House Democrats push CMS to cancel AI-driven Medicare approval program

More than a dozen House Democrats have pressed Centers for Medicare & Medicaid Services (CMS) Administrator Mehmet Oz to cancel a planned prior authorization pilot program that would expand AI-driven approval requirements to traditional Medicare. The program, set to begin testing in six states this January, represents a significant shift for traditional Medicare, which has historically operated without extensive prior authorization requirements.

What you should know: The pilot program incorporates artificial intelligence to help make healthcare coverage decisions, marking a departure from traditional Medicare’s historically streamlined approach.

• Representatives Suzan DelBene of Washington and Ami Bera of California led the Democratic opposition, arguing the program would “create administrative burdens for providers and patients.”
• The lawmakers noted that “traditional Medicare has rarely required prior authorization” and warned the system could “limit patients’ access to life-saving care.”
• CMS plans to roll out the program in six states starting in January, though specific states weren’t identified in the article.

In plain English: Prior authorization means patients need approval from their insurance company before receiving certain medical treatments or procedures. Traditional Medicare has rarely required this extra step, but the new pilot would use AI software to help decide whether to approve treatments—essentially having a computer algorithm weigh in on medical decisions alongside doctors.

Why this matters: The controversy highlights growing partisan tensions over Medicare reform approaches between cost containment and patient access.

• Democrats view the pilot as creating unnecessary barriers between doctors and patients, while some Senate Republicans see Medicare reforms as necessary for eliminating fraud and overpayments.
• The debate reflects broader tensions between Biden-era oversight expansion and the Trump administration’s goals to cut waste while modernizing CMS operations.

What they’re saying: Lawmakers and experts expressed strong concerns about replacing physician judgment with algorithmic decision-making.

• “Prior authorization is often seen as a roadblock to timely, even life-saving care—replacing the doctor’s judgment with an algorithm,” Kevin Thompson, CEO of 9i Capital Group, told Newsweek. “Let’s call it what it is: profit-driven healthcare. And profit motive and patient care mix about as well as oil and water.”
• The lawmakers wrote to Oz: “The American Medical Association notes, ‘Among America’s physicians, more than nine in 10 surveyed say that prior authorization has a negative impact on patient clinical outcomes.'”
• Alex Beene, a financial literacy instructor at the University of Tennessee at Martin, noted that while oversight is important, “Medicare Advantage has a history of requiring prior authorization” and has “garnered more negative reactions in recent years” partly due to such requirements.

The broader context: Senate Republicans are simultaneously pursuing wider Medicare reforms as part of waste reduction efforts.

• Republican Senator Thom Tillis of North Carolina said lawmakers were examining “CMS contracting practices, duplicate payments and upcoding as potential savings sources.”
• Bipartisan legislation from Senators Bill Cassidy, a Republican from Louisiana, and Jeff Merkley, a Democrat from Oregon, to reduce Medicare Advantage overpayments has gained interest and might be incorporated into larger budget measures.
• The Trump administration previously announced voluntary pledges from major insurers to simplify prior authorization in Medicare Advantage.

What happens next: CMS faces pressure to provide documentation about the pilot program and consider cancellation, while Senate committees continue debating broader Medicare reforms.

• “For the time being, the model isn’t nationwide and will be piloted in select states,” Beene said. “It’s difficult to say if this will eventually be implemented nationwide and will largely depend on how this pilot program goes.”
• Thompson predicted limited impact from the Democratic letter: “They’ll probably get an answer, but expect the same vague, carefully worded response.”