Special education teacher Robin Ginkel spent nearly two years fighting with her insurance company to try to get her to pay for back surgery recommended by her doctors after a workplace accident left her with a herniated disc and debilitating pain.
The project does not seem “ridiculous” to her, she says: “I am asking to benefit from health care to regain a normal quality of life and return to work.”
Initially rejected, the 43-year-old from Minnesota spent hours appealing the decision – even filing a complaint with the state – only to have her claims rejected three times.
She is now preparing to return to battle, having decided her best option was to try her luck with a new insurance company.
“It’s exhausting,” she says. “I can’t continue like this.”
Ms. Ginkel is not the only one to give up.
About one in five Americans covered by private health insurance said their provider refused to pay for care recommended by a doctor last year, according to a survey by the KFF Health Policy Foundation.
Brian Mulhern, a 54-year-old Rhode Island man, said his health insurance company recently rejected a request for payment for a colonoscopy after polyps were discovered in his colon — a discovery that prompted his doctor to advise him a follow-up examination within three years. years instead of the usual five years.
Faced with $900 in fees, Mr. Mulhern postponed the proceedings.
Long-simmering anger over insurance decisions exploded into the open earlier this month after the assassination of UnitedHealthcare CEO Brian Thompson, sparking a surprising wave of outrage of the public against the industry.
The crime sent shockwaves through the system, prompting an insurance company to cancel a controversial plan to limit anesthesia coverage and hit the stock prices of major companies.
Although the backlash raised the possibility that increased scrutiny could force change, experts said addressing that frustration would require action from Washington, where there is little sign of change. dynamics.
On the contrary: In recent weeks, Congress has yet to advance long-stalled measures aimed at making it easier for people on certain government-backed insurance plans to get their applications approved.
Many advocates also worry that problems will worsen as Donald Trump returns to the White House.
The president-elect has pledged to protect Medicare, which is government health insurance for those over 65 and some young people. He is known for his long-standing criticism of parts of the health care industry, such as high drug prices.
But he also pledged to ease regulations, pursue privatization, add work requirements to public insurance and cut public spending, of which health care is a significant part.
“As it stands, health care is a target,” 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 health insurance or decrease access to it, which goes in the opposite direction of some of these frustrations and will only make the problems worse.”
Republicans, who control Congress, have historically supported reforms to make the health care system more transparent, reduce regulation and reduce the role of government.
“If you take government bureaucrats out of the health care equation and have doctor-patient relationships, it’s better for everyone,” said House Speaker Mike Johnson. in video obtained by NBC News last month. “More efficient, more effective,” he said. “That’s the free market. Trump will be for the free market.”
Dissatisfaction with the healthcare system has long existed in the United States, where experts – including at KFF – point out that care is more expensive than in other countries and that performance is worse on 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 twice the average of other rich countries. according to the Peter G Peterson Foundation.
The last major reform, carried out under former President Barack Obama in 2010, focused on expanding health insurance in hopes of making care more accessible.
The law included measures to expand eligibility for Medicaid, another government program that helps cover medical costs for people with limited income. It also prohibits insurers from refusing patients with “pre-existing conditions,” thereby reducing the share of the population without insurance from about 15% to about 8%.
Today, about 40 percent of the U.S. population is insured by taxpayer-funded government plans—primarily Medicare and Medicaid—with coverage increasingly outsourced to private companies.
The remainder are enrolled in private company plans, which are typically selected by employers and funded through a combination of personal contributions and employer funds.
Even though more people are covered than ever before, frustrations remain widespread. In a recent Gallup pollOnly 28% of respondents rated health care coverage as excellent or good, the lowest level since 2008.
Public data on the rate of insurance denials — which can also occur after care has been received, leaving patients with hefty bills — is limited.
But surveys of patients and medical professionals suggest that insurance companies are requiring more “prior authorizations” for procedures — and insurance company denials are increasing.
In the state of Maryland, for example, the number of claim denials disclosed by insurers jumped more than 70 percent in five years, according to reports from the state attorney general’s office.
“The fact that we pay into the system and when we need it we can’t access the care we need makes no sense,” Ms Ginkel said. “As the process went on, it felt more and more like (insurance companies) were doing this on purpose in the hope that you would give up.”
Brian Mulhern, the Rhode Island resident who postponed his colonoscopy, likened the industry to the “legal mafia” — offering protection “but on his terms.” He added: “It seems more and more that you can pay more and more and get nothing.”
AHIP, a health insurer lobbying group, said claim denials often reflected erroneous submissions by doctors or predetermined decisions about what to cover made by regulators and employers.
UnitedHealthcare did not respond to a request for comment from the BBC for this article. But in an opinion piece written after the assassination of its CEO Brian Thompson, Andrew Witty, a director of the company’s parent company, defended the industry’s decision-making process.
It said it was based on “a comprehensive and continually updated body of clinical evidence focused on achieving the best health outcomes and ensuring patient safety”.
But critics complain that a for-profit health system will always be focused on its shareholders and bottom lines, and have linked the increase in claim denials to the growing use of artificial intelligence (AI). allegedly error-prone to review applications.
One developer said last year that its AI tool was not used to inform coverage decisions, but only to help guide providers on how to help patients.
Derrick Crowe, director of communications and digital for People’s Action, a nonprofit that advocates for insurance reform, said he hoped the shock of the killing would force change in the industry.
“Now is the time to turn a moment of private pain into collective public power to ensure that corporations stop denying us our care,” he said.
It remains to be seen whether this murder will strengthen the appetite for reform.
Politicians from both parties in Washington have expressed interest in efforts that could rein in the sector, such as increased oversight of algorithms and rules that would require breaking up big companies.
But there is no indication that the proposals will have a significant impact.
Trump’s nominee to lead the powerful Centers for Medicare & Medicaid Services (CMS), TV doctor Mehmet Oz, has already endorsed expanding coverage through Medicare Advantage, which offers Medicare health plans through of private companies.
“These plans are popular with seniors, consistently provide quality care, and have an incentive to keep costs low,” he explained in 2022.
Professor Buntin said the Republican election results indicate that the United States is not close to adopting the alternative – a public system like the United Kingdom’s National Health Service – any time soon.
“There is a distrust of people who appear to profit from illness — and yet that is the basis of the American system,” she said.