Hospice: Last Week Tonight with John Oliver | Transcript

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John: Welcome, welcome to “Last Week Tonight!” I’m John Oliver. Thanks so much for joining us. It has been a busy week. Ukraine continued to push into Russian territory, the internet tried to figure out what happened behind the scenes on this movie, and the Trump campaign tried to counter the enthusiasm for the Democrats’ new ticket with J.D. Vance, a man who perpetually looks like he got stuck 10% of the way to transforming into a werewolf, desperately trying to spin the joy of Harris‘s recent rallies as a negative. She says she’s having fun. But while she’s having fun, Americans are suffering under her policies. When she laughs during a speech, remember that there are American families crying this very day because they cannot afford groceries. When she does these rallies and does these events and does these fake dances, remember that there are parents who lost their children to drugs or violence who will never see their children move again, much less dance again.

John: What are you doing? Scolding people for enjoying stuff because there are sadder things happening elsewhere is a shitty thing to do, although it does make me curious what Vance is like in other social situations. “All right, kids, enjoy Sea World, meet us back here at 2:00, and remember, dolphins will sometimes kill porpoises for sport! Have fun! Scientists call it ‘porpicide!'”

Also, for what it’s worth: bumming everyone out with depressing facts about things you like isn’t how you become vice president—it’s how you put people to sleep once a week while aging like a wartime president. Get the fuck off my corner!

The Trump-Vance campaign has been trying to deflect charges of Republicans being “weird.” Just last week, Trump told a rally, “I think we’re the opposite of weird. They’re weird.” And told a radio host, “Nobody’s ever called me weird. I’m a lot of things, but weird I’m not.” So you know it’s getting to him. But also, nobody’s ever called you weird? Babe, be serious. You tried to buy Greenland, you stared at the sun during a solar eclipse, and you did this. That’s not something a normal guy does. I don’t know what a normal guy would do, because I’m also not one, but I know it’s not that.

The “weird” label has been particularly hard to shake, because Republican candidates further down the ballot keep compounding it, including some who won primaries just this week, like Royce White. He became Minnesota’s Republican Senate candidate, and he is a lot. He’s a former NBA player, far-right podcaster, and a die-hard Trump supporter, as he will tell you.

Donald Trump could get up on stage, pull his pants down, take a shit up at the podium, and I still would never vote for you fucking Democrats again. Let that sink in.

John: Okay, I’m letting it sink in. All right, it’s sunk in now, and I do still have some questions. Is there a place where Trump could take a shit that would make you vote for Democrats again? Like on a merry-go-round, would that make you vote for them? Or if he shit inside a gumball machine, would you vote for Democrats then? Or if he went into your bathroom, put the toilet lid down, and shit on the toilet instead of in it—would you at least consider voting for an independent who caucuses with the Democrats? You know what? Let that sink in and get back to me.

White’s been endorsed by Steve Bannon and Alex Jones, whom he once supported by writing this message on the side of his head. He’s also said—among other things—that he’s not sure if a plane hit the Pentagon on 9/11, claiming there’s no footage of it, which, of course, there very much is. And he even once tweeted out this map he claimed showed “crime in Minneapolis” is “out of control,” which turned out to be a map of the city’s drinking fountains, which is embarrassing. There are so many real crime maps he could’ve used, like this one—except I’m kidding. That’s New York’s rat information portal, you idiot! You just got schooled by the rat map! Rat map!

John: But White’s just one of a number of odd GOP Senate candidates. In Virginia, there’s Hung Cao, a retired Navy captain with no political experience, who’s also a very strange man.

Hung Cao: We can’t let it turn like this. There’s a place in Monterey, California, called “Lover’s Point.” The original name was “Lovers of Christ Point,” but now it’s become—they took out the Christ, it’s “Lover’s Point,” and it’s really—Monterey’s a very dark place now, a lot of witchcraft, and the Wiccan community has really taken over. We can’t let that happen in Virginia.

