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A Bridge to Nowhere: A Healthcare Case Study for Non-Reformist Design

Linda Huber

TL;DR

The paper investigates the harms of automated prior authorization in U.S. healthcare amid rapid datafication and argues that reformist attempts to 'improve the user experience' risk preserving and expanding insurer control. By applying design justice, feminist refusal, and abolitionist non-reformist reform frameworks, it critiques API-based automation as a potential bridge to nowhere while outlining a four-tenet blueprint for data justice. The work combines ethnographic fieldwork, regulatory analysis, and stakeholder perspectives to show how harm reduction can occur only if power imbalances are addressed beyond surface-level usability. Its central contribution is a practical, theory-grounded path toward non-reformist redesigns that expand problem framing, broaden intervention methods, empower marginalized users, and limit the influence of already-powerful actors across multiple domains.

Abstract

In the face of intensified datafication and automation in public sector industries, frameworks like design justice and the feminist practice of refusal provide help to identify and mitigate structural harm and challenge inequities reproduced in digitized infrastructures. This paper applies those frameworks to emerging efforts across the U.S. healthcare industry to automate prior authorization -- a process whereby insurance companies determine whether a treatment or service is 'medically necessary' before agreeing to cover it. Federal regulatory interventions turn to datafication and automation to reduce the harms of this widely unpopular process shown to delay vital treatments and create immense administrative burden for healthcare providers and patients. This paper explores emerging prior authorization reforms as a case study, applying the frameworks of design justice and refusal to highlight the inherent conservatism of interventions oriented towards improving the user experience of extractive systems. I further explore how the abolitionist framework of non-reformist reform helps to clarify alternative interventions that would mitigate the harms of prior authorization in ways that do not reproduce or extend the power of insurance companies. I propose a set of four tenets for nonreformist design to mitigate structural harms and advance design justice in a broad set of domains.

A Bridge to Nowhere: A Healthcare Case Study for Non-Reformist Design

TL;DR

The paper investigates the harms of automated prior authorization in U.S. healthcare amid rapid datafication and argues that reformist attempts to 'improve the user experience' risk preserving and expanding insurer control. By applying design justice, feminist refusal, and abolitionist non-reformist reform frameworks, it critiques API-based automation as a potential bridge to nowhere while outlining a four-tenet blueprint for data justice. The work combines ethnographic fieldwork, regulatory analysis, and stakeholder perspectives to show how harm reduction can occur only if power imbalances are addressed beyond surface-level usability. Its central contribution is a practical, theory-grounded path toward non-reformist redesigns that expand problem framing, broaden intervention methods, empower marginalized users, and limit the influence of already-powerful actors across multiple domains.

Abstract

In the face of intensified datafication and automation in public sector industries, frameworks like design justice and the feminist practice of refusal provide help to identify and mitigate structural harm and challenge inequities reproduced in digitized infrastructures. This paper applies those frameworks to emerging efforts across the U.S. healthcare industry to automate prior authorization -- a process whereby insurance companies determine whether a treatment or service is 'medically necessary' before agreeing to cover it. Federal regulatory interventions turn to datafication and automation to reduce the harms of this widely unpopular process shown to delay vital treatments and create immense administrative burden for healthcare providers and patients. This paper explores emerging prior authorization reforms as a case study, applying the frameworks of design justice and refusal to highlight the inherent conservatism of interventions oriented towards improving the user experience of extractive systems. I further explore how the abolitionist framework of non-reformist reform helps to clarify alternative interventions that would mitigate the harms of prior authorization in ways that do not reproduce or extend the power of insurance companies. I propose a set of four tenets for nonreformist design to mitigate structural harms and advance design justice in a broad set of domains.

Paper Structure

This paper contains 18 sections, 2 figures.

Table of Contents

  1. Introduction
  2. From Data Ethics to Data Justice: Frameworks for Reformist versus Systemic Change through Design
  3. Refusal & Abolition as Generative
  4. Non-Reformist Reforms as a Practical Framework for Data Justice
  5. Method
  6. Harm Reduction Through Automation, Datafication: A Case Study of Prior Authorization Reforms
  7. The Goals of Prior Authorization: Insurance Companies as Managers of "Low Value Care"
  8. The Goals of Prior Authorization Reform: “Burden Reduction” Through Datafication, Automation
  9. “A Bridge To Nowhere”: Health Data Professionals' Perspectives on Prior Authorization Burden Reduction
  10. “A Bridge to Nowhere”: Prior Authorization Automation as a Reformist Reform
  11. Discussion
  12. How Not to Build A Bridge to Nowhere: Refusing Prior Authorization
  13. Designing Data Justice: Four Tenets for Designing Non-Reformist Reforms
  14. Expanding The Problem-Frame
  15. Expanding the Methods or Strategies for Intervention
  16. ...and 3 more sections

Figures (2)

  • Figure 1: Overview of standardized "X12" information transactions underlying the prior authorization workflow
  • Figure 2: A "Prior Auth Peacemaker" pin distributed at a workshop on emerging prior authorization reforms attended by health data professionals. Photo taken by the author.