Even the biggest fans of capitalism do not believe that maximizing shareholder value is something that excuses all consideration of harm to customers, and healthcare is one of the few industries where customers experiencing harm is ubiquitous. Perhaps no other industry is as likely to affect every American individual directly and horrifically. Not weapons manufacturers, not companies that wreck the environment, not predatory lenders.

A 2014 RAND report singled out Epic as a roadblock to interoperability. With the company’s rise, researchers wrote, came an increasingly walled-off system. “By subsidizing ‘where the industry is’ rather than where it needed to go,” the report said, the government propped up an EHR market “that did not have the level of connectivity envisioned by the authors of the HITECH Act.”

In terms of bringing digital records to practices across the country, the HITECH Act has unquestionably succeeded: The percentage of US hospitals using digital rec­ords skyrocketed from 9.4 to 75.5 percent between 2008 and 2014. But the HITECH Act didn’t prioritize “interoperability”—the ability to transfer a medical file from one hospital to another. Unless programmers ensure that their system properly integrates with another, a doctor’s computer might spit out something akin to emoticons when queried for key test results.

Epic does work with hospitals and practices to link its system with competing ones, but it usually charges top dollar to do so.

A recent study by the American Medical Association and the online network AmericanEHR Partners found that 43 percent of physicians thought their software actually made their jobs more difficult. Doctors are investing the time to input data, but their offices are still having to fax and mail records like they did a decade ago. Less than 10 percent of hospitals say they’ve been able to trade records entirely through their digital systems.

All together, it’s like the Microsoft Office of health care software—more comprehensive than any of its competitors, even if its individual components are kind of meh.

“What you hear is that, if you were to buy the best of breed—the best cardiology system, or the best chemotherapy system—no one would ever choose Epic,” says Julia Adler-Milstein, a University of Michigan researcher who studies health care IT. As it stands, she says, using Epic is easier than trying to piece together better options from various software vendors. On top of that, Epic will tailor each installation on-site to a customer’s specific needs. What it doesn’t have—and ditto systems created by competitors Cerner and Meditech, the other bigwigs in EHR—is a framework to connect to other facilities using competing EHR systems.

Epic is probably here to stay, especially given the incredible investments hospitals have made to implement its system—Duke University, for example, reportedly spent $700 million on its Epic installation. That doesn’t mean Americans have to accept the status quo. According to Adler-Milstein, the University of Michigan researcher, “What we can do is force them to open up their system a little more, so that it plays better with others.” She hopes increased scrutiny pushes the company to publish its API—the code that lets others access information in its system—to allow other firms to build more user-friendly software.

I tried to create a spreadsheet that would guide readers through the appeals process for all the different types of insurance and circumstances. When a patient needs care urgently, for instance, an appeal follows a different track. But with each day of reporting, with each expert interviewed, it got more and more confusing. There was a point when I thought I was drowning in exceptions and caveats. Some nights were filled with a sense that I was trapped in an impossible labyrinth, with signs pointing to pathways that just kept getting me further lost

You may think that UnitedHealthcare is your insurer because that’s the name on your insurance card, but that card doesn’t tell you what kind of plan you have. Your real insurer may be your employer.

Government insurance is its own tangle. I am a Medicare beneficiary with a supplemental plan and a Part D plan for drug coverage. The appeals process for drug denials is different from the one for the rest of my health care. And that’s different from the process that people with Medicare Advantage plans have to follow.

The federal government sets minimum standards that each state Medicaid program has to follow, but states can make things more complicated by requiring different appeal pathways for different types of health care. So the process can be different depending on the type of care that was denied, and that can vary state to state.

I sought help from Jack Dailey, a San Diego attorney and coordinator for the California Health Consumer Alliance, which works with legal-aid programs across the state. On a Zoom call, he looked at an Excel spreadsheet I’d put together for Medi-Cal, California’s Medicaid program, based on what I had already learned. Then he shook his head. A few days later, he came back with a new guide, having pulled an all-nighter correcting what I had put together and adding tons of caveats. It was seven single-spaced pages long. It detailed five layers of the Medi-Cal appeals process, with some cases winding up in state Superior Court. There were so many abbreviations and acronyms that I needed to create a glossary. (Who knew that DMC-ODS stands for Drug Medi-Cal Organized Delivery System?) And this was for just one state!

It’s especially complicated in oncology, said Dr. Barbara McAneny, a former president of the American Medical Association who runs a 6,000-patient oncology practice in Albuquerque, New Mexico. “My practice is built on the theory that all the patients should have to do is show up and we should manage everything else … because people who are sick just cannot deal with insurance companies. This is not possible,” she said. McAneny told me she spends $350,000 a year on a designated team of denial fighters whose sole job is to request prior authorization for cancer care — an average 67 requests per day — and then appeal the denials. For starters, she said bluntly, “we know everything is going to get denied.” It’s almost a given, she said, that the insurer will lose the first batch of records. “We often have to send records two or three times before they finally admit they actually received them. … They play all of these kinds of delaying games.”

McAneny thinks that for insurance companies, it’s really all about the money. Her theory is that insurance companies save money by delaying spending as long as possible, especially if the patient or the doctor gives up on the appeal, or the patient’s condition rapidly declines in the absence of treatment. For an insurance company, she said, “you know, death is cheaper than chemotherapy.”

Vaccines are not only immensely useful; they also embody something beautifully human in their combination of care and communication. Vaccines do not trick the immune system, as is sometimes said; they educate and train it. As a resource of good public health, they allow doctors to whisper words of warning into the cells of their patients. In an age short of trust, this intimacy between government policy and an individual’s immune system is easily misconstrued as a threat. But vaccines are not conspiracies or tools of control: they are molecular loving-kindness.

In 2017, Americans spent $3.5 trillion on health care — a level nearly equal to the economic output of Germany, and twice as much as other wealthy countries spend per person, on average. Not only is this a problem for the people seeking care; it’s also a problem for the companies they work for. Currently, about half of Americans are insured through an employer, and in recent years companies have borne the financial brunt of rising costs. Frustrated, many employers have shifted the burden to workers, with average annual deductibles rising by more than 50% since 2013.