When a New York doctor tweeted recently about “payday loans” for doctors from a branch of UnitedHealth Group — which operates the giant insurance company UnitedHealthcare — we were intrigued.

Especially when we saw that the loan product — a “cash flow solution” for health care providers — was real.

The doctor’s tweet essentially accused UHG’s insurance arm of causing cash flow problems for providers in the first place, by denying claims and delaying payments — which echoes complaints we’ve heard over the years, and which the original tweet called “genius” — as in Evil Genius. When the boss who’s paying you late offers to front you money, at interest, to tide you over, it does sound like… a conflict of interest.

It turns out, because UnitedHealth Group is such a big, complex enterprise, it’s not quite that simple. 

But UnitedHealth Group’s size and complexity turns out to be the story. The company has grown into a “behemoth,” running the country’s biggest insurance company, and becoming the biggest employer of doctors, while also running big parts of the business-side back end for big chunks of the health care ecosystem. 

As one expert told us, “There's very little good news about what happens when these organizations. or these sectors of health care get bigger.” Costs and prices tend to go up, without a bump in quality.

And regulators, we learned, have struggled to keep up. 

It’s a wild ride with a sobering conclusion — and very much worth taking. 

As the expert who labeled United a behemoth wrote: “United has grown to its present immense scale largely without public knowledge.” Now we know. And knowledge is the beginning of power. 

BONUS TIP: This story reminded us of themes and insights from novelist, journalist, and activist Cory Doctorow, especially his recent book Chokepoint Capitalism and his recent essays about the “enshittification” of online life.

We also like Cory’s novels a lot, and have learned a ton from them. They’re often called science fiction, but the tech is usually present-day, or about a month into the future. His latest, Red Team Blues, is a smart, fun techno-thriller. 

Here’s a transcript of this episode. 

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