When Did Insurance Start Practicing Medicine?

There was a time—not that long ago—when this was simple.

You went to your doctor. They wrote a prescription. Your insurance covered it.

I remember getting three albuterol inhalers at a time. No hoops. No questions. Just care. Doctors had samples in the office. If you needed something, they handed it to you. You walked out treated.

Now it’s one inhaler, maybe. Prior authorizations. Step therapy. Denials. Appeals. Delays.

Somewhere along the way, the system flipped.

And I keep coming back to the same question: when did insurance companies start practicing medicine?

This didn’t happen overnight. It was a slow shift, and like most things in healthcare, it came down to money and control. Drug costs went up, insurance companies pushed back, and instead of working with doctors, they built systems to manage what patients could and couldn’t get.

That’s where formularies came from. Lists of approved medications. Not approved by your doctor, but by the insurance company. Then they added tiers—cheap drugs, expensive drugs—and suddenly what you got wasn’t just about what worked, it was about what cost less.

Then came prior authorization. This is where your doctor says, “My patient needs this,” and the insurance company says, “Prove it.” So now your doctor’s office is filling out forms, sending faxes, making calls, and waiting. Meanwhile, you’re waiting too. And after all that, you can still get denied.

And then there’s step therapy. This one is just stupid. “Try the cheaper drug first. If it doesn’t work, then we’ll consider the one your doctor actually wanted.” That’s not medicine. That’s a cost-control strategy pretending to be medical judgment. It delays care, frustrates patients, and puts barriers between you and treatment for no good reason other than saving money.

Behind the scenes, there’s another layer most people don’t even know about: pharmacy benefit managers, or PBMs. These are the middlemen. They decide what drugs are covered, what pharmacies you can use, and how much things cost. They negotiate deals and rebates, and they make money in the middle. So decisions about your medication aren’t just about what works—they’re tied up in contracts and margins.

Even the little things disappeared. Doctors used to give out sample medications all the time. That’s mostly gone now. Partly because of tighter regulations, partly because of liability, but also because the system has shifted toward tracking everything, billing everything, controlling everything. Free samples don’t fit well in that kind of system.

So here we are.

We’ve moved from a system where doctors made decisions and patients got treated, to one where insurance companies decide what gets approved, how much you get, and how long you have to wait. Doctors still make recommendations, but they don’t have the final say anymore.

And patients notice. You feel it when you can’t get the medication your doctor prescribed. You feel it when you’re stuck waiting for approval. You feel it when you’re told to try something that doesn’t make sense just to check a box.

That’s why people are starting to go around the system. Cash pay. Online pharmacies. Compounding pharmacies. Not because they want to be difficult, but because they’re trying to get treated without jumping through a dozen hoops.

I’m not saying the old system was perfect. It wasn’t. But it was simpler. It was faster. And in a lot of ways, it made more sense.

Now we’ve got a system where the people paying the bills are calling the shots, and the people actually taking care of patients have to ask permission.

And that’s the part that doesn’t sit right.

Because at the end of the day, it shouldn’t be this hard to get something your doctor says you need.