The United States is asking what’s next for health

Special education teacher Robin Ginkel spent nearly two years fighting with her insurance company to try to pay for back surgery her doctors recommended after a work-related injury left her with a herniated disc is a debilitating pain.

The plan did not seem “ridiculous”, he said: “I am asking to get health care to return to a normal quality of life and return to work.”

Initially rejected, the 43-year-old from Minnesota spent hours waiting to appeal the decision – even filing a complaint with the state – only to see her claims denied three times.

Now he is bracing himself for the battle to start over, having decided that his best option was to try his luck with a new insurance company.

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

Ms. Ginkel is not alone in throwing up her hands.

About one in five Americans covered by private health insurance said their provider refused to pay for care recommended by a doctor in the past year, according to a survey by the health policy foundation KFF.

Brian Mulhern, a 54-year-old from Rhode Island, said his health insurance company recently denied a request to pay for a colonoscopy after polyps were discovered on his colon — a discovery that he prompted his doctor to recommend a follow-up examination in three. years instead of the typical five.

Faced with $900 in out-of-pocket expenses, Mr. Mulhern abandoned the procedure.

The long-running furor over insurance decisions erupted into the public eye earlier this month after UnitedHealthcare CEO Brian Thompson was assassinated — and the killing unleashed a surprising wave of public outrage at the industry.

The crime sent shockwaves through the system, prompting an insurance company to announce a controversial plan to limit anesthesia coverage, and hitting the stock prices of big companies.

Although the backlash raised the possibility that the scrutiny could force change, experts said addressing the frustration will require action from Washington, where there is little sign of a change in momentum.

On the contrary: just in recent weeks, Congress has again failed to advance long-stalled measures aimed at making it easier for people on certain government-backed insurance plans to get their plans approved claims.

Many advocates are also worried about worsening problems as Donald Trump returns to the White House.

The president-elect has promised to protect Medicare, which is the government’s health insurance for those over 65 and some young people. He is known for his long criticism of parts of the health industry, such as the high prices for medicines.

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

“The way things stand today, health care is a target,” said David Lipschutz, co-director of the Center for Medicare Advocacy, a nonprofit organization that seeks to advance full Medicare coverage.

“They’re going to try to take away people’s health insurance or decrease people’s access to it, and that goes in the opposite direction of some of those frustrations and it’s just going to 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 healthcare equation and have doctor-patient relationships, it’s better for everyone,” House Speaker Mike Johnson said. in a video obtained by NBC News last month. “More efficient, more efficient,” he said. “It’s the free market. Trump will be for the free market.”

Unhappiness with the health system is long in the United States, where experts – including at KFF – indicate that care is more expensive than in other countries and performance is worse in basic metrics such as the expectation of life, infant mortality and safety during childbirth.

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

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

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

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

The rest are enrolled in private company plans, which are typically chosen by employers and paid for with a mix of personal contributions and employer funds.

Even though more people are covered than ever before, frustrations remain 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 rejections – which can occur even after care has been received, leaving patients with heavy bills – is limited.

But surveys of patients and medical professionals suggest that insurance companies require more “prior authorization” for procedures — and rejections by insurance companies are on the rise.

In the state of Maryland, for example, the number of claims 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,” said Ms. Ginkel. “As I went through the process, it felt more and more like (the insurance companies) are doing this on purpose in the hope that you will give up.”

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

AHIP, a lobbying group for health insurers, said claim denials often reflect faulty presentations by doctors, or default decisions about what to cover that had been made by regulators and employers.

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

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

But critics complain that a for-profit health system will still be focused on its shareholders and the bottom line, and have linked the rise in claims denials to the alleged growing use of artificial intelligence (AI) error-prone to review requests.

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

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

“This is a moment to take a moment of private pain and turn it into a public collective power to make sure companies stop denying us care,” he said.

Whether the assassination will whet the appetite for reform remains to be seen.

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

But there is little sign that the proposals are gaining significant traction.

Trump’s nominee to run the powerful Centers for Medicare and Medicaid Services (CMS), Dr. TV Mehmet Oz, has already endorsed expanding coverage from Medicare Advantage — which offers Medicare health plans through private companies.

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

Professor Buntin said the Republican election gains indicated the US was not about to embrace the alternative – a publicly run scheme like the UK’s National Health Service – anytime soon.

“There is a distrust of people who seem to benefit or take advantage of the disease – and yet this is the basis of the American system,” he said.