Democrats Move to Stop the WISeR Model
Lawmakers warn the WISeR model would replicate the worst abuses of Medicare Advantage, shifting life-or-death decisions to algorithms and for-profit contractors.
Several Democratic lawmakers are pushing back against the Trump administration’s plans to use artificial intelligence to assess the appropriateness and necessity of care for many seniors enrolled in the traditional Medicare program.
Alarmed by the proposal, a coalition of Democratic lawmakers – Representatives Suzan DelBene, Rick Larsen, Kim Schrier, Greg Landsman, Ami Bera, and Mark Pocan — have introduced legislation called the Seniors Deserve SMARTER Care Act to block the program before it begins.
“The administration has publicly admitted that prior authorization is harmful, yet it is moving forward with this misguided effort that would make seniors navigate more red tape to get the care they’re entitled to,” said DelBene in a press release.
Pocan added: “It is not an exaggeration to say that the requirement of prior authorization for traditional Medicare services will kill seniors.”
The Centers for Medicare and Medicaid Services (CMS) is planning to implement a policy that would let artificial intelligence (and private, for-profit contractors) decide what care many seniors on traditional Medicare can receive. The proposal, known as the Wasteful and Inappropriate Service Reduction (WISeR), would expand the use of prior authorization — a tool notorious for delaying or denying care in private Medicare Advantage plans — to traditional Medicare. Unlike Medicare Advantage plans, which maintain lists of hundreds if not thousands of procedures subject to prior authorization, traditional Medicare uses it for only 50 or so.
If the plans proceed, the WISeR model will launch in January 2026 in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. CMS would pay private technology vendors – like Cohere Health, Innovaccer and Zyter — to use AI to approve or deny care for several medical procedures..
What is especially troubling is that the vendors would be paid based on how much care they deny, earning a share of what CMS calls “averted expenditures”.
A profit motive to deny care
A unit of CMS called the Center for Medicare & Medicaid Innovation (CMMI) claims the WISeR model will “protect taxpayers” and “streamline” prior authorization using machine learning and “human clinical review”. But for many patients and their doctors, it could mean delays in providing the care patients need – or outright denial. In Medicare Advantage, insurers frequently delay or deny medically necessary care.
A 2022 report from the Department of Health and Human Services’ Inspector General found that private Medicare Advantage insurers ultimately approved 75% of claims they first denied, suggesting that many initial denials were unjustified. And a survey by the American Medical Association found that nearly one in three physicians said prior authorization had led to a serious adverse health event for a patient in their care.
The new CMS initiative would effectively outsource medical decision-making for a number of procedures to algorithms and private corporations, and it does so under a compensation arrangement that directly ties their revenues to denial rates.
“This creates a dangerous incentive to put profits ahead of patients’ health,” said Ami Bera, a physician co-sponsor of the bill. “These decisions should be made by doctors, not by algorithms designed to cut costs”.
As its sponsors point out, traditional Medicare was designed to cover American seniors without an outside entity second-guessing their doctors. Introducing prior authorization and AI denials moves the program closer to the privatized Medicare Advantage program, which is administered by insurance corporations, most of which operate on a for-profit basis. More than 80% of MA patients are enrolled in plans operated by UnitedHealthcare, Humana, Aetna and Anthem. The companies make far more money on their Medicare Advantage plans than their commercial plans, in large part because of the barriers to care – including prior authorization – the insurers have put in place as well as the billions of dollars in overpayments they receive annually from CMS by gaming the mechanism that determines how much they’ll be paid for each enrollee. Senators Bill Cassidy (R-LA) and Jeff Merkley (D-OR) have introduced legislation to eliminate most of the overpayments.
Proponents of WISeR (including CMS Administrator Dr. Mehmet Oz) frame the policy as a modernization effort. But there’s a vast difference between using technology to streamline paperwork and using it to ration care.
Giving control of seniors’ care to an AI system designed primarily to save money can put seniors’ lives in danger. This is not overheated rhetoric. We’ve already seen from numerous media reports what happens when algorithms run amok. And both UnitedHealth Group and Cigna are already being sued for allegedly using AI tools to deny care.
As someone who spent twenty years as a health insurance executive, I recognize this play for what it is: the next step in the long campaign to completely privatize Medicare.
This is the reason I am NOT on Medicare Advantage
They should just pay companies or hire retired physicians to review utilization for appropriateness. Not have companies making money by denying services. As with most government contracts, smells like some inside scheme to funnel money to someone with connections.