John: Okay. If Monterey is actually overrun by witches—which it’s not—I’m frankly furious there wasn’t a witchcraft storyline on Big Little Lies. How could you deprive us of Nicole Kidman showing up to a moonlit orgy and announcing, “We come to this place for magic?” Everyone’s head would’ve exploded! And while Cao and White are unlikely to win, other Republican candidates like Eric Hovde—Ned Flanders without the raw, sexual charisma—do have a real shot. This week, he won Wisconsin’s Senate primary in a landslide. He’s the wealthy CEO of a bank called Sunwest, so he’s self-financing his campaign. And he’s taken some flak for not just owning property in California, but spending a significant amount of time there—something he tried to deflect with this video.

Eric Hovde: It’s good to get out here for a good cold plunge. So the Dems and Senator Baldwin keep saying I’m not from Wisconsin, ha, which is a complete joke. All right, Senator Baldwin, why don’t you get out here in this frozen lake and let’s really see who’s from Wisconsin? I hope everyone has a great day. Take care.

John: Well, now I’m having a terrible day, because I did not want to see that at all. Why physically torture yourself to prove you’re from Wisconsin when your incredibly strong accent does that on its own? Also, challenging someone to meet you in a frozen lake to score political points is pathetic. I’d say it was a dick-measuring contest, but I’m guessing—given the temperature of that water—yours has disappeared into your body right now.

Hovde’s views are what you’d expect from a Republican candidate—from supporting repealing the Affordable Care Act to blaming immigrants for “all the crime that has unfolded.” But he can also be pretty awkward with voters, like when he showed up at a Juneteenth celebration and a radio host tried to feed him softball questions. And I’m going to warn you: this is extremely uncomfortable to watch.

Radio Host: What is a few of your takeaways from being down here at the Juneteenth parade here?

Eric Hovde: It’s a hell of a good party and I’m really enjoying it, man. You know, all these little entrepreneurs, selling their wares, really friendly people, great food.

Radio Host: Is there anything you’re going to take away from this that you didn’t know about black culture before that you know of today?

Eric Hovde: Look, I’ve spent a lot of time in black culture, and as Torey knows, I’ve spent a lot of time in places like Africa, because I have homeless shelters for abandoned kids and rescuing kids out of the streets. And I’ve been involved in schooling—charter schools and things of that nature.

John: Stop talking! Stop talking! You are hurting me to hear that! There are so many easy answers to the question “What have you learned about black culture today” and among the worst is definitely, “Not much, because I’ve already been to Africa.” Fun fact: Black American culture isn’t actually synonymous with African culture. If you want to know why, just Google “Juneteenth,” or ask one of the—quote—”little entrepreneurs” you just met. They’ll fill you in. And look, I get Republicans want to get out from under accusations of weirdness. But the way to do that is to stop being so fucking weird. Because fantasizing about your party’s candidate shitting in front of you? That’s weird. Warning everyone about the influence of Monterey witches? Weird! Inviting your female opponent to join you in a frozen lake? That is very weird! And I do apologize for laughing at these people. Partly because I know it’s not nice. But mainly, because—as we all now know—J.D. Vance believes every time someone laughs, somewhere in the world, a child loses their groceries for some reason.

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Moving on. Our main story tonight concerns death. The answer to the question: “What does the interior of an IHOP smell like?” Lots of us have questions about death. And luckily, this nurse on TikTok can answer at least one of them.

TikTok Nurse: Hey, good news to all you sinners out there. I have never seen anyone dying start seeing signs that they are going to hell—demons, fire, anything like that. So I think we’re good.

John: Yeah, are you sure about that, though? Because maybe patients aren’t telling you what they see. I get why someone wouldn’t want their last words to be: “Hitler, Jeffrey Epstein, and wait—is that my childhood dog, Rusty? What’re you doing here? And why does Charles Manson look like he respects you? What did you do, Rusty? Bad boy!”

