deferrals and compliance actions without placing every dispute into this rule.

Artificial intelligence may power the rule without becoming much of the rule

Artificial intelligence will be prominent in speeches, press releases and the preamble. It is less certain that CRUSH will contain extensive binding AI regulations. CMS already can use predictive models and claims analytics to select providers for review. It does not need a new regulation every time it changes an algorithm.

Detailed AI rules for Medicare Advantage coding would raise difficult questions about model validation, explainability, clinical review, performance measurement, proprietary information and appeal rights. Those questions are real, but they could slow a rule centered on immediate enforcement authority. CMS may instead state that data analytics can support payment, medical-review and enrollment decisions while reserving specific AI governance for guidance, contracts, audit protocols or a later rulemaking.

This distinction matters. Operationally, providers may encounter much more automated scrutiny even if “artificial intelligence” appears in few operative provisions. The legally significant change may be the consequence attached to an analytic flag—prepayment review, a site visit, revalidation or suspension—rather than the model that generated the flag.

What probably fell off the truck

The provisions least likely to emerge intact are a universal 90-day filing deadline; a general surety-bond requirement across provider classes; an across-the-board citizenship requirement for owners; immediate nationwide MolDX coverage administration; comprehensive regulation of AI coding tools; and a direct transplantation of traditional Medicare suspension procedures into every MA and Part D payment system.

Marketplace provisions also may have receded. Although the February RFI discussed federal and state-based Exchanges, the later Unified Agenda abstract describes Medicare, Medicaid and CHIP but does not mention the Marketplace. That omission may be accidental, but it is one more sign that the proposal reaching OMB is narrower than the original questionnaire.

Some enrollment concepts may be absent for the opposite reason: CMS has already proposed them elsewhere. The July home-health rule has become a vehicle for broad Medicare enrollment changes, including retroactive revocations, associated-party scrutiny and new risk-based authorities. Those provisions did not necessarily lose favor; they may simply have left the CRUSH package early.

The likely shape of the proposed rule

The most probable CRUSH proposal is a concentrated package built around four ideas

  • First, CMS will acquire or clarify authority to stop suspicious payments earlier, with greater use of prepayment review and some form of required coordination by MA and Part D plans. 
  • Second, enrollment will become more dependent on verified identity, ownership, management, location and affiliation information. 
  • Third, Medicaid agencies and managed-care organizations will face stronger revalidation, screening and information-sharing expectations. 
  • Fourth, CMS will establish targeted controls for conspicuous high-risk sectors, with molecular laboratories and DMEPOS suppliers likely to receive particular attention.

The rule’s practical significance may exceed its formal economic designation. A regulation need not impose a universal multibillion-dollar compliance system to have enormous consequences for an individual provider. A payment suspension, retroactive revocation or enrollment denial can be existential.

The central forecast is therefore not that CRUSH will create an entirely new program-integrity system. It will make the existing system faster, more interconnected and more discretionary. The 2006, 2011 and 2019 rules constructed the enrollment and screening architecture. CRUSH is likely to give CMS more ways to act on the signals that architecture produces—and to act before suspicion has matured into a completed fraud case.


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Sidebar:  Re ownership idenity, I asked a follow-up.   Is it really that they don't know the owners, they used fake IDs, or is it that the money wired at midnight to the Cayman Islands and the owners are in Macedonia?

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Honestly, the Cayman Islands and Macedonia comments are closer to the mark. FBI and DOJ can often identify the real participants eventually. The problem is that CMS may not know—at enrollment and payment time—whether the reported owner is the actual controller, a straw owner, a stolen identity, or merely the domestic face of a foreign organization. By the time investigators reconstruct that structure, Medicare has paid and the proceeds have been layered through shell companies and a chain of domestic and foreign banks.

The schemes fall into three overlapping categories:

  • False identity: stolen or fabricated identities are used to establish providers, order services or supply beneficiary data.

  • Nominee (nominal) ownership: the enrolled “owner” is a real, identifiable person but is not the true operator or beneficiary. Fingerprinting confirms who the nominee is; it does not establish who controls the nominee.

  • Offshore control and dissipation: the real operators are abroad, while proceeds pass rapidly through money launderers, shell companies and foreign accounts, making asset recovery and extradition difficult.

The enormous 2025 “Operation Gold Rush” case illustrates the combined model: DOJ alleged a foreign-based organization, foreign straw owners, stolen identities and an international money-laundering network. More recent prosecutions describe proceeds moving through global banks, a New Zealand shell company and even construction of a Philippine resort. DOJ’s Operation Gold Rush announcement; 2026 national takedown.

CMS essentially says this explicitly in the CRUSH RFI, 91 Fed. Reg. 9803: it describes opaque ownership, foreign-resident owners and actors beyond the practical reach of American law enforcement. Thus, “identity proofing” is partly an imprecise label for the larger problem of determining beneficial ownership, actual control and collectability before money is released.

But that rationale should not be overgeneralized to laboratory fraud. Many Texas and Florida genetic-testing cases involved perfectly identifiable domestic laboratory owners, marketers and telemedicine participants. Their identities were not the principal mystery; the failures involved kickbacks, medically unnecessary orders, weak prepayment controls and Medicare’s inability to stop aberrant billing quickly. A citizenship rule or more fingerprints would not have prevented most of those claims.

The most effective CRUSH package would therefore combine identity verification with beneficial-ownership disclosure, validation of the receiving bank account, scrutiny of marketers and affiliated entities, and rapid payment holds when billing suddenly becomes aberrant. Fingerprinting alone solves yesterday’s “Who is this person?” problem. The more serious contemporary question is: Whose business is this really, who receives the money, and can the government still reach either one tomorrow morning?