Why Healthcare Reform Promises Keep Failing Patients

I watched it happen again this year.

A friend of mine—brain cancer survivor, five years stable on her treatment protocol—got denied twice for medications she'd been taking without issue. One was an infused product. The insurance company suddenly wanted to review whether the hospital where she'd been getting infusions for five years was appropriate. The other kept her from getting debilitating headaches multiple times a week.

Both denials came after insurers publicly pledged to reform prior authorization.

She won both fights. But only because she had the knowledge, time, and fury to write a 25-page dissertation to her insurance company and call out the CEO on social media.

99% of patients don't even know they can appeal a denial.

For everyone else, the denial stands. They abandon treatment. Their health deteriorates. Some end up in emergency rooms. The insurance company faces zero legal liability for any of it.

That's the system working exactly as designed.

In 2018, major health industry groups released a "Consensus Statement" promising to make prior authorization less burdensome. Medical groups report that nobody has "moved the dial on the health plan side" since then.

In June 2025, over 50 insurers pledged reform again.

When reporters contacted more than a dozen major insurers that signed the pledge, half failed to provide specifics about which services no longer require prior authorization. AHIP, the trade group representing insurers, offered no details about treatments, codes, medications, or procedures released from prior authorization requirements.

The AMA President Bobby Mukkamala stated what everyone in healthcare already knows: "Insurers have made similar promises before and failed to deliver meaningful change."

Only 20% of adults have heard anything about the June 2025 pledge. Meanwhile, 73% of the public thinks delays and denials by health insurance companies are a major problem.

The reform theater continues because it addresses political pressure without threatening revenue.

You want to see how voluntary pledges work in practice?

UnitedHealth Group publicly committed to "furthering transparency" after facing scrutiny. The company then reported only 10 subsidiaries in its SEC filings for 2025.

The previous year, they disclosed nearly 3,100 subsidiaries.

That's not a typo. They went from 3,100 to 10 while announcing greater transparency.

UnitedHealth runs thousands of affiliated entities across Optum, insurance plans, data companies, physician groups, pharmacy services, and contracting vehicles. Each entity holds pieces of pricing agreements, pharmacy reimbursement structures, and rebate flows. When reporting shrinks from thousands of entities to a handful, practical visibility into the system drops dramatically.

From a governance perspective, leadership fulfilled the pledge by publishing a report.

From an operational perspective, the structure moved further behind internal walls.

That pattern repeats across the industry.

PBMs promise rebate pass-through while expanding administrative fees. Insurers promise lower drug costs while expanding vertical integration with specialty pharmacies. Companies promise transparency while narrowing the scope of what counts as reportable activity.

Most pharmaceutical companies run full teams called Field Reimbursement or Field Access Specialists. Their job is to go into provider offices and train staff on exactly what documentation an insurance company needs to approve a medication.

It's an arms race between provider offices and insurance companies over who has more information and can write a better letter.

Almost no patients know these processes occur in the doctor's office.

This paperwork warfare costs the healthcare system between $65 and $95 billion annually. Hospitals now spend more than 40% of total expenses on administrative costs. The average medical practice completes 43 prior authorizations per physician per week, spending about 12 hours on paperwork. Nearly 59% of physicians have staff members working exclusively on prior authorizations.

At those numbers, administrative burden isn't a bug. It's a feature.

The complexity serves a purpose. Insurance companies keep as much of the premium dollars they collect from patients, corporations, and the government as possible. They report to shareholders, not patients. The system rewards friction because friction protects margin.

Insurers claim they're not practicing medicine. By law, they cannot practice medicine.

But they decide which medications patients can access, which treatments get approved, and which therapies require months of appeals to obtain.

If an insurance company blocks a medication and something bad happens to the patient's health, there's no legal exposure for the insurance company. Only the provider faces liability.

The only thing protecting insurers from accountability is Congress and their ability to lobby it.

That asymmetry explains everything about why reform pledges fail.

Anna Hocum, 25, of Milwaukee, had her insurer repeatedly deny coverage for expensive treatment for a rare genetic condition that destroys her lung function. Her family and friends donated more than $30,000 through GoFundMe while waiting.

The insurer eventually reversed the denial without explanation. The approval is valid for only 12 months, requiring another prior authorization this year.

"It is scary. It's not guaranteed that it'll be accepted," she said.

Another patient, Ekirch, spent months fighting for IVIG treatment she'd received for years. After finally winning approval through external review, the authorization letter confirmed coverage would be valid for only one year.

The company wrote "We are pleased we can provide a favorable response in this case."

Ekirch noted the hypocrisy: "They act as though they are a benevolent organization doing me a favor" when "they fought me tooth and nail every step of the way."

Patients with chronic conditions requiring ongoing treatment face perpetual uncertainty about whether life-sustaining medications will be covered.

Even when you win, you haven't really won. You've bought yourself 12 months before the fight starts again.

In 2024, Medicare Advantage insurers denied 4.1 million prior authorization requests. Just 11.5% of denied requests were appealed.

But 80.7% of appeals overturned the initial denial.

That pattern has remained consistent since 2019. More than eight in ten appeals overturn initial denials.

If appeals succeed at that rate, why don't physicians appeal more often?

Because 62% of physicians don't believe the appeal will succeed based on past experience. Because 48% say patient care cannot wait for the health plan to approve. Because 48% have insufficient practice staff time or resources.