That nurse actually works for the type of medical business we’ll be focusing on tonight: hospice. And I realize that doing an episode about hospice is an almost offensive parody of this show—if someone else did that, it would genuinely be hurtful. But I promise, this is worth talking about. And you’re probably at least somewhat familiar with the concept of hospice—it’s end-of-life care that helps terminally ill people die comfortably. You may even have seen ads for hospice on TV—and if you live in Southeast Connecticut, you might’ve seen this weirdly horny one.

Ad Narrator: If there was one thing I could do over, I would have reached out sooner to Center for Hospice Care for my husband. When Center for Hospice Care came into our life, it allowed me to be with him. To really be with him without having to coordinate all his care. Their nurses, social workers, and other caregivers gave me the freedom to be his wife again. To love him like a wife.

John: Wow. That is—and I say this with absolute certainty—the single horniest hospice ad I’ve ever seen, from the fervid hand humping to this absolute masterclass in eye-fucking to the erotic vegetable-themed foreplay. That looks less like a hospice ad and more like a VHS tape called Tantric Sex for Couples Over 50.

Hospice is designed for those with terminal illness who choose not to get treatment to cure or control it, and it’s meant to provide support for the person and their family, including relief of symptoms and pain. And that support can take many forms, even allowing for moments like this.

News Anchor: A hospice patient got a special visitor. Peggy Garrison loves flamingos. She pays homage to the majestic animal with 158 trinkets and decorations she’s collected throughout her life. Now that the 75-year-old is in the final stages of cancer, a flamingo named Mango paid her a visit from the San Antonio Zoo. The San Antonio Zoo said it was happy to allow Mango to meet Peggy to honor the life she spent loving these animals.

John: That is great! I love that happened for Peggy! Although, do spare a quick thought for Mango the flamingo there. Imagine if you went to the home of someone you didn’t know and they had 158 images of you everywhere. You’d definitely think you were about to get murdered.

That woman and her family had a positive experience with their hospice provider. And the good news is, many, many people do. Lots of dedicated people work with hospices, providing huge relief for dying patients—particularly those who want to remain at home, where, in most cases, hospice care is provided. About 1.8 million Medicare beneficiaries now receive hospice care each year. In fact, you’ll probably encounter hospice at some point in your life—either for yourself or for a loved one. And at its best, it’s great.

Unfortunately, at its worst, it is not, as the hospice industry has become riddled with stories like these.

News Anchor: A local company agrees to a $75 million settlement over alleged overbilling of hospice services.

News Anchor 2: A Cleveland doctor has been sentenced to five years in prison for healthcare fraud connected to hospice operations in the state’s impoverished Delta region.

News Anchor 3: California’s Attorney General is announcing the arrest of over a dozen people accused of running a hospice scam in the Inland Empire.

John: It’s true. There is a lot of hospice fraud. A sentence, by the way, recently voted “least hot” by Things to Whisper into Your Partner’s Ear During Sex magazine. But it’s true: [whispering] there’s a lot of hospice fraud. [Speaks in normal voice] In fact, one government report estimated that hospices’ inappropriate billing costs Medicare hundreds of millions of dollars a year, and experts say they believe that figure to be far higher. And the financial consequences here are the least of the problems.

So given that, tonight, let’s look at hospice care: how it’s supposed to work, and what, too often, is happening instead. And let’s start with the fact that “hospice,” as we know it, is pretty new. Here’s a TV report from 1979, explaining it to Americans as if for the first time.

TV Reporter: A new concept for taking care of terminally ill patients is gaining interest in this country. It is called hospice and comes to us by way of England. The philosophy behind hospice is that once death has become inevitable, patients should be treated with great attention to their comfort and emotional needs.

John: Yeah, hospice actually came from England! And I know the British exporting a new way to die sounds like the perfect slogan for over 400 years of colonialism, but in this case, it was genuinely a good thing. The concept was originally conceived by Dame Cicely Saunders—seen here looking like she just slashed your tires. She was an English doctor and social worker, who’d been upset by the “wretched habits of big, busy hospitals where everyone tiptoes past the bed and the dying soon learn to pretend to be asleep.” Which sounds bleak but remember, that was in the U.K., home of the famous war-time poster: “Keep Quiet and Die.”

