Factually! with Adam Conover - Proof that Health Insurers Screw You Deliberately with T. Christian Miller and Patrick Rucker

Episode Date: February 5, 2025

Health insurance companies aren’t in the business of keeping people healthy—they’re in the business of making money. And that means they’ll go to extreme lengths to deny valid healthcare claims, sometimes with devastating, even fatal, consequences for the people they insure. We all know the system is broken, but journalists T. Christian Miller and Patrick Rucker have uncovered just how deep the rot goes in their exposé Not Medically Necessary. This week, Adam sits down with Miller and Rucker to discuss their shocking findings and whether there’s any hope of escaping the nightmare of for-profit healthcare.SUPPORT THE SHOW ON PATREON: https://www.patreon.com/adamconoverSEE ADAM ON TOUR: https://www.adamconover.net/tourdates/SUBSCRIBE to and RATE Factually! on:» Apple Podcasts: https://podcasts.apple.com/us/podcast/factually-with-adam-conover/id1463460577» Spotify: https://open.spotify.com/show/0fK8WJw4ffMc2NWydBlDyJAbout Headgum: Headgum is an LA & NY-based podcast network creating premium podcasts with the funniest, most engaging voices in comedy to achieve one goal: Making our audience and ourselves laugh. Listen to our shows at https://www.headgum.com.» SUBSCRIBE to Headgum: https://www.youtube.com/c/HeadGum?sub_confirmation=1» FOLLOW us on Twitter: http://twitter.com/headgum» FOLLOW us on Instagram: https://instagram.com/headgum/» FOLLOW us on TikTok: https://www.tiktok.com/@headgum» Advertise on Factually! via Gumball.fmSee Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

This is a HeadGum Podcast. Hello and welcome to Factually. I'm't know anything. Hello and welcome to Factually, I'm Adam Conover. Thank you so much for joining me on the show again. You know, some of the media were a little surprised when Luigi Mangione became a folk hero a couple months back for murdering a health insurance CEO in cold blood. I was not surprised. It made a lot of sense to me because I was aware

that the public by and large sees health care executives as killers themselves. But not killers who work with guns, killers who work with a pen behind a desk denying health care claims to benefit their shareholders. And that results in real harm to real people. Now, the people who run our health care companies say, no, no, no, we don't deny claims just to make a buck. No, we're trying to make the system better and more efficient by denying fraudulent claims. We're making healthcare more cheap and accessible for people with our pens. But you know what? If you want to dispute that account, well, it's pretty easy. You could just ask, I don't know, anyone you know.

I am willing to bet that you or someone you love has had a claim denied. Not because it was fraudulent, but just because your healthcare system was trying to save money by second guessing your doctor. And that means that in the American healthcare system, just because your doctor says that you need care, you cannot be sure that you will get it. But you know what? If the firsthand experience of tens of millions of Americans isn't enough to convince you, you are gonna be convinced by today's episode. Because today on the show,

we have two ProPublica reporters who recently published a blockbuster expose about just how blatantly the health insurance industry denies claims to save cash. There is actually a secret company within the health insurance industry whose only role is to figure out how to deny more claims for no other reason than to save money for the shareholders.

And by the end of this episode, you are going to have an absolutely clear view of why and how that is the case. But before we get into it, I want to remind you that if you want to support this show and all of the incredible stories that we bring you every single week that reveal the malfeasance of the world around you. You can do so on Patreon. Head to patreon.com slash Adam Conover. Five bucks a month gets you every episode of the show ad free. We also have a lot of wonderful community features

we would love to have you be a part of. And just to remind you, I am on tour with a brand new hour of standup comedy right now. The Nihilism Pivot Tour continues February 12th in Omaha, Nebraska, February 13th in Minneapolis, Minnesota, February 21st in Chicago, the 23rd in Boston. Then after that, Burlington, London, Amsterdam, Providence, Rhode Island, Vancouver, Eugene, Oregon, Oklahoma City and Tulsa, Oklahoma,

head to AdamConover.net for all those tickets and tour dates. I'd love to see you at a show and give you a hug at the meet and greet line afterwards. That's the Adam Conover guarantee. And now let's get to this week's episode. This week. We are talking about a company that you have never heard of, but that likely determines the health care outcomes for you, your loved ones, and hundreds of millions of other Americans. They're called Evacor and the big insurance companies hire

Evacor to make decisions on whether to pay for care for more than a hundred million people in this country. This company has created an elaborate system that makes it easy for insurance companies to deny care that many doctors say their patients need. And you know, it's just one part of the huge systemic clusterfuck of American healthcare, but it is also a perfect window into how bizarre

and insane our for-profit healthcare nightmare continues to be. I'm pretty sure that five minutes into this interview, you are going to be furious, but you are also going to be fascinated by how deep this rabbit hole goes. I am so honored to have two incredible investigative reporters on this show who broke the story. Their names are T.

Christian Miller and Patrick Rucker from the Capitol Forum and ProPublica. Let's get to this interview with T. Christian Miller and Patrick Rucker. T and Patrick, thank you so much for being on the show with us today. Thanks so much for having us. Glad to be here.

So let's jump right into it. What is this company, Evacor, and what role do they play in America's healthcare system as you are reporting on covered? So Evacor is kind of a part of a hidden industry in the healthcare industry. What they do is that they do what are called prior authorizations. So if your doctor wants to give you an MRI, he wants to give you a certain procedure,

your health insurance company gives that a thumbs up or thumbs down before you have that done. What the health insurance companies do is they subcontract that actual decision out to a company like Evacor. And Evacor is the one who actually says, yes, that person can get this procedure done and we're gonna pay for it. Or they'll say, no, we don't think that that procedure is medically necessary,

or we don't think that person needs to get that treatment. And so we're not gonna pay for it. And then the assurance company goes back to your doctor and says, hey, we made a decision that we're not gonna pay for that treatment that you want for your patient. So this is already to me somewhat insane that, you know, my doctor says, hey, you need an MRI, you need, uh, I don't know your gallbladder removed, whatever it is. Then we have to ask the insurance company if they're going to pay for it. The insurance company doesn't even give us an answer.

They go to another company that they've subcontracted to, to make the decision. Why doesn't the insurance company make the decision? Is that not the entire point of the insurance company? Like, isn't that the core thing that they do? Why are they subcontracting it? EvoCore is, it's evolution or it's even existence is at the end of a long road of the insurance industry specializing, compartmentalizing, putting different parts of its business at a different categories.

And even prior authorization, which didn't exist in the past, and 20 odd years ago, if your doctor said, I need a treatment, you more than likely or not, you would get it, whether that was that same scan or cancer treatment or whatever. Over time, this Evercore eventually became the company, one of the leading companies that does it. But these insurance companies started scrutinizing what the doctor wanted to do and say, I don't know, does he really need that scan?

That's pretty expensive. And so over time time that became more specialized and they eventually just boxed it all up into one independent operator, Evacor, which were just tasked with doing all this work for not all of it, but for the leading company that does this outside review. So is it the matter of like the insurance companies

keeping their hands clean, we didn't turn you down, Evacor did this other company that we contract with. I mean, it certainly kind of works out that way. You know, they can, they can ultimately say like, hey, they can go back to Evacor if they get a complaint and say, hey, Evacor, we think you made the decision the wrong way. We're going to come in, you know, on our white horse

and go ahead and allow this procedure to occur. Now what the, what Evacor, what Aetna and United and the big insurance companies who contract with Evacor will tell you is that the reason they use Evacor is because they're doing very specialized decisions in specialized area of medicine like oncology, that's a cancer care.

