In this episode of Raising America, Elizabeth Prann sits down with CEO of CareYaya and Chairman, Counterforce Health Neal Shah. Together, they discuss health insurance claims being denied, which leads to bankruptcy. When signing up for the coming year's health insurance plans, families don't have access to denial statistics... which is a huge problem when trying to plan ahead.
Transcript
INTRO
If you look at your calendar, the deadline to enroll in the Affordable Care Act is really fast approaching. It's November 1st. We're seeing a large
number of young people opting out or hesitant to enroll. And it could be because of headlines like this. Millions
of people are getting denied health insurance claims every single day. We sat down with the founder of Care Yaya
and the chairman of Counterforce Health. His name is Neal Shah. He's been through this before. His wife was diagnosed with
cancer in their 30s. They had to sacrifice everything to get her care because they continued to get denied.
The average 30some that goes through a major healthcare crisis has less than $400 of savings. So if the insurance
doesn't cover you, you are absolutely screwed in that situation. And more importantly, another very shocking
statistic. Last year about half a million Americans filed for personal bankruptcy. 83% of them had insurance.
70% of them filed because of medical bills. So of that you think about the majority are filing personal bankruptcy
due to medical bills. Shaw has gone through this before which is why he wrote an entire book about it. And now he's developing technologies
through Counterforce Health to help people like you and me when we do get denied. It could be something as simple
as a code. But what he says is that there's tools, tricks, and hacks to
outsmart some of these big insurance companies.
You and I have worked together in the past. What I think is most inspiring before I I you know push you on some of
the numbers that we're seeing and of course have you confirm them is just your personal journey with the insurance
companies. We talked a little bit prior to recording, but the the story that you tell when your wife was diagnosed with
cancer is really mind-blowing and it's really not that unique, right? Yeah. Yeah. It's happening to so many
people, you know. So, at that time, we were in our mid-30s. I'd actually just gone through a multiple years of caregiving experience for my grandfather
SHAH RECEIVED DENIALS WHILE WIFE BATTLED CANCER
through dementia and end of life. And then suddenly, my wife became uh diagnosed with a very aggressive breast
cancer, fast growing, harder to treat. And, you know, we were both working, you know, in our mid-30s at the time, and
she immediately had to take time off work and deal with treatment that went on much longer than expected. I had to
take a lot of sobaticals for my work to to help her. And then eventually I left my work to become a full-time caregiver.
And during that process, there were so many denials of claims. And we thought we had like Cadillac health insurance.
You know, like we've been paying into this since we were 22 and right new into the workforce. So we've have almost 15
years of health insurance payments. And yet, you know, and none of us have been sick. And yet when one of us gets sick,
just denial after denial. You know, chemotherapy drugs denied, major surgery denied. You know, bills upon bills for
routine visits and procedures denied. And you know when one and then both have stopped working and are just like
spending savings to deal with a health crisis it's like insult to injury when you have tens of thousands of dollars of
denials. And you know fortunately we were in a position where we had savings where we could just eat the cost and
deal with the stress later. But I think what was most eye opening and frustrating to me is I was in so many
cancer support groups you know for people caring for family members and many people were not in that financial situation. So they were literally
foregoing essential care that they need or their loved ones need, you know, foregoing chemo, foregoing surgery,
trying to save up to get it. And I thought this is just like heartbreaking, you know, where people have paid into a system and they're not able to get the
care they need when it comes time, you know, to need it. Um, so yeah, that was that was really the inspiration for for
this work. You know, you you talk about being in your 30s. A, you know, you don't plan or feel like you should be
YOUNG PEOPLE OPT OUT OF PAYING FOR HEALTH INSURANCE
diagnosed with cancer in your 30s. And to say that you had savings really is unique, right? I mean, I look at some of
these headlines and you see all these young people who are opting out of paying for health insurance because they
they simply can't. Yeah. So, you're in this position where you're unique, that you have savings, but
you're also dealing with the fact that you're in your 30s. You're not you're not supposed to be diagnosed with cancer. So you you think to yourself,
"Well, at least I have coverage." And then you don't. Yes. And and and I'm glad you brought up the point about savings because you're
right. I was in a unique situation. The average 30some that goes through a major healthcare crisis has less than $400 of
savings. So if the insurance doesn't cover you, you are absolutely screwed in that situation. And more importantly,
another very shocking statistic, last year about half a million Americans filed for personal bankruptcy. 83% of
them had insurance. and the and the sorry I skipped over this set 70% of them filed because of medical bills. So
of that you think about the majority are filing personal bankruptcy due to medical bills and usually it's a major
crisis that they have like cancer and 83% of them do have insurance. So what
WHAT ARE PEOPLE BUYING WITH THEY PAY FOR INSURANCE?
