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Category: Health Insurance

‘Delay’ and ‘Deny’: Even Health Insurance Companies Agree Prior Authorization Process Is Broken

Andy |

April Dembosky

Ocean McIntyre goes through a file folder of health insurance claims and denial letters at her home in Panorama City on Feb. 10, 2026.  (Jules Hotz for KQED)

When Ocean McIntyre started having vision problems at age 34, her health plan took a month to authorize a doctor visit.

When pressure in her brain started crushing her optic nerve, she spent three months tangled in bureaucratic red tape before the insurer finally permitted her to see a specialist, a neuro-ophthalmologist.

“He said if you had been seen earlier, we could have preserved your vision,” McIntyre remembered. “Now we’re just trying to see if we can save any of your vision. That was the first time it really clicked that the life that I had before was over.”

After a wide-ranging career as a tattoo artist, a private pilot, and a research assistant at NASA’s Jet Propulsion Lab near Pasadena, McIntyre is now 51, legally blind and struggling to find work. “I have no peripheral vision at all. It’s like looking through a straw, and what I see is semi-clear in one eye and completely blurry in the other,” she said. “I fall, I trip on things all the time, even in my own house. I’m obviously not flying anymore, not driving a car anymore.”

For decades, patients like McIntyre and their doctors have pressed California and other state lawmakers to rein in health insurers’ ability to review or refuse coverage for medical services after a physician has ordered them, a practice known as prior authorization. But the conversation shifted in December 2024 when Luigi Mangione allegedly murdered UnitedHealth CEO Brian Thompson, using bullets etched with the words “delay” and “deny.” The next year, an unprecedented 31 states, at least, passed laws limiting the use of prior authorization, almost all with bipartisan and near-unanimous support.

In 2025, 31 U.S. states passed prior authorization reforms. (Map: Marnette Federis/KQED)

While momentum for legislative change had already been building, several industry insiders and observers said the assassination of an insurance executive, and especially the public outcry that followed, was the catalyst that pushed so many laws over the finish line in 2025. Tens of thousands of people took to social media to both condemn the violence and to air their grievances about insurance tactics and barriers to care.

“It really highlighted for the country this amount of anger,” said Miranda Yaver, health policy professor at the University of Pittsburgh. “And I think that placed pressure on state legislatures.”

Health insurers felt the pressure, too, as lawmakers complained during committee hearings about their own experiences with prior authorization before voting in favor of local bills.

By summer 2025, a coalition of insurance companies issued a pledge to voluntarily streamline, simplify, and reduce the use of prior authorizations. Especially where state legislation aligned with these principles or was narrowly tailored, the insurance industry was more receptive than it had been in the past. Where there was still friction, insurance lobbyists stated their objections, but often struck a conciliatory tone.

Paul Markovich, president and CEO of Ascendiun, the parent company of Blue Shield of California, testifies before the House Committee on Ways and Means with other health insurance CEOs on Capitol Hill, in Washington, on Jan. 22, 2026. (Jose Luis Magana/AP Photo)

“Prior authorization process today sucks. We all take accountability for it,” saidPaul Markovich, CEO of Blue Shield of California, at a congressional committee hearing in January featuring a panel of five health insurance executives. “We are fixing it by reducing the number of services that are covered, offering an online service, and standardizing electronic submission of data.”

Prior authorization started out as a tool insurers used to control costs and tosafeguard patients against unnecessary or harmful treatments. It is typically applied to high-cost items, like experimental treatments, hospitalizations and surgeries, and certain prescription drugs.

For example, back surgeries are often denied because clinical trials show they provide little to no benefit to people who suffer from back pain compared to exercise and physical therapy. Brand-name medications can often be replaced with equally effective, but significantly cheaper, generic alternatives.

Two health insurance denial letters lie on Ocean McIntyre’s table, at her home in Panorama City. Many more are stored in boxes and file folders of communication letters from her health insurance on Feb. 10, 2026. (Jules Hotz for KQED)

“These efforts help keep coverage as affordable as possible,” said Chris Bond, spokesperson for AHIP, a national trade association for the health insurance industry.

But in more recent years, doctors complained that insurers were abusing prior authorization, applying it to more services or using it as a tactic to delay and deter patients away from care. In a 2024 national survey, doctors said they and their staff spent an average of 13 hours a week dealing with prior authorization requests; 23% of doctors said their patients had been hospitalized because of prior authorization delays, 18% said they’d experienced a life-threatening event, and 8% said a patient suffered permanent disability or death.

The mountains of paperwork and constant second-guessing by insurers drive burnout and push doctors into early retirement, said René Bravo, a pediatrician in San Luis Obispo and president of the California Medical Association.

