Wendell Potter on The Healthcare Crisis

Summary

The Al Franken Podcast

Episode: Wendell Potter on The Healthcare Crisis

Date: January 25, 2026
Guest: Wendell Potter, President of the Center for Health and Democracy; former VP of Corporate Communications at Cigna Health Insurance

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Episode Overview

This episode dives deep into America’s healthcare system with Wendell Potter, a former high-ranking insurance executive who "switched sides" to become a whistleblower and advocate for reform. Al Franken and Potter discuss why health insurance costs are skyrocketing, the inner workings of the insurance industry, how reforms like the Affordable Care Act (ACA) helped (and failed to help), the outsized influence of insurance and pharmaceutical lobbies, prior authorization denials, and potential avenues for real change.

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Key Discussion Points & Insights

1. Wendell Potter’s Insider Journey

• Background: Potter was a VP at top insurers (Cigna, Humana) for 20 years, leaving the industry in 2008 to become a whistleblower during the ACA debates (08:09).
• Why He Left: Two transformative experiences:
  • Witnessing people in rural Virginia with insurance waiting in barns for charity care due to high deductibles (12:10).
  • Handling the PR crisis over Cigna denying a liver transplant to 17-year-old Nataline Sarkisyan, who died after a delayed reversal (13:51).
• Quote:

  “Sometimes I've joked that looking back over my career, I was undercover for 20 years. But I saw what motivates these companies... they are beholden to shareholders and Wall Street.” — Wendell Potter (10:23)

2. How Health Insurance Really Works

• Profit Motive: Quarterly pressure to meet Wall Street earnings leads to cost-cutting and denial of care (10:23).
• Lobbying & Influence: Millions in premiums go to buy political influence and shape regulations (10:23).
• Quote:

  “They spend enormous amounts of premium dollars on campaign contributions, on lobbying expenses... I was a part of that too.” — Wendell Potter (10:23)

3. High Deductibles & “Consumer-Driven” Health Care

• Myth-Busting: Many insured Americans, including some on Medicare, still can’t access needed care due to high out-of-pocket costs (12:47).
• Industry Strategy: High-deductible plans were intentionally framed as a solution to cost, but simply shifted expenses to patients (25:49).
• Quote:

  “We sold it with the euphemistic term ‘consumer driven health care.' What it was hiding was... it made people pay more out of their pockets before coverage kicked in.” — Wendell Potter (25:49)

4. Health Care Denials & Prior Authorization

• Denials are Routine: Insurance companies regularly deny claims under the guise of “prior authorization.” These denials hit lifesaving treatments and are a profit tool (14:52, 23:56).
• Cigna Case: Denial and delay led to the death of a 17-year-old who needed a liver transplant (23:55).
• Quote:

  “That happens again, Al, even more today than it did before... About 20% of requests for coverage are denied. Some companies reject one out of every three.” — Wendell Potter (24:22)

5. The Affordable Care Act: Progress and Loopholes

• Medical Loss Ratio (MLR): ACA required insurers to spend 80–85% of premiums on care, but industry lobbied regulators for loopholes (15:37).
  • Now, companies count quasi-administrative tasks as care and buy up physician practices, moving profits “in-house” (16:39).
• Unintended Consequences: Out-of-pocket caps are high and rise each year. ACA didn’t limit prior authorization or other denial practices (54:03).
• Quote:

  “While the ACA did set a limit on how much you can charge out of pocket, those limits go up every year... you can be on the hook for $19,000 out of pocket before your coverage kicks in.” — Wendell Potter (54:04)

6. The Premium Crisis and the Loss of Subsidies

• End of Subsidies: Pandemic-era ACA premium subsidies have expired, causing premiums to double or triple for many, leading to mass coverage losses (31:13, 31:56).
• Death Spiral Threat: As healthier people drop coverage, those left are sicker, sending premiums higher—a destabilizing cycle (33:11).
• Quote:

  “When that happens, that could create a death spiral... more and more in that pool are sicker, and the insurance companies will increase their premiums next year... It’s really destabilizing the ACA marketplace.” — Wendell Potter (33:11)

7. What’s Next? GOP “Plans” and Real Reform

• Republican Proposals: Trump’s “great healthcare plan” is vague; ideas include direct payments and health savings accounts (HSAs), which mostly benefit the wealthy (36:21, 38:20).

• No Real Plan:

  “So there’s no plan?” — Al Franken
  “No, there’s no plan.” — Wendell Potter (39:14)

• Break Up Insurance Conglomerates: Bipartisan support may be growing to regulate or break up PBM/insurance behemoths (39:39).

8. Pharmacy Benefit Managers (PBMs) & Drug Costs

• PBMs Explained: Act as middlemen for insurers, extract profits both from manufacturers and patients (40:45).
• Industry Structure: Three PBMs, all owned by insurers, control 80% of market (40:42).
• Soaring Drug Prices: Manufacturers and PBMs collude in a “black box” rebate/kickback system—patients pay more (42:36).
• Lobbying Power: PBMs now drive more profit than insurance lines for big companies (48:25).
• Quote:

  “Cigna gets far more money in revenue and profits from the PBM than it does from his health insurance business.” — Wendell Potter (48:28)

9. Why Drugs Cost More in America

• Government Inaction: U.S. doesn’t negotiate drug prices, unlike almost every other wealthy nation (43:13).
• Quote:

  “Almost all the other countries have some means in which the government negotiates the price of medication. We just never have.” — Wendell Potter (43:13)

10. Medicare for All and Public Opinion

• Voters: Many fear losing employer-based coverage and distrust unknowns.
• Public Option/MFA for All Who Want It: A national program with opt-in, rather than mandatory replacement, may be politically viable (51:06).
• Quote:

  “I think this could be an opportunity... to put something like [Medicare for All who want it] forward and maybe more successfully. I think it could happen.” — Wendell Potter (52:18)

11. The Impact of Corporate Power and the Human Cost

• Social Reaction: The outrage after the UnitedHealth CEO’s murder was more about anger toward insurers’ practices than the violence itself (52:44).
• Systemic Harm: “Legal” denials cost lives as surely as explicit violence (53:32).
• Quote:

  “I've said that... it should be criminal because people die every day.” — Wendell Potter (53:32)

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Notable Quotes & Memorable Moments

On the Industry’s Motive

• “I saw what motivates these companies. They’re beholden to shareholders and a handful of Wall Street financial analysts... If you miss the consensus estimate... your stock is going to take a hit.” — Wendell Potter (10:23)

On “Consumer Driven Health Care”

• “We sold it with the euphemistic term ‘consumer driven health care.' What it was hiding was... it made people pay more out of their pockets before coverage kicked in.” — Wendell Potter (25:49)

On Prior Authorization Denials

• “It happens every day, Al. And it still does.” — Wendell Potter (14:35)

On PBMs and Profits

• “You can often keep your insurance card in your wallet, just go to the pharmacy counter and pay cash and get a better deal. It’s that crazy for a lot of drugs.” — Wendell Potter (40:05)

On Medicare Advantage

• “They advertise that you're going to get more coverage... but typically the coverage for those things is very paltry. People never hear in these advertisements that they will be subject to prior authorization.” — Wendell Potter (29:00)

On Political Prospects

• “The status quo is extraordinarily profitable for those guys.” — Wendell Potter (52:24)

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Timestamps for Key Segments

• Wendell’s Backstory & Departure from Insurance: 08:04 – 13:46
• Cigna Case (Nataline Sarkisyan): 13:51 – 13:55, 23:40 – 23:56
• High-Deductibles and Denials: 12:43 – 13:46, 14:52 – 15:29
• Medical Loss Ratio & Loopholes: 15:29 – 18:59
• ACA Subsidies Crisis: 31:13 – 33:11
• PBMs & Pharma Pricing: 39:39 – 43:13
• Congressional Hearings on Insurance CEOs: 46:43 – 49:20
• Public Option & MFA-for-All-Who-Want-It: 51:01 – 52:18

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Conclusion

Al Franken and Wendell Potter pull back the curtain on how the insurance industry prioritizes profit, uses administrative loopholes to skirt regulation, and denies or delays life-saving care. They dissect the causes behind rising premiums, the expiration of subsidies, and how pharmacy benefit managers balloon drug costs. While pathways for genuine reform exist—including public options or breaking up monopolies—political will is hamstrung by powerful lobbies and public anxiety about change. The personal stories Potter shares underscore what’s at stake: real lives, financial ruin, and a society at a crossroads.

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For more, visit Wendell Potter’s Center for Health and Democracy or follow ongoing policy debates on healthcare reform.

Transcript

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[Al Franken]

Hey, everybody, we got a great one today. You know, for a change, Wendell Potter, former VP of corporate communications at Cigna Health Insurance, well, he switched sides. He's now the president of the center for Health and Democracy and advocates for meaningful healthcare reform. And so today, Wendell's with us on why health insurance costs so damn much in this country. Well, I figured out why Trump decided not to invade Greenland and slaughter thousands of NATO troops, because next year, when they consider him for the Nobel Peace Prize, it would kind of count against him. Of course, what really happened was Taco Trump chickened out. The bond market and the stock market had gone south. Europe was going to enact retaliatory tariffs and hurt the economy. So we got the bizarre, rambling speech at Davos. Among other things, it was filled with lies. Here he is talking about how the war in Ukraine never would have happened if the 2020 election hadn't been stolen from him. It's a war that should have never started. And it wouldn't have started if the 2020 US presidential election weren't rigged. It was a rigged election.

[Wendell Potter]

Everybody now knows that.

[Al Franken]

They found out. People will soon be prosecuted for what they did. It's probably breaking news, but it should be. It was a rigged election. We can't have rigged elections. Now he says that was breaking news. Hmm. Have we heard anything about it since? Let's keep an eye out for when they announce these prosecutions. I'm sure the White House press corps will follow up and ask him when these prosecutions will be announced. Mr. President, you said in Davos people will soon be prosecuted for rigging the 2020 election. You said it was breaking news. When will we know the details of who's being prosecuted and on what charges? We haven't heard any follow up on that. And I was wondering if you could provide more about this breaking news that you announced in Davos. Well, Trump invited Putin to be on the Board of Peace along with Argentina, Canada, Egypt, Hungary, India, number of other countries and Putin. Putin on the Board of Peace. If I were a Gazan, that would make me go, oh, good, things are looking up. This is a guy who's killed 70,000 Ukrainian troops, bombed civilians, kidnaps their children. No one in the White House said to Trump, Mr. President, maybe not Putin on the Board of Peace. Board of Peace. Now Trump can veto all decisions, approve the agenda, invite members, dissolve the board entirely, and designate his own successor. This is his own personal un like the Trump Kennedy Center. And in Minnesota, thousands of ICE and Border Patrol agents continue to sow ever more chaos and terror. The FBI and DOJ have issued subpoenas to investigate Governor Tim Walz, Minneapolis Mayor Jacob Fry, St. Paul Mayor Kali Herr, Attorney General Keith Ellison, Hennepin County Attorney Mary Moriarty. And yet they refuse to investigate ICE Agent Jonathan Ross, who shot Renee Goode. Ross, they say, is at home recovering. But there may be an investigation into Renee Good's widow, however, to determine if she's an antifa agitator. And Trump continues to threaten to invoke the Insurrection Act. All this is so awful. We see video after video of ICE physically abusing people, dragging folks from cars, tackling them, throwing them to the ground. ICE agents are now going into hospitals and clinics, breaking into people's homes and taking them. You may have seen the video of an older Hmong man being taken out of his house in the freezing cold in just his underwear and socks and a flimsy blanket in 10 degree weather. Of course he is a citizen. They took a five year old child in the custody from his school. They used him as bait to lure his other family members out of their house. The chief of police for suburban Brooklyn park said that his officers when they're off duty are getting grabbed by ice. But just the ones of color. ICE is acting like a caricature of a fascist force. But Minnesotans are still going to the streets even when the temperature is 10 or 20 below and they're stepping up for each other, shopping for folks who can't leave their homes, taking kids to school. It's all very Minnesotan. And you know what? We aren't talking about the Epstein files. In a truth social post in 2024, Trump wrote that I was never on Epstein's plane, but it turns out that he was eight times just between 1993 and 1996. I wonder what could be in the other 5 million pages that haven't been released. Well, today we're turning to healthcare. It's January when folks insurance plans reset and many are experiencing sticker shock and paying this year's higher premiums. Let's discuss with former healthcare VP Wendell Potter. It's a great one, you know, for a change. Wendell, thank you for joining us.

