Regulating artificial intelligence, especially its use by health insurers, is becoming a politically divisive topic, and it’s scrambling traditional partisan lines.

Boosters, led by Trump, are not only pushing its integration into government, as in Medicare’s experiment using AI in prior authorization, but also trying to stop others from building curbs and guardrails. A December executive order seeks to preempt most state efforts to govern AI, describing “a race with adversaries for supremacy” in a new “technological revolution.”

“To win, United States AI companies must be free to innovate without cumbersome regulation,” Trump’s order said. “But excessive State regulation thwarts this imperative.”

Across the nation, states are in revolt. At least four — Arizona, Maryland, Nebraska, and Texas — enacted legislation last year reining in the use of AI in health insurance. Two others, Illinois and California, enacted bills the year before.

Legislators in Rhode Island plan to try again this year after a bill requiring regulators to collect data on technology use failed to clear both chambers last year. A bill in North Carolina requiring insurers not to use AI as the sole basis of a coverage decision attracted significant interest from Republican legislators last year.

DeSantis, a former GOP presidential candidate, has rolled out an “AI Bill of Rights,” whose provisions include restrictions on its use in processing insurance claims and a requirement allowing a state regulatory body to inspect algorithms.

“We have a responsibility to ensure that new technologies develop in ways that are moral and ethical, in ways that reinforce our American values, not in ways that erode them,” DeSantis said during his State of the State address in January.

Ripe for Regulation

Polling shows Americans are skeptical of AI. A December poll from Fox News found 63% of voters describe themselves as “very” or “extremely” concerned about artificial intelligence, including majorities across the political spectrum. Nearly two-thirds of Democrats and just over 3 in 5 Republicans said they had qualms about AI.

Health insurers’ tactics to hold down costs also trouble the public; a January poll from KFF found widespread discontent over issues like prior authorization. (KFF is a health information nonprofit that includes KFF Health News.) Reporting from ProPublica and other news outlets in recent years has highlighted the use of algorithms to rapidly deny insurance claims or prior authorization requests, apparently with little review by a doctor.

Last month, the House Ways and Means Committee hauled in executives from Cigna, UnitedHealth Group, and other major health insurers to address concerns about affordability. When pressed, the executives either denied or avoided talking about using the most advanced technology to reject authorization requests or toss out claims.

AI is “never used for a denial,” Cigna CEO David Cordani told lawmakers. Like others in the health insurance industry, the company is being sued for its methods of denying claims, as spotlighted by ProPublica. Cigna spokesperson Justine Sessions said the company’s claims-denial process “is not powered by AI.”

Indeed, companies are at pains to frame AI as a loyal servant. Optum, part of health giant UnitedHealth Group, announced Feb. 4 that it was rolling out tech-powered prior authorization, with plenty of mentions of speedier approvals.

“We’re transforming the prior authorization process to address the friction it causes,” John Kontor, a senior vice president at Optum, said in a press release.

Still, Alex Bores, a computer scientist and New York Assembly member prominent in the state’s legislative debate over AI, which culminated in a comprehensive bill governing the technology, said AI is a natural field to regulate.

“So many people already find the answers that they’re getting from their insurance companies to be inscrutable,” said Bores, a Democrat who is running for Congress. “Adding in a layer that cannot by its nature explain itself doesn’t seem like it’ll be helpful there.”

At least some people in medicine — doctors, for example — are cheering legislators and regulators on. The American Medical Association “supports state regulations seeking greater accountability and transparency from commercial health insurers that use AI and machine learning tools to review prior authorization requests,” said John Whyte, the organization’s CEO.

Whyte said insurers already use AI and “doctors still face delayed patient care, opaque insurer decisions, inconsistent authorization rules, and crushing administrative work.”

Insurers Push Back

With legislation approved or pending in at least nine states, it’s unclear how much of an effect the state laws will have, said University of Minnesota law professor Daniel Schwarcz. States can’t regulate “self-insured” plans, which are used by many employers; only the federal government has that power.

But there are deeper issues, Schwarcz said: Most of the state legislation he’s seen would require a human to sign off on any decision proposed by AI but doesn’t specify what that means.

The laws don’t offer a clear framework for understanding how much review is enough, and over time humans tend to become a little lazy and simply sign off on any suggestions by a computer, he said.