“There is nothing that causes physicians’ blood pressure to elevate like prior authorization,” he said. “You just say the word, and doctors bristle.”

California targets insurance companies

States are taking different approaches to regulating the insurance industry’s use of prior authorization. Some, like Nebraska and North Dakota, focused on expediting the process, mandating timelines for when reviews must be completed, while others restricted the use of artificial intelligence in making determinations.

Many states, including Texas, Arkansas, and West Virginia, have instituted “gold card” programs that exempt doctors from prior authorization if the treatments they order already have a high rate of approval. Others, including Rhode Island and Montana, focused on exempting certain treatments, such as preventive care, insulin, mental health and substance abuse treatment, or some cancer care.

David H. Aizuss, M.D., F.A.C.S., an ophthalmologist and chair of the board of trustees at the American Medical Association, in his office in Encino, California, on Feb. 10, 2026. (Jules Hotz for KQED)

“The California law is different. It puts the onus on the health plans,” said David Aizuss, an ophthalmologist in Los Angeles and chair of the board of trustees at the American Medical Association, which has been tracking state legislation.

SB 306 said that if a health insurer approves a medical service more than 90% of the time in one year, then it can’t require prior authorization for that service the next year.

“This creates a data-driven, common-sense approach,” said state Sen. Josh Becker, D-Menlo Park, who authored the bill. “If you’re approving it anyway, don’t make patients, providers jump through hoops.”

Though attempts to pass a previous version of this bill petered out in 2023, Gov. Gavin Newsom’s office was particularly involved in the passage of SB 306, mediating differences between doctors who supported it and insurers who opposed it, and directing the state Department of Managed Health Care to offer technical assistance.

The regulator is leading the implementation of the law. By July 2026, officials will instruct insurers on how to report the statistics that will be used to list procedures and medications that will be exempted from prior authorization, which regulators expect to publish by July 2027.

Aizuss believes a range of medications for hypertension, diabetes, asthma, and arthritis will make it onto the list, as well as certain outpatient mental health treatments and cancer surgeries.

He’s hopeful that California’s broad approach will lead to more overall transparency and be more effective than other states. Insurers have found loopholes to skirt around the requirements of gold card laws, he said, and the burden is on doctors to prove they should be exempt from prior authorization. For example, in Texas, only 3% of doctors have qualified for gold card status, Yaver said. The California law, by contrast, requires insurers and regulators do the legwork. “This is a positive step toward relieving physician administrative burden,” Yaver said.

Whatever the approach, McIntyre is relieved to see progress in California and across the country. She said no one should suffer a heart attack or a cancer relapse, or lose their vision, because they had to wait for care.

Millions may drop ACA coverage — and raise health insurance costs for everyone else

Andy |

If you are in this position reach out to us, there may be more affordable option that you can qualify for.

www.AZhealth.us | Andy Orlikoff | 623-742-3878

Greg Iacurci

Millions of people are likely to drop their health insurance now that enhanced premium subsidies for consumers who buy coverage on the Affordable Care Act marketplace have expired. That could increase costs for remaining enrollees, leading some experts to warn of a potential “death spiral” in the ACA market.

The lapse of enhanced premium tax credits at the end of 2025 led insurance premiums to more than double for the average subsidy recipient, to $1,904 per month in 2026 from $888 last year, according to estimates from KFF, a nonpartisan health policy research group.

Young, relatively healthy people are the most likely to drop their policy if they deem premiums to be too high and think coverage is not worth the cost, economists said.

That would leave an older, sicker population of enrollees, who are more likely to use their insurance and require costly care, economists said — which might prompt insurers to raise premiums further to offset the higher costs in a self-reinforcing cycle.

“If these [relatively young, healthy] individuals, whose health care costs are lower on average, exit the risk pool, the average cost of care will increase and thereby cause premiums to increase further,” Meredith Rosenthal, chair of the Department of Health Policy and Management at Harvard University’s T.H. Chan School of Public Health, said recently in a written interview with the university.

“The worry is that this process can spiral (known as a “death spiral”) and lead to further disenrollment and even higher premiums,” she said.

Millions of young people may drop ACA coverage

An Obamacare sign at a Miami insurance agency on Nov. 12, 2025.

Joe Raedle | Getty Images

About 22 million Americans received enhanced premium subsidies in 2025.

The Urban Institute and The Commonwealth Fund estimate that 7.3 million people will leave the ACA marketplace in 2026 due to the loss of enhanced premium subsidies. About 5 million of them would go uninsured, they wrote in a joint analysis, rather than find insurance elsewhere.

Young adults would see the largest increase in the number of uninsured people, they said.

