Will AI Decide if Seniors Get Care?
In a move that has reignited fears of death panels, the Trump administration is set to launch a controversial Medicare pilot program that hands over critical healthcare decisions to private companies using artificial intelligence. Starting in January 2026, the Wasteful and Inappropriate Service Reduction Model, or WISeR, will roll out in six states, including Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. The program reportedly tasks private AI firms with prior authorization duties, deciding whether Medicare will cover certain medical procedures for millions of older Americans. What's raising eyebrows is the explicit financial incentive for these companies to deny costly treatments, sparking concerns that profit motives could outweigh patient care.
AI Meets Medicare: A New Gatekeeper
The WISeR pilot aims to curb what the Centers for Medicare and Medicaid Services (CMS) calls "wasteful" or "inappropriate" medical services. Private contractors will reportedly deploy AI algorithms to evaluate requests for procedures such as nerve stimulator implants, skin and tissue substitutes, and knee arthroscopy for osteoarthritis. According to the Independent, the government insists that licensed clinicians, not machines, will make final decisions on coverage denials. However, the initial AI screening will heavily influence which cases even reach human review.
The program's architects reportedly argue that this approach will save Medicare billions over six years by reducing unnecessary spending and protecting patients from potentially harmful procedures. CMS officials say emergency services and hospital stays are exempt from the pilot, emphasizing patient safety. Abe Sutton, director of the Center for Medicare and Medicaid Innovation, described the model as a way to target expensive or risky practices, calling it "what prior authorization should be," as reported by NationOfChange.org.
Profits Tied to Denials, a Conflict of Interest?
Critics, however, see a troubling conflict of interest. The private companies running the AI systems will reportedly receive a share of the savings generated from denied claims. This means their profits depend on rejecting more procedures, creating a financial incentive to say no rather than yes. Experts warn this could lead to widespread rationing of care under the guise of efficiency.
Dr. Vinay Rathi, a surgeon and Medicare policy expert, likened the setup to the controversial practices seen in Medicare Advantage plans, where private insurers often delay or deny care to maximize profits. He cautioned that the pilot "directly puts them at odds with the clinicians" who want to provide timely treatment, as reported by NationOfChange.org.
Labor groups and retiree organizations have voiced strong opposition. The American Federation of Teachers issued a joint statement from President Randi Weingarten and Retirees Program and Policy Council co-chair Tom Murphy, calling the program an attempt to "transform Medicare into the very worst of private insurance," according to NationOfChange.org. They added that it introduces "extra hurdles that are burdensome to patients and often get in the way of their desperately needed treatments."
The Return of Death Panels?
According to the Independent, the pilot's critics have resurrected the specter of "death panels," a term that first gained traction during the heated debates over the Affordable Care Act. Back then, opponents claimed that government bureaucrats would decide who deserved care based on subjective judgments of social worth. While the WISeR pilot does not explicitly make life-or-death decisions, the idea that faceless algorithms could delay or deny coverage for essential procedures has stirred similar fears.
Democratic lawmakers have expressed concern that the program adds red tape to traditional Medicare, which historically required less prior authorization than private insurance. They argue that this will delay care and worsen health outcomes for seniors who rely on Medicare for timely treatment.
Patients Fear Delays and Denials
For many Medicare beneficiaries, prior authorization is already a source of frustration. Private Medicare Advantage plans often require extensive paperwork and waiting periods before approving treatments, leading to delays that can exacerbate health problems. Frances L. Ayres, a retired professor in Oklahoma, said she chose traditional Medicare to avoid these hurdles but now fears the pilot will bring the same obstacles to her coverage. "I think it's the back door into privatizing traditional Medicare," Ayres said, as reported by NationOfChange.org.
The American Medical Association has historically opposed prior authorization requirements, describing them "as one of the most burdensome and disruptive administrative requirements they face in providing quality care to patients," according to NationOfChange.org. While most patients who appeal denials eventually succeed, the majority never do, leaving many without needed care.
Innovation or Digital Gatekeeping?
The WISeR pilot is billed as an innovative use of technology to improve Medicare's efficiency and reduce waste. Yet, the irony is hard to miss. What is presented as a cutting-edge solution could function as a digital gatekeeper, quietly rationing care and shifting decision-making power from doctors to algorithms designed to cut costs.
The program's rollout in six states will serve as a test case for whether AI can fairly and effectively manage prior authorization without compromising patient care. But experts warn that once the framework is in place, it could expand far beyond the initial dozen procedures, potentially affecting a much broader range of treatments.
What Lies Ahead?
As the pilot begins, Medicare beneficiaries, healthcare providers, and policymakers will be watching closely. The stakes are high: millions of older Americans depend on Medicare for access to essential medical services. The question remains whether AI-driven prior authorization will deliver on promises of cost savings without sacrificing timely, quality care.
For now, the WISeR pilot stands at the crossroads of healthcare innovation and ethical controversy. It challenges us to consider how much control we want to hand over to algorithms when it comes to life-altering medical decisions. The future of Medicare may well depend on how this experiment unfolds.
References: Medicare will test using AI to help decide whether patients get coverage - which could delay or deny care, critics warn | Death panels? New Medicare pilot under Trump would require Obamacare-like authorization that GOP demonized | AI death panels or cost control? Medicare pilot hands denials to private algorithms