Still, insurers view the spate of bills as a problem. “Broadly speaking, regulatory burden is real,” said Dan Jones, senior vice president for federal affairs at the Alliance of Community Health Plans, a trade group for some nonprofit health insurers. If insurers spend more time working through a patchwork of state and federal laws, he continued, that means “less time that can be spent and invested into what we’re intended to be doing, which is focusing on making sure that patients are getting the right access to care.”

Linda Ujifusa, a Democratic state senator in Rhode Island, said insurers came out last year against the bill she sponsored to restrict AI use in coverage denials. It passed in one chamber, though not the other.

“There’s tremendous opposition” to anything that regulates tactics such as prior authorization, she said, and “tremendous opposition” to identifying intermediaries such as private insurers or pharmacy benefit managers “as a problem.”

In a letter criticizing the bill, AHIP, an insurer trade group, advocated for “balanced policies that promote innovation while protecting patients.”

“Health plans recognize that AI has the potential to drive better health care outcomes — enhancing patient experience, closing gaps in care, accelerating innovation, and reducing administrative burden and costs to improve the focus on patient care,” Chris Bond, an AHIP spokesperson, told KFF Health News. And, he continued, they need a “consistent, national approach anchored in a comprehensive federal AI policy framework.”

Seeking Balance

In California, Newsom has signed some laws regulating AI, including one requiring health insurers to ensure their algorithms are fairly and equitably applied. But the Democratic governor has vetoed others with a broader approach, such as a bill including more mandates about how the technology must work and requirements to disclose its use to regulators, clinicians, and patients upon request.

Chris Micheli, a Sacramento-based lobbyist, said the governor likely wants to ensure the state budget — consistently powered by outsize stock market gains, especially from tech companies — stays flush. That necessitates balance.

Newsom is trying to “ensure that financial spigot continues, and at the same time ensure that there are some protections for California consumers,” he said. He added insurers believe they’re subject to a welter of regulations already.

The Trump administration seems persuaded. The president’s recent executive order proposed to sue and restrict certain federal funding for any state that enacts what it characterized as “excessive” state regulation — with some exceptions, including for policies that protect children.

That order is possibly unconstitutional, said Carmel Shachar, a health policy scholar at Harvard Law School. The source of preemption authority is generally Congress, she said, and federal lawmakers twice took up, but ultimately declined to pass, a provision barring states from regulating AI.

“Based on our previous understanding of federalism and the balance of powers between Congress and the executive, a challenge here would be very likely to succeed,” Shachar said.

Some lawmakers view Trump’s order skeptically at best, noting the administration has been removing guardrails, and preventing others from erecting them, to an extreme degree.

“There isn’t really a question of, should it be federal or should it be state right now?” Bores said. “The question is, should it be state or not at all?”

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Now, though, it seems unlikely to become state law. In November, a vote to advance the bill beyond a legislative subcommittee failed. Four out of six Republicans on the Senate Medical Affairs Committee subpanel refused to vote on the measure.

Republican state Sen. Jeff Zell said during a November subcommittee hearing that he wanted to help “move this pro-life football down the field and to save as many babies as we can.” Still, he could not support the bill as written.

“What I am interested in is speaking on behalf of the South Carolinian,” he said, “and they’re not interested in this bill right now or this issue right now.”

While that bill stalled, it signals that abortion will continue to loom large during 2026 legislative sessions. More than three years after the Supreme Court overturned Roe v. Wade, measures related to abortion have already been prefiled in several states, including Alabama, Arizona, Florida, Missouri, and Virginia.

Meanwhile, the South Carolina bill also exposed a rift among Republicans. Some GOP lawmakers are eager to appeal to their most conservative supporters by pursuing more restrictive abortion laws, despite the lack of support for such measures among most voters.

Until recently, the idea of charging women who obtain abortions with a crime was considered “politically toxic,” said Steven Greene, a political science professor at North Carolina State University.

Yet at least 15 states introduced “abortion as homicide” bills during 2024-2025 legislative sessions, many of which included the death penalty as a potential sentence, according to Dana Sussman, senior vice president of Pregnancy Justice, an organization that tracks the criminalization of pregnancy outcomes.

Even though none of those bills was signed into law, Sussman called this “a hugely alarming trend.”

“My fear is that one of these will end up passing,” she said.

Less than a month after the bill stalled in South Carolina, another bill — which would create criminal penalties for “coercion to obtain an abortion” — was prefiled ahead of the Jan. 13 start of the state’s legislative session.

