How we fix our prior authorization problems…

For years, I thought I just had terrible luck with doctors and pharmacies. How was it that every couple months, I would wind up having to go back and forth between my pharmacy and my doctor to figure out why some medicine my kids or I had been prescribed wasn’t going to be available to us because of something called “prior authorization?”

I’m a local elected official, a mom, and I’m running for Congress. It’s not in my nature to take “no” for an answer, so every time this happens, I fight it. It’s exhausting. It’s lonely. It’s incredibly aggravating. Like so many experiences when it comes to health insurance…

As I’ve been out in the community meeting voters, I have learned how common this experience really is, and nowhere is the prior authorization problem more obvious than in Medicare Advantage.

A new KFF analysis finds Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024, up from 49.8 million in 2023. Of the 53 million requests they received from patients and providers, Medicare Advantage insurers only denied 4.1 million. That’s means that in 92.3% of cases, the prior authorization process simply presented a bureaucratic hurdle that providers and patients needed to clear to get the care they needed.

But here’s what’s really troubling, of the 4.1 million denials, only 11.5% were appealed. That means in 9 out of 10 cases where Medicare Advantage insurers denied someone the care their provider said they needed, the person who needed care simply accepted the decision rather than jump through the hoops required to challenge the decision. But what about those that appealed?

In 8 out of 10 cases, those appeals were overturned. The people with the time, resources, or sheer willpower to put themselves through the labyrinth of phone calls, lost online portal logins, form letters, and unhelpful AI-“help”-bots, end up getting the care their provider said they needed 80% of the time!

(Me on the phone with the pharmacy and my doctor)

If you’re thinking that prior authorization exists as a giant wall of paperwork meant to separate people from the care they need, you’d be correct. What’s worse, Donald Trump snuck a provision in his “One Big Beautiful Bill” to pilot a plan using prior authorization for traditional Medicare plans. Basically, the plan is to take a terrible system that denies people care in the private insurance market and apply it to everyone on Medicare!

But here’s the good news: as I’ve traveled the district and spoken with healthcare providers and patients, I have also learned that this mess is completely fixable.

I’m the kind of parent, teacher, and local government leader who believes in consequences. If you mess something up or do something that hurts your classmate, your sibling, or your neighbor, you should be held accountable for that. So, what should the consequence be when insurers challenge the care Medicare providers prescribe 53 million times, but only deny 7.7% of the requests? And how about when 80.7% of those denials are overturned?

Those insurers should not have access to Medicare patients. It’s that simple.

(No Medicare patients for you!)

Watch how quickly insurers stop playing games with the care patients need when they realize their core business is on the line. The federal government can use its power in the same way it now negotiates with pharmaceutical companies to bring down the price of specific brand-name drugs. It can tell insurers that they only have access to this massive pool of patients if they don’t attempt to erect administrative barriers to the care these patients need.

What about providers who overprescribe and request unnecessary and costly care? That’s the stated reason prior authorization exists in the first place, but the reality is, there are many judicious and effective providers who shouldn’t have to jump through hoops when they’re already doing their jobs well and getting their patients the care they need. We need to incentivize this kind of responsible behavior.

These providers should have a “golden ticket” that they can use to bypass the prior authorization process so long as they continue to responsibly provide necessary care.  

I believe in consequences and rewards!

This is what effective leadership in Congress can accomplish. We can look at a problem like prior authorization, and by judiciously applying carrots and sticks to the groups and people implementing these systems, we can deliver better, more cost-effective, results for the people who depend upon these systems.

This approach can also alleviate the daily headaches, exasperation, and heartache that goes along with getting yourself, your kids, or your elderly loved ones the care they need.