And so they'll say, we use Evacor because those guys have real experts, they can make smart decisions and they can do it quickly and also make sure that the doctors aren't making bad requests or making requests for fraudulent treatments that they might be doing to make money for themselves. The big thing that the insurance companies say in using these services, these subcontractors, is it's a way to make healthcare safer. It's a way to make sure that to bring out any fraud that's in the system way to make healthcare safer. It's a way to make sure that, you know, to bring out any fraud that's in the system and to make the whole process more efficient.

Now, whether or not it actually does that, that's a big question. Yeah, I mean, you're very giving a lot of credence to the insurance companies. Here's what they would tell you. What is your reporting show about the basis on which they make this decision? Well, we know that one of the reasons they hire Evacor

is because Evacor markets themselves explicitly as saying, hey, we can save you money. Now, the people we talk to never said it's a crude thing where the insurance company comes in and says, hey, we wanna screw more people over. It's more of like put the language of, you know, we've been spending a lot of money on MRIs this quarter, is there any way we can control that spending?

And what Evacor could do according to our interviews is they could kind of tweak this algorithm, but they can make it so that you would result in a higher denial rate than you have previously. So you actually cut back on some of that spending. So the insurance companies kind of have, like you said, distance where they can say, we didn't ask for more denials. We didn't say that explicitly. We just said we need to control our spend more. And that's what kind of ends up coming out the other end.

You describe in your reporting as that Evacor has a dial they use to adjust the amount of spending. Tell me about that. Well, let's say on Monday that you're a insurance company and you're spending, uh, I don't know, one out of every three MRIs is being approved and your client says, hey, that's too much money, we wanna cut that down. They would, we heard this metaphor several times that it's literally, well, it's a metaphor,

but a dial that they could say, we're gonna go from like one to three being approved to half that. And so they would just, not that this would be seen by the customer, meaning the patient, but there was this invisible dial where on Monday, if they were approving a certain fraction of these, these requests for care on Tuesday, they could just turn the dial to the left, turn it down. No one knew it was invisible. The patient who on Monday might've been approved on Tuesdays get rejected.

He has no idea. She has no idea what's going on, but this invisible dial has been turned and they were able to turn it up or down based on what kind of spend they wanted to do on that care. Okay. I think you guys have broken the record for how soon in an episode I'm getting angry. Because I mean, we're like,

what six minutes into this conversation. I'm fucking furious. Cause what you're telling me is that, you know, w which health insurers use Evacor? Just give me the name of one or two. But they all do. Yeah. Okay. So they all use it. So, uh, I'm at, I'm at anthem out of Edna, whatever. Uh, I go to my doctor, my doctor says you need this procedure. I submit, you know, that I need the procedure paid for, but unbeknownst to me, the CEO of the company or whatever executive has gone to Evacor and said, ah,

we spent a little bit too much money on those MRIs. We spent a little bit too much, too much money on cancer treatment. Can we do something about that? And then Evacor adjust the algorithm so that now they're simply rejecting more of that type of request, regardless of the, that is not influenced by my actual medical needs. Like I'm actually a person at the other end of the system. I need my MRI. I need my gallbladder removed. I need my, you know, chemotherapy, whatever it is. But I've been rejected not because of the circumstances of my medical condition,

but because of the business needs of the insurer. The insurer has said to Evacor, we're spending too much money on this. So that's hurting our bottom line. That's the reason they're saying it, right? We're spending too much money. And as a result, I don't get my care. They adjust the, they are adjusting their criteria for making medical decisions for me based on criteria that have nothing to do with my actual health.

That's what I'm hearing. You summed that up pretty well. How's that legal? I mean, I don't want to spend 50 minutes on the moral outrage part of the conversation. I want to learn more about this, but like, what the fuck? So, you know, one of the things about the insurance industry is that it's actually not that well regulated.

Insurance companies will have you believe that they're regulated by the state insurance commissioner, by the federal government. And actually what it is, is there's a lot of regulation that exists, but there's not a lot of regulating that occurs. So one of the things that a lot of people don't know is that the Department of Labor regulates about half of all insurance plans in the country.

And I would challenge you to go find anybody who thinks, hey, I got turned down for this prior authorization request, I need to go make a complaint to the Department of Labor. You might think I got it there by a local state insurance commissioner, but in point of fact, the insurance commissioners don't actually do a lot of health insurance regulating. They do a lot like FHIR in LA, and they do a lot with property casualty, but health insurance is generally,

generally most health insurance plans are regulated by the Department of Labor, which will freely admit they don't have enough people to do this job. That's a really good point. Like, you know, here in LA with the fires, you know, the insurance commissioner of California is like in the news, making statements about, you know, what the responsibility of the home insurers are going

to be, et cetera. The state regulator, I don't know how good a job they're going to do, but they are taking an active role, at least in the press, of this is something that we regulate. And I've never heard about that in relation to health insurance ever. It doesn't, there's no health insurance czar, even after the Affordable Care Act, the biggest reformation of the American healthcare system in decades, it doesn't seem like there's anybody watching these people

to make sure what they do. So they can just adjust the dial with a company, they have a subcontractor who they own, and that company is adjusting the dial on their behalf, and oops, 10,000 less MRIs are getting approved this quarter. Oops, 10,000 less, whatever, name any form of care that you want. Do you have any particular egregious examples of this

that might make us even angrier? Well, so we did we and our story we focused on a guy named Little John Cup and Little John Cup is a was a guy from Ohio who had some heart conditions. He went to his doctor and he'd been short breath and tired and the doc his doctor recommended that he get what's called a heart catheterization where they put a tube up into your heart and they kind of see what the blockage is, right? But Evacor says to a little John Cupps doctor, says, no, he doesn't need this procedure. They go back and forth for a while kind of fighting over whether or not he can get it.

He finally ends up settling. The doctor says, okay, I can't get this heart catheterization, but we'll do another thing called a nuclear stress test, which is cheaper, much cheaper than a heart catheterization. Uh, he goes in, gets this test shows he has a high blockage. And the next day he dies after he has this exam. Um, now whether or not, you know, would he have been saved if he'd had a quicker, uh, exam or the heart catheterization exam, we talked to experts who said yes, that would have fit, it he have been saved if he'd had a quicker exam or the heart catheterization

exam? We talked to experts who said yes, that would have been a help. He could have been put on medications earlier. One of those experts said no, that wasn't the case. But it's again this case where the doctor's clinical judgment, your doctor, little John Cupp's doctor, his judgment was overruled by this company called Ev core, which is owned by Cigna and which ultimately says, we're not going to pay for this procedure. So he gets put on hold for months and months and months until eventually he

gets the procedures that says, yeah, indeed you are, your heart is blocked. And you could have, um, maybe you should have gotten medication sooner. So the man is, uh, dying of a heart condition, uh condition and then is stuck in a months long, what holding pattern while the doctor argues not even with his insurer, with the insurers subcontractor. So you're down a couple levels of customer service hell arguing with Evacor and they negotiate, they settle on getting a test. Well, before we do the expensive procedure, let's do a test.

The test says, yes, he actually does have a serious condition that requires further care, but now the man is dead. He dies the next day. This is the American healthcare system in a nutshell, this fucking tragedy. Yeah, it just happens way too often. And you know, I went to Ohio, we talked to the family, his daughter's woman named Chris Kupp.

I mean, this guy was like, he was the breadwinner for the family. You know, he worked in defense contracting his whole life. He worked in a metal shop. You know, he's this like central, kind of out of simple casting blue collar guy who spent his whole life providing for his family. At the very, very end after he's managed to kind of get together enough money to get the family a bigger, larger home and get them on their feet, he dies.