“The issue is not going away. It’s a moral issue,” said state Sen. Richard Cash, who introduced the abortion bill that stalled in the subcommittee. “How far we can go, and what successes we can have, remain to be seen.”

‘Wrongful Death’

Florida law already bans abortion after six weeks of pregnancy. But a Republican lawmaker introduced a bill in October proposing civil liability for the “wrongful death” of a fetus. If enacted, the measure will allow parents to sue for the death of an unborn child, making them eligible for compensation, including damages for mental pain and suffering.

The bill says neither the mother nor a medical provider giving “lawful” care could be sued. But anyone else deemed to have acted with “negligence,” including someone who helps procure abortion-inducing pills or a doctor who performs an abortion after six weeks, could be sued by one of the parents.

In Missouri, a constitutional amendment to legalize abortion passed in 2024 with 51.6% of the vote. In 2026, state lawmakers are asking voters to repeal the amendment they just passed. A new proposed amendment would effectively reinstate the state’s ban on most abortions, with new exceptions for cases of rape, incest, and medical emergencies.

“I think that’s a middle-of-the-road, common sense proposal that most Missourians will agree with,” said Ed Lewis, a Republican state representative who sponsored the legislation to put the measure on the ballot.

Lewis said the 2024 amendment went too far in allowing a legal basis to challenge all of Missouri’s abortion restrictions, sometimes called “targeted regulation of abortion providers,” or TRAP, laws. Even before Missouri’s outright ban, the number of abortions recorded in the state had dropped from 5,772 in 2011 to 150 in 2021.

Meanwhile, Lewis backed another proposed constitutional amendment that will appear on the 2026 ballot. That measure would make it harder for Missourians to amend the state constitution, by requiring any amendment to receive a majority of votes in each congressional district.

One analysis suggested as few as 5% of voters could defeat any ballot measure under the proposal. Lewis dismissed the analysis as a “Democratic talking point.”

‘Gerrymandered’ Districts

Republican lawmakers aren’t necessarily aiming to pass abortion laws that appeal to the broadest swath of voters in their states.

Polling conducted ahead of Missouri’s vote in 2024 showed 52% of the state’s likely voters supported the constitutional amendment to protect access to abortion, a narrow majority that was consistent with the final vote.

In Texas, state law offers no exceptions for abortion in cases of rape or incest, even though a 2025 survey found 83% of Texans believe the procedure should be legal under those conditions.

In South Carolina, a 2024 poll found only 31% of respondents supported the state’s existing six-week abortion ban, which prohibits the procedure in most cases after fetal cardiac activity can be detected.

But Republicans hold supermajorities in the South Carolina General Assembly, and some continue to push for a near-total abortion ban even though such a law would probably be broadly unpopular. That’s because district lines have been drawn in such a way that politicians are more likely to be ousted by a more conservative member of their own party in a primary than defeated by a Democrat in a general election, said Scott Huffmon, director of the Center for Public Opinion & Policy Research at Winthrop University.

The South Carolina legislature is “so gerrymandered that more than half of the seats in both chambers were uncontested in the last general election. Whoever wins the primary wins the seat,” Huffmon said. “The best way to win the primary — or, better yet, prevent a primary challenge at all — is to run to the far right and embrace the policies of the most conservative people in the district.”

That’s what some proposals, including the “abortion as homicide” bills, reflect, said Greene, the North Carolina State professor. Lawmakers could vote for such a measure and suffer “very minimal, if any,” political backlash, he said.

“Most of the politicians passing these laws are more concerned with making the base happy than with actually dramatically reducing the number of abortions that take place within their jurisdiction,” Greene said.

Yet the number of abortions performed in South Carolina has dropped dramatically — by 63% from 2023 to 2024, when the state enacted the existing ban, according to data published by the state’s Department of Public Health.

Kimya Forouzan, a policy adviser with the Guttmacher Institute, which tracks abortion legislation throughout the country and advocates for reproductive rights, said South Carolina’s attempt to pass “the most extreme bill that we have seen” is “part of a pattern.”

“I think the push for anti-abortion legislation exists throughout the country,” she said. “There are a lot of battles that are brewing.”

KFF Health News correspondent Daniel Chang and Southern bureau chief Sabriya Rice contributed to this report.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Spartanburg County, in South Carolina’s Upstate region, has been fighting a measles outbreak since early October, with more than 50 cases identified. Health officials have encouraged people who are unvaccinated to get a shot by visiting its mobile vaccine clinic at any of its several stops throughout the county.