does insurance quote unquote mean anymore? Like if it's not there for you when you get cancer, why bother paying
into it? So I think it's I think it's absolutely heartbreaking. Well, and you've done the homework and and the digging. What what are we
buying? You know what? I I pay insurance and I'm still I mean that I I still have to pay all
these medical bills. So, what am I what am I purchasing exactly? I think I think people are buying like a fancy like payment scheme combined with
like a little bit of a negotiation scheme of like slightly cutting deals with drug manufacturers and PBMs to
slightly lower prices. Uh but I think you're really you're not buying much to be honest. I think many people are
better off in a private pay market just kind of like putting aside their savings. And and I think to your
question about what we're buying and think about this, tens of millions of Americans in about two and a half weeks,
November one, are heading into what's called open enrollment period, right? Where they decide their insurance for next year. Everybody on ACA plans, uh,
every older adult on Medicare and Medicare Advantage plans. So I think it's over 100 million if you combine both of those. So it's a huge huge
decision, right? This is one of the most important financial decisions most Americans will make for the next year.
They're making it in a complete vacuum. Zero transparency on what they're getting. You know, here I live in North
Carolina and you you go into the ACA marketplace or you go into kind of like your Medicare Advantage choices. Yes, sure. You can look at three, five
different um insurance company choices, the plans they offer. Can you tell anything about what's the likelihood if
I get cancer that this plan will deny uh chemo? No. no disclosure of statistics.
You can't even get a straight answer from the insurance companies on what was your last year's claim denial rate. Um
and and you know a lot of news organizations and investigative journalists have published these and the insurers always dispute but there is no
publicly available data. Some insurers are now pushing over 20% denial rates. Some insurers who you may know by name
have almost a 30% denial rate of claims. The average insurer now is pushing over
15% in America. So you have zero transparency on what's happening. uh and you know based on your health your
current conditions or your future conditions will you actually be covered? So I think it's uh yeah it's really
heartbreaking. You know people are making these important financial decisions in the vacuum and meanwhile they're paying top dollar. You know the premiums ain't cheap.
I I just I actually was speaking with another mother about this this week and she's self-employed with her husband.
She's got two girls. I could probably ask her to come on the show. and she said she was looking at the ACA website and it was like 2500 a month and she's
like we do really well but we are we hustle we don't work for anyone. She's
like we just can't like this is a huge part of our budget. Yep. Yep. And worst of all is you pay
that 2500 a month and then something happens and you're not going to get it. You're either going to have to pay massive deductibles and or you might get
denied and have to get into a massive bureaucratic battle. So, you know, in a situation like that, wouldn't you just be better off putting aside savings
gradually in a tax deferred HSA account um and over time accumulating it? You know, I think many people who go through
these serious illness do the math and realize they would have just been better off contributing to HSA. But I think that's really really sad that you know
and particularly this year because of like all the government debates and everything um people are really seeing
um the cost skyrocket because for years the government was subsidizing it. Right. Well, and for someone like me, I
WHERE IS THE MONEY GOING?
my first thought is where is all this money going? Um, uh, yeah, I have an answer for that.
Health insurance companies pockets, you know, since the since and and and I'm not a partisan person by by by any
means, right? I'm pretty apolitical, right? But since Obamacare was passed,
$400 billion have gone straight from Obamacare plans and government spending
into health insurance profits. The biggest beneficiary of Obamacare is United Health 160 billion and there have
been investigative reports on this uh by Jacobin and Liber report uh which I would highly recommend people read. So
these schemes, you know, that really marketed to the population as, oh, we're going to get everyone healthare. It's
really kind of like a scheme of we're going to force everyone into buying health insurance, penalize if you don't,
have no control on whether or not you actually get the coverage if you have a major catastrophic illness. And by the
way, government is going to spend your hard-earned tax dollars on just giving handouts to health insurance companies, you know. So the the money has gone into
the health insurance companies, not to people's care. So it's really sad if we're holding other, you know, if you
HOW DO HEALTH INSURANCE COMPANIES GET AWAY WITH DENYING CLAIMS?
look at and of of course like you said, we're we're just trying to provide people information. So I'm not trying to do fear-mongering or or claim that it's
some type of a pyramid scheme, but at the same time, companies are found guilty, private companies. Yeah.
So why are health insurance companies essentially getting away with this? And what is there any end in sight?
