A groundbreaking study from the University of Massachusetts Amherst uncovers a troubling dynamic in healthcare: low-income patients and their providers are significantly less likely to contest denials of health insurance claims compared to those in higher income brackets, revealing a critical dimension of inequality within the U.S. healthcare system. This discrepancy not only highlights disparities in access to care but points directly to systemic barriers that disproportionately burden economically disadvantaged and racially marginalized communities, particularly in the realm of preventive and “shoppable” medical services.
The investigation, spearheaded by Michal Horný, an assistant professor in the School of Public Health and Health Sciences at UMass Amherst, meticulously analyzed over 51,000 denied health insurance claims submitted between 2017 and 2019. These claims, tied to private insurance holders across the United States, reflect a broad cross-section of demographic data, revealing stark socioeconomic divides. Horný’s team observed that when low-income patients or their healthcare providers do challenge these claim denials, their efforts are markedly less successful compared to their higher-income counterparts, leading to continued financial and health inequities.
One critical insight from the research is that individuals with household incomes above $50,000 are far more likely to have denied claims overturned, resulting in reduced out-of-pocket expenses for essential medical services. This reversal rate disparity suggests systemic inefficiencies or barriers that inhibit lower-income patients from advocating effectively for themselves. It underscores a troubling feedback loop: those with fewer financial resources are less equipped or empowered to navigate the complexities of insurance claim appeals, exacerbating their financial vulnerability in an already costly healthcare environment.
This phenomenon becomes particularly alarming in light of Horný’s earlier findings published in JAMA Network Open, which identified a 43% higher likelihood of claim denials for preventive services among low-income patients. These services include critical screenings for cancer, diabetes, cholesterol, and depression, as well as contraception and wellness visits—services that are theoretically covered “free” under many insurance policies. The compounded effect of higher denial rates paired with fewer successful contests places these vulnerable populations at heightened risk for untreated health conditions and escalating medical debt.
Racial and ethnic disparities further intensify this trend. The study reveals that historically marginalized groups—Black and Hispanic patients in particular—are nearly twice as likely as non-Hispanic whites to face claim denials. While these groups tend to contest their claim denials less frequently, the success rates when they do appeal are paradoxically higher than those seen in white populations. However, the corresponding reduction in cost-sharing post-reversal remains disproportionately lower among these minority groups, indicating persistent structural inequities even within successful challenges.
Horný and her colleagues suggest several mechanisms underpinning these disparities. Barriers such as implicit bias within the healthcare system, under-resourced providers serving minority communities, and systemic racism likely impede access to the claim appeals process for many marginalized patients. Additionally, there is the possibility that some minority patients only pursue appeals for evidently erroneous denials, which may explain higher success rates but not the overall lower challenge rates observed.
The research also sheds light on the role of healthcare providers in the claims contestation process. Contrary to the initial assumption that patients themselves primarily initiate claim appeals, it became evident that providers often play a substantial role. Providers typically possess more experience and resources to negotiate with insurance companies, reflecting the complexities inherent in insurance billing processes. Nevertheless, providers serving lower-income and marginalized patients may lack adequate administrative support, technology, or workforce capacity to pursue every denied claim, compounding patient disadvantage.
A notable finding of the study is the absence of any significant correlation between patients’ educational attainment and their likelihood of contesting denied claims. This suggests that while education may influence many health behaviors, it does not necessarily equip patients with the tools or support necessary to navigate insurance dispute mechanisms, highlighting the uniquely daunting nature of the claims contest process.
The implications of this research extend beyond individual patient experiences, suggesting a systemic issue that calls for policy and regulatory intervention. Horný advocates for insurance companies and regulators to simplify and streamline the appeals process, emphasizing the need for accessible, user-friendly platforms that allow claimants to contest denials online at their convenience. Such reforms could mitigate the time and effort barriers that disproportionately impact those with less flexible work schedules or limited access to telephonic support.
Furthermore, the adoption of universal billing codes across payers is proposed as a strategy to reduce administrative errors—a common cause of claim denials—and ease the burden on healthcare providers burdened with complying with differing insurer requirements. Standardization could help prevent inadvertent denials caused by billing inconsistencies and enhance transparency throughout the process.
This study’s findings underscore an urgent and ongoing challenge within the U.S. health insurance landscape: administrative burdens and financial barriers are not distributed evenly but instead fall more heavily on the most disadvantaged groups. As unexpected medical bills continue to proliferate, they compound existing disparities and strain the safety nets intended to protect vulnerable populations. Addressing these systemic inefficiencies through thoughtful policy and operational changes is paramount to ensuring equitable access to healthcare and financial protection.
The research represents a critical step forward in illuminating the nuanced mechanisms driving healthcare inequity. By comprehensively analyzing claim denial and appeal patterns through a socioeconomic and racial lens, it invites the broader scientific and policy communities to have a data-driven conversation on how to make healthcare systems more just, responsive, and patient-centered. As healthcare costs and complexities continue to rise, ensuring transparent and accessible insurance practices will be vital to improving outcomes and reducing disparities nationwide.
Ultimately, this work highlights that access to healthcare is not solely about coverage but also about the ability to assert and secure that coverage effectively. Without reforms that empower low-income and marginalized patients and their providers to challenge erroneous claim denials, the promise of equitable healthcare remains elusive. This study charts a clear path forward, emphasizing the intersection of health policy, social justice, and economic empowerment in shaping the future of health insurance.
Subject of Research: People
Article Title: Claim Denials: Low-Income Patients From Disadvantaged Racial And Ethnic Groups Experienced The Largest Burdens
News Publication Date: 2-Jun-2025
Web References:
- Health Affairs Article
- JAMA Network Open Earlier Study
References: University of Massachusetts Amherst study led by Michal Horný, Health Affairs (2025)
Image Credits: UMass Amherst
Keywords: Social sciences, Demography, Human health, Health care, Health and medicine, Social research
