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Reforming Prior Authorization in Health Plans: A Bipartisan Issue for the 119th Congress? 

As the 119th Congress begins its legislative work, one of the issues gaining increasing attention within health care reform is prior authorization. But will this issue unite lawmakers across party lines, or will it become another partisan battleground?  

Prior Authorization: A Growing Problem 

Prior authorization is intended to ensure that medical services or treatments are medically necessary and cost-effective, helping to control health care expenses. However, over time, critics argue that prior authorization has become a cumbersome and bureaucratic obstacle that delays patient care. According to a 2024 survey by the American Medical Association (AMA), 94% of physicians report that prior authorization causes delays in patient care, with some of these delays resulting in worsened health outcomes (AMA, 2024). Moreover, health care providers are spending more time on administrative tasks related to prior authorization requests, detracting from their ability to focus on direct patient care. 

The burden of prior authorization is not confined to any one area of health care. Prior authorization affects public and private insurance systems and extends beyond medical services, including medications, imaging procedures, and durable medical equipment.  While prior authorization is used to manage costs and prevent overuse of health care  services, the process can be time-consuming and opaque, contributing to frustration for patients, providers, and insurers alike. 

A Bipartisan Issue? 

Prior authorization reform has historically garnered support from both parties, particularly as the system’s burdens have become more apparent. On the one hand, Democrats have focused on reducing administrative inefficiencies and improving access to timely care. At the same time, Republicans have typically championed efforts to cut through regulatory red tape and strengthen health care cost management. 

For instance, in the previous Congress, a bipartisan bill, The Improving Seniors’ Timely Access to Care Act, aimed to reduce the burden of prior authorization for Medicare Advantage beneficiaries by introducing requirements for transparency, quicker decision-making, and a more standardized process. The legislation received broad backing from both Democrats and Republicans (with over half of members in both bodies cosponsoring the bill), alongside support from leading medical and patient advocacy groups, including the AMA and the American Heart Association. 

As Congress moves into the 119th session, the push for reforms to the prior authorization process remains strong. However, expanding these reforms across broader health care  sectors, particularly private insurance, will require navigating complex political dynamics. While there is a shared interest in reducing administrative burdens, insurers and Republicans who prioritize cost control may resist significant changes to the system. 

Potential Pitfalls of Reform 

Despite the broad support for prior authorization reform, Congress will face several key challenges to pass meaningful legislation. 

1. Resistance from Insurance Companies: Many insurance companies view prior authorization as a necessary tool to manage costs and ensure the appropriate use of health care  services. While insurers may acknowledge the administrative burdens on providers, they often argue that eliminating or loosening prior authorization would result in unnecessary treatments, driving up health care  expenditures. This perspective could lead to significant pushback from the insurance industry, which may be able to influence lawmakers concerned about costs. 
2. Balancing Cost Control with Patient Care: One of the primary concerns of prior authorization reform is maintaining a balance between reducing administrative barriers and ensuring that only medically necessary treatments are covered. If the prior authorization process is reduced too much, there may be concerns about increased utilization of unnecessary services, which could ultimately increase the cost of health care across the board. 
3. Fragmentation Across Insurance Plans: With multiple insurance plans, both public and private, there is a lack of uniformity in the prior authorization process. Different insurers often have varying rules and guidelines, leading to confusion for both patients and health care  providers. Creating a standard process across different plans could face significant resistance from the insurance industry, which may prefer to maintain its own policies and decision-making frameworks. 

Where will the Administration Stand on the issue? 

During his previous presidency, President Trump made efforts to reduce the burden of regulatory requirements in health care, including addressing prior authorization. In 2020, his administration signed an executive order aimed at improving transparency in health care  pricing and addressing the burdens of prior authorization within both public and private health care systems. The executive order pushed for greater transparency from insurers regarding prior authorization rules and encouraged the development of electronic systems to streamline the process. 

Although President Trump has not specifically spoken about prior authorization reform since leaving office, his overall approach to health care reform—focused on reducing government regulation and enhancing competition within the health care market—suggests he may support efforts to reduce administrative burdens. However, his stance on health care policy generally favors market-driven solutions, meaning that any reform efforts might need to strike a balance between improving patient care and preserving cost-control mechanisms within the insurance industry. 

