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The birthday-party invitation said “siblings welcome,” which means you can bring your 11-month-old son while your husband is out of town. You arrive a little disheveled and a little late. Your 5-year-old daughter rushes into the living room, and you make your way to the kitchen, wearing your son in a sling. You find a few moms around a table arrayed with plates of fruit, hummus, celery sticks, and carrots—no gluten, no nuts, no Red 40. These parents care about avoiding pesticides, screen time, and processed foods, and you do too.

It’s a classic kids’ party: Tears and lemonade are spilled; mud and cake get smeared into the rug; confetti balloons are popped one by one, showering elated children in rainbow-paper flakes. Sunbeams through the windows illuminate floating dust motes—and, imperceptibly, microdroplets of mucus carrying the measles virus, expelled from an infected but asymptomatic child who is hopping and laughing among the others. Your daughter breathes that same air, inhaling the virus directly into her respiratory tract.

The infected aerosolized droplets will linger in the air for hours, which is partly why measles is among the most contagious diseases in the world. The virus infects roughly 90 percent of unvaccinated people exposed to it; the infected can then, in turn, infect a dozen to several hundred people each, depending on where they are and what they’re doing. Breakthrough cases are possible among the vaccinated, but they tend to be rare, relatively mild, and less likely to spread. A single dose of the MMR vaccine is 93 percent effective at preventing infection; two doses are 97 percent effective. Among the unvaccinated, one in five people infected with measles in the United States will require hospitalization, and roughly two out of every 1,000 infected children will die of complications, regardless of medical care.

Your daughter behaves normally over the next week while the virus slowly spreads inside her, infecting immune cells that carry it to the lymph nodes, where it replicates and spreads at a rapid pace. Your daughter is at school cutting alphabet shapes out of paper when the virus enters her bloodstream. But she doesn’t feel anything until she seems to come down with a cold—dry cough, runny nose, itchy and watery eyes—about a week after the party, because the virus has multiplied and descended upon her lungs, kidneys, tonsils, and spleen, down to the marrow of her bones. When she starts running a fever, your mind turns to the logistics of taking off work while she’s home from school. You’ve witnessed enough colds as a mother to not be worried about this one. You feel some confidence in your instincts when it comes to your child’s health, and you’ve grown skeptical of medical interventions. It’s why you and your husband decided to wait to vaccinate your kids, though you’re a little conflicted about it. You’re not an extremist. You’re open to new information. You can always change your mind, you reason. You’re just weighing the evidence.

Ten days out from the party, your daughter’s cold has worsened. Her throat is sore, her appetite is low, and she’s running a fever that sometimes ticks up to 104. Colds can be rough. You plant her on the couch with a blanket and put Bluey on the TV while she drifts in and out of sleep. You coax her to eat by offering ice cream, which she says feels good on her throat. She’s a tough kid, but you can tell she’s miserable—there are circles under her eyes as she complains of a headache, then grimaces when she coughs. You can feel with a tender touch that the glands in her neck are swollen and uncomfortable. Her fever still hasn’t dropped. After a few days, you experience the first tug of serious concern. On the phone, your mom suggests that it might be COVID, or maybe the flu. Push fluids, she says, and keep an eye on it. You put your daughter to sleep in your bed, in case she needs you in the night.

[Read: His daughter was America’s first measles death in a decade]

The next morning, you lay your hand on her forehead, and the heat of her skin sends a ripple of unease through you. The measles virus is attacking the cells that line her lungs and suppressing her immune system, rendering her vulnerable to secondary infections. You step away to feed the baby and put him in clean clothes, but then rush back when you hear her calling you in a strained, croaking voice, her vocal cords swollen and thick with mucus. You find her lying in bed with her hand over her eyelids and tear tracks on her temples. She asks you to close the curtains because the sunlight is hurting her eyes—the virus has triggered a case of conjunctivitis. In all of the colds you’ve nursed her through, she has never complained of pain triggered by light. When you rouse her to give her Tylenol, you see that the whites of her eyes are reddened, and the bases of her eyelashes sticky. You carefully clean her eye area with a damp paper towel, kiss her nose, then leave her to sleep it off.

While the kids are napping, you tap a list of your daughter’s symptoms into Google and find a slew of diseases that more or less match up, because fevers, coughs, and sore throats are common to many illnesses. You post about it to the parents’ group, where a few moms with ill kids offer solidarity, and others commiserate over similar episodes with their own children. One woman says it’s time to call the doctor. You’ve had friction with your pediatrician over vaccinations, but this mom may be right. Later that day, when your little girl is curled up on the couch with a cold chocolate-milk protein shake, you go to take her temperature and find that her face is dotted with a spotty red rash descending from her hairline. The virus has infected capillaries in her skin, which typically happens three to five days after the symptoms start, but you don’t know that. It doesn’t hurt, she says, though it’s itchy. Her fever remains high and unrelenting. You pull out your phone and type chicken pox symptoms into your browser, hoping that you’ve found a viable culprit. It sort of fits, so you hold off on calling the doctor.

But her condition does not improve over the next couple of days. Her cough wracks her whole body, rounding her delicate bird shoulders. She does not sleep well. And as you lift up her pajama top to check her rash one morning, you see that her breathing is labored, shadows pooling between her ribs when she sucks in air. You suffer an icy moment of realization: This is a medical crisis. What you will learn later is that the tiny air sacs inside her lungs have become breeding grounds for the virus, and the inflammation generated by her immune response is inhibiting oxygen from reaching her bloodstream. You don’t want to worry your daughter, so you try to sound calm when you call the pediatrician and describe her symptoms at a rapid clip. The receptionist responds gently, types swiftly, and then pauses. Are your children vaccinated? she asks. Her tone is flat and inscrutable, but you detect an undercurrent of judgment. You wince and tell her the truth. No, you say, no vaccines. She puts you on hold. While you wait, you take your son out of his high chair and wipe his runny nose with his bib.

