It isn’t exactly difficult to make sense of why so many people – patients and providers alike – revile prior authorization.

On principle, there’s the frustration that private insurers with profit interests may overturn clinical judgments concerning the treatment of patients they haven’t treated or even seen.

And in practice, it leads to delays in care, denials of coverage (sometimes for care that is medically necessary), and can fuel onerous processes for patients and their providers to navigate. What’s more, there is the physician frustration that “peer to peer” reviews of prescribing are typically not with true peers. (One patient who I interviewed for my book had their rare ENT procedure to address sudden hearing loss denied by a gynecologist, despite ears and vaginas being quite different anatomically.)

Collectively, this can produce learning costs because of opacity about what has prior authorization requirements as well as the appeal process when denials arise, compliance costs of coordination among patients, providers, insurers, and sometimes specialty pharmacies and gathering additional documentation of medical necessity and often requiring physicians to hire staff to manage these processes, and psychological costs amid provider burnout and patient stress and overwhelm from trying to obtain prescribed care.

Sometimes, the result of this is a nuisance – whether being the 71^st person in the queue to talk to a health insurance agent, or a few days of delay in being able to schedule imaging for an ongoing problem. Other times, as the foreword to the AELP report illustrates, the outcome is tragic, with author Hannah Garden Monheit writing about UnitedHealthcare denying the prior authorization for her father’s rehabilitation following leg amputation.

The words that she uses to describe this experience and their subsequent pushback against the insurers determination would sound familiar to most people who have had health concerns or live with someone who does.

“The system was working just as intended”

The processes were “impenetrable”

It required “sheer grit and determination”

“The bureaucratic maze was a dead end.”

“Illogical system.”

It is for this reason that I have characterized these processes as health care “rationing by inconvenience.” That is, since many appeals are successful, care isn’t rationed through final denial but rather through accumulated hurdles and inconveniences that combine to keep benefits out of reach.

Now, prior authorization didn’t originate without a purpose. Early certifications of hospital lengths of stay and the like were an early precursor meant to ensure the necessity of continued hospitalization, but the introduction of managed care brought new cost containment and profit maximization pressures as coverage decisions were made by those with fiduciary responsibilities to shareholders. When nearly 25% of health care spending is considered wasteful (by some measures, at least) and health care spending continues to climb and dramatically outpace high-income peers, finding ways to mitigate overuse looks like an attractive option, though these tools have since proliferated into nearly every corner of American medicine that is managed by private actors and have come to limit not only unnecessary care (good), but also necessary care (bad).

The good news is that when inappropriate denials are issued, appeal processes are in place. But as the AELP report and my book Coverage Denied illustrate, the plain reality is that navigating these processes – which requires a high level of health insurance literacy and administrative capital – is hard on a good day, and when we’re ensnared in this red tape, we’re rarely having one of our better days. Consequently, while operating as a cost containment tool, these processes can also drive inequities and, potentially, worse health outcomes. It is little wonder why prior authorization reform, though related to the managed care business model, has garnered bipartisan support at the state level and has marked potential for bipartisan support at the federal level.

Of course, reform is a far cry from an outright ban, which would ignite broader concerns (potentially from both parties) about managing runaway health care costs in the absence of this guardrail on moral hazard in prescribing (or perhaps, more cynically, the possibility of insurers using the removal of these prescribing guardrails as pretext to further increase the cost of premiums).

But the AELP report makes a number of compelling points (yes, points which also align with my own work in this space) that I expect will shape the dialogue concerning the path forward from pervasive prior authorization:

1. Prior authorization may not be the cost saver that it’s made out to be. Prior authorization requires administration. LOTS of administration by providers and insurers (though insurers are increasingly relying on AI tools with which to process claims and prior authorizations). Notably, the majority of appeals tend to be successful, such that in many cases, there is not a denial of care but rather a delay in care (if the patient appeals, which my work and others have shown is infrequent and unevenly distributed) that can necessitate costlier medical interventions or at least require substantial administration behind an eventual provision of coverage. What’s more, it can generate utilization because, for example, onerous step therapy protocols may require that the patients first undergo a series of ineffective treatments with subsequent office visit follow-ups that might have been avoided if pursuing the on-label treatment in the first place. Strikingly, the report notes, “By one estimate, insurers’ prescription drug utilization management techniques — including but not limited to prior authorization requirements — cost the U.S. health care system $93 billion annually, including increased administrative costs for insurers and physicians, increased costs to pharmaceutical manufacturers’ patient access programs… and increased patient cost-sharing obligations.”

2. Prior authorization’s burdens on physicians contributes to not only burnout, but attrition that fuels America’s physician workforce shortage. American Medical Association physician surveys on the burden of prior authorization are well-cited, revealing an average of 13 hours spent completing an average of 40 prior authorizations per week. In fact, one physician whom I interviewed for Coverage Denied observed that his pulmonology practice at a major university medical center had five staff dedicated to prior authorization administration, accruing to roughly a third of a million annually in salary alone (an amount that rural and other less resourced hospitals would be unable to afford). What’s more, the AELP report observes, “CMS estimates that ‘[f]or each provider, that’s approximately $34,000 and 700 hours of administrative time each year that could otherwise be used to take care of patients.’ Multiplied across the U.S. physician workforce, this amounts to over 650 million hours of administrative work per year, or the equivalent of 99,290 full-time physicians and advanced practice clinicians — more than the nation’s current physician shortage — plus another 213,474 clinic staff, at a cost of as much as $32.7 billion annually.” With the United States having a projected shortage of 86,000 physicians by 2036 (an estimate that will likely need to be revised upwards in light of newer immigration policies), and with any health coverage expansion realistically needing to entail building the workforce to support increased demands for health care (that is, the supply side of the equation), finding mechanisms of physician burden reduction is critical for providers and patients alike.

3. Rural and other less resourced hospitals’ greater difficulty managing prior authorization administration will exacerbate urban-rural health care disparities when rural hospitals are already facing new and worsening strains. The AELP rightly observes that prior authorization-related burden “weighs more heavily on independent medical practices and safety-net hospitals in rural and low-income metro areas, which typically have fewer administrative resources — including dedicated staff to handle prior authorization requests — than their large, corporatized counterparts. As a result, prior authorization heightens these providers’ risk of closure or acquisition and, therefore, patients’ risk of being stranded in a care desert or shunted to a corporate-owned provider that charges more for lower-quality care.” With people in rural communities tending to be in poorer health, the stakes of a delay in care may be more pronounced. 700 rural hospitals are already at risk of closing (and that’s before most of H.R. 1, the not-so-beautiful bill goes into effect), and the fiscal pressures of prior authorization administration, potential losses from reduced utilization in the face of denials, and H.R. 1’s exacerbation of uncompensated care can combine to yield dangerous, even tragic health outcomes for these populations and those who treat them.

4. The current policy response to these barriers is inadequate. It’s hard to argue with this. The Trump Administration’s response to prior authorization-related concerns has been conflictual at best, celebrating major insurers’ pledge to pare back prior authorization within days of announcing the introduction of new prior authorization into traditional Medicare through its new WISeR pilot. Though insurers have claimed that there is an 11% reduction in prior authorization reliance since the pledge was announced, data have not been made public to substantiate this. Other reforms attempted at the federal level (namely, the Improving Seniors’ Timely Access to Care Act, would only accelerate and streamline Medicare Advantage insurers’ prior authorization determinations within this faulty system – and perhaps counterintuitively, could increase denials if insurers’ core metric of review is timeliness as opposed to accuracy. States have worked to streamline prior authorization administration and more tightly regulate insurers’ use of AI in coverage determinations, though states cannot regulate most employer-sponsored insurance due to the constraints of ERISA preemption (stay tuned for more in my next book, The Health Care Trap: How U.S. Federal Law Entrenched the Power of Private Insurance).

In light of these observations, it is little wonder why the AELP concludes that Congress and state legislatures should ban the use of prior authorization as it exists today. More specifically:

· “Congress and state legislatures should ban Big Medicine insurance conglomerates — including those that administer public health care benefits — from owning or being affiliated with an entity that adjudicates prior authorization requests” so as to eliminate the financial conflict of interest.

· Congress and state legislatures should provide that prior authorization requirements cannot be imposed unless all of the following conditions are simultaneously met: Documented, evidence-based need given the clinician or item/service having a pattern of fraud, overprescribing relative to clinical efficacy, or experimental or high-risk indication that warrants peer-to-peer review and restriction to non-emergency medicine and elimination of reviewing entities’ conflicts of interest through adjudication by an independent third party and prohibition on AI-based denials and peer-to-peer review by an actual peer and more stringent time limits for rendering prior authorization decisions and application of a standardized prior authorization process that includes giving patients electronic access to their own prior authorization and claim information and ensuring that approval of a prior authorization confers a guarantee of coverage rather than permitting retroactive denials.

Thus, in this model, there is protection against the proliferation of prior authorization, assurance of independent and qualified human review, as well as procedural protections that relieve the burden that so often defines the American experience when navigating health care access.

There are many ways to address these profound challenges that pervade American health insurance delivery – I have advocated for shifting mainly from a prior authorization-by-default model to a model of retrospective audits of physicians, the outliers of whom will be assigned prior authorization requirements – but this set of proposals by AELP does a good job of confronting the financial conflicts, excessive reach, and procedural burdens with which American patients and their clinicians are left to navigate, with resource disparities driving further wedges between those who have meaningful access to benefits and those for whom protections are ultimately more illusory. That is, rather than trying to “right size” prior authorization by doing volume reduction within the existing financial model, it takes aim at the review process itself in a way that state and federal reforms to date have tended to struggle with, if not evading altogether.

With the Senate Finance Committee now seeking input on private insurance reforms, packages such as this offer ways to promote access to necessary care in a way that maintains the necessary guardrails but restores prior authorization’s application to settings of documented overuse and particular risk that merits additional expert review, rather than being centered on the extent of costliness, which can reinforce patient frustrations and distrust concerning decisionmaking power in the hands of entities that seek financial advantage. That is, the goal should not simply be less prior authorization, but rather a system in which prior authorization is an exception that must be justified, and a system that does not require “sheer grit and determination” to navigate successfully.

The health care access struggles of rural communities is hardly a new phenomenon, though successive political choices have shaped the character of these disparities over time. Shepherd opens the book with an account of President Lyndon Johnson’s visit to Pittsburgh (my current city of residence) as part of his travels to bolster support for his War on Poverty agenda. And unsurprisingly, reduced health care access for this population has translated into poorer health outcomes as well, whether looking to lower life expectancy (people in rural communities live lives that are two years shorter on average), rural Americans’ slightly higher chronic disease prevalence, higher rates of physical limitations, or consumption of alcohol and certain drugs.

But problem identification is the easy part. The great challenge is addressing these systemic features of American health care and broader policy delivery. That’s where politics comes into play, and with rural Americans typically voting more conservatively and identifying as Republicans but needing meaningful health care access (an issue typically “owned” by the Democrats and requiring the type of governmental intervention in national policy delivery that Republicans tend to revile), this has proven a tough nut to crack. Indeed, Shepherd opens Chapter 2 of Rural Pain, Republican Gain with a quote by President Ronald Reagan speaking in opposition to Medicare in 1961, likening its adoption to socialism disguised as a humanitarian project. Shepherd does a masterful job of taking on this important subject through compelling historical analysis situated in the lens of the American political economy of health and drawing on diverse strands of scholarship that help explain the politics underlying the parties’ advancement of divergent health and health-adjacent policies, robust quantitative analysis, and data visualization that places urban-rural health and health care disparities in stark relief.

The federal political environment is certainly a glaring setting in which to observe high-profile advancement of policies that help or harm the health or rural communities – and I certainly don’t envy Shepherd’s task of updating this manuscript amid work toward H.R. 1 – American reliance on federalism (the quintessential double-edged sword, as Jake Grumbach’s work powerfully reminds us) means that state and local governments also play a critical public health role. In Chapter 3, Shepherd turns his attention to this realm where Americans have observed patchwork health policy landscapes with respect to everything from Medicaid expansion to abortion to COVID-19 mitigation measures, with these different state health policymaking paths facilitated by America’s rejection of national health insurance. That ten states still have not expanded Medicaid despite its hefty amount of governmental support for improving state populations’ health care access – and will not expand Medicaid under the constraints of H.R. 1 – reflects a broader racial resentment that pervades this country and, important to Shepherd’s argument, shapes these residents’ experience and perceptions of a landmark Democratic health policy, whose effectiveness is impeded by this politics.

And important to this analysis, this wide-ranging policy divergence fuels urban-rural health disparities that prove costly. In fact, in every instance that Shepherd examines, electing Democratic state governments is associated with policies that promote longer and healthier lives, and the converse with Republican governance. Notably, Shepherd observes, Democratic control is associated with fewer premature deaths in rural communities. The question then becomes, Why do rural voters continue to support those who advance these health-harming policies?

One of the unfortunate misnomers of American politics is the widespread perception of the Democratic Party as being the party of out-of-touch elites (despite their advocacy for policies that advance the health and prosperity of low-income and middle class Americans) when compared with Republicans (whose economic policies disproportionately benefit the affluent). And until that changes, democratic accountability for poor health policies proves challenging, as Americans have witnessed and as Shepherd has carefully documented, noting that “Republican politicians have since the 1990s increasingly campaigned and pandered to the shared core identities, economic vulnerabilities, and resentments of heartland Whites in ways that appeal to rural White voters across economic classes and health experiences,” garnering their electoral support (p. 94). While this is not the first robust analysis of rural politics (see, e.g., Grossman and Hopkins’ Polarized by Degrees, examining polarization along education lines), anchoring these differences in health is critical writ large (after all, health intersects with essentially every aspect of our lives and accounts for nearly a fifth of the nation’s economy) and especially amid impending reduction of rural health care access as more of H.R. 1 provisions take effect.

The answer to much of the puzzle here lies in the concept of issue ownership, a concept that has been explored in depth by Pat Egan and other. The idea here is simple: some issues are more associated with one party than another, such that the party “owns” them. Democrats get environment and civil rights, while Republicans get defense and national security. Notably, Democrats are also seen as owning health care, contributing to the historically pro-Democratic leanings of unhealthy voters who are, consequently, more dependent on effective and accessible health policies. But as Shepherd documents, the rural voters who have shifted Republican are also generally less healthy, as are the typically older makeup of Republican voters, such that there is a transformation in the health and politics of these voters. Consequently, Shepherd observes, “the typical beneficiary of government health assistance in rural communities identifies with and votes for the party opposed to such programs.” And of course, we witnessed this play out in summer 2025 with the enactment of H.R.: while rural voters favored preserving or increasing Medicaid funding, rural voters were more likely than others to be amenable to cuts to this health insurance program on which they were disproportionately reliant.

Time will tell whether there is a political price to be paid for the cuts in the 2026 and 2028 election cycles. But complicating this issue is the reality that, as Shepherd documents, roughly 70 percent of rural counties constitute “news deserts,” resulting in less political knowledge, especially at the local level, and succumbing to the entertainment-like character of national cable news. And in the setting of limited news and potentially diminished trust, it can be difficult to communicate and persuade about the effect of health policies, even when they will be harmful to them. Sure enough, the result that Shepherd shows us, tracing urban-rural differences in health policy attitudes dating back to 2000, is rural voters are significantly less likely than others to see a government responsibility in health care delivery.

To a degree, it makes sense: If you have low trust in government, why would you want to place health care delivery in the government’s hands? And if you don’t believe that the government has a responsibility to ensure Americans’ health care access, then H.R. 1 looks like comparatively less of an affront, despite the estimated adverse effects whose ripple effects are not yet fully known. As is so often the case in American politics, partisanship and racial attitudes run deep, shaping wide-ranging policy attitudes and voter behavior – even rejecting government assistance with health, and Shepherd’s survey experiments offer new insights into these depths, highlighting how “deadly frames” observing that polices may also help immigrants or racial and ethnic minorities erode support for health policies, even among those with worse health-related circumstances.

Here, we see more clearly why accountability can prove so challenging in the wake of H.R. 1’s enactment: even rural voters in worse health and who benefit from Medicaid (whose largest group of beneficiaries are white people) may be deterred from rising up in opposition to recent cuts because Black and Hispanic individuals are overrepresented in the Medicaid population. And Shepherd’s examination of rural hospital closures offers still more salient insights that are sorely needed now and in the years to come.

Rural Pain, Republican Gain, which blends careful empirical and theoretical analysis of the urban-rural divide in politics broadly and health specifically, comes at a critical time of (hopefully) accountability for the recent axe to the safety net and (even more hopefully) envisioning a transformation of American health care delivery. Anyone hoping to be informed and part of those conversations should read it.

Available through University of Chicago Press and Amazon.

Prior Authorization in the Setting of This Type of Care

Prior authorization has two broad, related objectives in mind: cost containment and mitigation of overutilization. That is, prior authorization (and utilization management writ large) works to guard against the overtesting and overtreatment that runs up a substantial tab for the health care system (and can be costly to the patient, depending on their health plan). Because this is a cost containment tool, it tends to be directed at costlier forms of care (e.g., brand as opposed to generic drugs, MRIs as opposed to x-rays) and care where there could be overuse (e.g., the prescribing of MRIs for lower lumbar spine MRIs before the patient has undergone a course of physical therapy).

