In a guest essay in the New York Times, the CEO of UnitedHealth Group, Andrew Witty, wrote, "... we need to improve how we explain what insurance covers and how decisions are made."
Senator Chris Murphy stated that while he will never condone violence, policymakers need to listen to the visceral anger Americans feel toward insurance denials.
In California, health plans are not required by the state to report on a regular basis how often they deny treatment, which means there's limited oversight on patterns.
The assassination of UnitedHealthcare CEO Brian Thompson in Manhattan last week has drawn more media scrutiny of America's healthcare system than we saw in the entire 2024 presidential election.
In one study, researchers estimated that as many as 66.5% of personal bankruptcies are tied to medical issues like high bills or lost income due to illness.
A Kaiser Family Foundation (KFF) analysis found that about 40% of insured adults who faced problems paying medical bills usually experienced a claim denial.
In 2023, national health expenditures were around $4.9 trillion (about 17.6% of GDP). Projections from the Centers for Medicare & Medicaid Services Office of the Actuary indicate that annual health spending is expected to grow by 5.6% per year over the next decade, outpacing the average GDP growth of 4.3%. As a result, health spending is projected to account for 19.7% of GDP by 2032.
In 2024 alone, AHIP spent $11.77 million on lobbying, while major insurers added much more: UnitedHealth Group spent $10.76 million in 2023, Cigna spent $8.25 million in 2024, and the Blue Cross Blue Shield system collectively spent a massive $27.1 million in 2024.
Campaign contributions from the insurance industry have grown exponentially over decades, from about $14.4 million in the 1990 election cycle to a record $128 million in the 2020 cycle…
In 2019, when Medicare for All was a hot topic, the industry coordinated through the Partnership for America's Health Care Future (a coalition of insurers, hospitals, and pharma) to run ads and lobby lawmakers to oppose it.
When President Bill Clinton proposed health reform in the 1990s, the Health Insurance Association of America (AHIP's predecessor) spent $14-15 million on the infamous "Harry and Louise" advertising campaign that helped sink Clinton's plan.
Several high-profile Democratic presidential candidates, including Pete Buttigieg and Kamala Harris, initially voiced support for Medicare for All but later reversed or softened their positions.
OpenSecrets reported that during the 2009–2010 Obamacare debates, the healthcare industry spent a record $270 million on lobbying in a single year and shaping the law to their liking.
Over 2019–2024, UHG reportedly spent over $500,000 in Connecticut alone to block a state-level public option that threatened its business. UnitedHealth Group has been one of the top political spenders among insurers, contributing $4.47 million in campaign donations in the 2024 cycle alone.
In 2023, approximately 51 out of 62 UnitedHealth lobbyists were former government officials, exemplifying the "revolving door" between government and industry that strengthens its influence network.
When Congress created Medicare Part D (prescription drug coverage) and expanded Medicare Advantage in 2003, insurers and pharmaceutical companies deployed nearly 1,000 lobbyists (almost 10 per U.S. Senator) spending approximately $141 million on lobbying that year alone.
An analysis found that insurers and related groups filed 22.6% of all new federal lobbying registrations in early 2020, illustrating how heavily they were lobbying especially during pandemic policy-making.
In Colorado, a single-payer state constitutional amendment called ColoradoCare was defeated after insurers helped fund a well-resourced opposition campaign.
Similar scenarios have played out in California, where the insurance industry spent millions to defeat both a 1994 single-payer initiative (Proposition 186) and a 2014 proposition that would have required state approval for insurance rate hikes.
When President Harry Truman proposed universal public health insurance in 1945, the insurance industry supported the American Medical Association's record-breaking $1.5 million lobbying campaign to defeat it by branding it as "socialized medicine." The result? Truman's universal plan was blocked in Congress.
A Los Angeles man received a denial for a heart procedure stating he had requested spinal injections that were "not medically needed." However, he had never requested spinal treatment.
A denial letter addressed to a newborn in the NICU claimed the infant was feeding and breathing on his own, making day four of intensive care unnecessary. The baby was on a ventilator and receiving nutrition intravenously.
