Special education teacher Robin Ginkel spent nearly two years fighting with her insurance company to try to get her to pay for back surgery her doctors recommended after a work injury left her with a herniated disc and debilitating pain.
She said the plan did not seem “ridiculous”: “I am asking for health care to return to a normal quality of life and to return to work.”
Initially denied, the 43-year-old Minnesota woman spent hours appealing the decision — even filing a complaint with the state — only to have her claims dismissed three times.
Now she is preparing to start the battle again, having decided that the best option for her is to try her luck with a new insurance company.
“It's exhausting,” she said. “I can't go on like this.”
Ms. Ginkel is not the only one who has her hands raised.
Nearly one in five Americans covered by private health insurance reported that their provider refused to pay for doctor-recommended care last year. According to a survey conducted by the KFF Health Policy Foundation.
Brian Mulhern, 54, of Rhode Island, said his health insurance company recently denied a request to pay for a colonoscopy after polyps were discovered in his colon — a finding that prompted his doctor to advise a follow-up exam in three years instead of… The usual five.
Facing $900 out-of-pocket costs, Mulhern postponed the procedure.
Long-simmering anger over insurance decisions exploded into public view earlier this month after the killing of UnitedHealthcare CEO Brian Thompson — and the killing unleashed a stunning wave of public outrage in the industry.
The crime sent shockwaves through the system, prompting one insurance company to back away from a controversial plan to limit anesthesia coverage, and hurting the stock prices of major companies.
Although the reaction raised the possibility that the scrutiny could lead to change, experts said addressing frustration will require action from Washington, where there is little sign of a change in momentum.
On the contrary: In just the past few weeks, Congress has once again failed to advance long-stalled measures intended to make it easier for people in some government-backed insurance plans to get their claims approved.
Many human rights advocates are also concerned about the worsening problems with Donald Trump's return to the White House.
The president-elect has pledged to protect Medicare, government health insurance for people over 65 and some young people. He is known for his long-standing criticism of parts of the health industry, such as high drug prices.
But he also pledged to ease regulation, pursue privatization and add work requirements to publicly available insurance and cut government spending, of which health care is a major part.
“The way things look today, Medicare is a goal,” said David Lipshutz, co-director of the Center for Medicare Advocacy, a nonprofit that seeks to promote universal Medicare coverage.
“They will try to take away health insurance from people or reduce their access to it, and that goes in the opposite direction of some of those frustrations and will only make the problems worse.”
Republicans, who control Congress, have historically supported reforms aimed at making the health system more transparent, reducing regulation and reducing the role of government.
“If you take government bureaucrats out of the health care equation and have a doctor-patient relationship, it's better for everyone,” House Speaker Mike Johnson said. In a video obtained by NBC News last month. “More efficient and more effective,” he said. “This is the free market. Trump will be for the free market.”
Dissatisfaction with the health system has long existed in the United States, where experts — including KFF — point out that care is more expensive than in other countries, and performs worse on basic measures such as life expectancy, infant mortality, and safety during pregnancy. birth.
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 J. Peterson Foundation.
The last major reform, under former President Barack Obama in 2010, focused on expanding health insurance in hopes of making care more accessible.
The law includes measures to expand eligibility for Medicaid, another government program that helps cover medical costs for people with limited income. It also prohibits insurance companies from rejecting patients with “pre-existing conditions,” successfully reducing the percentage of the population who are uninsured from about 15% to about 8%.
Today, about 40% of the US population gets insurance through taxpayer-funded government plans – mostly Medicare and Medicaid – with increasingly contracted out to private companies.
The rest are enrolled in plans from private companies, which are usually selected by employers and paid for with a mix of personal contributions and employer funds.
Although more people are covered than ever before, frustrations remain widespread. In a recent poll conducted by GallupOnly 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 receiving care, leaving patients with high bills — is limited.
But surveys of patients and medical professionals indicate that insurance companies are requiring more “prior authorization” for procedures — and that denials by insurance companies are on the rise.
In Maryland, for example, the number of claim denials uncovered by insurance companies jumped by more than 70% over five years, according to reports from the state 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 any sense,” Ms. Ginkel said. “As I went through this process, I felt more and more like (insurance companies) were doing this on purpose in hopes that you would give up.”
Brian Mulhern, a Rhode Island resident who postponed a colonoscopy, likened the industry to a “legal mafia” — offering protection “but on their terms.” “It seems increasingly that you can pay more and more and not get anything,” he added.
AHIP, a lobbying group for health insurers, said denials of claims often reflect faulty submissions by doctors, or predetermined decisions about what to cover by regulators and employers.
UnitedHealthcare did not respond to the BBC's request for comment for this article. But in an opinion piece written after the killing of its CEO, Brian Thompson, Andrew Witty, the head of the company's parent company, defended the industry's decision-making.
He said it is based on “a comprehensive and constantly updated body of clinical evidence focused on achieving the best health outcomes and ensuring patient safety.”
But critics complain that the for-profit health system will always focus on shareholders and the bottom line, and have linked the spike in claim denials to the rise in the use of error-prone artificial intelligence to review claims.
One developer said last year that its AI tool was not being used to inform coverage decisions — only to help guide providers on how to help patients.
Derek Crowe, director of communications and digital at People's Action, a nonprofit that advocates for insurance reform, said he hopes the shock of the killing will change the industry.
“This is a moment to take a moment of private pain and turn it into collective, public power to ensure that corporations stop taking our care away,” he said.
It remains to be seen whether the murder will strengthen the desire for reform.
Politicians of both parties in Washington have expressed interest in efforts that could rein in the industry, such as tighter oversight of algorithms and rules that might require breaking up big companies.
But there is no indication that the proposals are gaining meaningful acceptance.
Trump's nominee to run the powerful Centers for Medicare and Medicaid Services (CMS), TV doctor Mehmet Oz, has previously supported expanding coverage by Medicare Advantage — which offers health care plans through private companies.
“These plans are very popular among seniors, consistently provide quality care and have the incentive needed to keep costs low,” he explained in 2022.
Professor Pontin said the Republican election gains suggested the US was not about to embrace the alternative – a publicly run scheme like the UK's National Health Service – any time soon.
“There is a mistrust of people who appear to benefit or benefit from the disease — but that is the basis of the American system,” she said.