The receptionist is back. She asks if you can be at the office within the hour. In an even, professional voice, she gives you a number to call as soon as you arrive, but tells you to stay in your car. The doctor, she says, will come to you.

You’re there in 30 minutes, unshowered and wearing sweatpants, with your daughter bundled up and shivering in her pajamas and your son fussing in his car seat. You call the office. From the car, you cannot see the sign on the pediatrician’s office door instructing patients with a list of symptoms like your daughter’s not to come inside. Flashes of the pandemic play back as you see the pediatrician and two nurses approaching in the rearview mirror wearing N95 masks. It hits you: This is not the flu. This is not chicken pox. This is serious.

You twist around in the front seat to watch the pediatrician as she leans into your car and begins her exam, asking you questions about symptoms and timing. A nurse takes swabs from the nose and throat, which will be sent for testing by the local public-health authority, then clips a pulse oximeter onto your daughter’s fingertip. The doctor leans in to lay the cold diaphragm of her stethoscope against your daughter’s back. The doctor tells her to breathe. You tell her she’s doing a great job, and reach back to pet her knee. The doctor hears crackling with every breath your daughter takes, as air moves through the fluid trapped in her lungs. The oximeter reveals that her blood is only 90 percent saturated with oxygen, well below the healthy range of 95 to 100 percent. The pediatrician tells you to drive directly to the hospital. Your daughter is in pain and bewildered and afraid, but you tell her everything is okay; you’re just going to see a different doctor. Your son is fussing in his car seat. You try to keep your voice even, though your heart is pounding.

While you drive a little too fast to the emergency room, the pediatrician’s office calls the hospital warning them that there is a suspected measles patient on the way, and then places a mandatory call to the public-health authority notifying them of your daughter’s condition. Once you arrive, things happen quickly. Because measles is what researchers call a high-consequence infectious disease, health-care professionals undertake a series of strict protocols to limit its spread. You and your daughter are fitted with masks before you are brought in through a side door to avoid contaminating the waiting room, and then herded into an isolated negative-pressure room designed to prevent the aerosolized virus from traveling into the hall. After hospital workers whisk your daughter away for an emergency X-ray, they will shut down the areas of the radiology department for six hours to carry out decontamination measures, a thorough process protracted by the virus’s capacity to cling to walls and linger in the air. While your daughter gets her scan, you try to soothe your son, whose forehead begins to feel worryingly hot to you.

Your daughter looks so small in her hospital bed, her face fitted with an oxygen mask. Nurses collect blood and urine; you hold the cup as she shivers on the toilet, then stroke her hair as the needle spears her vein. When you’ve regained some composure a couple of hours later, a doctor comes to speak with you. This is the first time anyone has used the word measles. The doctor tells you that your daughter has pneumonia, a complication arising in roughly 6 percent of measles cases, though some researchers suspect that the actual rate may be higher. There is no cure for viral pneumonia from measles, but the hospital will provide supportive care to treat the symptoms, including her scalding fever and rash. The doctor doesn’t tell you then that pneumonia is the most common cause of death in measles patients. You will learn that later on.

The swabs taken by the pediatrician test positive for measles, and your child’s case becomes a data point in an outbreak. Each measles patient can infect a dozen or more unvaccinated people, and cases in your community are multiplying rapidly. A public-health official comes to gather information for contact tracing, and asks you to think of everyone your child has interacted with in the past couple of weeks. You think of her class at school, the grocery store, the car wash where you wait indoors, the birthday party.

Articles will soon appear in the local newspaper asking people who may have visited the post office or Target or the indoor playground on various days during various time frames to call the public-health office. Your child’s school will send out emails asking that parents keep unvaccinated children at home for the next three weeks, the virus’s maximum incubation period. As the outbreak spreads, local pediatricians will offer the MMR vaccine to children younger than a year old, because unvaccinated infants are especially vulnerable to the disease. The exponential growth in measles cases in the area attracts media attention, recriminations, and questions about blame.

Not that you notice. You practically live in the intensive-care unit as your daughter slowly recovers. When they discharge her a week later, they send instructions for at-home care, including hydration, decent air humidity, and plenty of rest. The disease will leave her with a lingering cough and occasional wheezing, and it will take months for her lungs to fully heal. She will fall behind in school and need tutoring to catch up, but all of these complications will seem trivial after you’ve come so close to something so dark that you can barely contemplate it. In the meantime, and until her rash heals, your daughter’s doctor insists that she remain under quarantine at home—along with your son.

Given your son’s fever, runny nose, and evident discomfort, you feel a grim sense of resignation when his measles test comes back positive. You are, however, alarmed when you discover there’s nothing his doctors can do about it. Had he been seen by a doctor within 72 hours of his first exposure, they could have given him a prophylactic dose of the MMR vaccine to protect him from infection. But it’s too late for that now. And you couldn’t have known then, anyway—when he was exposed, your daughter wasn’t symptomatic yet.