The idea eventually migrated over here and the first American hospice began caring for patients in 1974. More soon followed, mainly consisting of “a constellation of charities, mostly reliant on volunteers.” But in 1982, Reagan made a big change, when he authorized Medicare to cover the cost of hospice, after advocates convinced lawmakers “it would be cheaper for Medicare than paying for the aggressive treatment that so many patients received up until they died.” That move meant there was now a lot more money to be made in the hospice business. And today, of the country’s nearly 6,000 providers, three-quarters are for-profit.

One of the biggest and earliest was Vitas, which was founded by two teachers and Don Gaetz, who is, fun fact, Matt Gaetz’s dad. Which is kind of surprising. I didn’t think Gaetz had parents in the traditional sense. I just assumed someone jizzed on a Goodfellas poster. Vitas made its founders extremely wealthy. In 2004, it sold for $406 million to Chemed, best known as the owner of Roto-Rooter, a plumbing company. On Glassdoor, Chemed is described as bringing “a professional dignity to times of transition and sewer line clogs.” So now you know who to call if you’re facing your own mortality and/or a backed-up shit pipe.

The point is, hospices can be big business. And it’s worth talking about exactly how they make money. Basically, once you’re enrolled in a hospice, they get a flat fee every day. For routine care, it’s a little over $200 a day for the first 60 days, and a little less for however long you’re in hospice after that. And that can create a clear incentive to sign up as many patients as possible. A marketer for one hospice in Georgia was even recorded telling a sales rep, “How do you solicit patients? You see somebody sitting on the front porch in a wheelchair and you hit the brakes.” And you know our system’s broken when a hospice provider’s target demo is “kidnapped porch grandmas.”

One big way hospices can get referrals, though, is by befriending staffs at nursing homes and doctor’s offices. In fact, Vitas has been particularly aggressive in its sales tactics, like when they were caught doing this in the middle of 2020.

News Anchor: Text messages we obtained show Vitas salespeople visiting multiple Bay Area nursing homes and doctor’s offices during the pandemic. They took numerous selfies with health care workers, some bringing gifts of pizza, chicken, or doughnuts. Under one picture, a rep even wrote, “Six boxes of these made their way into a local nursing home that isn’t allowing food in from the outside.” A fellow employee texted back, “Sneaky, sneaky.” Another email shows a manager running a weekend referral contest, saying, “Whoever gets the most selfies with medical personnel could win. Personnel including nursing home staff, emergency room staff, physicians, or nurses.”

John: It’s true. To get patient referrals, they were sending sales reps into nursing homes and encouraging them to get selfies with healthcare workers who were interacting with high-risk populations at the height of COVID. That sounds like a plan literally hatched by the coronavirus itself. And incidentally, you know what’s not “sneaky, sneaky”? Bragging about your unethical sales tactics in writing—that is more “stupid, stupid.”

So that is one way hospices can make money—getting as many patients as possible. Another is to then spend as little on those patients as you can. Underwhelming care is a persistent complaint about hospices, with a recent survey finding “over 1 in 5 families said their hospice agency did not always provide timely help.” And recent investigations by HHS have found some alarming examples of neglect—like a hospice that billed Medicare for 17 days of care for a 70-year-old patient that they never visited. Instead, they just called his family to inquire how he was doing. And it is hard to defend the quality of that company’s service when they were—quite literally—phoning it in.

But it gets worse because they also found multiple cases of severe neglect, like when a hospice “skipped home visits and failed to assess the amount of pain one patient endured,” with that patient eventually suffering “a maggot infestation in his feeding tube” that required a trip to the emergency room. Which is horrifying! Treatment for dying people ideally should not sound like a scene from a fucking Saw movie.

