Yet even for those with health insurance, coverage does not ensure access to care, much less high-quality and affordable care. Research shows that 1 in 3 Americans seeking care report delaying or forgoing treatment because of the “administrative burdens” of dealing with health insurance and the health care system, creating additional barriers beyond costs.
Some of these are basic tasks, such as scheduling appointments. But others relate to strategies that health insurers use to shape the care that their patients are able to receive – tactics that are often unpopular with both doctors and patients.
In addition, more than 40% of Americans under 65 have high-deductible plans, meaning patients face significant upfront costs to using care. As a result, nearly a quarter are unable to afford care despite being insured.
As scholars of health care quality and policy, we study how the affordability and design of health insurance affects people’s health as well as their out-of-pocket costs.
We’d like to unpack five of the most common strategies used by health insurers to ensure that care is medically necessary, cost-effective or both.
At best, these practices help ensure appropriate care is delivered at the lowest possible cost. At worst, these practices are overly burdensome and can be counterproductive, depriving insured patients of the care they need.
Claim denials
The strategy of denial of claims has gotten a lot of attention in the aftermath of the killing of UnitedHealthcare chief executive officer Brian Thompson, partly because the insurer has higher rates of denials than its peers. Overall, nearly 20% of Americans with coverage through health insurance marketplaces created by the ACA had a claim denied in 2021.
While denial may be warranted in some cases, such as if a particular service isn’t covered by that plan – amounting to 14% of in-network claim denials – more than three-quarters of denials in 2021 did not list a specific reason. This happens after the service has already taken place, meaning that patients are sent a bill for the full amount when claims are denied.
Although the ACA required standardized processes for appealing claims, patients don’t often understand or feel comfortable navigating an appeal. Even if you understand the process, navigating all of the paperwork and logistics of an appeal is time-consuming. Gaps by income and race in pursuing and winning appeals only deepen mistrust among those already struggling to get appropriate care and make ends meet.