In fact, 19- to 34-year-olds account for nearly half — about 2.3 million — of the anticipated increase in the number of uninsured people, according to Jessica Banthin, a senior fellow at the Urban Institute and co-author of the analysis.

By comparison, about 500,000 of those who will be uninsured are 55 to 64 years old, Banthin said.

“It all comes down to who really feels like they need to have health insurance,” said Emma Wager, a senior Affordable Care Act policy analyst at KFF.

There’s evidence insurers raised premiums for 2026 due to a riskier population of insured consumers, experts said.

Insurers raised their gross premiums by an estimated 26% for 2026, on average, according to KFF. This is the total premium, including the consumer’s share and whatever is covered by premium tax credits.

Insurers indicated in filings to state regulators that 4 percentage points of that 26% is due to their expectations that healthier people would drop coverage if the enhanced premium tax credit lapsed, Wager said.

The rest of the increase is due to other factors inflating the cost of health care, such as new specialty drugs becoming available, the cost of labor and consolidation among medical providers, Wager said.

The public will get a clearer picture of how many people dropped their ACA marketplace coverage and the demographics of those individuals when data becomes available over the summer, Wager said.

Why death spiral concerns may be premature

Colorado residents fill out cards and share their stories for content to send to congressional representatives regarding health-care cuts on Nov. 1, 2025, the first day of ACA open enrollment, in Northglenn, Colorado.

Tom Cooper | Getty Images Entertainment | Getty Images

Some policy experts say that warnings of a death spiral in the ACA marketplace are premature.

For one, the disappearance of enhanced subsidies seems to be a one-time shock to the system, they said.

“I think the death spiral concern is understandable, but may be a slight exaggeration,” Michael Gusmano, a professor of health policy at Lehigh University, wrote in an e-mail. “What seems likely is that the loss of people from the overall pool will lead to increases in price — and this will further erode the willingness of people to sign up.”

Additionally, the way premium tax credits were designed should prevent a death spiral, policy experts said.

The tax credit structure caps households’ out-of-pocket expenses for insurance premiums as a percentage of household income. For example, the enhanced federal subsidies capped outlays at 8% of household income, while the lowest earners paid 0%.

While the enhanced subsidies have disappeared, the standard premium tax credits — which have been in place since 2014 — remain.

Now, out-of-pocket premiums are capped at roughly 10% of annual income for qualifying consumers. The cap declines on a sliding scale, down to about 2% for lower earners.

The more money you take away from the subsidies the greater the prospect of death spiral is.

Gerard Anderson

professor of health policy and management at Johns Hopkins Bloomberg School of Public Health

These income caps would likely prevent a death spiral, economists said. If insurers raise premiums, those increases are borne largely by the federal government via tax credits, not consumers, they said.

“All those higher premium costs mostly get translated into higher government subsidies,” John Graves, a professor of health policy and medicine at Vanderbilt University, wrote in an e-mail.

Millions fewer people may enroll, but there would still be “stable risk pools” by virtue of the income caps, he wrote.

Consumers least likely to sign up

Patients are prepared for surgery on the opening day of UCI Health – Irvine in Irvine, California, Dec. 10, 2025.

Paul Bersebach/MediaNews Group/Orange County Register via Getty Images

Aside from young consumers, those least likely to sign up or re-enroll in ACA marketplace coverage are people who no longer qualify for any premium tax credits, experts said.

These are consumers who earn more than 400% of the federal poverty level, which equates to $62,600 for a one-person household.

Many of these households qualified for enhanced subsidies but are no longer eligible — meaning they must pay the full, unsubsidized insurance premium out of pocket.

The Urban Institute and The Commonwealth Fund estimate that the average annual premium for consumers over the subsidy cliff jumped to about $8,500 in 2026 from about $4,400 in 2025.

In 2025, about 3% of ACA enrollees — nearly 725,000 people — earned between 400% and 500% of the federal poverty line, for example, according to a Bipartisan Policy Center analysis of federal data.

How an ACA death spiral becomes more likely

Something that policy experts say would be more likely to trigger a death spiral: Converting the current subsidy structure into a fixed-dollar payment for consumers, an idea that Republican lawmakers and President Donald Trump have broached.

In that case, the premium increase would be borne entirely by individuals rather than by the federal government, Graves said.

“The more money you take away from the subsidies, the greater the prospect of death spiral is,” said Gerard Anderson, a professor of health policy and management at Johns Hopkins Bloomberg School of Public Health.

