America asks what’s next for health care

Special education teacher Robin Ginkel spent nearly two years fighting her insurance company trying to get it to pay for back surgery her doctors recommended after an injury. Due to work, she suffered a herniated disc and debilitating pain.

The plan doesn’t seem “ridiculous,” she said: “I’m asking for health care to return to a normal quality of life and return to work.”

Initially denied, the 43-year-old woman from Minnesota spent hours appealing the decision — even filing a complaint with the state — only to see her request denied three times.

Now she is preparing for the fight to start again after deciding her best option was to try her luck with a new insurance company.

“It’s tiring,” she said. “I can’t continue like this.”

Ms. Ginkel was not alone in raising her hand.

About 1 in 5 Americans covered by private health insurance said their provider refused to pay for care recommended by their doctor last year, according to a survey by health policy organization KFF.

Brian Mulhern, a 54-year-old man from Rhode Island, said his health insurance company recently denied his claim for a colonoscopy after polyps were discovered on his colon. – a finding that prompted his doctor to recommend a follow-up examination within three hours. years instead of the usual 5 years.

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

Long-simmering anger over coverage decisions exploded in public opinion earlier this month after UnitedHealthcare CEO Brian Thompson was murdered — and the killing sparked an astonishing wave of outrage. public surprise towards this industry.

The crime has sent shockwaves through the system, prompting an insurer to reverse a controversial plan to limit opioid coverage and hit the stock prices of major companies.

While the reaction raises the possibility that scrutiny could force changes, experts say addressing the frustration will require action from Washington, where there are few signs of change. See the motivation will change.

On the contrary: in just the past few weeks, Congress has failed to advance long-stalled measures that would make it easier for participants in some government-backed insurance programs to get approve their claim.

Many advocates also fear the problem will get worse when Donald Trump returns to the White House.

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

But he also vowed to loosen regulations, pursue privatization and add work requirements to available public insurance and cut government spending, of which health care is a key part. important.

“In the current climate, health care is the target,” said David Lipschutz, co-director of the Center for Medicare Advocacy, a nonprofit seeking to advance comprehensive Medicare coverage. .

“They will 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 problem worse than.”

Republicans, who control Congress, have long supported reforms aimed at making the health care system more transparent, cutting regulation and reducing the role of government.

“If you take government bureaucrats out of the health care equation and you have a doctor-patient relationship, it’s going to be better for everyone,” House Speaker Mike Johnson said. . in a video obtained by NBC News last month. “More efficient, more effective,” he said. “It’s the free market. Trump will support 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 in other countries and performance is worse in Basic data such as life expectancy, infant mortality rate 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 wealthy countries, according to the Peter G Peterson Foundation.

The most recent major reform, under former president Barack Obama in 2010, focused on expanding health insurance in hopes of making care more accessible.

The legislation includes measures to expand eligibility for Medicaid, another government program that helps cover medical costs for people with limited income. It also prohibited insurers from turning away patients with “pre-existing medical conditions,” successfully reducing the uninsured population rate from about 15% to about 8%.

Today, about 40% of the population in the United States receives coverage from taxpayer-funded government programs — primarily Medicare and Medicaid — with coverage increasingly contracted to companies. private.

The remainder are enrolled in plans from private companies, often selected by the employer and paid for with a combination of individual contributions and employer funds.

Even though more people are insured than ever before, frustration is widespread. In a recent Gallup pollJust 28% of respondents rated health care coverage as excellent or good, the lowest since 2008.

Public data on insurance denial rates — which can also occur after receiving care, leaving patients with huge bills — is limited.

But surveys of patients and medical professionals show insurers are requiring more “prior authorizations” for procedures — and insurers are opting out. increase.

In Maryland, for example, the number of claim denials disclosed by insurers has increased more than 70% in five years, according to a report from the state attorney general’s office.

“It doesn’t make sense for us to pay into the system and then when we need it, we can’t access the care we need,” Ms. Ginkel said. “As I went through this process, I felt more and more like [the insurance companies] intentionally doing this in the hope that you will give up.”

Rhode Islander Brian Mulhern, who stopped doing colonoscopies, compared the industry to the “legal mafia” – offering protection “but on their terms.” “It seems like more and more people are paying more and getting nothing in return,” he added.

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

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

He said it was based on “comprehensive and continuously updated clinical evidence, focused on achieving the best health outcomes and ensuring patient safety”.

But critics complain that a for-profit health system will always focus on its shareholders and profits, and link the rise in claim denials to the growing use of intellectual Artificial intelligence (AI) is said to be error-prone to review requirements.

One developer said last year its AI tool was not being used to inform insurance decisions — only to help guide providers on how to support 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 time to take a little bit of our private pain and turn it into collective power to make sure companies stop denying us our care,” he said.

Whether the murder will fuel a hunger for reform remains to be seen.

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.

But there are few signs that these proposals are gaining significant traction.

Trump’s nominee to run the powerful Centers for Medicare & Medicaid Services (CMS), TV physician Mehmet Oz, has previously endorsed expanding coverage of Medicare Advantage – which offers plans Medicare health insurance through private companies.

“These plans are popular with seniors, consistently provide quality care, and have the momentum needed to keep costs low,” he explained in 2022.

Professor Buntin said the Republican election victories showed that the US would not soon adopt the alternative – a publicly run program like the UK’s National Health Service – at any time.

“There is mistrust of people who seem to be profiting or benefiting from disease — but that is the foundation of the American system,” she said.