The Headlines
Who Is Running Iran, and How Doctors Cashed In on a Consumer Protection Law
23 Apr 2026
Transcript generated automatically by AI and may contain errors.
Chapter 1: What is the main topic discussed in this episode?
A big yacht, the Lexus, bragging about money. Those are just props. That's not the engine. That's not the emotion that my music is running on.
That is, of course, Jay-Z. I'm John Caramonica, one of the critics behind the New York Times' 30 Greatest Living American Songwriters Project. We interviewed some of the songwriters on our list, including Taylor Swift, who hasn't sat for a video like this in a long time. Watch all the video interviews for free at nytimes.com slash 30greatest or in the app.
From The New York Times, it's The Headlines. I'm Tracey Mumford. Today's Thursday, April 23rd. Here's what we're covering. One of the key questions swirling as the U.S. attempts to negotiate an end to the war in Iran is, who is really running Iran?
The new supreme leader, Ayatollah Mujtaba Khamenei, was wounded in airstrikes at the start of the war, which killed his father, the previous supreme leader, and he's been in hiding while he recovers. He still has not been seen in public since he took over, and that has fed into uncertainty about the country's leadership.
To try and trace Iran's new power structure, the Times spoke with senior Iranian officials, members of the Islamic Revolutionary Guards Corps, and others familiar with the country's inner workings. Several officials told The Times that Hominé's injuries are severe. He's had surgery on his hand and leg, and his face and lips were badly burned, making it difficult for him to speak.
They say he's sharp and engaged, but he hasn't released a video or audio message because he doesn't want to appear weak in his first public address. Also, because of fears he could be targeted again, messages to him are handwritten, sealed in envelopes, and relayed via a human chain from one courier to the next.
They travel on highways and back roads, in cars and on motorcycles, until they reach his hideout. His responses go back the same way. That combination of his injuries and the challenge of reaching him has led Hominé to delegate decision-making to commanders in the Revolutionary Guards Corps. It's essentially left the hardline military calling the shots.
Those generals were the ones who came up with the strategy of closing the Strait of Hormuz and of striking neighboring countries in the Gulf. They were the ones who agreed to the temporary ceasefire and who decided to pull the plug on more peace talks this week because they felt President Trump was trying to pressure Iran to surrender.
Overall, Iranian officials tell The Times the generals are feeling confident in this moment, like they've been able to prevent the U.S. and Israel from toppling the regime, and that the country still has leverage in the conflict. Now, a few more quick updates on the war.
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Chapter 2: Who is currently running Iran and what are the power dynamics?
For Trump, that date is May 1st, next Friday. While Republicans in Congress have largely backed his campaign so far, some have signaled they won't continue that support after that deadline. If lawmakers don't authorize the war, Trump will either have to pull back immediately or give himself a one-time 30-day extension that would be used to safely withdraw U.S. forces.
There's also a chance he could push past the deadline altogether, though, which would not be unprecedented. In 2011, President Obama continued military operations in Libya past 60 days, which prompted bipartisan backlash. A couple of years ago, Republican and Democratic lawmakers banded together to take on one of the most costly and frustrating parts of medical care, surprise billing.
Every year, millions of Americans who unexpectedly saw a doctor out of network, often in emergency rooms, would be hit with far higher bills than what their health plans normally covered. So Congress passed the No Surprises Act, which barred out-of-network doctors from billing patients directly.
Chapter 3: What challenges does the new supreme leader of Iran face?
Instead, physicians can take their claim to a government-approved arbitrator to try and make a case for how much they think the patient's insurance company should pay them.
This new law, by all accounts, did do a lot to solve the problem of surprise medical bills, so patients are no longer in the middle of these billing disputes between insurers and doctors. But what we found is that doctors have been flooding this new arbitration system with millions of claims and getting paid rates much, much higher than they did in the past.
Sarah Cliff is an investigative health reporter at The Times who's been looking into how the new system works.
Each side submits what they think is a fair price for the medical care rendered. They submit some arguments, and then the arbitrator selects one of them. There is no middle ground. Somebody is going to win. And once the arbitrator picks someone, that is the final decision. There is no route to appeal. Sometimes the numbers that insurers and doctors bring to the table are wildly different.
There was one case that we looked at where the insurance company offered $2,600 for a test of blood flow to the brain. The doctor asked for $330,000 and they won that dispute and got that money. We saw this happening repeatedly in this massive data set that had millions of claims. We saw gynecologists who were getting 600 times the normal rates for placing a contraceptive called an IUD.
And the doctors are overwhelmingly winning these disputes. We found that in 88% of the cases, they win and they're often winning hundreds of times of what they used to get paid before this law passed. One of the mysteries is why the results are so lopsided. It surprised the lawmakers who wrote this law when we asked them about it. There are a few theories.
One is that the arbitrators are paid on a per-case basis, so they have an incentive to render decisions favorable to doctors, to have doctors continue bringing them disputes. Another is that doctors are just viewed more positively by the public than insurance plans are, and maybe arbitrators have those same kind of biases that the general public does.
Sarah says as a result of the huge new payouts doctors are getting, some insurance companies say they're having to raise premiums for patients, essentially passing along the cost of this new arbitration system. A study out this week found that after a national suicide prevention effort went into effect a few years ago, the rate of youth suicides in the U.S. dropped.
Three numbers helped me find the help I needed.
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