And that leaves the family back again with Chris Cupp who's driving a school bus trying to keep her kids and her family together now help the help of her father. Her father was the guy who, her father was the guy who was always by her side at every step in her life. And now she's got to kind of live without, without that emotional support, not that financial support all because of some decision that was made far from any kind of direct contact with her father's medical doctor. And what's worth remembering, this is a guy who had insurance.

Yeah. It's not like he was like begging or went to the Sisters of the Poor and said, God, would someone please help me? I mean, he had a doctor who said, you're sick. He had a card in his wallet that said, you are insured. And so despite all of that, he still had at this moment of anguish and desperation is got to navigate helplessly through this completely Byzantine and, you know, to his point of view and anyone's point of view,

probably just completely unintelligible. Passwords, you know, mazes, checkpoints, bottlenecks that he has got to figure out while the clock is ticking on this critical condition. Yeah. Uh, and I think, I mean, that story, thank you for sharing it. And again, makes me angry. It makes me angry because so many people have experienced exactly that story. Uh, it's like absolutely endemic across the country that people have experienced it.

And I talked a little bit in my intro about the public response to Luigi Mangione's murder of Brian Thompson, the UnitedHealthcare CEO, right? Where people celebrated this murder because they see the healthcare insurance companies as murderers. They see them as killers because they have experienced this. They have a friend or a family member who has died.

I can only imagine how Mr. Cupp's family feels about the insurance company's culpability. Now, I read what the insurance company said about, you know, Brian Thompson, people like him. No, this is a man who's trying to get people care. This is a man who's trying to improve the health care industry. I don't want to make it about that guy, right? But that is how they cast themselves.

We're trying to improve access. We're trying to remove fraud from the system, et cetera. Do you feel your reporting shows otherwise that in fact, this is about, Hey, these companies are just trying to save money and they're doing it by turning a dial down on real people's lives, on real people's medical care. Hey, if we get, if we just give out 5% less care this year, turn the dial down, then we make 5% more money. Is that what's going on? I think one uncomfortable truth in our system is there is whether explicitly or implicitly like

rationing of care. Someone is going to decide like that's too much, that dosage is wrong. You don't need that scan. The question is, do you want that decision to be left to a company that has every incentive to say no? Because when they say no, they get more money. The conflict of interest is out in the open. So like the idea that like there might be excessive care, that excessive care, that seems to me like a debate that's worth having and always valid.

But again, the idea you would lead that critical decision to a company that has every incentive to say no. Yeah. Over someone's actual doctor, right? Like my doctor knows me, my doctor has examined me. Mr. Cupp's doctor examined him and said, this is what you need. And then a bureaucrat, maybe with an MD at the end of their name, but a bureaucrat somewhere else at the end of a customer service line says, no, it's, it, that's not the person

that anybody thinks should be making the decision. Sure. You got to double check the doctor sometimes. You want checks and balances, but like should, what's the point of medicine if we're not going to listen to the expertise of the accredited doctor who is examining the actual patient? Isn't that the person who should know? Yeah. I mean, this, this has, there's a lot of subtlety in this. That was pointed out to me by somebody, uh, one of the people we were talking to and it's this.

So like if you're a national healthcare system, like they have all over the world, your main interest is the long-term health of your citizen, right? So you're going to do a lot of preventative care. You're going to encourage going to the gym. You might pay for walks in the woods or whatever else. If you are a insurance company, you know that that patient at the end of the line is somebody who's going to be there for maybe two, three years. They might switch insurance to somebody else. They might go to another employer, get a new job somewhere else. So is your interest in that person's long-term health in the same way that like if you have your own national healthcare system, or is your interest really in just kind of like, I'm going to pay for medical treatment for now, but I'm not going to do

some of the things that are actually cheaper. And in the long run, for a better person, I'm going to focus on the bottom line of making money. And that to me was a kind of real insight into kind of just the very, very, the very base original framing, how you might look at this differently. If you know this is somebody I'm supposed to protect and keep healthy for life,

versus this is somebody I have to protect and keep healthy for the next quarter. Right. And you had to put a finer point on that. I mean, it's, you can imagine for the insurance company, the nightmare scenario is someone's got a chronic condition. You're prolonging their life with a very long and expensive treatment for you. This is a double whammy. You're like prolonging this guy's life in the short term. It's alleviating his pain

in the short term with a costly treatment, maybe an infusion, maybe a cancer drug. And you guys going to just live longer anyway. So you're like, this is the worst scenario for your bottom line. That's a really good point. I know that the most healthcare costs are incurred in the last couple of years of life, right? Like that, that's, that is really where the money goes out the door from the insurance company's perspective is the cancer patient in the last couple of years. Uh,

even I imagine, you know, even folks just dying of old age, right? There's more and more stuff you got to do. But from your perspective, if you're being the cynical healthcare CEO, you're like, well, these people are fucking dying anyway. We're going to pay the most amount of money to keep this motherfucker alive an extra year. Just let them die now. Let's just say no now.

Right. Uh, that, and I really think you make a good point about if you know that you are gonna care for someone over the course of their entire lives as a national health insurer, well, hey, if I spend 10 bucks when they're 15 years old, when they're 25 years old, helping them have good health practices

or getting them vaccinated or whatever it is, all those various things you can do. They'll make them healthier later. You know you're going to save money, but like, I don't know how long people stay with one insurer in the United States. It can't be an enormously amount of time. I'm going to guess it's maybe 10 years. Maybe it would be a long amount of time to stay with one insurer, probably less, right? It's three years. Three years, right? So you would look at that person and say, well,

any money that goes out the door for this person's care right now, that doesn't benefit me, the insurer at all, because three years from now, they're going to go to some other insurer. So I might as well just say, no, no, no, no, no. And then when they get sicker, that's some other health insurer's problem because they're going to have to deal with, you know,

we said no to the MRI today in three years when they need a, I don't know, a triple bypass or whatever the fuck it is. Well, that's someone else's problem. We didn't pay 500 bucks for the MRI now or whatever, how much it was fucked up. Yeah, that's right. And that's because, and that's because, you know, it's, it's not because people are changing insurance every three years. It's because America has this weird thing where our insurance is a tax or employment usually. Yeah. Most people get their jobs through their companies. And as we all know, nobody stays in their job that long anymore. I mean, 50 years ago, sure, you went in and you punched your paycheck every day for 30

years. That never happens anymore. So as we become this much more mobile society, we've actually decreased and decreased and decreased the amount of long-term investment you're going to have in somebody's healthcare because you're just going pop off the next person to the next company and get your next insurance that way. Yeah, completely insane. And that, by the way, is another burden for people

when they switch insurers. I mean, this is my very small scale medical insurer complaint, right? But I had to switch insurers because I was on Writers Guild Insurance. Currently I'm on Actors Guild Insurance because my most recent work was acting last year, not writing for television.

And I'm very lucky to have the insurance, but the main thing I use, I see a therapist, I have to submit a super bill for my therapist. So I did what I do, every six months she gives me the bill, I send her the insurer. They said, well, not only did you send it to the wrong place because actually we work with a subcontractor for mental health care.

So you need to send it somewhere else. Also the whole bill needs to be reformatted. Instead of putting the code at the top and then you went on January 1st, January 7th, January 14th, we actually needed to go January 1st code, January 7th code, January 14th code. So now I got to go back and I say, please prepare me a new bill. And I got to send the thing. And like, this is such a tax on, now this is again, very small scale for me,

not a big complaint, I can handle it. But multiply that by the many millions of people in the United States who every three years have to do this. And just the administration, administrative tax on people's time is immense. And then when you're talking about, if you have an actual heart condition, if you have cancer, something like that, and you're needing to do that, it's insane.

