By Rafael Benavente

Medicare’s New Era: AI, Prior Authorization, and the Battle Over Access to Care

Introduction

Medicare has long been considered the crown jewel of American social policy—a program that guarantees health coverage for seniors and people with disabilities. For decades, one of its biggest advantages over private insurance has been its simplicity. Beneficiaries in traditional Medicare could access most services without the maze of prior approvals that plague patients in Medicare Advantage and employer health plans.

That is about to change. Beginning in 2026, the federal government will test a new program known as WISeR (Wasteful and Inappropriate Services Reduction), which introduces AI-assisted prior authorization into traditional Medicare. The move represents a historic shift in how the program manages care—and it has sparked intense debate over whether this is a necessary modernization or a dangerous erosion of patient access.

At the same time, private insurers—including those running Medicare Advantage—are pledging reforms that could make prior authorization easier, faster, and more transparent. Together, these changes raise profound questions: Is Medicare aligning with private insurance, or is private insurance moving closer to Medicare’s traditional simplicity? And most importantly—what does this mean for patients?

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What Is Prior Authorization?

Prior authorization is the process by which an insurer requires doctors to obtain approval before a treatment, procedure, or prescription is covered. The stated purpose is to prevent unnecessary or wasteful spending. In practice, it often delays care, forces patients and doctors to wade through bureaucratic hoops, and sometimes leads to outright denials.

For years, prior authorization has been one of the most hated aspects of American healthcare. Doctors complain it wastes time and undermines medical judgment. Patients complain of postponed surgeries, delayed medications, and lost trust in the system.

Traditional Medicare stood apart because it used prior authorization sparingly. Most beneficiaries had straightforward access to care without jumping through insurance hurdles. That relative simplicity was one reason millions of seniors preferred it over Medicare Advantage, which has far more restrictive approval processes.

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The WISeR Pilot: Medicare Experiments With AI

In January 2026, the Centers for Medicare & Medicaid Services (CMS) will launch the WISeR model in six states—Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.

Key Features

• Applies to 17 outpatient procedures, including nerve stimulator implants, skin substitutes, and certain knee surgeries.
• Decisions will be assisted by artificial intelligence algorithms, but final calls will be made by licensed clinicians.
• Review contractors will be financially incentivized to cut “wasteful” care.

Why It Matters

This is the first large-scale experiment to bring prior authorization into Original Medicare, breaking with decades of precedent. Critics worry it undermines the very advantage that traditional Medicare had over Medicare Advantage—speed and simplicity of access.

Moreover, the use of AI adds a new layer of complexity. Will algorithms be biased toward denial? Will clinicians be pressured to side with cost-saving decisions? These questions remain unanswered.

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A Shift in Medicare’s Identity

For many seniors, Medicare’s appeal lay in avoiding the frustrations of private insurance. By piloting prior authorization, CMS risks blurring the distinction between Original Medicare and Medicare Advantage.

Some policy experts argue this is inevitable. Healthcare costs are soaring, and Medicare faces long-term solvency concerns. Introducing prior authorization—even selectively—signals a shift from a patient-first model to a cost-control model.

Yet others caution that this could backfire politically. Seniors are a powerful voting bloc, and if they perceive that Medicare is becoming less accessible, it could spark backlash.

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Private Insurers Promise Reform

At the same time that CMS is piloting prior authorization in Medicare, private insurers are pledging to make it easier. In June 2025, major insurers—including UnitedHealthcare, Aetna, Cigna, and Humana—signed an agreement with HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Mehmet Oz to reform the system across Medicare Advantage, Medicaid, employer plans, and ACA marketplaces.

The Commitments

1. Electronic Standardization: All requests must use modern FHIR APIs, reducing fax-based delays.
2. Narrowing Scope: Insurers will reduce the number of services requiring prior approval.
3. Continuity of Care: Approvals must transfer if a patient changes health plans.
4. Real-Time Approvals: Goal of 80% of requests processed instantly by 2027.
5. Clinical Oversight: Denials must be reviewed by qualified physicians.

