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.
- 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.
- 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.
- 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.