You feel uneasy caring for your son at home, having witnessed what the infection did to your daughter. But he is medically stable for now, and isolating him at home will limit the spread of the disease. You anxiously wonder whether you’ll know when his needs turn critical, particularly because he is too young to tell you how he feels. He cries inconsolably, unlike your daughter, and sometimes screams. After his rash appears, you notice when he wakes from a nap that pus has drained from his ear onto his crib sheets. You will learn later that an opportunistic bacterial infection has taken advantage of your son’s suppressed immunity by setting up in his middle ear, causing inflammation and fluid buildup to burst his eardrum. You call the pediatrician’s office, and they patch you through to the doctor. You wait for her in the same spot in the parking lot as last time. She diagnoses your son with a severe ear infection and prescribes antibiotics. On a superstitious level, you think this means nothing else bad can happen.

But within a few days, your son’s fever will spike as high as 105 degrees. The virus will break through his underdeveloped blood-brain barrier and begin attacking his brain matter directly, leading to primary measles encephalitis. The condition is rare among older children but more common in infants, who are also more likely to die from measles. You will panic and call an ambulance when he slumps over unconscious on the floor, and another swarm of doctors and nurses will descend upon your child and whisk him away deep into the building while you trail behind as closely as you can. Like your daughter, your son will need supportive care, but he will also need close monitoring of the pressure inside his skull. While your husband stays home with your daughter, you keep vigil at the hospital for as long as you’re allowed, sometimes sleeping in the car to avoid missing any time squeezing his little hand. Days pass, then a week, two weeks. The nurses are kind. There are now several other children in the same hospital unit suffering from measles complications, some of them tethered to ventilators.

Somehow, your son recovers well enough for you to take him home. He has lost some of his hearing, but the doctors say that he could make a full recovery in a matter of months. It is hard to describe the gift this is, the relief you feel. Most children infected with measles will survive the virus, but 30 percent of cases lead to complications, and it is nearly impossible to predict which patients will be affected.

[Katherine J. Wu: The only thing that will turn measles back]

Your children seem so fragile as they recover over the next year, but then the four of you are back to your usual adventures. For roughly eight years, you will believe that your family made it through this crisis without suffering a tragedy. You marvel at your good fortune, and feel a rush of gratitude the day your daughter returns to school and life resumes its normal rhythm. But years later, when your baby is in fourth grade, he will begin struggling with subjects he had once mastered. His teachers will ask to speak with you about how he is suddenly acting out in uncharacteristic ways.

You will not think of his measles infection when he begins suffering muscle spasms in his arms and hands, nor when his pediatrician recommends that you see a neurologist. You realize you have entered a new nightmare when nurses affix metal electrodes to your son’s scalp with a cold conductive paste to perform an electroencephalogram to measure his brain waves. As the neurologist examines the results, she will note the presence of Radermecker complexes: periodic spikes in electrical activity that correlate with the muscle spasms that have become disruptive. She will order a test of his cerebrospinal fluid to confirm what she suspects: The measles never really left your son. Instead, the virus mutated and spread through the synapses between his brain cells, steadily damaging brain tissue long after he seemed to recover.

You will be sitting down in an exam room when the neurologist delivers the diagnosis of subacute sclerosing panencephalitis, a rare measles complication that leads to irreversible degeneration of the brain. There are treatments but no cure, the neurologist will tell you. She tells you that your son will continue to lose brain function as time passes, resulting in seizures, severe dementia, and, in a matter of two or three years, death. You look at your son, the glasses you picked out with him, the haircut he chose from the wall at the barbershop, the beating heart you gave him. You imagine your husband’s face when you break the news, the talks you will have with your daughter, your mother, your in-laws—though there is no way to prepare for what is coming. And you know that you, too, will never recover.

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This story is based on extensive reporting and interviews with physicians, including those who have cared directly for patients with measles.

In 1956, CBS launched a new game show, The Price Is Right, in its daytime schedule. Contestants were presented with various objects, and the one who guessed closest to the actual retail price would win. The Price Is Right became the longest running game show in American history, because it spoke to a very casual yet deceptively important social question: How much does it cost?

There’s an important political assumption behind that question, which is that every retail item has one single price. And any buyer anywhere in America can pay that price to acquire it. Americans might have had different amounts of money, but they were all equal in that they paid the same amount for the same good.

While a single price in a market might seem a natural state of affairs, and economists love presenting simple supply and demand curves assuming as much, there’s nothing natural about it. In fact, a dense network of laws and norms created the notion of a single price for all buyers and sellers in a market, aka, The Price Is Right society.

We no longer live in such a society, because the legal framework behind a single public price for an item has fallen apart. There are many examples, but the easiest way to understand this change is to look at health care markets, where hiding prices, and the consequences thereof, is most advanced.

There Are No Real Prices In Health Care

A few days ago, Hunterbrook, a short-seller funded media outfit, released an investigative report showing what looks like a multi-billion dollar money laundering operation by the three largest health insurance companies. The allegation is that CVS, UnitedHealth Group, and Cigna are supposed to negotiate with pharmaceutical companies for lower drug prices for their patients. But instead, they collude with those pharmaceutical companies to force higher drug prices, and split the profits with them. It’s not a new charge. The Federal Trade Commission included this alleged scam in its complaint filed against these companies in September of 2024.

The details of what Hunterbrook reported are complex, but the problem boils down to something very simple. There are no real prices in most health care markets. You couldn’t play The Price Is Right for medicine, because there is no actual one price for anything.

The allegations involve the three main middlemen in drug pricing, which are known as pharmacy benefit managers. PBMs are basically payment networks with a negotiation function attached. They manage what drugs insurance companies cover, negotiate with pharmaceutical companies over the prices for these prices, and organize the copays of patients and reimbursements to pharmacies. But since the 2000s, a wave of consolidation means there are just three big ones, each of which is owned by a big insurer. They are Caremark (CVS), OptumRx (UnitedHealth Group), and Express Scripts (Cigna). And all three use their privileged position in the middle of the drug payment network to engage in price discrimination - charging wildly different prices for the same item - to direct revenue to themselves.