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The Looming “Subsidy Cliff” and the Soaring Cost of Obamacare Coverage in 2026

Andy |

If you get your health insurance through the Affordable Care Act (ACA) Marketplace, you might be facing sticker shock during this year’s Open Enrollment. While the underlying cost of health coverage is undeniably rising, a massive policy change—the expiration of crucial pandemic-era subsidies—is set to hit millions of Americans’ wallets with a significant increase in 2026.

Here is a summary of the expected increases and what is driving them:

1. The Shocking Rise in Premiums

Insurance companies are proposing major premium hikes for ACA plans. The base cost (gross premium) for coverage on the Marketplace is increasing by an estimated 26% on average for 2026 plans.

However, the real blow for many will come from the net premium—the amount enrollees pay after financial assistance.

2. The Expiration of Enhanced Subsidies (The “Subsidy Cliff”)

The main catalyst for the massive increase in out-of-pocket costs is the scheduled expiration of the enhanced Premium Tax Credits (PTCs) at the end of 2025.

3. The Problem of High Deductibles

While monthly premiums capture attention, high deductibles remain a core issue for many ACA enrollees. Even with subsidized premiums, many families still face very high out-of-pocket maximums. For some lower-income families, deductibles can be set as high as $14,700 for a family of four.

Furthermore, as insurers and employers look for ways to offset rising gross costs, there is concern that a new wave of rising deductibles will be implemented to keep premium costs down, shifting more financial risk onto the consumer.

4. Why Are Underlying Costs Rising?

The subsidy expiration only exacerbates a pre-existing trend of rising healthcare costs. Key drivers include:

What to Do Next: As the Open Enrollment period is underway, it is critical for consumers to check their new premium costs and shop for plans, as the best value plan may have changed significantly from the previous year. Lawmakers continue to debate solutions, including proposals to extend the subsidies or redirect the funding directly to patients to help offset high out-of-pocket costs.

As a health insurance broker in Surprise, AZ I can help. Plans off exchange and outside the ACA are available.

Contact Andy Orlikoff Today!
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2026 Open Enrollment: Americans fear spike in healthcare costs, making some Republicans nervy

Andy |

By Jeff Miller

For the past few weeks, Shana Verstegen has been “sick to her stomach” wondering what might happen to her family’s health insurance next year.

Ms Verstegen and her husband both work for a small business as fitness trainers, meaning they have to pay for their own plan.

The Wisconsin parents of two have saved an estimated $800 (£601) a month on their health insurance through Affordable Care Act, also known as Obamacare, premium tax credits.

Set to expire at the end of the year, the federal subsidies are now at the heart of the battle over the US shutdown. Democrats will not back a spending deal that reopens the government unless Republicans renew the subsidies.

Ms Verstegen and others are watching anxiously, wondering what kind of financial consequences they would face if a deal can’t be reached.

“Everything’s getting more expensive now anyway, and this would be another major hit for our family,” she said.

Health policy experts say time is running out to prevent millions from losing their health insurance because the price hikes will make it unaffordable.

The tax credits were first introduced through former President Barack Obama’s Affordable Care Act (ACA) in 2014 and then expanded during the Covid pandemic.

Some Americans could see their monthly cost of insurance – also known as a premium – rise by hundreds of dollars on 1 November, said Leighton Ku, a health policy professor at George Washington’s Milken Institute School of Public Health.

“If you are one of the 20 or so million people who’s getting your health insurance through the marketplace, if you’re about to see prices on average double, that’s a big deal,” he said. “It’s going to be too late real soon.”

Red states would be hardest hit

 

Of the roughly 24 million people who get their health insurance through the ACA Marketplace, a vast majority benefit from the premium subsidies.

Stacy Cox, a photographer in Utah, has saved over $10,000 a year on average since she started benefiting from the subsidies in 2022.

“It is an absolute lifeline for so many of us,” said Ms Cox, who has an autoimmune disease.

But if the tax credits are not extended, Ms Cox said she will have to quit her newly launched photography business and find a different job that provides health insurance.

Around seven million people like Ms Cox are expected to stop buying health insurance through the marketplace if the tax credits end, Ku said. Of those, around four to five million are expected to lose health care coverage altogether because they won’t be able to find other means, data suggests.

Many of those who will be affected are working-class people who don’t qualify for Medicaid, the government-run programme which provides healthcare insurance for low-income adults, children, pregnant women, elderly adults and people with disabilities.

The hardest hit could be those in 10 US states – most of which vote Republican – that have chosen not to expand eligibility for Medicaid.

“One of the political paradoxes of all this is that the places that get hurt the most are states that are more conservative,” said Ku.

If the subsidies expire and healthier people begin to opt out of insurance, that will also raise premium prices overall for Americans, as a sicker pool of customers will drive up healthcare costs, said Elizabeth Fowler, a distinguished scholar at Johns Hopkins Bloomberg School of Public Health.