I think that the lobbying and and you know, not to like target necessarily companies. I think health insurance in the past, you know, had been working
better. So, it's not that the industry, you know, kind of by existence is flawed. It's the industry today and the
way it's developed over the last 10-15 years has gotten completely out of control. Um, I think the health
insurance companies have extremely powerful lobbying interests in DC, both parties. Um, you know, if you study the
history of the revolving door, um, you know, the person who led Medicare and Medicaid under Obama went Marilyn
Taverner went to become the CEO of AHIP, which is the health insurance lobbying organization right afterwards. Who was
her replacement? a United Health executive who um had a bunch of stock in the company was allowed to take over
Medicare and Medicaid um and was given an ethics waiver um to be able to kind
of you know uh oversee the program where the biggest contract beneficiary is his former employer. So you know you have
this revolving door between people who are setting health insurance policy in DC and people who are leading large
health insurance companies. At the same time over the last 15 years there has been an unbelievable series of mergers
and acquisitions to the point where three to four large completely control
the market. So I actually I you know I my prior background I was a hedge fund manager before I became kind of an entrepreneur in healthcare and I I
really love free markets. I'm a you know hardcore kind of free market capitalist but I also recognize when markets aren't
free and I think this is not a free market. This is a collusion market with
three or four companies that box out any competition that have bought up every other competitor in sight and you know
that now kind of price collude and that keep innovation out. So if I wanted to start a health insurance company because
I'm not pleased with the plans on offer to me in North Carolina I can't start one you know and and you know wherever you live like you probably couldn't
start one. So there's no innovation going on. So I think that's why that you have market concentration series of
mergers um you know they control up and down the supply chain. So health insurance companies bought each other
but they also boughtarmacies you know they also bought I think 10% of doctors
in America are directly or indirectly employed by United Health subsidiary so you have like a lot of kind of um power
concentration that doesn't allow for kind of free market and price discovery and you have no price transparency the consumer so yeah I think it's I think
it's a really it's a tough industry the way it's set up now there are if so your advice so parents
OTHER INSURANCE OPTIONS
are listening to this or families or single young people because we use that example. One of the producers on our team uh is dealing with these insurance
claims being denied and he was planning on them not being denied. Right. So,
this is something that Newton that you knew have to budget for. Are there you mentioned there essentially is a monopoly or there's
there's it's really hard for companies to break through, but are there other options? Are there, you know, I know
that there's um different religious options or people that have these private health insurance. Are would you
encourage people to explore that or would you encourage the HSA avenue? A thousand%. I I'd encourage people to
explore all options and, you know, become kind of educated about it. It's one of the most important financial decisions you can make, you know, and
you want to make it thoughtfully when you're healthy to plan for when you get sick because you don't want to make it after the fact. So, I'd say first, uh,
with the person that you're referring to that is currently experiencing a denial, there are ways to fight back. A denial,
I think most people, um, and I wrote about this in my book, most people, um, don't understand that a denial is not
final. That a denial is just the start of a back and forth negotiation with the health insurance company. And I think
most people view it as, oh, well, they know about healthcare. I don't, so I'm denied XYZ. That means I'm not going to
get it covered. That's definitely not the case. We find that 99% of people don't appeal denials. But of the 1% who
appeal, 40 to 50% of them win at baseline. And if you do a more thoughtful appeal with much more robust
research, you can increase your winning odds to 70 to 80%. So my number one goal through my work now over the past year
is let's help as many Americans appeal denials as possible. And let's do it in a thoughtful, robust, high-quality
research way so they can win. Um, we built free AI tools here at Counterforce Health. That's that's kind of like our
organization. And it's a social enterprise funded by um uh government grants and grants from research
universities. We built free AI tools helping people automate appeal. You know what we would call the way Amazon did
with one-click delivery. You know, if I lost my phone charger, I go on Amazon on one click it. It's here tomorrow morning. Similarly, if you have a health
insurance appeal, you know, uh put your information into counterforcealth.org and you can appeal literally in less
than a minute. Um and not just appeal, it's an extremely robust researchbacked appeal. you know, the models are trained
on tens of thousands of appeal strategies. They're trained on and have real-time access to um medical research
databases to prove why you need XYZ chemotherapy or why you need a certain rheumatoid arthritis drug and you know
back it with robust medical evidence and we find that people are reporting over 70% win rates when they do these
appeals. So, I think that step number one is if you ever find yourself in this situation, view it as a negotiation.