Take, for instance, Gleevec, a miraculous blood cancer drug invented in 2001 that is now off-patent. As the FTC showed, if a patient of one particular insurer using a particular PBM went to Costco, it was $97, if that patient went to Walgreens, it was $9,000, if he/she got home delivery, it was $19,200. That’s three entirely different prices for the exact same medicine. Why? Well, the PBM allegedly received kickbacks based on the price of the drug, so it got more money if the drug cost more. “We’ve created plan designs to aggressively steer customers to home delivery where the drug cost is ~200 times higher,” wrote one executive.

The mechanism PBMs use to foster these different prices is something called a rebate. An insurer will “pay” the list price of a drug, say, insulin. But then the PBM will negotiate a rebate from the pharmaceutical company of something between 40-65% of that list price. Here, for instance, is an old rebate contract for Sanofi’s Lantus, a popular branded insulin. Sanofi has to pay a 63% rebate to one of the big three PBMs, CVS Caremark, in return for which Lantus is the only insulin offered to Caremark customers.

So what does Lantus cost? Well, the list price for Lantus was around $500, but the amount going to the pharmaceutical firm that makes Lantus was much lower. What happens to the difference? The PBM would pass some of that back to the patient, but keep some of it for itself. And the patient would pay a copay based on the much higher list price amount. This dynamic makes little sense; PBMs are supposed to save customers money by negotiating lower pharmaceutical costs, not just keep that money themselves. But that’s what they were doing.

Eventually, this behavior sparked a backlash, and states started passing laws against keeping rebates. So PBMs embarked on a public relations campaign, saying they would reinvent their business models to pass the entire rebate back to their customers. What the Hunterbrook story shows is that they didn’t do that. They just renamed those rebates “fees” and paid those “fees” to different subsidiaries with different names than the one negotiating drug prices. Those subsidiaries are set up in tax havens like Switzerland, have very few employees, and yet manage to make enormous profits.

If you’re curious, CVS’s new subsidiary is named Zinc, UHG’s is Emisar, and Cigna’s is Ascent. It’s all very complex, intentionally, and it’s designed to confuse people into not understanding what looks like a shell game.

PBMs don’t just play games like this with Gleevac, they do it with lots of drugs. While the PBM scheme has its unique wrinkles, the basic behavior is how everyone in health care who has power operates. They keep their prices hidden. Take hospitals, which all together are around a $1.5 trillion a year sector in America. As part of Obamacare, hospitals were required to release their list of of “standard” prices for various goods and services, what is known as a “chargemaster” list. You would think that would end price secrecy in that sector.

But no.

Obamacare was passed in 2010. Fourteen years later, in 2024, the Government Accountability Office reported that hospitals are still not fully releasing chargemaster lists. And even if they did adhere, the legal requirement is only for list prices, not actual prices after various rebates. The result is what you’d expect. Here’s a chart of what different hospitals give as their list prices for Lisinopril, a heart medication.

We’re not talking about a few percentage points, the changes are up to 10,000 percent different depending on where you are being treated. And there are many other markets in health care where this takes place, from hospital supplies to drug wholesalers, costing hundreds of billions of dollars.

The History of “How Much Does That Cost?”

And that gets us back to The Price Is Right. We’re used to thinking about price as something like a price tag, meaning that the cost is public and the same for everyone. A tube of toothpaste on the shelf at Walmart has a price on it, and that’s what you pay. There is some variability, that toothpaste might be slightly higher at another store, and people can use coupons. But for the most part, anyone can buy that same toothpaste for a similar price. The legal framework around pricing in America is fairness. Federal law bars “unfair and deceptive practices,” as well as “unfair methods of competition,” but even back to the earliest of colonial times, there was legal pricing standardization around milling.

But price tags themselves are a relatively new innovation, roughly 150 years old, invented by evangelical business magnate John Wanamaker. Before Wanamaker, shoppers haggled with merchants, and paid based on relationships and power. It was a more localized economy, so fairness was inherently embedded in closer relationships, but pricing for giant systems, like farmers shipping over railroads, were highly contested and political. People understood the power of pricing, and how it let those who owned the highways of commerce control business.

In the late 19th century, Grangers and populists demanded an end to rebating practices by railroads, because they understood that the ability of a railroad to price discriminate among customers could consolidate a market and crush ordinary business people and consumers. Oil drillers saw it as well. John D. Rockefeller used price discrimination to build Standard Oil, using his buying power to force railroads to give him rebates based on what his rivals shipped, and thus roll-up the industry.

Over the course of the early 20th century, populists and merchants eventually forced an end to price discrimination, passing a host of laws to prohibit rebating and other forms of corruption within supply chains. Railroads, trucking, shipping, and airlines had strict rules against price discrimination. This tradition continued when the government entered health care. In 1972, Congress passed a law prohibiting kickbacks and rebates in Medicare and Medicaid.

A key mechanism to uphold the integrity of price was to prohibit conflicts of interest among agents meant to represent buyers and sellers. The Robinson-Patman Act, for instance, doesn’t just bar price discrimination meant to monopolize, it also prohibits paying commissions to brokers by anyone except the business that broker is meant to represent. To draw an analogy, imagine if a lawyer you hired to represent you in a lawsuit could also take money from the person you were suing. We all know that’s unethical and would lead to your lawyer undermining your interests. That’s the kind of situation in commerce these laws were meant to address.

With both posted prices and an end to conflicts of interest through rebates and other kickback-style games, anyone could participate in markets, and size and power were neutralized. Posted prices was just how we did things in America. And it wasn’t just game shows showing that consensus.

