One in five working-age adults with private insurance said they or a family member had coverage denied for doctor-recommended medical care in the past year, according to a new Commonwealth Fund report that found denials can delay care, worsen health problems and leave patients with medical debt. The report, based on the Commonwealth Fund 2025 Affordability Survey, examined two types of insurance denials: prior authorization denials, which occur before care is received, and claim denials, which occur after care has already been provided.
Types of Denials and Wait Times
Among privately insured adults, 21% said they or a family member had experienced a coverage denial for care recommended by a doctor in the past year. Thirteen percent reported a prior authorization denial, 8% reported a claim denial, and 1% reported both types of denials. Many patients reported waiting two weeks or longer for a decision.
The Cost of Denied Care
Prior authorization denials were more closely tied to delayed treatment than claim denials. Forty-one percent of people who experienced a prior authorization denial said it delayed medical care, and 28% said their health problem worsened as a result. While the financial consequences were especially pronounced for patients who experienced claim denials, nearly 70% of people who had a claim denial said it cost them or their household more money, and 43% said the denial led to medical debt they are still paying off. More than half said the original denied bill was $1,000 or more.
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The administrative complexity of health insurance often mirrors the inefficient checklists found in other bureaucracies. Rigid decision cycles can prevent timely resolution of urgent needs.
This creates a system where the provider is forced to act like a claims adjuster, delaying treatment while the paperwork circulates. Essentially, a medical visit becomes a negotiation over administrative protocols rather than a discussion about health outcomes.
Appeals and Outcomes
Only about half of people who experienced a coverage denial chose to appeal the insurer’s decision. Many reported they were uncertain about whether they had the right to appeal, doubted an appeal would make a difference or were unsure whom to contact. Still, the appeals process can yield results. Among those who did appeal a prior authorization denial, more than half ultimately received some form of coverage—either for the recommended care (30%) or an alternative treatment (25%). One-third of those who challenged a claim denial had their bills reduced or eliminated.
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Systemic Issues and Regulatory Context
“When delivering health care, the goal is to get patients what they need, when they need it,” Commonwealth Fund President Dr. Joseph R Betancourt said in a statement. “As a primary care physician, I’ve seen firsthand how challenging it is for patients trying to manage the complexity of the prior authorization process. It is difficult, time-consuming, and frustrating for all involved.”
Sara R. Collins, study coauthor and Commonwealth Fund senior scholar, noted that the complexity of the U.S. healthcare system is leaving many patients caught between their providers and their insurance companies. “We need greater transparency, expansion of appeal rights, and standardization of utilization review processes across all insurance plans to help patients have confidence in their insurance – that it will enable them to stay healthy and avoid medical debt,” Collins said. The findings come amid growing scrutiny of these practices. The Centers for Medicare & Medicaid Services finalized a rule in 2024 aimed at streamlining prior authorization, while provider groups have cited the administrative burden as a driver of rising collection costs.