A landmark legal case against United Behavioral Health (UBH) found the company used overly strict guidelines not aligned with accepted standards, resulting in the wrongful denial of mental health and substance abuse treatment for tens of thousands of patients.
One pediatric gastroenterologist noted that his patients’ MRE scans were routinely denied as “not necessary” in favor of older CT scans, even though MREs were the safer, recommended option for children.
One major insurer (Aetna) was sued in a class action for systematically denying proton therapy; it ultimately agreed to a multi-million dollar settlement over these practices.
Robert "Skeeter" Salim, a prominent attorney, had his advanced throat cancer treatment (proton therapy) denied by Blue Cross as "investigational." Internal appeals were handled by external review companies that simply copied and pasted the insurer's guidelines to uphold the denial.
Dr. Debby Day described how nurses at Cigna would prepare denials for doctors to sign off. She characterized their work as "increasingly sloppy," with many cases that should have been approved getting denied upfront.
Studies by KFF found that about 69% of insured adults who experienced a denial did not even know their plan had an appeals process or that they had the right to challenge a denial.; Across all types of private health insurance, roughly 85% of denied claims go unappealed.
In ACA marketplace plans, of the over 48 million denied in-network claims in 2021, consumers filed only 90,599 appeals. That's an appeal rate of just 0.2% (approximately one in 500 denied claims).
The KFF survey found those who use a lot of health services (i.e., visited their provider over 10 times per year) had higher rates of denial—about 27% of people in the top utilization group. In contrast, only 14% of those who visited their provider less than 3 times a year experienced a denial.
A joint report by federal and state regulators in 2022 found many insurers failing to comply with mental health parity, effectively denying mental health care at levels that would not occur for analogous medical care.
Insurance claim denials have risen 16% from 2018 to 2024.
Elisabeth Rosenthal's 2023 investigation notes that millions of Americans are now encountering denials for claims that "once might have been paid immediately".
Another former executive defended the practice from a business angle, illustrating the mindset: He said he understood the economics and that the system "has undoubtedly saved billions" for Cigna.
Health Net (a California insurer) was found to have paid bonuses to employees specifically for canceling coverage of sick policyholders to dodge big claims.
For every dollar Wendy pays, approximately 80-85 cents eventually goes to medical claims—hospital care, doctor visits, and prescriptions. The remaining 15-20 cents breaks down into administrative expenses (around 13-14 cents) and profit (roughly 1-4 cents).
In 2023, UnitedHealth Group CEO Andrew Witty received $23.5 million in total compensation. CVS Health (which owns Aetna) CEO Karen Lynch earned $21.6 million. Cigna's CEO David Cordani earned $21 million.
Despite inflation and post-pandemic healthcare challenges affecting most Americans, the insurance giant reported a $5.6 billion profit, exceeding Wall Street expectations.
Federal regulators found some companies "gaming the system by misallocating expenses... while minimizing reported administrative expenses and profits".
An NBER study found that after the ACA's implementation, some insurers responded to the MLR rule by increasing claims spending by 7–11% rather than lowering premiums.
Private equity's involvement in healthcare began in earnest in the early 2000s, but it accelerated dramatically following the 2008 financial crisis, when low interest rates and a search for stable returns pushed firms toward recession-resistant sectors.
Initial acquisitions focused on niche specialties like dermatology, radiology, and urgent care. After the ACA expanded insurance coverage in 2010, private equity moved aggressively into core services, including hospitals, emergency medicine, and nursing homes.
Today, private insurers administer coverage for more than half of Medicare beneficiaries (through MA plans), most Medicaid enrollees (via Medicaid managed care organizations), and millions of Americans purchasing subsidized coverage on the ACA marketplaces.
A 2022 HHS Inspector General report found MA plans wrongly denied 13% of prior authorization requests and 18% of payment claims that met Medicare coverage rules.
The statistics are even more grim for vulnerable populations: our infant mortality rate stands 5.4 per 1,000 births compared to just 1.6 in Norway, while our maternal mortality rate is three times higher than peer countries.
That's nearly $496 billion per year with roughly 15% of all health spending going to billing clerks, claims processors, insurance middlemen, and administrative overhead.
