Private insurers' incentives and limits of prior authorization

Miranda Yaver’s new book, Coverage Denied: How Health Insurers Drive Inequality in the United States (Cambridge UP, 2026), has lots of examples and incidents that will seem quite familiar to anyone who has dealt with health insurance coverage in the United States. In a sense, this book speaks to everyone because we have all been in situations like the ones that Yaver hears about from her interviewees. We know what it is like to have a test or a scan or a prescription ordered by a medical professional for us only to have an insurance company tell us that we cannot have that test or scan or medicine. Yaver dives into this quagmire and unearths the constellations of causes and reasons why this is now the essential operating process for much of American health insurance. By unpacking these causes and reasons, Coverage Denied clarifies so many of our experiences and helps us to think about the myriad ways in which health insurers and health insurance contribute to inequality in the United States, across a range of dimensions including race, socio-economic position, gender, sexuality, ability, and more.

Part of what Yaver’s research finds is that very few individuals appeal coverage denials with their insurance companies. The question becomes one of who is denied coverage or tests or prescriptions, and who is going to try to access the means for getting those denials reversed. This is part of the administrative burden that is not equally distributed, given different economic, disability, employment, and family situations. Thus, the appeals process is part of the driver of inequality in terms of healthcare and healthcare coverage. The findings also note that women are more likely to be denied coverage than are men, in part because women often make more use of healthcare than do men. But this inequity translates across minoritized groups, including those who are disabled and sick, of lower economic status, and/or are Black or Hispanic. Thus, the access to medical care is distributed unequally across a number of different vectors.

The denial of coverage, thus the denial of care, also leaves the medical professionals in a quandary as well, since they are unsure of what to prescribe and what is likely to actually happen for a patient. Thus, those trying to prescribe different kinds of care, be it tests or prescriptions or interventions, have little certainty that their patients will receive what the prescribing individual intends for them. While the initial reason behind coverage assessments and the requirement for prior authorization was cost containment, the results, at this point, are a system that often does not work for those who need medical assistance and for the medical professionals working with their patients. Coverage Denied: How Health Insurers Drive Inequality in the United States is a patient-centered book in that it focuses on the experiences of patients as they try to work their way through this distorted and obtuse system, but it also brings in the perspective of medical providers because they are often equally lost in terms of knowing what kind of care their patients can and do receive.

This book is as must read for anyone who is interested in the way healthcare and health insurance operate in the United States, and why these issues, policies, and processes are often so confusing and confounding.

Coverage Denied can be purchased at The White Whale Bookstore in Pittsburgh, PA.

Lilly J. Goren is a professor of political science at Carroll University. She is co-host of New Books in Political Science. She is co-editor of The Politics of the Marvel Cinematic Universe Volume I: The Infinity Saga and of The Politics of the Marvel Cinematic Universe Volume II: Into the Multiverse as well as co-editor of the award winning book, Women and the White House: Gender, Popular Culture, and Presidential Politics. She can be reached @gorenlj.bsky.social

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