By Lauren Sausser, KFF Health News

HENRICO, Va. — Sheldon Ekirch spends a lot of time on hold with her health insurance company.

Sometimes, as the minutes tick by and her frustration mounts, Ekirch, 30, opens a meditation app on her phone. It was recommended by her psychologist to help with the depression associated with a stressful and painful medical disorder.

In 2023, Ekirch was diagnosed with small fiber neuropathy, a condition that makes her limbs and muscles feel as if they’re on fire. Now she takes more than a dozen prescriptions to manage chronic pain and other symptoms, including insomnia.

“I don’t feel like I am the person I was a year and a half ago,” said Ekirch, who was on the cusp of launching her law career, before getting sick. “Like, my body isn’t my own.”

Ekirch said specialists have suggested that a series of infusions made from blood plasma called intravenous immunoglobulin — IVIG, for short — could ease, or potentially eradicate, her near-constant pain. But Ekirch’s insurance company has repeatedly denied coverage for the treatment, according to documents provided by the patient.

Patients with Ekirch’s condition don’t always respond to IVIG, but she said she deserves to try it, even though it could cost more than $100,000.

“I’m paying a lot of money for health insurance,” said Ekirch, who pays more than $600 a month in premiums. “I don’t understand why they won’t help me, why my life means so little to them.”

For patient advocates and health economists, cases like Ekirch’s illustrate why prior authorization has become such a chronic pain point for patients and doctors. For 50 years, insurers have employed prior authorization, they say, to reduce wasteful health care spending, prevent unnecessary treatment, and guard against potential harm.

The practice differs by insurance company and plan, but the rules often require patients or their doctors to request permission from the patient’s health insurance company before proceeding with a drug, treatment, or medical procedure.

The insurance industry provides little information about how often prior authorization is used. Transparency requirements established by the federal government to shed light on the use of prior authorization by private insurers haven’t been broadly enforced, said Justin Lo, a senior researcher for the Program on Patient and Consumer Protections at KFF, a health information nonprofit that includes KFF Health News.

Yet it’s widely acknowledged that prior authorization tends to disproportionately impact some of the sickest people who need the most expensive care. And despite bipartisan support to reform the system, as well as recent attempts by health insurance companies to ease the burden for patients and doctors, some tactics have met skepticism.

Some insurers’ efforts to improve prior authorization practices aren’t as helpful as they would seem, said Judson Ivy, CEO of Ensemble Health Partners, a revenue cycle management company.

“When you really dive deep,” he said, these improvements don’t seem to touch the services and procedures, such as CT scans, that get caught up in prior authorization so frequently. “When we started looking into it,” he said, “it was almost a PR stunt.”

The ‘Tipping Point’

When Arman Shahriar’s father was diagnosed with follicular lymphoma in 2023, his father’s oncologist ordered a whole-body PET scan to determine the cancer’s stage. The scan was denied by a company called EviCore by Evernorth, a Cigna subsidiary that makes prior authorization decisions.

Shahriar, an internal medicine resident, said he spent hours on the phone with his father’s insurer, arguing that the latest medical guidelines supported the scan. The imaging request was eventually approved. But his father’s scan was delayed several weeks — and multiple appointments were scheduled, then canceled during the time-consuming process — while the family feared the cancer would continue to spread.

EviCore by Evernorth spokesperson Madeline Ziomek wrote in an emailed statement that incomplete clinical information provided by physicians is a leading cause of such denials. The company is “actively developing new ways to make the submission process simpler and faster for physicians,” Ziomek said.

In the meantime, Shahriar, who often struggles to navigate prior authorization for his patients, accused the confusing system of “artificially creating problems in people’s lives” at the wrong time.

“If families with physicians are struggling through this, how do other people navigate it? And the short answer is, they can’t,” said Shahriar, who wrote about his father’s case in an essay published last year by JAMA Oncology. “We’re kind of reaching a tipping point where we’re realizing, collectively, something needs to be done.”

The fatal shooting of UnitedHealthcare CEO Brian Thompson on a New York City sidewalk in December prompted an outpouring of grief among those who knew him, but it also became a platform for public outrage about the methods insurance companies use to deny treatment.

The return of Donald Trump to the White House in 2025 will spark a significant shift in U.S. economic policy across numerous issue areas, but changes to U.S. trade and industrial policy might be more subtle than severe. We are still operating under many of the trade policies Trump set during his first term. After campaigning in 2020 against the broad-based and damaging tariffs Trump imposed, President Biden maintained and even expanded U.S. trade restrictions and other forms of economic nationalism.

