AI program opens the door to Medicare privatization, advocates warn

Puget Sound Advocates for Retirement Action are sounding the alarm on a pilot program introducing prior authorization to Medicare, relying on third-party private companies’ AI tech

SEATTLE, WA (October 8, 2025) — A new pilot program using artificial intelligence to determine whether care is covered by Medicare is slated t0 roll out in January in six states, including Washington. Advocates fear this pilot program will both deny needed care and push Medicare towards privatization and a profit-driven model, a concern echoed by members of Washington’s congressional delegation.

The program, called the Wasteful and Inappropriate Services Reduction Model (or the somewhat tortured acronym WISeR), will use AI for prior authorization reviews to determine whether care is covered under Medicare and Medicare Advantage. That’s a significant change; beyond the new tech, prior authorization has rarely been used in Medicare coverage. In Medicare Advantage, advocates say prior authorization has resulted in denials or serious delays of essential care.

Medicare bureaucracy is notoriously slow. Finding a resolution more quickly may seem like a positive step on the surface, certainly to doctors and hospitals that face uncertainty about whether the cost of care provided will be reimbursed. Prior authorization is already controversial for the role it plays second-guessing medical professionals actually treating patients. But there’s reason to be even more concerned about using AI to handle the complex information involved in these reviews.

First, AI models are not sentient; they don’t think. While the exact nature of the WISeR Model tech is unclear, AI is broadly made and operates through aggregation of large data sets that the tech can analyze and use to spit out information. So this technology isn’t examining specific cases and making determinations; it’s capabilities are likely more like making guesses based on a wide-range of available data. Human bodies are complex, with many different factors impacting each individual’s need for care — that’s one of the reasons advocates question the rationale of prior authorization use altogether.

And beyond the questions around the technology’s capabilities, there’s a broader concern about longterm impacts.

The program sees the federal government partnering with a third-party private tech companies to handle sensitive public data. Security breaches could negatively impact millions. And the encroachment of private businesses into Medicare administration raises deep concerns that the use of this tech is a backdoor to a for-profit Medicare model, or privatizing Medicare entirely. Those fears are buoyed by the compensation structure for the third-party companies involved, which will be paid with a share of the savings their tech generates. That raises the question: will these companies’ tech prioritize quality care or will it instead work primarily to generate maximum profit?

“These companies are basically ‘bounty hunters,'” said Puget Sound Advocates for Retirement Action in a newsletter. “They are compensated based on their record of denying care and reducing spending in original Medicare despite the data that shows original Medicare spends 22% less per patient than Medicare Advantage. Introducing ‘bounty hunters’ into original Medicare…what could possible do wrong?!”

These concerns are echoed by Sen. Patty Murray in a statement, who said she will oppose the program in every way possible in the Senate. Members of Congress are also denouncing the WISeR program, and the use of prior authorization in Medicare altogether. U.S. Rep. Susan Delbene of Washington led a letter to the Trump administration signed by five members of Washington’s congressional delegation — and many colleagues — laying out their concerns about the program and raising questions.

And a resolution introduced by U.S. Representatives Mark Pocan (WI-02) and Jan Schakowsky (IL-09) articulating the disastrous consequences of the program has been signed by Representatives Delbene, Jayapal and Smith from Washington. That resolution notes that, “some Medicare Advantage plans that already use AI in prior authorization decisions have been found to have error rates as high as 90%.”

Medicare services are largely continuing during the ongoing federal government shutdown, and PSARA is encouraging supporters to get the word out about the danger posed by WISeR and prior authorization in Medicare now before the pilot program starts. PSARA is urging elected officials to take a stand to protect Medicare, and their October newsletter shares suggestions for contacting local newspapers and a template letter to the editor. PSARA is also encouraging folks to reach out to the office of U.S. Senator Maria Cantwell to urge her to publicly oppose the use of AI and prior authorization in Medicare more broadly.