A pair of health policy experts are calling for a fundamental restructuring of how health insurance companies approve medical treatments, arguing that the current prior authorization system has become an undue burden on patients and physicians alike.

The Hill opinion piece, authored by Miranda Yaver, assistant professor of Health Policy and Management at the University of Pittsburgh, and Topher Spiro, senior fellow at the Center for American Progress, contends that prior authorization has expanded far beyond its original purpose. The practice began in the 1960s as a limited tool to verify hospital admission necessity but has since proliferated to cover prescription drugs, imaging, surgeries and numerous other procedures.

The authors note that while some healthcare waste exists—researchers have estimated approximately 25 percent of U.S. healthcare spending may be unnecessary—the current system creates barriers even where no overuse problem exists.

What the Left Is Saying

Progressive health policy advocates largely support the authors' critique of prior authorization. The American Medical Association has conducted surveys showing physicians report that delays and denials tied to prior authorization can lead to worsening patient conditions and, in some cases, contribute to deaths. Yaver and Spiro cite federal data finding that 13 percent of prior authorization denials by Medicare Advantage plans were wrongful.

The authors argue that initial insurance company denials often function as healthcare rationing through administrative inconvenience. Their research indicates seven in 10 patients characterized prior authorization as a burden in seeking prescribed medical care. They contend marginalized patients are disproportionately affected, left behind by processes requiring health insurance literacy and persistence to navigate appeals.

Yaver and Spiro propose shifting prior authorization reviews to independent clinicians free from conflicts of interest and financial incentives that reward denials. They advocate for strict 48-hour deadlines and reviews grounded in consistent evidence-based clinical guidelines developed by physicians rather than each insurer's own rules. Their approach would target reviews based on claims data identifying costly, overused services while exempting routine and emergency care.

What the Right Is Saying

Conservative healthcare analysts counter that prior authorization remains a necessary tool for controlling costs and preventing unnecessary medical spending. Critics of reform argue that eliminating or significantly curtailing prior authorization requirements would lead to increased insurance premiums as wasteful testing and procedures proliferate without oversight.

Some free-market health policy advocates maintain that market competition, not government-mandated process changes, should drive improvements in utilization management. They argue insurers have financial incentives to approve medically necessary care efficiently, as delayed treatment often results in higher costs down the line.

Others contend that Massachusetts's tiered approach, which Yaver and Spiro cite approvingly, represents a state-level experiment rather than a proven national model. These analysts suggest any reforms should preserve private insurers' ability to manage care delivery and resist one-size-fits-all federal mandates that could increase administrative complexity in different ways.

What the Numbers Show

According to research cited by the authors, approximately 25 percent of U.S. healthcare spending may be classified as waste, including administrative complexity and overutilization. The Medicare Advantage prior authorization denial error rate stands at roughly 13 percent based on federal findings. Survey data indicates seven in 10 patients experience prior authorization as a burden when seeking prescribed care.

Major health insurers have announced their own reforms in response to criticism. UnitedHealthcare recently stated plans to reduce prior authorizations by 30 percent by the end of 2026, representing approximately 20 percent of its medical claims volume. Industry groups note that such voluntary streamlining efforts demonstrate the private sector's capacity for self-regulation without legislative mandates.

The Bottom Line

The debate over prior authorization reform reflects broader tensions between cost control and patient access in the American healthcare system. Yaver and Spiro argue their targeted, tiered approach could transform reviews from a broad barrier into a precision tool while reducing physician administrative burden and burnout.

Opponents of sweeping reforms maintain that prior authorization serves a legitimate function in managing healthcare costs and preventing overutilization, and that any changes must balance access concerns against the need for fiscal sustainability. Legislative efforts to address prior authorization have gained traction in some states, with Massachusetts serving as an early laboratory for more targeted review approaches. Watch for continued industry-led reforms and potential federal action on standardization of prior authorization processes.

*Miranda Yaver is author of 'Coverage Denied: How Health Insurers Drive Inequality in the United States.' Topher Spiro is author of 'A Patients' Bill of Rights to Lower Costs.' The views expressed are those of the authors.*