The Inner Monologue

If you’ve ever had a doctor prescribe a medication or recommend a procedure—only to have your insurance company deny it—you’re not alone. In the United States, the frustrating reality is that insurance companies, not doctors, often have the final say about your health care. This dynamic leaves many patients feeling powerless and doctors feeling frustrated. But it doesn’t have to be this way.

Well-run national health systems in other countries have found ways to keep medical decisions in the hands of doctors and patients—without insurance companies standing in the way. And unless you’re extremely wealthy, there’s no easy way to bypass these insurance hurdles in the U.S.

Let’s explore how we got here, what it means for your health, and how things could be different.

How Insurance Companies Control Your Health Care

Over the years, insurance companies have gained more power over what treatments patients receive. Here’s how they do it:

• Prior Authorization: Before you can get certain treatments or medications, your doctor must get approval from your insurer. If they say “no,” you’re out of luck—unless you can pay out of pocket.
• Step Therapy (“Fail First”): Insurers may force you to try cheaper, less effective treatments first—even if your doctor believes a different approach would work better.
• Quantity Limits: Insurance can dictate how much of a medication or therapy you receive, regardless of your doctor’s recommendation.
• Nonmedical Switching: Sometimes, insurers drop coverage for a medication, forcing you to switch—even if your current treatment is working.
• Network Restrictions: You may have to leave a trusted doctor or hospital if they’re not “in network,” regardless of your medical needs.

The Consequences for Patients and Doctors

• Doctors’ Authority Undermined: Even the best medical advice can be overruled by insurance policies.
• Delays and Denials: Administrative hurdles can postpone or block necessary care, sometimes with serious health consequences.
• More Paperwork, Less Care: Doctors spend hours each week fighting insurance companies instead of treating patients.
• Worse Health Outcomes: Many patients report that insurance denials have led to deteriorating health.

Why Does This Happen?

Insurance companies argue that these rules help control costs and prevent unnecessary care. Critics, however, say these policies prioritize profits over patients—and that medical decisions should be made by doctors, not insurers.

How Other Countries Do It Better

The good news? It doesn’t have to be this way. Countries with well-run national health systems—like the UK, Australia, Germany, and the Netherlands—don’t have the same insurance company hurdles. Here’s what sets them apart:

• Universal Coverage: Everyone is covered, so care isn’t dependent on insurance approval.
• Minimal Red Tape: Less paperwork means doctors can focus on patients, not bureaucracy.
• Decisions Based on Need: Treatments are guided by medical evidence, not cost-cutting policies.
• No Profit Motive in Denials: In systems like the UK’s NHS or Germany’s non-profit insurance funds, there’s no financial incentive to deny care.

Examples of Better Systems

• UK’s NHS: Funded by taxes, with no prior authorizations or coverage denials for standard care.
• Australia & the Netherlands: Rank among the best in global health care efficiency and patient satisfaction.
• Germany, France, & Japan: Use non-profit, government-regulated insurance funds that must cover everyone.

Can You Just Pay Your Way Out in the U.S.?

Some might ask: “Can’t I just pay for the care I want?” The answer is yes—but only if you’re extremely wealthy.

The Real Cost of Bypassing Insurance

• Routine Care: A single doctor visit can cost $70–$300. Add labs, imaging, and prescriptions, and you’re looking at thousands per year.
• Hospitalization: A three-day hospital stay averages $30,000. Major surgeries or cancer treatment can exceed $100,000.
• Catastrophic Illness: Long-term ICU stays, organ transplants, or advanced cancer can cost hundreds of thousands to over a million dollars.

To reliably pay for all your care out of pocket, experts estimate you’d need at least $5–10 million in liquid assets. Only about 1% of Americans have that kind of wealth.

The Bottom Line

In the U.S., insurance companies—not doctors—often decide what care you receive. Meanwhile, well-run health systems worldwide prove that medical decisions can be left to doctors and patients, without interference from profit-driven insurers.

Unless you’re among the wealthiest 1% of Americans, insurance company rules will continue to dictate your health care options.

Imagine a system where your doctor’s advice—not an insurer’s bottom line—determines your care. Other countries have made it happen. Shouldn’t we expect the same?

Have you experienced insurance denials or delays? Share your story in the comments!