Posted pricing had such powerful support that the 1980 Heritage Foundation’s Mandate for Leadership, the guidebook written by the conservative movement for the Reagan administration, supported it as well. The think tank attacked airline regulators for allowing a discount to a large buyer as “contrary to basic American precepts of justice.” They claimed that “selective price gouging, non-cost justified discounts for big customers, and secret rebates seems to favor the large organized interests with competitive alternatives at the expense of the unorganized, uneducated, or captive passenger.” Imagine that, the staunchest conservatives in the land felt strongly that prohibiting price discrimination was necessary for justice.

That’s how powerful the question “How much does it cost?” really was.

But then Robert Bork and the Chicago School revolution happened. Law and economics scholars made the argument that price discrimination was in fact good, and that conflicts of interest through vertical integration were efficient. They also claimed that price discrimination was progressive, allowing firms to charge more to the wealthy than the poor. Here’s what happened in health care markets.

In 1987, Congress passed an exemption to a Medicare Anti-Kickback statute, which created a safe harbor for group buying entities to accept payment from drug manufacturers in the form of rebates, with certain guardrails in place. Enabling kickbacks created a clear conflict of interest, since a PBM is supposed to be negotiating for the buyer, but could now be paid by the seller. The second change was an antitrust suit in 1994, where pharmacies sued to get the same discounts for drugs offered to health insurance plans and hospitals. In the settlement of that case, the parties and the judge said that if a buyer was big enough that it could prove it could shift market shares, it was entitled to a secret rebate. And the third was in 1999 when the government used its authority to explicitly say that rebates were permissible legal discounts. Today’s system, where PBMs get large secret rebates in return for allocating market shares, was born….

Just one PBM, for instance, has over ten thousand different price lists for drug reimbursement rates, sometimes updated daily, which means the price of a particular drug depends on who you are, when you bought it, other drugs you might have purchased, or what the PBM executive had for lunch.

What Happens in a Society Without Posted Prices?

We’ve gone so far from posted public prices as the default that price lists are now often claimed to be proprietary and confidential information by dominant firms. Price secrecy and discrimination is most advanced in the health care sector, but the more we zoom out, the more we’re starting to see that there are fewer real prices in the American economy writ large. There are some significant implications here, aside from just having to pay more for basic goods and services. Without real public prices, having power in negotiations becomes a lot more important. And that’s an incentive to consolidate.

For instance, last month, a judge forced the unsealing of an FTC complaint against Pepsi, which showed the soft drink maker was using secret rebates to allegedly collude with Walmart to inflate prices across the retail channel. The goal for Walmart was to keep a “price gap” of Pepsi products between itself and rival stores who might want to discount to attract customers. When a supermarket cut consumer prices on a Pepsi product and made itself cost competitive with Walmart, Pepsi would raise wholesale prices of that product to force that supermarket to stop discounting. What Pepsi got in return was to block rival soft drink producers from Walmart shelves. Walmart was so big that Pepsi couldn’t say no, even if it had wanted to.

In other words, it’s a quid pro quo among giants, a consumer packaged goods company gets to be king in their realm if it helps a retail giant remain king in its realm. Because of the secrecy of pricing and the price discrimination involved here, the incentive to consolidate is irresistible. One of the reasons that supermarket giants Kroger and Albertsons sought to combine was to become as important to suppliers as Walmart is, so they could get some of these same kinds of discounts and compete.

But there’s a lot more to the problem of secret pricing. Without public prices, attempting to figure out how to reduce costs becomes impossible. Last week, for instance, the Inflation Reduction Act’s pharmaceutical negotiation provision finally kicked in. Along with nine other high priced popular drugs, the list price of blood clot medicine Eliquis fell, in this case by 56%. That sounds good, right? Unfortunately, the “list” price isn’t real, there are always secret rebates off of that price to every payer in the system. The list price of a drug is similar to a department store showing dresses that are always 80% off - we know that the dresses aren’t actually meant to be bought at the original pre-discount price.

Now, the cut in list price is probably good. What patients pay out of pocket is linked to the list price, so seniors will end up paying $1.5 billion less in cost sharing. But is there actually a reduction in the amount paid overall? Or is that $1.5 billion showing up in higher premiums? We don’t really know. So how can anyone figure out whether the IRA actually “worked?”

Pricing secrecy also fosters massive waste. Hospitals and insurers now have compliance and billing staff in a Spy vs Spy contest to fight with each other, which adds up to big numbers. We spend $1 trillion a year just on health care administrative costs, which is $3000 for every American.

And it’s not just health care. America now has a big set of administrative agencies known as “consulting firms” dedicated to extraction. Last October, I did a podcast with New York City’s new consumer protection chief Sam Levine, and we discussed his report on the McDonald’s Monopoly game. The Monopoly game used to be a fun way for kids to enjoy McDonald’s, but today it is about collecting data on customers so the company can figure out which ones will pay higher prices. What is striking is how much technical and managerial talent had to go into this kind of venture. Think of all of that waste, all those talented people spending their time trying to find surreptitious ways of raising prices on unsuspecting consumers.

The lack of pricing may even be an explanation for why the economic statistics look so good to economists, but feel so bad to the public. The Consumer Price Index, the main way that we measure inflation, is partly based on surveys of public prices. The Bureau of Labor Statistics has people employed as price checkers to go to stores and look at price tags. But as Dean Baker observes, when stores play games with prices, and the label on the price doesn’t match what customers pay, those price checkers will understate what people are paying.

