Private Health Insurance Doesn’t Always Ensure Coverage, Survey Shows

One in five adults with private insurance was denied coverage for themselves or a family member for care their doctors recommended, according to a Commonwealth Fund report published on Thursday.

Among more than 4,500 adults with private insurance who responded to a healthcare affordability survey, 21% reported a coverage denial in 2025. Of those receiving denials, 13% received prior authorization denials, 8% received claim denials, and 1% received both.

“When delivering healthcare, the goal is to get patients what they need, when they need it — and decisions about care should be guided by the clinicians and care teams who understand their patients best,” said Joseph Betancourt, MD, MPH, president of the Commonwealth Fund, in a press release.

Betancourt, an associate professor of medicine at Harvard Medical School in Boston, noted that he recently recommended an endoscopy for a patient experiencing gastrointestinal problems. A prior authorization request for the procedure was denied twice. After some discussion with the insurer, the procedure was covered — but with a significant copay.

“For the 5 days that we’re waiting for pathology, you’re sitting on pins and needles, because you know that denial potentially can cost your patient their life,” he said.

Betancourt added that he often sees prior authorization denials for diagnostic procedures, and increasingly for medications, including GLP-1 receptor agonists.

“It’s really challenging, because we are seeing the development of these new and very effective therapeutics, but our ability to get them to patients is often limited by these prior authorization approvals, and obviously by the price,” he said.

Among survey respondents who received prior authorization denials, 41% said the denial led to delayed care, 28% said it made their health problem worse, and 8% said they learned about a health problem later than they would have liked to.

Of those who received claim denials, 69% said the denial cost them or their household more money, 68% said it caused worry or anxiety, and 21% said their health problem worsened as a result.

Notably, 43% of respondents said claim denials led to medical debt that they are still paying off, with more than half reporting bills costing more than $1,000.

The process seems intentionally designed to be difficult to navigate so that the default is “giving up,” which has significant consequences for patients, Betancourt noted.

Forty-seven percent of respondents did not appeal their prior authorization denial, and the same share did not appeal claim denials. Four in 10 respondents who did not appeal their prior authorization request denial stated they “didn’t think it would make a difference,” and five in 10 who received claim denials and did not appeal stated they didn’t think they “had the right” to appeal.

Of the 53% of respondents who appealed a prior authorization denial, about half said the insurer ultimately approved the care or offered coverage for an alternative type of care. Among those with claim denials, only one in three said the insurer reduced or scrapped their bill.

“While I understand we all play a part in controlling healthcare costs, I think we need to find a better way to deliver that quality care, and to really count on doctors to make good decisions,” Betancourt said.

He noted that physicians have extensive training in determining which tests to use and when to access decision supports. “If we truly believe that the evidence should be the guide for care, then I think we should be given more agency to do that,” he said.

As for policy solutions, “it really is about timeliness, transparency, and simplicity,” he added.

The report specifically called for standardizing and streamlining prior authorization procedures across all health plans, funding consumer assistance programs to help patients resolve disputes, borrowing from state innovations such as “the gold card” approach, and expanding public reporting of healthcare claims and denials.

More transparency could help the public and policymakers see how these tools are used. “Are we talking about saving money for shareholders or trying to control healthcare costs?” Betancourt asked.

The Commonwealth Fund’s survey was conducted by SQL Server Reporting Services (SSRS) from July through October 2025 via telephone and online interviews in English and Spanish.

Researchers interviewed a random, nationally representative sample of 6,353 adults ages 19 to 64 in the U.S. The report focuses on the 4,589 respondents in the sample who have private insurance through an employer plan, the Affordable Care Act marketplaces, or the individual insurance market.

Most respondents completed the survey online. Results were weighted to account for patterns of response that could potentially bias results. The overall maximum margin of sampling error was +/- 1.5 percentage points at the 95% confidence level.