[Wendell Potter]

My pleasure. Thanks for having me on.

[Al Franken]

Your career has been in the in healthcare, right?

[Wendell Potter]

It has been, yeah. From for many years.

[Al Franken]

And you were a VP at cigna?

[Wendell Potter]

I was a vice president at Cigna and Humana before that. All together about 20 years working for big insurance companies.

[Al Franken]

Okay. And what year did you leave?

[Wendell Potter]

I left in 2008.

[Al Franken]

Just before the ACA.

[Healthcare Policy Expert / Commentator]

Yeah.

[Wendell Potter]

Same year you were elected to the Senate.

[Al Franken]

Yeah.

[Wendell Potter]

And. And I became a whistleblower in 2009 during the time that Congress was debating whether what became the Affordable Care Act.

[Al Franken]

Sure.

[Wendell Potter]

Had left the industry a few months before that and thought I would help advocates for reform understand how the insurance industry really operates and how they would be trying to kill reform efforts. After Obama was inaugurated and Congress got down to work on reform. And they ultimately told me if I wanted to make a difference, I should go public rather than stay anonymous. And I ultimately agreed to testify before Congress. I testified before the Senate Commerce Committee.

[Al Franken]

What did your job entail at cigna?

[Wendell Potter]

When I was at Cigna, my job gave me a lot of visibility into how insurance companies really operate. I was the chief spokesman for the company. My team and I handled what we referred to as high profile cases. When a reporter called with questions about why CIGNA was Refusing to pay for a patient's treatment. They would call me or my, my staff. I also handle financial communications. My name was on every one of Cigna's financial earnings quarterly earnings reports for, for 10 years. And I also handle government affairs communications, my handle and wrote talking points for our lobbyists. I spent a lot of time in Washington working with our trade associations and our, and the ad hoc groups that we would form to, to kill reform. Going back to the, even the Clinton years. That's when I started working for the industry and played a role in killing the Clinton health care reform plan.

[Al Franken]

Oh, okay. Congratulations. It's now you left for a reason. And this is a high paying job. This is a six figure job. And you, you quit. Why was that?

[Wendell Potter]

Well, I saw too much. I think the industry and my former bosses would probably regret having hired me. I was a newspaper reporter, my first career, so that was one thing. I had a reporter's sens. Sometimes I've joked that looking back over my career, I was undercover for 20 years. But I, I saw what motivates these companies. You know, the ones that are listed on the New York Stock Exchange, like Cigna and Humana, they are beholden to shareholders and a handful of Wall street financial analysts. And every three months the, the game is to try to make sure that you meet Wall Street's profit expectations. And if you don't, if you miss the consensus estimate of how much the company should earn per share, then you can expect your stock is going to take a hit. And if you are an executive, that means your net worth is going to take a hit because most top executives are paid largely in stock options and stock grants. But I also saw how these companies spend enormous amounts of premium dollars on campaign contributions, on lobbying expenses. I'm sure you, you saw plenty of it or at least the consequences of that. And I was a part of that too.

[Al Franken]

I do want to ask you about the medical loss ratio in a little bit and whether that helped at all. Yeah. But just first I want to ask you why you left your job. Was there an event that made you leave?

[Wendell Potter]

Oh, there was. There actually were two major events. One was going back home to visit family in Tennessee and reading in my local newspaper about something that was called a healthcare expedition. A few miles away at a county fairground. And I borrowed my dad's car.

[Healthcare Policy Expert / Commentator]

I was curious.

[Wendell Potter]

I never heard of anything like that. And I drove to Wise County, Virginia, which is a small town in southwestern Virginia in the, the coal mining area. And I saw, when I went through the Fairground gates, people who were standing in long lines. It had been raining, they were soaking wet. But they weren't going to leave their places in line because they had waited in many cases for over a year to get care that was being provided, I noticed, by doctors and nurses who were volunteering their time. They were being treated in barns and animal stalls on this fairground site.

[Al Franken]

Now, I'm assuming these are people who don't have insurance.

[Wendell Potter]

No, that's not exactly true. A lot of them had insurance, even some of them had Medicare. But many of them had private insurance that had very high deductible plans. And that was one of the things that I was responsible for in my job, was to try to get people to believe that high deductible plans were the silver bullet that was going to reduce spending on health care. I knew high deductible plans, making people pay a lot of money out of their own pockets before their coverage will kick in was going to result in a lot of Americans not getting the.