So, will Congress and the administration act on reforming prior authorization this year? While bipartisan support for reform exists, the complexities involved in balancing patient care, cost control, and insurance company interests could complicate the passage of significant legislation. As the legislative process moves forward, watching how Congress navigates these challenges will be important. However, we have seen over the past month that most citizens are angry about health insurance profit levels and perceived lack of access to care – so Congress will need to act on this issue one way or another before the end of 2025.   

The Trump Administration is poised to reshape American health care policy with two high-profile and polarizing figures: Robert F. Kennedy Jr., nominated to head the Department of Health and Human Services (HHS), and Mehmet Oz, the celebrity doctor tapped to lead the Centers for Medicare and Medicaid Services (CMS). Their starkly different approaches to health care—prevention versus medicine—set the stage for potential clashes on key issues. One such issue, Medicare coverage of Ozempic, highlights the philosophical divide between these two leaders and serves as a litmus test for the future of U.S. health care. 

Medicare and Medicaid for GLP1-s 

Ozempic, a GLP-1 receptor agonist originally developed to treat Type 2 diabetes, has rapidly gained attention for its weight-loss benefits. For many, the drug represents a breakthrough in managing obesity, a major driver of chronic diseases in the U.S.   

The Biden administration proposed to expand Medicare coverage of GLP-1s beyond its use to treat type 2 diabetes or cardiovascular disease.  If the Trump administration finalizes the rule, CMS estimates 7 percent more Americans would have access to the drug.  But Medicaid coverage remains limited, with only 13 state Medicaid programs paying for GLP-1s for obesity treatment, 

GLP-1s headline the government’s list of medicines that will be subject to price negotiations over the next year as part of the Inflation Reduction Act.  In addition to traditional Medicare, these drugs, including Ozempic, will also be subject to price negotiations,  

The Ozempic Debate: A Microcosm of Medicine vs. Prevention 

Dr. Mehmet Oz has championed the potential of Ozempic and other GLP-1s, calling the drug ‘massively beneficial’ for improving cardiovascular health and overall quality of life. He sees expanding access to drugs like Ozempic through Medicare and Medicaid as a critical step in addressing obesity and its associated costs. 

In stark contrast, RFK views Ozempic with deep skepticism. He has labeled it a ‘scam’ and insists that the true solution to obesity lies in lifestyle changes, such as eating healthier and exercising more. In interviews, he has criticized the pharmaceutical industry for profiting off what he considers preventable health issues, stating that Americans have been ‘misled’ into seeking quick fixes rather than addressing the root causes of their health problems. 

RFK ’s Prevention-First Agenda 

As head of HHS, RFK brings a prevention-focused vision to health care policy. He has long advocated for systemic reforms, including stricter regulations on processed foods, food additives, and environmental toxins. He aims to address obesity by overhauling the U.S. food system, rather than relying on pharmaceutical interventions. His skepticism extends beyond the GLP-1s to the broader role of the pharmaceutical industry, which he accuses of prioritizing profit over public health. 

RFK plans to reallocate resources within HHS, shifting the focus of agencies like the National Institutes of Health (NIH) from infectious diseases to chronic disease prevention. However, implementing such sweeping reforms will be no easy task. HHS is a massive bureaucracy, and many of his proposals—such as limiting fluoride in drinking water or promoting the value of unpasteurized or “raw” milk—also fall under the purview of other federal agencies, like EPA and CDC. Institutional inertia and budgetary constraints may further hinder his efforts. 

Dr. Oz Supports New Innovations 

Mehmet Oz’s tenure at CMS will likely emphasize medical innovation and treatment. A vocal supporter of GLP-1s like Ozempic and Wegovy, Oz views such drugs as essential tools for improving public health outcomes. He has advocated for making GLP-1 inhibitors widely accessible and believes Medicare and Medicaid coverage of these drugs would yield significant long-term health benefits. 

Oz’s enthusiasm for medical solutions extends to telehealth and digital health technologies, which he sees as critical for increasing access to care. His leadership may prioritize policies integrating these technologies into Medicare and Medicaid programs, potentially creating new avenues for managing obesity and other chronic conditions. 

The Ozempic debate is likely the first of many policy clashes between RFK Jr. and Oz. As CMS Administrator, Oz could advocate for expanding Medicare coverage of Ozempic, while RFK Jr., as head of HHS, may push back in favor of prevention-focused alternatives 

The  focus may shift toward public health campaigns promoting lifestyle changes, potentially delaying access to pharmaceutical interventions for those who need them. On the other hand, if Oz’s perspective dominates, Medicare and Medicaid could see expanded pharmaceutical coverage, but at significant financial cost and without addressing the underlying causes of obesity. 