American physician practices spend four times more on billing-related costs than their Canadian counterparts—about $83,000 per doctor annually in the U.S. versus $22,000 in Ontario.
A 2022 investigation found U.S. hospitals and clinics spent $25.7 billion in one year just contesting insurers' claim denials amounting to nearly $57 in extra administrative costs per claim.
The practice dates back to World War II, when the federal government imposed wage freezes to control inflation. Companies couldn't attract workers by offering higher pay, so they began offering benefits, notably health insurance, as a workaround.
In 1943, the War Labor Board ruled that these fringe benefits didn't count as wages, and in 1954 the IRS cemented this by making employer health insurance contributions tax-deductible.
One analysis found that in nine states, the entire unemployment check wouldn't even cover the COBRA premium. In Alaska for example, family COBRA premiums were 132% of the state's average UI income.
As part of the 2009 stimulus, the federal government temporarily subsidized 65% of COBRA premiums. With that subsidy, about 34% of eligible people opted for COBRA.
The vast majority who declined COBRA cited cost as the main factor, with 80% of non-enrollees complaining it was still too expensive, despite the subsidy.
One study concluded about 7.7 million workers lost jobs that provided health insurance, affecting an additional 6.9 million dependents who were on those plans.
Another KFF analysis of marketplace (ACA) plans found a similar pattern: enrollees had access to only about 40% of physicians in their area through their plan's network.
Nearly a quarter of enrollees were in plans that included 25% or fewer of local doctors. In Chicago, certain marketplace plans had only 14% of area doctors in-network.
In New York, the state attorney general conducted a secret shopper survey across 13 major health plans' directories for mental health providers. The result: 86% of the listed in-network mental health providers were effectively ghosts.
New York passed a law in 2016 against ghost networks, but since then, regulators have issued only one fine of $7,500 to a plan, even after hundreds of consumer complaints.
Industry-wide, ProPublica noted that all fines combined across states amounted to a tiny fraction of 1% of insurers' profits—merely a "cost of doing business" that does not compel change.
A 2024 study by the Commonwealth Fund found that 45% of insured, working-age adults received a surprise medical bill or were charged for something they believed their plan would cover at no cost in the past year.
13% of prior authorization denials in MA were for services that met Medicare's coverage rules and should have been approved under traditional Medicare.
The OIG also found about 18% of payment denials were wrong, meaning providers were not paid for care that was indeed covered, likely deterring those providers from treating MA patients.
According to KFF, only about 11% of denied prior authorization requests in MA were appealed in 2021, but when appealed, 75% were decided in favor of the patient (the plan's denial was reversed).
The World Health Organization defines universal health coverage as enabling everyone to get the services they need without suffering financial hardship.
A 2024 study at a major cancer center found that among patients initially denied radiation therapy, 10% had to accept lower radiation doses than prescribed due to insurer requirements, a dangerous change linked to decreased tumor control and survival.
The AMA survey revealed 78% of physicians report that patients "abandon recommended treatments" because of authorization struggles and insurance red tape.
In the early 1980s, only about 8% of U.S. families filing bankruptcy cited healthcare expenses as a contributing factor. But by the mid-2010s, roughly two-thirds of personal bankruptcies involved medical issues, equivalent to about 530,000 American families filing for bankruptcy each year because of illness or medical bills.
A study in the American Journal of Public Health found that among those who declared medical bankruptcy, the majority had been middle-class earners and three-quarters had health insurance at the onset of illness.
In 2021, Andrea Coy's infant son contracted a severe pneumonia that necessitated an airlift by helicopter from a local hospital to a specialized children's hospital. The air ambulance was out-of-network, leading to a staggering $65,000 bill for the short flight. Their insurer (UnitedHealthcare) only covered about $28,000 of it.
GoFundMe's leaders have noted that while they never intended the platform to become a healthcare funding source, medical expenses have become the most common category of fundraiser on the site.
Internal estimates suggest roughly one-third of all GoFundMe fundraisers are for healthcare costs. As of the early 2020s, more than 250,000 health-related campaigns are started each year, collectively raising over $650 million annually.
