https://www.linkedin.com/pulse/barring-profits-basic-coverage-switzerland-keeps-robqc

Roughly two-thirds of the U.S. population has health coverage through private insurance companies. Despite paying about $1,600 a year out of pocket on deductibles, copayments, and coinsurance, Americans have no guarantee their insurer will cover the cost of their care. Because insurance companies in the United States seek to maximize their profits, they have an incentive to deny payment for some services, even for recommended care, and to raise monthly premiums and out-of-pocket costs.

Switzerland has also struggled to make health care affordable for all residents, with one of the highest levels of out-of-pocket spending per person in the world, comparable to the U.S. average. Like the U.S., it relies largely on private health insurance, with residents choosing among competing insurers. But unlike the U.S., Switzerland bars insurers from profiting off basic plans. That difference helps explain why nearly a third of the U.S. population has medical bills or debt they are paying off over time, while only 2 percent of the Swiss population reports the same problem.

Regulating Private Insurers in Switzerland

Switzerland’s current system of mandatory basic health insurance (obligatorische Krankenpflegeversicherung, or OKP) was established in 1996 and requires all residents to purchase health insurance from authorized private insurers. Today, 100 percent of the population is covered through OKP, and everyone has access to the same nationally defined baseline benefits package, regardless of insurer. Because everyone is enrolled, costs are spread out across healthier residents and those who need more costly care.

Premiums are set by insurers but subject to federal approval. All plans include a minimum annual deductible of CHF 300 (USD 340), 10 percent coinsurance capped at CHF 700 (USD 794) annually, and a daily hospital fee; adults can choose plans with deductibles up to CHF 2,500 (USD 2,835) in exchange for lower premiums. The Swiss government also caps the price of services and what insurers pay providers to control costs.

While the federal government sets these baseline standards, it does not sell insurance directly. Residents choose among private insurers based on premiums, deductibles, provider restrictions, and networks, while guaranteed a core set of protections. Those who don’t enroll are assigned a plan by their local government and are responsible for late fees and past-due bills.

The most fundamental feature of the Swiss insurance market is that insurers are prohibited from earning a profit on basic health plans and must use a community-rating premium structure that shares costs between sicker and healthier individuals. Any surplus collected from basic premiums that exceeds paid claims must either be held in reserve to cover future costs or be returned to policyholders. Insurers also cannot deny coverage for any medically necessary care included in the basic package.

Insurance companies can, however, profit from supplementary private insurance, which covers services such as dental care and private or semiprivate hospital rooms. For these plans, insurers can reject applicants and vary premiums based on health status, age, and sex.

Despite federal regulations, affordability remains a major hurdle in the Swiss health system. Out-of-pocket spending is among the highest in the world, and premiums, which do not vary with income, can burden families who do not qualify for subsidies. Still, the system rests on a strong commitment to social solidarity, and some Swiss see these costs as the price of insuring everyone, even the most vulnerable. Because deductibles and coinsurance on basic plans are capped each year and claims for covered care cannot be refused, few residents fall into medical debt.

America’s Underregulated Private Insurance Market

The U.S. private insurance market is not entirely unregulated: the 2010 Affordable Care Act (ACA) prohibits insurers from denying enrollment based on preexisting conditions, age, or sex. The ACA also requires plans to cover essential health benefits and cap out-of-pocket spending, and it provides income-based subsidies for coverage bought through the marketplaces.

Since private insurers are permitted to operate for profit, they still have an incentive to limit what they pay out to maximize their earnings. While people cannot be denied enrollment, insurers can delay payment for doctor-recommended services or deny claims altogether by arguing the care was not medically necessary or by citing other technicalities.

In 2025, one in five U.S. working-age adults with private insurance said they or a family member had been denied treatment their doctor recommended in the past year, and about 40 percent of them said the denial led to delayed care. More than two in five adults whose claim was denied reported it led to medical debt they are still paying off. In one survey, most working-age adults with private coverage who were paying off medical bills or debt blamed insurance companies.

While both Switzerland and the United States have an individual mandate requiring residents to enroll in a health plan — which is necessary for maintaining balanced risk pools — enforcement differs greatly. Since 2019, the ACA’s federal tax penalty for going without coverage has been reduced to $0, and only four states and Washington, D.C., impose their own financial penalties.

In both countries, a person’s insurer, out-of-pocket spending, and provider networks vary widely. But while federal regulation in Switzerland ensures all residents have robust minimum coverage standards, without fear of insurers creating obstacles to care in pursuit of their own profit, American patients have far fewer protections against companies that refuse or stall payment for care.

https://www.aei.org/commentary/the-democrats-already-have-a-healthcare-playbook-for-2029/?utm_campaign=22139279-ECON_NLR%20Vital%20Signs&utm_medium=email&_hsenc=p2ANqtz-_y1mg21d3JknEciULh5_aXyPYC2iUEkirlIFOZ9Gq7-WaC9Uxh0h2XeaWIxenX7YPGM5M7S3SdtaH2mJHs5Nu6EPSOvQ&_hsmi=446383067&utm_content=446383067&utm_source=hs_email

As the midterm elections approach, politicians are debating healthcare within the broader context of “affordability,” or, more precisely, the challenge voters say they are facing in paying their regular bills. An interesting battle within the Democratic Party is underway over the appropriate response to this concern, with some favoring Medicare for All and others voicing skepticism about that approach.

Leading congressional Democrats, including Sen. Ron Wyden of the Finance Committee, are hedging their bets, but the most likely scenario is still one of incrementalism rather than sweeping reform.

Medicare for All has always been more effective as a rallying cry for the Democratic Party than as a roadmap for getting a bill through Congress. Although many voters are exasperated with the state of American healthcare, support for Medicare for All falls when its costs, which are considerable, are made clear to survey respondents. There is also a broad lack of confidence in the government’s ability to competently manage healthcare insurance for the entire country.

