Health Insurance Change to Improve Service for 257 Million Americans

Newsweek

5 hours ago

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More than 30 health insurance companies have announced they will be implementing new changes to "streamline" health plans, a move expected to benefit 257 million Americans.
Major insurers, including UnitedHealthcare, Blue Cross, Cigna, CVS Health, Humana and Elevance Health, will "streamline, simplify and reduce prior authorization—a critical safeguard to ensure their members' care is safe, effective, evidence-based and affordable," according to a press released shared by AHIP, a national health insurance association, on Monday.
This affects those using Commercial coverage, Medicare Advantage and Medicaid managed care.
Why It Matters
There has been growing resent targeted at major health insurers in recent years, and notably, since UnitedHealthcare CEO Brian Thompson was fatally shot in December last year. The incident kick-started a wave of anger from the American public towards health insurance companies over issues to do with expenses, denied claims and others.
This latest move by health insurers, to give patients faster access to health care with "fewer challenges navigating the health system," could be a ploy to regain some public favor, as well as an action to improve the health care system as a whole, experts have warned.
"Business decisions are typically strategic rather than accidental," Ge Bai, a professor of health policy and management at Johns Hopkins Bloomberg School of Public Health, Maryland, told Newsweek.
What To Know
Patients will most likely notice these changes through "faster, more direct access to appropriate treatments and medical services with fewer challenges navigating the health system," AHIP said in its press release.
Meanwhile, providers will find that prior authorization workflows are more streamlined, allowing for a "more efficient and transparent process overall," AHIP added.
"If these measures are effective, Americans should have to wait less time to receive necessary procedures, and health care providers should have more time to spend with patients," Tom Baker, a professor of law at the University of Pennsylvania Carey Law School, told Newsweek.
Baker said that while American health care "needs streamlining," it is also important to remember that "we have given private health insurers an impossible job."
"We ask them to facilitate low friction access to needed care while also controlling health care costs," he added.
The upcoming changes includes the implementation of "common, transparent submissions for electronic prior authorization" through the development of standardized data and submission requirements. This new framework is currently scheduled to be operational by January 1, 2027.
Health insurers have also said they will reduce the number of claims subject to prior authorization, with clear reductions expected by January 1, 2026.
As of January 1, 2026, health insurers said they will also ensure a continuity of care when patients change plans.
"When a patient changes insurance companies during a course of treatment, the new plan will honor existing prior authorizations for benefit-equivalent in-network services as part of a 90-day transition period," AHIP said.
Under the new changes, health plans will also provide clear, comprehendible explanations of how to apply for appeals and guidance on next steps, depending on the outcome of the determinations.
In addition, participating health plans confirmed that all non-approved requests based on clinical reasons "will continue to be reviewed by medical professionals," a commitment that is already in effect, AHIP said.
In 2027, at least 80 percent of electronic prior authorization approvals will be answered in real-time, the association added.
File photo: application and instructions paper work for the Health Insurance Marketplace from the Department of Health and Human Services.
File photo: application and instructions paper work for the Health Insurance Marketplace from the Department of Health and Human Services.
Jon Elswick/AP
What People Are Saying
Ge Bai, a professor of health policy and management at Johns Hopkins Bloomberg School of Public Health, Maryland, told Newsweek: "Patients in need of care might find it easier to access, but insurance premiums will rise more rapidly due to higher medical spending. There is no reason to streamline unless the business environment and political circumstances demand it, which is the case for this matter at this time. The downside of negative publicity is too severe for the industry not to act quickly to repair its public image. 'Streamlining' can provide immediate relief, allowing the industry to claim full credit and repair image, while future premium increases can always be attributed to other factors, so it's a wise, strategic move."
She added: "There is no free lunch when it comes to insurance. More pre-authorization controls spending and premiums but makes patients' lives harder; less pre-authorization will raise premiums while easing the burden for some patients."
Adam Block, a professor of public health at the New York Medical College, told Newsweek: "The potential downstream effects are very large if they are implemented. More and more provider offices are spending a disproportionate amount of time doing paperwork related to payment of medical care instead of medical care itself, while we are seeing shortages of providers in areas such as mental health and primary care. In other words, if properly implemented it could be easier to get an appointment with a provider and the provider could spend more time addressing individual health concerns."
He added: "There are large numbers of denials for claims and providers spend their limited time dealing. Plans must deal with patients who 'doctor shop' for providers who will provide them with the prescriptions, diagnostics or procedures they want, even if they are not in line with evidence-based medicine. What has resulted is an 'arms race' between health plans and providers, where health plans work hard to only pay for necessary care in line with evidence-based practice and providers work hard administratively to get anything they deem necessary reimbursed."
Kim Keck, president and CEO, Blue Cross Blue Shield Association said: "These measurable commitments—addressing improvements like timeliness, scope and streamlining—mark a meaningful step forward in our work together to create a better system of health. This is an important foundation to address bigger problems together, at a time when technology and interoperability can deliver real improvements to patient experience."
What Happens Next
The impact of some of these changes will be felt next year while others will come into play in 2027. However, whether these changes will have an effect is uncertain, with Block telling Newsweek: "I am concerned they are more aspirational than guaranteed."
He added that as the commitments have come from trade associations, "these associations generally do not have the ability to require any of their member plans to adhere to the recommendations."