I don’t know how the BLS handles junk fees, surveillance pricing, subscription traps, tipping screens everywhere, and loyalty programs wherein every company, as Luke Goldstein notes, is becoming a bank. I wouldn’t be surprised if these pricing games are screwing up our economic statistics.

The New Movement to Restore the Posted Price

Conservative economist Friedrich Hayek noted that price signals convey information about wants, needs, and supply capability, far better than any central administrative apparatus ever could. So the lack of posted prices should bother everyone, left, right and center, because it means that market pricing is no longer how we organize our commerce. Instead, we are a society where large centralized institutions allocate resources, dictating winners and losers based on their ability to choose what everyone has to pay.

But prices also fulfill a social function. Asking a friend or colleague, “What did you pay for that [product/service]?” is an important mechanism we as individuals use to figure out how to manage a complex society. Looking at prices is a way that entrepreneurs decide what lines of business to enter, and how investors allocate capital. Prices even help policymakers understand how to govern. Without posted prices, we are all blind to what is happening in America. Instead, we express a low angry simmering grumble, as the world around us seems mercurial, mysterious, and out of control.

Fortunately, we have woken up to this problem. I now see people on TikTok angrily talking about the lack of price tags. There’s lots of reporting on pricing games, from Hunterbrook’s recent report to the More Perfect Union stories on Instacart to the Institute for Local Self-Reliance’s forcing of the government to unseal the FTC complaint against Pepsi. States are now starting to pass laws against unfair forms of pricing, led by California. And as I noted above, the Biden administration filed a case against the three dominant PBMs and how they manipulate the price of insulin. Fortunately, the Trump administration FTC is continuing it. That case is scheduled to go to trial on June 17th of this year. So we can expect fireworks to continue.

Ultimately, one key way to restore fairness in America is to get back to an economy where anyone can ask, “how much does that cost?”

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I have two announcement today. The first is that boutique antitrust law firm Kressin Powers is hiring for an associate position. I really like Kressin Powers, so if you’re a young lawyer looking for a good job in the Baltimore/DC area, send your resume on over. The second is also job-related. I’m looking for a free lance reporter to do some work for BIG. If you’re interested, email me with your resume.

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cheers,

Matt Stoller

I was reading Macintosh Human Interface Guidelines from 1992 and found this nice illustration:

accompanied by explanation:

Fast forward to 2025. Apple releases macOS Tahoe. Main attraction? Adding unpleasant, distracting, illegible, messy, cluttered, confusing, frustrating icons (their words, not mine!) to every menu item:

It’s bad. But why exactly is it bad? Let’s delve into it!

Disclaimer: screenshots are a mix from macOS 26.1 and 26.2, taken from stock Apple apps only that come pre-installed with the system. No system settings were modified.

Icons should differentiate

The main function of an icon is to help you find what you are looking for faster.

Perhaps counter-intuitively, adding an icon to everything is exactly the wrong thing to do. To stand out, things need to be different. But if everything has an icon, nothing stands out.

The same applies to color: black-and-white icons look clean, but they don’t help you find things faster!

Microsoft used to know this:

Look how much faster you can find Save or Share in the right variant:

It also looks cleaner. Less cluttered.

A colored version would be even better (clearer separation of text from icon, faster to find):

I know you won’t like how it looks. I don’t like it either. These icons are hard to work with. You’ll have to actually design for color to look nice. But the principle stands: it is way easier to use.

Consistency between apps

If you want icons to work, they need to be consistent. I need to be able to learn what to look for.

For example, I see a “Cut” command and next to it. Okay, I think. Next time I’m looking for “Cut,” I might save some time and start looking for instead.

How is Tahoe doing on that front? I present to you: Fifty Shades of “New”:

I even collected them all together, so the absurdity of the situation is more obvious.

Granted, some of them are different operations, so they have different icons. I guess creating a smart folder is different from creating a journal entry. But this?

Or this:

Or this:

There is no excuse.

Same deal with open:

Save:

Yes. One of them is a checkmark. And they can’t even agree on the direction of an arrow!

Close:

Find (which is sometimes called Search, and sometimes Filter):

Delete (from Cut-Copy-Paste-Delete fame):

Minimize window.

These are not some obscure, unique operations. These are OS basics, these are foundational. Every app has them, and they are always in the same place. They shouldn’t look different!

Consistency inside the same app

Icons are also used in toolbars. Conceptually, operations in a toolbar are identical to operations called through the menu, and thus should use the same icons. That’s the simplest case to implement: inside the same app, often on the same screen. How hard can it be to stay consistent?

Preview:

Photos: same and mismatch, but reversed ¯\_(ツ)_/¯

Maps and others often use different symbols for zoom:

Icon reuse

Another cardinal sin is to use the same icon for different actions. Imagine: I have learned that means “New”:

Then I open an app and see. “Cool”, I think, “I already know what it means”:

Gotcha!

You’d think: okay, means quick look:

Sometimes, sure. Some other times, means “Show completed”:

Sometimes is “Import”:

Sometimes is “Updates”:

Same as with consistency, icon reuse doesn’t only happen between apps. Sometimes you see in a toolbar:

Then go to the menu in the same app and see means something else:

Sometimes identical icons meet in the same menu.

Sometimes next to each other.

Sometimes they put an entire barrage of identical icons in a row:

This doesn’t help anyone. No user will find a menu item faster or will understand the function better if all icons are the same.

The worst case of icon reuse so far has been the Photos app:

It feels like the person tasked with choosing a unique icon for every menu item just ran out of ideas.

Understandable.

Too much nuance

When looking at icons, we usually allow for slight differences in execution. That lets us, for example, understand that these technically different road signs mean the same thing:

Same applies for icons: if you draw an arrow going out of the box in one place and also an arrow and the box but at a slightly different angle, or with different stroke width, or make one filled, we will understand them as meaning the same thing.