And providing subpar care is bad enough. But some hospices engage in outright fraud to overbill Medicare. Because if patients require a higher level of care, hospices can bill the government at a much higher rate—as much as $1,500 a day for “continuous home care,” sometimes called “crisis care.” Vitas was even sued by the DOJ in 2013 for “billing Medicare for more costly crisis care services when certain patients did not need” them. Over eight years, the government says that Vitas generated nearly $1 billion in revenue from crisis care, and while the company didn’t admit wrongdoing, it did pay $75 million to settle that case. You know, the kind of thing we all do when we haven’t done anything wrong.

And Vitas is by no means the only company accused of doing this. Passages Hospice used to be the biggest hospice company in Illinois until this happened.

News Anchor: Passages Hospice in Moline forced out of business today after the indictment of one of its owners on federal fraud charges. Lawyer Seth Gillman of Lincolnwood was charged by the feds last month for allegedly overcharging Medicare and Medicaid. The company and its 300 workers statewide—history. Gillman faces up to 15 years if convicted.

Interviewee: I would describe him as the lowest form of life. He deserves what’s coming to him.

John: Wow. You know how wretched you have to be for a middle-aged Midwestern woman to call you “the lowest form of life”? She didn’t even dress it up with a “he’s not my cup of tea” or “I think he has a lot to answer for.” That is Midwestern for, “I hope he dies in pain, and I’ll personally block traffic to ensure an empty funeral home.”

Gillman was eventually sentenced to six and a half years in federal prison for masterminding a $20 million fraud scheme that included enrolling patients in expensive inpatient care they didn’t need. Families told reporters that Passages employees even misled them into believing their loved ones had serious or terminal illnesses when they didn’t. A federal court found Gillman pocketed millions annually and enjoyed a lavish lifestyle that included corporate airplanes and luxury sports cars, behavior his own lawyer, in a court filing, partly attributed to the fact he was “ingesting cocaine on a daily basis.” That was his defense. Imagine how guilty you have to be for your own lawyers to say: “Your Honor, my client might as well be Shaun White the way he was shredding down mountains of pure white powder. I’m talking in his defense, you understand.”

But it’s not just exaggerating the amount of care patients are getting. Hospices can also enroll patients who shouldn’t even be there in the first place. Because while there is a requirement that patients have a life expectancy of six months or less, most of the Medicare spending on hospice is now for patients whose stays exceed six months. And look, obviously, it’s a good thing when someone lives longer than their prognosis. This show is not pro-death. Well, to be honest, sometimes we are. But most of the time, we’re not.

But there are worrying signs that some hospices are enrolling patients who don’t need their care. And one indicator of this is the “live discharge rate”—basically, how many people leave hospice alive. Now, a small amount of live discharges are to be expected. Someone might be choosing a different hospice, or even opting to pursue curative care again. But experts told us a live discharge rate of more than 30% is high, and anything over 50% is a serious red flag for possible fraud. And yet, an analysis in California found that last year, more than 500 hospices there had a live discharge rate greater than 70%, with 135 having a 100% live discharge rate. Which is wild. Once 100% of people in your care are leaving alive, you’re not a hospice—you’re a hotel. And statistically, an incredibly safe one.

And there are horror stories where patients have been kept in hospice when they clearly didn’t need to be. Take what happened to Patricia Marble. After her doctor recommended hospice for her, she signed on with a company called Amedisys. But as the years went by, her daughter realized something might be up.

News Anchor: My mom trusted her nurse. My mom trusted these people. Trusting them so much, Marble says she didn’t question the long list of drugs, including fentanyl and morphine, to make her comfortable. The hydrocodone, they would sit—they sat next to her and told her she could take it whenever she was in pain. Medical records shared with Fox 25 Investigates show Marble remained in hospice care for five years. Then, earlier this year, Braggs said she went against the hospice nurse’s orders and finally took her mom to an outside doctor.

