America is asking what’s next for health care

Special education teacher Robin Ginkel has spent nearly two years battling her insurance company to try to get it to pay for back surgery her doctors recommended after a workplace injury left her with a herniated disc and debilitating pain.

The plan didn’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 from Minnesota spent hours appealing the decision — even filing a complaint with the state — only to see her claim 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 exhausting,” she said. “I can’t go on like this.”

Mrs Ginkel is not alone in throwing up her hands.

About one in five Americans covered by private health insurance reported that their provider refused to pay for treatment recommended by a doctor last year, according to a study from the health policy fund 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 on his colon — a discovery that prompted his doctor to advise a follow-up examination within three years instead of the typical five.

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

Long-simmering anger over insurance decisions exploded into the public eye earlier this month after UnitedHealthcare CEO Brian Thompson was murdered — and the killing sparked a surprising wave of public outrage in the industry.

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

Although the reaction raised the possibility that scrutiny could force changes, experts said it would take action from Washington, where there is little sign of a change in momentum, to address the frustration.

On the contrary: just in the last few weeks, Congress has again failed to move forward with long-standing measures aimed at making it easier for people on certain government-sponsored insurance plans to get their claims approved.

Many advocates are also concerned that the problems will worsen as 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 long-standing criticism of parts of the healthcare industry, such as high drug prices.

But he has also promised to loosen regulation, pursue privatization and add work requirements to publicly available insurance and cut public spending, of which health care is a large part.

“As things stand today, health care is a goal,” said David Lipschutz, co-director of the Center for Medicare Advocacy, a non-profit that seeks to promote comprehensive 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 those frustrations and would only make the problems worse.”

Republicans, who control Congress, have historically backed 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 doctor-patient relationships, it’s better for everybody,” House Speaker Mike Johnson said. in a video obtained by NBC News last month. “More effective, more efficient,” he said. “It’s the free market. Trump will be for the free market.”

Dissatisfaction with the healthcare system is long-standing in the United States, where experts – including at KFF – point out that care is more expensive than in other countries and that performance is worse on basic metrics such as life expectancy, infant mortality and safety during childbirth.

The US spent more than US$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 last major reform, under former President Barack Obama in 2010, focused on expanding health insurance in hopes of making care more accessible.

The law included measures to expand eligibility for Medicaid, another government program that helps cover medical costs 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 about 8%.

Today, about 40% of the population in the United States gets insurance from taxpayer-funded government plans—mostly Medicare and Medicaid—with coverage increasingly outsourced to private companies.

The rest are enrolled in schemes from private companies, which are typically chosen by employers and paid for with a mixture of personal contributions and employer funds.

Although more people are covered than ever before, frustrations remain 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 number of insurance denials — which can also happen after care is received, leaving patients with large bills — is limited.

But surveys of patients and doctors suggest that insurers are requiring more “prior authorization” for procedures — and rejections by insurers are on the rise.

In the state of Maryland, for example, the number of claim denials disclosed by insurance companies has increased by 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 makes no sense,” Ms Ginkel said. “As I went through the process, it felt more and more like (the insurance companies) are doing this on purpose, hoping you’ll give up.”

Brian Mulhern, a Rhode Islander who postponed his colonoscopy, compared the industry to the “legal mafia” – offering protection “but on their terms”. He added: “It seems increasingly that you can pay more and more and get nothing.”

AHIP, a lobbying group for health insurers, said claim denials often reflected flawed submissions by doctors or predetermined decisions about what to cover that had been made by regulators and employers.

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

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 a for-profit health system will always be focused on its shareholders and bottom line, and have linked the rise in claim denials to the increasing use of allegedly fallible artificial intelligence (AI) to review claims.

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

Derrick Crowe, communications and digital director for People’s Action, a non-profit that advocates for insurance reform, said he hoped the shock of the killing would force change in the industry.

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

Whether the murder will strengthen the appetite for reforms remains to be seen.

Politicians from both parties in Washington have expressed interest in efforts to rein in the industry, such as increased oversight of algorithms and regulations that would require breaking up large companies.

But there is little to suggest that the proposals have meaningful traction.

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

“These plans are popular with seniors, provide consistent quality care and have a necessary incentive to keep costs down,” he explained in 2022.

Prof. Buntin said Republican electoral gains indicate the U.S. isn’t about to embrace the alternative — a publicly run system like Britain’s National Health Service — anytime soon.

“There’s a mistrust of people who appear to be benefiting or benefiting from illness — and yet that’s the foundation of the American system,” she said.