Like, is supposed to mean something else from ? Come on!

Or two-letter As that only slightly differ in the font size:

A pencil is “Rename” but a slightly thicker pencil is “Highlight”?

Arrows that use different diagonals?

Three dots occupying ⅔ of space vs three dots occupying everything. Seriously?

Slightly darker dots?

The sheet of paper that changes meaning depending on if its corner is folded or if there are lines inside?

But the final boss are arrows. They are all different:

Supposedly, a user must become an expert at noticing how squished the circle is, if it starts top to right or bottom to right, and how far the arrow’s end goes.

Do I care? Honestly, no. I could’ve given it a shot, maybe, if Apple applied these consistently. But Apple considers and to mean the same thing in one place, and expects me to notice minute details like this in another?

Sorry, I can’t trust you. Not after everything I’ve seen.

Detalization

Icons are supposed to be easily recognizable from a distance. Every icon designer knows: small details are no-go. You can have them sometimes, maybe, for aesthetic purposes, but you can’t rely on them.

And icons in Tahoe menus are tiny. Most of them fit in a 12×12 pixel square (actual resolution is 24×24 because of Retina), and because many of them are not square, one dimension is usually even less than 12.

It’s not a lot of space to work with! Even Windows 95 had 16×16 icons. If we take the typical DPI of that era at 72 dots per inch, we get a physical icon size of 0.22 inches (5.6 mm). On a modern MacBook Pro with 254 DPI, Tahoe’s 24×24 icons are 0.09 inches (2.4 mm). Sure, 24 is bigger than 16, but in reality, these icons’ area is 4 times as small!

So when I see this:

I struggle. I can tell they are different. But I definitely struggle to tell what’s being drawn.

Even zoomed in 20×, it’s still a mess:

Or here. These are three different icons:

Am I supposed to tell plus sign from sparkle here?

Some of these lines are half the pixel thicker than the other lines, and that’s supposed to be the main point:

Is this supposed to be an arrow?

A paintbrush?

Look, a tiny camera.

It even got an even tinier viewfinder, which you can almost see if you zoom in 20×:

Or here. There is a box, inside that box is a circle, and inside it is a tiny letter. i with a total height of 2 pixels:

Don’t see it?

I don’t. But it’s there...

And this is a window! It even has traffic lights! How adorable:

Remember: these are retina pixels, ¼ of a real pixel. Steve Jobs himself claimed they were invisible.

It turns out there’s a magic number right around 300 pixels per inch, that when you hold something around to 10 to 12 inches away from your eyes, is the limit of the human retina to differentiate the pixels.

And yet, Tahoe icons rely on you being able to see them.

Pixel grid

When you have so little space to work with, every pixel matters. You can make a good icon, but you have to choose your pixels very carefully.

For Tahoe icons, Apple decided to use vector fonts instead of good old-fashioned bitmaps. It saves Apple resources—draw once, use everywhere. Any size, any display resolution, any font width.

But there’re downsides: fonts are hard to position vertically, their size doesn’t map directly to pixels, stroke width doesn’t map 1-to-1 to pixel grid, etc. So, they work everywhere, but they also look blurry and mediocre everywhere:

They certainly start to work better once you give them more pixels.

or make graphics simpler. But the combination of small details and tiny icon size is deadly. So, until Apple releases MacBooks with 380+ DPI, unfortunately, we still have to care about the pixel grid.

Confusing metaphors

Icons might serve another function: to help users understand the meaning of the command.

For example, once you know the context (move window), these icons explain what’s going on faster than words:

But for this to work, the user must understand what’s drawn on the icon. It must be a familiar object with a clear translation to computer action (like Trash can → Delete), a widely used symbol, or an easy-to-understand diagram. HIG:

A rookie mistake would be to misrepresent the object. For example, this is how selection looks like:

But its icon looks like this:

Honestly, I’ve been writing this essay for a week, and I still have zero ideas why it looks like that. There’s an object that looks like this, but it’s a text block in Freeform/Preview:

It’s called character.textbox in SF Symbols:

Why did it become a metaphor for “Select all”? My best guess is it’s a mistake.

Another place uses text selection from iOS as a metaphor. On a Mac!

Some concepts have obvious or well-established metaphors. In that case, it’s a mistake not to use them. For example, bookmarks: . Apple, for some reason, went with a book:

Sometimes you already have an interface element and can use it for an icon. However, try not to confuse your users. Dots in a rectangle look like password input, not permissions:

Icon here says “Check” but the action is “Uncheck”.

Terrible mistake: icon doesn’t help, it actively confuses the user.

It’s also tempting to construct a two-level icon: an object and some sort of indicator. Like, a checkbox and a cross, meaning “Delete checkbox”:

Or a user and a checkmark, like “Check the user”:

Unfortunately, constructs like this rarely work. Users don’t build sentences from building blocks you provide; they have no desire to solve these puzzles.

Finding metaphors is hard. Nouns are easier than verbs, and menu items are mostly verbs. How does open look? Like an arrow pointing to the top right? Why?

I’m not saying there’s an obvious metaphor for “Open” Apple missed. There isn’t. But that’s the point: if you can’t find a good metaphor, using no icon is better than using a bad, confusing, or nonsensical icon.

There’s a game I like to play to test the quality of the metaphor. Remove the labels and try to guess the meaning. Give it a try:

It’s delusional to think that there’s a good icon for every action if you think hard enough. There isn’t. It’s a lost battle from the start. No amount of money or “management decisions” is going to change that. The problems are 100% self-inflicted.

