The U.S. has made great progress in getting more people insured since the Affordable Care Act took effect in 2014. The share of uninsured Americans ages 18 to 64 fell from 18% before the ACA to 9.5% in 2022. And preexisting conditions no longer prevent coverage or lead to an increase in premiums.
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
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