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

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 non-reformist design to mitigate structural harms and advance design justice in a broad set of domains.