[Al Franken]

Care, not getting care or going into debt.

[Wendell Potter]

And that's exactly what I saw face to face. I saw a lot of people, people I could have grown up with, Al, because I'm from that part of the world, waiting to get care in a barn because their insurance would not cover what they needed. Because until they paid a substantial amount of money out of their own pockets, and these folks just didn't have money to spend out of their own pockets for care.

[Al Franken]

Okay, so. So this event was one of the reasons you left. What was, what was the other?

[Wendell Potter]

The other was a few months later, I, as I mentioned, one of the things my team and I did was handle high profile cases when CIGNA would refuse to pay for for some treatment that a patient needed. A 17 year old girl in Los Angeles was scheduled to have a liver transplant. But at the last minute, just as the surgery was about to take place, a medical director from CIGNA said he did not think that transplant was medically necessary.

[Al Franken]

Jesus.

[Wendell Potter]

And so he pulled the plug. Essentially he said, we're not going to pay for it.

[Al Franken]

How is it possible that a girl who is lined up to get a liver transplant, that some doctor ruled that she really didn't need a liver transplant?

[Wendell Potter]

Yeah, that's one of the reasons I left was to tell people this happens every day, Al. And it still does.

[Al Franken]

That's what I want to ask you about in terms of if you believe the ACA has, how it's helped and how it hasn't.

[Wendell Potter]

It helps some in this particular area, it did not. In fact, it's only gotten worse. What I'm referring to is something that's referred to as prior authorization when an insurance company refuses to cover something because they insist on reviewing and approving a treatment plan before they'll pay for it. And that also extends to medications and imaging. And insurance companies have realized this is a great way for them to meet those profit expectations because the more care they deny, the more money is left over for them to reward their shareholders and consequently their top executives.

[Al Franken]

Well, there's a medical loss ratio have play here because there's a limit to how much profit these companies can make. And that's 20%, right?

[Wendell Potter]

Yes. And that was one of the things that I testified about was the need for some limits on the medical loss ratio because increasingly, insurance companies were spending less and less of premium dollars on.

[Al Franken]

And that was my, My piece of the. One of my pieces of the act was the medical loss ratio.

[Wendell Potter]

I remember that. I remember that. And I'm so grateful for it because it did a lot of good. As you, as you know, as you recall, it. It requires them to pay at least 80% and in some cases, 85% of premium dollars on healthcare.

[Al Franken]

Yeah. On a small, small group. 80% on a large group policy. 85. And what that means is they have to spend at least 80 or 85% of their premiums on actual health care.

[Wendell Potter]

That's right.

[Al Franken]

And not on CEO salaries or stock, you know, not on advertising and marketing and on administration.

[Wendell Potter]

That's right. It wasn't airtight, though. And here's, here's part of, part of the problem here.

[Al Franken]

This.

[Wendell Potter]

As the regulations were being written, the industry was able to get the Department of Health and Human Services and CMS and other regulators to allow them to count various things as health care that really were more administrative in nature. So even though your intent was to make sure that they were spending 80 to 85% largely paying claims, they had the regulations written in ways that gave them a lot of latitude. That's one thing that they did to get around the congressional intent. The other was for them to begin to acquire pieces of the healthcare delivery system, doctor's offices, physician practices and clinics. That has been what these big companies have been buying up in recent years. UnitedHealth Group in particular, which is in Minnesota, as you know.

[Al Franken]

Well, we know that very well. Of course, last year we had the assassination or murder of Brian Thompson. Who, the CEO of United Healthcare.

[Wendell Potter]

Yeah, United Healthcare. UnitedHealth Group, which is a parent company, owns scores and scores of physician practices it is now the largest employer of doctors in the country. Many people realize that. But as they have been able to do that to get more and more into healthcare delivery, and this is on the other side of their house. UnitedHealthcare is called Optum, which is a very big division of the company and that's the division that's bought all these physician practices and clinics and other parts of healthcare delivery. They're able to circumvent the, again, do a workaround medical loss ratio because healthcare delivery is not a part of the medical loss ratio, just health insurance. So as they have gotten more and more into healthcare delivery, they're actually paying themselves and as they're doing that, they're able to reduce their medical loss ratio to meet the, to stay in compliance.

[Healthcare Policy Expert / Commentator]

With the medical loss ratio provision of the law.

[Al Franken]

I wish, I wish I had known that before the Republicans took over Congress.

[Wendell Potter]

I know.

[Al Franken]

And Trump became president. So nothing's going to happen with that.

[Wendell Potter]

I'm afraid it may not. It's something that I continue to write about and talk about and I'll be spending quite a bit of time in Washington. But I fear you're right. Probably nothing's going to happen.

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[Al Franken]

So you didn't complete the story about why you the event that made you leave.

[Wendell Potter]

Well, Natalie Sarkeesian was the 17 year old girl that I was talking about. Her family was just outraged and they didn't know that Cigna could do this. Few people know that their insurance company can make a decision like that. So they decided to make a stink about it. They, they organized their family and friends, they got the media in Los Angeles interested in this story. My phone was ringing off the hook. It became a very big PR problem for Cigna that endured for days and days. Eventually I went to the CEO and other top executives and said, look, this is a big PR nightmare for the company. We're getting a lot of bad press. Well, the company reversed that denial largely because of the bad press. So the company reversed that denial. But the problem is when you delay care, it's really like when someone needs a liver transplant.

[Al Franken]

And that's what she needed.

[Wendell Potter]

Right, right then. And that liver was not available. When Sigma said it would pay for.

[Al Franken]

The transplant, they actually said it wasn't.