Conclusion 

The leadership of RFK Jr. and Mehmet Oz at HHS and CMS marks a pivotal moment for American health care. The Ozempic debate encapsulates the broader philosophical divide between prevention and medicine, offering a glimpse into the challenges and opportunities that lie ahead. Whether their approaches can coexist—or whether one will prevail—remains to be seen.  

The Trump administration’s approach to Ozempic may offer a glimpse into U.S. health care policy for the next four years.  How will HHS and CMS address chronic diseases, allocate resources, and balance prevention with treatment?  How will Medicare and Medicaid navigate the institutional and budgetary constraints while pursuing transformative change? 

Moreover, the dynamic between RFK Jr. and Oz may set the tone for how the Trump Administration handles other contentious health care issues, from vaccine policies to public health emergencies. Will their contrasting visions lead to innovation and compromise, or will their differences hinder progress? 

We have been hearing a lot from Elon Musk and Vivek Ramaswamy lately, the chosen co-leads of the President-Elect Trump’s Department of Governmental Efficiency (DOGE). We have even watched Musk take down a government funding extension bill almost single-handedly. But what is DOGE, and what will it do?

What is DOGE?

The idea of a federal agency dedicated solely to improving governmental efficiency may sound like a bureaucratic paradox. (The department of redundancy department, anyone?) However, in some circles, there are growing concerns about inefficiencies, waste, and redundancy in government operations. The new Department of Governmental Efficiency (DOGE) is purported to make government processes more effective, transparent, and cost-efficient.

DOGE is an envisioned federal agency that would act as a central body to evaluate, enhance, and coordinate the performance of various government functions. Its mission would be to identify areas where improvements can be made in operational efficiency, streamline bureaucratic processes, reduce wasteful spending, and ensure that government agencies are delivering services effectively. The goal is for DOGE to serve as a hub for coordinating efforts to eliminate inefficiencies rather than creating new programs or regulations.

In essence, DOGE would be a “management consultancy” for the U.S. government, aimed at rethinking how federal agencies operate on a day-to-day basis. The department would rely on a mix of data analytics, performance audits, process optimization, and employee feedback to identify opportunities for improvement across a wide range of government functions, from military procurement to social services delivery.

Why Does DOGE Seem to be Needed?

Proponents of DOGE base their arguments on the idea that the U.S. federal government, with its vast size and complex operations, is often plagued by inefficiencies. Several issues have sparked calls for systemic changes in the way the government operates: ·

• Wasteful Spending: According to various reports from the Government Accountability Office (GAO), the federal government loses billions of dollars annually through inefficiencies, such as outdated systems, redundant services, and unnecessary administrative overhead. In a time of growing national debt, addressing waste is seen by many as critical.
•  Bureaucratic Red Tape: Federal and State government agencies often face criticism for their cumbersome processes, slow decision-making, and excessive regulation. Citizens and businesses alike find themselves bogged down by layers of approval, paperwork, and delays.
• Fragmented Services: The federal government operates hundreds of departments and agencies, each with its own mandates, processes, and systems. This fragmentation can lead to duplication of efforts, inefficiency, and a lack of coordination across agencies, reducing the quality and speed of public service delivery.
• Public Perception: A recent Pew Research Center poll found that trust in the federal government is at an all-time low, mainly because of frustration with bureaucratic inefficiency and perceived waste. Citizens increasingly want a government that delivers results quickly and effectively.

Given these concerns, DOGE would address the need for a department that acts as a “watchdog” over government operations, identifying areas for reform, and implementing changes that would improve performance, reduce redundancy, and ultimately save taxpayer dollars.