Especially in light of America’s aging population, there is a significant demand for long-term care services, inpatient rehabilitation facility care, and skilled nursing care. People admitted to long-term care typically can no longer safely live independently due to a combination of physical, cognitive, or social limitations (e.g., absence of caregiver support). Those admitted to inpatient rehabilitation facilities are recovering from serious illnesses, injuries, or surgeries (so, think serious neurological events, severe neuromuscular disorders, amputations), and undergo at least three hours of intensive physical therapy per day. Admission to skilled nursing facility is recommended when the patient cannot safely return home due to medical, physical, or cognitive impairments that necessitate significant medical supervision and rehabilitative therapy following a hospitalization (e.g., after a major joint replacement, stroke recovery, or advanced wound care).

So, why use prior authorization for this care? Well, it’s expensive, with a private room in a long-term care facility hovering around $355 per day, inpatient rehabilitation care averaging around $1,500 per day, and skilled nursing facility care around $360 per day. With the average lengths of stay in these types of care averaging around 1-3 years, 13 days, and 25 days respectively, those costs add up very quickly.

But then the question is, Is this a site of overuse? Here, the answer is generally no. Though HHS OIG found in 2016 that some were admitted to inpatient rehabilitation facilities when they were too frail to undergo the required physical therapy, if anything, long-term care is a site of underutilization because it is made inaccessible due to high out-of-pocket costs. While there may be the overprescribing of care within facilities, admission to them is not where the issue is. And unlike a medication that costs $200 without insurance coverage, paying for this care out-of-pocket in the setting of a prior authorization denial is prohibitively expensive for most people.

The Denial Rate for these Services Is Staggeringly High

The OIG analysis investigated denials of prior authorization for admission to long-term care hospitals, inpatient rehabilitation facilities, and skilled nursing facilities. Notably, KFF found looking at the aggregate Medicare Advantage data that 7.7% of prior authorizations are denied by Medicare Advantage insurers, 80.7% of which were partially or fully overturned upon appeal. This relatively low rate of denials writ large makes is all the more notable that within these three domains of care, the denial rate was through the roof among major insurers, with CVS Health Corporation (affiliated with Aetna) denying a whopping 80% of long-term care hospital admissions and UnitedHealth Group denying 66% of admissions to inpatient rehabilitation facilities. The average denial rates across the 19 MAOs were 65% and 54% respectively.

Denial rates for skilled nursing facilities were lower, but among the biggest insurers, were still higher than the aggregate denial rates might suggest, with Humana and CVS Health Corporation denying 13.5% of these requests.

Keep in mind, these are patients who can no longer live independently at home, or who are recovering from serious medical conditions and need a safe place for close monitoring and physical therapy. If this care is denied – or even delayed pending an insurance appeal – this is highly destabilizing for the patient and their family or other network of care providers. Unlike a medication denial, which may be upsetting and debilitating to the patient, this causes ripple effects for spouses, children in the “sandwich generation,” and beyond. And what can unfold is loss of work hours, potentially loss of one’s job if one doesn’t have sufficient vacation and sick leave to attend to medical needs, emotional strain, and more.

Profit Considerations Are a Significant Factor Driving These Denials

Because prior authorization aims to contain costs in America’s notoriously expensive health care system but is not meant to override issues of medical necessity, let’s dig into what these data show.

The OIG reports identified the differences between denials by Medicare Advantage Organizations with for-profit versus nonprofit contracts. Not surprisingly, those with for-profit contracts were significantly more likely to deny, especially when looking to long-term care hospitals and skilled nursing facilities (though the latter category has a much lower denial rate overall).

As the reports indicate, “MAOs have a financial incentive to deny SNF-level care and instead approve a lower level of care, such as home health services or outpatient therapy” and “[d]ifferences in denial rates between for-profit and nonprofit MAO contracts suggest that financial incentives may be partially driving higher denial rates among some MAOs.”

That is, the inescapable conclusion is that financial incentives seem to play a role in decisionmaking about health coverage. Of course, this is what many Americans intuitively know or have suspected, fueling the public outrage against private health insurers following the murder of UnitedHealthcare C.E.O. Brian Thompson. These data lend credence to the perception of the American health care system all too often being driven by a “profits over patients” model, as opposed to what insurers have long claimed: that these are commonsense tools with which to manage costly overuse – that is, waste in the system.

Now, a caveat. We don’t know whether the patient populations differ between these groups of MCOs. Admittedly dated data from 2000 comparing enrollment in for-profit and non-profit Medicare HMOs suggests few differences in these patient populations, but it would be helpful to know more.

Many Denials Are Reversed Upon Appeal, If People Appeal

The good news is that initial denials are not final denials – that is, there is an appeal process of which patients can avail themselves. The bad news is as I show in my book Coverage Denied: How Health Insurers Drive Inequality in the United States and in a related Journal of Health Politics, Policy, and Law article, most patients do not pursue this process and patients from marginalized backgrounds are especially unlikely to fare well in that endeavor. More specifically, I find that someone earning $25,000 annually is about 9 percentage points less likely to appeal a denial than is someone earning $100,000 annually, when controlling for a number of other factors (e.g., sex, race, age, education, health status). What’s more, Black and Hispanic Medicaid patients and less healthy patients are less likely to win appeals that they do pursue. After all, navigating the red tape of modern medicine is difficult on a good day, and we’re rarely having our best day when we’re doing this.

Overall, I find that about half of appeals are successful, and this estimate is supported by KFF in the setting of the ACA marketplace, as well as recent analysis by the Commonwealth Fund. So, what gets in the way of patients appealing? They don’t understand that they can appeal, they undervalue appeals (that is, they underestimate the average rate of reversal upon appeal), and they are deterred by bureaucracy.

This made all the more disturbing that a claim reviewer for Elevance told me, “We’re told denying things is okay because people can appeal.” And they can appeal. But insurers know that that event is unlikely because it is immensely burdensome for patients and their physicians. This is why I characterize these challenges as health care “rationing by inconvenience.”

There are a couple of reasons why we might expect these factors to be especially pronounced in the Medicare Advantage setting. Seniors tend to have somewhat lower health insurance literacy, making the health insurance bureaucracy feel even more onerous. What’s more, poor health status is predictive of successful appeal, those requiring these high levels of care may be especially unlikely to successfully jump through these hoops.

Now, back to the OIG reports. Consistent with expectations, a small minority of people (18%) appealed skilled nursing facility denials, though the appeal rate is higher than that observed in the aggregate Medicare Advantage prior authorization data (11.5%), with the disparity likely attributable to the difficulty of simply foregoing this higher level of care. Here are the overall reported rates of reversal:

You read that right: an average of a 95% reversal upon appeal of an initial denial of prior authorization for skilled nursing care. And within these broader categories, one finds quite high variation among insurers, with Elevance having a reversal rate nearly double the average across these 19 MAOs when looking to long-term care (followed closely by UnitedHealth Group at 57%), while BCBS of Michigan reported double the average rate of inpatient rehabilitation facility reversals, followed closely by Elevance at 83%, and both Elevance and UnitedHealth reported over 99% reversals rates upon appeal over skilled nursing facility care. (Some useful context: Looking across Medicare Advantage care, KFF found a prior authorization denial reversal rate of 80.7%, which is still very high, though less than that observed in skilled nursing facility coverage decisions.

To be sure, this does not mean that an average of 95 out of 100 denials of prior authorization for skilled nursing facility care were inappropriate. There could be a billing code or other administrative error that made the treatment and diagnosis codes appear misaligned. There could have been insufficient documentation of the patient’s condition. The patient’s condition may have changed and made it clearer that this was the appropriate level of care for the patient. But these numbers do suggest a high rate of inappropriate denials, which are destabilizing for patients and their families and other caregivers. And with the claim reviewer whom I interviewed saying that there is limited, if any, attention paid to non-clinical factors (e.g., stairs to get to one’s home, support system) when deciding whether continued skilled nursing care is appropriate, there is reason to suspect that even among those for whom this care is ultimately approved, this is not the end of their insurance battles.

The Role of Contractors

Many Medicare Advantage Organizations use contractors to review initial requests for prior authorization. naviHealth, a subsidiary of the MAO UnitedHealth Group, is a prominent one, using algorithmic predictions using the software tool nH-Predict to predict (based on millions of past medical records across patients) and assess appropriate care options. They then manage the utilization review process of approving or denying prior authorization.

The OIG report suggests that outsourcing to contractors like naviHealth can be harmful, with naviHealth denying more requests for skilled nursing facility care than did MAOs when doing determinations internally (14% vs. 11%), and with more of those denials reversed upon appeal if patients can overcome the burdens of appealing (97% vs. 89%). Similar disparities were observed in long-term health care and inpatient rehabilitation facility care. And problematically, patients will not be aware at the time of their insurance enrollment whether their plan does this type of outsourcing.

Takeaways

So, what do we make of all these findings?

For starters, the discrepancies between aggregate Medicare Advantage findings and those in the new OIG reports hammers home the importance of having more granular, service-level denial, appeal, and reversal data, both for oversight and to promote patients’ informed decisionmaking at the point of enrollment. Finding the best health insurance plan isn’t always an objective assessment of “what plan offers the best benefits.” More often, it’s finding the best health insurance plan for you, based on your utilization pattern. And if you are having increased mobility issues and have had a fall and greater impairment of activities of daily living, you’ll probably want to ensure your plan has good coverage for long-term care hospitals not just on paper, but meaningfully in practice.

And from the regulatory perspective, an overall prior authorization denial rate of 7.7% can mask serious issues in health insurance delivery in areas of care that lack easy alternatives. This is not a world where you want drug A, insurance doesn’t want to cover it, so you give drug B a chance because it may have off-label benefits. The alternative can be deterioration and significant disruption to one’s family as people are thrust into caregiving roles, potentially at a financial cost with less time to work.

It is also critically important to understand the reasons for these high reversal rates upon appeal, especially given the low rates of appeal.

Are they driven by errors on the part of the insurer? If so, it would be good to provide resources to better train those reviewing prior authorizations and claims, and develop a system to penalize insurers that elicit high rates of procedural denials when corrective action has not taken place or has not led to improvement.

Are they driven by errors on the part of the provider? If so, it would be good to improve the clarity with which conditions must be documented for particular types of care, especially if a different standard of review is used in these costly areas of treatment.

Is it simply that new facts about the patient came to light or their condition changed? There isn’t much we can do here, and this would be an appropriate use of an appeal process to clarify and elaborate on a prescribing choice.

It’s difficult to understand where to cast blame and more importantly, where to deploy policy intervention, without this critical information.

Of course, the broader issue is what to do with prior authorization in this space. As you may have gathered from my broader work, I’m not a fan of this tool, partly because it can be a vehicle for delays and denials that are then burdensome to appeal and which drive inequities in the process, and partly because it has proliferated into most corners of American medicine, even where there is not evidence of overuse. This latter point is especially salient in the context of these reports.

America’s seniors tend to have higher health needs and less disposable income, making insurance coverage essential to accessing care that they understand to be within their health benefits. And in a country with notably expensive health care, higher level care is not a site of overuse – if anything, it’s a site of underuse. I have no illusions that prior authorization isn’t going anywhere in a next couple of years (though there is bipartisan if not unanimous agreement on its flaws when looking to state-level policymaking), but there are ways that it can reasonably be right-sized to better promote patients’ access to appropriate care.

If prior authorization is aimed at curbing waste, it should not be used to compel families to prove repeatedly that a stroke survivor needs rehabilitation or that someone who cannot live safely alone needs skilled care. These denial and reversal rates – both staggering – show that burden of proof has been shifted onto the very people least equipped to bear it. While improving efficiency is all well and good, a measure of a health care system is not the efficiency with which it says “no,” but rather how reliably it delivers necessary care to those who have nowhere else to turn.

I am writing to express my strongest opposition to CMS’s proposed rule CMS-2454-IFC, “Medicaid Community Engagement Requirement for Certain Individuals Interim Final Rule with Comment Period.” Through HR1, the so-called “One Big Beautiful Bill Act,” Congress had already enacted draconian cuts that the Congressional Budget Office estimated would result in nearly a trillion dollars in cuts and 10 million people losing Medicaid alone. This proposed rule goes even farther than the widespread and dangerous cuts enacted in HR1, making even more people with medical conditions vulnerable to falling through the cracks and losing the Medicaid coverage on which they depend for their ongoing care.

I begin by describing my background and qualifications within this domain of health policy. I then describe the ways that HR1 addressed medical frailty as well as caretaking. Next, I turn to concerns related to state discretion in verifying caregiver status for exemption purposes. I then turn to the ways that the CMS rule goes beyond Congress’s requirements in its definition of medical frailty, and the harmful implications of this.

Background and Expertise

I am an Assistant Professor of Health Policy and Management at the University of Pittsburgh, where I hold secondary appointments in political science and public affairs, and where I conduct research on health insurance, administrative burden, and the politics of health reform. I have a doctorate degree in political science from Columbia University and did postdoctoral training in health services research at the University of California, Los Angeles. I am the author of Coverage Denied: How Health Insurers Drive Inequality in the United States and publications appearing in such outlets as Health Affairs Scholar; Journal of Health Politics, Policy, and Law; JAMA Pediatrics; World Medical & Health Policy; Publius; and Lancet Regional Health-Americas, with additional health policy writings appearing in such outlets as The New York Times, The Washington Post, The Guardian, MS NOW, and The Hill. I also co-lead the Scholars Strategy Network’s Medicaid Working Group, which delivered a legislative briefing in advance of the HR1 vote, and which has worked through op-eds and policy briefs to expose the ways that HR1 – in particular the so-called “community engagement requirement” – deepen administrative burden. What’s more, I teach courses that focus on inequitable administrative burdens, including those observed in the work requirements adopted in Arkansas and Georgia.

HR 1’s Specifications on Medicaid Work Requirements

That Congress enacted Medicaid work requirements for the expansion population at all was a deeply misguided policy choice in light of the reality that 92% of Medicaid enrollees are already working or are unable to work. As such, these requirements are not so much work requirements as they are paperwork requirements. But Congress has enacted the requirements and tasked CMS with implementing them, so now we turn to what HR1 actually specifies, to appreciate the implications of CMS’s more stringent requirements.

Section 71119 of HR specifies that those excluded from the requirements include certain exemption categories:

1. Caregivers: One “who is the parent, guardian, caretaker relative, or family caregiver (as defined in section 2 of the RAISE Family Caregivers Act) of a dependent child 13 years of age and under or a disabled individual”

a. Section 2 of the RAISE Family Caregivers Act defines a family caregiver: “The term ‘family caregiver’ means an adult family member or other individual who has a significant relationship with, and who provides a broad range of assistance to, an individual with a chronic or other health condition, disability, or functional limitation.”

2. Medically frail: “One who is medically frail or otherwise has special medical needs (as defined by the Secretary), including an individual— who is blind or disabled (as defined in section 1614); with a substance use disorder; with a disabling mental disorder; with a physical, intellectual or developmental disability that significantly impairs their ability to perform 1 or more activities of daily living; or with a serious or complex medical condition.”

Roughly 7.3 million family caregivers aged 18 to 64 were Medicaid beneficiaries in 2025, typically providing substantial amounts of unpaid care, so it’s important that these individuals sustain their access to health insurance. And notably, with respect to medical frailty, Congress focused on conditions’ inference with activities of daily living and the complexity or seriousness of the medical condition, and not the extent to which it precludes one from carrying out any paid work.

Caregivers

We applaud CMS for responding to the concerns of caregiver organizations and others who emphasized the importance of protecting this category of Medicaid recipients. However, the verification process that may unfold from CMS’s rule may be more stringent than required by Congress, leaving this already vulnerable population even more vulnerable to falling through the cracks and losing critical access to health coverage. This is especially critical to address because family caregivers consistently report worse physical and self-reported health than do non-caregivers. Not only is this population especially vulnerable to anxiety, depression, and burnout, making access to behavioral health benefits especially critical, but caregivers also experience higher rates of obesity, current asthma, chronic obstructive pulmonary disease, and arthritis when compared to non-caregivers, further highlighting the essential nature of this population sustaining their Medicaid coverage.

· Verification Process: While HR1 does not specify the verification of caregiver status, CMS rule compels states’ verification of whether one is exempt and compels eligibility reviews at the point of application as well as renewal, and they may conduct additional periodic checks, each of which constitutes an opportunity for one to lose their coverage. We know from Medicaid unwinding, for example, that two thirds of Medicaid disenrollments were not due to change in income, but rather were procedural disenrollments – that is, they had missed a deadline by which to provide documentation. Paperwork is policy, and enabling states to impose additional verification checks runs the risk of additional caregivers losing coverage.

· Documentation Standards: CMS gave states discretion to establish verification processes. It would be optimal policy to specify self-attestation as the method of verification, so as to avoid the dangerous possibility that some states will choose documentation methods so onerous that people meeting the exemption standard will nevertheless lose their health coverage.

In sum, while the approach to caregivers is not necessarily more stringent than the statutory requirements, it enables states to go much farther than Congress required. Reining in state discretion with respect to increased eligibility checks is essential to protecting the health care access of this vulnerable population that struggles with a wide range of physical and behavioral health conditions.

