Special education teacher Robin Ginkel spent nearly two years fighting her insurance company to try to pay for back surgery that her doctors recommended after a work-related accident. left him with a herniated disc and debilitating pain.
The plan did not seem “crazy”, he said: “I would like to receive health care to return to normal life and return to work.”
When he was initially denied, the 43-year-old from Minnesota spent hours waiting for a decision – and even filed a complaint with the state – only to see his applications rejected three times.
Now he is ready for the fight to start again, after making the best decision he could choose was to try his luck at a new insurance company.
“It’s tiring,” he said. “I can’t go on like this.”
And Ginkel isn’t the only one who has her hands up.
About one in five Americans covered by private health insurance reported that their provider refused to pay for care recommended by a doctor in the past year, according to a survey conducted by the health policy center KFF.
Brian Mulhern, 54, of Rhode Island, said his health insurance company recently denied a request to pay for a colonoscopy after polyps were found in his colon – a discovery that made that his doctor advises a follow-up examination within three. years instead of the usual five.
Due to the $900 out-of-pocket cost, Mr. Mulhern postponed the operation.
Long-standing anger over insurance decisions exploded into public view earlier this month after UnitedHealthcare CEO Brian Thompson was killed — and the killing unleashed a surprising wave of public anger in the industry.
The scandal shocked the system, prompted one insurance company to reverse a controversial plan to cut coverage for anesthesia, and drove down the share prices of major firms.
Although the response has raised the possibility that the review could force change, experts said that dealing with the confusion will require action from Washington, where there is no sign of a change of pace.
To the contrary: just a few weeks ago, Congress again failed to move forward with long-delayed measures intended to make it easier for people on certain federally sponsored insurance plans to apply for they are accepted.
Many advocates are also worried about the worsening crisis, with Donald Trump returning to the White House.
The president-elect has promised to protect Medicare, the government’s health insurance for people over 65 and some young people. He is known for his long-standing criticism of aspects of the health care industry, such as high drug prices.
But he has also vowed to lower regulations, push for independence and increase work requirements for publicly available insurance and cut government spending, of which health care is a big part.
“The way things stand today, health care is the goal,” said David Lipschutz, co-director of the Center for Medicare Advocacy, a nonprofit that seeks to advance comprehensive Medicare coverage.
“They’re going to try to take away people’s health insurance or limit people’s access to it and that goes to the other side of some of these depressing things and it’s going to make the problems worse.”
Republicans, who control Congress, have long supported reforms aimed at making the health care system more transparent, reducing regulations and reducing the role of the government.
“If you take government regulators out of the health care equation and have doctor-patient relationships, it’s better for everybody,” said House Speaker Mike Johnson. in a video obtained by NBC News last month. “It’s more efficient, more efficient,” he said. “That’s a free market.” Trump will be for the free market.”
Dissatisfaction with the health care system is long-standing in the US, where experts – including KFF – show that care is more expensive than in other countries and performs worse on basic metrics such as life expectancy, infant mortality and safety during childbirth.
The US spent more than $12,000 (£9,600) per person on healthcare in 2022 – almost double the average of other rich countries, according to the Peter G Peterson Foundation.
The last major reform, under former president Barack Obama in 2010, focused on expanding health insurance in hopes of making care more affordable.
The law included measures to expand eligibility for Medicaid, another federal program that helps cover medical expenses for low-income people. It also prevents insurers from rejecting patients with “pre-existing conditions”, effectively reducing the proportion of the population without insurance from about 15% to about 8%.
Today, about 40% of the US population receives insurance from taxpayer-funded government plans – mainly Medicare and Medicaid – with increasing coverage offered to private companies.
The rest are enrolled in plans from private companies, which are often chosen by employers and paid for through a combination of personal contributions and employer funds.
Even though more people are covered than ever before, confusion is still common. In recent Gallup pollsonly 28% of respondents gave a good or fair rating, the lowest level since 2008.
Public data on the rate of insurance denials — which can happen again after care is received, leaving patients with heavy debts — is limited.
But surveys of patients and medical professionals suggest that insurance companies require “prior consent” for procedures – and rejection by insurance companies is increasing.
For example, in the state of Maryland, the number of denied claims disclosed by insurers has increased by more than 70% in five years, according to reports from the state attorney general’s office.
“The fact that we’re paying into the system and then when we need it, we can’t get the care we need is unconscionable,” Ms. Ginkel said. “The more I went on, the more I felt like it [the insurance companies] do this on purpose in the hope that you will give up.
Brian Mulhern, a Rhode Islander who gave up his colonoscopy, compared the industry to a “legal mafia” – which provides protection “but on their terms”. He added: “It seems more and more that you can pay more and get nothing.”
AHIP, an advocacy group for health insurers, has said that denials of claims often reflect wrongful claims by doctors, or preconceived decisions about what to cover made by regulators and employers.
UnitedHealthcare did not respond to the BBC’s request for comment for this article. But in an opinion written after the murder of its CEO Brian Thompson, Andrew Witty, head of the firm’s parent company, defended the industry’s decisions.
He said it was based on a “comprehensive and evolving body of clinical evidence aimed at achieving better health outcomes and ensuring patient safety”.
But critics complain that the for-profit healthcare operation will remain focused on its owners and the bottom line, and have linked the rise in counterclaims to the growing use of artificial intelligence (AI) that is said to be flawed in evaluating applications.
One manufacturer said last year its AI tool was not being used to inform safety decisions — only to help guide providers on how to help patients.
Derrick Crowe, director of digital communications for People’s Action, a non-profit organization advocating for insurance reform, said he hopes the death scare will force change in the industry.
“This is the moment to take a moment of private pain and turn it into a collective power of society to ensure that companies stop denying our attention,” he said.
Whether the killing will strengthen the will to seek reforms remains to be seen.
Bipartisan politicians in Washington have expressed interest in efforts that could rein in the industry, such as tougher enforcement of algorithms and rules that could require the dissolution of large firms.
But there are few signs that the proposals make sense.
Trump’s nominee to run the powerful Centers for Medicare & Medicaid Services (CMS), TV doctor Mehmet Oz, has previously endorsed expanding coverage by Medicare Advantage – which offers Medicare health plans with private companies.
“These plans are popular among seniors, consistently provide high-quality care and have the necessary incentives to keep costs low,” he explained in 2022.
Professor Buntin said the Republican electoral gains showed that the US was not going to accept an alternative – a publicly run system like the UK’s National Health Service – anytime soon.
“There’s a distrust of people who appear to be profiting or benefiting from illness — yet that’s the foundation of the American system,” he said.
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