Opportunities for DOGE in Health Care

If DOGE were to focus on health care, there are several areas where DOGE could look at to improve efficiency and deliver better results for patients, providers, and taxpayers alike:

• Reducing Waste in Medicare and Medicaid: Medicare and Medicaid are two of the largest federal health care programs, and although they are popular, they are often criticized for inefficiencies such as fraud, abuse, and excessive administrative costs. DOGE could conduct audits to identify waste areas and recommend changes to improve cost-effectiveness while maintaining or improving the quality of care.
• Simplifying Health Care Administration: One of the biggest inefficiencies in federal health care is the complexity of the systems. Billing, reimbursement, and reporting requirements differ across programs, creating confusion for providers and delays in care. DOGE could advocate for simplified billing systems, electronic health records (EHR) interoperability, and a streamlined process for claims and reimbursements.
• Improving Inter-Agency Coordination: Federal health care programs operate across multiple agencies, including the Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), and the Department of Veterans Affairs (VA). DOGE could help facilitate better communication and coordination between these agencies, ensuring that health care services are provided efficiently and that patients are not caught in bureaucratic red tape.
• Leveraging Technology: Technology has the potential to significantly improve health care delivery, yet many federal health care programs still rely on outdated systems. DOGE could push for the adoption of advanced technologies such as AI for predictive analytics or telemedicine for broader access to care, improving both efficiency and patient outcomes.
• Enhancing Transparency: DOGE could play a key role in improving transparency in federal health care programs. By publicly reporting on cost savings, wait times, and the effectiveness of different programs, DOGE could build public trust in government health care services and create an environment where agencies are held accountable for their performance.

Pitfalls and Challenges

While DOGE could have a significant impact on improving health care efficiency, there are several challenges that must be considered:

• Resistance from Health Care Stakeholders: Health care providers, insurance companies, and even governmental health agencies might resist changes proposed by DOGE, especially if these changes threaten their existing practices or financial interests. Resistance from powerful health care lobbyists could slow down or block meaningful reforms.
• Political Gridlock: Health care is a highly politicized issue, and efforts to reform federal programs often face strong opposition. Even if DOGE identifies areas for improvement, political polarization could prevent any support. Also, and more importantly, Congress may be hesitant to delegate its authority to a new department, especially when it comes to decisions that affect millions of constituents.
• Lack of Direct Legislative Power: Without the authority to pass laws or implement changes directly, DOGE’s ability to enforce reforms would be limited. (See larger discussion below.)
• Complexity of Federal Health Care Programs: U.S. health care is a labyrinth of federal regulations, state-based programs, private insurance systems, and various health care providers. This complexity presents a significant challenge for DOGE to navigate and reform, as any proposed changes would need to account for local differences and legal constraints.
• Initial Implementation Costs: While DOGE’s long-term goal is to reduce costs, the initial effort to set up the department, assess health care programs, and implement reforms could be expensive. The government would need to balance short-term investments with long-term savings to justify the creation of DOGE.

How Will DOGE Get Anything Done Without Congressional Authority?

One of the most significant hurdles DOGE would face is its lack of direct legislative authority. Congress holds the power to dictate federal policy, and any attempt by DOGE to overhaul operations could be met with resistance from lawmakers. However, there are ways in which DOGE could make an impact even without direct Congressional approval:

1.  Executive Orders: The President could establish DOGE through an executive order, mandating the department to improve government efficiency. While this may not grant the department the power to enforce its findings directly, it could set a tone for change and demonstrate the administration’s commitment to reform.
2. Collaboration with Congress: DOGE could work closely with lawmakers to craft policies that incentivize government agencies to implement efficiency recommendations. By showing clear benefits in terms of cost savings and service delivery, DOGE could build political support for broader reform efforts.
3. Public Advocacy: By focusing on transparency and publishing the results of its efforts, DOGE could garner public support for reforms. Public pressure could, in turn, push Congress to adopt some of its recommendations.

In addition to alternative approaches, Musk and Ramaswamy have brought in a “closer” to ensure tasks are completed effectively. The addition of Brad Smith to the DOGE team is expected to enhance the team’s focus on efficiency. His unique combination of private and government experience positions him to identify opportunities for improvement effectively. Mr. Smith, is an entrepreneur, Rhodes Scholar, and former head of the Center for Medicare & Medicaid Innovation (CMMI) in the last Trump Administration (Side Note: His latest company, CareBridge, just announced its sale to Elevance Health in a deal worth $2.7 billion.) He will likely be able to push through health care reforms with less resistance than those considered “D.C. outsiders.”

Conclusion

The Department of Governmental Efficiency (DOGE) could offer an innovative solution to address the inefficiencies plaguing the federal government for decades. While it faces significant challenges, including resistance from entrenched interests and a potential lack of authority, its potential to improve government performance, save taxpayer money, and restore public trust is considerable. It’s all up to politics now—whether DOGE can become a transformative force in modernizing the U.S. federal government, or is this all just political theater?