Medical Frailty

Here, CMS went above and beyond the dictates of Congress, raising the dangerous possibility that those with significant medical conditions will lose the Medicaid coverage on which they depend. HR1 frames medical frailty with respect to one’s condition but rather whether the condition is serious or complex or interferes with an activity of daily living. CMS, without any need to do so, exempts “medically frail or otherwise have special medical needs that significantly impair their ability to comply with the requirement” and ties medical frailty not simply to the enrollee having a qualifying diagnosis, but rather to whether the condition prevents one from working. What’s more, it states that people with HIV/AIDS, end-stage renal disease, and cancer would not necessarily be exempt from the work reporting requirements.

Requiring a functional-work limitation presents a number of problems for patients and others, with the ultimate result of burden and more widespread coverage losses.

· Chronically ill people may be capable of working but may struggle to maintain consistent employment. Those managing significant medical conditions may need additional work flexibility – whether the ability to work remotely during a flare-up or the need to schedule more medical appointments during business hours – which can impede their ability to ability to sustain gainful employment, especially if these conditions lead to significant job turnover that comes to be seen as an employment liability that impedes hiring, even if they are not technically incapable of working. For example, by not automatically exempting those in end-stage renal disease, those reliant on dialysis (about two thirds of those in ESRD) may struggle to balance employment and these weekly medical appointments. If a newly-Medicaid-enrolled cancer patient is having a difficult time during their chemotherapy, the short look-back period for new Medicaid applicants may preclude their maintaining Medicaid and, in turn, their cancer treatment. People in the middle of medical treatment will take on new administrative burdens of proving their condition repeatedly. If these factors lead to a loss of employment that leads to the loss of Medicaid coverage, this leaves the patient vulnerable to dangerous exacerbation of their condition – whether metastasis of cancer, unmanaged and escalating depression, or having life-saving medications like insulin kept out of reach. Chronically ill patients’ ability to work may be highly variable from week to week, month to month, so an assessment of inability to work at all is not only difficult, but divorced from the reality that this population lives. And sustaining Medicaid coverage is essential to managing medical conditions so that they can be balanced with stable employment.

· Preventing chronically ill people from working at all is broader than maintaining employment within one’s field. Expecting that chronically ill patients not only demonstrate an inability to work in their profession (e.g., no longer being able to sustain a teaching job), but an inability to work at all, even at a job for which they are wildly overqualified, also places unreasonable documentation demands on this sick population.

· Demanding that doctors assess a patient’s inability to work at all is burdensome and outside their scope of training. Absent greater clarity on the documentation process to prove an inability to work – a standard to which Congress did not hold these enrollees – the burden to make these assessments of being exempt is likely to fall on physicians. This poses three core problems:

1. Physicians are already facing substantial burdens and burnout, which only exacerbates America’s dangerous physician workforce shortage, which is exacerbated by problems of costly physician attrition. These assessments of sick Medicaid enrollees run the risk of constituting non-billable hours and exacerbating existing burdens in the practice of modern American medicine. Federally-qualified health centers, which overwhelmingly serve Medicaid patients, are already stretched very thin and don’t have extra resources to divert toward added documentation burdens.

2. Physicians are trained to diagnose and treat illnesses and injuries, not to determine whether a patient is incapable of any work. While they do supply evidence of patients’ disabling conditions when patients seek to go on SSI or SSDI benefits, this assessment of restrictions on functional limitations is with respect to the patient’s current employment and is typically over a shorter time horizon (e.g., needing to take a few months away from work to recover) and does not take into account what types of employment might be available to the patient. This is made even more complicated by chronically ill patients’ ability to work likely varying from month to month, making a comprehensive assessment challenging. Dr. Vin Gupta observed of the new expectation of them, “Physicians are increasingly being asked to function not simply as clinicians but as arbiters of this very complex bureaucratic eligibility.”

3. Even if physicians are qualified to assess inability to work, not all physicians are qualified to assess the relationship between particular conditions and ability to work. With not only a physician workforce shortage writ large, but particular shortages in many areas of medicine (e.g., psychiatry, OB-GYN, physicians competent in HIV/AIDS care, rural medicine), it is especially difficult to access the relevant care in a timely manner to not only receive treatment but also to receive this assessment, and such physicians are especially overburdened.

· CMS did not enumerate specific conditions qualifying for exemption, but homelessness is not an exempt category because it is not a medical condition. This is deeply misguided and will trap the unhoused in cycles of poverty. Roughly 55% of the unhoused rely on Medicaid to address their significant health needs:

o Two thirds of the unhoused have a mental health condition

o Roughly a third struggle with substance use disorder

o High rates of chronic illness, including AIDS and diabetes complications

Increasing the rate of untreated mental health and substance use disorders will only worsen health outcomes, strain on emergency departments, and likely increased and costly interaction with the criminal justice system. What’s more, poverty is a leading cause of premature death, highlighting the myriad factors that interfere with this population’s improved health. On top of that, it can be particularly difficult to secure employment when unhoused – from health status to the need to access computers to apply for jobs to the need for clean professional clothes to greater interaction with the criminal justice system to low credit ratings – so penalizing this population for these systemic challenges by depriving them of the ability to manage their chronic conditions is not only cruel, but more cruel than Congress specified.

· Failure to enumerate qualifying conditions gives states flexibility, but that’s a double-edged sword. By not enumerating conditions that garner automatic exemption, not only does this create greater uncertainty for the physicians who may be asked to attest to inability to work, but it empowers states to lay out more stringent requirements, which will be deeply harmful to their states’ enrollees. It is little wonder why Families USA Executive Director Anthony Wright observed that with this rule, “CMS is requiring duplicative documentation and prohibiting states from taking full advantage of consumer-friendly tools like self-attestation.”

There is simply not a world in which implementing this rule does not lead people with significant health issues and disabilities to lose critical access to their Medicaid coverage. And as greater numbers of people lose coverage – through a combination of stringent requirements and paperwork burdens – there will be increased rates of uncompensated care that strain hospitals, many of which are already operating in the red. And the effects of hospital closures are not just felt by Medicaid enrollees, but rather by the publicly and privately insured alike as longer wait times and driving distances ensue.

CMS’s interpretation of HR1 – which was already malevolent to the core – only reinforces that the cruelty is the point. CMS and Congress can pretend that these requirements are not requiring the medically frail to work, but rather to participate in broader community engagement activities such as volunteering. But this misses the reality that low-income people struggling to stay afloat with basic necessities are not in a position to volunteer. What they need is health care access and, when possible, income, even if it is fluctuating to the point of noncompliance with the work requirement as elaborated by CMS. What’s more, while Congress exempted medically frail individuals because of their medical status, CMS’s proposed rule effectively transformed the exemption into a case-by-case assessment of impairment with compliance with work requirement. And on top of all of this, by constraining state discretion beyond the dictates of HR1, the CMS proposed rule is building additional burdens into states’ implementation of the work requirements.

There are no good ways to implement a Medicaid paperwork requirement, but CMS has not chosen the least bad course of action. I urge the amendment of this proposed rule to allow people with serious or complex health conditions as well those who are unhoused to submit a self-attestation, which would reduce physician burden and uncertainty as to the scope of qualifying conditions and their intersection with particular types of or any types of work.

I am writing to express my strongest opposition to CMS’s proposed rule CMS-2449-P, “Medicaid Managed Care State Directed Payments and Medicaid Fee-For-Service Targeted Medicaid Practitioner Payments.” The cuts enacted through HR1 were dangerous enough, in addition to directly penalizing Medicaid expansion states by imposing more stringent constraints on them, but this proposed rule goes even farther than the widespread and dangerous cuts, tripling the pain that will be felt by America’s most vulnerable.

I am an Assistant Professor of Health Policy and Management at the University of Pittsburgh, where I hold secondary appointments in political science and public affairs, and where I conduct research on health insurance and the politics of health reform. I have a doctorate degree in political science from Columbia University and did postdoctoral training in health services research at the University of California, Los Angeles. I am the author of Coverage Denied: How Health Insurers Drive Inequality in the United States and publications appearing in such outlets as Health Affairs Scholar; Journal of Health Politics, Policy, and Law; JAMA Pediatrics; World Medical & Health Policy; and Lancet Regional Health-Americas.

H.R. 1, the so-called “One Big Beautiful Bill Act” imposed draconian cuts to Medicaid, with nearly a trillion dollar cut to Medicaid funding and an expected 10 million people losing coverage as a result of the reforms put forward. Though the cuts are directed at Medicaid, the effects will be felt far more broadly as hospitals face increased strain, potentially leading to closures that necessitate 30-mile farther driving distances for hospital care, likely resulting in worse outcomes for the publicly and privately insured alike.

Among the cuts to Medicaid, Congress sought to make a dramatic reduction to state-directed payments (SDPs), which work to address Medicaid payments paling in comparison to those of commercial insurance, bridging at least some of the gap between the cost of delivering care to low-income patients and the reimbursement for those services rendered. While 90% of physicians currently accept new privately insured patients, just 70-75% of physicians accept Medicaid patients. This greater scarcity can mean that Medicaid patients have to go farther distances or wait for longer durations for medical appointments, despite this population already facing systemic disadvantages. SDPs have been essential to making it financially feasible for providers and hospitals to offer comprehensive coverage to Medicaid enrollees, and it can tie higher reimbursements to states’ measures toward value-based care, which is seen by both political parties as a key way to contain America’s high health care spending and improve the return on investment. By making it more tenable to accept Medicaid enrollees, Medicaid patients have a better chance at meaningful access to care, in the absence of which there will be worse outcomes and greater reliance on emergency departments, fueling overcrowding and uncompensated care.

HR1’s attacks on SDPs made specific reference to limiting SDPs in managed Medicaid in the states and the District of Columbia, and applied caps on certain types of SDPs across four specific areas of health care: inpatient hospital services, outpatient hospital services, nursing facility services, qualified practitioner services at academic medical centers. The Congressional Budget Office estimated that these changes would equate to $149.4 billion in Medicaid cuts, or around 16% of the total Medicaid cuts under HR1.

The Centers for Medicare and Medicaid Services (CMS) is tasked with implementing the Act. But rather than implementing Congress’s wishes, the proposed rule – without rhyme or reason – goes above and beyond the dire cuts that Congress enacted.

1. The rule senselessly extends the constraints on SDPs to territories as well. This is deeply damaging to regions whose Medicaid programs are already under immense strain due to poor economic conditions combined with lower FMAPs. For example, nearly half of Puerto Ricans are on Medicaid and roughly half of Puerto Rico hospitals are at risk of closure. Puerto Rico relies heavily on SDPs to boost the severely underfunded hospital and physician reimbursement rates, which form an unusually high share of their patient caseload. Constraining SDPs may be the final nail in the coffin, exacerbating Puerto Rico’s already poor health care conditions.

2. The rule needlessly extends the constraints on SDPs to all SDPs in all categories of health care. This will make it more difficult for hospitals and providers to provide comprehensive health care in areas of health care delivery beyond the four areas that Congress spelled out. So, for, example, maternal health and behavioral health care become in the crosshairs under the CMS proposed rule, despite Medicaid covering 41% of births in a country that has on average poor maternal health outcomes (thus making even more necessary that patients have access to care). What’s more, nearly 40% of the nonelderly adult Medicaid population has a mental health or substance use disorder condition, yet CMS’s unnecessary and misguided decision to take aim at SDPs in these categories of care (and others) will make it even less likely that these individuals can access needed care, which is saying something given that only 40% of psychiatrists accept Medicaid currently. Not only will providers feel even more strain than Congress intended, but this strain may be felt especially acutely by rural hospitals, hundreds of which are already at risk of closure before most of HR1 goes into effect. When a rural hospital closes, the driving time to the next hospital increases by 20-40 miles depending on the type of health care one requires, with the result of worse outcomes (ironically, for disproportionately Republican voters).

3. Despite SDPs applying to managed Medicaid plans, the CMS rule senselessly takes aim at fee-for-service Medicaid as well, diverging not only from Congress’s intentions with HR1, but from how SDPs have historically been applied. This is not about ensuring program integrity. This is about penalizing people who are poor. And making it harder for this population to access needed health care is only more likely to keep them trapped in a cycle of poverty, unable to enjoy upward economic mobility or to exercise the “personal responsibility” about which this administration pontificates.

4. Despite HR1 not addressing the “uniform dollar or percentage” option, CMS whipped out of thin air a decision to eliminate this option that accounts for two thirds of SDP spending. The result would be a requirement that states further reconfigure their financing arrangements at a time when they are already scrambling to assume the administrative burden of compulsory work requirements for the expansion population, 92% of which is working or exempt but which in this administration’s eyes just doesn’t experience enough administrative burden.

This is not the entirety of the morally bankrupt deviations from Congress’s almost as morally bankrupt intentions. But the fact that it more than triple the drastic SDP cut – from $149.4 billion to $515 billion – speaks volumes. While the pain will be felt far and wide across the Medicaid population, providers, and hospitals, particularly vulnerable groups – namely, children and pregnant people, who are disproportionately reliant on Medicaid, will feel the pinch especially. And nothing screams “supporting family values” quite like taking senseless policy steps to further erode the health care access of children and pregnant people (at a time of already reduced access to reproductive health care).

Of course, administrative agencies have some degree of bureaucratic discretion when carrying laws into effect, hence the myriad political science and legal analyses of “may” versus “shall” and the breadth of congressional delegation and the specificity therein. But this proposed rule not only goes well beyond the scope of Congress’s aims in HR1, especially given that Congress actually enumerated specific areas of care where the restrictions were meant to apply, but the rule also concocts new cuts out of thin air that are as senseless as they are cruel, and which will harm patient outcomes and hospitals’ financial security.

I have reviled the Loper Bright line in which Chief Justice Roberts wrongly asserts that agencies have no special competence in statutory interpretation. Unfortunately, this rule lends credence to that claim, showing a blatant disregard for SDPs’ historic role in Medicaid delivery alongside departures from congressional directives. This rule should be rescinded and confined to the particular domains of health care that Congress took the time to spell out.

So, what is AHRQ?

AHRQ was created in 1999 through the Healthcare Research and Quality Act, and it supports health services research, the field that examines health care delivery to patients, and it supports patient safety research and data analytics tools to improve the American health care system. What’s more, it funds health services research training programs at predoctoral and postdoctoral levels, helping to shape the next generation of trainees who will tackle the many challenges facing our system.

So, why would the House Appropriations Committee seek to eliminate this funding, along with funding for AHRQ’s Patient-Centered Outcomes Trust Fund? The House Appropriations Republicans have called AHRQ “duplicative,” though nothing could be farther from the truth.

While the National Institutes of Health do critical work to fund and conduct biomedical research, AHRQ isn’t just a key federal agency supporting health systems research. It is the federal agency supporting health systems research.

I’ll be candid: This one’s personal. AHRQ funded my postdoctoral fellowship at UCLA (go Bruins), where I began the foundational work toward my recently published book Coverage Denied: How Health Insurers Drive Inequality in the United States.

Some of the many other postdoctoral training programs funded by AHRQ are at the elite ivies that the Trump Administration gets off on targeting – Harvard’s Health Policy Training Grant, Columbia’s Patient Safety and Health Services Training Program, Yale’s Training Program in Health Services Research, and UPenn’s Postdoctoral Training Program in Health Services Research, while others are at other elite private universities (e.g., Johns Hopkins University’s Training in Health Services Research, Emory University’s Health Services Research Center Training Grant, Stanford University’s Health Services Research Training Program, University of Chicago’s Health Services Research Training Program) and at large public universities (e.g., University of Michigan’s Health Services Research Training Program, UC Berkeley-UCSF Health Services Research Training Program, UNC-Chapel Hill’s Training Program in Health Services Research, University of Alabama-Birmingham Health Services Research Training Program, Ohio State University’s Accelerating Health Services Research Training Program).

In states big and small, red and blue, and in universities public and private, the next generation of researchers are trained to probe important questions about health care delivery. Sure, if you’re a staunch conservative, it can be useful to use Harvard and Columbia as punching bags (all while recruiting from their law schools’ Federalist Societies to identify future conservative judges and justices), but health services research isn’t about scoring political points. It is the essential but often unglamorous work of helping people from Alabama to Washington and everywhere in between to tackle how best to deliver care and ensure meaningful access to it.

There are some aspects of the Trump Administration’s attacks that can be remedies in a different administration with proper staffing support and restoration of funding, though the practical feasibility of doing so is certainly in question. But cutting training programs means losing entire cohorts of new talent in the field – whether deterring people from pursuing doctorate programs in health services research or depriving graduating PhDs from postdoctoral training programs before advancing their careers – and that will set the field back immeasurably, with effects that endure far beyond this administration and its immediate aftermath.

And without AHRQ funding, health services researchers at various career stages are left without support for new projects and are no longer receiving notices of award for existing funded work, potentially making it unsustainable to pursue career paths in academia (whether squarely in academia such as the path I’ve taken or carving out career paths that combine clinical medicine and health policy research like many of my friends have).

So, what is the research that the Trump Administration is so hostile to funding?