If implemented effectively, these reforms could make prior authorization less burdensome across the private system—perhaps even making Medicare Advantage more attractive compared to traditional Medicare, which is now adopting the very barrier it used to avoid.

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Comparing the Two Systems

Feature	Traditional Medicare (Pre-2026)	WISeR Pilot (2026)	Medicare Advantage (with reforms)
Prior Authorization	Rare	Required for 17 services	Broad, but being reduced
Decision Process	Local Medicare contractors	AI + clinician review	Insurer-employed clinicians
Speed	Minimal delays	TBD (AI-assisted)	Goal: 80% real-time by 2027
Patient Experience	Simplified access	Risk of new delays	Potentially improving if reforms work

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The Role of AI: Help or Hindrance?

The most controversial aspect of WISeR is its reliance on artificial intelligence. AI could speed up approvals, catching clear-cut cases that don’t need human review. But it could also systematically deny care if algorithms are trained to err on the side of cost savings.

Critics point out that contractors managing the system will have financial incentives tied to reducing spending. Even if doctors make the final calls, they may face subtle pressure to align with cost-saving AI recommendations.

Transparency will be key. Patients and providers will demand data: How often does AI recommend denial vs. approval? Are appeals successful? Without robust oversight, skepticism will remain.

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The Patient Impact: Stories Behind the Policy

For seniors, the stakes are deeply personal. Imagine a patient awaiting a nerve stimulator implant for chronic pain. Under today’s traditional Medicare, the doctor schedules the procedure. Under WISeR, that patient may wait days—or weeks—for an AI-assisted review.

Advocates worry about delayed cancer screenings, postponed surgeries, and denials of treatments that improve quality of life. These are not abstract concerns. In Medicare Advantage, prior authorization denials have been widely documented, sometimes with devastating outcomes.

CMS insists WISeR will avoid those pitfalls by limiting the scope to specific outpatient procedures and by requiring clinician oversight. But skepticism remains high.

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Political Fallout: Medicare’s Sacred Status

Medicare is not just a health program—it is a political third rail. Seniors vote, and they fiercely protect their benefits. The idea of introducing red tape into Original Medicare could trigger significant backlash.

At the same time, Democrats and Republicans alike have long sought ways to rein in Medicare spending. The WISeR pilot could be framed as an innovative way to cut waste without cutting benefits. Whether voters buy that argument is another story.

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Potential Benefits If Done Right

It’s worth noting that prior authorization, in theory, can reduce unnecessary care. Overuse of certain procedures drives up costs and exposes patients to risks. If AI-assisted reviews can target waste while preserving access, the system could improve efficiency.

For example, some skin substitute treatments for wounds are widely considered overprescribed and costly. If WISeR can reduce only those abuses without delaying genuine cases, it might strike a balance.

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Risks of Mission Creep

Critics fear the slippery slope. Today it’s 17 procedures in six states. Tomorrow it could be hundreds of services nationwide. Medicare Advantage began with limited prior authorization in the 1990s. Now, it is deeply entrenched and often cited as a barrier to care.

The question is whether WISeR is a limited experiment—or the first step toward a permanent, broader regime.

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The Future: Convergence or Divergence?

Ironically, Medicare and private insurance seem to be moving in opposite directions:

• Medicare is adding prior authorization.
• Private insurers are pledging to scale it back.

Will the systems converge on a middle ground, where AI and technology streamline approvals while cutting abuse? Or will patients face the worst of both worlds—more bureaucracy, less access, and fewer rights?

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Conclusion

Medicare’s WISeR pilot represents a turning point in the history of American healthcare. By testing AI-assisted prior authorization, CMS is signaling a willingness to sacrifice some of Medicare’s historic simplicity in the name of cost control.

Whether this improves efficiency or erodes access will depend on implementation, transparency, and political will. At the same time, private insurers’ promises to reform prior authorization raise hopes that the system could become faster and fairer—but only if they follow through.

For seniors, the stakes are clear: access to timely, necessary care is on the line. For policymakers, the challenge is to balance sustainability with compassion. And for the rest of America, the WISeR experiment will be a preview of how far technology—and federal authority—will be allowed to reshape healthcare in the decades ahead.

By Rafael Benavente

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