Dr. Miranda Yaver Examines How ERISA Shapes Health Insurance Inequities

On October 16th, the Public Policy Program hosted Dr. Miranda Yaver for a lecture titled Justice Denied: The Legal Architecture of Health Insurance Inequity. Dr. Yaver is an Assistant Professor of Health Policy and Management at the University of Pittsburgh and a 2025 Healthcare Fellow at the Roosevelt Institute. In her highly informative lecture, Dr. Yaver traced how a little-known law originally designed to regulate pensions has become one of the most powerful legal barriers to equitable health insurance access in the United States.

Her forthcoming book, Coverage Denied: How Health Insurers Drive Inequality in the United States (expected 2026), builds on historical research, interviews, and survey data to examine how health insurance coverage denials exacerbate income, education, and racial inequalities and prop up a broadly inequitable health care system. Yaver presented research from a new book project that traces the origin of some of these insurance barriers and inequities to the Employee Retirement Income Security Act of 1974 (ERISA). Initially passed to curb pension fraud, ERISA’s impact has expanded to govern employer-sponsored health benefits. Its broad preemption of state laws prevents states from taking action to expand coverage or regulate many aspects of private health insurance, especially for self-insured employer plans. Dr. Yaver noted how ERISA has quietly become one of the most consequential health policy laws in the country, but it was never designed to function that way.

Dr. Yaver situated ERISA in the broader historical context of employer-sponsored health care. She explained how health benefits became tied to employment during World War II, making workers’ access to care precarious during periods of economic downturn. ERISA establishes minimum standards for employer benefit plans and places their regulation under the Employee Benefits Security Administration in the U.S. Department of Labor. Crucially, ERISA’s preemption clause prevents states from directly regulating these plans, limiting their ability to mandate coverage, impose prior authorization reforms, and hold insurers legally accountable.

To illustrate the consequences, Dr. Yaver shared patient stories. In one case, a retiree diagnosed with prostate cancer saw his treatment denied after a change in insurers. He chose a less expensive but far more grueling treatment option, and when coverage for the initial treatment was later approved, ERISA’s limitations left him without legal recourse to recover costs. Such cases, she explained, are not uncommon, and reflect how ERISA narrows patient protections compared to state-regulated insurance plans.

Dr. Yaver also presented new findings from a nationwide survey of 2,569 adults, which she shared publicly for the first time during the lecture. Thirty-six percent of respondents reported having experienced at least one health insurance coverage denial. Among those, only 56% appealed, and just under half of those who appealed were successful. Appeal outcomes reflected socioeconomic disparities: respondents with higher incomes and more education were more likely to win. Most respondents were unaware of whether their plan was self-insured (a critical legal distinction under ERISA) and very few said they would be satisfied with the limited remedies ERISA allows.

She described coverage denials not just as financial barriers but as significant sources of administrative and psychological burden. Patients must learn why their care was denied, navigate appeals, and contend with complex paperwork and insurer communications. These burdens fall disproportionately on low-income patients, who are less likely to have the resources or time to challenge denials. 

ERISA’s preemption also has broader policy consequences. States have sought to address coverage delays and denials through reforms such as regulating prior authorization processes or requiring timely review of claims. But because self-insured plans fall under ERISA, these state-level reforms leave large segments of the workforce unaffected. Judicial interpretations have consistently upheld this preemption, and although Congress has revisited ERISA over the years, its core structure has remained intact.

In her conclusion, Dr. Yaver argued that ERISA operates as a structural driver of health inequity. Wealthier patients are more likely to challenge denials, while those with fewer resources often forgo treatment or absorb the financial costs. This dynamic allows insurers to deny coverage with minimal risk, further entrenching inequities. She also noted that entrenched industry interests, including private insurers who benefit from ERISA’s protections, have successfully lobbied against reforms.

Dr. Yaver observed the irony of a law designed to protect workers from pension abuses becoming one whose greatest effect is leaving workers vulnerable in their moments of need.  By limiting legal remedies and preempting state efforts to strengthen consumer protections, ERISA continues to shape the landscape of health coverage and access in ways that are often invisible to patients, but deeply consequential to their health and financial security.