And you've got, um, and, and just to find a point in that, like you talked about, you know, uh, sorry, Fred, you, you, you put that number in the upper right-hand corner. Didn't you know that should be the lower left-hand corner? What's wrong with you? That's the kind of thing that would be SLP positions, but that's the kind of thing that might kind of ties back to the dial a little bit. It would be, you know, if they want to change the parameter who gets approved and denied, it would be picking on things and little changes that would be, sorry, buzzer went off,

you did that wrong, that's a denial. You could adjust that based on what you wanted to do. And it's, it's, you know, the dial is this, it's, it's a consistent theme for the way they operate. Ladies and gentlemen, it is time to take your nutrition to the next level. Meet Huel today's sponsor. Huel is spelled H-U-E-L and it is the global complete nutrition brand trusted by over 400 million people. And right now, new customers can try it for 15% off plus a free gift using my exclusive offer at Hewlett.com. Their Black Edition Ready to Drink is a complete meal in a bottle, high in protein, low in sugar, and packed with all the nutrients you need to perform your best.

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So I want to ask, you said that a couple, at some point in the past, there was less of an emphasis on these prior authorizations, that it was easier to go to your doctor and have them call for a procedure and have it be done. And that the insurance companies started looking for, you know, the prior authorizations became a bigger part of the process. Why was that? Was there some business shift in the insurance industry

that made them pursue this path more deeply? There's one thing I thought was interesting. I was talking to people that had been through this, had been in this industry for like 20 years or more. They said, look, you have to understand, go back 20, 25 years. It might be Patrick was covered for an inpatient acute drug rehab treatment, no questions asked. Two weeks inpatient, bed, three meals a day, physicians attending, all that stuff. And the insurance companies and ultimately the employers paying for this as well. They're like, wait a minute, that seems excessive. Shouldn't someone see it? Patrick

really needs like two weeks of acute care. And so they started to scrutinize that. And then maybe they scrutinized some other things that were like pretty defensible, I'd say, in terms of just giving a second look at what kind of care people should be getting automatically. And then look, you just follow that line, you know, down into the right until you get to where we are now where even something as simple as a lino cane patch, a simple like $10 over the counter patch for pain relief for your lower back,

for instance, talk to patient, what through this, and then they got it. Nope, sorry, you gotta get a prior authorization for that. We're not going to just going to shell out the money for that. And then gets rejected. And then you've got to repeal and the number was in the upper left, not the bottom right or something like that. And next thing you know, the doctor's exhausted, the patient's exhausted. They say, screw it.

I'll just shell out the 10 bucks and just put this behind me. And versions of that happen all the time where they either the visit position or the patient just says, I'm done, I'll just, I'll just pay for it myself. They're skipping. Yeah. And so like, that's a really important point right there is how to use the word appeals. So, AVOCOR, insurance company, they can say, no, we're not going to pay for those

treatment. You can appeal that and you can, you can go through this whole long procedure to do that. But as you just said, Adam, it is the, the, it is the administrative burden on you or your doctor to kind of chase this one little claim for $10 or $1,000. It's just immense because we know the Kaiser Family Foundation has done a study where only 1% of these healthcare claim denials actually get appealed. And the appeal system itself, we tried to, ProPublica, we tried to put together a kind of a map of how you can, you know, a reader's guide,

how can you appeal your healthcare claim denial. And we had a reporter that covering healthcare for many decades try and put together this map. And she spent six or seven weeks trying to do it. And in the end, it was so complicated because every insurance company has their own system of how to do appeals. Federal government has a different system.

State governments have a different system. It was literally impossible to put together any kind of all encompassing map to show this is how we fix things in this country so you can appeal more easily. Insane. And this also goes to something that I've talked about on this show before is if you're in this situation, there are like in some places like pro bono, like healthcare advocates who can help people navigate these systems.

And if you're ever in, you know, one of these thickets, that can be like really useful because it is there is a certain piece of it where it's like, hey, they count on nobody pushing back. And so if you do push back and you are able to find the wherewithal, many people are not able to because they're so sick and they don't have the fucking time. But if you're able to push back, you can often make headway sort of in the same way where, you know, you call your cable company, you're like, my cable bill is too high. And they say, okay, okay, okay, we'll lower your bill.

There is a little bit of that, but they generally make it hard. And you know what this reminds me of is it reminds me of gift cards. You know, why do companies like gift cards? It's because some percentage of people forget that they have a gift card or they don't go to the store. I've got like probably 500 bucks in gift cards sitting around in my house. I'm like, I got to go to that restaurant.

I got to go to like Bass Pro shops or wherever the fuck it was. And you don't use it. And that's free money for the company, because like like it's just some number of people are gonna forget. Now if you take something like appealing your health insurance denial, which is massively harder, right? That probably 80, probably maybe 15% of people forget a gift card, some small number. The number of people who aren't going to appeal a health insurance denial when you make it that difficult is massive. And so that's like free money for the company to do it.

They don't even like have a hunch you're not gonna redeem that def card. They know down to the percentage, to the dollar amount. They've got that all priced out. They're not like, but this guy's not really gonna redeem this. They know exactly and put that into their calculation of how hard to squeeze you.

Yeah. And it makes sense to me also why a lot of times They know exactly and put that into their calculation of how hard to squeeze you. Yeah. And it makes sense to me also why a lot of times when you go to doctors, they, you know, have their own defensive way that they work with insurance. They'll say, oh, we don't put this through insurance. You have to pay out of pocket for this. And so a lot of like, you know,

affluent rich people who have insurance get used to, well, even though I have insurance, my doctor, well, I pay a couple extra hundred bucks for this or that because, you know, I can afford it. And we all agree that it's like too much of a hassle to even work with my insurance company on this. We end up creating all these weird defensive practices in healthcare just to accommodate these fucking awful companies. Yeah, I mean, if you're a doctor and you've got a, so in an appeal, the first thing you might have heard of these before your listeners, uh, these peer to peer reviews, right? And that's where the insurance company says, no,

we're not going to pay for this. But if you want to have a, uh, if you want to have your doctor call our doctor and they can talk and you can argue why we need this procedure to actually be done. You know what? Your doctors just get paid for that. Your doctors don't make any money off that. Right.

It's like the cable company window, you know? I will call you from like four to midnight and at some point in time, during that time, your doctor is going to be available to talk to the insurance company doctor about why this is the procedure that I think is right. And so, it's not surprising that a lot of doctors aren't going to be that aggressive in following up and trying to do an appeal because it's a lot of time for them. It takes a lot of money that they're not making on seeing more patients. And so it often falls to you.

You're the one who's going to have to sit there and send in a lookup on some scientific website, the journal articles that show that, yeah, this proton beam therapy, this radiation treatment, that really is good for my kind of cancer. Who has the wherewithal to do that? Who has the ability to kind of go through a bunch of like peer-reviewed journals, submit those to the insurance company, and hope that they will say they will be convinced of the error of their ways. But yeah, indeed. Yeah. You should get some sharps. Cafe.

It's just doesn't happen all at all. It's just, it's so incredibly difficult. Yeah. So do you feel that this, the rise of these prior authorizations and ever core and the dial, I mean, we've seen so many companies in the past few decades start to squeeze their core product in order to improve their bottom line. You know, um, I think about, I go to the grocery store, there's less cashiers than ever. You know,

I feel the way Corey doctor is phrasing shitification, which I am broadening a little bit, but this general feeling that you interact with these companies and you see how they cut their service to the bone to save a couple bucks and they actively make their own service worse. And it's just, you know, it's capitalism operating, demanding constant growth, demanding growth in profits. And they, oh, if we cut a cost here, we cut a cost here, we cut a cost here, we cut a cost here.