The motivation for such consistency, however, was in large part political: It was an open secret in Washington that Biden’s advisors, needing “Rust Belt” votes to win reelection and facing a vocally protectionist opponent in Trump, viewed economic nationalism as the only viable approach. Now unburdened by such concerns and facing the reality of a failed political strategy, Biden has a short time to remedy past policy errors and improve the United States’ economic and geopolitical prospects before Trump takes office.

There are several significant moves he could make.

The suggestions that follow are undoubtedly optimistic but are neither impossible nor futile. Some smart moves, such as nixing most U.S. tariffs, are off the table because they would require Congress. Other actions, such as initiating new free-trade-agreement talks, take time and could therefore be easily stopped by the incoming Trump administration before they got far.

Biden could, on the other hand, take several other moves that would constitute a significant and more durable improvement in policy.

He should start with tariffs. Ideally, Biden would reembrace his 2020 campaign position on the economic and geopolitical harms of indiscriminate U.S. tariffs and terminate both the “national security” tariffs on global steel and aluminum imports and the “Section 301” tariffs on Chinese imports that began under Trump. Both measures were imposed on dubious grounds and have since inflicted serious pain for little gain. Because they were implemented unilaterally, moreover, Biden could nix them with the stroke of a pen.

Just as important, full termination would mean that reinstituting the tariffs next year — or adding even more on top of them as Trump has promised — would require the next administration to undertake lengthy bureaucratic investigations. In the meantime, freer trade would flow, and other tariffs and trade restrictions — such as the dozens of “trade remedy” measures on Chinese imports — would remain in force, mitigating claims that Biden was leaving the economy vulnerable to a flood of nefarious foreign goods.

Barring full termination of these tariff actions, Biden should eliminate those that have no plausible connection to our economic or national security. This includes tariffs on simple consumer goods from China — tiki torches, vacuum cleaners, baby blankets, etc. — as well as supposed national security tariffs on metals from close allies in Europe and Asia. Even on economic nationalists’ own terms, these measures make little sense, and quickly reimposing them next year, at a time when inflation still resonates with voters, might prove politically nettlesome. Tariffs imposed by the U.S. raise prices for American consumers — not usually a good look for politicians.

Beyond the tariffs, Biden might also consider terminating the global “safeguard” restrictions on imported solar panels, which are both costly and unnecessary. Thanks in part to these measures, solar panel prices are far higher here than abroad, thus harming U.S. solar installation companies and slowing the energy transition. Removing the safeguard would thus help advance Biden’s climate ambitions, while leaving Chinese solar cells and modules subject to several other, more targeted U.S. trade restrictions.

Next, Biden should encourage Congress to retake some of the constitutional authority over tariffs that the legislative branch delegated to the president during much of the 20th century, when everyone assumed that the president wouldn’t abuse such power — an assumption that the first Trump administration proved incorrect. Because it’s unclear whether federal courts would stop the global tariffs that Trump has promised this time around, the only sure way to eliminate this risk rests with Congress. Reform legislation has been offered in this regard, and encouraging and signing it would significantly lower the risk of damaging future Trump tariffs. It would also be a credit to Biden’s legacy, at little cost to him; he can make reforms now that would be binding on his successors, but his own presidency was not limited by them.

Finally, Biden should turn to investment and fast-track federal approval of a Japanese company’s proposed acquisition of U.S. Steel, which has been held up for months on obviously political grounds. As has been widely documented, U.S. Steel’s shareholders and management overwhelmingly approve of the offer from Nippon Steel, as do many American steelworkers. Industry experts also widely agree that Nippon’s acquisition — involving billions of dollars in new U.S. investments and creating a Western counterbalance to China’s steelmaking prowess — would benefit both the American steel industry and national security more broadly. Approving the deal, which Trump has vocally opposed but former Trump advisors have cheered, would also signal to the world that the U.S. government — or, at least, half of it — remains open for business and welcoming to beneficial foreign investment.

This wish list is, of course, idealistic. But it would represent a radical improvement in U.S. policy — one that Biden could achieve quickly, in some cases unilaterally. Such progress is all but guaranteed not to happen in 2025. And at this point, anyway, it’s not like the president has anything to lose.

Scott Lincicome is the vice president of general economics at the Cato Institute.