Don't just assume denial means I'm not getting covered. More importantly than that, you have three or four appeals to
the insurers. It's called an external review. I wrote a detailed about this in my book and I'm happy to send anyone a
guide if they email me or reach out to me. Um but um uh there's a detailed process in every state to external
review which means the state insurance commissioner will appoint independent third party to arbitrate it between you
and the insurer and you don't have to pay anything for that. Over 80% of people win those. And then worst case,
if that fails, you can always take them to court and litigate. And the majority of patients will win in litigation. So
there are multiple steps you can take. You don't even have to take them all. Simply trying to take some of those steps will make the insurance company
back off. I think a lot of times this is a game where they're just they're denying it thinking, "Oh, the person's
not going to do anything. Why not pocket the money?" Because there's no penalty to them. So if you just simply push back, it starts creating pressure on
them. And there are penalties to them for the further steps. If you think about it, I mean, we negotiate
REASONS FOR DENIALS
everything. We negotiate with our partners. We negotiate with our children. We negotiate with our schedules. You were talking about all
the the steps that people have to go through to appeal, which really you're making it more simple,
but if you look at some of these reasons, and again, this is a an easy Google search, so it's not like this is
information was hard for me to obtain. Yeah. Yeah, we're getting 34% of denials for other or unlisted, 18% for
administrative, 16% for excluded services, and then you have lack of prior authorization and
lack of medical necessity. What I'm saying is like these are very all of them are very vague like I mean there's
a couple that are very very clear. Yeah, I I'll I'm happy to simplify that, you know, for the So, you know, in in our
research, we added up and bucketed those and we believe that approximately 75% of
the denials are fairly easily appealable and 20 to 25% of them are not. And the
excluded services is kind of the category where it's explicitly not covered under your plan or explicitly out of network is generally not barring
an emergency, you know, or extenduating circumstance, right? But the remaining 75% of them, you know, if I had to
oversimplify it, I will categorize it into two buckets. One is administrative and billing related errors. And by that
I mean the visit was for a emergency appendecttomy because you know your
appendix was about to rupture or had ruptured and and you needed kind of surgery right away and it was mclassified by a certain code to be
routine abdominal operation. So therefore, okay, you went to the wrong doctor and you didn't get preapproval
and okay, we're not going to pay, right? That is something easily fixable like by our AI system can figure that out. But,
you know, more importantly, and we see people processing these through our AI system. More importantly, this is
something the insurance companies should also be able to know, right? They have AI too, but conveniently, they're
they're not doing it and they're denying it and they're putting the burden on you to stress out and figure out. So, how's
a regular person supposed to know what is the right billing code for an emergency appendecttomy? Like, you know,
sure you can go to Google, you can go to chat GPT. A lot of resourceful maybe younger people or middle-aged people
figure that out, but a lot of people, you know, without those resources won't. A lot of older people, you know, who we help, a lot of older people are not
necessarily going to be able to figure this out on their own. So, I think that that billing and administrative coding
related errors extremely extremely easy fix. That's about 20 to 25%. The
remaining kind of like 40 45% is this gray area of what's called not medically
necessary or medical necessity and that is a complete gray area and that is something where the insurer is saying
why didn't you try something cheaper and then you have to prove well I did or my
doctor said it won't work. So you know we had a great example of this where uh there was a woman recently that we
really helped with a kidney cancer you know and kidney cancer and she had a tumor on her kidneys and multiple
surgeons professionally apped is way too risky to cut that out because of where
it's located there could be major damage to the kidney and to other organs and you know she's not in amazing health
overall because she's kind of like a little bit more advanced in age. So they were like there is only one way to treat
this and it's proven and it's effective and it's microwave ablation where you don't have to kind of go in and excise
it out but you can treat it with like microwave ablation. Insurance denied it left and right and
the surgeons were like desperately writing letters and and it was just like they were saying hey this is the only
thing we can do. This is the only thing we can do. She was writing emotional letters and you know they were completely ignoring it. Thankfully her
husband happened to hear about us on a show like on radio or something and was like oh I'll check out the site. their
free AI tools and came to our site um and you know put in all their information and got like a very robust
researchbacked appeal based on her history based on her policy coverage document based on her denials of saying
okay logically here's all the reasons why we can't do XYZ other procedures this is the only reason microwave
ablation works put that through got it approved got it done and she's cancer free now so that's kind of an example
where most people would pan like she and her husband don't have 45 grand lying around, you know? So, like it's either
not going to happen or they're going to go into massive amount of debt to do it or in the meantime they're going to have
a tremendous amount of stress. Can you imagine if you're dealing with this kind of cancer, the last thing you need is
this existential stress of I can get it out, but the insurance is not paying for
it. So, you're under this massive amount of stress. If you can solve that for you, that's a home run. And, you know, I think that's one where the insurance
company should know better, but they're creating the burden on you of, oh, please write all this detail. And if you're fortunate enough to have a
brother that's a doctor who will sit there for 10 hours and write all this step by step, great. But most people aren't. So, you know, they're going to
be screwed. This is where I think AI and just kind of innovation can really help that this is kind of like having, you
know, a doctor in your pocket, so to speak. You know, where somebody with a legal and medical background, which is
the AI, can do this for you in seconds and do it in a very professional and robust way that can help you get the
care you need. But but my long long way answer, sorry for your question, but the 75% of reasons for denials are very
easily appealable and I feel like they're just kind of BS reasons to put up roadblocks so people don't get the care.
Well, it's BS and it feels like you're capitalizing on someone in emotional
times. Like to me it feels very David and Goliath and it feels like
you have two people at the table and one of them is in a state of grief or a state of panic and they're thinking of
finances and their health and the other person is this monotone robot. That's like when you describe these scenarios
it's like what I'm visualizing is two people at the table and it it's just not a fair fight. Yes.