They keep doing it until the entire thing fucking sucks ass, right? Is that what has happened in the health insurance industry, but they've done it by cutting out on, cutting payments to their own, their own patients? We can, we can trust one person who saw this up close for many years. We did a story about a year ago now about a woman at Cigna who had been one of these medical directors,

which is a doctor hired by Cigna to review these claims and or requests for care. And she said, it wasn't like that when I started 15 years ago, where we would, you know, as peers, as doctors, I mean, these are physicians who, who I imagine got into the industry and the profession because they had a calling of medical service of some kind. And they would huddle together and say, Hey, look at this case. Does he think this guy really needs this acute treatment or not?

And they would think about it and they'd be able to take a breath and talk and work it out together. And then by the time she quit, but a couple of years ago, they were being monitored, you know, minute by minute to how fast they were doing these, these cases. And also no scrutiny for what happened downstream from these reviews. Then even like, Hi, I wonder some kind of longitudinal study, like Patrick, is he any good at his job?

Like when he denies his cares, do these people end up dying? There was not even a whiff of a scrutiny of the kind of reliability or quality of the work these doctors were doing in the last couple of years. That's a really good point because what they are doing is saying, hold on a second, do these doctors really need to assign this care? Does this person really need the inpatient stay for two weeks or whatever? Let's be really sure about that. But what they're not doing, according to you is saying, Hey, when we adjust our dial, are more people dying?

Like these people ensure millions. So they could do a study and say, how many patients have died? Well, just over the course of our reporting for years, we've been doing this for two years now, we asked one way or the other, countless times, guys, Insurance Industry X or Company X, give us one sign and memo and email and directive to all the staff,

anything that showed that you had some kind of concern or like we're measuring how reliable or how good these decisions were being made. And we never saw anything. And I'll tell you something else. One of the things that's so like, like Patrick said, capital form and ProPublica have been reporting on this stuff for almost two years. And so, you know, being reporting nerds, we go to like a lot of the conferences, we kind of pay attention to the conferences in the insurance industry. And I will tell you, it's amazing the rush to embrace AI. I mean, it was like

in a lot of other quarters, it was kind of a lot of reluctant and is AI a good thing or a bad thing? I mean, the insurance industry is just like full ahead trying to do what you're talking about, what Cory Doctor talked about, the inshittification of everything is like AI is going to solve so many costs and count so many steps we now have in our process that there's really no question about whether or not that's going to end up being a good thing for the patients or how is it going to affect actually health versus how it's going to make it cheaper to deliver healthcare. I'm sorry.

That is so chilling. They are rushing to embrace AI to make medical decisions for the people that they ensure. Uh, so that means that no longer will it be my doctor requests care for me. It goes to the insurer. No longer is it a person or a doctor at the insurer? It's an algorithm. It's they're just going to run it through a system. And that's going to say yes or no. What possible justification is there for that?

Well, so in the story that Patrick was talking about that he did last year with David Armstrong, one of our colleagues, about Cigna's making decisions, what they found out is that basically what had occurred is that the doctors were teed up. So there's a medical doctor at the end of this process who works for the company that makes a final decision, What they found out is that basically what had occurred is that the doctors were teed up. There's a medical doctor at the end of this process who works for the company that makes a final decision, but that doctor is not involved until the very last minute.

What they found was that Sydney was making decisions in less than a second on whether or not to approve or deny medical care. Then the doctor would sign off on that in the most technical definition of sign off. In other words, they would never open a file, but there'd be a sign off on it, right? So yeah, they could still say a doctor signed off on this decision to make a, to reject a particular procedure. But I mean, the involvement of the doctor was, I'm going to tell them, Patrick, was like the second, I wonder what it finally was.

There is a final part of the bottleneck is a doctor has to look at the denial. The AI can, you know, hum and do its work and make a big pile for the doctor to review and sign off on. But you're a doctor who now is looking on your desk at a mile high stack of paper that is all, by the way, primed for denial because AI has done all that. Or you got to just pick up your pen electronically and just sign off on it. And you're going to feel a lot of pressure to do that when your manager is breathing down your neck saying, what's the matter, Susie? Can't you hurry this up?

But just see how the pilot getting any smaller. So there is ultimately that final, my fingers in the air check on the, on the, on the decision that the robot might make. But if you're, if your doctor is under duress with an inbox, crowded to the sky, I don't think it's a surprise what kind of decisions you're gonna get. Yeah, I mean, this sounds like the kind of doctor that if you use one of these online pharmacies

to get dick pills, right, or Rogaine or whatever it is, these very low importance medical procedures, and you go on a chat with the, you know, like, oh, a doctor will approve it. And it's just like a chat saying like, do you need this or that? And you're like, yes. And then they, you know, they just give you a check.

And then they say, right? It's like the doctor is barely involved. They type 10 words into a chat box and then, you know, ship you whatever. That's like a big part of the medical system now, at least for those particular pharmaceuticals. That's one thing for cosmetic treatments or lifestyle drugs or whatever. It's another, again, when this is accepting or rejecting a claim for cancer treatment, or for surgery, or for something that actually affects people's lives.

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Factually use code factually to get 40% off your first box and a free item of your choice for life hungry root.com slash factually Like what what do we know about the technology that they are calling AI? Because you know, the AI that everyone is excited about is large language models, is generative AI, which is just a fucking word salad machine. And that is useful for a couple purposes, right? It's useful if you want magnetic poetry, you want something to assemble some words for you to take apart later as part of your creative process. It's like dubiously useful as a search engine

and shit like that. It does not make medical decisions about people's lives. It's just like looking at the entire corpus of human text and outputting a plausible response, right? That is what it does. It does not actually reason, but it produces text that humans mistake for reasoning. That is the fundamental purpose of AI. So, or of large language models specifically, is that what they plan on using

or is there some other thing that they're calling AI? What the fuck are they talking about? Well, so like in the case of Evacor, for instance, I'll say two things. Number one, AI is definitely a marketing buzzword. So when there's an insurance company talking about using AI, they might be referring to just very simplistic, like you can't order a vitamin D test if you don't have a vitamin D problem, right? That's not AI. But in the case of Evacor, for instance, that's how they would actually manipulate the, their algorithm would say, based on all the previous cases that we've looked at that look similar to little John Cupp's heart condition, I think that, yeah, you probably should have

this test. But I think that with only about a 70% degree of certainty, right? So if you're an insurance company, say, okay, 70% degree of certainty is okay, go ahead and give that test. But if they want, no, no, you got to be way more certain. I want you to be 90% certainty that this guy needs his tests or else let's turn it down. That's how they would actually adjust that. And it was actually a legit algorithm using large language modeling based on medical records, hundreds and hundreds of thousands of medical records they had seen in the past. And that's how they would make their predictions to whether or not some guy with this kind of medical record

needs this kind of treatment. And you can be sure that this AI machine does not have a stethoscope around its neck or is ever going to feel your pulse unlike your doctor. Right. Because, I mean, humans are not an assemblage of past medical records where individual people with our own histories, who are again being treated by an actual person. Like, you say what you will about the American medical system.

For the most part, you do go see a doctor and the doctor talks to you. I guess there's a lot of people who have trouble accessing a doctor. I shouldn't get too far out over my skis there. But like, when I am in a room with a doctor, the doctor is touching me and listening to me, and that's how it's supposed to go.

It's supposed to be a one-on-one interaction. To have that then be overruled by an algorithm that is just looking at past data is insane. And the two things about this that I think are so disgusting are that A, first they're cutting to the bone by denying more care. But now that they've done that, they are now cutting to the bone even more. Why are they excited about AI? Because it'll help them cut the costs that they incur by denying the care.