But on a Monday afternoon in Boiling Springs, only one person showed up.

“It’s progress. That progress is slow,” Linda Bell, the state epidemiologist with the Department of Public Health, said during a recent press briefing. “We had hoped to see a more robust uptake than that in our mobile health units.”

As South Carolina tries to contain its measles outbreak, public health officials across the nation are concerned that the highly contagious virus is making a major comeback. The Centers for Disease Control and Prevention has tallied more than 1,700 measles cases and 45 outbreaks in 2025. The largest started in Texas, where hundreds of people were infected and two children died.

For the first time in more than two decades, the United States is poised to lose its measles elimination status, a designation indicating that outbreaks are rare and rapidly contained.

South Carolina’s measles outbreak isn’t yet as large as those in other states, such as New Mexico, Arizona, and Kansas. But it shows how a confluence of larger national trends — including historically low vaccination rates, skepticism fueled by the pandemic, misinformation, and “health freedom” ideologies proliferated by conservative politicians — have put some communities at risk for the reemergence of a preventable, potentially deadly virus.

“Everyone talks about it being the canary in the coal mine because it’s the most contagious infectious disease out there,” said Josh Michaud, associate director for global and public health policy at KFF, a health information nonprofit that includes KFF Health News. “The logic is indisputable that we’re likely to see more outbreaks.”

Schools and ‘Small Brush Fires’

Spartanburg’s vaccination rate is among the lowest of South Carolina’s 46 counties. And that was true “even before covid,” said Chris Lombardozzi, a senior vice president with the Spartanburg Regional Healthcare System.

Nearly 6,000 children in Spartanburg County schools last year — 10% of the total enrollment — either received an exemption allowing them to forgo required vaccinations or did not meet vaccine requirements, according to data published by the state.

Lombardozzi said the county’s low vaccination rate is tied to misinformation not only published on social media but also spread by “a variety of nonmedical leaders over the years.”

The pandemic made things worse. Michaud said that fear and misinformation surrounding covid vaccines “threw gasoline on the fire of people’s vaccine skepticism.” In some cases, that skepticism transferred to childhood vaccines, which historically have been less controversial, he said.

This made communities like Spartanburg County with low vaccination rates more vulnerable. “Which is why we’re seeing constant, small brush fires of measles outbreaks,” Michaud said.

In Spartanburg, the overall percentage of students with required immunizations fell from 95.1% to 90% between the 2020-21 and 2024-25 academic years. Public health officials say a minimum of 95% is required to prevent significant spread of measles.

Children who attend public and private schools in South Carolina are required to show that they’ve received some vaccinations, including the measles, mumps, and rubella vaccine, but religious exemptions are relatively easy to obtain. The exemption form must be notarized, but it does not require a doctor’s note or any disclosure about the family’s religious beliefs.

The number of students in South Carolina who have been granted religious exemptions has increased dramatically over the past decade. That’s particularly true in the Upstate region, where religious exemptions have increased sixfold from a decade ago. During the 2013-14 school year, 2,044 students in the Upstate were granted a religious exemption to the vaccine requirements, according to data published by The Post and Courier. By fall 2024, that number had jumped to more than 13,000.

Some schools are more exposed than others. The beginning of the South Carolina outbreak was largely linked to one public charter school, Global Academy of South Carolina, where only 17% of the 605 students enrolled during the 2024-25 school year provided documentation showing they had received their required vaccinations, according to data published by the Department of Public Health.

No one from Global Academy responded to interview requests.

‘Health Freedom’

In April, after visiting a Texas family whose daughter had died from measles, Health and Human Services Secretary Robert F. Kennedy Jr. wrote on social media that the “most effective way to prevent the spread of measles is the MMR vaccine.” He made a similar statement during an interview on “Dr. Phil” later that month.

But these endorsements stand at odds with other statements Kennedy has made that cast doubt on vaccine safety and have falsely linked vaccines with autism. The CDC, under his authority, now claims such links “have been ignored by health authorities.”

“What would I do if I could go back in time and I could avoid giving my children the vaccines that I gave them?” he said on a podcast in 2020. “I would do anything for that. I would pay anything to be able to do that.”

Throughout 2025, he has made other misleading or unsupported statements. During a congressional hearing in September, Kennedy defended his past claims that he was not anti-vaccine but affirmed his stated position that no vaccines are safe or effective.