The system is designed to exploit exhaustion.

A study covering 30% of the entire Medicare Advantage market found claim denial rates of 17% as a share of initial claim submissions. But 57% of all claim denials were ultimately overturned, resulting in a 7% net reduction in provider revenue based on denials that were not overturned.

Medicaid managed care organizations show an even starker pattern, with a 12.5% prior authorization denial rate—more than twice the Medicare Advantage rate.

94% of physicians report that prior authorization leads to delays in patients' access to necessary care. 78% report that the process can lead to patients abandoning their physicians' recommended course of treatment.

24% of physicians report that prior authorization has led to a serious adverse event for a patient in their care, including hospitalizations, life-threatening events, and deaths.

79% of physicians say that a prior authorization delay or denial leads to a patient paying out of pocket for a medication when the health plan doesn't cover the prescription.

Prescription abandonment rates approach nearly 40%.

Slightly more than half of physicians report that prior authorization affects patient job performance.

The system creates a two-tiered structure where access depends on socioeconomic resources rather than medical necessity.

The patient who can write a 25-page dissertation gets care. The patient who can't walks away from treatment.

Most reform conversations feel comfortable until you introduce consequences tied to money, contracts, and control.

I've sat in those rooms more times than I can count.

An advocacy leader pushes for change. A policy leader nods. A commercial leader asks one question: "What does this do to margin?"

That question ends most reform conversations.

People soften for three reasons.

First, proximity to power. Most voices in the reform conversation depend on the system they're criticizing. Advocacy groups rely on funding. Consultants rely on contracts. Internal leaders rely on job security. The moment you push for penalties that hit revenue, you put those relationships at risk.

Second, misaligned incentives. No one gets rewarded for reducing friction if that friction generates profit. PBMs generate billions through complexity. Insurers protect margin through utilization management. Talking about penalties for inappropriate denials directly challenges a revenue stream.

Third, lack of aggregated proof. One patient story creates empathy. It doesn't create leverage. Without scale, leaders dismiss the problem as an edge case.

The people who control the economics control the outcome. Insurers. PBMs. Large employer purchasers. Everyone else influences the narrative. Only a few groups control what actually changes.

That's why the system tolerates reform theater. It protects the financial engine.

If an insurer forces a clinically stable patient to fight for a therapy they've used successfully for five years, that event should trigger a direct financial and operational consequence.

Not a warning. Not a report. A penalty that hits the business.

Start with automatic claim reversal plus patient restitution. The insurer should reimburse every out-of-pocket dollar the patient paid during the delay. On top of that, they should pay a defined penalty multiple—two to three times the patient cost.

Add administrative burden compensation. The insurer should pay a standardized compensation fee to the patient and the provider for every unjustified prior authorization or denial that gets overturned.

Escalate to provider-side consequences. Every overturned denial tied to a stable therapy should get logged and attributed to that insurer. Once they cross a threshold, they lose formulary flexibility or face mandated external review for future decisions in that category.

Tie it to employer economics. When you aggregate inappropriate denials across populations, you quantify the number of denials, time to therapy delay, patient abandonment rates, and downstream medical costs from disruption. You bring that data to the employer who funds the plan. Now the employer sees that the insurer created friction that increased total cost of care and hurt employee health. The consequence becomes contractual. The employer can demand rebate clawbacks, renegotiate PBM terms, or switch vendors.

Add regulatory exposure. Repeated patterns of overturned denials for stable patients should trigger automatic audits and fines. Pattern-based enforcement driven by real-world data. If an insurer shows a 40% overturn rate on prior authorizations for a drug class, regulators should step in and impose financial penalties tied to that pattern.

The consequence cannot depend on whether a patient pushes back. It has to trigger the moment the system creates unjustified friction.

I've been in the mud for 18 years of my life. I know what terrible health feels like.

I'm here to fight for those who don't know how to get through the slog and through the mud.

This is the United States of America, a country I'm proud to be a citizen of, and one that needs to do better for its citizens when it comes to healthcare.

I see this as my act of patriotism and the mission that God has put me on for the good of his people.

When I look at healthcare executives who perpetuate this system, I see people who are okay with the status quo. People who point to the system as being the problem but do nothing in their power to fix it.

As a man of principles, that disgusts me.

I don't doubt that when I need care in the future, my insurance company will look to play games with me. I've noticed many insurance company and PBM employees following me on social media.

But I'm here for that public battle.

Because the alternative is watching more patients walk away from treatment. More families depleting retirement savings. More people dying while fighting for care they've already been approved for once.

Until transparency threatens revenue, you'll see pledges without progress.

Until consequences hit the business, you'll see reform theater without reform.

And until we stop celebrating the patient who fought through the system while ignoring the ones who walked away, we'll keep pretending voluntary compliance means anything at all.

In the last blog, I laid out the build:

Now I want to name the force behind all of it.

A patient is someone sitting on a lifetime of health intelligence that no textbook can replicate, and when empowered, changes health outcomes for themselves and the system around them.

Advocacy Intelligence means knowing what to ask, what to track, what to challenge, and what to do next based on the insights of the advocacy community and empowered patients.

The patient brings the lived experience.

Advocacy Intelligence turns that experience into strategy.

Together, they create a voice that shows up prepared, pushes for better decisions, and drives better information, stronger self-advocacy, more coordinated care, and a clearer path to better outcomes.

Join the early access list and help build what comes next. Email us at [email protected].