They're like, we're spending too much on our care denial system. It costs too much for us to say no. Here's a way for us to say no cheaper. So now even the doctors who they were employing to say no to you before, these fucking stooges who are agreeing to be a part of the denial system, those people are being cut out and now they are just at the end of an algorithm.

So it's the enshinshitification of the en-shitification. Well, and you're right, they never get tired of looking to cut costs. If you think they're ever going to reach a point where they're like, hey, I don't know, you think we've done that enough this quarter? No, no, no, no, no, no. Like they are never tired when it comes to finding ways to reduce costs and cut it to the bone, as you said. And is there not a regulator anywhere who can say,

I mean, if they get to a hundred percent no rate, that would sure make them happy. What if they come up with an AI that just says, no matter what, it says, no, we reject you. It doesn't like, is there anybody in the country who has oversight over these companies who could say, actually, that's too high of a no rate. You are no longer serving the purpose of being an insurer. Like people are no longer receiving care at all.

What is the guardrail against this behavior? Ultimately, and this is happening in some states, the lawmakers are saying this is ridiculous. Like in Texas, they have something they call a gold carding system where like if Dr. Patrick has never been found to committed a fraud or have that judgment, you can't, the bias would be Dr. Patrick's going to get the treatment that he's requesting for his, um, you've used your name by the way. I just want to say you've both been,

you've been a patient who was in drug, uh, rehabilitation. You've been a doctor who was denying care to people, working at the insurance company, and now you're a gold card doctor in Texas who has a hundred percent record. So you've lived a really varied life and I love that for you. Patrick is around, Patrick is around.

Sorry, go on with your point please. Oh no, and I think, so I'm in North Carolina, I mean I would pick up the paper the other day and there's an effort in North Carolina to ban, the headline was ban prior authorizations. So some people have had enough. I mean, what's gonna get hard about this is ultimately denying the prior authorizations is gonna,

the employers are gonna have to pay more, insurance companies might have to like, put less money in their pocket in terms of profits. So they'll be, yeah, there'll be some back and forth, but I think some States have decided, uh, due to pressure, maybe due to some things they've read and, you know, and some reporting that, that this is just indefensible. But I mean, relying on state legislators or Congress to do something about this,

does it's cold comfort to, to imagine that that is that we're going to have a legislative fix for the health insurance system. When again, I, every time we talk about health insurance, I have to bring up that Barack Obama's signature achievement when he ran on healthcare reform and had a 60 vote majority in the Senate, a filibuster proof majority was the affordable care act, which was at the time lauded as a Titanic achievement. It was like one of the largest pieces of legislation,

one of the most impactful pieces of legislation passed by any president in the past 20 years. And here we are. How long has it been 15 years later? And no one's sitting here going, hey, the health insurance system is good in America. Or even, I mean, I think more people are covered than were back then. That's an improvement.

It is now easier to go with a, it's easier to get a very low quality of, you can now pay a lot of money to get very bad insurance. You didn't used to be able to do that before the ACA. Apart from that, we have that was the effort. Like the Democratic Party spent fucking, you know, four years trying to make that happen. And that was the best we got. So the idea that the legislator either in the state or in Congress is going to help us doesn't seem super likely because we'd have to go through all that shit again.

Well, here's some worse news. Oh, okay. Thank you. Please hit me. I can't wait to hear it, Patrick. Well, just that these insurance companies, when they say no, that is not considered a medical decision.

They are not saying you can't get the treatment. You can go pay for it yourself. So they're shielded largely from liability if something goes wrong. Really? There are cases, you can, in some cases where they sue and they can when they settle. But for the most part, the insurance company when they say no, it's not deemed legally turning down their care. You're just saying this is a cover.

So there aren't a lot of place to get a toehold to fight back for for being denied and claiming you were harmed. And here's here's another thing, though, is that going back out on what you said, there actually are tools right now in place that that were enacted under the Affordable Care Act, that is just never put to use. So one thing we hear often is more transparency, just like let us shop for insurance programs and I want to know what your denial rate is. I want to know what percentage of requests are you turning down.

That legislation to require that, that exists so the federal government could right now begin asking for that information and may simply never have. So when we talk about getting back to this bizarre thing that the Department of Labor oversees most insurance, there's 160 million people whose insurance is covered by the Department of Labor. There are about 400 people in the Department of Labor who actually monitor the healthcare provided to those 160 million people. They literally never make a decision on any kind of individual case.

They do like big picture stuff like insurance company X is denying thousands and thousands of procedures. But like if you individually have a problem with your healthcare, you're basically not going to get listened to by anybody. So the tools are out there, the system's out there, there's never been enough resources or money. And I know that that sounds ridiculous now in terms of the current administration's desire to cut and cut and cut. But if there do exist mechanisms to increase and step up just transparency, enforcement, all those kind of good things that just have never been enacted under repeatedly different administrations.

So, yeah, why haven't they been pursued when they're in the statute? And you know, we've had a couple of administrations who putatively care about this issue, so why not more enforcement? I don't know, I like campaign contributions. Okay, yeah, I mean, that's a pretty good explanation. It seems like there's a lack of belief on the part of anyone

that this system can be changed after the Affordable Care Act. I mean, the folks who support single payer healthcare, I've been around for this entire debate that, okay, let's zoom out a second. Even if we were to ban prior authorizations, right, nationwide, I'm still looking at it going, hey, the insurance companies are giant corporations

that operate under capitalism. They have, as big motherfuckers as I think the CEOs and the executives are, they are merely the recipients of the pressure placed upon them by Wall Street and the economy at large. That pressure causes them to need to cut that, or that pressure causes them to need to increase their profits.

There's only so many people in the country, how do they increase their profits? By cutting, by inshitifying their product. And so if we were to say, well, you can't inshitify this way, no more prior authorizations, they're gonna find another way to do it. And so the problem is that we're trying to provide a public benefit that you cannot really provide

at a massive profit, but via capitalism, and that's the fucking problem. And other countries have solved this by not providing that via capitalism, instead they do it via the state. And we have many things in America that we provide via the state because you can't make a profit off of them, such as roads. Right. You can't, I'm sorry to go back to like economics one-on-one here, but like, you know, we all agree we probably shouldn't try to have some company make a profit

off of roads that should just be a public service. And so we provide those via tax dollars. We could do that via healthcare. That's what single payer healthcare is. Every piece of research ever written shows that that is a cheaper way to provide better care to a large population. And almost every other developed country in the world uses that method with better success than we do.

And people have been making that argument in America for 25 years, and we have not been able to do it. So it feels like we have decided as a culture, well, I, we're just stuck with this because I don't know. I mean, Bernie Sanders ran on Medicare for all very vociferously. Even the Medicare for all people on the left have kind of quieted down a little bit about it because we know it's not fucking happening. I hate to be a doomer on here because normally I'm, I'm, Hey,

here's the positive shit we can do to change the world kind of guy. But that's, that's sort of where I am on this issue. I'm just curious about you guys. How do you feel about it? Go ahead, Chief. I was going to say that like, so, you know, one of the benefits of being an investigative reporter is you spend a lot of time and get really in depth on something. And I covered a lot of different things in my life. But when you really begin to look at any kind of intensity at just how large the economy is of the healthcare sector so

that it's 17% of America's GDP depends on the money making that goes into health. Wow. How do you extract that system in any way that doesn't leave behind economic carnage to doctors, companies, people who are employed by these companies. Like how do you begin to fix that system? That's why, you know, Obamacare was this kind of effort to kind of wrestle with the reality that this is an important industry. It does a lot of good for a lot of people.