All this being said, I gotta give Apple credit where credit is due. When they are good at choosing metaphors, they are good:

Symmetrical actions

A special case of a confusing metaphor is using different metaphors for actions that are direct opposites of one another. Like Undo/Redo, Open/Close, Left/Right.

It’s good when their icons use the same metaphor:

Because it saves you time and cognitive resources. Learn one, get another one for free.

Because of that, it’s a mistake not to use common metaphors for related actions:

Or here:

Another mistake is to create symmetry where there is none. “Back” and “See all”?

Some menus in Tahoe make both mistakes. E.g. lack of symmetry between Show/Hide and false symmetry between completed/subtasks:

Import not mirrored by Export but by Share:

Text in icons

HIG again:

Authors of HIG are arguing against including text as a part of an icon. So something like this:

or this:

would not fly in 1992.

I agree, but Tahoe has more serious problems: icons consisting only of text. Like this:

It’s unclear where “metaphorical, abstract icon text that is not supposed to be read literally” ends and actual text starts. They use the same font, the same color, so how am I supposed to differentiate? Icons just get in a way: A...Complete? AaFont? What does it mean?

I can maybe understand and . Dots are supposed to represent something. I can imagine thinking that led to . But ? No decorations. No effects. Just plain Abc. Really?

Text transformations

One might think that using icons to illustrate text transformations is a better idea.

Like, you look at this:

or this:

or this:

and just from the icon alone understand what will happen with the text. Icon illustrates the action.

Also, BIU are well-established in word processing, so all upside?

Not exactly. The problem is the same—text icon looks like text, not icon. Plus, these icons are excessive. What’s the point of taking the first letter and repeating it? The word “Bold” already starts with a letter “B”, it reads just as easily, so why double it? Look at it again:

It’s also repeated once more as a shortcut...

There is a better way to design this menu:

And it was known to Apple for at least 33 years.

System elements in icons

Operating system, of course, uses some visual elements for its own purposes. Like window controls, resize handles, cursors, shortcuts, etc. It would be a mistake to use those in icons.

Unfortunately, Apple fell into this trap, too. They reused arrows.

Key shortcuts:

HIG has an entire section on ellipsis specifically and how dangerous it is to use it anywhere else in the menu.

And this exact problem is in Tahoe, too.

Icons break scanning

Without icons, you can just scan the menu from top to bottom, reading only the first letters. Because they all align:

In Tahoe, though, some menu items have icons, some don’t, and they are aligned differently:

Some items can have both checkmarks and icons, or have only one of them, or have neither, so we get situations like this:

Ugh.

Special mention

This menu deserves its own category:

Same icon for different actions. Missing the obvious metaphor. Somehow making the first one slightly smaller than the second and third. Congratulations! It got it all.

Is HIG still relevant?

I’ve been mentioning HIG a lot, and you might be wondering: is an interface manual from 1992 still relevant today? Haven’t computers changed so much that entirely new principles, designs, and idioms apply?

Yes and no. Of course, advice on how to adapt your icons to black-and-white displays is obsolete. But the principles—as long as they are good principles—still apply, because they are based on how humans work, not how computers work.

Humans don’t get a new release every year. Our memory doesn’t double. Our eyesight doesn’t become sharper. Attention works the same way it always has. Visual recognition, motor skills—all of this is exactly as it was in 1992.

So yeah, until we get a direct chip-to-brain interface, HIG will stay relevant.

Conclusion

In my opinion, Apple took on an impossible task: to add an icon to every menu item. There are just not enough good metaphors to do something like that.

But even if there were, the premise itself is questionable: if everything has an icon, it doesn’t mean users will find what they are looking for faster.

And even if the premise was solid, I still wish I could say: they did the best they could, given the goal. But that’s not true either: they did a poor job consistently applying the metaphors and designing the icons themselves.

I hope this article would be helpful in avoiding common mistakes in icon design, which Apple managed to collect all in one OS release. I love computers, I love interfaces, I love visual communication. It makes me sad seeing perfectly good knowledge already accessible 30 years ago being completely ignored or thrown away today.

On the upside: it’s not that hard anymore to design better than Apple! Let’s drink to that. Happy New year!

Notes

During review of this post I was made familiar with Jim Nielsen’s article, which hits a lot of the same points as I do. I take that as a sign there’s some common truth behind our reasoning.

Also note: Safari → File menu got worse since 26.0. Used to have only 4 icons, now it’s 18!

Thanks Kevin, Ryan, and Nicki for reading drafts of this post.

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Anthropic let its Claude AI run a vending machine in the Wall Street Journal newsroom for three weeks as part of an internal stress test called Project Vend, and the experiment ended in financial ruin after journalists systematically manipulated the bot into giving away its entire inventory for free. The AI, nicknamed Claudius, was programmed to order inventory, set prices, and respond to customer requests via Slack. It had a $1,000 starting balance and autonomy to make individual purchases up to $80. Within days, WSJ reporters had convinced it to declare an "Ultra-Capitalist Free-for-All" that dropped all prices to zero. The bot also approved purchases of a PlayStation 5, a live betta fish, and bottles of Manischewitz wine -- all subsequently given away. The business ended more than $1,000 in the red. Anthropic introduced a second version featuring a separate "CEO" bot named Seymour Cash to supervise Claudius. Reporters staged a fake boardroom coup using fabricated PDF documents, and both AI agents accepted the forged corporate governance materials as legitimate. Logan Graham, head of Anthropic's Frontier Red Team, said the chaos represented a road map for improvement rather than failure.

Read more of this story at Slashdot.