[Wendell Potter]

Necessary for her, it wasn't necessary. They changed, you know, you know, the company changed, changed its mind and said it would pay for it, but it came too late. And Nataline died just about five hours after Cigna said it would cover the transplant.

[Al Franken]

Jesus.

[Wendell Potter]

She got sicker and she was 17. And she could be with us today if it had not been for that delay. That happens again, Al, even more today than it did before. I just saw a story this week. Kaiser Family foundation does a lot of research looking at denial rates within the health plans that people buy through the so called Obamacare marketplaces. The exchanges.

[Al Franken]

Right, the ACA.

[Wendell Potter]

Exactly. About 20% of the requests for coverage are denied. That's on average, some of these companies, like United in this report reject one of every three requests for coverage. So it's, it's gotten worse and Congress really needs to address it and state legislatures. And that is why you referenced the murder of Brian Thompson. There was such an outpouring of outrage, not at the murder, but at the way insurance companies operate these days.

[Al Franken]

And that surprised me.

[Wendell Potter]

Yeah, surprised me too. Although I have known, even going back to my career, I knew that people despise their health insurance companies. Most of us go throughout the year reasonably healthy without having to test the limits of our health insurance policy. But when we get sick, we often find out it's not what we thought it was, it's not as valuable, it doesn't cover as much as we had thought. And we often are exposed to high out of pocket cost. That's one of the reasons I formed this organization called the Lower out of Pockets Now Coalition. Because people can't afford to use their insurance. And the cost of a family policy now the average cost is, is $25,000. So as the cost of the coverage goes up, also the cost of what you have to pay out of pocket, that goes up too.

[Al Franken]

Why is that? Other than obvious. Obvious interests of the insurer. But I mean, what, how did that happen? How does that happen?

[Wendell Potter]

It happened when I was in the industry. The executives and the consultants to the industry said one way that the industry, the companies can make more money is by paying fewer claims, making people pay more out of their own pockets first. And we sold it with the euphemistic term consumer driven health care Jesus. And we were experts at getting people to believe things that just simply were not true or that were coded in language like consumer driven health care. What it was hiding, obscuring, was the fact that it made people pay more out of their pockets before their coverage would kick in. They did this. That never owned up to it. But the real reason for doing this was, again, so they would have more money to reward shareholders. So the more money we pay out of our own pockets, the more money they can reward their shareholders. And we use the term. Back then, my CEO and I and others would say Americans needed to have more skin in the game. I bet you heard that a time or two when you were at the Senate.

[Al Franken]

Yeah, but that wasn't the. That was the opposite of the aca, of the intent.

[Wendell Potter]

Oh, exactly. The. Exactly. But the opponents of reform and going back before you were in the Senate and Obama was president before the ACA was passed, that's when these plans began to take hold. And executives, including me, were saying, patients are the problem. They need to be paying more for their health care because they're not exposed enough to the real cost of health care.

[Al Franken]

I'm assuming then that the care a patient pays for out of pocket doesn't count toward the mlr.

[Wendell Potter]

No, no, it doesn't. It does not. It does not. The insurance industry, the insurance company is only held accountable for. Well, it does have some bearing. But as long as insurance company can say that they paid 80. Again, 80% if it's a small group or an individual, or 85% if it's a large group on health care. And again, that's a very squishy definition of what healthcare encompasses. And they've even used it to the point of seeing how they get like. Like in the Medicare program, for example, Medicare Advantage, United and other companies send nurses out to people's homes to do what's referred to as health risk assessments. And they count that as improving someone's care. When actually the intent, the reason for doing that primarily is to see if they can find evidence that they can claim that the person is sicker than they actually are. Because when they do, they're able to get more money from the federal government, from the federal Medicare program through the program that's called Medicare Advantage. So they've even been able to figure out how to make a profit center from doing some of the work that is actually, in their interpretation, providing care.

[Al Franken]

Wow. Now I get Medicare. I get my health care through Medicare, but I don't do Medicare Advantage. Good. It advertises too much for me. Is that if they're advertising that much, it's a profit center.

[Wendell Potter]

Exactly. You're so right. It's and I wish more people were as astute as you because it is too good to be true. They advertise that you're going to get more coverage for, you know, things like dental and vision and hearing. Typically the coverage for those things are, are very paltry. They're not very substantial. People don't they never hear in these advertisements that they are going to be subject to this prior authorization we've been talking about. That doesn't happen in the traditional Medicare program. Prior authorization is almost unheard of in traditional Medicare. Very, very prevalent in Medicare Advantage. And once again UnitedHealthcare one study showed that they reject about a third. Yes. Of requests for coverage in their Medicare Advantage plan. So people don't hear that they sign up for these plans. You know, I just say whenever I can buy or beware because it is.

[Healthcare Policy Expert / Commentator]

Too good to be true.

[Wendell Potter]

And they are not required to advertise truthfully. Which is another thing that I advocate for these companies.

[Al Franken]

Advertising truthfully is something you advocated for.

[Wendell Potter]

I do now. I do now. If drug companies have to in their TV ads at the end have some fast talking person say here are the side effects or potential side effects. Why shouldn't insurance companies be held to the same standard that you may not get the coverage for the care that you need because of prior authorization. You don't hear anything in those ads. So that's one thing. I talk to members of Congress. Why don't you at least address that among other things. But that's one thing that might keep people from signing up for these things unwittingly or thinking they're going to get something more than they do and wind up not getting the care that they need.

[Al Franken]

Now Americans overwhelmingly like the ACA or at least approve of it. Right. Anyway.

[Wendell Potter]

Right.

[Al Franken]

But now it's kind of at a crisis point because just it's unaffordable for so many Americans and they're not extending the subsidies. That's it's too late now, right?