A potential guide for what Democrats might do in lieu of Medicare for All can be found in a document posted in July by Wyden on behalf of many of his Senate colleagues. It lists scores of ideas for reforming healthcare insurance and care delivery, including through the possible adoption of Medicare for All, although the balance of the paper points toward more public control and regulation than a major push for a monolithic public plan.

Wyden is following the playbook Democrats used to successfully advance the Affordable Care Act (ACA) from 2008 to 2010. In the months leading up to the 2008 election, then-Senate Finance Committee Chairman Max Baucus had worked with outside experts and fellow Democrats to draft a white paper on healthcare, which he released just days after then-Sen. Barack Obama won the presidency. That document would serve as the blueprint for the bill Baucus would draft and pass in the Senate in 2009, which later became the foundational ACA law.

Many healthcare concepts that are now familiar because of their inclusion in the ACA were promoted in the Baucus white paper, including the individual mandate, new premium subsidies for non-employer coverage for individuals with incomes below 400 percent of the federal poverty line, a large Medicaid expansion, and accountable care organizations, which are provider-led—as opposed to insurer-owned—managed care plans.

Wyden is explicit in his July release that he views the development work conducted by Baucus before 2009 as a model for what he hopes to accomplish in the run-up to 2029. However, he framed the ideas presented in the July release not as proposals he supports but as ideas for which he is soliciting feedback (responses to his “request for information” are due by October 2). It is possible, depending on what occurs in November 2028, that Wyden will publish a more prescriptive plan after the election to signal more clearly his intentions for 2029.

Wyden’s document zeroes in on consumer dissatisfaction with aspects of private insurance and divides the ideas under review into three categories: lowering costs for consumers and making enrolling in insurance easier, removing barriers to accessing care and lowering administrative costs, and regulating the for-profit companies providing insurance and care to patients.

Some of the more noteworthy concepts included in the document include:

• reversing most of the budget cuts and regulatory changes implemented during the second Trump administration
• developing transition plans that might allow Medicare for All to be approved with less immediate disruption to the current coverage of many Americans
• creating an option for states to offer single-payer coverage
• creating a nationwide “public option,” sponsored and run by the federal government, that would be offered to consumers buying individual coverage through the exchanges established by ACA and which might use Medicare’s regulations to set reimbursement rates for services or allow the government to negotiate rates with the providers of services in each market

• developing new Medicare or Medicaid “buy-in” options that could be offered to all Americans regardless of their employment status and incomes
• creating a single online entry point for enrolling in coverage that both those getting employer-sponsored and non-group coverage could use
• allowing states to add to essential health benefits based on emerging evidence of effective services

• stricter state oversight over premium increases requested by insurance plans, potentially including caps
• eliminating deductibles and coinsurance for some “non-shoppable” services, and applying lower limits on total annual out-of-pocket costs based on a person’s income
• reinstating the enhanced premium credits in place from 2021 to 2025 that the GOP Congress allowed to expire
• allowing the ACA premium credits to go to lower-income workers enrolled in employer coverage, which the current “firewall” prohibits and which might be provided irrespective of the share of the premium paid by workers, and
• restricting the business practices of for-profit companies participating in the healthcare industry, including insurance companies, private equity investors, and other “middlemen”

The connecting theme behind these ideas is a publicly regulated system, with the government taking on the responsibility of providing affordable coverage options for all Americans, with cost-sharing that is capped relative to household income. Wyden and other Democrats are willing to consider all manner of new controls and subsidies to ensure these objectives are achieved, but it is of course easier to promise these outcomes than to deliver them. An especially formidable obstacle is likely to be the service providers who believe Medicare and Medicaid’s payment rates are too low to serve as guides for private coverage too. Cutting payments to all providers is easier than designing reforms that more precisely target waste and inefficiency, but the ability of Democrats to overcome industry opposition to payment reductions in 2029, as they did when writing the ACA, is not assured.

In addition, even with some provider cuts, the aggregate federal cost of a plan that includes some of the more prominent ideas in the Wyden plan (not including Medicare for All), could be significant. For instance, the Congressional Budget Office has estimated that rolling back policies that tightened administration of the ACA credits, along with reinstating on a permanent basis the enhancement of the credits originally approved in 2021, would increase projected federal budget deficits by $662 billion over 10 years. Democrats are certain to favor tax hikes on well-to-do Americans in 2028, but it is not yet clear that those potential sources of new revenue would be sufficient to fully offset the most expensive ideas the Wyden document teases.

The heavy investment Senate Democrats are making in the development of their 2029 agenda for healthcare contrasts with the GOP’s approach, which is less focused. The Trump administration released a one-page framework earlier this year (“The Great Healthcare Plan”), but there has been little follow-up and no visible movement among congressional Republicans to approve new legislation.

Republicans should take the Wyden document seriously. If voters opt once again for change in 2028 rather than continuity, it is near certain Democrats will use the power voters granted them to prioritize passage of a major healthcare bill. The GOP could make that scenario less likely to occur if it developed, promoted, and tried to advance an alternative approach. There are multiple sound ideas they could embrace to make healthcare more affordable without excessive reliance on public regulation, such as by allowing consumers to keep the savings when they choose lower-cost insurance and care providers. Refining those ideas and putting them into legislation would put the party in a better position to compete with what is coming from their opponents in both 2026 and 2028.

https://healthcareuncovered.substack.com/p/propublica-wants-to-hear-about-your?utm_source=post-email-title&publication_id=255152&post_id=222201228&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

Insurers promised to cut back on prior authorization. Now, ProPublica wants to know whether patients are still being denied or delayed care – and they need your help.

Last year, many of the country’s biggest health insurers promised to cut back on prior authorization. That’s the extra approval step insurers require before they’ll pay for a treatment, test, drug or piece of medical equipment. The pledge came after years of anger from patients, doctors and lawmakers in both parties.

I was skeptical then and I’m skeptical now. Prior authorization makes money for insurers. Every delay and every denial can mean care that never gets paid for. Companies don’t easily give up tools that pad their bottom line.

