there are three big categories of barriers. The application barrier, the interview barrier, and the document barrier. And that’s what we spent most of our time iterating on and building a system that could slowly learn about those barriers and then intervene against them.

The application is asking, “Are you convicted of this? Are you convicted of that? Are you convicted of this other thing?” What is that saying to you, as a person, about what the system thinks of you?

Often they’ll call from a blocked number. They’ll send you a notice of when your interview is scheduled for, but this notice will sometimes arrive after the actual date of the interview. Most state agencies are really slammed right now for a bunch of reasons, including Medicaid unwinding. And many of the people assisting on Medicaid are the same workers who process SNAP applications. If you missed your phone interview, you have to call to reschedule it. But in many states, you can’t get through, or you have to call over and over and over again. For a lot of people, if they don’t catch that first interview call, they’re screwed and they’re not going to be approved.

getting to your point about how a website can fix this —  the end result was lowest-burden application form that actually gets a caseworker what they need to efficiently and effectively process it. We did a lot of iteration to figure out that sweet spot.

We didn’t need to do some hard system integration that would potentially take years to develop — we were just using the system as it existed. Another big advantage was that we had to do a lot of built-in data validation because we could not submit anything that was going to fail the county application. We discovered some weird edge cases by doing this.

A lot of times when you want to build a new front end for these programs, it becomes this multiyear, massive project where you’re replacing everything all at once. But if you think about it, there’s a lot of potential in just taking the interfaces you have today, building better ones on top of them, and then using those existing ones as the point of integration.

Government tends to take a more high-modernist approach to the software it builds, which is like “we’re going to plan and know up front how everything is, and that way we’re never going to have to make changes.” In terms of accreting layers — yes, you can get to that point. But I think a lot of the arguments I hear that call for a fundamental transformation suffer from the same high-modernist thinking that is the source of much of the status quo.

If you slowly do this kind of stuff, you can build resilient and durable interventions in the system without knocking it over wholesale. For example, I mentioned procedural denials. It would be adding regulations, it would be making technology systems changes, blah, blah, blah, to have every state report why people are denied, at what rate, across every state up to the federal government. It would take years to do that, but that would be a really, really powerful change in terms of guiding feedback loops that the program has.

when you start to read about civic technology, it very, very quickly becomes clear that things that look like they are tech problems are actually about institutional culture, or about policy, or about regulatory requirements.

If you have an application where you think people are struggling, you can measure how much time people take on each page. A lot of what technology provides is more rigorous measurement of the burdens themselves. A lot of these technologies have been developed in commercial software because there’s such a massive incentive to get people who start a transaction to finish it. But we can transplant a lot of those into government services and have orders of magnitude better situational awareness.

There’s this starting point thesis: Tech can solve these government problems, right? There’s healthcare.gov and the call to bring techies into government, blah, blah, blah. Then there’s the antithesis, where all these people say, well, no, it’s institutional problems. It’s legal problems. It’s political problems. I think either is sort of an extreme distortion of reality. I see a lot of more oblique levers that technology can pull in this area.

LLMs seem to be a fundamental breakthrough in manipulating words, and at the end of the day, a lot of government is words. I’ve been doing some active experimentation with this because I find it very promising. One common question people have is, “Who’s in my household for the purposes of SNAP?” That’s actually really complicated when you think about people who are living in poverty — they might be staying with a neighbor some of the time, or have roommates but don’t share food, or had to move back home because they lost their job.

I’ve been taking verbatim posts from Reddit that are related to the household question and inputting them into LLMs with some custom prompts that I’ve been iterating on, as well as with the full verbatim federal regulations about household definition. And these models do seem pretty capable at doing some base-level reasoning over complex, convoluted policy words in a way that I think could be really promising.

caseworkers are spending a lot of their time figuring out, wait, what rule in this 200-page policy manual is actually relevant in this specific circumstance? I think LLMS are going to be really impactful there.

It is certainly the case that I’ve seen some productive tensions in counties where there’s more of a mix of that and what you might consider California-style Republicans who are like, “We want to run this like a business, we want to be efficient.” That tension between efficiency and big, ambitious policies can be a healthy, productive one. I don’t know to what extent that exists at the state level, and I think there’s hints of more of an interest in focusing on state-level government working better and getting those fundamentals right, and then doing the more ambitious things on a more steady foundation.

California seemed to really try to take every ambitious option that the feds give us on a whole lot of fronts. I think the corollary of that is that we don’t necessarily get the fundamental operational execution of these programs to a strong place, and we then go and start adding tons and tons of additional complexity on top of them.

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.”