And I'm just think and you're telling me all these examples and I'm like how do we get here? Or if I do a Google search and it says there's 200,000 denials a
day and that's just with ACA, that's not including Medicaid and Medicare. And I'm thinking to myself, how many of those is
someone's life on the line? Like that's what I'm like, how do we get here?
Yeah, a lot. So, and and thanks for bringing up the stat. One in five adult Americans have had a who who are on
health insurance have had a claim denied within the last year. And in aggregate, there were about 5 billion health care
claims going through the American healthcare system last year. 850 million were denied. And of course, there's only
300 million people in the country. So if you kind of do the math, it's the sickest people who have multiple interactions with the healthare system
every year who are being denied routinely. So we have parents of kids with special needs, parents of kids with
like major illness, rare disease. We have young people who are going through suddenly a major cancer. We have midlife
people, you know, kind of like my wife and many others that I've met are suddenly going through breast cancer, colon cancer. And by the way, these
rates of these cancers are really skyrocketing in people in their 30s and 40s. So, it's hard enough when you get
this, but it's even harder when you take time off of work. You're dealing with your existential stress of am I going to
die? And then you're dealing with financial stress on top of that of, oh, all this treatment that I need, boom, I
got denied on something. And it's like, think about when you go through cancer, you know, you're going to go through multiple interactions with the health
healthare system. And if you have a if you're kind of like rolling the dice, 20% chance of something being being denied, well, a cancer patient over the
course of this year might do 15 or 20 billable things. So, it's likely you'll face multiple denials just if you play
out the odds. And, you know, I think that's that's a disgrace to the way our healthare system is set up.
Well, and like you said, our our goal here is not to necessarily make people um angry at at politics or to point
fingers at politics. And for someone who supports capitalism, I'm thinking to myself, did it just get out of control?
Did it just get did the beast just get too big? I mean, and everything always comes down to lobbyists, you know. I did
a show on we did a show about like why are our kids getting strawberry milk at schools
and it's like the one woman I spoke with was like don't f with the dairy lobbyists. Like Yeah. Yeah. I think Yeah. I think it's I
think you know and you're right like I also believe in capitalism and I feel like capitalism the best of it is free
market competition and government out of it. I think that you know I kind of believe there's two spectrums of society
and the way things head that don't work. One is government does everything. I generally think that model doesn't work
and that would be traditionally called kind of like communism or socialism, right? But another model is where
government does a bunch of things and prioritizes a few businesses and then massively allows those businesses to get
concentrated. What would be called maybe crony capitalism which then works pretty similar to the former model, you know,
where you don't have a lot of rights. The best model is when there's a freely functioning market of robust competition. you know, if you don't like
United Health, you can go switch to a 100 other health insurance companies, which is what used to be the case 20, 30 years ago, right? Like, and and I think
that this became a hot button point, I think, for populist kind of um sentiment, you know, with the Luji
Manion and United Health Shooting. And it's like, well, that kind of stuff doesn't happen in free market capitalism because people have a lot of choice.
They can just say, okay, I'm not going to buy from this one. I'm going to go elsewhere. Look at the car market or look at your choices when you want to
buy a computer. You know, there's like millions of options. Um, and I think that that this market needs to return to
that. But barring that, I actually think the freest market is where people get to
control their own financial destiny. So if you put things like health savings accounts on level playing field with
forced buying of health insurance and you can say, well, you can choose to contribute to this or you can choose to
have your taxfree dollars go to HHSA. Same with, by the way, it's not that the government just allows you to buy health
insurance. The government funds a lot of health insurance, right, through Medicare, Medicaid, as well as Obamacare
subsidies. The government is spending hundreds of billions of dollars directly of taxpayer money. And I did the math
that if all of this money was just given to individuals to fund their HSAs, like
let's say you could give everyone a a couple thousand in their HSAs and then lower income people and senior citizens
more because those people are already currently getting it through Medicare, Medicaid, like you could fund a lot of
HSAs and then all the other people like the um you know lady you mentioned who has her family and the 2500 a month of
premiums. Imagine that 2500 a month going to an HSA. you know that's like 30
grand a year basically right and and over a course of years you have built up an enormous amount of savings such that
when something happens to you you spend on that savings the last thing I'll say on this model a true free market model
which Singapore does is the cost of healthare goes way down because currently in our healthare system two
trillion out of the five trillion that we spend as a country goes into administrative you know kind of administrative waste I I I I believe and
if you just had your own money you go to the doctor, you have price transparency and you just buy directly. Everyone's
better off. Doctor's making more money. It's a faster process. You're spending less. Um, right now the insurance
companies are dictating also what the doctors can do, what the nurses can do or can do. And they all hate it too. So,
kind of to your point about alternatives, I think some of the happiest, you know, people I find who
have good healthcare experiences are going to direct care. Like you see a lot of docs going to like direct primary
care. I think a lot of the um organizations that you mentioned are like religious or faith-based organizations running kind of insurance
pools are much better. I think a lot of people are choosing to go to HSAs and this people are doing despite of like
penalties and stuff, right? Because like the way our health insurance industry works is everybody's pushed into it. So I see that those there are really
pockets of great innovation going on, but I think we need government to kind of step out of the market and allow
people to, you know, come up with free market solutions because the system's very clearly broken. I had a couple
thoughts when you were talking when you talked about they're also dictating the price. I mean I after a certain age
EXPENSIVE MAMMOGRAM BILLS
women as you know are required to get mammograms and I of course didn't even think about it. It was covered by insurance and I looked at the bill
and my mammogram was like I think it was 7600. It was so and I thought to myself how many of these are a day? Why are
they so expensive if technology is so advanced to me? That's what and like you said to my my the wheels were turning
where I'm like oh my goodness are they all working together? Are is this a little bit of collusion? You're telling
me that a routine mammogram is $7,000? It took me seven minutes. I know. And and and if you go cash pay,
I bet you get a fraction of that price. So, you know, and I I don't know the exact, right?