ProPublica is now trying to find out whether the promises meant anything. Reporters Max Blau and Brandon Roberts are investigating how insurers’ continued use of prior authorization is affecting patients. They want to know if people are still facing delayed or missed care.

I’m delighted they’re doing this. ProPublica can do the kind of reporting my small team can’t do yet – and they need your help.

If you’re covered by Medicaid, CHIP, an ACA marketplace plan or Medicare, and you’ve had a prior authorization request delayed or denied, they want to hear from you. That includes people in Medicare Advantage plans, where prior authorization is especially prevalent. It also includes people in traditional Medicare, where it has been rare until very recently.

The Trump administration is testing a program called WISeR that brings prior authorization into traditional Medicare for certain services in several states. Private tech companies are doing the reviews. As we have reported previously, this could be the start of turning traditional Medicare into something that looks a lot more like Medicare Advantage. If you’re in traditional Medicare and have run into WISeR, ProPublica wants to hear about it.

The reporters also want to hear from people who see the process from the inside. That includes doctors, nurses and office staff who fight these battles every day. It also includes regulators and people who work for insurance companies.

That last group matters. I know from my own years in the industry how much insiders know that the public never sees. If you work at an insurer and you’ve seen how prior authorization really works, please consider reaching out.

ProPublica says it will read everything submitted and won’t publish anything without your consent.

You can share your story here.

https://www.managedhealthcareexecutive.com/view/medicare-advantage-enrollees-more-likely-to-leave-after-new-complex-diagnosis?ekey=RUtJRDo1ODIyQzMzMS0wNDZELTQ0NkItQjlGRS03NTE4MUEwNjQ2QzM%3D&utm_campaign=newsletter_featured_b&utm_medium=email&_hsenc=p2ANqtz-_cFia7QLrHFn7kmO7Dj0tmtp6RW1mq27UAnDJ5cBOm370Z7XTzaTQQFHAWeKTUTx971znv6BDSuH4eCJ8-86_u-MGFGA&_hsmi=437158304&utm_source=hs

Medicare Advantage enrollees who developed a new complex condition, such as congestive heart failure or Alzheimer’s disease, were more likely to leave their plan for traditional Medicare the next year, according to a study published Aug. 21 in JAMA Health Forum.

Medicare Advantage (MA), the private alternative to traditional Medicare, covered 54% of Medicare beneficiaries in 2025, the study noted. MA plans offer perks traditional Medicare doesn’t guarantee, such as spending caps and built-in drug coverage, but they also use prior authorization and limited networks that can slow down care. Folks with bigger health needs have left MA at higher rates than healthier enrollees.

However, leaving isn’t simple. In most states, insurers don’t have to sell Medigap, the supplemental coverage that fills traditional Medicare’s gaps, to someone who skipped it when they first signed up. That can leave beneficiaries who get sick later stuck without that backup option.

The study was led by Mark K. Meiselbach, Ph.D., of the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health, and his team, who said past studies treated a new diagnosis as simply yes-or-no and mostly tracked switches to traditional Medicare. The researchers wanted to see whether leaving MA increases with the number of new conditions a person develops and to separate switches to traditional Medicare from switches to a different MA plan, something earlier research hadn’t done.

JAMA Health Forum finds Medicare Advantage members with new complex diagnoses increasingly switch to traditional Medicare, highlighting MediGap barriers, state protections, and plan limits.

The retrospective cohort study used Medicare enrollment and claims data from 2016 through 2021, analyzed in late 2025 and early 2026. Researchers tracked beneficiaries who stayed in an MA plan all of 2016 and had no complex condition through 2018. Using a standard federal algorithm, they flagged eight conditions: heart attack, Alzheimer disease, atrial fibrillation, chronic kidney disease, chronic obstructive pulmonary disease (COPD), depression, congestive heart failure and stroke.

A treatment group of 219,942 beneficiaries developed one of those conditions in 2019; a comparison group of 834,984 did not develop one through 2021. Using a difference-in-differences design, researchers compared how disenrollment changed for each group before and after 2019, then checked whether that change depended on how many new conditions someone developed, their state’s Medigap rules, and whether their MA plan was a health maintenance organization (HMO).

Developing any new complex condition raised MA disenrollment by 3.3 percentage points. Almost all of that increase came from people leaving for traditional Medicare rather than switching to a different MA plan. The more conditions someone developed, the more likely they were to leave: 1.4 percentage points with one new condition, up to 12.8 points among the 1,010 people with four or more. A new Alzheimer’s disease diagnosis had the single biggest effect, an 8.6 percentage point increase, while the rest ranged from 2.9 to 5.0 points.

Beneficiaries in the four states with Medigap guaranteed-issue and community-rating rules, Connecticut, Maine, Massachusetts and New York, were 1.5 percentage points more likely to leave for traditional Medicare than beneficiaries elsewhere. Those enrolled in HMO plans were less likely to leave for traditional Medicare but more likely to switch to a different MA plan.

Dual-eligible beneficiaries, who qualify for both Medicare and Medicaid, left for traditional Medicare at higher rates and switched MA plans less often, which the authors said tracks with Medicaid reducing their need for Medigap. Plan star ratings didn’t matter much: those in 4- or 5-star plans left at about the same rate as those in 3-star plans after a new diagnosis, suggesting star ratings don’t capture how well a plan serves sicker members.

“These findings underscore the difficulty of making an initial enrollment decision in Medicare,” the study’s authors wrote in the discussion. “Beneficiaries cannot foresee all of their future health needs when they first enroll in MA, but the consequences of that decision may depend on health events that occur years later.”

Strengths in this study include the tracked disenrollment trends before 2019, not just a single before-and-after comparison, and the study found no sign the groups were already diverging. The results also held up after adjusting for other chronic conditions people developed.

