Though coverage denials and delays impose on physicians and patients (especially marginalized patients) substantial administrative burden, the persistence of this practice is inevitable. Drawing on interviews with patients and former health insurance executives, this chapter reflects on harms caused by prior authorization and offers a menu of state and federal solutions to expand access to care, while also reflecting on how the 2024 election results impact their likelihood. A growing complication is major insurers’ increasing reliance on AI tools to process prior authorizations and claims in seconds. Though many states have sought to lessen prior authorization burden in targeted ways, this reach is limited because the Employee Retirement Income Security Act preempts state policies that “relate to” much of employer-sponsored health insurance. Despite some appetite for reform in Congress, legislative efforts have stalled. The 2024 election results signal a likely acceleration of America’s reliance on privatization (especially Medicare Advantage), so it is especially important to understand the impact of these managed care practices and ways to mitigate their burdens.