Basically, my my kind of guess from other people that I've seen doing direct pay in these situations is it's 7,600
and then you have to hit X amount of your deductible or you have to do X amount of co-ay, right? So, you're still
out of pocket doing whatever. make up a number, you know, xx x 500,000, whatever. If in a similar market, you
just go direct cash pay somewhere, you can probably get equivalent or cheaper, you know, and and I think that's like a
lot of people are shocked when they ask for the cash price and just say, I will pay out of pocket, no insurance. They
oftentimes get a 80 or 90% lower price and then they do the math and they're like, well, even with insurance, I'm
worse off than if I just pay cash for the whole thing. And then you realize well the provider like they actually
would prefer me to pay cash too because they're not getting as much you know from the insurance. So it's a artificial
massive inflation of price. And I think that there's a hot debate going on right now. And what I'm most encouraged about
is that there's bipartisan focus on this. You know I think that you know interestingly enough I I observe
politics and this is one issue that I've seen Marjorie Taylor Green and AOC agree on in recent weeks. They're both railing
on this point and you see them on X and Twitter and all their, you know, testimonies in Congress, but they're
both saying and highlighting these cases of like, why is health care so expensive if you have health insurance? Like
what's the point? And I think it's price obiscation. You know, people who go direct are just having a better experience. So, I I I'm optimistic that
this will change. I also want I I want people to feel empowered because for it does seem
INVESTING IN YOUR HEALTH
intimidating, but I want people to feel like they they can. So, you know, we explored different options whether it be
concier medicine or what have you because we were really alarmed and we haven't taken
the steps to do so. Yeah. But we're also two working parents who waited until our late 30s to have
children. So, we were financially supported all. So, I I don't want to to approach this
without the knowledge that some people may not be financially settled like that they they may not have the
means. We have the means to make these choices and right now we're choosing insurance, but we also could, like you
said, invest in an HSA. What about the people who you work with may not have that, right?
Yeah, I think Yeah. I mean, the people I work with and and frankly a lot of the people that we help don't have these choices and, you know, they're forced
into, you know, kind of current plans. If they have a choice, I would strongly urge them because we're heading into
open enrollment, so it's very timely to do this episode. I would urge them to just calculate different scenarios and
you know maybe even call the insurance and ask them some of these questions. But what I find even people with more
modest means if they're on let's say ACA Obamacare plans, you know, there is a
choice of am I going to pay a $25 $2,500 a month premium or am I going to find
the lowest premium plans possible that have very high deductibles and literally
cut my premium payments by a lot and whatever amount of money I am not paying, maybe put some of that into HSA.
So that way I'm actually better off in terms of I'm spending less on insurance, but I have it in case something
disastrous happens and then the rest I'm stocking away for a rainy day and I'm going to use that, you know, to kind of
get the care that I need. So I think actually in some way that shift is already happening uh to people. But
yeah, I mean I think otherwise and oh sorry the final thing I'll say because I also speak with a lot of um middle-aged
people who are caring for aging parents and by the way this is extremely important decision because middle-aged people are worried about healthcare.
Sure. younger people, sure, but where you should be most worried is when you're helping your mom and dad because
health care needs in the last 5 to 10 years of your life, that's where all the money is spent. You know, there's an
interesting statistic that last year 50% of healthcare spending in the US went into people in the last two years of
their lives. So, you know, it's kind of like when you really think about bankruptcy level healthcare, that is happening a lot. So, if you're helping
your mom or dad, if you're like a sandwich generation, middle-aged person taking care of kids, mom and dad are also kind of going through this process.
it's changed so much that they don't know what to do and they're really marketed by these Medicare Advantage plans. Make sure you really help them
thoughtfully figure out which plan is right for them. Um because that's really when it will financially break the bank.
