The Struggle to Get Medical Care in the US
Traci Hurley says it was devastating watching her husband battle cancer in late 2021. “It was heartbreaking and terrible,” she said. “I lived in fear every day.” A struggle made worse, she says, because so many of the skirmishes were with her insurance company. “No family should have to struggle to receive the treatment recommended by their doctor while fighting for their life,” she said.
The Problem of Insurance Denials
Millions of Americans say they have difficulty getting medical care: either they are unable to pay extremely high deductibles or, like Dan Hurley, they are unable to get testing and treatment covered by health insurance companies. Both Hurleys weren’t just doctors; Dan, an ear, nose and throat surgeon, was also adept at cutting through insurance red tape for his patients. “And yet we still ran into a lot of problems,” Traci said. "If we as two doctors had to fight as much as we had to fight to get a treatment approved, what about people who have no medical knowledge? What happens to them every day?"
A Personal Struggle with Insurance
Dan was an avid hiker until his excruciating back pain was discovered to be cancer. He was diagnosed with chondrosarcoma, an extremely rare bone tumor. To save his life, the tumor had to be removed along with Dan’s hip. The insurance only covered part of the costs. Traci said, "Many of his treatments were denied. We had PET scans, we were denied CT scans. We had chemotherapy, we had radiation, we had certain medications that required prior authorization and were denied." According to Traci, the reason for the insurer’s denial is that they have "no medical indication."
The Business Model of Health Insurance Companies
Ron Howrigon, now a consultant, worked for health insurance companies for two decades. “The health insurance companies know that five percent of their members bear 50 percent of all costs,” he said. “So I have a lot of financial incentive to make their lives as difficult as possible.” Howrigon says the business model is different than other industries: "The more your customers use your product, the less money you make. Your incentive is to stop them from using your product."
Denial Rates of Health Insurance Companies
A CBS News analysis of about 1.3 billion federal health insurance claims over three years shows that insurers denied 19% of in-network claims in 2024 – about 1 in 5. But for the largest insurer, United Healthcare, that was a significant decline from the previous two years, when it denied up to a third of its federal claims.
The Consequences of Insurance Denials
Dr. Elisabeth Potter, a surgeon who treats up to 60 patients with breast cancer each week, said, "Insurance companies have frankly made it harder to be healthy in the United States." She says insurance denials actually lead to higher costs: "I have two employees who spend most of their day dealing with insurance. It seems like everywhere we go there’s a problem, whether it’s an insurance company saying, ‘You know, we’re not going to cover the cost of your surgery at this surgery center,’ or ‘We’re not paying for this drug, we want you to take a different drug.’"
Rationing Through Inconvenience
Miranda Yaver, an assistant professor at the University of Pittsburgh, says insurance companies know that only a small percentage of people will actually appeal claim denials. “We are all vulnerable to rejection,” she said. “Not all of us can easily weather the storms when it comes to appealing and overcoming these hurdles.” Yaver calls it “Rationing through inconvenience.” “A lot of people don’t know they can even appeal,” Yaver said.
A Widow’s Fight for Change
Dan Hurley died on August 3, 2023. A week later, his wife received a letter from the insurance company asking her to pay $80,000 for chemotherapy that had previously been approved but was suddenly retroactively denied. “It was a real slap in the face to get it that day,” she said. Dan Hurley’s fight has become his widow’s fight. "There’s a part of me that says, ‘Oh, he’d be so proud of me,’ but there’s also a part of me that says, ‘Come on, chop, chop, you’ve got this, let’s go, pick it up, don’t be sad, you know, carry on.’ Because that’s what he was like.”