Braggs: The doctors were telling me that there’s a problem, that there’s a problem with her being on hospice for five years. Meanwhile, 76-year-old Patricia Marble is still very much alive.

News Anchor: How are you feeling now?

Patricia Marble: I’m feeling a whole lot better. They just fed me the medication, and I just took it myself, like she told me. It was surreal. It just—all of a sudden, this nurse turns into running my household.

John: That is awful. She was in hospice unnecessarily for five years, with the company billing Medicare almost half a million dollars for her care. That should never happen. There is a reason you’ve never seen a lawn sign that says, “In this house, love is love, science is real, and we’re being held prisoner by hospice nurses, please send help.”

Now, I do have to tell you, Amedisys insisted at the time that allegations she was discouraged from seeing an outside physician were “completely false,” though they did later enter a confidential settlement with the family, which hopefully that woman got to enjoy, because she lived for seven more years after that segment aired.

And it can be even easier than that to end up in hospice unnecessarily. Because they’re supposed to admit a patient on the recommendation of their medical director, in consultation with the patient’s own physician, “if any.” But if that “any” doesn’t exist, or isn’t available, then the whole decision might come down to a doctor on the hospice’s payroll.

What’s more, there have been multiple cases where doctors have accepted bribes or kickbacks to refer and recertify patients who didn’t need care—including in this incredible video.

News Anchor: You are looking at undercover video of a doctor accepting kickbacks for referring patients to hospice care—patients who don’t need it.

Undercover Doctor: We were expecting a lot more than that.

Other Person: But doc, you need to help me get some patients in the door.

Undercover Doctor: But what more do you want? I just gave you nine patients, what the [expletive] do you want? You know how much I can get from somebody else for twenty-five—for nine patients? [Expletive] 250 bucks a piece.

John: Yeah, that’s a doctor essentially selling his patients to a hospice agency. And—and I know this is not remotely the point—but honestly, kind of lowballing it. Because $250? That’s it? You’re selling human beings, not a pair of fucking AirPods.

That same doctor served as a medical director for a different hospice group where several nurses testified that the vast majority of hospice patients were not terminally ill, including one who had a regular job at Walmart. The group even enrolled patients with illnesses such as Alzheimer’s and dementia by falsely telling them they had less than six months to live and sent chaplains to lie to the patients and discuss last rites and preparations for their imminent death. Which is horrendous. Frankly, anyone who knowingly took part in that deserves to rot in hell. Except, sadly, we now know that doesn’t exist. So where’s the next worst place? Tampa, I guess? They deserve to rot in Tampa!

And some hospices don’t even bother lying to patients about their diagnosis—they just enroll people anyway. Hospices have been found to enlist family and friends to act as make-believe clients, lure addicts to enroll with the promise of free painkillers, dupe people into the program by claiming it’s free home health care, and have even stolen personal information to enroll “phantom patients,” essentially engaging in identity theft. That is how people have been enrolled in hospice without even knowing it.

In Mississippi, a 29-year-old pregnant woman learned she’d been enrolled in something called “Revelation Hospice” only when she visited her doctor for a blood test. And I will say, if you’re going to unexpectedly discover you’re a hospice patient, there’s no more fitting name than “Revelation Hospice.” The only way it could’ve been more on the nose is if it were called the “Surprise, Bitch! You’re in Hospice!” Hospice.

And while that’s clearly ridiculous, it can also be dangerous, because—as this journalist points out—while enrolling in a hospice does give you access to certain types of care, it also prohibits you from others.

Journalist: Hospice provides only palliative care, not curative care. So if you sign up for hospice, you lose, you know, your regular medical coverage. And in one case, a woman lost her place on a transplant waiting list. So it has real ramifications.