I mean that's a whole episode. I we we've we've talked about that our our producing team because there is a such a
generation that I'm in that that you as well where we're we have we still have young kids. We had kids later and then
we're taking care of aging parents. So we're probably going to approach that. When when you did a lot of your research
WHAT DOES SHAH FIND SURPRISING IN THE HEALTH INSURANCE INDUSTRY?
for your book, what did you find most surprising? And I want to couple this with do you feel like when you see
Marjorie Taylor Green and AOC agreeing on something that it will get better, especially with all of the things that
you've learned? Uh thousand%. And it's because I I found surprising how many people are extremely
frustrated with the system. Like when I went through it, first I thought we were just alone, bad luck. Then I talked to a
lot of other caregivers who were dealing with, you know, family members with serious illness. Then I was like, "Oh, maybe this is a sub community um that is
just like getting shafted by the insurance industry." And then in researching my book, ended up talking to a lot of people in the healthcare
system. And then that was like really the eye openening of how many nurses, doctors, social workers, even hospital
administrators are so frustrated and fed up with the system that it's not even working for them. And really, I think
the most surprising element of the entire book actually, which isn't even related to like directly what families are experiencing, but indirectly is this
idea that doctors and nurses, one of the main reasons they burn out of healthcare
and leave is because they're sick of what the health insurance companies are doing. like they want to help you when
they see, oh, I'm the cancer surgeon and I can't do this procedure on this lady
to remove her kidney tumor. Like, and the insurance company keeps denying it. In some cases, the person doesn't win and they die. And at some point, you see
that over and over in your career and you're like, "All right, I'm just going to quit. I'm going to go do something else because like I I'm I'm not able to
do do my craft." Um, so I actually think that was the most surprising that this is contributing to a burnout and
disillusionment and healthcare workforce shortage. And I actually think the way our population is aging and the rising
rates of chronic illness, we need more people to help people, not less. So I think that was kind of one of the most
surprising things. And then on the other side, I actually found it very empowering that a lot of people who have
been through this journey uh are doing things to help others, you know. So like in my case, like if I'd not gone through
this journey, I would have never thought this was a major crisis. So I'm I'm thinking, okay, what can I do? So okay,
we can do technology innovation, build AI tools to help. Other people I found that went through these major journeys
started, you know, kind of small nonprofits or community organizations helping people with breast cancer, colon
cancer. And there's some great patient advocacy organizations out there that are formed by this kind of experience of
people. Triage cancer is a big one. Patient advocate foundation is a big one where they will literally help anyone
who's struggling with this. You can call them. It's completely free. You know, proono work. And the vast majority of
people I I find in this field dealt with it personally, found it very frustrating, found a way out of it, and
then were like, "Okay, now I'm going to spend a lot of my time helping other people go through it." So, I think like power of the community is awesome.
Well, and you know what I love so much about the the what you're creating with these with artificial intelligence? So
CAREYAYA'S AI PROGRAM TO HELP PEOPLE
often we do these stories like AI is replacing this and this and this and what you're saying is actually we're
filling a vacuum. There's no one who's helping these people. Like there's no one taking on the insurance. You're you're literally, you know, and I think
that's such a positive light for us to focus on because so often we say, "Oh, AI is replacing therapy. AI is
replacing your accountant. AI is going to replace your news person." But this there's there's hundreds of millions of
claims being denied. All of that money being funneled to insurance companies. Yeah. And you're actually creating a
tool where we there is really not a lot of people doing this. Yeah. Yeah. I agree. I I I I think your
um analogy earlier on of David versus Goliath, I think that's like the perfect analogy where we need to give tools to
David to fight back, you know, because there's no way you're going to be able to fight back on traditional means like
spending 10 hours writing a letter. Most people don't have the knowledge, aren't lawyers, aren't doctors, you know, so
this is something where AI can learn, do it faster, do it much more accurately. And critically, as the system helps more
and more people, the system gets better and better. So, I think this is a great example of like how we can use AI to like help people at scale.