However, there are limits. Since new conditions were identified from claims, which usually show up after a diagnosis, the authors said their numbers likely undercount the true effect rather than overstate it. Counting conditions is also an imperfect stand-in for true complexity, and the group with four or more new conditions was small, just 1,010 people, so those figures carry more uncertainty. The data ends in 2021 and doesn’t reflect newer MA plan designs.

The authors confirmed that state Medigap protections make it easier for more ill beneficiaries to switch to traditional Medicare, but expanding those protections more broadly could push Medigap premiums up for everyone. And MA star ratings, as they currently work, may not reflect how well a plan actually serves members whose health needs have grown more complex.

https://healthcareuncovered.substack.com/p/insurers-are-rejecting-more-prescriptions?utm_source=post-email-title&publication_id=255152&post_id=208057023&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

First-time prescription rejections rose 67% between 2018 and 2024, with nearly half of denied patients receiving no comparable medication within 90 days.

A new study published in JAMA puts hard numbers behind something patients and doctors have been telling me for years: getting a prescription filled increasingly means running an obstacle course of denials, prior authorization forms, and step therapy requirements — and a lot of people never make it through.

Researchers from Johns Hopkins Bloomberg School of Public Health and the American Enterprise Institute analyzed more than 2 million first-time attempts to fill prescriptions for brand-name drugs that have no generic alternative, using pharmacy claims data covering nearly every major insurance market in the country: commercial plans, Medicare, Medicare Advantage, Medicaid, and ACA marketplace plans. The data ran from January 2018 through September 2024.

Here’s what they found:

• Rejections are way up. In 2018, insurers turned down 24.3% of first-time fill attempts for these drugs. By 2024, that had jumped to 40.7% — a 67% increase.
• Coverage rules are the driver. Overall, 32% of initial attempts were rejected: 14.8% because the drug was excluded from the formulary outright, and 17.2% because it required prior authorization or step therapy — insurer-speak for “try something cheaper first.”
• Nearly half of rejected patients got nothing. Of everyone who was turned down, only 38.6% eventually got the original drug within 90 days, and 13% got a different drug in the same class. But 48.4% — essentially half — received no medication in that class at all within three months.
• Delays add up. Even patients who eventually got their medicine waited an average of 12.2 days after the initial rejection.
• Where you get your coverage matters enormously. Rejection rates were highest in ACA marketplace plans (48.7%) and Medicaid managed care (49.8%) — nearly one in two prescriptions. Traditional Medicare drug plans (24.0%) and Medicare Advantage (19.8%) had noticeably lower rejection rates.

Why this matters

The insurance industry has a ready answer for all of this: prior authorization and step therapy exist to control costs and steer patients toward drugs with the best evidence behind them, not just the most expensive ones. There’s some truth in that — utilization management can reduce unnecessary spending and has, in some cases, nudged prescribing toward cheaper, equally effective alternatives.

But this study makes clear that the tradeoff is not small or hypothetical. When nearly half the people who get turned down simply never receive treatment in that drug class — not “later,” not “with a substitute,” but never, at least within 90 days — that’s not utilization management working as intended but as a barrier that outright blocks care for a huge share of patients, many of whom presumably still need what their doctor originally prescribed.

The study lands in the middle of a real fight over these practices. Federal regulators have been pushing to speed up and standardize prior authorization. Several states have passed laws limiting insurer review times, exempting doctors with track records of low rejection rates from prior authorization requirements altogether, or requiring plans to honor authorizations a patient already has when they switch coverage.

Insurers will point out that some of the increase in rejections reflects more brand-name drugs entering the market during the study period. But that doesn’t explain away the core finding: patients across every type of coverage are hitting more roadblocks, and for close to half of them, the medicine their doctor decided they needed simply never arrives.

https://links.washingtonpost.com/s/vb/-EUvaxFcJplQEX3qaZfdNRAnp0MGOWYaCYHvLqShmKIDlV07Oyi-FlxsNBiavJoMcz3PNclaOcdrmMRGzSHoZfnJ_UcAvJ3UnkmhzjgzOMcVAUM05xj_Se6_iBuNe_Ngi8c_7CjEdxEdF3oWeQ92VLHsXdirR7A0aRXq8Q/Sumw3cirsVT0csIf-v1IYk2xkO4EJnfD/21

In today’s issue: A federal watchdog is renewing the debate over whether private insurers are overutilizing prior authorization to delay patient careNew polling shows how the Trump administration’s approach to health policy could impact the midterm electionsDrugmakers are tweaking GLP-1 formulations, showing that industry still views the drug category as a revenue winner It’s a sweltering day in Washington, and yet Health Brief persists.

Medicare Advantage, operated by private insurance plans, has come under scrutiny. (Jenny Kane/AP)

