The US is asking what’s next for health care

Special education teacher Robyn Ginkel spent nearly two years fighting her insurance company to get her to pay for back surgery her doctors recommended 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 for medical help to get back to a normal quality of life and back to work.”

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

Now she is preparing for the battle to begin again after she decided to try her luck with a new insurance company.

“It’s exhausting,” she said. “I can’t go on like this.”

Ms. Ginkel was not the only one to throw up her hands.

About one in five Americans covered by private health insurance reported that their provider refused to pay for care recommended by their doctor in the past year. according to a survey 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 discovery that prompted his doctor to recommend a follow-up exam in three years. instead of the usual five.

Faced with $900 out of pocket, Mr Mulhern put the procedure on hold.

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

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

While the backlash raised the prospect that the controls could force a turnaround, experts said it would take action from Washington, where there was little sign of a change in momentum, to reverse the frustration.

To the contrary: In just the past few weeks, Congress has once again failed to advance long-delayed measures to make it easier for people on certain government-backed insurance plans to get claims approved.

Many advocates are also worried about worsening problems with Donald Trump’s return to the White House.

The president-elect has promised to protect Medicare, which is the government’s 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 regulation, continue privatization and add work requirements to universal insurance and cut government spending, a major part of which is health care.

“Today’s business is about health care,” said David Lipschutz, co-director of the Center for Care Advocacy, a nonprofit that seeks to expand comprehensive Medicare coverage.

“They’re going to try to take people away from health insurance or reduce people’s 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 care 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 everybody,” said House Speaker Mike Johnson in a video obtained by NBC News last month. “More efficient, more efficient,” he said. “This is a free market. Trump will be for the free market.”

Dissatisfaction with the health care system is longstanding in the U.S., where experts — including those at KFF — note that care is more expensive than in other countries and outcomes are worse on key measures such as life expectancy, infant mortality and safety during giving birth

The US will spend more than $12,000 (£9,600) per person on healthcare in 2022 – almost double that of other wealthy countries, according to the Peter G. Foundation. Peterson.

The last major reform, under former President Barack Obama in 2010, focused on expanding health insurance in hopes of making health care more affordable.

The law included measures to expand eligibility for Medicaid, another government program that helps cover medical expenses for people with limited incomes. It also prohibits insurers from turning away patients with “pre-existing conditions,” successfully reducing the uninsured population from about 15% to about 8%.

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

The rest participate in private company plans, which are usually chosen by employers and paid for through personal contributions and employer funds.

Despite reaching more people than ever before, frustration remains widespread. In a recent Gallup pollonly 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 happen after care has been received, leaving patients with large bills — is limited.

But surveys of patients and health care providers show that insurance companies are requiring more “prior authorization” for procedures — and denials by insurance companies are on the rise.

In Maryland, for example, the number of claim denials disclosed by insurers has jumped more than 70% in 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 sense,” Ms Ginkel said. “As I went through the process, I felt more and more that (the insurance companies) were doing this on purpose in the hope that you would decline.”

Brian Mulhern, a Rhode Islander who put off colonoscopy, likened the industry to a “legal mafia” — offering protection “but on their terms.” He added: “It seems more and more like you can pay more and more and get nothing.”

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

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

He said it was based on a “comprehensive and constantly updated body of clinical data aimed at achieving the best health outcomes and ensuring patient safety”.

But critics complain that the for-profit health care system will always be focused on its shareholders and outcomes, and attribute the rise in claims denials to the growing use of allegedly error-prone artificial intelligence (AI) to process claims.

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

Derrick 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 force change in the industry.

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

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

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

But there is little sign that the proposals have much force.

Trump’s nominee to head the powerful Centers for Medicare and Medicaid Services (CMS), TV doctor Mehmet Oz, has previously supported expanding Medicare Advantage coverage, 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.

Professor Buntin said the Republicans’ election victories showed the US was not going to accept an alternative – a public scheme such as the UK’s NHS – any time soon.

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