So, blue sky for me, you know, after everything that we've learned today, five years down the road, will the
WHAT WILL THINGS LOOK LIKE IN 5 YEARS?
landscape look different? Will we see more competition because people are saying, "Hey, I'm going to do the HSA
route or I'm going to do faith-based or I'm just going to just do self-pay." All of these different options. Do you think
that that things will look better? Yeah. Uh my my prediction by 2030 is that the
insurance industry is going to be a fraction of what it is right now. I think the vast majority of healthcare in the country is going to go into
combination of HSAs, self-pay, faith-based organizations kind of like other because I think it's past a point
of no return. It's so clearly broken. I think when you have different ends of the political spectrum rail against it,
you have 2026 midterms coming up. You know, I talked to tons of people on the ground who are like our most of our work
is helping sandwich generation family caregivers care for aging parents. And I mean to the person, people are so fed up
with the way their own care and their mom and dad's care is financed and paid for that I think there's going to be major change which I think bodess well
for everyone. You know, free market competition, innovative care models, and critically um lower spend and I think
more autonomy. You know, I think can't emphasize that point enough, but I think the healthcare workers are so frustrated
by this and I think we need to encourage more people to go into these fields. So I think more autonomy and and I really
like you know if you look back 30 40 years ago this idea of like the independent neighborhood doctor you know
that kind of like ran their own practice had direct relations with patients you know your family got to know them you
know I mean this is the way I kind of grew up you know it's like you know your parents knew them and then maybe they
even helped with your delivery and then you're taking your kid there you know I like that type of like community based
healthcare and it is not like that anymore because of all this like insurance bureaucracy and I think that
if we kind change the system, it will go back to that. And I think that's just like better for everyone. So yeah, I'm
pretty optimistic about the future. And I think we're going through probably the hardest time right now, but sometimes you have to go through the hard time in
order to get to a better. Well, and I also think you just encouraging people and you have this
wealth of resources and wealth of knowledge and you say, listen, you know, I've helped people. You don't have to
have all the means. Like you said, you've helped people who are really struggling because those who are suffering sometimes are the people with
kids with special needs or people who have health issues and maybe they just feel like they're debilitated and there
like you said it's the David and Goliath situation. So before I let you go, maybe top tips
for folks who are facing this who like you said there's a some big decisions that are going to be made ahead of
SHAH'S ADVICE WHEN CHOOSING INSURANCE
November 1. So if you were speaking with a young family, what would you suggest? Yeah. Um, I think for families like go
and do as much research as possible on the plans you're purchasing. It's going to be one of the biggest financial
decisions that you're going to make for the next year, which plan you choose. And make sure you proactively reach out
to the insurers and ask them just like very basic polite questions about what percent of claims did you deny last
year, common things that were denied, and then think through your own conditions. By the way, I really not
that I love AI overall. I think there there are some pros and cons with AI, but in a situation like this, if you really want to inform yourself fast, use
chat GPT or use I mean use our AI tools or use anyone's AI tools, but just go have brief conversations with AI because
it can it's AI is almost like your Google assistant where it's just going to do a lot of searches for you fast.
So, it will help find information and just plug in which plans you're choosing from into the AI and say, "Pull for me
approximate denial rates for these plans." Then type in what are your current conditions that you or your
family members are dealing with or anticipated conditions. I realize that's kind of hard to do, but put those in and
say what's the probability if I choose XYZ, you know, will I face a denial or not? I think that patient empowerment
here is key and there isn't a lot of information, but if you spend the time searching using AI tools, you can find a
lot of info and then make a thoughtful decision that way. And then also highly encourage people to look into these
self-pay and HSA and faith-based, you know, options because I think some of these are much better. And if you just
simply read reviews, I think reviews and and hate to say it, even Reddit, you know, if a lot of um if a lot of
middle-aged people like aren't using Reddit, I would highly recommend it because you can crowdsource these answers. You know, go to Reddit and go
to forums and see what other families are doing. And oftentimes, depending on what state you're in, what city you're in, you'll find people using really
innovative options that you haven't heard of. Um, and you'll also find a lot of like honest positive and negative
reviews of your different plan choices. But I think that health insurance, you know, com outside of maybe home buying
is probably one of the most important financial decisions you can make. And you don't think about it when you're
healthy, but you realize as soon as you or your loved one gets sick that how important that financial decision was.
And it is the number one thing that is leading people into personal bankruptcy. So, you know, it's very important to be
very thoughtful about how you make decisions. So yeah, empower yourself. And also, by the way, if you want free guides, email me or reach out to me
anytime. I'm happy to send over a bunch of stuff. I'm very passionate about this topic. Yeah, we're going to include everything in in the YouTube synopsis just because
OUTRO
you really do have a lot of knowledge and I think you would agree especially with what you've been through is that
you don't realize you don't realize pain or even you don't have a good
perspective until you've gone through health issues or someone that you've that you love has gone through health issues. Just how nothing else matters,
right? everything falls by the wayside. Like you said, you you gave up your job, your wife, everybody
to make sacrifices. So, we we want to make sure that we remind folks that there are just so many resources out
there. Yeah. 100% agree. I think it's like once you empower yourself, you don't have to be as pessimistic. You know, I think you
can be optimistic that you're at least prepared to anticipate what needs may come and then oftentimes you're
financially much better off. All right, Neil, you're the best. We're so grateful for you. Thank you for joining us.
Great. Thanks so much, Liz. I really appreciate the opportunity.