The Lead Brief: A new report from a federal watchdog found that three of the nation’s largest Medicare Advantage insurers routinely denied requests for post-acute care services, which could intensify scrutiny of prior authorization practices in the rapidly growing program.The Office of Inspector General for the Department of Health and Human Services examined more than 2,000 prior authorization decisions made in June 2024 by Aetna, UnitedHealthcare and Humana.→ That’s the subject of the latest report from The Post’s Christopher Rowland.The OIG focused on services often needed after a hospital stay, including long-term acute care hospitals and inpatient rehabilitation facilities. Delays or denials can leave patients stuck in hospitals longer than necessary or without access to specialized recovery services.The report found denial rates for long-term acute care hospitals ranged from 70 percent to 80 percent, while denials for inpatient rehabilitation services exceeded 50 percent across all three insurers. Why it matters:  More than half of Medicare beneficiaries — roughly 35 million people — are now enrolled in Medicare Advantage plans, giving a handful of insurers enormous influence over access to care.“As enrollment in Medicare Advantage continues to grow, so does the urgency and importance of ensuring that [insurance companies] are delivering on the value that the federal government pays them to provide,” the OIG report said.Complaints about Medicare Advantage coverage denials are nothing new, but the report underscores the potential impact they can have.The Centers for Medicare and Medicaid Services, which oversees the Medicare Advantage program,has been working with insurers over the last year to scale back their use of prior authorization. What to watch:  The report could add fuel to several legislative proposals on Capitol Hill that would require insurers to submit more information about claim denial rates and, for Medicare Advantage plans specifically, additional encounter data related to patient care. The OIG report found for-profit Medicare Advantage organizations denied coverage more frequently than nonprofit plans, a pattern investigators said suggests financial incentives may play a role in utilization management decisions.→ But the report’s data predates pledges that private insurers have made to decrease use of the practice for all consumers. Companies have reported early progress in reducing prior authorization for many services.“This report reflects data from 2024. Since then, health plans have voluntarily eliminated roughly 6.5 million prior authorizations across markets — including more than 15 percent in Medicare Advantage,” said Mary Beth Donahue, president and CEO of the Better Medicare Alliance.Insurers also pointed to previous findings, including ones from the HHS watchdog in 2018, that raised concerns about whether many inpatient rehab facilities met Medicare’s standards or were providing unnecessary care that ultimately harmed patients.“The reports ignore serious, well-documented concerns about wide variations in the cost and quality of post-acute care and skilled nursing facilities,” said Chris Bond, a spokesperson for insurance industry group AHIP.BUT WAIT, THERE’S MORE→ A companion report issued by the OIG also renews scrutiny of insurers’ use of contractors to conduct prior authorization reviews. Investigators found a UnitedHealth Group subsidiary, formerly known as NaviHealth, denied nursing home care more frequently than insurers themselves or other vendors. The subsidiary, which rebranded to Home & Community Care in 2024, has allegedly used an algorithm to determine care needs. The OIG report doesn’t mention the reported algorithm usage. UnitedHealth Group has maintained that coverage decisions are always made by a human, thereby rejecting claims that the algorithms led to improperly denied care. However, the claims are at the center of an ongoing lawsuit filed by the families of deceased Medicare Advantage patients. The inspector general is urging CMS to take action to ensure plans are not improperly denying care. CMS officials told Christopher the agency is examining insurance denials by collecting data through a pilot program and conducting audits. The agency added that it “will continue using its full range of oversight and enforcement tools to identify potential issues, hold plans accountable and strengthen program integrity while protecting beneficiary access to care. ”Read the full story: “Seniors needed long-term care and rehab. Their private Medicare plans said no.”

https://www.commonwealthfund.org/publications/surveys/2026/jun/how-health-insurance-coverage-denials-affect-americans-2025-affordability-survey?utm_campaign=The%20Connection&utm_medium=email&_hsenc=p2ANqtz-9kQBUvqEIvbywwm-ONJBo53-mPZZXYX5Eyc7jPK7XAPklDVSbOSky6UYcApLBlJmZ6StN5nYB_Hkk4znKBYmRpb9fdsQ&_hsmi=422834981&utm_content=422834981&utm_source=hs_email

Findings from the Commonwealth Fund 2025 Affordability Survey and Focus Groups.

U.S. adults with private insurance are anxious and frustrated about getting and paying for the care they need through their health plan. One of patients’ main concerns is uncertainty about whether their insurer will cover a health procedure or prescription drug that their doctor says they need, particularly for a serious medical condition.

Insurers can deny coverage for a variety of reasons. For example, they might deem a treatment or procedure to be medically unnecessary. Payment can also be denied for care delivered by an out-of-network provider, or for services the plan simply doesn’t cover. Administrative or billing errors can also trigger a denial.1

In this brief, we report findings from the Commonwealth Fund 2025 Affordability Survey on patients’ and families’ experiences with insurance coverage denials. We pair these findings with those from focus groups on the same topic. We examine experiences with two types of denials: those that occur before care is received, which we refer to as prior authorization denials, and those that occur after care has been provided, which we refer to as claim denials.

SSRS interviewed a nationally representative sample of 6,353 adults ages 19 to 64 from July 22 to October 27, 2025. Our analysis focused on 4,589 respondents with private insurance, either through an employer or the Affordable Care Act (ACA) marketplaces and individual insurance market. To gain a deeper understanding of people who experienced coverage denials, SSRS also conducted eight online focus groups with a total of 45 privately insured adults across the United States. To learn more about the survey and the focus groups, see “How We Conducted This Survey.”

Highlights

• Experience with denials: One in five (21%) U.S. working-age adults with private insurance reported that they or a family member had experienced an insurance company denial of coverage for medical care recommended by a doctor in the past year, either before or after the care was provided.
• Treatment delays: Forty-one percent of people who experienced a prior authorization denial said it led to a delay in medical care, and more than a quarter (28%) said a health problem got worse because of it. More than 60 percent said the denial caused worry and anxiety.
• Out-of-pocket costs and medical debt: Among people who experienced a claim denial, nearly 70 percent said it cost them or their household more money. More than two in five (43%) adults who experienced a claim denial reported that the denial led to medical debt that they are still paying off.
• Appeals: Only about half of those who experienced a denial appealed the decision, citing uncertainty over their right to do so and whether it would make a difference if they did, as well as confusion about who to contact.

Survey and Focus Group Findings

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Who experiences coverage denials?

We asked U.S. working-age adults with private insurance coverage if their insurance, or the insurance of a household member, denied coverage for recommended medical care. One in five (21%) working-age adults reported a coverage denial in the past year for a health care service recommended by a provider, either their own or that of a family member. Thirteen percent reported a prior authorization denial, 8 percent reported a claim denial, and 1 percent experienced both a prior authorization denial and a claim denial.

In focus groups with people who reported having a prior authorization or claim denial, participants reported that coverage denials, and the process of challenging them, often had significant consequences for their finances, health, and well-being.

Denied: John’s Story

John, who is in his early 60s, had surgery on both rotator cuffs. His provider recommended physical therapy (PT) as part of his recovery. For the first surgery, his PT was fully covered. After the second surgery one year later, his insurance company denied coverage for PT.

