Coverage Denied Publication Day is Here!

Today marks the day that my book Coverage Denied: How Health Insurers Drive Inequality in the United States is officially released out into the world.

What a long, strange trip it’s been.

Originally conceptualized in fall 2019 amid my own health insurance barriers by my health insurer through UCLA (Health Net… It was Health Net), leading to a pilot survey in early 2020 (what timing) thanks to a Diversity, Equity, and Inclusion grant from the university, getting sidetracked with COVID research and new course preps, and then finally putting pen to paper in earnest in May 2022, when I ran a larger survey and began to conduct semi-structured interviews with patients, physicians, and others across the country.

The truth is that I hadn’t set out to write a book. I also hadn’t set out to probe the physician side of the burdens that emerge from these managed care practices. But as I began to look over my survey data – from the close-ended reports of high rates of denials, inequities in pursuit of subsequent insurance appeal processes, and upending of health and economic decisionmaking, to the open-ended reports of the psychological toll of these barriers and the ways their health was disrupted – I realized that I didn’t just have data. I had a story.

And what a tremendous privilege it was to have patients trust me with their stories of anxiety, frustration, pain, and suffering as they navigated the red tape of modern medicine. It is little wonder why I dedicated the book to them (along with my loving husband).

To be honest, I wasn’t sure what to expect, as this was far afield from any of the research that I did while in graduate school, during which I had been engaged in data collection on separation-of-powers conflict over environmental regulation. I had taken a survey methods course back in 2013, but had limited experience with qualitative methods. And to top everything off, it was my first big health policy project, outside of broader commentary in op-ed and related forms amid health insurance reform efforts.

But as I got “under the hood” with my survey findings, I was moved to see how much my own experience navigating health insurance complexities (and in my case, armed with a lot of health insurance literacy and broader privilege) mirrored those of wide-ranging patients across the country, all left asking themselves, Can I appeal? How does this work? Is it even worth it? And I extended my interviews from patients to physicians, I was struck by the breadth of complexities and inefficiencies with which they are confronted daily, and which consume non-billable hours playing phone tag with insurers in between clinical appointments and other work, engaging in “peer to peer” reviews with people are in an inappropriate specialty (a patient whom I interviewed had their rare hearing surgery denied by a gynecologist, and last I checked, ears and vaginas are quite different), prescribing in a “black box,” or writing appeals and submitting documentation that either was already supplied on the front end but which was requested again or finding additional medical research to support a clinical decision about a patient they had been treating for years.

The reality is that the American health care system is not built for ordinary Americans to navigate successfully. Consequently, it is a site of profound health inequities whose effects spill over to everything from economic security to trust in the system to political engagement. And compounding all of this is the additional reality that much of that burden lands on physicians’ shoulders – of that of their staffs if their office can afford to delegate the tasks of some of this coordination with health insurers – at a time when Americans are struggling with a physician workforce shortage and physicians themselves are burned out.

So, where does the politics come into play with all of this?

Prior authorization and associated managed care tools that contribute to delays and denials of coverage did not appear or get entrenched organically. They reflect decades of intentional political choices that combined to lead America to this point in health insurance delivery. Decades of unsuccessful efforts toward national health insurance, obstructed by accusations of socialized medicine and a preference for voluntary insurance, ultimately led national health insurance to be scaled down to the still momentous enactment of Medicare and Medicaid through amendments to the Social Security Act. It is telling that LBJ signed Medicare into law at the Truman Presidential Library in Independence, Missouri as a nod to his long, hard-fought effort toward health coverage expansion. But as rising health care spending and health inflation combined, it became attractive to find new tools with which to rein in some of that spending.

It began narrow in scope, such as certifying hospital lengths of stay. This was to the ire of physicians as they began to see their autonomy getting intruded on, but it wasn’t ultimately all-encompassing. But as America’s cost containment concerns combined with a political shift to the right, such that a shift toward privatization became attractive, that all changed. With 1973, America saw the enactment of the Health Maintenance Organization Act and later, the introduction of more flexible (but less cost-containing) preferred provider organizations through which coverage decisions were made. Reliance on managed care continued to climb, including in traditionally public areas of insurance but where politics has shifted toward widespread privatization that reshapes the calculus when making coverage decisions.

Today, most costly care and even some less costly care requires prior authorization, and millions are denied every year (keeping coverage out of reach), on top of the hundreds of millions of claim denials Americans face every year (keeping payment out of reach in a county with notoriously costly medical care). And as the outpouring of frustration following the events surrounding UnitedHealthcare in December 2024 reflect, it’s to the profound ire of patients and physicians alike.

The politics is everywhere in the origin story, and it is everywhere in explaining why that moment of outcry and outrage did not provoke policy reform. Congress is notoriously gridlocked, and health policy is notoriously gridlocked among other policies. To address these systemic barriers and resulting inequitable burdens, one must confront the delivery of managed health care, which means not only limited room for bipartisan cooperation but also confrontation with the insurance lobby. Let’s just say I’m not holding my breath, and there’s a reason why federal and state efforts have tended to address these barriers with a scalpel rather than a hammer, improving the streamlining of these processes so as to improve efficiency of administration without disturbing their overall application.

To quote Bob Dylan, “Money doesn’t talk, it swears.” (Obscenity, who really cares…)

The good news is that unlike DC, states have been moving the needle on prior authorization policy in a bipartisan if not unanimous fashion. The bad news is that states can’t touch the majority of people in employer-sponsored insurance because of the constraints of the Employee Retirement Income Security Act (ERISA), on which I’m now masochistically writing another book.

While Coverage Denied offers thoughts on an alternative pathway to balancing health care access and cost containment, I don’t pretend to have the answers, and I’m certainly not blind to the political realities in which we now operate. But my hope with this book is that it will contextualize – for academics, patients, physicians, and policymakers – the scale of this policy problem, the diversity of experiences with denials and the burdens of rectifying them, and the need for action to better protect patients and their physicians. I hope you’ll give it a read!

Coverage Denied: How Health Insurers Drive Inequality in the United States is available through Cambridge University Press, Amazon, Strand, Powell’s, The White Whale (for you fellow Yinzers), and more.

And if you’d like to tune into my book launch on April 28, here is the link to register (livestream link is toward the bottom): https://www.eventbrite.com/e/book-launch-miranda-yaver-coverage-denied-wsarah-boden-tickets-1985603975943?aff=oddtdtcreator

Thanks for reading!