Aija Nemer-Aanerud, Health Care for All Campaign Director, People’s Action
People’s Action and our allies fought hard to win health care for millions through the Affordable Care Act and Medicaid expansion. 91 percent of Americans now have health insurance, even though there is still work to do to ensure everyone can get coverage, particularly immigrants and those living in holdout non-expansion states.
Despite this, we are increasingly hearing from our members that the major barrier to accessing care isn’t lack of coverage, but the quality of that coverage. Every year, private insurers refuse to pay for care at least 248 million times—this is a claim denial or prior authorization denial (Pollitz et al. 2023). Some private insurers deny as many as four out of five claims (Rucker et al. 2023) and only 0.2 percent of denials are appealed, likely due to the convoluted and time-consuming appeals process.
To address this growing problem, People’s Action Institute launched a new campaign, Care Over Cost, to help people get the care they need while simultaneously building a bigger base of people fighting for policy shifts to expand access to health care. Anchored through our member groups nationwide, Care Over Cost’s teams of volunteers, including former health care company lawyers, challenge denials and draw public attention to the ways insurance company practices need to drastically shift to deliver the care people actually need.
When insurers overrule doctors, people suffer
Health care in the United States is an expensive and ineffective patchwork of public and private programs which fail to deliver care to people who need it most. Many cannot afford plans offered through the ACA or discover only when they get sick that high deductibles and in-network restrictions prevent them from accessing care.
When an insurance company refuses to pay for medically necessary care, people suffer. They acquire debt, go bankrupt, stay sick or injured, and even die. Some private insurance companies deny claims even when this violates their contracts with policyholders and laws regulating coverage.
Health outcomes are worse when an insurance company requires prior authorizations for preventative services like colonoscopies, (Alltucker 2023) or uses artificial intelligence to instantly reject claims without opening a patient file (Rucker et al. 2023).
Health insurers assert that these practices limit unnecessary medical services, reduce potential harms, and ensure consumers don’t pay for care they don’t need, However, these personal decisions should be made by a patient and their provider, not a private company.
How we fight insurance claim denials
Carly is a 29-year-old woman from Beaver, Pennsylvania. A rare condition, nMALS, causes severe pain when she eats, so she must insert nutrition into her veins or intravenously to survive. A surgery could correct her condition, but Carly’s insurer not only refused to pay for the procedure, they stuck her with a $17,000 bill for diagnostics. Without this surgery, doctors said there was a two in three chance Carly would die in the next five years.
A retired insurance industry lawyer with Care Over Cost worked with Carly to challenge her denial of care. We also contacted Carly’s U.S. Senator, Bob Casey. After receiving a call from Sen. Casey’s office and a petition signed by thousands of Care Over Cost supporters, Carly’s insurer agreed to cover the surgery and cancel most of her bill.
Our Care Over Cost campaign combines three approaches to help people like Carly win the care they need:
- Outreach: We reach out to tens of thousands of people to ask whether they are experiencing problems accessing care through their insurance, and we invite them to organize with us to address their problem.
- National Appeals Team: A team of contract and insurance law experts, medical experts, and organizers supports people experiencing insurance usability problems to file appeals and communicate with and between their insurance companies, providers, and regulators.
- Public campaigns: We support policyholders who are wrongfully denied care by their insurers to increase those individuals’ ability to resolve their cases favorably and raise public awareness about claims denials.
This individual case work is important for getting those individuals care they need in the here and now, and it is effective at shifting narrative to help decisionmakers see the gaps they need to fill in our health care system. Perhaps most important, we find that this work is an effective way to build a lasting base of directly impacted people who can fight for bigger policy change down the line. This is critical because the individual case work alone will never allow us to address the over 248 million annual denials of care.
At People’s Action, we know ordinary people, organized effectively, have the power to drive social change upwards to win tangible improvements. Through organizing, we’ve won health insurance for millions and stopped Wall Street banks from selling predatory payday loans. We pushed banks to end redlining through the Community Reinvestment Act and helped win the creation of the Consumer Financial Protection Bureau. We reversed healthcare laws that discriminate based on a person’s citizenship.
To achieve our goal of Health Care for All, it will take millions of people organized where they live to demand change. That’s one reason we’re calling for an Organizing Revival to revitalize the fundamental skills of community-based organizing all across the country. The Organizing Revival is a 10-year project to reground our movement for social change in the best practices of relational power-building, so we can, together, demand the deep structural changes our country needs.
Good organizing, which builds from the ground up, is essential to create systemic change. Organized people have the power to shift narratives, attitudes, and behaviors, and can challenge the forces in our society that cause harm.
Investing in organizing is investing in the power of everyday people
Just as organizers must create new ways to work together through a shared understanding and infrastructure, so too must funders. Longer-term, trust-based investments will empower those closest to social problems to name and lead on the specific solutions they know to be most effective for their time, context, and place. By working together and within our own communities to advance policy solutions, we can create lasting systemic change that will positively impact us all.
References
Alltucker, Ken. “Doctors and patients are worried this large health insurer’s new policy will delay care.” USA Today, May 24, 2023.
Pollitz, Karen et al. “Claims Denials and Appeals in ACA Marketplace Plans in 2021.” KFF, February 9, 2023.
Rucker, Patrick et al. “How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them.” ProPublica, March 25, 2023.