Health care is a contract among adults: a patient seeks care, a clinician provides it, and payment follows. Prior authorization inserts an unaccountable third party between judgment and action. It delays care, drives up administrative cost, and erodes the dignity of both patient and physician. To address these issues, there is a growing movement to end Prior Authorization in Pennsylvania. Pennsylvania can do better. We will.
The moral case
Medicine is a voluntary exchange. When a doctor and a patient agree on a treatment, no bureaucracy has the right to override that decision absent fraud. Prior authorization turns permission into power. It says you may act only after a clerk consents. That is not health care. That is rationing by stall. Ending it is not a technocratic tweak; it is a statement about who owns your life and your time.
Where Pennsylvania stands today
Pennsylvania made initial progress with Act 146 of 2022, which tightened oversight of commercial plans and set basic timelines for decisions. The Insurance Department followed with operational guidance to make those timelines real on January 1, 2024. It was a start, not a finish.
See: Act 146 summary page and the Department’s implementation notice.
Meanwhile, the federal government set new minimums. CMS’s 2024 Interoperability and Prior Authorization Final Rule requires payers to deliver faster decisions (72 hours expedited, 7 days standard), provide specific denial reasons, report metrics, and stand up FHIR APIs by 2027. That’s the floor, not the ceiling.
See: CMS fact sheet and deck (fact sheet PDF; overview page).
The human cost
Doctors are not imagining the damage. The AMA’s 2024–2025 survey shows heavy delays, treatment abandonment, and burnout tied to prior authorization. Patients pay for this in lost days, worsened conditions, and avoidable hospitalizations.
See: AMA’s 2024 survey brief and full 2024 report (PDF). American Medical Association+1
In public programs, the burden is real too. KFF’s August 2025 analysis documents how states are tightening prior‑auth rules in Medicaid managed care, underscoring momentum for reform.
See: KFF’s issue brief: “Prior Authorization Process Policies in Medicaid Managed Care”.
The goal in Pennsylvania
The goal is simple: restore the primacy of the doctor‑patient decision and remove the delay machinery that blocks it. In practice, that means:
- Default to yes when insurers miss the clock. If a plan cannot decide on time, the answer is approved.
- Gold‑card clinicians and services with high approval rates. Stop re‑asking questions we already answered.
- Ban prior auth for common, high‑value categories. Stabilization care, prenatal and post‑partum care, medication‑assisted treatment for addiction, and stable chronic therapies should not be trapped in paperwork.
- Honor continuity. When patients change plans or prescribers, previously authorized, stable treatments should carry over for a meaningful period.
- Go fully electronic, real‑time. One API standard. No faxes. Instant status visibility. This complements the federal rule and accelerates it in our market.
Who is covered, honestly
A hard truth: federal ERISA limits a state’s reach. Most large, self‑funded employer plans are preempted from state mandates on benefit rules. We will attack what we control and set a standard others will feel compelled to match.
See: Gobeille v. Liberty Mutual for the controlling precedent on ERISA preemption (Cornell Law). Legal Information Institute
Even with ERISA, millions of Pennsylvanians can benefit immediately: people in fully insured plans, Pennie marketplace coverage, Medicaid/CHIP managed care, and state employee plans. We also have leverage through procurement and public reporting to pull the rest in.
See: Pennie, Pennsylvania’s state‑based exchange and DHS’s PA FAQ for providers.
What success looks like
Success is measurable. Decision times shrink from days to hours. Approval rates for routine, evidence‑based care move to real‑time. Patients no longer abandon treatment because a form sat in a queue. Physicians spend their time in clinic rooms, not on hold. Health plans publish their metrics. And when they miss deadlines, patients are not punished.
The path
We will pursue statutory reform for state‑regulated markets, operational reforms through Medicaid contracts and Pennie plan certification, and transparency that exposes laggards. We will align with federal timelines where useful and surpass them where necessary. We will make it easier for responsible plans to comply and harder for bad actors to hide.
Why this matters
Health care is not a favor dispensed by committees. It is a right to act on your judgment and your doctor’s knowledge. Prior authorization is an admission that a plan can ration your life by delay. Pennsylvania should reject that premise and replace it with one rule: if care is medically necessary and agreed upon by the treating professional and the patient, permission is not required.
Resources
- CMS Final Rule summary (fast decisions, APIs, transparency): CMS fact sheet. CMS
- Pennsylvania’s baseline law: Act 146 (2022) and Insurance Department notice. Pennsylvania General AssemblyPa Code and Bulletin
- Physician burden data: AMA 2024 results and overview article. American Medical Association+1
- Medicaid policy landscape: KFF 2025 brief. KFF
- ERISA preemption primer: Gobeille v. Liberty Mutual. Legal Information Institute
We need to end the permission culture in Pennsylvania health care. If you share that goal, join me.