Between the award fiscal years of 2019 and 2023, AHRQ has distributed nearly $622 million in grants across the country to fund woke topics like:

· Evaluating the Role of Telemedicine in Improving Rural Emergency Department Sepsis Care

· Social Networks in Medical Homes and Impact on Patient Care and Outcomes

· Impact of Payment Methods on Service Delivery at Community Health Centers

· Effects of integration of advanced practice providers into surgical group practice

· Understanding primary care utilization and barriers to care among sexual and racial/ethnic minority populations

· Influence of social vulnerability on buprenorphine treatment and opioid overdoses after an opioid-related emergency department visit among commercially insured and Medicare Advantage beneficiaries

· Applications of Trajectory and Transition Modeling Methods to Characterize the Dynamic Relationship Between Food Insecurity, Health, and Health Care Use in Low-Income Older Adults in the United States

· Engaging Patients in Diagnostic Error Reporting

· Understanding the effect of increases in the minimum wage on access to health care and health

· Impact of Government Nutrition Benefit Program Participation on Children’s Health and Healthcare Utilization

· Optimizing the Risk-Adjusted CUSUM for Monitoring Hospital Non-cardiac Perioperative Outcomes

· Examining the Integration of Hospitals, Public Health, and Social Services to Target the Social Determinants of Health Using Patient-Centered and Comparative Effectiveness Research Methods

· Financial assistance for low-income Medicare beneficiaries: Using natural experiments to assess effects on care and health outcomes

· Determinants, Outcomes, and Financial Incentives Associated with Cardiac Rehabilitation Enrollment After Cardiac Surgery

· Understanding the impact of perinatal insurance disruptions on maternal and child health outcomes

· Tele-Recovery: Engaging Stakeholders to Adapt and Pilot Test a Scalable Transitional Rehabilitation Intervention for Older, Rural ICU Survivors

Can you even imagine the horrors that can unfold if we, the nation with some of the worst maternal health outcomes among OECD countries, better understood how to avoid health insurance disruptions that might hinder better maternal and child health? *shudders*

Can you even imagine what someone committed to family values might say about healthier pregnant people, new moms, and their babies? The scandal!

And those typical liberals, wanting to help hospitalized patients to avoid potentially deadly hospital-acquired infections. Tsk tsk.

But back to the more serious note, it is going to be difficult for the United States to improve its health outcomes if it is unable to properly assess the effectiveness of medical and health policy interventions. From patient safety to social determinants of health to health insurance, AHRQ has been there to support essential research and training to advance not just the field in the abstract, but patient health directly.

There are additional reasons why attacking AHRQ is so wrong-headed if you care about reining in costs. (Note: I am not arguing that there is anything resembling good faith efforts toward cost containment by this Administration. Any rhetoric to that effect is pretext for dismantling higher education and health care, but it’s helpful to engage with their line of argument, however blatantly disingenuous it is.) If you care about addressing America’s exorbitant health care spending, a sensible person would look to look to invest in work that ensures that prescribed treatments are indeed clinically effective.

The Patient-Centered Outcomes Trust Fund works toward the development and dissemination of an evidence basis for decisionmaking about the effectiveness of interventions in health care delivery. This has the potential to reduce overuse, which is costly to the health care system. While there are complicating political, financial and cultural factors that have prevented the Patient-Centered Outcomes Research Institute (PCORI) from having a bigger footprint, research does suggest that this work has advanced patient-centeredness in health care.

Research funded by AHRQ has advanced understanding of value-based research in a country that likes to kvetch about high health spending. So, Republicans calling to eliminate AHRQ fits within two patterns observed this Trump Administration:

1. Imposing broad-based cuts on agencies and programs about which they have such little knowledge that they fail to appreciate ways that their efforts will backfire.

2. Exclusively examining cost savings or other benefits in the first period without looking a step or two down the game tree to see broader ramifications.

Now, I have no illusions that the goal is not actually to simply cut spending, but to hobble the public health apparatus because of broader hostility to government as well as the possibility that health care interventions that could help them and their constituents might also help racial, ethnic, and sexual minorities. Unfortunately, not unlike Republicans’ gutting of the Medicaid program on which conservative rural populations disproportionately depend, the renewed attack on AHRQ will be harmful to patient health across the country, to researchers across the country, and it will lead to less efficient health care delivery. That doesn’t make America great, and it only contributes to our health outcomes falling farther behind our high-income peers.

You simply can’t improve a health care system you have chosen not to understand.

Call your members of Congress to tell them to protect AHRQ: 202-224-3121.

First, some context.

In 2008, Congress passed and President Bush signed into law the Mental Health Parity and Addiction Equity Act (MHPAEA), which required that health insurers’ provision of behavioral health benefits be on par with benefits afforded those seeking medical or surgical care. This parity is defined along the dimensions of quantitative treatment limitations as well as non-quantitative treatment limitations. The former are simpler to address; if you offer coverage for up to 20 physical therapy sessions (for example), you shouldn’t be more restrictive in your provision of coverage for psychotherapy sessions if that coverage is offered at all. That is, the MHPAEA didn’t compel the provision of those benefits, but specified that conditional on providing those benefits, they shouldn’t be inferior.

The non-quantitative treatment limitations are where things can get gnarlier, because among other things, it might require that utilization management not be more restrictive in the behavioral health space than it is in the medical or surgical space. But as you might imagine, that’s harder to enforce than assessing quantities of treatments covered.

The Affordable Care Act was the next game-changer for mental health care, requiring that behavioral health benefits be considered one of the 10 “essential health benefits” that would be included in covered plans.

So, by 2014 (when the ACA went into effect), plans were covering this type of care and it legally had to be on par with other benefits.

Sounds great, right? The coverage barriers were solved? Well, not quite…

There are a few core reasons why this legislation has not delivered on its promise of delivering needed relief to the 1 in 5 Americans struggling with mental illness in a given year. As I tell my students every semester, laws are only as good as their enforcement, and the MHPAEA suffers from weak enforcement and despite notably insufficient access to behavioral health care, few violations are investigated, let alone penalized. What’s more, the complexity and opacity of non-quantitative treatment limitations makes it very difficult to accurately assess whether a given health plan has violated the Act. Another thing I always tell my students: complexity and opacity are not friends to effective health reform or accountability. And to top it all off, there is a severe shortage of behavioral health providers, driven among other things by health insurers’ low reimbursement rates for these services.

The result of all of this is that a lot of patients end up falling through the cracks, and at a time when their brain may be telling them to give up rather than summoning the stamina to withstand red tape standing between them and their prescribed care.

In fact, in 2019, Bloomberg covered the tragic story of Max Tillitt, who had been inpatient for three weeks to recover form a heroin addiction and who seemed to be making progress. Despite his addiction specialist wanting him to remain in treatment at the facility for a while longer, United Behavioral Health declined to cover the longer stay. Ten weeks after his discharge, Max died of a drug overdose at the young age of 21.

It is thus little surprise that a number of the patients and families whom I interviewed for Coverage Denied were struggling to access behavioral health care for themselves or their children.

One Texas journalist reflected of the enduring struggles to secure mental health care for his son, often having to pay out-of-pocket for what they believed to be within the terms of their health plan, “We live frugally. One thing we postponed was retirement plan contributions. We withdrew 401(k) money early just to pay the bills. Now, my wife and I are approaching retirement age with little savings.”

Joanne, a mother of two in New York City, likewise suffered immense psychological and financial costs in the course of securing treatment for her transgender and severely depressed daughter Eli. “Medical denials are frustrating to appeal to start with, and appealing denied mental health claims is even more mind-boggling.” And notably, Joanne had a lot of advantages working in her favor: she has a master’s degree and her husband is a lawyer, she used to work for a large company in pharmaceutical and medical device sales so she understands the health care system, and she has a high-quality health insurance plan. Yet it still provoked years of struggle.

Eli was diagnosed with ADHD, anxiety, depression, OCD, and autism spectrum disorder. Though she had been seeing an outpatient therapist, when by the time Eli was in eighth grade, she was struggling with worse depression and increased difficulty regulating her emotions, despite having a good team of providers through NYU, and it became clear that she needed more care. Eli agreed to go to a short-term (up to 90-day) residential treatment facility when an intensive outpatient program failed to provide the needed relief.

Despite residential treatment being for a long duration by definition, the initial prior authorization that was secured was for just over one week, after which the treatment was reviewed through new prior authorizations “every couple of days.” Joanne reflected of this time, “We got approved for ten days the first time, then three days the next time, then seven days, then four days. You’re on a string because if the insurance doesn’t approve you that time, you’ve got about 24 hours to go and get your kid. It was horrible. You can’t make any plans because we need to be able to go get her if she’s not approved for more care. And they also know they can be yanked the next day. How does that help them?”

Joanne was lucky to be just a two-hour drive from the facility, but this was far from a given, and patients in this facility were from up and down the East Coast and beyond.

When Eli got denied because she was improving and was judged to no longer require this intensive level of care – it was no longer deemed medically necessary – she did a partial hospitalization program, but it was only three weeks long and over Zoom due to the COVID-19 pandemic. The result was that Eli had limited engagement with the program and at its conclusion, she struggled to attend and perform well in school, and she decompensated, even engaging in self-harm and struggling with suicidal ideation.

The team at the hospital through which they had been obtaining care decided that a more intensive, longer-term level of care was appropriate, and they ultimately found a 30-75-day program in California, which was covered (except for about $3,000 in out-of-pocket costs) but with new prior authorizations every few days.

Again, once Eli began to respond to treatment, continued care was denied as no longer medically necessary, despite the facility writing (in light of Eli’s recent decompensation), “If aftercare

plan [long-term residential treatment facility] is not followed, client’s prognosis is poor. Parents are unable to contain client, and it is likely that client will regress into old behaviors, which pose a serious risk to client and family safety. Client’s emotional dysregulation remains intense and creates severe disruption in client’s ability to function in daily life.”

The grounds for the denial of prior authorization was frustrating to Joanne. The letter read, “You are motivated for recovery and participating in your treatment. You are medically stable. You are taking your medications as prescribed and doing better.”

This was all true, of course, because Eli was benefiting from the structure of the program. And Joanne had seen Eli’s precipitous decline in the absence of that bolstered support.

She hired a consultant and a lawyer to assist with appealing. She cashed in her 401(k) and liquidated the inheritance that she otherwise would have gotten from her parents. She did everything he could. “We had no choice. It was an untenable situation for everyone, including Eli, to continue living the way we were living and walking on eggshells.”

Joanne and Eli are far from the only patients struggling to navigate this type of health care. And to be sure, there are points at which such a high (and costly) level of care is no longer clinically indicated. But to them, it felt deeply damaging to fail to appreciate the gravity of her condition outside the controlled environment, and the red tape and financial burdens that emerged in this setting often felt insurmountable, and would have been insurmountable if they had different jobs.

Clinical guidelines are important, but their deployment in this space highlight some key ways in which there is progress left to be made in realizing the promise of behavioral health parity.

To read more about other barriers that patients and mental health providers face in in the mental health space (or broader health care), read Coverage Denied.

UnitedHealthcare CEO Tim Noel stated on this policy shift, “Eliminating these requirements is one more way we are working to make it easier for patients to get the care they need when they need it and ensure doctors can spend more time with their patients.” Though it is not entirely clear yet which care will no longer require prior authorization – UnitedHealthcare has specified only “select outpatient surgeries,” “some diagnostic tests, such as echocardiograms,” “some outpatient therapies,” and “some chiropractic care” – this announcement is welcome news to physicians and patients alike.

Prior authorization, or required insurer pre-approval for prescribed care, has long frustrated patients and physicians. A January 2026 KFF tracking poll finds it is the greatest burden that patients face when accessing their health benefits, and American Medical Association (AMA) surveys consistently show high levels of physician burden associated with it, along with risks to clinical outcomes.

This practice began as a cost control tool aimed at preventing overtreatment. Following the explosion of managed health care, prior authorization now extends to most costly care – from prescription drugs to high-tech imaging to wide-ranging tests and procedures – far beyond its original, narrow scope. Guarding against low-value care is appropriate in a country whose health spending dwarfs that of peer nations. But ballooning prior authorization requirements have intensified physician burden and burnout even as health care spending continues to climb.

Rather than effectively controlling costs, prior authorization often shifts costs onto patients and their physicians, who must support substantial staffing to offset the proliferation of paperwork burdens.

Surveying 1,340 patients across the country, analyzing health plan data, and interviewing 111 patients, physicians, and others, I found widespread delays and denials of health coverage – often, though not always through prior authorization – that thrust patients and physicians into the red tape of modern medicine. By necessitating cumbersome, multi-layered appeal processes, prior authorization drives barriers to health care not through outright denial, but through rationing by inconvenience.

When care requires prior authorization, physicians must submit documentation – for example, description of failed drug trials. If denied, they may undergo a “peer-to-peer” review with an insurer-employed physician who is often outside the relevant specialty, increasing the likelihood of erroneous denials and additional layers of appeal.

One physician interviewee reflected, “It’s frustrating because you’re going to win in the end. You know the criteria. You know the patient qualifies for it. Yet you’re battling week after week, delay after delay for what you know they qualify for.”

And while the streamlining and expediting of electronic prior authorization outlined in the recently proposed Centers for Medicare and Medicaid Services (CMS) rule may speed up coverage decisions, it will not pare back the denials that necessitate those appeals that drive widespread paperwork burden and coordination hassles with insurers. As that same physician interviewee noted, “I don’t need a timelier denial. I need an acceptance.”

As physicians juggle these burdens alongside clinical duties and protracted insurance battles, patients may be untreated or receive suboptimal treatment that is less burdensome to obtain. I find that less affluent patients are significantly less likely than others to appeal denials and are more likely to delay medical care and non-medical purchasing while navigating coordination among their physician, insurer, and pharmacy.

These processes occupy non-billable hours for clinicians. It is little wonder why AMA surveys reveal that 40 percent of physicians have staff who are dedicated to prior authorization administration – support more available in large systems than in less resourced or smaller practices.

In fact, one pulmonologist employed at a major university hospital whom I interviewed reflected on this, “If they’re making somewhere around $60,000 a year to be a mid-level administrative professional, we’re talking $300,000 a year in salary alone to deal just with prior authorization, and it still takes two days, and the patient has to go to pharmacy twice. It’s a huge number of resources. And we’re just one department spending this.”

Inequity in physicians’ staffing support is understudied but critical. Black and Hispanic physicians are especially underrepresented in academic medicine and especially likely to work in solo practices, where paperwork burden will fall more on their own shoulders. A policy brief published by the Journal of the American Board of Family Medicine highlights racial disparities in these practices, such that Black and Hispanic physicians are more likely than their white counterparts to operate a solo practice, and less likely to work in a practice of 6-20 providers (see Table 1).

This is no accident. Minority physicians experience lower rates of promotion, contributing to departures from academic medicine that might offer burden reduction. The result is heightened burnout that spills over to their disproportionately marginalized patients.

All of this unfolds amid a severe physician shortage. The American Association of Medical Colleges estimated that an additional 86,000 physicians will be needed by 2036, and when restrictive immigration policies further compromise the nation’s ability to meet the growing health demands of its aging population. 137 million Americans, or 40 percent of the U.S. population, already live in mental health professional shortage areas, and psychiatrists are especially likely to work in solo or two-person practices that lack administrative infrastructure. With this added burden, prior authorization risks making this field less sustainable precisely when demand is surging, leaving a growing share of the population to experience unmet health needs (see Table 2).

One good bit of news through this lens is that geographic disparities in physician burden due to staffing issues may not fall neatly along geographic lines, because hospitals are currently 2.5 times more likely to acquire rural physician practices than urban practices (though this is in reaction to pronounced disparities preceding this shift).

Physicians currently complete an average of 39 prior authorizations per week. This burden increases burnout, adverse mental and physical health consequences, and they may be at greater risk of making medical errors. They may even push clinicians out of the practice of medicine altogether, further eroding access to care as Americans’ health outcomes continue to pale in comparison with high-income peer nations. As one physician interviewee reflected, “Much more often than not, we can get the drugs we need, but only after we jump through all the hoops, thereby delaying care.”

It is thus especially striking that one claim reviewer for Elevance stated in an interview, “We’re told denying things is okay because people can appeal.”

There are undoubtedly reasons to curb low-value care, and appeal processes exist when incorrect decisions are made. But the cumulative effect is widespread patient and physician burden that destabilizes health care delivery.

And given that some denials are driven by administrative error, some of this burden is unnecessary – failing to contribute to appropriate guardrails, instead contributing only to physician and patient burden that is borne disproportionately by those with fewer resources. To take just one example, a neurologist whom I interviewed prescribed an in-lab sleep study for their patient, who was then denied on the grounds that they had not yet had a home sleep study, which they had under that insurance.

“You just paid for this two weeks ago. How is this not in your record? How do you have such little information in your system that you’re not even looking to see that you just paid out that code? Of course, they could. They choose not to. Then I have to get on the phone and call them, I tell them the patient had a home study on this date, and they, say, ‘Okay, we’ll approve it.’ It’s literally a 30 second conversation. But how much delay was there, and what are the chances I don’t call? Maybe I don’t call and I just let the denial go. They do this all the time with drugs too. You’re paying for these drugs. Why don’t you track what they’ve tried and failed?”

To be sure, this is not the modal experience with prior authorization, but it is certainly not anomalous either, And this physician at a well-resourced university hospital often came back to the question, “What if someone can’t incur these costs?”

