The deadly cost of insurance denials in America’s healthcare system
Luigi Mangione’s alleged killing of UnitedHealthcare CEO Brian Thompson has sent waves through the medical community. This horrific act of violence, while tragic and inexcusable, forces us to confront an uncomfortable reality: frustration with the unchecked power of publicly traded insurance companies has reached a boiling point, for patients and doctors alike.
As a pain management physician, I deeply empathize with the anguish of denied care. While my patients desperately seek relief, insurance companies reject treatments that are evidence based, cataloging them as “unnecessary” or “experimental.” They use opaque and unreliable artificial intelligence algorithms to deny care and rely on the medical record notes to contextualize the humanity of my patients. The process of scheduling appeals with insurance representatives or “peer” reviewers is frequently a time-consuming exercise in futility. Decision-making “peers” can be individuals without expertise in the relevant medical field, incentivized to deny care. The appeals process can take months, leaving patients to suffer while the clock ticks on their quality of life.
The stakes are not just financial — they’re profoundly human. Insurance denials often force doctors to fall back on older, cheaper options that are less effective and carry higher risks. For pain patients, this can mean a return to opioids, which insurers readily cover. And while opioids are reasonable in certain circumstances, they also have well-documented side effects and an established role in America’s addiction crisis. When insurers lag behind medical evidence, they not only undermine patient care but perpetuate public health emergencies like the opioid crisis.
Insurers argue that denials are necessary to control costs and prevent overutilization. But when denials become routine, when they disregard medical evidence, and when they disproportionately impact vulnerable populations, they cease to be a tool for efficiency and become a mechanism of harm.
When a patient qualifies for Original Medicare, I am relieved, as it is subject to stricter regulatory oversight as compared to private insurers. In my specialty, it can at times more reliably cover newer, innovative treatments, such as peripheral nerve stimulation. This advanced procedure involves implanting a tiny wire near a nerve for just eight weeks to rewire the brain and spinal cord’s pain signals. Remarkably, even after the wire is removed, the treatment can continue to provide lasting, life-changing pain relief.
Such was the case for one of my patients, Mr. JA, a decorated U.S. Army colonel and military veteran who had undergone more than 26 surgeries, and who was suffering from chronic neck pain, migraines and hand numbness. After receiving nerve stimulation therapy, he was able to completely eliminate his pain medication and regain a sense of normalcy — a transformation that would have been unlikely under private insurance. Unfortunately, for many others, particularly younger patients or those without traditional/government-run Medicare plans, access to such life-changing treatments is frequently out of reach, sacrificed at the altar of corporate profit.
Insurers’ unchecked power
Commercial health insurers wield enormous influence, often prioritizing profits over patients. UnitedHealthcare reported over $20 billion in profit in 2023, yet patients continue to face barriers to care. Insurers argue that denials prevent overuse of services, and while there is truth in the fact that medical overspending can result in patient harm while impacting annual economic burden and taxpayers, when cost-cutting trumps medical necessity, the system fails everyone except the shareholders.
Doctors have limited recourse. Our clinical expertise is too often overridden by algorithms and cost analyses. Patients, meanwhile, are confused and disheartened, as they have seemingly few solutions but endless medical bills. This compromises trust in the healthcare system and breaks down what should be a sacred doctor-patient relationship.
A way forward
Recent events are an opportunity for President-elect Trump and the new administration to re-evaluate the unchecked power of the commercial insurance industry. We need:
- Transparency in denials: Insurers must publicly disclose data on claim denials, including reasons and outcomes of appeals, as well as their use of AI to deny claims. Sunlight is the required disinfectant.
- Independent review panels: Every denial of care should be reviewed by independent boards of medical experts with relevant specialty training, ensuring decisions are grounded in the most up-to-date evidence rather than old guidelines and profits motives.
- National standards: A federal framework for claims and appeals would ensure fairness and consistency, overriding the patchwork of state regulations that currently lets insurers exploit loopholes.
Healthcare should heal, not harm. The current system, which allows insurers to dictate care while evading accountability, erodes trust and endangers lives. Reforming these practices is more than just a policy goal. It is a moral imperative.
Shravani Durbhakula, MD, MPH, MBA, is an academic pain physician and anesthesiologist practicing in Nashville, Tenn. She is the former pain medicine program director at Johns Hopkins School of Medicine and serves on the board of directors of the American Academy of Pain Medicine Foundation.