Emily Hilliard, a spokesperson for the Department of Health and Human Services, told KFF Health News that Kennedy is “pro-safety, pro-transparency, and pro-accountability.” Hilliard said HHS is working with “state and local partners in South Carolina” and in other states to provide support during the measles outbreaks.

Meanwhile, Kennedy has frequently championed the idea of health freedom, or freedom of choice, regarding vaccines, a talking point that has taken root among Republicans.

That has had a “chilling effect all the way down through state and local lawmakers,” Michaud said, making some leaders hesitant to talk about the threat that the ongoing measles outbreaks poses or the effectiveness and safety of the MMR vaccine.

Brandon Charochak, a spokesperson for South Carolina Gov. Henry McMaster, said the governor was not available to be interviewed for this article but referenced McMaster’s comment from October that measles “is a dangerous disease, but in terms of diseases, it’s not one that we should panic about.”

On a separate occasion that month, the Republican governor said he does not support vaccine mandates. “We’re not going to have mandates,” he said, “and I think we are responding properly.”

Even though the South Carolina Department of Public Health has repeatedly encouraged measles vaccines, the push has been notably quieter than the agency’s covid vaccine outreach efforts.

In 2021, for example, the agency partnered with breweries throughout the state for a campaign called “Shot and a Chaser,” which rewarded people who got a covid vaccine with a free beer or soda. By contrast, the pop-up measles vaccine clinic at the Boiling Springs Library featured no flashy signage, no freebies, and wasn’t visible from the library’s main entrance.

Edward Simmer, interim director of the Department of Public Health, would not speak to KFF Health News about the measles outbreak. During a legislative hearing in April, Republican state lawmakers voted against his permanent confirmation because of his past support for covid vaccines and masking. One lawmaker specifically criticized the agency during that hearing for the Shot and a Chaser campaign.

Public health officials in other states also have been blocked from new roles because of their covid response. In Missouri, where MMR vaccine rates have declined among kindergartners since 2020 and measles cases have been reported this year, Republican lawmakers rejected a public health director in 2022 after vaccine opponents protested his appointment.

In South Carolina, Simmer, lacking lawmakers’ confirmation, leads the public health agency in an interim capacity.

South Carolina Sen. Tom Davis of Beaufort was the only Republican on the Senate Medical Affairs Committee who voted to confirm Simmer in April. He told KFF Health News that his Republican colleagues raised valid questions about Simmer’s past support for covid vaccines.

But, Davis said, it would be “tremendously unfortunate and not beneficial from a public health perspective” if the Republican Party just took a stance against vaccines “as a matter of policy.”

The Department of Public Health had administered 44 doses of the MMR vaccine through its mobile health unit from October to mid-November. The last mobile vaccine clinic was scheduled for Nov. 24. But health officials are encouraged that patients are seeking vaccines elsewhere. The agency’s tracking system shows that providers across Spartanburg County administered more than twice as many measles vaccines in October as they did a year ago.

As of mid-November, more than 130 people remained in quarantine, most of them students at local elementary and middle schools. Cases have also been linked to a church and Greenville-Spartanburg International Airport.

“We’re reminding people that travel for the upcoming holidays increases the risk of exposures greatly,” said Bell, the state epidemiologist. “Due to that risk, we’re encouraging people to consider getting vaccinated now.”

KFF Health News correspondent Amy Maxmen contributed to this report.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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“It’s good to be home,” he said after one hospital stay in early June, “yet I’m tired and ready to get on with things.”

In 2023, Tennant, of Bridgeport, West Virginia, was diagnosed with cholangiocarcinoma, a rare cancer of the bile ducts that had spread throughout his body.

None of the initial treatments prescribed by his doctors had eradicated the cancer. But a glimmer of hope came in early 2025, when Tennant was recommended for histotripsy, a relatively new procedure that would use ultrasound waves to target, and potentially destroy, the largest tumor in his body — in his liver.

“My dad was a little nervous because it was something new, but it definitely gave us some hope that he would be around a little bit longer,” said Tennant’s daughter, Amiya.

There was just one hitch: His insurer wouldn’t pay for it.

Tennant, 58, died of cancer on Sept. 17. His story illustrates how a bureaucratic process called prior authorization can devastate patients and their families.

