When Daniel was consumed with severe and inexplicable pain for months, his physician prescribed an MRI. However, his health insurer required that it approve the test as well before he could undergo the procedure. When the insurer denied the prior authorization, that began his long journey to diagnose and treat his syringomyelia, or a cyst in his spinal column. For Daniel, it meant over a year of debilitating pain, weight loss, suicidal depression and dependence on opioids amid delayed diagnosis and treatment. And his repeated appeals of the denied authorization drained what little energy he had.
While writing my forthcoming book (on health insurance coverage delays and denials), I found that Daniel’s tragic experience is all too common. Of the 1,340 people I surveyed, 36% experienced at least one instance of coverage denial, often through prior authorization, that kept medical care out of reach. Prior authorization has been typically deployed by private health insurers, infuriating doctors and patients. Now, though, thanks to the Trump administration, Medicare beneficiaries will begin facing these obstacles to care as well.
Private insurers usually deploy prior authorization to limit low-value care and contain health care costs.
Starting next year, through its implementation of the Wasteful and Inappropriate Service Reduction (WISeR) Model, the Centers for Medicare and Medicaid Services (CMS) will begin a pilot program that will import the prior authorization process to traditional Medicare plans in six states. The program will even employ artificial intelligence tools to decide whether those Medicare beneficiaries will receive the care physicians say they need.
Private insurers usually deploy prior authorization to limit low-value care and contain health care costs. Though the tactic was used sparingly in its early days, it is now applied to most higher-cost drugs and nearly all surgeries and procedures. While most prior authorizations are ultimately approved, they are a source of headaches and frustration among patients and physicians alike, sowing distrust in the health care system. Prior authorization creates delays and denials of health coverage — and the process of challenging denials is highly burdensome, especially for people who are already struggling with severe or even life-threatening health conditions.
Appealing a coverage denial demands a high degree of health insurance literacy and fortitude that most of us lack, especially in a health crisis. Coordinating between one’s physician and insurer, all while potentially going untreated, can lead patients such as Daniel to experience a sense of overwhelm and a loss of autonomy amid this navigation anxiety. It is little wonder why so few patients ultimately opt to appeal. In fact, among the 3.2 million denials of prior authorization rendered by Medicare Advantage plans in 2023, just 11.7% were appealed despite most appeals resulting in a reversal of the initial denial.
Thus, health care becomes rationed not through a final denial of coverage, but rather through accumulations of inconveniences as patients — especially those from marginalized backgrounds — struggle to navigate America’s labyrinthine health insurance bureaucracy. Perhaps not surprisingly, the use of prior authorization has effects that are not only pervasive, but also inequitable. My research has found that less affluent patients are less likely to appeal, and sicker patients and Black and Hispanic Medicaid patients are less likely to appeal successfully.
The roughly 33 million Americans in Medicare’s traditional fee-for-service plans have largely been able to evade these administrative burdens, as these plans use prior authorization very rarely, such as for durable medical equipment. On the other hand, 99% of Medicare Advantage beneficiaries have prior authorization requirements in their plans. But with the proposed changes under the Trump administration, the enrollees relying on traditional Medicare will get ensnared in red tape as well, likely leading to delayed or forgone care.
Health insurers’ reliance on AI to process claims has already faced legal challenges. And remember, most of Medicare’s beneficiaries are 65 or older. Older adults tend to have lower health insurance literacy, are more likely to have significant health challenges and more frequently suffer from cognitive decline, which makes navigating the complexities of these health insurance processes particularly onerous, if not infeasible. CMS Director Dr. Mehmet Oz asserts that this pilot program is aimed at “crushing fraud, waste, and abuse.” But it will inevitably drive delays in care — and burdens of appealing — for seniors across the country. It will likewise exacerbate administrative burden for physicians, who must submit prior authorization documentation, conduct “peer to peer” reviews of denials, and craft appeal letters on behalf of their patients. In fact, quite apart from simply combating overprescribing, prior authorization-related burdens can actually lead to underprescribing to avoid subsequent delays or rejections of coverage. What’s more, health insurers’ reliance on AI to process claims (including from Medicare Advantage beneficiaries) has already faced legal challenges. Lawsuits filed against UnitedHealth, Cigna, and Humana challenge the deployment of AI programs to decide the amount of coverage that patients required, regardless of the recommendations of the treating physician. Despite the scrutiny in court, only a small minority of patients (usually more advantaged patients) appeal these prior authorization denials. In other words, the high rate at which these denials are reversed — as high as 90 percent, according to the lawsuits — can be an acceptable cost to insurers if the process is so burdensome that few ever challenge the decisions in the first place. Daniel ultimately received his spinal cord stimulator, but through his long-term suffering, he was left wondering what might have been absent his supportive family and team of physicians advocating for his access to care at each turn in the health insurance maze. Applying the tools of managed health care to seniors, who may face cognitive decline and worsened physical health, is a recipe for disaster in which, for far too many, health benefits will feel illusory. In a nation as wealthy as the United States, seniors’ epitaphs should not be at risk of reading, “Died of red tape.”
Miranda Yaver
Miranda Yaver is an assistant professor of health policy and management at the University of Pittsburgh and a health care fellow at the Roosevelt Institute. 