UnitedHealthcare’s announcement of reduced reliance on prior authorization by the end of 2026 is a welcome step in the right direction, eliminating the application of this process for select outpatient surgeries, certain diagnostic tests, and certain outpatient therapies. The precise scope of these changes is not yet clear, as the full list of affected treatments has not yet been published, but it builds on ongoing efforts to streamline and pare back these requirements that have generated widespread backlash.

Though major insurers have pledged to reduce reliance on prior authorization and have announced an 11 percent reduction thus far, the scale of America’s physician shortage and its ripple effects to patient care demand more than incrementalism, especially at a time when CMS is introducing new prior authorizations to traditional Medicare. UnitedHealthcare’s announcement is important, but this insurer accounts for 15 percent of America’s health insurance market (and, for example, it is Blue Cross Blue Shield that has the largest market shares in most metro areas), and many more patients and physicians need relief from barriers and burdens to which these processes contribute.

Without broader efforts to substantially reduce prior authorization requirements, red tape will continue to undermine both the physician workforce and patients’ ability to obtain timely care.

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!

You know, the stuff that led us to spend our 20s pursuing doctorate degrees, despite knowing that our friends outside of academia were generally having more enjoyable experiences in their 20s and may very well have more lucrative career paths as well.

You know, the reading and production of thoughtful research that got us into this line of work. Perhaps you haven’t totally forgotten it?

I’ll tell you why I am in academia. I had wonderful professors at UC Berkeley – people who introduced me to constitutional law and statutory law, people with whom I debated tensions between individual liberty and national security, people from whom I learned research design, and in a different part of campus, people with whom I delved into great literature by authors like Jane Austen and Virginia Woolf. Like many political science majors, I had planned to go to law school, but I wanted to work first and graduating in the great recession, jobs were scarce. So, I worked on campus at UC Berkeley’s Goldman School of Public Policy in programs, development, and events. But one day, I ran into one of my favorite professors and expressed interest in research, and the rest was history.

I began a full-time research assistant position, hand-coding all of the significant legislation from 1887 to 2008 (why yes, I have read No Child Left Behind AND omnibus budget reconciliation acts, because I know how to have a good time on a Friday night), and realizing that as much as I loved studying law, what I really loved was unpacking through data collection how Congress was designing laws under different political conditions, and thinking about what that meant for public policy.

And the rest was history. Bye bye law school, hello grad school. And I felt fortunate to be able to begin my academic career at Columbia, where I built my methodological toolkit and poured over research, scouring for not just gaps in the literature, but big ideas in the field.

My academic career has been rife with ups and downs, twists and turns. There have been periods during which I’ve been far more engaged with teaching than with research, and more recently, vice versa. But while the ideas have waxed and waned, the constant has always been a love of writing.

At a department party at the end of the academic year that I finished my doctorate, the outgoing department chair said a few words to us. I don’t remember everything he said, but one thing stuck out: There are people who are prolific readers and writers, and one should be a writer.

Now, I love both dearly. Joseph Conrad once wrote, “I assure you to leave off reading was like tearing myself away from the shelter of an old and solid friendship.” As someone who reads constantly but rarely for pleasure, this resonates. There is so much simple joy in curling up on the sofa with a cat, a blanket, and a good book – whether a treatise on the American health care system, the poetry of T.S. Eliot, or a novel by Michael Chabon. What’s more, good writing is often learned by reading others’ good writing, and when I find that words aren’t coming to me as readily and the blank page feels as though it’s judging me, I crack open some Hemingway, and I find clarity in my argument and how I want to convey it.

I have always been, and always will be, a writer.

From writing an unpublished novel when I was in high school to taking advanced fiction classes at 92Y while in grad school to having a forthcoming book Coverage Denied: How Health Insurers Drive Inequality in the United States, it is in my blood.

The writing of Coverage Denied was furious. It was indignant. It was righteous anger. It was a speed that I hope I can get back again without succumbing to a manic episode. But every time I crafted a particularly good sentence or paragraph, or did a satisfying reorganization to promote clarity, or integrated relevant research that contextualized a problem’s ripple effects and made the passage “sing,” there was always satisfaction and joy.

Some social scientists have asserted that AI can do our research better than we can. The reality is that AI could not have written Coverage Denied.

Coverage Denied draws on interdisciplinary literature, administrative data, and my nationwide survey, but it also draws on the 111 semi-structured interviews that I conducted with patients, physicians, former health insurance executives, patient advocates, and health insurance lawyers. As patients and providers welcomed me into their lives, often sharing with me their vulnerabilities, I pieced together new facets of the American health care system’s complexities and failures. This rich analysis of patient and provider lives being upended by health insurance barriers simply cannot be outsourced. And this is true of most of the political science work that I admire and to which I aspire – whether the marriage of data and patient narratives in Fragmented Democracy, the conceptualization of the Divided Welfare State, and so much more.

AI has many valuable uses. It has helped me to find words to trim from an abstract that’s a smidge too long, to punch up a chapter title, to come up with some class activities to break up my lecture, to come up with a list of wrong answer choices for the multiple choice section of an exam, and to design a figure for a lecture slide so that I don’t have to fuss too much with the work that isn’t intellectually rigorous. But good writing comes from good thinking, and AI does not think creatively in new and innovative ways about health care delivery or the American welfare state or federalism. It synthesizes existing knowledge, rather than moving the field forward.

Of course, there are people in the field who are more focused on improving the precision with which we estimate more established relationships. Personally, I find a lot of those papers can be best characterized as mathematical masturbation rather than being conceptually innovative, but if they’re pushing the methodological field forward, more power to them. And when doing more squarely technical work, AI may look like a silver bullet. (I do wish to remind people that while there is a stereotype about academics knowing more and more about less and less, we don’t need to actively reinforce that perception.)

But to characterize AI as outperforming social scientists is not only a bald-faced lie, but it exposes one’s own undervaluing of creative thought and inability to discern (or disinterest in discerning) quality writing that pushes the reader to reconceptualize politics, policy, and law.

As nearly anyone who has graded a paper that was generated by ChatGPT can attest to, AI does not produce good writing. Not only does it hallucinate citations, but it fails to offer any originality or a clear point of view. It produces vague generalities without real insights. It offers a reminder that proper syntax and good writing are not the same, and as a professor I would certainly rather point out how an engaged student can refine their writing to improve their argument than grade another banal paper that is the product of intellectual laziness.

What’s more, this excessive reliance on AI leads me to the inescapable question: Why are you in this field?

Not everyone in the social sciences has an easy alternative pathway to YouGov or Meta, but the “AI will replace academics” crowd typically has the methods chops to have their pick of more lucrative industry jobs. I will never characterize a career as a calling – it is a profession, just as with law, medicine, and beyond – but it is profession that I love and to which we generally gravitate because we love to sit with ideas and converse with the literature and put pen to paper to push the field forward.

I dearly wish my students liked writing and learning the way I always have, but I expect fellow academics to, at least on balance. And we’re in the ideas-generating business. Why would we want to outsource the fun stuff?

I know exactly how I came up with the idea for my first solo paper: I was coding No Child Left Behind as a research assistant and came across a curious provision that seemed to be a workaround from the Supreme Court’s decision in US v. Lopez because it conditioned schools’ funding on guns-free school zones following the Court’s striking of the Guns-Free School Zones Act, which had been grounded in interstate commerce. So, I did a deep dive into Congress’s use of Title VI of the Civil Rights Act of 1964 to condition federal funds on regulatory compliance, potentially in domains where more direct enforcement mechanisms were foreclosed, and before I knew it, I had an article acceptance. And not only was that an obviously desirable outcome as a graduate student, but the process was fun!

Apart from being saddened at the thought of anyone wanting to outsource this enjoyable creative process, as opposed to using tools to finesse and tighten prose, I worry about the way that graduate students are thinking about academic careers when this framing in Substack posts, on social media, and beyond is becoming the model. Good teaching and mentorship inspired my pursuit of an academic career and reading good research inspires me to produce that myself, and I hope that that isn’t lost amid overreliance on these new bells and whistles that rob of us the intellectual rigor that is, or should be, our bread and butter.

I try – admittedly with imperfect success – to instill in my undergraduate and graduate students a love of learning and an appreciation of writing. And no matter what advances come our way (and of course, I dearly hope the AI bubble bursts as soon as possible), that’s not changing.

And with that, I am stepping off my soapbox. For now.

As a health policy professor, I often talk with my students about social determinants of health, or the array of non-medical factors (e.g., education, poverty, environment, housing) that profoundly affect our health. In fact, while medical care accounts for 10-20 percent of our overall health, social determinants account for the remaining 80-90%! In fact, this helps to shed light on why America’s exorbitant health spending has such a poor return on investment in terms of health outcomes: we concentrate our investments on the health care side of the equation while spending comparatively less on social supports. The result is something akin to pouring water down an open drain: we have the investment (the water) but we can’t build the reserve.

Of course, budgets reflect political values and America’s underinvestment in its safety net (well, more recently, its hollowing out of its safety net) is the product of intentional political choices. But there are also an array of political choices – from gerrymandering to dilute political competition to campaign finance laws that can allow corporations to drown individuals’ political voices to laws directly taking aim at voting rights – that fall under the umbrella of political determinants of health, or the political decisions that drive health access and outcomes by reshaping the strength (or lack thereof) of political representation and whose interests are advanced on Election Day.

U.S. voter turnout already lags in comparison to many OECD countries, and there are notable participation gaps along race and class lines, as well as health lines: people in poor health are less likely to vote. And this health bias can be recursive because politicians have more incentive to be responsive to higher-propensity voters, which can perpetuate policies that exacerbate health-voting participation gaps.

This is a problem. It is hardly surprising that someone who has lived experience with Medicaid or SNAP, or whose health is otherwise in the crosshairs in moments of proposed health reform, would have a vested interest in the election of a certain type of candidate who might differ from the preference of someone who is healthy, has not had to navigate public programs, and consequently may see less value in raising taxes to invest in programs that promote equitable access to health care. Political scientist Jamila Michener’s Fragmented Democracy illustrates beautifully, albeit painfully through administrative data and interview-based evidence the salience of the intersection of health, poverty, and feelings of political disempowerment that can all too often be self-reinforcing. And a report by The Century Foundation found that non-voters are more supportive of expansions of the safety net… but until they turn out on Election Day, their voices are muted.

Which brings us to the SAVE Act.

Let’s start with disabusing ourselves of the misguided notion that widespread voter fraud is a problem in American elections. It’s not. Comprehensive analysis by election law scholar Justin Leavitt found that among nearly a billion votes cast between 2000 and 2014, there were just 31 credible cases of voter fraud.

Not 310,000. Not even 31,000. 31.

The Brennan Center for Justice compiled a number of other studies, estimating (for example) that the upper bound on double voting was 0.02% (though likely much lower), the absence of widespread voter impersonation, and just 30 cases of suspected noncitizen voting from among 23.5 million votes cast. Even the conservative think tank The Heritage Foundation, which orchestrated Project 2025, found only a miniscule number of credible cases of voter fraud. And when we consider the odds of being a pivotal voter, even as I write this in Pennsylvania, it is little wonder why comedian John Oliver compared the value of voter fraud to risking criminal penalties to forge a Bed, Bath & Beyond coupon.

I’d say that voter ID laws are a solution in search of a problem, but they’re really a solution to a different problem: people of color having the temerity to participate in the democratic process, and those seeking to suppress these votes are gallingly doing so with the blessing of the Court majority led by John Roberts in Shelby County v. Holder. And while most people do have a form of government-issued ID, it is neither universal nor costless to obtain, whether taking into account the direct costs (it costs $45.50 to get an initial driver’s license in Pennsylvania) or opportunity costs of the time and effort to obtain it, which may bring into the picture social determinants of health barriers (e.g., if the office is not accessible via public transportation). Not only do nearly 29 million U.S. citizens lack a non-expired driver’s license, but 7 million lack any other form of government-issued photo ID. And of course, non-possession of a government-issued ID is unevenly distributed, with Black and Hispanic, less affluent, and lower educational attainment individuals especially unlikely to have a current ID, with the potential result that there will be further inequities in ability to exercise the constitutionally protected right to vote.

But as if these inequities weren’t bad enough, the SAVE Act is not an ordinary voter ID law. It does not compel the provision of a state ID or driver’s license, but rather proof of citizenship in the form of a passport or driver’s license.

Not only do only about half of Americans have a passport, but there is marked geographic variation, ranging from 20.7% (West Virginia) to 79.9% (New Jersey), raising the notable irony that this policy would exacerbate administrative burdens the most in red states. (The states with the lowest rates of passport possession are West Virginia, Mississippi, Alabama, Arkansas, and Kentucky.)

So, you don’t have a passport. That can be remedied, right?

Yes, but it’s not so simple. The cost of a first-time passport book is $130, which is a nontrivial price tag and arguably a poll tax by another name. (Remember, poll taxes didn’t cost an arm and a leg – around $35 in today’s currency – but the way that they were administered were strategically prohibitive barriers, ultimately giving rise to the 24^th Amendment.) What’s more, poor health and poverty can be bidirectional: not only do illness and disability make it harder to sustain gainful employment, potentially trapping people in poverty conditions, but as anyone who has had to choose between groceries and prescriptions (or had to remove things from the conveyor belt as costs add up) can tell you, the stresses of economic precarity take a toll on physical and mental health, reinforcing this constellation of hardships.

And let’s think about the logistical process of obtaining said passport, and the administrative burdens therein. One must fill out a form online and print it (assumptions: home broadband and possession of a printer). One must have evidence of citizenship in the form of an original birth certificate or a full validity, undamaged passport (assumption: possession of an original copy of one’s birth certificate). One must obtain a government-issued photo ID – or two, if one’s ID is from another state (assumption: possession of a government-issued photo ID, which as discussed above is not costless to obtain). And one must print a high-resolution recent color photo, which may require a trip to get a passport photo taken.

Now imagine doing all of this when feeling physically or mentally unwell. Or being disabled. Or juggling medical appointments and other responsibilities.

Administrative burdens can impede access to many benefits to which people are entitled. One need look no further than Medicaid work requirements, which led 18,000 Arkansans to lose Medicaid coverage despite working or being exempt. And I have worked to show that red tape can impede access to health benefits because even though appeal processes are in place when barriers arise, less affluent patients don’t appeal as often, and sicker and Black and Hispanic Medicaid patients tend not to prevail as often. While burdens can be felt throughout the population (you’d be hard-pressed to find someone who enjoys schlepping to government agency offices and filling out long and complex forms), these burdens are often felt disproportionately by those who are living on the margins – whether living paycheck to paycheck, lower health literacy and administrative capital, or battling health conditions that at once raise the costs borne by patients as well as the stakes of being unable to fulfill bureaucratic directives.

All told, researchers at the Brennan Center estimated that 9 percent of voting-age American citizens lack proof of their citizenship and would be disenfranchised under the SAVE Act – whether because their documents are in someone else’s possession (e.g., their parent has their birth certificate) or because their documents were lost, destroyed, or stolen. Notably, they state that this is likely a conservative estimate and unsurprisingly, there are racial inequities, such that America would witness worsened voting participation gaps and poor substantive (and likely descriptive) representation for those from historically underrepresented groups, which also happen to be on average in worse health.

So, what we’re left with is a bill that is blatant voter suppression poorly cloaked in concern about election integrity, imposing senseless financial and administrative burdens that are facially neutral toward U.S. citizens but which are felt most acutely by racial and ethnic minorities, those who are lower-income or who have less educational attainment, and who experience disability and health conditions that raise the costs of compliance with these new and senselessly onerous terms – all to exercise an ostensibly constitutional right as opposed to a policy benefit. It is a poll tax by another name and must be treated as such.

And what happens when those in power are not facing voters who are bearing the costs of their misguided health polices? When the electorate that is not simply eligible in theory, but capable of voting in practice has never felt the pinch of rising health care costs or the strain of navigating health-related administrative burdens? Lived experience matters. It can help to shed light on policy defects that were unanticipated. It can elevate the importance of putting issues on the legislative agenda. And without it, policy runs the risk of being poorly delivered (whether intentionally or inadvertently) to the target population, and patients suffer. Demands for health reform do not accrue, or do not resonate. Feelings of political disempowerment become validated and persist. Rinse, repeat. E.E. Schattschneider’s famous conceptualization of “a new policy creates a new politics,” but the health policies that emerge from these feedback effects run the risk of systematically leaving key populations behind.

Infuriatingly, this is a feature, not a bug. And unlike many other domains of failed policies, by reshaping the contours of the American electorate, it would be an especially difficult one from which to reverse course.

The SAVE Act has garnered ample support thanks to a good old fashioned American combination of ignorance, racism and xenophobia, and cowardice in the face of threats of primary challenges from the most conservative segments of the Republican Party.

Concern will not help the patients who become governed by politicians who do not have health care interests in mind.

Concern will not help salvage what is left of the American democratic process when voting rights are put in a shredder.

And rest assured, concern will not spare the political careers and legacies of politicians whose cowardice dominates fidelity to the Constitution.

If we care about health, equity, and the integrity of American voting, it is imperative that we recognize the SAVE Act for what it is: a deliberate effort to narrow whose voice counts in America. It is a war against democracy, and a war against public health.

Call your members of Congress to oppose the SAVE Act. 202-224-3121.