“You start to get into a death spiral where premiums become even more expensive and more out of reach for more people,” she said.

Divisions emerge among Republicans

 

Some Republican leaders in Congress have maintained they will discuss the future of subsidies once the government reopens.

But at least a few Republicans want their party to take action now.

Representative Marjorie Taylor Greene, a close ally of President Donald Trump’s, has said she is in favour of the tax credits, adding that her own children’s premiums would go up if they end.

“I’m absolutely disgusted that health insurance premiums will DOUBLE if the tax credits expire this year,” the Georgia lawmaker said.

Republican Senator Lisa Murkowski this month introduced a bill to extend the credits for two years, while Senators Dan Sullivan and Tommy Tuberville are also in support.

Trump appeared open to negotiating with Democrats over their health care agenda, saying last Monday that if it’s “the right deal, I’d make a deal”. But he seemed to walk back those remarks later.

Experts said Republicans’ opposition to the subsidies is representative of their general dislike of the ACA, also known as Obamacare.

“Some of it has to do with the belief that it’s big government intrusion, and so they resent it for that,” Ku said.

In addition to the expiration of the tax credits, Republicans were also able to target the ACA this year through Trump’s tax and spending bill, which made steep cuts to Medicaid, changes Democrats are also seeking to reverse.

Republicans argue those cuts are aimed at eliminating waste, fraud and abuse of federal funding.

Time ticking to save subsidies

 

The deeper cuts to Medicaid are not expected to take effect for years but the Democrats who want the healthcare premiums to stay at current levels have to race against a looming deadline – the 1 November open enrollment period.

Some Republicans have argued that the subsidies can be resolved later since they only expire at the end of the year, but Ku said some health insurers have already changed their rates in response to the expiration, and may not be able to change them.

If the subsidies are not renewed before November, people will make their insurance decisions assuming their premiums are set to double, even if the credits are renewed at a later date.

“The mechanics of fixing this problem this late in the game are complicated,” Ku said.

Ms Verstegen said if her rates go up, her family will have to make financial sacrifices. Her family already has a deductible of $14,000, and she is still paying back a major hip surgery from two years ago.

“I truly believe that if this goes away next year, a lot of people are going to be very upset, and that’ll show up in elections,” she said.

Health care affordability was not a top issue in 2024 or other recent elections, as Americans have grown accustomed to accessing health insurance through the ACA.

But if people start to see their insurance prices rise, especially in red districts, that could prove a political liability for the Republican Party, Ku said.

“If I were a representative from Texas or Georgia, I would be feeling some doubts,” he said. “But in a game of chicken, you never want to show your doubts.”

Need assistance in finding affordable Health Insurance?

Contact: Andy Orlikoff

www.AZhealth.us

623-742-3878

Your Health Insurance IS Going To Increase By The Biggest Percentage in 15 Years!

Andy |

 

Your Health Insurance Is About to Get More Expensive—Here’s Why

 

If it feels like your health insurance costs are always going up, you’re not imagining it. According to a recent survey from Mercer, a consulting firm, health benefit costs are projected to increase by 6.5% in 2026—the highest jump in 15 years. This trend is a wake-up call for both employers and employees, as everyone’s wallets are about to feel the pinch.

 

What’s Driving the Price Hikes?

 

The rise in costs isn’t just due to one single factor; it’s a perfect storm of several powerful trends:

 

How Employers Are Responding

 

Facing these mounting costs, employers are looking for ways to manage their budgets. The survey found that a growing number of companies plan to make changes to their health plans in 2026. This often means raising deductibles and co-pays, which shifts more of the financial burden directly onto employees.

However, some employers are also exploring new strategies to curb costs without simply making their employees pay more. They are focusing on managing high-cost claims and using high-performance network plans, which guide employees toward a curated list of providers known for quality care and lower costs. At the same time, many companies are still prioritizing employee well-being by expanding access to mental health services.

 

What This Means for You

 

For most employees, these changes will mean a higher paycheck deduction for health coverage. On average, employees can expect to see their premium share rise by 6% to 7% in 2026.

This is why your next open enrollment period is more important than ever. It’s crucial to take a close look at all your options. You’ll need to balance the monthly premium with potential out-of-pocket costs like deductibles and co-pays. Choosing a high-performance network plan might seem restrictive, but it could save you a significant amount of money in the long run.

Don’t wait until the last minute. By understanding these upcoming changes, you can make an informed decision that protects both your health and your wallet.

I can help you with options.

Andy Orlikoff 623-742-3878

www.AZhealth.us

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