John: Yeah, you can lose your access to lifesaving treatment if you enter hospice, which makes it extra brutal when you consider that, as you’ve seen, people can be signed up without their knowledge. A cancer patient lost access to chemotherapy treatment after being put in hospice without his knowledge, and others were denied kidney dialysis, mammograms, and coverage for life-saving medications. And those just aren’t things you should be able to lose without realizing. Chemotherapy isn’t like a set of keys or the wife of the head of the Church of Scientology. Where’s Shelly, David? Where’s Shelly? It’s been 17 years. I’m starting to think something bad’s happened.

Now the government has tried to put some controls in place. For instance, to discourage hospices from enrolling healthy people indefinitely, it penalizes ones where the average stay of patients exceeds six months. It’s not a bad idea in theory. Unfortunately, in practice, hospices have found ways to get that average down, like padding out their roster with new patients or, even worse, dumping or discharging those who are staying too long, even if they genuinely need care.

The CEO of one company, Novus Health Services in Frisco, Texas, wasn’t shy about encouraging his employees to get patients out the door to reduce that average length of stay.

News Anchor: These are the offices of Novus Health Care Services in Frisco. Its website says it offers hospice and home health care services all over North Texas. Brad Harris founded the company. This is his public profile picture on Facebook. The FBI quotes Harris as telling one worker, “You need to make this patient go bye-bye.” In another case, asking healthcare executives to “find patients who would die within 24 hours,” saying of one of his patients, “If this [expletive] would just die.”

John: Holy shit. Look, you could say that Brad Harris is a greedy, heartless monster, but nothing you could call him will ever be as insulting as featuring this photo in that news report—a photo in which he somehow appears to be drunk, high, and shitting himself all at the same time. I’ve seen newscasts use nicer photos for school shooters. NBC 5 local news is fucking vicious.

But one of the key problems here is, outside of major fraud cases like that, there are shockingly few consequences for bad behavior—and the barriers to operating a hospice can be much lower than you’d think. For instance, a medical background isn’t required to enter the business. And Medicare only requires that hospices be inspected once every three years. And some appear to skirt even the most basic requirements.

For instance, state licensing laws require that hospices at least have a physical office, which doesn’t feel like too much to ask. But a recent audit in California found 112 hospices all shared the address of this building in Van Nuys. Which is ridiculous. That building cannot hold 112 offices. Unless, of course, they’re owned and operated by mice working within the walls. That’s right: mouse hospice—you can have that idea for free, Pixar! It’s like Ratatouille meets the first ten minutes of Up! Why aren’t you already making it now?

And by this point, I think it’s pretty clear, we’ve strayed a long way from the ideal with which this tire-slasher started. So what can we do? Well, some states are trying to fix things—though those plans can often run into opposition. In Connecticut, a bill that would’ve merely required a study about banning private equity ownership of hospices stalled out last year, after opposition from Republicans like this man.

Republican Politician: The suggestion that somehow the profit motive is somehow adversely impacts the quality of a business is a very dangerous thing to do in America. If people didn’t invent things, if people didn’t come up with new cures, then they would not exist. And if you don’t have a reason to create those things, then you won’t. This is America. This is a free market country. This is a capitalist country. This is not a socialist country, and it will not be if I can help it.

John: Right. He voted no because he believes in the ideals of America, which is also why—and this is true—last year, he was the lone “no” vote on a resolution exonerating the victims of the 17th-century Connecticut witch trials, partly because, and I quote, he didn’t want to paint “America as a bad place with a bad history.” And I don’t know what’s weirder: the fact he did that, or the fact that Connecticut didn’t bother to exonerate victims of witch trials until last year. What happened that made them suddenly decide to address this? “You know, I always assumed the women we murdered in the 1600s were guilty of witchcraft, but then I saw Barbie, and about halfway through that America Ferrera speech, I thought, ‘Oh shit! The witches! We should really get on that!’”

But thankfully, there has been some progress. At the federal level, CMS embarked on a project to make unannounced site visits to every Medicare-enrolled hospice, and as a result, it’s since revoked the Medicare enrollment of 48 of them, with nearly 500 more having their Medicare billing privileges deactivated and requiring another inspection before they can bill again. Which is a good start. California’s also placed a moratorium on new hospice licenses—although there is concern that bad actors are simply expanding into less-regulated states like Arizona, Nevada, and Texas instead.