[Healthcare Policy Expert / Commentator]

Yeah.

[Al Franken]

The shutdown of course was in large part about the subsidies and, and we're seeing premiums now skyrocket. KFF Non Partisan Health Policy Research Group. You must know them estimate the average recipient would see their premiums more than double this year. There's been quite a few different estimates for this and then none of them good. But it seems to depend on your, on a number of things like your income, what kind of policy you have. But most Americans are going to face much higher premium. What is the main determinant of how much your policy goes up?

[Healthcare Policy Expert / Commentator]

Well, it depends on whether or not you were eligible for an enhanced subsidy that was put in place during the Biden administration, during the pandemic. That's what has gone away. That means that hundreds of thousands of people who were newly insured, they were able to afford coverage as a result of that, have lost that subsidy. And so they're the ones who are losing the ability to afford insurance. I live in Philadelphia, and there was an article in the local paper that at least 70,000 people in just Pennsylvania alone have dropped their insurance because they can't afford it. Their policies have doubled in price, if not tripled in some cases.

[Al Franken]

It's been reported that a 1.4 million fewer people enroll in the ACA, which is actually, I thought might be more.

[Healthcare Policy Expert / Commentator]

I think it will be more down the road. I think that will continue to decline.

[Al Franken]

I see people who are healthy and feel they can risk not getting sick. Does that mean the people who do get insurance will be sicker and insurance companies will further raise their premiums?

[Healthcare Policy Expert / Commentator]

That's exactly what I think is going to happen. And one of the reasons I thought it was really important to extend those subsidies, because the people who are dropping their coverage are the ones that not only are having trouble affording it, but they are more than likely the youngest and the healthiest people who think they can take that risk. People who have health conditions who are older are probably going to be doing their best to stay covered because they will be running an even greater risk by dropping their insurance. So when that happens, that that creates or could create what's referred to as a death spiral of more and more people who are in that pool of people who get their coverage through the exchanges are sicker. And then as a consequence of that, the insurance companies will increase their premiums next year. And then that will probably lead to more people dropping their coverage. So it's really destabilizing the ACA marketplace significantly. By doing this.

[Al Franken]

We kind of touched on this a little bit. Did Democrats miss an opportunity to address the high costs of ACA insurance when Biden was in the White House and Democrats had the majority in both Houses, did they squander their chance to address the cost of the aca? And what could they have done that they didn't do?

[Healthcare Policy Expert / Commentator]

I think they could have. There were a number of things they could have done that I was disappointed they didn't do. And one was to address some of the problems that continue to exist even after the ACA was passed. And of course, we know that when the Republicans were running the show during the first Trump administration, there were numerous attempts to repeal it. It wasn't repealed outright.

[Al Franken]

Who knew Health care was complicated. That's what. After McCain did the thumbs down.

[Healthcare Policy Expert / Commentator]

That's exactly right. Exactly right. But the administration could have looked to do something more to move beyond the Affordable Care act when they had a majority, but they didn't do it. And a lot of members of Congress that I talked to, they were justifiably proud of the Affordable Care Act. But we're thinking that, well, we've got that done. And of course, any kind of healthcare policy legislation is risky, is very polarizing, but I think they just played it too safe.

[Al Franken]

But you could do that under reconciliation, right? Yes. Which means all you need, the 51 votes. The 50 plus vice president Harris.

[Healthcare Policy Expert / Commentator]

Exactly. There was a time when we had her to be the majority of the Senate.

[Al Franken]

Yeah. So what are. What are Republicans offering? I know, that's. I'm sorry. Yeah, that was a punchline. But what, like, what is Trump proposed? I know he proposed something about, like, giving tariff money to buy health insurance. Wasn't that something I heard a couple months ago?

[Healthcare Policy Expert / Commentator]

Yeah. I think he probably has conflated tariffs with the. With health care. Who knows? But what he most recently has proposed is what he refers to as the great health care Plan. And this is what we've been waiting for, for what, 10 years now, that he said is on the way. But all we have so far is two or three paragraphs about what it supposedly is. And even the Republicans in the Congress are just calling it a framework. At one point, they were calling it a concept of a plan, I think the President called it, that he's proposing, and this is not fleshed out, but his idea is to spend money directly to people rather than doing the subsidies, which were in the form of tax credits that went to insurance companies to enable them to buy coverage more, more affordably. Trump is saying, well, let's send that money directly to individuals and families. Let them put it in a health savings account.

[Al Franken]

Right.

[Healthcare Policy Expert / Commentator]

And they can spend that money as they want to for health care. But he's never said how much money that he's going to send. And health insurance is expensive.

[SpinQuest Legal Disclaimer]

Yes.

[Al Franken]

So is he going to send, you know, $20,000 or $15,000 to every.

[Healthcare Policy Expert / Commentator]

Right.

[Al Franken]

You know, a family of three or four or whatever?

[Healthcare Policy Expert / Commentator]

Yeah, I kind of doubt it. I don't think he knows how much it really cost. And he's saying that is a way to penalize the insurance companies because we won't be sending money directly to them. But he's, he would put the burden on individuals to use that money to buy their coverage. So the money would still go to the same insurance company. So I right. Hope that people will wake up to realize this is nothing more than smoke and mirrors. But the other thing he wants to do, which has been a favorite of Republicans for a long time, is put this money, give it to them, so they can put it in a health savings account.

[Al Franken]

Right. That, that exists, right?

[Wendell Potter]

That exists.

[Al Franken]

Right.