I’ll start with the personal. Even though I was born in the wrong decade (my top three artists are Springsteen, Dylan, and The Beatles, and Spotify estimated my age at 78 in my most recent Spotify Wrapped), Bruce is the soundtrack of my life. I began seeing him in 1995 at the Bridge School Benefit Concert at the Shoreline Amphitheater in Mountain View (for when you need The Boss with a side of Hootie) and then on the Ghost of Tom Joad Tour in 1996. My first Springsteen shows with the “heart stoppin’, earth shockin’, earth quakin’, heart breakin’, air conditioner shakin’, Viagra takin’, history makin’, legendary” E-Street Band were in the three Oakland Arena shows on the 1999 reunion tour. Memorably, my mom and I waited outside for hours for tickets (an experience my students will never have) and only had tickets for the first two nights, then showed up on night three, got behind the stage tickets from a scalper, and had the time of our lives. And so this then-thirteen-year-old was hooked, and I mean hooked. When The Rising was released, my mom and I drove around the Bay Area listening to it on repeat, stopped for lunch, then drove some more, immediately falling in love with it and deciding which states we could plausibly travel to in order to maximize our time with The Boss (Portland, OR was drivable from the Bay Area and my grandmother lives in Florida so we could schedule an overdue trip around that show, and mercifully more northern California dates were added.

And from the general admission pit, leaning on the stage over the course of many tours, I received from the band two setlists (framed in our living room), blew kisses to Bruce, supported Bruce when he crowd surfed over me (why yes I did support a part of his anatomy featured prominently on a certain 1984 album cover), said hi to Clarence (rest in power), had my sign request taken (“I Came From Harlem FOR YOU,” and in another instance laughed at: “Professor Seeking Professor for NSA Dance”), and made more memories than I could have ever dreamed as a merely wannabe Jersey Girl from firmly middle-class roots. And perhaps most importantly, while waiting in line for the bus from the Meadowlands to the Port Authority in 2012, I met someone who has become one of my two closest friends in the world, with whom I did a memorable duet to “Thunder Road” at my wedding, after I quoted from “If I Should Fall Behind” in my wedding vows and before my husband and I had our final dance together, to Kingdom of Days,” a lovely song on a mediocre album, about growing old with the love of your life (“we laugh beneath the covers and count the wrinkles and the grays”).

With Bruce, it isn’t just music. It is yearning. It is urgency. It is conviction. It is righteousness. It is storytelling about all too forgotten voices in American communities from the Jersey shore to California’s central valley and everywhere in between. In his most recent concerts, it’s been a contemplation on mortality and making every moment count. “It’s your ghost moving through the night, your spirit filled with light, I need, I need you by my side, your love and I’m alive.”

John Lennon and Bob Dylan are the true masters of the “fuck you” song. (Oh the hours I’ve spent fantasizing about singing “Positively 4th Street” to Trump…) Bruce’s anger is often tied to disillusionment and broken dreams, but in the end, there is always redemption. To paraphrase Jon Stewart at the Kennedy Center Honors, when you listen to Bruce’s music, you aren’t a loser; you are a character in an epic poem… about losers.

And of course, in the aftermath of the tragic murders of Renee Good and Alex Pretti, Bruce released his new song, “Streets of Minneapolis,” filled with an unmistakable righteous outrage at the lawlessness terrorizing American cities at the direction of the current occupant of the White House:

“Against smoke and rubber bullets, in the dawn’s early light
Citizens stood for justice, their voices ringing through the night
And there were bloody footprints where mercy should have stood
And two dead left to die on snow-filled streets, Alex Pretti and Renee Good

Oh our Minneapolis, I hear your voice singing through the bloody mist
We’ll take our stand for this land and the stranger in our midst
Here in our home they killed and roamed in the winter of ‘26
We’ll remember the names of those who died on the streets of Minneapolis”

The conditions now are more dire than ever, as America descends so far into authoritarianism that even Neil Gorsuch is beginning to see the light. And amid so many challenges our nation has faced, Bruce has not only always had public service announcement to support local food banks, but lent a voice to the downtrodden and shined a light on injustices… at least for those looking beyond the energetic beats of songs like “Born in the USA” and “Badlands” to listen to the meaning. (Arguably, if the 1982 version of “Born in the USA” had been released instead, while Bruce wouldn’t have quite the same net worth, he would have had fewer Reaganites coopting his music to wrap themselves in the flag while stepping on the American dream.) Beyond the romance of my favorite song, “Thunder Road,” and the coming-of-age of “Growing Up,” one finds a portrait of American struggle that only the Boss himself can do justice in capturing, echoing the struggles of everyone from Vietnam veterans (even drawing on John Kerry’s Senate Foreign Relations Committee speech for inspiration: “How do you ask a man to be the last man to die in Vietnam? How do you ask a man to be the last man to die for a mistake?”) to those facing broader economic turmoil and self-doubt.

On the 1999 Reunion tour, Bruce debuted two poignant songs – one calling attention to an injustice that tragically has persisted, and another a portrait of hope and redemption in the face of despair.

On February 4, 1999, the unarmed 23-year-old Amadou Diallo was shot and killed when the New York City Police Department fired 41 bullets at him, 19 of which struck him. This was hardly the first example of police brutality, in particular toward people of color, and far too little has been done to address these systemic injustices that I have proudly marched in the streets of New York City and Los Angeles to combat (even acquiring the badge of honor of an arrest by the LAPD due to a curfew violation with BLM in June 2020). There are policy solutions that we know are not only possible, but necessary, from body cams to accountability of police officers who have committed infractions to not hiring police officers with domestic abuse records. And of course, music is not substitute for policy change. But as we’ve seen with songs like “Hurricane” and “Blowin’ in the Wind” by Dylan, and the eternal “We Shall Overcome,” music can animate, move, and raise to public awareness these injustices that not every corner of society sees, but which are all too real for those living on the margins.

In October 1999 in Oakland arena, I listened to Bruce perform “American Skin (41 Shots)” and I cried as he highlighted the fear with which far too many Black and Brown people feel in interactions with law enforcement:

“41 shots, Liana gets her son ready for school
She says, “On these streets, Charles, you’ve got to understand the rules
If an officer stops you, promise me you’ll always be polite
And that you’ll never ever run away
Promise Mama you’ll keep your hands in sight

Is it a gun? Is it a knife? Is it a wallet? This is your life
It ain’t no secret (it ain’t no secret)
It ain’t no secret (it ain’t no secret)
No secret my friend
You can get killed just for living in your American skin”

And of course, I recognized my own privilege because I do not have the demographic characteristics that would make me likely to be questioned by police if my hands were not in view, or be subjected to an inappropriate search.

This was hardly the only song I heard that tour that was a call to action: As a native Californian who often went to Sacramento, it was hardly uncommon to see laborers facing not only fears about immigration status, but dire working conditions. Don’t let anyone tell you that immigrants are taking jobs that Americans want… or if they make that argument, invite them to spend a day picking avocados and then ask them how their back is feeling and how they feel about those wages relative to the physical toll, not to mention in the summer heat that often surpasses 100 degrees.

Enter The Ghost of Tom Joad, both the title song (inspired by one of my favorite books, The Grapes of Wrath) as well as the lesser-known ballad “Sinaloa Cowboys,” telling the story of immigrants trying to make a living working in the orchards and then falling down the path of helping to make drugs at a Central Valley ranch, leading one of them to die.

“They left their homes and family
Their father said, “My sons one thing you will learn,
For everything the north gives, it exacts a price in return.”
They worked side by side in the orchards
From morning till the day was through
Doing the work the hueros wouldn’t do…

You could spend a year in the orchards
Or make half as much in one ten hour shift
Working for the men from Sinaloa
But if you slipped the hydriodic acid
Could burn right through your skin
They’d leave you spittin’ up blood in the desert
If you breathed those fumes in.”

All too often, especially under the Trump presidency, people degrade and dehumanize immigrants, not only lacking the compassion that should be afforded anyone trying earnestly to make a living and simply exist in a world that seems to constantly impose on them seemingly Sisyphean tasks to simply be employed and insured, but also apparently forgetting the very fabric of how America was built.

We are a nation of immigrants, and I’m damn proud of it. I’m a European mutt who spent college teaching ESL and creative writing to students whose immigration status I couldn’t have cared less about, and whose professional life is enriched every day by the perspectives of my diverse cohort of students, many of whom are international or first generation or otherwise from communities unlike my own.

Enter “American Land,” which appeared on the 2012 album Wrecking Ball but which he debuted in 2006 on the Seeger Sessions tour and shined a light on the immigrant roots that run deep in New York City and beyond:

“There’s diamonds in the sidewalk, there’s gutters lined in song
Dear, I hear that beer flows through the faucets all night long
There’s treasure for the taking, for any hard working man
Who will make his home in the American land…

The McNicholas, the Posalskis, the Smiths, Zerillis too
The Blacks, the Irish, Italians, the Germans and the Jews
They come across the water a thousand miles from home
With nothing in their bellies but the fire down below

They died building the railroads, they worked to bones and skin
They died in the fields and factories, names scattered in the wind
They died to get here a hundred years ago, they’re still dying now
Their hands that built the country we’re always trying to keep out.”

I’m not sure that there’s a better encapsulation of America ignorance about our roots, and the devastating consequences on full display with ICE’s lawlessness, than that last line. Whether it’s my great grandmother coming from central Europe to the US only knowing the words “I go” but enabling her daughter – my grandmother – to grow up to work in the California State Capitol, or whether it’s the ESL students I tutored while working my way through UC Berkeley, we all have an immigrant story (some more recent than others) and deserve to work toward what the American dream means for us. Bruce’s music reminds us of that.

Of course, the American experience is deeply flawed even for those of us whose families have been here for generations (not that that seems to insulate us from ICE’s inhumane tactics), and so much of Bruce’s music is about those trying to make ends meet, hitting walls, and feeling as though so many once closely-held dreams and promises have been broken. All too often, what once appeared to be opportunity becomes obscured by disillusionment, a sentiment that Bruce echoes arguably better than anyone.

One of my favorite songs is “The Promised Land,” and I couldn’t tell you how many times – in the depths of despair, or when feeling like my best was never good enough (another good Bruce song from Tom Joad) – I listened again and again to the lyrics:

“I’ve done my best to live the right way
I get up every morning and go to work each day
But your eyes go blind and your blood runs cold
Sometimes I feel so weak I just want to explode
Explode and tear this whole town apart
Take a knife and cut this pain from my heart
Find somebody itching for something to start.”

And of course, this is a rocker that elicits fist pumping determination at redemption. The acoustic version that I heard for the first time on the Devils and Dust tour at Oakland’s Paramount Theater felt different, not just because it was muted, but because it wasn’t clear whether he still believed in these possibilities that we so often latch on to as we hear the opening harmonica chords.

And of course, who (other than Ronald Reagan and his acolytes) could forget the eternal words of “Born in the USA”: “You end up like a dog that’s been beat too much
Till you spend half your life just covering up.”

When Bruce announced his new tour, making zero secret of the fact that it was in direct opposition to the seemingly daily atrocities and constitutional violations that we’re witnessing (and which make Watergate look, quite frankly, quaint by comparison), the White House issued a statement that made a number of Springsteen references, a poor effort at getting a rise out of him. But the reality is that Trump is exactly who Bruce has been singing about for decades, every time he plays a song I love so much that I had its lyrics tattooed onto me. That song, of course, is “Badlands.”

Trump has everything he could possibly need, and then some. He has enriched himself while in office well beyond what the Emoluments Clause of our Constitution permits. He golfs more than the demands of the presidency should allow. He has hangers-on who dote on him as much as their collagen-filled bodies will allow. And yet when the Supreme Court had the temerity to rule against him on tariffs, he announced that he would not withdraw, but rather increase the tariffs to 15% (further complicating geopolitics and harming Americans’ pocketbooks). He is the very embodiment of,

“Poor man wanna be rich,

Rich man wanna be king,

And a king ain’t satisfied

‘Til he rules everything.”

(And boy do I wish Trump were the Chicken Man.)

From the rustbelt of Youngstown, OH (“Youngstown”) to the agricultural fields of California (“Ghost of Tom Joad”) to the economic depression of Asbury Park (“My City of Ruins,” “My Hometown”), to the working man’s struggle as bankers enrich themselves (“Jack of all Trades”), to a couple struggling with crippling debt such that “there’s winners and losers and don’t get caught on the wrong side of that line” (“Atlantic City”), Bruce’s music reminds the downtrodden that they still matter. That they are heard. That they are seen. And in a nation whose vulnerable and conscientious communities currently live in alternating states of fear and anger, that is precious.

I wish that my doctorate in political science helped me see a way out of this nightmare. I lost track of the number of nights I’ve wanted to find a reason to believe, but listened to “The Promise” instead. But even without a clear end in sight, we know that there will be a time after this. Midterm elections are this November, hence Republican determination to impose poll taxes by another name. The mixed blessing of America’s election administration fragmentation is that it is difficult to have a comprehensive assault on American election administration, though to be sure John Roberts as well as those who are pushing for the SAVE Act are doing their darndest. And even without much more than a glimmer of hope, putting one foot in front of the other is not only important, but necessary.

I am devastated for our country, but I am also determined. In these dark times, alongside elevating the voices of the too many people and communities left behind by failed policies, Bruce’s music provides the essential reminder: Dreams will not be thwarted, faith will be rewarded.

Thanks, Boss.

As the foundations of American public health have been threatened at best and crippled at worst, and as America experiences a senseless, avoidable measles epidemic, Americans deserved answers. What they got was gaslighting and evasion (as well as a glimpse at the sorry state of the United States Senate).

Let’s start with the cagey responses that evaded direct answers to things for which there is ample scientific evidence:

Bernie Sanders: Do vaccines cause autism?

Jay Bhattacharya: I do not believe that the measles vaccine causes autism.

Sanders: I didn’t ask about measles. Do vaccines cause autism?

Bhattacharya: I have not seen a study that suggests any single vaccine causes autism.

As much as those testifying on the Hill seem to categorically revile “yes or no” questions, in a normal world, the Director of the National Institutes of Health would be able to assert clearly, without evasion, “No, vaccines do not cause autism.”

But of course, we’re not in a normal world, so instead we get the much narrower reference to a “single vaccine,” which raises questions about how he is thinking about the MMR vaccine, which is a combination of three vaccines in a single shot. In fact, the dangerously misguided change to America’s childhood vaccine schedule was focused on having fewer shots per visit, bizarrely relying on the country case of Denmark, which had a recent whooping cough epidemic and which has a much more robust safety net to support its citizenry if they fall ill.

What’s more, Bhattacharya pushed back on some of the Democrats’ (factually accurate) vaccine statements, saying “You can’t just say vaccines. You have to say vaccine-by-vaccine,” and said that some vaccines are less well-studied than MMR.

Repeat after me, Jay: Vaccines do not cause autism. And no, you don’t need to rush to RFK Jr.’s defense, claiming that he has been “caricatured quite unfairly.” We see the interviews, and we see the context in which he is questioning sound science (might I add, without a scientific background).

Sprinkled throughout Bhattacharya’s responses were conservative talking points that would have made Justice Alito happy (and that’s never a good thing). In response to Patty Murray’s question about research with fetal tissue, Bhattacharya replied, “There are alternatives available. Using tissue from aborted embryos – aborted babies – is not necessary for science.” Subtle, Jay. Subtle. Patty Murray isn’t wrong when she called this a “political decision by the NIH.”

Now let’s dive further into the gaslighting. The lies. There were a lot of them.

“We didn’t cut any research funding.” “I do not believe patients’ care was disrupted” when clinical trials were forced to cease operations due to funding issues. “There is no war on science.”

Talk to virtually anyone in a public health school about what government-funded research has been like over the last year. Finding researchers whose grants were canceled because they were out of alignment with the administration’s priorities is like shooting fish in a barrel.

To be sure, grant funding was always competitive. But under previous administrations – whether Democratic or Republican – the focus was on the aims. The promise of the research. The innovation. The qualifications. Under this administration, vast realms of public health research have been swept up into the abysmally misguided “DEI” executive order because we deign to acknowledge that structural racism plays a role in health, or that we’re in a Black maternal health crisis, or that ensuring vaccine equity is an important public health goal.

But it’s 2026, so that’s crazy talk.

And sure, many many grants were restored. But it wasn’t because the NIH was being charitable or pro-science. It was because of court orders to address illegal grant terminations. “We recognized judicial legitimacy” doesn’t deserve a pat on the back — it’s literally the bare minimum (though too often under the Trump Administration, even that low bar isn’t met.

To say that there is no war on science when people studying health inequity or vaccines cannot qualify for grant funding is as baffling as it is infuriating.

And for Bhattacharya to blame researchers rather than the NIH for disruption of clinical trials’ operations – which he asserted to Maggie Hassan – feels akin to an arsonist blaming a homeowner for not having critical documents in order before their house was burned to the ground. “I ordered that there would be continuity of care” is far from feasible when support is being wildly disrupted, with limited communication amid frequent and chaotic changes… chaos that has proven to be a feature and not a bug of this administration.

One thing that was unmistakable in the hearing was Bill Cassidy’s buyer’s remorse.

Jay Bhattacharya: We have to reestablish trust in public health. If you just double down on the same, we’re not gonna change it.