It’s infeasible to count the people harmed by this overwhelmingly unpopular practice, which, by delaying or denying care, helps drive health insurers’ profits. No government agency or private group tracks such data.

That said, KFF Health News has heard from hundreds of patients in recent years who claim that they or someone in their family has been harmed by prior authorization. More than 1 in 4 physicians surveyed by the American Medical Association in December said that prior authorization had led to a serious adverse event for a patient in their care. And 8% responded that prior authorization led to a disability, birth defect, or death.

In June, the Trump administration announced a pledge, signed by dozens of private insurers, to streamline prior authorization, which often requires patients or their medical teams to ask insurers for permission before proceeding with many types of care. It remains unclear when patients can expect to see improvement.

The commitments “depend on the full cooperation of the private insurance sector” and will “take time to achieve their full effect,” said Andrew Nixon, a spokesperson for the Department of Health and Human Services. But the pledge exists, he said, “to prevent tragic deaths like Eric’s from occurring at the hands of an inefficient system.”

Chris Bond, a spokesperson for AHIP, a health insurance industry trade group, said he could not speak to any specific insurer’s prior authorization policies. Broadly, though, he said prior authorization “acts as a guardrail” to make sure medicines and treatments are not used inappropriately.

At the same time, he said, insurers recognize that patients can be frustrated when their doctor-recommended care is denied. That’s why “there is a dedicated effort across the industry to make the process more straightforward, faster, and simpler for patients and providers,” Bond said.

In the meantime, the process continues to take its toll on people like Eric Tennant, whose grave diagnoses often require expensive health care services.

“Eric is gone,” his widow, Becky, said. “He’s not coming back.”

Tennant was a safety instructor for the West Virginia Office of Miners’ Health Safety and Training and insured by the state’s Public Employees Insurance Agency, which contracts with UnitedHealthcare to administer benefits for state employees, their spouses, and dependents.

In February and March, UnitedHealthcare, the Public Employees Insurance Agency, and an outside reviewer issued a series of denials that concluded Eric’s benefits would not cover histotripsy, claiming the treatment was not medically necessary. Becky Tennant estimated the procedure would cost the family about $50,000 out-of-pocket.

Although the treatment wasn’t guaranteed to work, it was worth a shot, the Tennants thought, so they considered withdrawing money from their retirement savings. But then, in May, after KFF Health News and NBC News posed a series of questions to UnitedHealthcare and the Public Employees Insurance Agency about Eric’s case, the agency reversed course. PEIA decided to cover his treatment.

Notably, the agency contacted KFF Health News about the approval hours before it notified the Tennant family of the decision.

But the approval came too late. Eric was hospitalized in late May and prescribed medication that prevented him from undergoing histotripsy at that time. His family held out hope that his health would improve and he would qualify for the procedure that summer.

In July, they took a family vacation to Marco Island, Florida. It would be their last. Two days after they returned home, a scan revealed Eric’s cancer had continued to spread. Histotripsy was out of the question.

“I’m sad for what we will miss out on,” Becky said. “I’m sad at the unfairness of it.”

She said if Eric had been able to undergo histotripsy in February, as originally recommended by his doctor, it might have destroyed the tumor in his liver that ultimately killed him.

“We’ll never know. That’s the thing. Any lawyer for the insurance will say, ‘Well, you don’t know it would have helped.’ No. You took that chance away from us,” she said.

In October, Samantha Knapp, a spokesperson for the West Virginia Department of Administration, told KFF Health News that the Public Employees Insurance Agency has not changed its policies related to prior authorization for histotripsy and continues to follow UnitedHealthcare’s guidelines.

UnitedHealthcare declined to answer questions for this article.

On Sept. 17, in a hospice bed set up in their dining room, Eric was surrounded by his family and their dogs as he died. Becky held his hand as his heart rate began to drop.

“He wasn’t afraid to die, but he didn’t want to die,” she said. “And you could tell the last day that he was fighting it big time.”

At the very end, she whispered in his ear: “You know I love you. You have been the best husband and the best dad, and you’ve always taken such good care of us,” Becky recalled.

And then, she said, he gasped. His eyebrows seemed to shoot up in wonder. During his last moment alive, she said, he smiled.

“The look on his face was pure, total amazement,” she said. “I still can’t believe he’s not here.”