[Healthcare Policy Expert / Commentator]

It exists. It was created years, you know, some years ago during a Republican administration. But it has to be tied to a high deductible plan and it cannot be used to pay premiums. Currently, under current law, you can't use it to pay premiums. So they would have to change federal law to change the HSAs, the health savings accounts. But here's the thing. Most people who have HSAs are pretty wealthy folks. Not many people of modest means have them. And if they have them through work or something, there's not much money in them. So they, it never has really caught on. They are a tax shelter for wealthy folks.

[Al Franken]

So really good. So he's got something. He's got something for them.

[Healthcare Policy Expert / Commentator]

Exactly. So that's, that's the plan so far.

[Al Franken]

Okay, so there's no, no plan?

[Wendell Potter]

No, there's no, there's no, there's no plan.

[Healthcare Policy Expert / Commentator]

It's not going to happen.

[Al Franken]

If you could, what would you do to reform the insurance industry? You know, we talked about like them owning medical practices and pharmacy benefit management. I mean, is there anything to breaking them up?

[Wendell Potter]

There is.

[Healthcare Policy Expert / Commentator]

And that actually does have some bipartisan interest. There's a Republican congressman from Georgia, Buddy Carter, who's a pharmacist, by the way. He understands these PBMs pretty well.

[Al Franken]

Yeah, I want to talk about PBMs or pharmacy benefit managers because they just make a hell of a lot of money and drive up the cost of pharmaceuticals, right?

[Wendell Potter]

Oh, they do.

[Healthcare Policy Expert / Commentator]

And that's why when we, if we have to take drugs and we go to the drugstore and pick up our medicine and find out when we get there, even we think we've got a good insurance. But we find out that sometimes we have to pay hundreds, sometimes thousands of dollars for our prescription medications, you can often keep your insurance card in your wallet, just go to the pharmacy counter and, and say, I'll pay cash and get a better deal. It's that crazy for a lot of drugs. And it's because these pharmacy benefit managers, the three biggest are owned by three big insurance companies, and together they control 80% of the PBM market.

[Al Franken]

What does a PBM do? Just for.

[Healthcare Policy Expert / Commentator]

A PBM works very closely with an insurance company, and so closely that the three biggest ones are owned by insurance companies. But they supposedly broker deals with drug makers, and they negotiate with drug makers to get it to arrive at a price that will be available to people who are in a certain insurance plan.

[Al Franken]

Okay.

[Healthcare Policy Expert / Commentator]

And then they determine how much pharmacists will be paid. They are a middleman, as you can see, in the pharmacy supply chain. But they've gotten so big and so powerful that they extract enormous amounts of money out of that pharmacy supply chain. And in many cases, these deals they strike is just really bogus because they sometimes capture and keep more money than the cost of the drug, and certainly a lot more than what they pay the pharmacist. And we wind up, often, we being patients, having to pay quite a bit of money out of our own pockets because they determine that, too. They determine how much you will have to pay out of your own pockets, even with your insurance card. So they're. They've become incredibly powerful. And the way that they work with drug makers is that they. They demand rebates, which. A better term for this is they. They demand a kickback from drug makers. This is legal. That's currently legal. But they will say to Johnson Johnson or Pfizer or Eli Lilly or Merck or someone, we will list your drug on our formulary, but you have to give us a rebate. It's extraordinarily complicated, as everything else in healthcare is. But they've constructed it deliberately. Yeah, deliberately. And it's like a black box. No one, including lawmakers, has much visibility into exactly how they operate.

[Al Franken]

I've been in those hearings, and it's largely impenetrable.

[Healthcare Policy Expert / Commentator]

Yep.

[Al Franken]

Let's talk about pharma. Pharma. More about pharmaceuticals. US Makes a lot of pharmaceuticals, Right? Make a.

[Wendell Potter]

Yes.

[Al Franken]

A high percentage of or a large percentage of our pharmaceuticals. But we pay here a lot more than the rest of the world.

[Healthcare Policy Expert / Commentator]

We do. We do.

[Al Franken]

Why are we paying so much more than the rest of the world? I mean, it. European countries or other countries, the government negotiates, right?

[Healthcare Policy Expert / Commentator]

That is exactly right. Almost all the other countries have some means in which the government negotiates the price of medications. We just never have.

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[Al Franken]

So Wendell, on Capitol Hill today, I guess on the House side, there were a couple hearings on health insurance. Executives testified. How, how did that go?

[Healthcare Policy Expert / Commentator]

Yeah, two House committees testified before two big committees, the Ways and Means Committee and the Health Subcommittee of Energy and Commerce. It's really a historic hearing because I don't think even during the Obama administration when the ACA was being debated that you had the whole lineup of these big CEOs on the hot seat. And they were on the hot seat. You know, they, they came pretty well prepared with their talking points.

[Al Franken]

And now what you prep, you used to Prep Insur. The CEOs for, for these hearings, right? I did, yeah.

[Healthcare Policy Expert / Commentator]

I worked for them for 20 years and I prepped them for every public appearance. So I knew what they would be doing and, and I knew that they would be pointing the finger of blame away from them, which is exactly what they did. They're saying that it's the, the fault of drug companies, of hospitals, of doctors. They're the reason why we have escalating healthcare costs in this country. But what I am seeing is that there is bipartisan agreement among members of those committees and the Senate as well to do something about the structure of these companies, about their PBMs. You may know that Elizabeth Warren and Josh Hawley have teamed up on legislation that would address the vertical integration of these companies, the anti competitive nature of these companies and how they do business, particularly UnitedHealth, which is the biggest and based in Minnesota.

[Al Franken]

Yeah. And that of course owns PBMs and.

[Wendell Potter]

Exactly.

[Al Franken]

Would you say make more money than the insurance side?