A comprehensive study in the American Journal of Public Health found that only about 12% of medical campaigns met their goal, and 16% received no donations at all. In other words, nearly 88% of campaigns fail to reach their target, often collecting only a fraction of the cost of care.
As one journalist noted, paying for care via GoFundMe is being "normalized as part of the health system, like getting blood work done or waiting on hold for an appointment".
As of March 2023, about 160 million Americans live in areas with mental health professional shortages, with over 8,000 additional providers needed to fill the gap.
In 2021, only 47.2% of U.S. adults with any mental illness received treatment, and even among those with serious mental illness, only about 65% received care.
A recent report found that over 700 rural hospitals (about 31% of all rural hospitals nationwide) are at risk of shutting down due to financial losses.
Studies have found mixed evidence on health outcomes, but some research shows increased mortality for time-sensitive conditions after rural hospital closures.
A revolutionary gene therapy for spinal muscular atrophy (SMA) can prevent a fatal or disabling outcome in babies, but it costs $2.1 million for a single dose.
According to the American Medical Association's 2024 survey, an overwhelming 94% of physicians report that prior authorization delays necessary patient care.
Physicians have among the highest suicide rates of any profession, with an estimated 300-400 doctors dying by suicide annually, more than double the rate of the general population.
During a typical day, physicians spend nearly half their time (49%) on electronic health records and desk work, while only 27% of their time is spent in direct patient care.
A primary care doctor typically earns only about 1-2 RVUs (relative value units, the measure that determines payment) for a 20-minute office visit (roughly $50–$100) while a specialist performing an hour-long procedure can generate 10+ RVUs worth thousands of dollars.
A 2023 study found that shorter primary care visits were significantly associated with more inappropriate antibiotic prescribing for respiratory infections.
2023 marked the first time that corporate owners (including private equity firms and insurers) owned more physician practices (30.1%) than hospitals did (28.4%).
The American College of Physicians found that most physicians view private equity's influence negatively, with only 10% regarding it in a positive light.
Doctors directly employed by private equity-owned practices were significantly less likely to report high job satisfaction or autonomy compared to those in independent settings.
Nearly 60% of doctors reporting that after their practice was acquired by a corporate entity, their ability to make the best care decisions for patients worsened.
Studies show that when physician practices are acquired by hospitals or health systems, prices for the same services typically increase by 14% or more.
A 2022 JAMA study estimated that to fully meet all preventive, chronic, and acute care guidelines for an average patient panel, a primary care physician would need to work 27 hours per day.
Even the American Medical Association, which historically has never supported unions, now does so, endorsing physicians' right to collective bargaining and is working to expand those rights, especially as more doctors become employees.
Studies show promising results: one analysis found DPC patients had 65% fewer ER visits and about 35-50% fewer hospitalizations compared to similar patient populations…
Since 1999, the Accreditation Council for Graduate Medical Education has required "systems-based practice" as a core competency, pushing training programs to teach residents about the broader healthcare system.
One qualitative study of final-year medical students found they were shocked by the billing and coding demands they encountered during clinical rotations.
Dr. Linda Peeno, who worked as a medical reviewer for Humana in the 1980s, revealed in congressional testimony that during her job interview, she was specifically asked if she could "be tough" because she would be "expected to keep a 10 percent denial rate".
In 2015, Dr. Jay Ken Iinuma, who served as an Aetna medical director, testified under oath that he "did not personally review patients' medical records" …
Natalie Collins, a former UnitedHealthcare service representative, explained that during her training, there was no instruction on how to actually pay the claim that a customer was disputing; "the entire training was about different ways to deny the claim".
Under various laws (like the False Claims Act, or OSHA regulations for health insurance under the ACA), an employee is theoretically protected from retaliation for reporting certain types of violations.
Former Aetna CEO, Mark Bertolini, after leaving his post, expressed that we should debate single-payer and acknowledged the flaws in the current system.
Thanks to a 2023 rule change, families stuck in that predicament can now qualify for subsidized marketplace plans. This was projected to help nearly 1 million Americans obtain more affordable insurance.
In January 2021, the federal Hospital Price Transparency Rule took effect, requiring hospitals to post their prices for services and negotiated insurance rates publicly.
