Inside the Healthcare Denial Machine

From 2007 to 2008, I worked at a small firm that helped put together patient reports for the big health insurance companies. Here's what I saw.

My first job out of college was in the medical insurance industry, as a technical writer, back in 2007. With an English degree and no actual skills, a recruiting agency had placed me in the role solely because I could type fast, which I attribute to years of talking shit in CounterStrike.

The company—which no longer exists—was based in Irvine, California, a wealthy and anodyne suburb in Orange County, where I went to school. My job was to help doctors put together patient reports for insurance companies like Liberty Mutual, and a recommendation was made as to whether the specifics of someone’s injury entitled them to care.

It was a motley crew of tech writers, and we’d always grab lunch together. The veteran was a Mexican guy who commuted in by bus from Santa Ana who loved rap and was always sending me links to DatPiff. Also of note was “Dirty Dave,” a handsome former frat guy on the med school track who always had a few eBay tabs open for “Ed Hardy.” (The “dirty” distinction… I’ll leave that to your imagination; he was a fun hang.) There was a fancy Korean guy with great hair who was excellent at his job but rarely talked to anyone, as he seemed to loathe the concept of work. And, a little later, a fancy and sweet Korean girl who dressed really well for Orange County whom everyone had a crush on. (I was told much later that they would end up dating.)

It was mind numbing work. The days would circle into themselves, but I was young, stupid, and just grateful to be making $13 an hour—enough to pay rent (I lived in a non-insulated garage in a house with four other guys for $600 a month) and get fucked up on the weekends.

The work itself was easy, and occasionally gruesome. We were processing dozens of cases a day. The beats of a typical patient report went something like this, and ranged in length from a single paragraph to twenty pages, depending on how complicated the injury was:

Patient X is a 39-year-old construction worker who fell from a second-story balcony at his job site. He sustained a concussion and ruptured spinal disc at C4, and is unable to work. The patient is requesting NSAIDs, chiropractic care, and lumbar back support. Based on the evidence provided, our recommendation is…

Most of the doctors were retired or weren’t actively practicing, for reasons we didn’t dare inquire about; they sat in another room, in a cushy corner of the floor with natural light. Once the doctors finished going over the patient’s paperwork and writing their reports, they would print them out, make the short walk over, and drop them in a little wire basket where one of the technical writers would grab them to work on.

As far as the physicians went, there were a few favorites. If Dr. R—a genial and clean-cut man with a quick smile whose reports were always concise and pristine—dropped one of his packets into the basket, we’d all rush over to try and grab it first; it was an easy notch for the day’s quota. The same couldn’t be said for someone like Dr. K, who had a tendency to ramble and for whom coherent sentences posed a unique challenge. His reports would often languish in the basket untouched until one of us caved.

As technical writers, we were less writers and something closer to editors. We were asked to format reviews a certain way and refine the doctors’ work into something that made sense to a layperson.

As I came to understand it, our company was just another layer of invisible bureaucracy in the insurance machine, and one of our duties as tech writers was to strip out the humanity in each of the reports.

One of the words we were tasked with editing out was “suffered”—which the doctors still had a tendency to use. (Except, notably, Dr. R., the consummate professional.) A patient, for example, couldn’t “suffer” if his sleeve happened to get caught in a plain miller at work, grinding his thumb and index finger into hamburger meat. The preferred term, per the insurance companies, was “sustained.”

Our job was to apply gloss, to smooth out and render pain in the most unremarkable clinical terms. We were never given exact figures, but I quickly realized that only a small minority of patients were receiving affirmative recommendations from doctors for the care they had requested; maybe 15 to 20% on a good day. Most of those were to alleviate back pain.

I lasted a little under a year there. I had become numb to the suffering and needed a change, so I moved to New York in the fall of 2008 with a few hundred dollars and not much else.

One day at my new job in New York, I received a Gchat from my old coworker, the one who was always putting me onto new rap tapes. He said that our favorite doctor, Dr. R, had killed himself in his car.

From a business perspective, the whole racket was kind of brilliant: Millions of people buy in to health insurance plans, and yet, a tiny fraction of that money is actually used to help anyone. The insurance companies had made the calculation that contracting out to third-party providers to rubber stamp their No’s was a far better use of their time and energy, and better for the bottom line. A patient could submit all their paperwork and get all their MRIs and X-rays and prescriptions in order, their hardship and suffering self-evident, and still be denied any form of basic coverage. It’s not difficult to understand why everyone is fed up. Roll out the guillotines.

That said, I used to think that our healthcare system was broken. But the modern wellness industry, at least as I’ve come to understand it, is just another byproduct of a system doing exactly what it was designed to do: extract as much capital out of its devitalized constituents as possible. Would we even need “wellness” if we had a healthcare system that took care of us?

One last quick story:

A few years ago, maybe around 2018, my not-yet wife and I were walking down Dekalb in Fort Greene, on our way to dinner. It was a gorgeous summer evening. Then we heard a loud crash behind us, that discordant scream of metal on metal.

A woman on her bike had run a red light and was hit by a car. The street was busy, and about a dozen people all sprung into action to help. Someone chased down the driver to make sure he stopped, and someone else grabbed her gnarled bike, which was somehow 12 feet away from her.

I was in a small group that moved to get her out of the street, and I’ll never forget what she said. She was clearly concussed, body contorted like a pretzel, and yet her sunglasses were miraculously still on.

“Please don’t call an ambulance,” she said, barely audible. “I don’t have health insurance.”