Bill Cassidy: Now we have a measles outbreak among those who did not trust. To further cast doubt upon the vaccines for no scientific reason - that’s not gonna increase trust.

He stepped in it, and he knows it. Be prepared for a robust Bill Cassidy Rehabilitation Tour, and don’t let him get away with it. As a physician who is not conspiratorial, Cassidy cannot plausibly feign the ignorance of many of his colleagues (*cough* Tuberville). He knew the science, and he knew the lies he was being fed, but he was too concerned about a primary contest to bother prioritizing the public health system on which we all depend.

Of course, this hearing had the classic “wow, what state had to scrape the bottom of the barrel so much that they elected this guy to office?” moments. Apparently the junior senator from Indiana, Jim Banks, needs to be reminded that just because Massachusetts and Indiana have roughly the same populations doesn’t mean that Indiana is entitled to equivalent levels of NIH funding… at least not until Indiana develops multiple research hospitals on par with Massachusetts General Hospital and Brigham and Women’s Hospital (to start… and let’s not forget the many premier universities even just on the red line despite the This Is Spinal Tap joke that Boston isn’t much of a college town).

But in between those moments of “I cannot believe these are the people running our government” when looking at the Senate majority, there was a much greater sense of not surprise, but nevertheless fury at Bhattacharya’s unwillingness to confront the reality that under his leadership and the direction of Donald Trump, the NIH has deeply damaged our once strong public health institutions, sowed widespread distrust in highly effective vaccines – distrust that will literally kill people (we had three measles deaths last year and this year’s case count is already dwarfing 2025) – and it’s unclear how or when that trust will be rebuilt.

I basically grew up working on political campaigns, and certainly was a political junkie from the outset. (I hope you were sitting down for that breaking news.) And unlike many of my friends, students, and others, I didn’t come out of the gate with particularly cynical impressions of those in politics – I don’t hero worship and I know that there is a certain type of person who enters that line of work, but I believe that we can and should demand responsiveness, empathy, and accountability, and while I don’t want to make the perfect the enemy of the good, I don’t believe that we must settle when it comes to critical issues that strike at the heart of our values. Unfortunately, I don’t get the impression that that is the modal perception of our elected officials, let alone those within the Trump Administration.

The dedication to public service and public health that we can and should demand of our NIH Director wasn’t evident, and in its place we get entitlement to lie and evade questioning about critical issues affecting health care access, research agendas, and more. And we should not be comforted by his assertion to Patty Murray, “I can guarantee that we will focus our clinical trial offers on advancing health and not an ideology.”

Like many of my colleagues in political science and public health, I am weary. I am livid. I am fearful, especially for those more vulnerable than I. And, let’s face it, the pace of my becoming gray-haired has accelerated appreciably.

My Michigan coauthors and I analyzed in Lancet Regional Health-Americas the first 100 days of institutional arson toward American public health, so I will not repeat that here (though to contextualize the scale of what transpired, our first draft clocked in at over 11,000 words). And a lot of shit has gone down since then – perhaps most notably in health care, the ax to the American welfare state through the not-so-beautiful bill and the upending of our childhood vaccine schedule, to our detriment (thanks, Bill Cassidy).

And that doesn’t even get into the daily assault on American democracy, engaging in takeovers of American cities to terrorize anyone who deigns to speak another language or look a little different – or, hell, is just exercising the First Amendment right to protest. You know, like a “free speech absolutist” might.

And even that doesn’t get into the daily geopolitical fuckery that will take incalculable time to repair with our allies – or as they might call themselves at this point, our former allies.

There’s a lot of fury to go around. And we are the baddies.

(Forgive me while I take a minute to weep at my much earlier thoughts that George W. Bush was the worst thing that could happen to America. But no, I’m not doing revisionism on those atrocities.)

To be honest, I’m not even sure that my greatest rage is toward the occupant of the White House, because I only ever expected him to insult, infuriate, and denigrate everything that our nation stands for.

I am not an optimist by nature. I fancy myself more of a realist than a cynic, though the last several years has certainly been a delicate dance between the two. I assumed that Trump would take every ounce of power and then some and run with it. But after years of hearing (arguably bullshit arguments) about “constitutional conservatives,” I hoped that even if congressional Republicans would gleefully rejoice in the demise of the American welfare state that they revile despite their constituents benefiting from it, at least a sufficient number of them might take issue with the lawless takeovers of American cities, needless trade wars that will upend the American economy (and is already showing troubling signs), the insane efforts to seize land out of petulance over not winning a Nobel (someone needs a reminder about the best things in life being earned), the hollowing out of critical agencies that go well beyond Republican goals to shrink government, and the daily authoritarian chaos including the suggestion that we should even not have midterm elections. Instead of accountability — you know, Congress’s Article I responsibility — America has gotten enabling and even empowerment from people placating this president with servile obsequiousness beneath the dignity even of a branch that many Americans look upon with the disdain they do of cockraoches.

And I am horrified by the extent to which all of this has been with the blessing of Chief Justice John Roberts, who not only gutted a key portion of the Voting Rights Act of 1965 in Shelby County v. Holder (2013), but authored the immunity decision of Trump v. United States (2024). Roberts will be remembered with all the fondness of Taney, and he will have earned every ounce of that revile (no, salvaging most of the Affordable Care Act does not offset any of that).

I do not have high hopes for Year Two. I am hoping that this November, there will be accountability, though that will demand that Democratic leadership meet this moment in a way that – for reasons that elude me – Senator Schumer seems fully resistant to doing. Public opinion has shifted markedly against this Administration, and it is only continuing to get more chaotic as Trump becomes increasingly unhinged, without grownups left in the room to temper his worst impulses.

It’s going to be a rocky, infuriating, galling ride, and I am in this fight. I hope you are too. In the meantime, a playlist that may resonate on this January 20 or on “one of those days,” which these days feels like every day.

Back to work…

Playlist for Today (or When the Moment Strikes)

• Positively 4^th Street (Bob Dylan)

• Gimme Some Truth (John Lennon)

• Lawyers, Guns, and Money (Warren Zevon)

• Million Dollar Loan (Death Cab for Cutie)

• Troubled Times (Green Day)

• Gaslighter (The Chicks)

• Fortunate Son (Credence Clearwater Revival)

• Crippled Inside (John Lennon)

• Idiot Wind (Bob Dylan)

• Masters of War (Eddie Vedder cover of Bob Dylan)

• FDT (YG, Nipsey Hussle)

• American Land (Bruce Springsteen)

• This Land Is Your Land (Woody Guthrie)

The nearly two-hour-long interview got narrowed down to a minute or two of air time, so for those who were moved by the stories you saw, I thought I’d take a moment to offer some broader context for the book, which is available for pre-order through Cambridge University Press and Amazon.

It is not an accident that I wrote a book on health insurance coverage barriers. Not only had I had a number of experiences of health insurance barriers and administrative burdens while a graduate student and shortly thereafter, but upon beginning my postdoctoral fellowship in health policy at UCLA, everything was getting denied. Consumed with anxiety while on the phone with my health insurer, I made mental to-do lists of all the things I needed to be working on when instead I was fighting insurance battles that I realized I was as equipped as anyone to fight. If it was this challenging for me, what on earth would my neighbor do in this position? And so, the book was borne…

Coverage Denied combines survey research, administrative data from select states, and 111 interviews to probe the political foundations of health insurance barriers, the scope of this health policy problem, the way that it deepens health and economic inequities through the imposition of administratively burdensome appeal processes that marginalized patients are ill-equipped to navigate, and the way that it reinforces physician administrative burden and, in turn, burnout.

That prior authorization and claim denials would disrupt patients’ health care access and financial security may be unsurprising, especially to those who have more extensive experiences navigating the complexities of the American health care system. But the intensity of this patient experience is striking, with one interviewee commenting, “Winning an Emmy Award was easier than getting my insurance company to pay for my care.”

That this would deepen inequitable experiences of administrative burden may be a bit less obvious, though for those who have navigated protracted and anxiety-inducing insurance appeals, it may resonate. I characterize this health insurance practice as “rationing by inconvenience”: the denials issued are not final per se, but the appeal processes are cumbersome and place significant time, energy, and health literacy demands on patients (with health literacy being unevenly distributed among the population), as well as demanding significant resources of medical practices, many of which have dedicated staff to manage health insurance administration. In fact, though the average American adult reads at an eight grade level, ChatGPT estimated that UnitedHealthcare’s description of its appeal processes was written at a 12^th to 13^th grade level.

It is little wonder why I find that less affluent patients are significantly less likely than their counterparts to appeal, and that patients not appealing cited challenges such as lack of knowledge or understanding about the appeal process as well as skepticism about the value of appealing.

Thus, many people do not appeal, and health care is rationed not through final denials but rather through the accumulation of administrative barriers and inconveniences of patients and their prescribers.

Patients discussed contemplations of divorcing their loving spouses in order to become Medicaid-eligible. Of postponing important home or car repairs to accommodate unexpected medical expenses. Of depleting retirement savings to ensure their child’s access to behavioral health care. And navigating the health insurance runaround while lying in their hospital beds, even facing hospitalizations that would have been obviated if their outpatient prescriptions had been approved in the first place.

Meanwhile, physicians spoke to the “black box” of prescribing amid inconsistent and ever-changing formularies, the “song and dance” of prescribing, peer-to-peers with people who were less than their peers, and appeals with the submission of information in unreasonably narrow time windows (information that often had already been provided).

And though Congress has sought to enact the Ensuring Seniors’ Timely Access to Care Act, which if passed would have expedited prior authorization processing by Medicare Advantage plans, as one physician characterized the misguided focus, “I don’t need a timelier denial. I need an acceptance,” a sentiment that was echoed across many interviews that characterized these insurer processes as akin to practicing medicine without a license.

Coverage Denied lays out these challenges – from both patient and physician perspectives – across a broad range of health care and draws on American political economy, health services research, public policy, historical, and legal analysis to offer the first comprehensive account of how we got here, the harms wrought by this system, and what can be done (at least if the American political system becomes more conducive to health policy reform, which is notoriously fraught). I’m admittedly biased, but this may be especially vital to understand as new prior authorization requirements come to traditional Medicare, and as artificial intelligence tools occupy an increasing role in health insurers’ coverage determinations.

If you were interested in or enraged by the CBS Sunday Morning segment, I hope you’ll pre-order Coverage Denied, which offers both historical and contemporary perspectives on this policy problem and a path forward

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It’s January 6 and whether thinking about geopolitics or public health, it has already felt like a long year.

Following the Trump Administration’s reckless upending of the childhood vaccine schedule to recommend far fewer vaccines, bringing it in line with Denmark (which has a far more robust social safety net and, I might add, a recent whooping cough epidemic), I got into a Facebook tiff with a Stanford professor who shall remain nameless but who came to the defense of Jay Bhattacharya, Vinay Prasad, and Marty Makary.

(Please excuse me while I choke back vomit and then rejoice in having come from a family of Cal bears… obligatory Go Bears.)

Part of the argument they made was about the importance of respectful civic discourse, of which I was initially just dismissive in the current climate, but then it got me thinking.

Do we really need to be civil with those who are killing our public health to an extent that people will most assuredly die from preventable diseases and it will take not just years, but decades to repair?

I think of myself as a good person. I pay my taxes, I’m a supportive friend, I rescue cats, I’m a good professor and take pride in mentoring students (especially those from underrepresented groups), I do charitable giving, and I advocate for inclusive policies and vote for candidates who pledge to lift people up rather than concentrate wealth at the top.

But I’m also of the belief that respect is earned and civility is not the appropriate response to those who are incinerating everything from public health to democracy itself, with the blessing of Chief Justice John Roberts (our very own C.B. Bucknor in robes). And I believe that it is better to be good than to be friendly. (What can I say, New Yorkers are my people.)

Imagine telling the parent of a child who senselessly died from a measles outbreak that they must “be civil” and “respectful” to the anti-vaxxers in their community who contributed to reduced herd immunity, endangering their family. (Or giving “be civil” advice to the parent of a trans child whose mental health declined precipitously when denied gender-affirming care under this Administration.)

Now think about the reality that the people leading our public health bureaucracy – Robet F. Kennedy Jr., Jay Bhattacharya, Vinay Prasad, Marty Makary, and Mehmet Oz – are not rubes listening to their quirky aunt who tells them that vaccines cause autism and whatever you do, don’t take Tylenol when you’re pregnant because she heard something on talk radio.

Perhaps they can’t hear the cries of parents whose children are hospitalized with measles, because their heads are too far up their asses – or more likely, too far up Trump’s ass (an unfortunate affliction). But these are people who know better. They understand what it means for the Wakefield study to have been retracted in spectacular fashion, with Wakefield even losing his medical license. They are capable of comprehending peer-reviewed research and know the difference between correlation and causation. They know exactly what they are doing. And they don’t care about the body count that will accumulate as a direct result of their reckless actions.

Science is iterative and there is uncertainty and there must be grace for good faith efforts to get some things wrong. But these are not good faith actors. This is the rejection of sound science for purely opportunistic reasons at the expense of the public’s health and safety. (See also the actions of Joe Ladapo, who I knew at UCLA and who absolutely knows how wrongheaded and dangerous his actions as Florida Surgeon General are, but who prioritized seizing an opening for power and influence.)

This is not a commentary on how these people behave in their private lives. I have a hard time believing that truly good people would sleep well at night inviting the proliferation of uninsurance and infectious diseases, but setting that aside, at the end of the day, making the choice to enter public life means being judged based on one’s actions rather than their private behavior. It’s a conscious choice to be judged on that basis, and the actions taken defy logic, science, and any semblance of decency.

This does not demand respect and civility. It demands accountability and swift removal from power, and action that demands bipartisan cooperation around issues that should (but I recognize won’t) transcend party lines given that infectious diseases do not discriminate between party identifications.

As you may have guessed from my… well, everything… I’m a Democrat. But I’ve long criticized a number of Democrats for meeting crises and institutional arson with kumbaya vibes. Frankly, I think that’s partly why we’re here now.

Grants have been canceled. We are greatly restricted in what we can research with federal funding. Critical health agencies are being axed or rendered impotent (see AHRQ, HRSA, SAMHSA), which will make it virtually impossible to support health policy predoctoral and postdoctoral training programs. Health insurance programs are being gutted and sabotaged. Vaccine schedule changes are putting people at risk for dangerous infectious disease outbreaks. And they’re not even a full year into the horror they are determined to unleash.

When someone responds to this with “be civil,” remind them what’s at stake, and ask them what they have to gain from defending these reckless and destructive actions.

And as for those running what’s left of our public health bureaucracy, I just have three words: Bless their hearts.

In my Introduction to Health Policy and Management course, among other things, we discuss the challenges that marginalized patients face in seeking health care – from explicit discrimination to implicit bias – and the ways that can lead patients to delay or forego medical care, potentially leading to worse health outcomes. We talk about the different ways that women and men are treated when presenting with the same or similar symptoms, such as with respect to pain medication administration.

We also discuss health literacy, and the challenges that many patients face in everyday health care utilization tasks – from navigating the many complexities insurance enrollment, to finding a health care provider amid outdated network directories, to distinguishing between necessary and unnecessary or emergent and nonemergent care.

I am the best-case scenario: I am an upper middle class white native English speaker from the United States, with a doctorate degree, thorough knowledge of my medical history, and more knowledge of medicine and the health care system than probably 99.9% of non-medical professionals.

And I like doctors, not only because I have a number of friends who are physicians, but largely because I have historically been very fortunate with my own doctors over the many years, even as I’ve moved around the country. Having a wonderful pediatrician helped to form my early impressions of medical professionals, especially amid some childhood health problems. Kaiser Permanente didn’t know how to diagnose my rare endocrine disorder so it went undiagnosed until my mid-20s, when I was connected with a NYP-Columbia endocrinologist who I’m still convinced can actually walk on water, along with a couple of other spectacular physicians. And when I moved to the Boston area, I had another saintly endocrinologist, with whom my Columbia doctor had trained, and with whom I am still in touch.

When wonderful doctors save your life (and along with it, your sanity), it’s easy to be predisposed to like those in the medical profession. Of course, there have been some duds along the way, but I’m a good self-advocate and it never impeded access to appropriate care.

And I don’t need my doctor to be my friend. I have plenty of friends. I need sage advice on how best to proceed.

So, back to the emergency department extravaganza.

Emergency departments are not an ideal place to be in general – it is loud, simultaneously slow and frenzied, patience runs low, and did I mention it’s loud? I try to be patient, cool, calm, collected, and knowledgeable. (Admittedly, patience isn’t always the recipe for getting seen expeditiously, but I try to be an easier part of their night.)

I lived in or near NYC for close to a decade, I’m a Yankees fan (please don’t stop reading), and I got mistaken for a New Yorker my first day there, when I was herding people to walk faster at Penn Station when I was en route to a Springsteen concert. I have a strong personality, and a high tolerance for abrasiveness.

The attending was brash and when I began to give a short but appropriately thorough history, he cut me off and said, “I saw your chart,” and when I was discussing the recent labs and was going to discuss how they may have worsened over the last week and a half, he immediately cut me off and said “I saw the labs.” Not exactly a trust-building exchange, but he set me up with the right IV meds and I had a wonderful nurse and we quickly got things moving in the right direction.

