by Alvin Blackshear | Historian & Researcher <ablackshear@gmail.com>
“AI is now deciding who gets healthcare in six US states.” It is the kind of sentence built to travel fast, and for older Americans who have spent decades trusting that traditional Medicare would simply pay for what their doctor ordered, it lands like an alarm. So is it true? Is artificial intelligence actually deciding whether Medicare patients receive medical treatment, or does that framing exaggerate what the federal government is actually doing?
The honest answer sits in uncomfortable middle ground. The underlying story is substantially real. Medicare has launched an important and controversial experiment involving AI-assisted prior authorization. But describing this simply as “AI deciding who gets healthcare” leaves out critical details about human review, existing Medicare coverage standards, the narrow set of services involved, and the difference between a coverage determination and a physician’s decision to provide care. At the same time, legitimate concerns about delays, financial incentives, transparency, and algorithmic influence should not be waved away merely because a headline overstates the case.
What Exactly Is WISeR?
The program at the center of the controversy is the Wasteful and Inappropriate Service Reduction Model, known as WISeR, created by the Centers for Medicare & Medicaid Services (CMS). It began operating on January 1, 2026, with prior authorization requests starting January 5 and application to relevant services beginning January 15. The model is scheduled to run through December 31, 2031. It applies to selected services under Original Medicare, not Medicare Advantage, and it operates in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. CMS says the purpose is reducing fraud, waste, abuse, and low-value medical care, and the program targets a defined list of procedures and services rather than all Medicare-covered healthcare. In July 2026, the Senate voted against an effort to overturn WISeR, allowing the pilot to continue.
This distinction matters: WISeR is not an AI system reviewing every Medicare patient’s medical care. It is a technology-assisted prior-authorization and prepayment-review system covering a specific set of services that CMS considers vulnerable to inappropriate utilization, fraud, waste, or abuse.
Is AI Actually Making the Decision?
This is the question at the heart of any honest fact check. CMS explicitly permits WISeR contractors to use technologies including artificial intelligence and machine learning. But CMS also states that appropriately trained clinicians participate in verifying whether requests satisfy Medicare’s coverage requirements. Three claims deserve to be separated. It is accurate to say AI is being used as part of Medicare’s prior-authorization process. It is potentially misleading to say AI independently determines whether a beneficiary may receive healthcare. The more precise formulation is that private contractors use AI and machine learning-assisted systems together with clinical review to determine whether certain services meet Medicare coverage requirements.
There is also a distinction often lost in the headlines: a Medicare coverage decision is not identical to a medical decision. A physician can recommend a procedure while Medicare separately determines it will not pay for it. For many patients, however, that distinction can feel largely theoretical. If Medicare declines to pay for an expensive treatment, the practical result is often that the patient cannot obtain it at all.
Why CMS Built the Program, and Why Critics Are Worried
CMS argues that wasteful healthcare spending represents a significant share of American medical expenditures, and that the services selected for WISeR already have established coverage criteria, generally involve elective rather than emergency treatment, carry safety concerns when performed unnecessarily, and have histories of fraud or inappropriate use. Emergency and inpatient-only services fall outside the program entirely. The government’s argument, in short, is not that AI should practice medicine. It is that technology can more efficiently determine whether a procedure satisfies existing Medicare rules before taxpayers pay for it.
Critics raise four distinct concerns. Prior authorization already generates substantial complaints within Medicare Advantage and private insurance, so extending it into traditional Medicare marks a meaningful policy shift. Proprietary AI systems create questions of explainability, since physicians and patients may not know precisely how a case was evaluated. The payment structure has also drawn scrutiny because contractors can benefit financially from savings generated by preventing expenditures, which critics argue could incentivize denials, even as CMS maintains that contractors are simply rewarded for catching genuinely wasteful spending. Finally, human review does not automatically eliminate algorithmic influence. Even when a clinician confirms a determination, the AI system may shape which cases get flagged and what information the reviewer ultimately sees, which raises a harder question: when does AI merely assist a decision, and when does it effectively shape it?
Are Patients Already Being Harmed?
This claim deserves particular caution. There are documented reports of authorization delays, and Senator Maria Cantwell (Washington-D) released a 2026 report citing Washington hospital data suggesting that patients undergoing WISeR-covered procedures experienced substantially longer processing times. But documented delays, denied payment, allegations of denied medically necessary care, and proof that AI itself caused measurable patient harm are not interchangeable claims. A responsible account should avoid concluding that AI is harming Medicare patients unless evidence establishes the full chain from algorithm to incorrect determination to delayed or denied treatment to actual harm. That evidence remains under active investigation.
The Transparency Problem
The Electronic Frontier Foundation has filed a federal Freedom of Information Act lawsuit seeking information about WISeR’s underlying AI systems, including details on algorithms, vendor arrangements, accuracy testing, bias testing, hallucinations, and ongoing monitoring. This creates an unusual situation: the federal government is testing AI-assisted healthcare decision-making while the information needed to independently evaluate those systems may not yet be public. That does not prove the algorithms are unsafe. It establishes that independent verification remains difficult.
Misinformation, or an Oversimplified Warning?
Calling the original claim simply “misinformation” would go too far. The essential facts are real: Medicare is testing technology-enabled prior authorization involving AI and machine learning in six states, private contractors are participating, and coverage determinations can affect patients’ access to particular procedures. But “AI is deciding who gets healthcare” is more sweeping than the evidence supports.
The more consequential story may be the quieter one. For decades, Americans have debated whether insurers and government bureaucracies should second-guess physicians’ medical judgment. Artificial intelligence has now introduced a new actor into that old dispute. The sharper question is not simply whether AI is denying healthcare. It is how much influence an algorithm should have over a decision that can determine whether a patient can actually afford to follow their doctor’s advice, and what standard of evidence the government should have to meet before allowing an opaque system to shape that decision at all.
References:
CMS, WISeR Provider and Supplier Operational Guide. https://www.cms.gov/priorities/innovation/files/wiser-provider-supplier-guide.pdf
CMS, WISeR Request for Applications. https://www.cms.gov/files/document/wiser-model-rfa.pdf
KFF, Examining the Potential Impact of Medicare’s New WISeR Model, February 10, 2026. https://www.kff.org/medicare/examining-the-potential-impact-of-medicares-new-wiser-model/
Congressional Research Service, “Overview of the Medicare Wasteful and Inappropriate Service Reduction (WISeR) Model,” updated May 12, 2026. https://www.everycrsreport.com/reports/IF13133.html
Federal Register, CMS, original WISeR implementation notice, July 1, 2025. https://www.federalregister.gov/documents/2025/07/01/2025-12195/medicare-program-implementation-of-prior-authorization-for-select-services-for-the-wasteful-and
Sen. Maria Cantwell, WISeR Snapshot Report, 2026. https://www.cantwell.senate.gov/imo/media/doc/wiser_snapshot_report.pdf
EFF v. CMS, federal complaint, filed March 25, 2026.
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