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No notó al diminuto insecto hasta el lunes, cuando empezó a sentir dolor en el músculo de la pantorrilla. Esa misma mañana, hizo una cita virtual con una doctora —recomendada por su plan de salud—, quien le recetó un tratamiento de 10 días con doxiciclina para prevenir la enfermedad de Lyme, y le insistió en que también fuera a una consulta en persona. Así que, más tarde ese mismo día, fue, sin cita previa, a una clínica cerca de su casa en Brunswick, Maine, donde la evaluaron y le recetaron una dosis más alta, única, del mismo medicamento.

Fue una buena decisión porque el personal de la clínica encontró otra garrapata en el cuerpo de Leah durante esa visita. Además, después de enviar uno de los insectos a un laboratorio para su análisis, el resultado de la prueba fue positivo para Lyme.

“Pude haberme enfermado seriamente”, dijo Kovitch.

Pero la aseguradora de Kovitch rechazó cubrir la visita a la clínica. ¿La razón? No había obtenido una derivación de su médico para ver un especialista ni autorización previa. “Su plan no cubre este tipo de atención, por lo tanto, rechazamos este cargo”, explicaba un documento.

Las aseguradoras de salud han argumentado durante años que la autorización previa ayuda a reducir el fraude, los gastos innecesarios y a proteger a los pacientes. Y si bien estos rechazos suelen asociarse con tratamientos costosos, como los del cáncer, la diminuta picadura de una garrapata que sufrió Kovitch muestra cómo las compañías también utilizan esta política para evitar pagar por servicios de todo tipo, incluso cuando son considerados económicos y médicamente necesarios.

Promesas de cambio

El gobierno del presidente Donald Trump anunció este verano que docenas de aseguradoras privadas de salud aceptaron realizar cambios significativos en el proceso de autorización previa.

La promesa incluye eliminar por completo el requisito de autorización para ciertos servicios médicos. También se acordó otorgar un período de gracia a pacientes que cambian de plan médico, para que no enfrenten nuevas reglas que interrumpan sus tratamientos en curso.

Mehmet Oz, administrador de los Centros de Servicios de Medicare y Medicaid (CMS), anunció en una conferencia de prensa en junio que algunos de los cambios entrarían en vigencia en enero.

Pero, hasta ahora, el gobierno federal ha ofrecido pocos detalles sobre cuáles de los códigos de diagnóstico —utilizados para fines de facturación médica— quedarán exentos de autorización previa, o cómo hará que las aseguradoras privadas cumplan las nuevas reglas. No está claro si casos como el de Kovitch, relacionados con la enfermedad de Lyme, estarían exentos.

Chris Bond, vocero de AHIP, el principal grupo comercial de la industria de seguros médicos, confirmó que las aseguradoras se comprometieron a implementar algunos de los cambios para el 1 de enero. Otros cambios tomarán más tiempo. Por ejemplo, las compañías acordaron responder al 80% de las solicitudes de autorización en “tiempo real”, pero eso no ocurrirá sino hasta 2027.

Andrew Nixon, vocero del Departamento de Salud y Servicios Humanos de Estados Unidos (HHS), explicó a KFF Health News que los cambios prometidos por las aseguradoras buscan “reducir la burocracia, acelerar las decisiones de atención médica y fomentar la transparencia”, aunque advirtió que requerirán tiempo para lograr un impacto completo.

Mientras tanto, algunos expertos en políticas de salud se muestran escépticos sobre si las compañías realmente cumplirán con lo prometido. No es la primera vez que las grandes aseguradoras anuncian una reforma del proceso de autorización previa.

Bobby Mukkamala, presidente de la American Medical Association (AMA), escribió en julio que las promesas hechas por las aseguradoras en junio son “casi idénticas” a las que la industria del seguro hizo en 2018.

“Creo que esto es una estafa”, opinó Neal Shah, autor del libro Insured to Edith: How Health Insurance Screws Over Americans — And How We Take It Back (“Asegurados hasta la muerte: cómo el seguro de salud perjudica a los estadounidenses y cómo podemos recuperarlo”).

Según Shah, las aseguradoras firmaron el acuerdo impulsadas por la presión pública. La indignación colectiva contra las compañías aseguradoras aumentó tras la muerte del director ejecutivo de United Healthcare, Brian Thompson, en diciembre. Oz indicó que el compromiso de las aseguradoras fue una respuesta a la “violencia en las calles”.

“Cada vez rechazan más reclamos”, dijo Shah, que es uno de los fundadores de Counterforce Health, una compañía que usa inteligencia artificial para ayudar a los pacientes a apelar las negativas del seguro. “Nadie se hace responsable.”

