Special education teacher Robin Ginkel has been working with insurance companies for nearly two years to get them to pay for back surgery recommended by her doctor after a work-related injury left her with a herniated disc and debilitating pain. It has been fought for a long time.
She said she didn’t think the plan was “ridiculous” and said: “I’m asking health care providers to get back to a normal quality of life and get back to work.”
Initially denied, the 43-year-old Minnesota native held out for hours to appeal the decision and even filed a complaint with the state, only to have her claim rejected three times.
She has now decided that her best option is to try her luck with a new insurance company and is preparing for the battle to begin again.
“It’s tiring,” she said. “We can’t continue like this.”
Ginkel isn’t the only one raising his hand.
Roughly 1 in 5 Americans with private health insurance reported that a health care provider refused to pay for treatment recommended by a doctor in the last year. According to a survey by the Health Policy Foundation KFF.
Brian Mulhern, 54, from Rhode Island, said his health insurance company recently denied payment for a colonoscopy after polyps were discovered in his colon. The discovery makes it one year instead of the usual five years, when doctors advised him to get retested within three days.
Faced with a $900 out-of-pocket expense, Mulhern postponed the procedure.
The killing of UnitedHealthcare CEO Brian Thompson earlier this month exploded long-simmering anger over insurance decisions; caused waves.
The crime shocked the system, causing one insurance company to backtrack on a controversial plan to limit anesthesia coverage and hurting the stock prices of major companies.
The reaction raised the possibility that oversight would force change, but experts said addressing the dissatisfaction would require action from Washington, which shows little sign of changing momentum.
On the contrary, Congress has failed in recent weeks to advance long-stalled measures aimed at making it easier to approve claims for people enrolled in certain government-sponsored insurance plans. There wasn’t.
Many supporters also worry that the problem will worsen as Donald Trump returns 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 parts of the medical industry, including the high prices of medicines.
But he also vowed to ease regulations, push for more privatization, add work requirements to publicly available insurance and cut government spending, largely on health care.
“Right now, health care is being targeted,” said David Lipshutz, co-director of the Medicare Advocacy Center, a nonprofit organization that advocates for comprehensive Medicare coverage.
“They’re going to try to take away people’s health insurance or reduce people’s access to health insurance, and that’s going to go in the opposite direction of what some are complaining about, and it’s only going to make the problem worse.”
Republicans who control Congress have historically supported reforms aimed at making the health care system more transparent, cutting regulations and reducing the role of government.
“The more we can remove government bureaucrats from health care and create a doctor-patient relationship, the better for everyone,” said House Speaker Mike Johnson. In a video obtained by NBC News last month. “It’s more efficient, it’s more effective,” he said. “That’s the free market. Trump will support the free market.”
There has been long-standing dissatisfaction with the U.S. health care system, with experts including KFF saying it costs more than other countries and underperforms on basic indicators such as life expectancy, infant mortality, and childbirth safety. It is pointed out that there are.
The US spent more than $12,000 (£9,600) per person on health care in 2022. This is almost double the average for other wealthy 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 health care more accessible.
The law included measures to expand eligibility for Medicaid, another government program that covers health care costs for people with limited incomes. It also prohibited insurance companies from denying patients with “pre-existing conditions,” successfully reducing the proportion of the uninsured population from about 15% to about 8%.
Currently, approximately 40% of the U.S. population receives insurance through taxpayer-funded government plans (primarily Medicare and Medicaid), and coverage is increasingly outsourced to private companies.
The remainder is enrolled in private company plans, typically chosen by the employer and paid for through a combination of personal contributions and employer funds.
Although more people are affected than ever before, dissatisfaction remains widespread. In a recent Gallup pollOnly 28% of respondents rated their health coverage as “excellent” or “good,” the lowest level since 2008.
There is limited public data on insurance denial rates, which occur even after treatment is received and can leave patients with high bills.
However, a survey of patients and medical professionals suggests that insurers are requiring more “pre-authorization” for procedures and that denials by insurers are on the rise. .
In Maryland, for example, the number of claim denials disclosed by insurance companies jumped more than 70% over five years, according to a report from the state attorney general’s office.
“The fact that you’re paying into the system and not getting the care you need when you need it makes no sense,” Ginkel said. “As I went through the process, I felt more and more like this.” [the insurance companies] They do it on purpose, hoping you will give up. ”
Brian Mulhern, a Rhode Island resident who postponed a colonoscopy, compared the industry to a “legal mafia” that offers protection “with conditions.” He added: “It started to feel like I was paying more and more and getting nothing.”
AHIP, a health insurance lobby group, said claim denials often reflect inaccurate submissions by doctors or prior coverage decisions made by regulators or employers.
UnitedHealthcare did not respond to the BBC’s request for comment for this article. But Andrew Whitty, the head of the company’s parent company, defended the industry’s decision-making in an opinion piece written after CEO Brian Thompson was killed.
He said it was based on a “comprehensive and continuously updated body of clinical evidence focused on achieving the best health outcomes and ensuring patient safety.”
But critics complain that for-profit health systems have always been focused on shareholders and profits, and blame the spike in claim denials on artificial intelligence (AI) application review, which is said to be error-prone. They claim that this is linked to an increase in the use of
One developer said last year that its AI tools were not used to inform coverage decisions, but only to guide health care providers on how to help patients. said.
Derrick Crowe, communications and digital director for People’s Action, a nonprofit organization that advocates for insurance reform, said he hopes the impact of the murders will force changes in the insurance industry.
“Now is the time to take our private pain and turn it into public collective power to stop corporations from denying us care,” he said.
It remains to be seen whether this murder will strengthen the appetite for reform.
Politicians of both parties in Washington have expressed interest in efforts that could rein in the industry, such as increased oversight of algorithms and rules that would require breaking up large companies.
However, there is little sign that this proposal will gain any meaningful traction.
Mehmet Oz, the TV doctor nominated by President Trump to run the powerful Centers for Medicare and Medicaid Services (CMS), previously supported expanding coverage through Medicare Advantage, which provides Medicare health plans through private companies. I was doing it.
“These plans are popular among seniors and have the necessary incentives to consistently provide high-quality care and keep costs low,” he explained in 2022.
Professor Bunting said the republican election victory showed the US was not going to embrace the alternative – a publicly run system like the UK’s National Health Service – any time soon.
“There’s a mistrust of people who profit or appear to profit from disease, and that’s the basis of the American system,” she says.