Platforms like Turquoise Health and Healthcare Bluebook compile the machine-readable price files from hospitals and provide searchable interfaces that let patients look up procedures and compare prices across facilities.
Companies like MDSave and Sesame offer online marketplaces where patients can search for procedures and see set cash prices from local providers, often at significant discounts for paying upfront.
…is Apple Health Records on the iPhone. Launched in 2018, this feature allows patients to download and aggregate their medical records from participating hospitals and clinics. By 2022, it was connected to over 800 healthcare institutions covering 12,000+ locations in the U.S., U.K., and Canada.
When patients have electronic access to health information and digital tools for self-management, many studies document positive outcomes like better disease control and higher satisfaction.
Before 2020, only about 8% of Americans had ever had a telemedicine visit. But during the pandemic's height, telehealth accounted for an estimated 13% of all outpatient visits nationwide.
By late 2023, over 12.6% of Medicare beneficiaries were still receiving services via telehealth each quarter, and 86.9% of hospitals were providing telehealth services.
Teladoc Health alone reported facilitating over 50 million virtual visits as of late 2022, with about one in four Americans having access to their services through employers or health plans.
Forward Health takes a tech-forward approach: their clinics feature body scanners and genetic tests, with a flat fee (around $149 per month) covering all primary care services.
A typical DPC practice charges $50-$100 monthly for adults. The AAFP reports that 99% of DPC practices offer same-day appointments, and the average panel size for a DPC physician is around 413 patients
ClearHealthCosts grew by partnering with media organizations in various cities, including CBS News, spreading the word and increasing data contributions from community members.
Companies like BurstIQ have worked with Colorado's Medicaid program on a pilot using blockchain for patient profiles to test if it improved data integrity and portability.
A report by Digital Health Insights notes that crypto payments can reduce transaction costs and delays in healthcare, particularly for global payments.
The Dentacoin foundation also proposed smart contracts for a "dental assurance" program, effectively a subscription between patient and dentist written to blockchain.
Highmark, a large Blue Cross Blue Shield insurer, deployed AI in its payment integrity department with remarkable results: in 2019 alone, their AI-driven fraud prevention saved approximately $260 million. Over five years, their AI implementations saved over $850 million.
A CDC report indicated tele-triage and symptom bots saw heavy usage during COVID surges, helping direct patients appropriately when systems were overwhelmed.
By 2022, 62% of healthcare executives had adopted AI-centric strategies, up from 33% in 2018, reflecting how mainstream AI has become in operational thinking.
In July 2024, over 100 patients, nurses, and advocates protested at UnitedHealth Group's headquarters, calling out an "epidemic" of claim denials amid record corporate profits.
The No Surprises Act, which protects patients from unexpected out-of-network bills, gained momentum after patients with enormous surprise bills were invited to the White House to share their stories.
Before the No Surprises Act, 33 states had enacted some form of surprise billing protection, with 18 states implementing comprehensive laws covering both emergency and in-network hospital services.
New data shows 60% of "not medically necessary" denials and 80% of "experimental" treatment denials get reversed through IMR or insurer reconsideration.
"Bill of the Month" Series: A joint KFF Health News-NPR monthly series examines outrageous medical bills. Since 2018, it has analyzed nearly $6.3 million in medical bills and spurred numerous improvements.
Two patients from this series were even invited to the White House to share their stories, experiences which helped drive Congress to pass the No Surprises Act.
The alliance Lower Drug Prices Now brings together patient advocates, seniors' organizations like AARP, nurses' and teachers' unions, and businesses struggling with employee drug costs.
The American Medical Association has worked alongside patient coalitions to streamline prior authorization, with both groups testifying to the harm caused by unnecessary delays.
Several analyses suggest UCC could be implemented without increasing total healthcare spending and might even reduce it through administrative savings and better price negotiations.
Contribution limits are relatively low ($4,150 individual/$8,300 family in 2024), and you can't use HSA funds to pay for insurance premiums or many types of direct care.
Studies consistently show that hospital mergers lead to price increases of 20-40% in concentrated markets, with no reliable improvement in care quality.
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