Mainland corporations are given millions of dollars by Hawaii insurance companies to interfere with decisions made between patients and their doctors, while patients struggle to find a primary care provider and clinics fail. Many leaders in government are concerned, but often with keeping powerful health care interests satisfied rather than helping patients. That may seem like an exaggeration, but it is what we see in the fight over prior authorization and resistance to House Bill 250 and the 2025 Revised Patient Bill of Rights.

Most Americans have encountered prior authorizations: either having waited on a medication themselves or watched someone they love be denied care. Prior authorizations require doctors to get approval before providing care. In the 1960s, these policies were used for government programs like Medicare to limit unnecessary hospital stays. Later, they applied to expensive procedures where the physician had a financial stake. Now, valuable time is lost seeking approvals for medications that cost less than a plate lunch.

I am a board-certified family doctor caring for more than 1 out of every 100 people on Hawaii island. Every day, I see the strain our community is under from the shortage of primary care doctors. I understand that getting rid of all prior authorizations is not realistic. When used responsibly, they can help manage costs. But according to a study in the journal Health Affairs, removing unnecessary prior authorizations would allow each provider to complete nearly 1,900 more visits per year. That would be the equivalent of adding 700 doctors to our workforce, the very number the University of Hawaii says we are short.

When people cannot get appointments, they end up in urgent care, or worse, in the emergency room. Some are hospitalized when that could have been prevented. Some never make it to care at all. Insurance companies admit they approve 90% of prior authorizations. So most of this waste, the lost time, the added cost, the lives disrupted, is for nothing but the profit of mainland companies that thrive on blocking care. Worse, patients are denied care entirely. Decisions are often not based on medical standards. They are made behind closed doors, with few requirements for insurers to explain their reasoning or disclose the impact on patients. Doctors are left arguing with clerks or automated systems while patients lose time, stability and sometimes, lose their lives. Appeals are slow and the processes to hold insurers accountable are limited and often ineffective.

HB 250 and the Revised 2025 Hawaii Patient Bill of Rights have been introduced and are moving through the state Legislature. These are not symbolic bills. They are written to address the reality that patients are being harmed by delays and denials while providers are buried in administrative work. HB 250 would require insurance companies to report how often they deny care, how long decisions take, and whether artificial intelligence was used.

The Revised Bill of Rights as originally written by the Hawaii Provider Shortage Task Force would require that any denial involving automation be reviewed by a specialist in the same field as the treating physician and that patients be told when automated systems are making decisions about their care. These bills give the insurance commissioner more authority to track compliance and enforce the rules.

None of this change will happen unless lawmakers act. And they will not act unless they hear from the people they represent. Call your elected officials. Write to them. Tell them these bills matter. I invite you to attend upcoming talks on prior authorization reform, where health care experts and local providers will offer insight on how to fix this broken system (visit 808ne.ws/ priorauthorization). Your voice matters.

Esther Smith, M.D., is a family doctor on Hawaii island and vice president of the Hawaii Provider Shortage Task Force.