He plans to appeal the denial through his PT provider. “I’m going back to the physical therapist to ask them to resubmit my application, see if they can reword it and make a better case for me.”

https://e.infogram.com/aaa5fb3c-4952-4010-a0c0-35531d0c0fc8?src=embed&embed_type=responsive_iframe

Coverage denials can harm peoples’ health and financial well-being. Over half (63%) of working-age adults with private insurance who experienced a prior authorization denial of coverage for medical care said it caused them or their households worry or anxiety. About 40 percent said that a prior authorization denial delayed medical care, and more than a quarter (28%) said that their health problem worsened as a result. Three in 10 said they spent more money because of the prior authorization denial. That’s because when coverage is denied, some patients may elect to pay for their care out of pocket.

Denied: Sally’s Story

Sally, who is in her 40s, was due for a routine mammogram. Her gynecologist recommended that she also get an ultrasound, because she has dense breasts. Sally was told the ultrasound would be covered when she called prior to her appointment, but after she had the procedure, her insurance company refused to pay for it.

Sally says she’s still fighting the claim denial, but she’s feeling discouraged. She feels her insurance provider “will try to wiggle out of anything they can.”

Having a claim denied after receiving care leaves patients and their families on the hook for medical bills they didn’t expect. Nearly 70 percent of people who experienced a claim denial said that the denial cost them or their household more money. Thirty percent reported the denial had led to a delay in their health care, possibly because they were reluctant or financially unable to seek additional care. One in five people said their health problem worsened as a result.

For focus group participants, coverage denials were often a source of financial stress. Some patients who appealed their insurer’s denial said their health care provider had threatened to send their overdue bills to collections while they awaited their insurance company’s decision. They feared that their credit score would suffer if they continued waiting for an insurer’s decision.

I’m very busy right now. I haven’t pursued any avenue. I just paid for [the test]. I didn’t want to; I was afraid, and I haven’t learned much about credit, how it affects me, or whether it affects me. . . . I decided not to proceed with any legal means. I just paid it.

Oscar, a man in his 30s who had a claim denial for lab tests

Coverage denials also affected peoples’ subsequent medical care decisions. Some focus group participants said they were avoiding getting needed medical care because of their coverage denial. Following a coverage denial, one participant stopped seeking care for her ongoing health issue, which remains unresolved. Others are postponing future checkups or procedures because of how uncertain insurance coverage can be. Even just the anticipation of coverage denials and unexpected bills led some participants to avoid seeking care.

I feel like I’ve been unable to address the initial issue. . . . I don’t want to go back [to the doctor] with the very high chance [care] gets denied again.

Mary, a woman in her 20s who had a claim denial for lab tests

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Coverage denials can have serious financial consequences. More than two in five (43%) adults who had a claim denial said the denial caused them or their household to incur medical debt that they are still paying off. More than half of the adults said that their original bill was $1,000 or more.

For many focus group participants, the accumulation of medical debt because of a coverage denial had made them hesitant to get health care again. Worry about financial consequences of additional care further exacerbated the anxiety and stress they experienced.

Denied: Jaime’s Story

Jaime was at dinner with his wife when he lost consciousness. She called an ambulance from the restaurant, and Jaime was taken to the hospital. Arriving barely conscious, he was told the hospital was out of his plan’s network.

“Because of the type of insurance I have, they just said they couldn’t accept me due to the coverage. . . . I had to wait hours for them to call back and forth between the hospital and the insurance company before they finally allowed the hospital to provide coverage for me.”

Jaime’s insurance covered some of his tests at the hospital but not all of them — for example, they covered a magnetic resonance imaging scan but not an electrocardiogram. He said he was convinced that “anything they could find not to pay, basically, they didn’t.” A few months later, Jaime’s insurance notified him that they also would not cover the $3,000 ambulance bill.

Jaime was left with significant medical debt. He makes monthly payments, so the debt doesn’t affect his credit. He worries, however, about future medical bills.

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Even though patients have a right to appeal an insurer’s decision to deny coverage for a health care service, only about half appealed. When asked why they didn’t appeal a coverage denial, many people believed it would not make a difference. Many also doubted they had a right to appeal a decision or expressed confusion about who they were supposed to contact.

Patients in focus groups described a time-intensive, confusing, and highly frustrating process to appeal coverage denials. They often weren’t sure if they should contest the denial with their provider or insurance company, or even why they should have to appeal at all, since the denial was for care their doctor recommended.

[I] gave it my all in appealing the whole situation. . . . I got the run around like, ‘Oh, you need to speak to this person.’ Then they transferred me back to that person and the phone would ring and ring, and I’d give a voicemail and they wouldn’t call me back for two or three days. I’m still fighting with them.

Sally, a woman in her 40s with a claim denial for ultrasound

Several focus group participants felt that appealing a coverage denial would be futile. One thought that insurance companies take advantage of patients’ lack of knowledge about the health system. Many expressed frustration with the lack of transparency from insurers, saying patients “have no clue what’s going to be covered” when a doctor recommends health care. Over time, this pattern eroded participants’ trust in both their health care providers and insurance plans.

I hate the way it felt like I got conned. . . . I think [the insurance companies] know that the average person is not going to ask the right questions or know the right information. They take advantage of that, which I think is terrible, especially . . . those who are elderly or anything like that who don’t have the help or the resources.

Jaime, whose claim for emergency care was denied

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About half of people challenged their coverage denials, but they were not always successful. Among those who challenged prior authorization denials, 30 percent said that their insurer approved the recommended medical care, and a quarter received approval for a different type of care. But in one-third of appealed cases, the insurer continued to deny the care. Nearly 80 percent of people who challenged their prior authorization denial and had received a decision on their appeal at the time of the survey said they waited two weeks or more for their insurance company’s decision.

Among patients and their families who challenged a claim denial, only one-third (33%) said their insurer reduced or eliminated the amount of money they owed. Thirty-six percent said their insurer denied their appeal, similar to the share of people who were unable to reverse their prior authorization denials. More than 60 percent of those who challenged their claim denial and had received a decision on their appeal at the time of the survey said that their insurer took one month or more to reach a decision.

