Millions denied care. Almost no one fights back.

The Scale

By conservative estimates, more than 200 million coverage denials are issued each year. Some estimates put the number as high as 850 million.

Nearly 60% of those who face denials have their care delayed as a result. Some face serious health consequences, including death, from forgoing care. Others receive care and face serious financial consequences. Many tens of millions of Americans carry some form of medical debt.

The Recourse Gap

Patients have recourse, but it is typically difficult, costly, and time intensive. Most don't know it exists.

Appeal rates are less than 1% in many contexts, even though pursued appeals lead to high rates of overturn. The complexity and fragmentation of U.S. health insurance make it difficult to collect comprehensive data and protect rights secured by law.

Who Bears the Burden

The burden of pursuing recourse falls heaviest on those least able to carry it.

People in urgent medical situations, living with disabilities, managing chronic conditions, or navigating unforgiving caregiving and workplace responsibilities face compounding barriers. If overturning a denial requires ten hours on hold during business hours, what are you to do if your employer won't give you time off?

It should not be the job of individuals to resolve the mistakes of health insurers as a form of unpaid labor. Those with the least capacity to fight face grave injustice and harm.

Inequities

Wrongful denials don't fall equally. Some groups are hit much harder than others.

People of color, disabled people, immigrants, low-wage workers, and those with certain medical conditions have all faced higher rates of wrongful denial. Many of these gaps are getting worse as insurers adopt AI systems trained on historically biased data.

The AI Problem

Insurers have begun using AI systems to issue denials, some of which ensnare patients who have rightful claims.

These systems have been alleged, and in some cases found, to be incorrectly and unfairly denying claims. They are typically opaque, preventing individuals, advocates, and regulators from understanding the reasoning behind decisions. The critical question is not whether coverage decisions and appeal processes will be automated with AI, but who will control that AI, and whether it will be designed to prioritize fair outcomes and the interests of people, or corporate profits.

The Data Gap

There is a lack of comprehensive, centralized evidence on the full scope of wrongful denials and the harm they cause.

Estimates exist, but come from limited slices of data. Applying an HHS OIG-derived rate to post-service denials would suggest between 36 million and 153 million inappropriate denials annually. Serving as a leading source for the data needed to produce reliable estimates is a key part of our vision.