It makes people a lot of money too. How do we sort of reconcile that with, as you point out, there's all kinds of studies that show you that America's healthcare system does not provide anywhere near the kind of healthcare outcomes that other countries' national systems do. So how do you kind of achieve that? It just, you understand how really impossible it is. This is not something like Meyer, like whatever, we need to change, we need to privatize something or not privatize something. It is really hard to fix something that is almost a fifth of the world's largest economy. I really appreciate you giving me that perspective of how difficult it really is and how many

people's livelihoods rely on it. And even if you were to statutorily impose the best possible system and you were to say, we've dotted every i, crossed every t, this is absolutely the best possible system, and you were to say, we've dotted every I, crossed every T, this is absolutely the best system it could possibly be, you are going to disrupt the economic lives of millions and millions of people who are participating in this system, and that is very difficult to do politically, even if you do it perfectly. That is the incredibly high bar we have to jump over.

It reminds me of one of the best explanations I ever heard for why did it take so long to eradicate slavery in America is because a huge part of the economy of America was based on it. How do you remove root and branch a system like that, that it literally the entire country is based on? Climate change has the same problem.

Fossil fuels are embedded in our society that deeply. And that's what this makes me think of, that our horrible healthcare system that results in death and waste and fraud and abuse is that deeply embedded in our economy in the same way. And that's like the most difficult task ever to uproot. Patrick, please go ahead. Well, just I don't know if we call this hope or just realism or what, but there are ways that we don't have to stretch our brain that hard to think about ways that can make this

at least a little better. Like, you know, there's a flip on your light switch in your house. You know who runs that? A power company. You know how they're regulated? Well, pretty heavily. They have very like modest returns to investors. They're heavily regulated. If they want to raise their rate, they have to get all kinds of clearance. They can't go to Wall Street beating their chest and say, we're going to grow 10% a year until Kingdom Come. They are like, there is a model for a modest return on investment. It's called a power company. So if they were regulated and operated more like power companies and less like whiz bang,

you know, uh, dynamos on Wall Street, that would arguably seem to help. The other thing is Medicare for all, Medicare Advantage or Medicare for all. That is a system that captures everyone over 65. It operates. Yes, there's problems. Yes, it's often in the red. That is a system where you don't have, we've eliminated the profit motive and you have a nationalized healthcare system for everyone over 65.

So again, this is a brain exercise. It's not that hard to think about lowering that down. So you're catching more of the population. So that this, some of these alternatives are, you know, without having to, everyone hit the floor with shock to think about a single payer system, there are like ways you can improve this system that that involve more care and concern for the patient. Right, so it's expanding what currently works, adding regulation, expanding Medicare.

That could, we do that over the course of the next 100 years, we improve people's lives and we get ourselves towards more of a sane system. Rather than doing what the Clintons were considering in the 90s. Let's replace all of private health insurance with a single payer system. That, that's not happening, but the Medicare for all pledge that was Sanders trying to sort of reckon with this system and saying, let's expand the most popular best thing that

we have and start there. Right. But you do have to understand we're still operating in this world of economic constraints, right? So when you went back to like, why are we at where we are? It was really the federal government back in the 70s that was looking at paying healthcare costs

and wanting to keep healthcare costs down. Because prior to that, insurance companies don't care. If you want to order a bunch of fake tests, if you want to order a bunch of too much medicine, that's fine. We're just going to raise your premiums next year. We're just going to keep raising them. I'm sure it's got to be, they don't care how much you spend, as long as they can keep raising premiums over and over and over again to cover that spend. So it was the federal

government back in the 70s that began to say, we, the taxpayers, are spending way too much money on healthcare, so we need to create this HMO, these HMOs. That's where the HMO act. And that's where you first begin to really get this idea of rationing care, to hold down taxpayer costs and to have like a smooth growth in expenses for taxpayers. So that's where that begins. I'm missing something because how are taxpayers paying for, I think of an HMO as being private insurance.

So how are taxpayers paying for it in the 70s? So Medicare and Medicaid are right now still, like 100 million people are covered by, more than 100 million people are covered by those two programs, right? Yeah. So back when Medicare and Medicaid were paying for higher, higher costs each year,

then Nixon administration passes the health maintenance organizations to overall hold down costs across medicine and across medical spending. And they create these insurance plans where health care, you can only go see one certain doctor in one certain place. And the idea is to kind of hold down medical costs nationwide. And that's where you begin to get into rational medical care really. So this isn't a problem that has always existed. It came about in a certain response at a certain time when medical costs were going up and up and employers were having to pay those medical costs a problem that has always existed, it came about in a certain response at a certain time

when medical costs were going up. Not an employer having to pay those medical costs for saying, we need to hold down some of these medical costs because we're just getting hit with more and more bills over the year. I guess the point is, well, one point is that, and this is the part that's hard to talk about, again, rationing care. Someone has got to decide this is needed. This isn't the question is, do you want to leave that to a company that has an incentive to say no,

or an agency or a gatekeeper who is, doesn't have that incentive because the pressure to, you know, costs are going to go up. There's going to be pressure to like, you know, have more care. Um, the question is, who's going to be the person that's going to judge that. Yeah. Well, what I find shocking about this issue still is you, you two have revealed, you know,

a shocking detail about how these companies deny care, right? That there is this subcontractor called ever core that literally just year over year will be like, ah, a little bit less cancer treatment this year for a couple million people to save this company some money so they have a better return. That is absolutely shocking. At the same time, you are revealing something that the public already knows because the public has experienced it.

Like there's probably not a person in the country who hasn't grappled with their health insurer at some point. And yet, you know, it seems to be one of the most intractable issues. So I'm just curious, do you feel insane, you know, that you are pointing out, you know, you're doing the foundational investigative reporting that we deeply need on the topic. And yet you are adding to the evidence that we all already have of how fucked up

this system is. And we've been having it for decades and yet we haven't made improvements. I will say that is, is, uh, when you, that is something that frustrates me. So, uh, Patrick and I are both investigative reporters. We've done this a long time. Any investigative reporter with her salt wants to make the world a better place. I do feel a certain sense of frustration when I'm writing about this, when I realized, you know, I heard this reporter number 6,257 who's reported on these things.

And as you said, it's been going on year after year and year. How do we fix the system? It's just that it's like, I can write one story about some abuse, some sort of like corruption that's happened in LA and the LACA council will hold a hearing, we'll kind of fix those things up. Great. But this, this problem, it's so big and it's so giant that what can any one person do? And the answer is, it's really, really hard.

That's why you probably haven't seen any major healthcare legislation since 2010, because nobody came out clean. Everybody got burned in that reform. Everybody came out exhausted and battered and bruised. And so you take on a tiger, you're gonna get scratched. But you might wanna like remind ourselves in case you're wondering, like, am I crazy? The answer is no, because we've talked to a lot of people in the industry who'd worked there for

five, seven, 10 years. Some go in, take one smell and they're out again. Cause they know what's going on and they don't want to be any part of it. Others find a way to stay and they eventually, once you talk to them past point of five minutes where they get past their talking points, no one's defending this system. So there's nothing about this. Like we're missing something or like it somehow isn't a redeemable part of this that we're like not getting just as a starting place. You're not crazy.

I'm curious if the murder of Brian Thompson has changed the tone of what you're hearing. I assume you've talked to folks in the industry in the couple months since in your reporting. And, you know, look, the work you do is invaluable. The anger it generates among the public is real. The public is angry about it. And yet, you know, having this one moment where a man is murdered explicitly because of the business practices of the company, that is the stated motive for the murder

is really a remarkable event. Do you see any evidence that it has changed the thinking of anybody on the inside of these companies? I mean, the companies themselves have one incentive and one motive. They don't answer to the doctors, the patients, they answer to their shareholders and the analysts who are breathing down their neck.

