Josh Butler – President Butler Benefits & High Plains Health Plan

In Federalist No. 51, James Madison famously wrote:

“If men were angels, no government would be necessary. If angels were to govern men, neither external nor internal controls on government would be necessary.”

Of course, he was speaking about the structure of governmentan d the need for checks and balances in a world where human nature is far from perfect. But what if we applied that same lens to the modern healthcare system?

Let’s start with the most visible symbol of institutional distrust in medicine today: prior authorization.

The System We’ve Created

Prior authorization is the insurance industry’s way of saying: “We don’t trust you.”

We don’t trust that doctors will always act in the best financial interest of the plan.
We don’t trust that patients won’t pursue unnecessary procedures.
We don’t trust that the system will self-regulate.

So the system inserts a permission slip into the middle of clinical decision-making.

Need an MRI? Ask the insurer.
Want to start a new medication? Ask the insurer.
Need a specialist referral? Ask the insurer.

In theory, these controls exist to prevent waste. In reality, they often delay care, frustrate providers, and exhaust patients, all in the name of cost containment.

Madison’s Mirror

Madison argued that government power must be both empowered and restrained, that it must “control the governed” and also “control itself.”

This is where the healthcare analogy breaks down.

Insurers are empowered to control doctors and patients, but who is controlling the insurers?

Who is requiring them to act transparently?
To justify their denials?
To be timely?
To be clinically relevant?

In most cases, no one.

Employers, who fund the majority of care in America, have outsourced their fiduciary authority to opaque intermediaries.

Doctors have become glorified clerks, spending hours a week on paperwork for treatments they were trained to provide.

And Patients? Patients have no recourse but to wait, appeal, or pay out of pocket.

It’s a system in which one party (Big Insurance) governs without any meaningful checks, and Madison would have called that dangerous.

If Doctors Were Angels…

Let’s entertain the idea.

If doctors were angels:

• They would never recommend unnecessary imaging.
• They’d prescribe the most cost-effective treatments.
• They’d manage chronic disease proactively and compassionately.

In such a world, prior authorization wouldn’t be necessary.

But here’s the real twist: most doctors already behave that way.
They practice based on evidence, not exploitation.
They want to help, not hustle.

The real threat to balance isn’t rogue clinicians, it’s misaligned incentives, administrative bloat, and intermediaries who profit from friction – including “brokers” BTW.

Restoring the Balance

Madison wasn’t naive. He knew that systems had to be designed for imperfect people. The goal wasn’t to expect angels, it was to build checks that guard against tyranny.

In healthcare, we need to do the same.

That means:

• Replacing arbitrary controls with transparent clinical guidelines
• Empowering plan sponsors to reclaim fiduciary oversight
• Rewarding outcomes, not denials
• Using technology to enable trust, not enforce suspicion

If we truly want to restore sanity in American healthcare, we don’t need to wait for angels.

We just need to stop giving unchecked power to those who profit from pretending everyone else is a devil.