US asks what’s next for health care

Special education teacher Robin Ginkel spent nearly two years fighting her insurance company to try to get her to pay for back surgery recommended by her doctors after a work-related injury left her with a herniated disc and debilitating pain.

The plan didn’t seem “ridiculous,” she said: “I’m asking to get health care so I can get back to a normal quality of life and get back to work.”

Initially denied, the 43-year-old Minnesota woman spent hours in detention 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 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.”

Ms. Ginkel isn’t 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 a study 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 found on his colon, a finding that prompted his doctor to recommend a follow-up within three years instead of the typical five.

Faced with $900 in out-of-pocket costs, Mr. Mulhern postponed the procedure.

Long-simmering anger over insurance decisions erupted into the public sphere earlier this month after UnitedHealthcare CEO Brian Thompson was killed — and the killing unleashed a startling wave of public outrage across the industry.

The crime sent shockwaves through the system, prompting an insurance company to cancel a controversial plan to limit anesthesia coverage and hitting the share prices of major firms.

While the backlash raised the possibility that the vetting would force a change, experts said addressing the frustration would require action from Washington, where there was little sign of a change in momentum.

Quite the contrary: In just the past few weeks, Congress has once again failed to move forward long-delayed measures aimed at making it easier for people with certain government-backed insurance plans to get their claims approved.

Many advocates are also concerned about worsening problems when Donald Trump returns to the White House.

The president-elect has promised to protect Medicare, which is government health insurance for people over 65 and some younger people. He is known for his long-standing criticism of parts of the health care industry, such as high drug prices.

But he also promised to loosen regulations, continue privatization and add work requirements to publicly available insurance and cut government spending, a major part of which is health care.

“As things stand today, health care is a target,” said David Lipschutz, co-director of the Center for Medicare Advocacy, a nonprofit that seeks to improve overall Medicare coverage.

“They’re going to try to take away people’s health insurance or reduce people’s access to it, and that 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 aimed at making the health care system more transparent, reducing regulations 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 everybody,” said House Speaker Mike Johnson in a video obtained by NBC News last month. “More efficient, more efficient,” he said. “This is 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 from KFF – point out that care is more expensive than in other countries and outcomes are worse on key indicators such as life expectancy, infant mortality and safety during birth.

The US will spend more than $12,000 (£9,600) per person on healthcare in 2022. – almost twice the average for 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 includes measures to expand eligibility for Medicaid, another government program that helps cover medical expenses for people with limited incomes. It also prohibited insurers from turning away patients with “pre-existing conditions,” successfully reducing the uninsured population from about 15% to roughly 8%.

Today, about 40 percent of the U.S. population receives insurance from taxpayer-funded government plans — primarily Medicare and Medicaid — with coverage increasingly outsourced to private companies.

The rest are covered by private company plans that are usually chosen by employers and paid for with a combination of personal contributions and employer funds.

Although more people are covered than ever before, frustration remains widespread. In a recent Gallup pollonly 28% of respondents rated health coverage as excellent or good, the lowest level since 2008.

Public data on the rate of insurance denials — which can also happen after receiving care, leaving patients with hefty bills — is limited.

But surveys of patients and medical professionals show that insurance companies are requiring more “prior authorization” for procedures — and denials from insurance companies are on the rise.

In the state of Maryland, for example, the number of claim denials disclosed by insurers has jumped more than 70 percent 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 don’t have access to the care we need doesn’t make sense,” Ms Ginkel said. “As I went through the process, I felt more and more that (insurance companies) were doing this on purpose in hopes that you would opt out.”

Brian Mulhern, the Rhode Island resident who postponed his colonoscopy, compared the industry to the “legal mafia” — offering protection “but on their terms.” He added: “Increasingly it looks like you can pay more and more and get nothing.”

AHIP, a lobbying group for health insurers, said claim denials often reflect misapplications by doctors or predetermined decisions about what to cover made by regulators and employers.

UnitedHealthcare did not respond to a BBC request for comment for this article. But in an opinion piece written after CEO Brian Thompson was killed, Andrew Whitty, head of the firm’s parent company, defended the industry’s decision-making.

It 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 a for-profit health care system will always be focused on its shareholders and the bottom line, and link the rise in claim denials to the growing use of artificial intelligence (AI), which is said to be error-prone to request review.

One developer said last year that its AI tool is not being used to inform coverage decisions — only to help providers know how to help patients.

Derrick Crowe, communications and digital director for People’s Action, a nonprofit that advocates for insurance reform, said he hopes the shock of the killing will force change in the industry.

“This is a moment to take a moment of personal pain and turn it into a public collective power to ensure that companies stop denying our care,” he said.

It remains to be seen whether the killing will increase the appetite for reform.

Politicians from both parties in Washington have expressed interest in efforts that could rein in the industry, such as tightening oversight of algorithms and rules that would require the breakup of big firms.

But there is little sign that the proposals have any meaningful force.

Trump’s nominee to lead the powerful Centers for Medicare & Medicaid Services (CMS), TV doctor Mehmet Oz, has previously endorsed expanding coverage from Medicare Advantage — 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.

Prof. Buntin said Republican electoral gains showed the US would not accept the alternative – a publicly run scheme like the UK’s National Health Service – anytime soon.

“There’s a distrust of people who seem to be profiting or benefiting from the disease — and yet that’s the bedrock of the American system,” she said.