[Healthcare Policy Expert / Commentator]

Oh, absolutely. I worked for Cigna for 15 years and it was a very big company when I was there. But a few years ago Cigna bought Express Scripts, which is one of those big PBMs. And now Cigna gets far more money in revenue and profits from the PBM than it does from his health insurance business. In fact, in 2016, Cigna brought in about $47 billion revenue. In 2024, it brought in $247 billion. Most of that additional money came from their PBM. So that just gives you an idea of how much money we're talking about here. It was a big. And it still is a big health insurance company, but it gets far more money. The division that has Express Scripts is much, much bigger now than. Than the healthcare division that has the health insurance.

[Al Franken]

Oh, my God. So that tells us a lot about why we pay so much more for our drugs.

[Healthcare Policy Expert / Commentator]

Exactly. And as you can imagine, the lobbyists for the PBM business, they're spending an enormous amount of money trying to protect that golden goose.

[Al Franken]

You know, I know that you are for Medicare for All.

[Healthcare Policy Expert / Commentator]

Yes.

[Al Franken]

But, you know, a lot of Americans, I think During World War II, Americans started to get their insurance from their place of work.

[Healthcare Policy Expert / Commentator]

Yes.

[Al Franken]

And a lot of Americans like that. And I remember during the 2020 campaign, Democrats like Warren and Bernie and a couple others were for Medicare for All.

[Healthcare Policy Expert / Commentator]

Yes.

[Al Franken]

And I think there were a lot of, you know, suburban voters who get their insurance through their employer. And we were looking at those districts and that people didn't want to give up our healthcare system for a government run because something. They didn't know what it would be.

[Healthcare Policy Expert / Commentator]

That's right.

[Wendell Potter]

Yeah.

[Healthcare Policy Expert / Commentator]

It's an unknown to a lot of people.

[Al Franken]

Right. So Buttigieg, as I remember, was for Medicare for All who want it. Was that what is.

[Healthcare Policy Expert / Commentator]

As far as.

[Wendell Potter]

You're right.

[Healthcare Policy Expert / Commentator]

Yep.

[Al Franken]

And is that such a bad idea? Because other countries. Right. Have all different kinds of systems.

[Healthcare Policy Expert / Commentator]

Yes.

[Al Franken]

I mean, UK has a. Has, you know, national health and. But not that many. And a lot. A lot of countries, you get your. Get your insurance from. From your employer or you get it from a private insurer.

[Healthcare Policy Expert / Commentator]

Yeah.

[Al Franken]

So Medicare for all who want it. How's that?

[Healthcare Policy Expert / Commentator]

I. You know, it has a lot of merit, and I think it's something that we are looking at. We're doing a lot of research and polling on this. There's a great deal of support for changes. Once again, we are at this point where I think we were before when the debate on the Affordable Care act began. People are very frustrated and concerned and upset with insurance companies in particular, more than I've ever seen it. So I think this could be an opportunity, the next window we have to put something like that forward and maybe more successfully. I think it could happen. I think it. And you're right. In other countries like the uk you can, everybody can be covered by the National Health Service, but you can also go to a private provider, a private hospital, private doctors, you can get private insurance. Germany, other countries, you, you have that ability as well too. But you had a national program that covers everybody. But some people can opt out of it or they can get additional insurance. And I think that probably is more likely what we would, we could have here in this country.

[Al Franken]

Well, it's going to even, I mean, to get that is going to take a lot of, a lot of good elections.

[Healthcare Policy Expert / Commentator]

I think you're exactly right. And overcoming an enormous amount of opposition from my former employers because the, the status quo is extraordinarily profitable for those guys.

[Al Franken]

Now, you, you said that you are, you were kind of shocked by the reaction to Brian Thompson's murder.

[Wendell Potter]

Yeah.

[Al Franken]

And all the outrage that poured out. In retrospect, are you surprised by it?

[Wendell Potter]

In retrospect, and as I've seen it, no, because a lot of it al. It triggered people's storytelling. Two things can be true. And I say, I say this. It's. The, the murder was horrific and you cannot condone that. Any kind of violence is, is wrong. But what people decided to do was to use this as an opportunity for them to go to social media to talk about how they or someone they knew had, had been denied care. In many cases, life saving care.

[Al Franken]

Like the girl. Like the girl who didn't get the liver transplant. Exactly. And died. That's the same kind of crime. In a way, it is.

[Wendell Potter]

And I've said that it is a, it is a crime. It is a, it's, it's. Well, maybe not because it is legal. The way they operate is certainly legal. In my view, it should be criminal because people die every day.

[Al Franken]

And the ACA did not address that.

[Wendell Potter]

No, the, the, the Affordable Care Act, Obamacare did not meaningfully address that. And in fact, al, looking back, it has enabled these companies to act even more with impunity in certain ways. And for them to.

[Al Franken]

How so?

[Wendell Potter]

Well, there were no constraints on prior authorization, so they've expanded the use of it. And while the ACA did set a limit on how much you can charge out of pocket, those limits go up every year and they're extraordinarily high. If you have a family plan that you get through the ACA Marketplace, you can be on the hook for $19,000 out of your own pocket before your coverage kicks in. There are not a lot of families in this country who can afford that, and that's every year that resets every year. So it was an oversight or I think the members of Congress just were not thinking that the companies would use that as a way of using the back door to deny coverage or to make people who are sick pay a lot more out of their own pockets and get them off the hook for covering the care that they need.

[Al Franken]

Oh boy. Well, thank you.

[Healthcare Policy Expert / Commentator]

You're welcome.

[Al Franken]

Well, I hope you enjoyed listening. That beautiful music is by Leo Kotke, the great Leo Kotke. I want to thank Peter Ogburn for producing this podcast. We'll talk again next week.

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[Al Franken]

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