Source: United States House of Representatives – Congresswoman Suzan DelBene (1st District of Washington)
Today, Congresswomen Suzan DelBene (WA-01), Greg Landsman (OH-01), Ami Bera, MD (CA-06), Kim Schrier, MD (WA-08), Mark Pocan (WI-02), and Rick Larsen (WA-02) introduced legislation to protect seniors from new red tape the Trump administration is implementing in traditional Medicare. The Seniors Deserve SMARTER (Streamlined Medical Approvals for Timely, Efficient Recovery) Care Act would repeal the Centers for Medicare and Medicaid Services’ (CMS) Wasteful and Inappropriate Service Reduction (WISeR) model.
WISeR would implement new prior authorization requirements in traditional Medicare in six states (New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington) beginning January 2026. The model would hire private companies to use artificial intelligence to automate prior authorization. These companies are compensated based on a share of “averted expenditures,” rewarding participants based on the volume or cost of care they deny.
In recent years, the U.S. Department of Health and Human Services (HHS) revealed that Medicare Advantage plans ultimately approved 75% of requests that were originally denied, and a 2022 HHS report further revealed that Medicare Advantage plans frequently violated Medicare coverage rules in their use of prior authorization. Nearly a third of physicians report that prior authorization has led to a serious adverse health event for a patient in their care.
“We know that prior authorization in Medicare Advantage and elsewhere ultimately limits access to care, increases the burden on loved ones and care providers, and leads to worse health outcomes,” said DelBene. “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. Congress needs to step in and protect seniors, their families, and health care workers by stopping this model.”
“Seniors shouldn’t have to worry about whether AI decides if they get the care they need. It’s reckless. Time and again, the Trump Administration is making it harder for Americans to access healthcare – and now they’re targeting Medicare, something tens of millions of seniors have paid into and rely on,” said Landsman.
“As a doctor and former Chief Medical Officer of Sacramento County, I’ve seen how harmful prior authorization can be when it delays or denies necessary care for patients,” said Bera. “The WISeR model takes that a step further by financially rewarding companies for denying care through so-called ‘averted expenditures.’ That creates a dangerous incentive to put profits ahead of patients’ health. These decisions should be made by doctors, not by algorithms designed to cut costs. We should be working to strengthen Medicare, not layering on more red tape that threatens access to timely, high-quality care.”
“Time and time again, we’ve seen how prior authorization has led to dangerous delays in care and undermined overall patient health,” said Schrier. “The WISeR model would only make the problem worse for seniors in Washington State and would empower artificial intelligence to make critical healthcare decisions. As a physician, I know that healthcare decisions should be made by patients and doctors, not insurance companies. That’s why I’m proud to support this legislation and stand against this program.”
“It is not an exaggeration to say that the requirement of prior authorization for traditional Medicare services will kill seniors,” said Pocan. “Not only that, but the use of AI in determining whether or not treatment is necessary is extremely reckless. Unlike Medicare Advantage plans that already use AI in prior authorization decisions, traditional Medicare is supposed to cover you, no questions asked. This is a disastrous idea of epic proportions and should be immediately rescinded.”
“The WISeR Model is just the latest example of the Trump administration making health care worse,” said Larsen. “People, not unregulated AI, should lead health care decisions. I am proud to co-lead this legislation to stop the implementation of WISeR. I will continue to fight back against the Trump administration’s efforts to privatize Medicare, as well as their efforts to take away health care from more than 30,000 people I represent.”
Days before announcing the WISeR model, HHS Secretary Robert F. Kennedy, Jr. and CMS Administrator Mehmet Oz touted a non-binding commitment from insurance plans to reduce prior authorization in Medicare Advantage, acknowledging the harm and burden it puts on patients.
The legislation is endorsed by the American Podiatric Medical Association, Physicians for a National Health Program, The Center for Health and Democracy, Social Security Works, Just Care USA, Washington State Medical Association, Washington State Hospital Association, Texas Medical Association, Washington Community Action Network, Healthcare is a Human Right Coalition, Puget Sound Advocates for Retirement Action, Health Care for All – Washington, and Social Security Works WA.
In August, DelBene and Bera led a group of 17 House Democrats raising concerns about the WISeR model and the negative impacts it could have. They asked several questions about how it would be implemented. The administration never responded to the inquiry.
In May, DelBene introduced legislation to help seniors get the care they need when they need it by reforming prior authorization in Medicare Advantage.
The full text of the bill can be found here.