And experts say there’s still so much more that we should be doing, including targeting hospices with especially high live-discharge rates for particular scrutiny. And it’s important that these changes are made, because to reiterate, hospice care—when done well—is hugely beneficial to those who are dying and their families. It is too important to just hope the free market fixes it.

And if you or someone you know is looking for hospice care, I’m afraid that right now, your best bet might be to rely on word-of-mouth recommendations. And if those aren’t available, you can consult this government website. It’s not perfect, but it can at least give you some info on the hospice you’re considering. And if there’s little to no information about it, that might be a sign they’re not reporting their quality data to Medicare, so I’d strongly consider somewhere else.

Look, this industry badly needs reform. And until that happens, at the very least, hospice ads should be required to paint a much more accurate picture—even if that ends up looking like this.

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Ad Narrator: If there was one thing I could do over, I would have reached out sooner for my husband. I wanted to be with him again. To really be with him. To sit with him. To hold his hands. To introduce some sliced vegetables into our routine. That’s right. Return to heart enhance hospice care and sewage solutions. Here at Hearts and Hands Hospice Care and Sewage Solutions, we are proud to be with you every step of the way. Well, not always literally there. [Laughs] We might call you once in a while to check in. But that’s not a guarantee. We love our patients so much. It is truly heartbreaking when they pass away. I assume. I’ve never actually seen that happen because last year, we had a 100% live discharge rate. Which, the more I think about it, is a little weird. It’s not that weird. And once you are enrolled with us, you will receive excellent care. Don’t just take that from me. Take it from some of our patients.

Patient: Hearts and Hands is amazing. Grandma was just sitting on her porch, minding her own business, when this man came up and enrolled her. It was that fast. We almost didn’t know what we were signing. They have been making sure my final six months were comfortable for the last eight years. And to be honest, I don’t think I would have even noticed if any social workers or nurses had shown up. We have been too busy fucking. My body is dying but my penis is not. We’re fucking everywhere. On the couch, in the kitchen. In the minivan. In the foyer. By the trash cans. That seat you’re sitting in—don’t sit there. Especially walks by the lake. We like to get caught by joggers. Act like we’re mad. “Hey, what are you looking at? Stop it. What are you looking at, pervert?”

Ad Narrator: We go above and beyond to bring joy and comfort to our patients. We can even hook you up with an emotional support flamingo.

Second Patient: This flamingo! I never wanted to see you flamingo up close. That feels clear to me now. The flamingo was fine. I think she would have been happier if the hospice had provided drugs or nurses or doctors. But no. It was just Coconut the flamingo. And honestly, Coconut was pretty useless when Grandma had a seizure.

Second Patient: Oh my god! Grandma! Coconut, do something! Why are you here?

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Ad Narrator: Our business is making sure you get to make the most of your final days. Or more specifically, that we get to make the most out of your final days.

Random Guy: You are going to hell.

Patient: Hell doesn’t exist, fella. I got that from a reliable source. Funny story, I wasn’t even supposed to be in hospice. Turned out, my doctor took a bribe to sign me up.

Random Guy: That makes sense. A sick man couldn’t come this many times a day. He would die of dehydration.

Patient: I come so much.

Random Guy: So you are not dying?

Patient: No. I’m fine. You want to do it again?

Random Guy: No. I’m fucking tired. What?

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Ad Narrator: Hearts and Hands Hospice Care and Sewage Solutions. Honestly, we are better at the sewage part.

[Cheers and applause]

John: That’s our show. Thanks so much for watching! We’re off for the next two weeks, back September 8th! Good night!

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Background Voices: Are you thirsty? I am so thirsty. Let me get some of that. Get your own. Okay.

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Background Voices: Oh my god. Oh, that’s good. So many fluids in my mouth. Let’s go! Okay!

[End credits roll]