So, I mean, that's not to smear anybody. That's just, that's a simple arithmetic. I mean, that's, so past- The feelings of the people on the inside don't matter. Well, to some degree, I mean, I do wanna say this. I do wanna say this. You know, it is not bullshit that people who are in health insurance companies want to help people.

They get paid money to dole out money for healthcare. Do I think that most people in the healthcare business are like greed heads who want to deny claims? No. When we're talking about denial of claims, most claims get paid. That's the bottom line. Most claims get paid in this country one way or the other. But it's that 10%, that 20% of claims that don't get approved, don't get paid or requests

don't get approved that is infuriating. I think that health insurance executives that I've talked to talk about wanting to tell a better story. And that might be bullshit, that might be kind of PR stuff, but there is some truth to transparency, like sunlight coming in. Let's take a closer look at what it is you're doing and why you're doing it and what are your rules? We don't know what your rules are to turn something down.

We don't know what all these little subcontractors are. Tell us more about what it is you're doing it and why you're doing it and how you think it could be made better. Don't just sit back in the dark never commenting on these things or never saying anything about why it is that these decisions are happening until you're caught in some very public situation where you've denied some kid a cancer treatment and all of a sudden you've got a kind of like back pedal. So, you know,

this might, I don't want to sound like an industry shill, but I do want to represent the idea that the healthcare insurance and health insurance industry does things for a reason. And it is like, you can't expect businesses to necessarily operate for good reasons. Businesses operate to make money. It's the government, our government that regulates the kind of shapes and influence the behavior. So if you want to really fix the healthcare system, maybe you can rely on private industry, but really you should be looking at like, why aren't there more people in regulating the stuff that thank you so much.

That's such a wonderful overview of the problem. Uh, and it's the problem of humanity because I fully believe that most of the people who work for these companies are good folks who want to help people because honestly, most people in the world are good folks who want to help people. That's the human condition. Humans are generally good. The systems we create are bad and harmful. And humans, when placed into a bad system, will aid and abet bad outcomes. And most of them are like, I'm doing my best fucking here, but you know, like this is what the system imposes upon me. Right? I wish I didn't have to read ads for companies

to do my podcast, but that's the only way I can pay for my podcast. So I make my little compromises, right? We're all, there's no ethical behavior under capitalism. Right? Now I do think there's one exception, and that's the people at the compromises, right? We're all, there's no ethical behavior under capitalism, right? Now, I do think there's one exception, and that's the people at the very top, right? It's the CEOs of the companies,

the people who have the most power and the people who profit the most and are the most able to say, you know what, this system is bad, let's change something. I do find those people to be culpable. But again, it's a systemic problem of the system that we have all created for ourselves. We need to change the system

if we wanna change the outcomes. We have a system that incentivizes people to, incentivizes good people to do bad things. Where is our power to change the system? It's the government. It is our democracy. We all vote for leaders who ideally put regulations in place who change the system to make it better

as they have done in some countries. We just have not done it in the United States. And of course, our democracy's all fucked up, it doesn't work perfectly, but this is unfortunately the way the world fucking works. This is how humans behave when we get together. Thank you for allowing me to sort of like, teeing me up to relay my core beliefs

about how human society functions. I think the health insurance industry is a great example of them. to relay my core beliefs about how human society functions. I think the health insurance industry is a great example of them. It's a fucking devil of a problem. This is the problem of human society writ large is what we're talking about here. And I can't thank you guys enough for coming on the show

and more importantly for doing the work that you do because you are, if it were not for investigative reporters like yourselves, we would not even know exactly how the system is failing us and exactly how it needs to be fixed. So you are doing the very basic work that we need done at a time when there's less and less of it being done than ever because of the death of journalism in this country for reasons that we've talked about

in other episodes of this show. I'd love for you to talk just for a moment. You mentioned ProPublica a few times. We love ProPublica here on this show. I just love if you could talk for a second about what you do, the work that ProPublica does and how people can find more of it and support it to round us out here. Yeah, thanks for that up for me. So ProPublica, we're a nonprofit, non-partisan organization that does in-depth investigative reporting.

And as you noted, that's vanishing in a lot of newsrooms throughout the, throughout the country because of our business situation of our industry. The newsrooms themselves are vanishing, let alone the investigative reporters. Yeah. So we have about 200 reporters who work at ProPublica, do in-depth investigative work and all kinds of things. Please contact us, especially now, if you have any kind of tips. I want to make a special little plug here.

We are continuing to do investigate payment denial to doctors practices. So if there's any doctors out there in your audience, any billing managers out there in their audience who want to share with us their stories about billing problems, please get in touch with me, T. Christian Miller at ProPublica or Patrick Tu at Capital Forum. Let us know. We were doing some data work that we kind of want help on. So yeah, we are a nonprofit company that's trying to do the most, solve the most difficult problems and look into the most in-depth issues to try

and kind of expose them and let you, the public figure out how to fix it. And one more, and not just, that's, that's all true. And also if you, insiders in the industry here are listening to this and they're snapping their pencils that they're angry and feel like there's something on their chest. They want to get off. Please as well. Those, those are, we can't do our work without people that have got firsthand knowledge and understanding of how the system works. So, uh, of course invite and hope that those people give an impulse to get in touch. Don't, don't fight it. I love that you are ending. See, a lot of times I end our episodes with what can people do to help? How can they get involved? I love that you guys are pitching.

If you have inside information about corruption in the insurance industry, tip off these investigative reporters. That is incredible. And I know that I talked about how frustrating it is to constantly be screaming about these issues. It's because I feel it myself. You guys do the original work.

I'm the broadcaster, right? I see my role as taking, trying to signal boost the investigative work of what you do. And I'm like, I've been doing this shit for over 10 years and the problems keep getting worse and I get a little frustrated. But I have to have faith at the end of the day

that when we bring sunlight to these issues, that is the first step. It is necessary work that needs to be done to, uh, uh, you know, build a better world for all of us. And so I thank you for being a part of this project and for coming on the show to talk to us about it. It's just incredible work. And, uh, thanks for, thanks for really pissing off, pissing off all of us today.

Thanks, Adam. I would be, we could be there to serve that for you. Thank you so much for coming on and please everyone listening, go check out ProPublica and your work, Patrick and T thank you so much for being here. Thank you. Thanks. Well, thank you once again to T and Patrick. If you want to check out their reporting,

head to pro publica.org and please support them there. If you want to support this show directly, you can do so on Patreon for five bucks a month. You get every episode of the show ad free for 15 bucks a month. I will read your name in the credits of the show and put it in the credits of every single one of my video monologues. This week. I want to thank Amy Thor Tron, David Snowpack, Eric Carlson and scooty. Chimkin nuggy. Thank you so much.

Scooty Chimkin nuggy for supporting the show. If you want me to read your dumbass username live on the show, that no offense scooty Chimkinuggy, thank you so much Scooty Chimkinuggy for supporting the show. If you want me to read your dumbass username live on the show, then no offense, Scooty Chimkinuggy. It's actually a very charming and intelligent username. I will read any username, no matter how dumb or charming it is. Just go to patreon.com slash Adam Conover, 15 bucks a month, or support the show at any level you want.

Once again, if you wanna come see me in Omaha, Minneapolis, Chicago, Boston, Vancouver, uh, where, uh, Eugene, Oregon, tons of other cities had to Adam Conover.net for all those tickets. I want to thank my producers, Tony Wilson and Sam Roudman, everybody here at Headgun for making the show possible. Thank you so much for listening. We'll see you next week on factually. That was a HitGum Podcast. Hey, it's Nicole Byer here. Let me ask you something.

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