It was hectic in the ED. People were being boarded there for a couple of days waiting for beds upstairs. Perhaps he was just overwhelmed dealing with frustrated patients, and I caught him on a bad day. Not ideal, but it’s not like he’s my outpatient doctor who I’d see again. And I didn’t think much of it again.

Until I overheard him talk to the patient in the room next to mine.

I’d seen that patient in the waiting room earlier. He was in his 60s, disheveled, and seem to be a bit confused. In response to the physician saying, “What brought you in here today?” the patient began to give their history – I didn’t get all of it, but he was going to see an infectious disease physician, got really weak and winded walking just a few steps, and came to the ED instead – and again, he cut off the patient.

“I’m not an infectious disease doctor. This isn’t an infectious disease clinic. This is an emergency department. What do I need to say so you’ll understand that’s not what we do here?”

I was shocked. The patient seemed flustered. And when he began to explain his medical history, the physician cut him off and said, “I saw your chart.”

I teach in my health policy classes the public health problems of ED overcrowding and overutilization for non-emergent care, or for what could have been outpatient care if the patient had the proper supports and access to treatments in place. When tensions are running high because of these avoidable problems, I understand feeling frustrated at being relatively powerless to help.

But this was a patient who didn’t know where to turn. He expressed that he was struggling with daily tasks like bathing, dressing, and household chores. He was struggling to get in to see a therapist. He was feeling ill and scared by his relatively recent decline in ability to go about his day. He may not have been in poverty, but he certainly wasn’t living comfortably. And he didn’t know how to find different types of providers who might be better equipped to help him, let alone how to advocate for himself in this setting that can be overwhelming even for those far more fortunate than he.

What he needed was compassion, not a scolding.

He was rightly connected with a social worker, but I can’t help but wonder just how much longer it might be before this patient might feel comfortable seeing another physician to address his shortness of breath and other physical challenges. He had expressed to the physician his embarrassment at his precipitous decline, and the response he got was interruptions, curtness, and railroading.

(Lest you suspect it was just the tensions of this degree of overcrowding, a close friend and colleague had a similar experience with this same physician a while back. And emergency medicine, by definition, demands a high frustration tolerance… a tolerance that I know myself to lack but that’s one of many reasons why I chose a career in research and teaching.)

There are any number of reasons why might one have diminished trust in health care providers. Conscious or unconscious bias on the basis of race, disability, gender identity or sexual orientation, weight, or being seen as being to blame for conditions related to behaviors such as eating, drinking, or smoking. And we know that amid pronounced physician shortages, it is very costly to try to find an alternative provider when encountering judgment or otherwise not feeling heard or respected. While improving representation can help, it’s a slow process that is difficult to accomplish in the current policy environment, with not only the elimination of affirmative action but also runaway higher education costs and undercutting of loan forgiveness efforts.

And none of this would have helped the poor patient I overheard while receiving my four rounds of IV calcium – a patient whose experience aligned all too closely with so many themes of the health policy course I teach every semester (and which admittedly, may breed cynicism among my students).

I hope that this physician was just having a bad couple of days. And I really hope that that patient got connected with the appropriate resources that he can not only survive, but also thrive. But as I went home close to midnight, I was left with at once a sense of anger and sadness, as well as a sense of purpose about what I teach and write on.

Coverage Denied was a labor of love that combines a nationwide survey with administrative data from a handful of states and 111 semi-structured interviews with patients, physicians, health insurance lawyers, former health insurance executives, patient advocates, and others to lay bare the human impact of managed care practices of prior authorization and coverage denials. It combines patient and physician storytelling with scholarship and data to contextualize the growth of privatization, how prior authorization fits within that framework of health care delivery, how this practice deepens physician administrative burden, and how it upends patients’ health and economic lives due to administrative burdens of appealing, which many patients – especially those from marginalized backgrounds – opt out of altogether.

After all, most of the physicians whom I interviewed had between two and five staffers dedicated primarily to administration related to insurance – namely, prior authorization – an immense financial lift that many medical practices cannot accommodate. This is especially problematic because Black physicians are particularly underrepresented in academic medicine, where such staffing support (which relieves physician burden) is easier to come by.

And now we’re seeing the introduction of new prior authorization requirements in traditional Medicare, with implementation through AI tools. Of course, much to my chagrin, AI is here to stay, but as we discuss with our students, there are good uses of AI and bad uses of AI. Claim and prior authorization processing: Bad use of AI.

The reality is that AI is imperfect. As most fellow faculty can attest to, it still sometimes makes up citations, and it creates real challenges for us as instructors. Now imagine that what’s at stake isn’t a paper that’s worth 10% of your grade, but rather whether your grandmother can pick up her expensive new cholesterol drug.

In fact, in the lawsuits directed against UnitedHealthcare, Cigna, and Humana’s use of AI to manage approvals for Medicare Advantage plans, it was alleged that the insurers deployed these tools knowing that the reversal rate of these denials (upon appeal… if people appeal) was an astonishing 80-90%. (For context, in general the reversal rate when appealing claim denials is around a coin toss.)

To be clear, this doesn’t mean that the error rate is 80-90%: there could have been an error with the initial submission, or new information may have come to light relevant to a coverage determination. But it does suggest that at least a nontrivial number of denials reflect not appropriate guardrails on overprescribing and runaway health care costs, but rather wrongful denials, which can have profoundly adverse effects on patients’ health and financial wellbeing.

You might, sensibly, think, well, at least these wrongful denials are getting reversed. The problem is that most people don’t appeal, and those who do are not a broad cross-section of patients. Rather, I find in my book and related work that people from marginalized groups especially tend to underestimate the value of appealing, that less affluent patients are less likely to appeal, and that Black and Hispanic Medicaid patients and sicker patients are especially unlikely to prevail when navigating the complexities of the American health insurance system.

Distressing though this is, this may not be terribly surprising if, like me, you’ve spent a lot of time trying to conquer the fragmentation and complexities of American health insurance. Are they in-network? Is there a prior authorization? Why did it get denied? How much longer am I going to have to stay on hold? Damn it, the call dropped. How do I appeal? Oh my god where am I going to find a fax machine in 2025?

That is, prior authorization operates as a structural driver of health and economic inequity, and it’s about to get worse for America’s seniors. This is especially problematic because this is a population that is likely to have more significant health needs, in combination with generally lower health literacy. The result may be new impediments to health care for Medicare beneficiaries who may have actively sought to avoid managed care practices that are notorious for causing delays and denials of coverage.

So, what we’re seeing here is that insurers’ deployment of AI tools can improve efficiency when it gets it right, but when it gets it wrong – which appears to happen at a higher rate than through human review – it can send seniors down the unfortunate path of administrative burden, which harms marginalized groups more than others but which can cause widespread consternation (or worse). And this will only get worse not only due to the application of this technology, but because of America’s acceleration of reliance on Medicare Advantage, in which 99% of enrollees have at least some prior authorization requirements.

And outside the context of Medicare, moving over to the world of self-insured health plans govered by the Employee Retirement Income Security Act (ERISA), in which 65 percent of covered workers are enrolled, these 100 million or so enrollees are especially vulnerable when they are wrongly denied (e.g., because of AI-induced error) because ERISA bars them from meaningful legal recourse if they sue.

I’ve been thinking more lately about trust in the American health care system, and the fact that the November 2024 Gallup survey showed just 31% of Americans having a favorable view of the American health care industry. The reality is that it’s so easy to lose trust in the system when it’s giving you the runaround – whether as the patient being told that they cannot access treatment that their trusted physician has prescribed (with the caveat that patients typically do not know the evidence bases for prescribed care), or as the physician given limited windows between seeing patients within which to discuss the rejection of prior authorizations being reviewed by physicians in inappropriate specialties.

Coverage Denied will help contextualize how we arrived at this uniquely American experience of pervasive barriers to health care access, and show the many varied experiences navigating our health insurance maze – from physical to behavioral health, from chronic illness to acute injury – and its upending of trust among American patients and their doctors.

Pre-order Coverage Denied: How Health Insurers Drive Inequality in the United States here.

These enhanced subsidies were a game-changer in improving the affordability of securing health insurance through the ACA marketplace, reducing the cost of premiums by an average of 44 percent. And these benefits are widespread, with a near doubling of the number of people receiving these enhanced premium tax credits between 2020 and 2024. All in all, this has improved health insurance affordability for around 20 million people.

As Republicans zeroed out the mandate penalty in the Tax Cuts and Jobs Act, there was concern that people would drop out of the marketplace, leaving premiums to increase sharply, undercutting the ACA’s effectiveness. After all, the mandate was viewed as a critical component of the “three-legged stool” metaphor according to which the ACA had long been described. But much to the surprise of policymakers and health policy researchers (including me, to an extent), the ACA remained highly robust to these changes, in no small part because the subsidies offset premium increases for those with qualifying incomes.

That is, subsidies are in the driver’s seat in preserving the stability of the ACA marketplace.

Amid expectations that these enhanced subsidies would be permitted to expire at the end of the calendar year – in turn, prompting younger and healthier people to drop out of the marketplace, leaving the risk pool on average older and sicker and thus costlier to insure – marketplace insurers requested their largest premium increases since 2018. The result: Marketplace enrollees would pay, on average, 75 percent more for their monthly premiums.

And unlike most of the Medicaid decimation signed into law with the “One Big Beautiful Bill Act” (though I can think of some words that begin with “b” that would be more fitting than “beautiful” to describe this assault on the American safety net), this pain would be felt in 2026 (well, really during the December 2025 open enrollment period).

Republicans learned the hard way in 2017 that they will pay if they seek to repeal the ACA, and the ACA’s popularity is notably higher now, increasing from 49 percent in 2017 to a record high 66 percent in the June 2025 KFF tracking poll. Thus, it is little wonder why they have instead turn to this alternative strategy of not outright repeal, but rather sabotage, potentially hobbling the effectiveness of this legislation so greatly that its favorables will take a hit.

Given the complexity of these moving parts – after all, this is a much wonkier debate than the more cognitively simple “repeal and replace” debate – and the limited information with which most voters operate, this may be the case. Though unlike some policies that are farther removed from one’s everyday experience, people will know if they’re paying more for their insurance.

Contrary to Senator McConnell’s characterization of the Medicaid cuts, people do not just get over the inability to afford health coverage.

So, perhaps it is unsurprising that ten House Republicans are seeking to extend the marketplace subsidies one more year.

Make no mistake, these House members do not care about health insurance access – after all, all but one of them voted to gut Medicaid. They do not want to defend the progress of the ACA. They want to protect their party’s electoral prospects.

One such member is David Valadeo of California’s 22^nd Congressional District, in which two thirds of residents are on Medicaid, a fact that did not stop Valadeo from voting for the OBBBA, which also contained a number of restrictions on access to health insurance through the marketplace. And this district is R+1 according to the Cook Partisan Voter Index, suggesting a great political vulnerability if the Democrats are savvy this election season.

If this legislative effort is successful, it would protect marketplace from sticker shock for one more year, and nothing more. It will not signal buyer’s remorse when it comes to the health cuts, let alone a broader philosophical turn in the Republican Party.

So then this raises the question of what the Democrats should do.

My two cents: Democrats should not take the bait. By voting for this legislation, not only would this bail Republicans out of their failed health policy (to the extent that senseless cuts can be construed as “policy”), but it would obscure for voters the responsibility for the massive health insurance cuts that would inevitably unfold immediately after the 2026 election. And the result would a hampering of Democrats’ ability to make meaningful and enduring progress in access to health insurance.

Of course, this will demand that Democrats be effective messengers about this strategy, and messaging has not historically proven to be their forte. But the stakes are simply too high for Democratic leadership to fall for this cheap trick to get through the midterms, with Republicans hoping that enough political chaos will unfold between January 2027 and November 2028 that they can evade accountability.

The Affordable Care Act was a true game-changer for tens of millions of Americans, whose health is simply too important to be cynically handled like Lucy’s football.

It was once the case that people struggling with severe mental illness would face lengthy hospitalizations, extending months or even indefinitely. We’ve all seen Girl Interrupted, right? This approach is no longer the case, with inpatient hospitalizations typically lasting for about a week, often on a voluntary basis, with involuntary admission reserved for those who are a danger to themselves or others. But it is not with the goal of keeping these populations away from society for the long term, but rather offering shorter-term stabilization of acute symtoms and getting the individuals connected with proper outpatient supports (e.g., medication, stable housing, and potentially a step-down program).

What’s more, we also know that mental health care is most effective when the person is ready to accept help and make the necessary changes to one’s behaviors and circumstances.

But on July 24, the Trump White House issued an executive order based on the premise that “Endemic vagrancy, disorderly behavior, sudden confrontations, and violent attacks have made our cities unsafe.”

Let’s take a step back for a second. The mentally ill are more likely to be victims than perpetuators of crime. Not to mention, crime has been going down (not that you’d know it based on Sean Duffy’s terror at the thought of public transportation).

So, what does the EO stipulate? “Shifting homeless individuals into long-term institutional settings for humane treatment through the appropriate use of civil commitment will restore public order… The Attorney General, in consultation with the Secretary of Health and Human Services, shall take appropriate action to… encourag[e] civil commitment of individuals with mental illness who pose risks to themselves or the public or are living on the streets and cannot care for themselves in appropriate facilities for appropriate periods of time…. And provide assistance to State and local governments… for the identification, adoption, and implementation of maximally flexible civil commitment, institutional treatment, and ‘step-down’ treatment standards that allow for the appropriate commitment and treatment” of this population.

Let’s start with some logistical realities: Long-term institutionalization not only costs immense resources and treats mental illness as a penalty rather than a set of challenges for which there are coping mechanisms and other strategies to help mitigate its effects, but it impedes such individuals’ ability to rebuild a life in effort to survive and thrive, whatever that looks like for them. What’s more, there is a shortage of psychiatric beds in the United States, with the result that someone in need of treatment for acute suicidality or psychosis may be waiting in the emergency department for days (not the most calming setting in which to recover). In fact, health policy scholar Zoe Lindenfield and her coauthors found that in 2023, there were an average of 28.3 psychiatric beds per 100,000 persons, with lower rates in regions with a higher share of Black residents, while “60 beds per 100,000 is supported in the literature.” And while for-profit hospitals such as those owned by Universal Health Services can step in and offer services, they can be motivated by financial considerations rather than emphasizing treatment adequacy, and many of their centers have been under Department of Justice investigation for fraud and patient abuse, even being implicated in a False Claims Act case at the Supreme Court.

But now let’s think about what it would really look like if the administration cared sincerely about addressing issues of mental illness.

For starters, it would extend the Biden Administration’s enhanced premium subsidies for marketplace plans through the ACA, since they brought down dramatically the cost of health insurance for many. Gaining health insurance is associated with people being more likely to have a usual source of health care (e.g., a primary care provider, who may be able to prescribe an antidepressant while the patient waits to be able to get in to see a mental health professional) and less likely to have unmet health needs. Surprise surprise, the administration is letting the enhanced subsidies expire at the end of the year, and researchers at KFF estimate that the result will be that people in ACA marketplace plans will face premium increases of on average 75 percent. This will make health insurance prohibitively expensive for many, such that many people will drop their coverage, potentially having gaps in care including behavioral health care. And when mental illness is untreated, it can be more difficult to stay on top of physical health, not to mention sustain gainful employment.

And now the big one: An administration sincerely concerned about untreated mental illness would not have pursued approximately a trillion dollars in Medicaid cuts (on top of cuts to the broader safety net by slashing food security through SNAP). Medicaid is the single largest payer for mental health services in the U.S., and thus is a lifeline for those struggling with mental illness and substance use disorders. Thanks to the combination of ACA and Medicaid cuts, it is estimated that approximately 17 million people will lose their health coverage, making it exceedingly difficult to obtain needed treatment to manage these conditions and to remain employed and in stable housing.

Related, and on top of all of this, hospitals are going to close as a result of these Medicaid cuts and impeding increases in uncompensated medical care, and some financially struggling hospitals have already closed inpatient psychiatric units. This will only make it more difficult for people who, when struggling, earnestly want emergent and intensive psychiatric treatment, but who now may have nowhere to turn. Such individuals may have to drive much farther distances, which also means being farther away from their support systems, which may be counterproductive to successful treatment.

It is little wonder that the Cook County Jail, LA County Jail, and Rikers Island are America’s three largest health facilities. It doesn’t have to be that way, but America’s successive political choices to incarcerate rather than invest in treatment has pushed us in this direction, and it’s only going to get worse.

That is, America relies heavily on the criminalization of mental illness. And given the centrality of social determinants of health like education, housing, and poverty, it is difficult to see how the Administration’s concerns about the management of mental illness can be seen as sincere rather than band-aid efforts and an acceleration of the treatment of the mentally ill as criminals. That is, by imposing health insurance barriers, accelerating hospital closures, worsening economic precarity through failed economic policy, and exacerbating food insecurity through SNAP cuts, America will witness worse health outcomes including mental health outcomes.

We are not without tools to address untreated mental illness: Improve access to insurance, improve Medicaid reimbursement rates so as to promote greater Medicaid participation by providers, and adopting policies to incentivize practicing in the mental health field, while also working to help people find and maintain safe and secure housing and employment. Instead, as with so many policies we’ve seen since January, the Trump Administration has opted to set the nation back by decades or more.