Special education teacher Robin Ginkel spent nearly two years fighting her insurance company to try to get it to pay for back surgery doctors recommended after a work-related injury left her with a herniated disc and debilitating pain.
The plan didn’t seem “ridiculous,” she said: “I’m looking for health care to get back to a normal quality of life and back to work.”
Initially denied, the 43-year-old from Minnesota spent hours on hold appealing the decision — even filing a complaint with the state — only to see her claims denied three times.
Now she is preparing to start the battle again, after deciding that her best option is to try her luck with a new insurance company.
– It’s exhausting – she said. “I can’t go on like this.”
Mrs. Ginkel is not the only one raising her hands.
About one in five Americans covered by private health insurance reported that their provider refused to pay for care recommended by a doctor last year, according to research by the Foundation for Health Policy KFF.
Brian Mulhern, a 54-year-old from Rhode Island, said his health insurance company recently denied a request to pay for a colonoscopy after polyps were discovered in his colon — a discovery that prompted his doctor to advise a follow-up exam within three years instead of the usual five.
Faced with $900 in out-of-pocket expenses, Mr. Mulhern adjourned the proceedings.
Long-simmering anger over insurance decisions exploded into the public eye earlier this month after UnitedHealthcare CEO Brian Thompson was killed — and the killing set off a stunning wave of public anger at the industry.
The crime rocked the system, prompting one insurance company to reverse a controversial plan to limit anesthesia coverage and hitting the stock prices of major companies.
While the backlash has raised the possibility that the probe could force change, experts say addressing the frustration would require action from Washington, where there is little sign of a shift in momentum.
Quite the contrary: In just the last few weeks, Congress has once again failed to initiate long-delayed measures aimed at making it easier for people on certain government-backed insurance plans to get their claims approved.
Many advocates also worry about worsening the problem as Donald Trump returns to the White House.
The president-elect has promised to protect Medicare, which is the government’s health insurance for people over 65 and some younger people. He is known for his long-standing criticism of parts of the healthcare industry, such as high drug prices.
But he also promised to loosen regulations, continue privatization and add work conditions to publicly available insurance, and cut government spending, of which health care is a major part.
“As things stand today, health care is the goal,” said David Lipschutz, co-director of the Medicare Advocacy Center, a nonprofit that seeks to advance comprehensive Medicare coverage.
“They’re going to try to take away people’s health insurance or reduce people’s access, and that goes in the opposite direction of some of these frustrations and would only make the problems worse.”
Republicans, who control Congress, have historically supported reforms aimed at making the health care system more transparent, reducing regulation and reducing the role of government.
“If you take government bureaucrats 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. “More efficient, more efficient,” he said. “It’s the 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 – point out that care is more expensive than in other countries and that it performs worse on basic indicators 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, was aimed at expanding health insurance in hopes of making it more affordable.
The law included measures to expand eligibility for Medicaid, another government program that helps cover medical expenses for people with limited incomes. It also prohibits insurers from turning away patients with “pre-existing conditions,” successfully reducing the proportion of the population without insurance from about 15% to roughly 8%.
Today, about 40% of the U.S. population receives insurance from taxpayer-funded government plans—mainly Medicare and Medicaid—with coverage increasingly contracted out to private companies.
The rest is enrolled in private company plans, usually chosen by employers and paid for through a combination of personal contributions and employer funds.
Although more people are covered than ever before, frustrations are still 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 happen even after care is provided, leaving patients with hefty bills — is limited.
But surveys of patients and medical professionals suggest that insurance companies are requiring more “prior authorization” for procedures — and insurance company denials are on the rise.
In the state of Maryland, for example, the number of denied claims discovered by insurers jumped more than 70% over five years, according to reports from the attorney general’s office.
“The fact that we pay into the system and then when we need it, we can’t access the care we need doesn’t make sense,” Ms Ginkel said. “As I went through the process, it seemed more and more [the insurance companies] do this on purpose in the hope that you will quit.”
Brian Mulhern, a Rhode Island resident who put off getting a colonoscopy, compared the industry to a “legal mob” — offering protection “but on their terms.” He added: “Increasingly it seems you can pay more and more and get nothing.”
AHIP, a lobbying group for health insurers, said claim denials often reflect erroneous submissions 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 op-ed written after CEO Brian Thompson’s murder, Andrew Witty, the boss of the company’s parent company, defended the industry’s decision-making.
He said it was based on a “comprehensive and constantly updated body of clinical evidence aimed at achieving the best health outcomes and ensuring patient safety”.
But critics complain that the for-profit healthcare system will always be focused on its shareholders and the bottom line, and link the rise in claim denials to the increasing use of allegedly error-prone artificial intelligence (AI) to review claims.
One developer said last year that its AI tool was not being used to inform coverage decisions — only to help providers help patients.
Derrick Crowe, director of communications and digital for People’s Action, a nonprofit that advocates for insurance reform, said he hopes the shock of the killing will force the industry to change.
“This is the moment to take a moment of private pain and turn it into public collective power to make sure companies stop denying us care,” he said.
It remains to be seen whether the assassination will strengthen the appetite for reform.
Politicians from both parties in Washington have expressed interest in efforts that could rein in the industry, such as stricter oversight of algorithms and rules that would require the breakup of large companies.
But there is little sign that the proposals have any significant force.
Trump’s nominee to lead the powerful Centers for Medicare & Medicaid Services (CMS), televangelist Mehmet Oz, previously supported expanding Medicare Advantage coverage — which offers Medicare health plans through private companies.
“These plans are popular with seniors, consistently provide quality care, and have the necessary incentive to keep costs low,” he explained in 2022.
Professor Buntin said the Republican gains in the election showed the US would not soon accept the alternative – a publicly run scheme like the UK’s National Health Service.
“There’s a mistrust of people who appear to be making money or benefiting from an illness — and yet that’s the basis of the American system,” she said.
