Episode summary
The Broken US Healthcare System is Failing Millions of Americans with Warris Bokhari
The Real Eisman Playbook
· · 1 hr 18 min · Hosts: Steve Eisman · Guests: Warris Bokhari
Summary
The episode argues that U.S. health insurance is failing at scale because insurers are optimizing for short-term economics rather than patient care. Warris Bokhari says there are about 5 billion claims a year and roughly a 17% denial rate, implying 850 million denials and 70 to 90 million Americans affected in a given year. He argues that many denials are not substantive medical judgments but fast, AI-driven defaults that most patients never appeal.
Bokhari says Claimable was built to help patients overturn denials for expensive drugs and biologics, with a flat $50 fee and AI-assisted appeal letters that combine the patient’s story, clinical evidence, state law, and prior insurer precedents. He says appeal success can be very high when patients do fight back, but fewer than 1% of denied claims are appealed because the process is hard when people are sick.
The discussion breaks the system into commercial insurance, Medicare Advantage, Medicaid, and ACA plans, and argues that all four are under pressure at once. Bokhari says Medicare Advantage was distorted by risk coding and vertical integration, Medicaid was left with a sicker pool after disenrollment rules changed, and ACA markets are being hit by higher costs, consolidation, and PBM-driven pricing. He also says insurers are increasingly using “breakage” and “shift left” tactics to delay payment and preserve float.
Key takeaways
- Warris Bokhari says U.S. insurers deny about 17% of claims, which he translates into roughly 850 million denials a year and 70 to 90 million affected Americans.
- Claimable charges a flat $50 per appeal and uses AI to build denials appeals around clinical evidence, patient impact, state law, and insurer precedent, according to Bokhari.
- Bokhari says fewer than 1% of denied claims are appealed, which lets many denials stand even though he says appeal overturn rates can be very high.
- He argues Medicare Advantage was distorted by aggressive risk coding and vertical integration, then repriced lower when the government changed coding rules.
- He says Medicaid and ACA plans are also under strain from sicker pools, consolidation, PBM pricing, and insurers’ efforts to delay payment through breakage and shift-left tactics.
Notable quotes
“If you really look at the number of claims photo filed in a year, which is about 5 billion, you look at a 17% denial rate, you're looking at 850 million denials a year”
“These insurers are applying bad policies really quickly using AI”
“we built an AI system to actually help patients appeal these denials”
“From our data, depending on the area, it's anywhere between 70 and 93% we see in overturns”
“if you appeal, you have a good chance of winning”
How the episode opens
What do you see is the fundamental nature of the problem in medical insurance in the United States? What's the basic problem? Today we're going to talk about the health care system of the United States.
We're all involved. Everybody participates and we all know on some level there's something wrong and we need to talk about it. If you really look at the number of claims photo filed in a year, which is about 5 billion, you look at a 17% denial rate, you're looking at 850 million denials a year.
It's about 70 to 90 million Americans. That's an enormous number.
It's huge because often times like these denials, they mean nothing. I've had an insurance executive tell me that something like 96% of their appeals get overturned. They know it. Patient goes to the doctor, doctor's office fills out the paperwork and 1.2 seconds later, the claim is denied. And that's 15 to 20% of the time.
These insurers are applying bad policies really quickly using AI. — Wow. I heard a story from a dad the other day who was literally sitting in the garage of his house with a loaded gum because he felt that the failure of not being able to pay for the medical care for his daughter was just too much to bear.
I need to gather my thoughts. — It's a very real moral injury. 50% of cancer patients go bankrupt inside of two years — In the United States of America. — In the United States of America. — That's unbelievable. — Wow. That's the crisis of our times that's being played out. Let's turn to solutions for a little bit. Hi, this is Steve Eisman and welcome to another episode of the real Eisman playbook. And today we're not going to talk about stocks.
From the episode’s captions: roughly the first two minutes, lightly cleaned. Keep watching on YouTube →
Topics
- ai claim denials
- healthcare policy
- medicare medicaid
- aca
- healthcare profit pressures
Companies and tickers mentioned
- Claimable
Watch the episode
Summary, takeaways and quote selection by Octagon. Quotes are short excerpts; the full conversation is in the episode.
More from The Real Eisman Playbook
-
The AI Debate is No Longer Boom vs Bust: Why It’s Time to Go Back to Stock Picking | The Weekly Wrap -
The Midterms Have Changed the AI Narrative: S&P Down 4.4%, Nasdaq Down 5.5% | The Weekly Wrap -
Why Young Americans Feel Locked Out with the Lemonade Stand Podcast | The Real Eisman Playbook Ep 82 -
Anthropic’s Growth is Slowing: Is AI Capex Next? | The Weekly Wrap -
Inflation, The Deficit & Why the Dollar Stays King with Benn Steil | The Real Eisman Playbook Ep 81 -
AI Narrative Switched, Debt Yields Spike | The Weekly Wrap
The Real Eisman Playbook, this episode and its artwork belong to Steve Eisman. Octagon is not affiliated with the show; this page is an independent summary.
