About 20% of respondents reported a coverage denial for recommended care

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. [MEDPAGE TODAY]

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.

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