Some focus group participants described a time-consuming and stressful process to appeal coverage denials. They often felt “caught in the middle” between their provider and insurance company as they tried to navigate a system that seemed designed to work against them.

[The insurance company] said, ‘You’ve had enough [physical therapy appointments].’ My physical therapist [says I need more], he’s still arguing for me, but they said no. . . . It’s almost like they will always give you an initial denial and see whether or not you’ll actually fight them on it.

John, who had a prior authorization denial for physical therapy following shoulder surgery

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When asked who they held responsible for their coverage denial, nearly nine in 10 people blamed their insurance company. And many also blamed the health care system in general. Others viewed their providers as responsible for the denial, and more than one in five blamed the government for their experience.

In focus groups, some participants described how their ordeal with a coverage denial caused them to “totally lose trust” in their health care provider or insurance company, particularly when they had been explicitly told by at least one party that their care would be covered. Participants’ frustration with the health care system was palpable, and many remarked that insurance companies or the health system needed to change.

Denied: Nathan’s Story

Nathan didn’t anticipate a months-long fight with his insurance carrier while his wife battled cancer. Early in her treatment, the oncologist ordered genetic testing to look for mutations that would influence her response to therapies. Nathan and his wife were initially told that diagnostic genetic testing would be covered by their insurance, at least partially. But after the testing was completed, they were shocked to learn their insurance would not cover it.

Nathan began the frustrating process of contesting the denial. “You get in this loop of, holy cow, you ask eight people the same question. You get eight completely different answers.”

The couple eventually appealed to the oncologist, who submitted additional information to justify the necessity of the testing. While the insurance company elected to cover part of the testing, Nathan still couldn’t get a clear answer on his final bill amount.

What Can Government Do to Help Consumers?

Prior authorization can be a useful tool for protecting patients from low-value care that provides little benefit or might actually harm them. However, the processes insurers currently use lack clear rationales that patients and their providers can understand. Most troubling is that prior authorization is preventing patients from getting the care they need while placing additional burdens on physicians and their staff.

When asked what policymakers might do to help consumers, focus group participants said there should be greater transparency in insurer decision-making with “no ambiguity” in which procedures are covered. Some participants thought there should be external oversight by “another entity outside the insurers themselves” and said there must be clear reasons “why an insurance company is rejecting coverage, particularly when the test or procedure is ordered or recommended by a doctor.” There was also a desire for transparency to see where their premium dollars were going. Said one participant, “They are not using the money to pay for my care, and that is what frustrates me a lot.”

A Patchwork of Inadequate Laws and Regulations

The United States has a dated and patchwork system of regulations governing coverage denials and patients’ right to appeal them. Denial rules for employer plans have not been updated since 2000.2 In 2010, the ACA extended those rules to apply to all nongrandfathered individual and marketplace plans.3 While the Biden administration issued a new set of regulations on denials in 2024, these apply only to plans that fall under the jurisdiction of the Centers for Medicare and Medicaid Services (CMS), including marketplace plans in the 30 states that use the federal HealthCare.gov platform. They do not apply to employer plans or marketplace plans in states that run their own marketplaces.

Several states have passed laws that go further than federal requirements. States, however, lack jurisdiction over large, self-insured employers, which employ the majority of Americans.

In 2025, the largest U.S. health insurers announced a voluntary commitment to streamline prior authorization processes, including reducing the number of services subject to prior authorization and honoring preapprovals for a set period when people switch health plans.4

Clearly, there is a need to bring order to the fragmented set of laws governing coverage denials. Congress can accomplish this through standardization across all types of insurance and through the expansion and strengthening of rules regarding transparency in coverage decisions, oversight of insurers, and patients’ rights to appeal decisions. Options include:

Expanding the right to appeal. Consumers in nongrandfathered health plans, including employer plans, have the right to appeal coverage denials, and insurers are required to review and reconsider their decisions. If an insurer still denies coverage, patients have the right to an independent third-party review, and the insurer must accept the outcome of that review.

However, federal regulations restrict third-party appeals to denials based on medical necessity, which one study found made up just 5 percent of all denials.5 The majority of denials are for unspecified reasons, administrative issues, excluded services, and lack of referral or prior authorization.6 Consumers would be better served if all denials were eligible for external review.

Standardizing and streamlining prior authorization procedures in all health plans. The Biden administration issued a rule in 2024 seeking to increase transparency and standardization of prior authorization procedures for insurers selling plans in the 30 marketplaces that use HealthCare.gov, as well as those in other public programs.7 Beginning in January 2027, these payers must maintain a secure electronic portal with their list of covered items and services, documentation requirements for prior authorization, and a record of prior authorization requests and responses. CMS recently introduced a new proposed rule that would extend these requirements to prior authorization of prescription drugs.8

The federal government could expand both rules to cover all marketplace and employer plans. It also could require much greater transparency about insurer criteria for selecting services that need prior authorization.9

Learning from states’ approaches to prior authorization. At least 10 states have implemented a “gold card” approach for providers that reach a threshold level of prior authorization approvals. This enables providers to deliver certain services or prescribe drugs without seeking prior authorization.10 Several other states have shortened timelines for insurers to respond to prior authorization requests, required reviewers to meet clinical qualifications, or exempted or limited some services from prior authorization review, such as mental health care or care for chronic conditions. Although these state actions do not affect people in self-insured employer plans, they can inform federal policy.

Funding consumer assistance programs. The ACA authorized Consumer Assistance Program (CAP) grants to help states establish or strengthen services for patients to inform them of their rights and help them resolve health plan disputes. In the first year, CAP grants allowed states to recover more than $18 million for patients.11

Although federal funding for CAP grants has ended, the programs still exist in 31 states and the District of Columbia and continue to save consumers money (for example, Connecticut recovered $4.3 million for patients in 2021).12 Reinstating federal funding could help establish CAPs in the 20 states that currently don’t have them.

