Examining AHIP’s Pledges on Prior Authorization
In a RealClearHealth paper published this week, Prior Authorization: AHIP’s Commitments, Paragon Health Institute's Jackson Hammond explores recent actions taken by America’s Health Insurance Plans (AHIP) in partnership with the Trump Administration to look at reforms to when and how individuals are subjected to an insurance tool called prior authorization. First announced in July of 2025, AHIP has specifically made commitments to “streamline, simplify and reduce prior authorization,” and the paper builds out a solid framework for insurers as they consider where best to focus their efforts.
While some may be rightfully skeptical about where progress on prior authorization can be made in 2026 and beyond, AHIP’s commitments directly align with the Trump Administration’s efforts to remove barriers to access and drive down health care costs for everyday Americans – striking a balance between areas where prior authorization is a useful tool to protect against waste, fraud, and abuse, and reducing reliance on prior authorization where sound evidence supports patient and provider decision-making.
These efforts are also important to show that common sense policy changes can be implemented, and implemented quickly, without the need for legislative or regulatory action. By coming to the table to proactively address potential inefficiencies and cost drivers, payers are directly responding to criticisms of the program’s flaws and stepping up to deliver real savings for the American people.
Medical societies, patient advocates, and others have long argued for changes to prior authorization for a range of diseases, treatments, and procedures – citing a number of stressors and potential poor health outcomes that can result from delayed or denied treatment. Study after study finds that a majority of Americans now identify prior authorization as a major challenge to receiving the care that they and their doctors believe they need – with the half of all insured adults subjected to prior authorization requirements in the last two years reporting personal difficulty in navigating the complex process.
Delayed care and abandoned treatment can lead to costly complications and repeat emergency room visits for untreated or worsening conditions, adding health care costs where prior authorization had intended to contain them. Additional costs to the system come in the form of time intensive paperwork and processes that providers face when working to obtain access to their recommended treatment for a patient or appeal a denial.
This also results in a direct impact to the American workforce and productivity as providers are spending more time addressing prior authorization claims versus actually seeing patients, and employees are forced to take time away from work to navigate the process for themselves or a family member.
For all of these reasons, it makes sense for AHIP to commit to exploring improvements to how, when, and why prior authorization policies are used – not only for medical claims as laid out in their commitment statement but also for pharmaceutical claims, which is of interest to CMS and the Administration.
As touched on in the paper, patients with migraine may hold the key. Migraine affects around 40 million people in the United States, less than half of which are diagnosed and fewer still on medication. It disproportionally affects women by large margins and often throughout their lifetimes.
Many people living with migraine self-manage their mild-to-moderate migraine attacks with over-the-counter medications, while others with acute migraine seek prescription medications or other medical treatments such as injections or nerve blockers. Frustratingly for patients, even when they seek medication they are often faced with process barriers to receiving the newer treatments that have recently entered the market – treatments that the American Headache Society now says should be frontline options for those with migraine.
Beyond the impact this has on Americans who are living with migraine, the effects on our national economy are also considerable. Direct cost estimates vary between those with episodic versus chronic migraine, but on an annualized per patient level exceed $2,500 and $8,000, respectively. Costs to the economy in these estimates include a wide range of 60,000 to 600,000 lost workdays across sectors, and indirect cost estimates around 6 to 9 times higher than annual direct patient costs. These are Americans who want to go to work, live their lives, and contribute to society, but are being held back by the inability to properly treat their migraines.
In short, the science underpinning new treatments, the economic impact of inefficient care, and the substantial population of Americans who are suffering from migraine without the ability to properly treat it, all point toward migraine as an area where reduced reliance on stringent prior authorization mechanisms would be a win for all involved.
The insurers participating in AHIP’s efforts on prior authorization, the Trump Administration, and other advocates of utilization management reform have demonstrated an important interest in getting these tools right – and the near-term chance to demonstrate tangible health outcome and economic benefits in migraine care provides a unique pilot area to do so.
RealClearHealth