Reporting health care claim denials and appeals. The ACA requires all nongrandfathered health plans, including all employer plans, to report data on claim denials, the reasons for the denial, and the total number of denied and appealed claims.13 However, the federal government has limited enforcement to just marketplace plans sold through 30 marketplaces operated by the federal government. The Biden administration’s 2024 rule increases data reporting requirements for these plans, but patients may not be aware that this information is available on an insurer’s website.14 Expanding public reporting of these decisions to include all marketplace plans and employer plans — and making the data accessible and understandable to consumers on publicly accessible websites — would further the public’s understanding of insurer practices.

HOW WE CONDUCTED THIS SURVEY

The Commonwealth Fund 2025 Affordability Survey was administered by SSRS from July 22 to October 27, 2025. The survey consisted of telephone and online interviews in English and in Spanish and was conducted among a random, nationally representative sample of 6,353 adults ages 19 to 64 years living in the United States. The survey interviews were completed via a multiframe approach, which included address-based samples (ABS), prepaid cell phone samples, and the SSRS Opinion Panel. Interviews were conducted online or on the phone via ABS (n=1,794), via prepaid cell phones (n=328), and online via the SSRS Opinion Panel (n=4,231).

The sample was designed to exclude anyone age 65 and older, while also allowing for a sufficient sample of those anticipated to experience more health care affordability challenges (such as coverage denials, billing errors, or medical debt). Statistical results were weighted in stages to compensate for sample designs and patterns of nonresponse that might bias results. In the first stage of weighting, base weights were applied to account for sampling probabilities and were computed separately for each of the three sample frames. The base-weighted samples were combined using a compositing adjustment. Finally, the combined sample was calibrated to match target population benchmarks.

The resulting weighted sample is representative of the approximately 196 million U.S. adults ages 19 to 64. The survey’s margin of sampling error is +/– 1.5 percentage points at the 95 percent confidence level. The ABS portion of the survey achieved a 14.4 percent response rate, the prepaid cell portion achieved a 1.5 percent response rate, and the SSRS Opinion panel portion achieved a 2.5 percent response rate.

This brief focuses on 4,589 adults in the survey with private insurance. The resulting weighted sample is representative of approximately 130.6 million adults ages 19 to 64 with private insurance. The margin of sampling error for the subgroup of those with private insurance is +/– 1.7 percentage points at the 95 percent confidence level.

SSRS conducted eight online focus groups in April 2025, prior to fielding the survey. Six focus groups were in English, and two were in Spanish, with a total number of 45 participants. The focus groups informed the development of survey questions designed to capture people’s experience with coverage denials, billing errors, and medical debt. This brief highlights the experiences of the 27 participants who experienced coverage denials.

Patients are often left ‘out of network’ as hospitals, insurers clash over cost

No one wants to see health insurance premiums rise. Individuals, small businesses and large employers are already under inflationary pressures. But it will be far worse if health insurance companies fail to help address rising costs facing healthcare providers. 

Lengthy contract negotiations between health insurers and healthcare providers are becoming the norm, leaving patients — our shared customers — in a confusing and concerning ‘out-of-network’ status, while health insurers and providers point fingers at each other.

An overused but accurate phrase applies: healthcare providers are facing a perfect storm of pressures, particularly in California, and especially systems that serve large shares of Medi-Cal and Medicare patients. 

Among our nation’s 6,000 hospitals, our flagship hospital, Community Regional Medical Center in Fresno, serves the fourth highest percentage of Medicaid patients and is fifth for overall government reimbursement. 

While being one of America’s most essential hospitals is rewarding, recent federal changes designed to slow the growth of healthcare spending have resulted in a 15% reduction in Medicaid funding — roughly $1 trillion in cuts nationally over the next decade.

At the same time, California legislation increased the minimum wage for healthcare workers to $25 per hour. While there is none more deserving of this than healthcare professionals, the ripple effects are significant. At our organization these adjustments add $100 million annually in labor costs and will only grow. 

Further constraining hospitals are the legal requirements to treat anyone who arrives in their emergency departments, regardless of ability to pay. What other industry is required to provide service first and figure out how to get paid for it later? 

Our health system absorbed a $231 million reimbursement shortfall last year for the care of government-insured patients, and we must brace ourselves for more. Higher numbers of ER visits from underinsured patients, as well as higher levels of charity care and bad debt will further widen the gap between our cost for providing care and how much we’re reimbursed. 

In the meantime, insurance companies want hospitals to agree to rates that don’t keep pace with rising costs. While government payers offer predictable approval processes and payment timelines, private health insurers increasingly rely on cumbersome prior authorizations, payment denials, paying less for services and slow reimbursement. These practices add administrative costs, strain cash flow, reduce overall reimbursement and threaten our fiscal stability.

Insurers face pressure from employers and members to limit the growth of premiums. But too often, that pressure is used to resist necessary and reasonable rate increases for providers. Health insurers often blame providers for the high cost of care, but hospitals like ours are keenly focused on greater efficiency. In fact, we’re a low-cost leader when compared to the average California hospital. 

In some cases, insurance companies propose quality incentive programs as a substitute for adequate reimbursement, then publicly criticize health care providers when we find this unacceptable. I wholeheartedly support performance incentives as a tool for improvement, but not when these programs are used as a mechanism to transfer greater financial burden to hospitals.

As stalled negotiations become increasingly common, regulators and policymakers should take a broader view of healthcare costs by examining health insurer reserves, and their administrative and marketing expenses. 

For safety-net healthcare providers like us, modest profit margins are not just about staying afloat, they are critical to reinvestment in technology, facilities, our workforce, and public health initiatives that are essential to the communities we serve.

There is much at stake if payers win the war of words over contract rates. Access to healthcare services, healthcare jobs and the stability of institutions that communities rely on will diminish. 

When providers are forced to make deeper cuts to manage this convergence of pressures, patients ultimately pay the price.