Resolver el caso

La factura que Kovitch recibió por su cita en la clínica fue de $238 y tuvo que pagarla de su bolsillo luego de enterarse de que su aseguradora, Anthem, no cubriría ni un centavo. Primero intentó apelar la decisión. Incluso consiguió una remisión retroactiva de su doctora de atención primaria, que respaldaba la necesidad de la visita.

No funcionó. Anthem volvió a negar la cobertura. Kovitch dijo que cuando llamó para averiguar la razón, la representante con la que habló no supo explicarle.

“Era como si no lo entendieran”, explicó Kovitch. “Todo lo que repetían, una y otra vez, era que no tenía autorización previa”.

Después, Jim Turner, vocero de Anthem, atribuyó el rechazo de la aseguradora a un “error de facturación” cometido por Maine Health, el sistema de salud que opera la clínica donde Kovitch fue atendida. Según Turner, el error provocó que el reclamo se procesara como si fuera una visita a un especialista, en lugar de una visita de atención sin cita previa o de urgencia.

Turner no proporcionó documentación que mostrara cómo ocurrió el error. Los registros médicos que Kovitch entregó muestran que Maine Health codificó su visita como “mordida de garrapata en la parte inferior izquierda de la pierna, primer encuentro”, y no queda claro por qué Anthem la interpretó como una visita a un especialista.

Después de que KFF Health News contactara a Anthem para preguntar sobre la factura de Kovitch, Turner dijo que la compañía “debió haber identificado el error de facturación antes, en el proceso, y pedimos disculpas por los inconvenientes que esto le causó a la señora Kovitch”.

Caroline Cornish, vocera de Maine Health, dijo que no es la primera vez que Anthem niega cobertura a pacientes que llegan sin cita previa. Señaló que las reglas de procesamiento de Anthem a veces se aplican de forma incorrecta a este tipo de visitas, lo que lleva a “rechazos inapropiados”.

Afirmó que estas visitas no deberían requerir autorización previa y que el caso de Kovitch ilustra cómo las aseguradoras suelen utilizar los rechazos administrativos como respuesta inicial.

“Maine Health considera que las aseguradoras deberían enfocarse en pagar la atención que sus afiliados necesitan, en lugar de crear obstáculos que retrasan la cobertura y pueden desalentar a los pacientes a buscar atención”, dijo. “El sistema, con demasiada frecuencia, está en contra de las personas a las que se supone que debe servir”, agregó.

Finalmente, en octubre, Anthem le envió a Kovitch una actualización de su resumen de beneficios, en la que se indicaba que una combinación de pagos de la aseguradora y descuentos cubriría el costo total de la consulta. Kovitch contó que una representante de la empresa la llamó para disculparse. A principios de noviembre, recibió el reembolso de los $238.

Pero hace poco se enteró de que, según nuevas reglas establecidas por Anthem, su cita anual con el oftalmólogo ahora requiere una derivación de su doctora de atención primaria.

“Esto sigue igual”, dijo. “Pero ahora conozco mejor cómo actúan”.

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She didn’t notice the tiny bug until Monday, when her calf muscle began to feel sore. She made an appointment that morning with a telehealth doctor — one recommended by her health insurance plan — who prescribed a 10-day course of doxycycline to prevent Lyme disease and strongly suggested she be seen in person. So, later that day, she went to a walk-in clinic near her home in Brunswick, Maine.

And it’s a good thing she did. Clinic staffers found another tick on her body during the same visit. Not only that, one of the ticks tested positive for Lyme, a bacterial infection that, if untreated, can cause serious conditions affecting the nervous system, heart, and joints. Clinicians prescribed a stronger, single dose of the prescription medication.

“I could have gotten really ill,” Kovitch said.

But Kovitch’s insurer denied coverage for the walk-in visit. Its reason? She hadn’t obtained a referral or preapproval for it. “Your plan doesn’t cover this type of care without it, so we denied this charge,” a document from her insurance company explained.

Health insurers have long argued that prior authorization — when health plans require approval from an insurer before someone receives treatment — reduces waste and fraud, as well as potential harm to patients. And while insurance denials are often associated with high-cost care, such as cancer treatment, Kovitch’s tiny tick bite exposes how prior authorization policies can apply to treatments that are considered inexpensive and medically necessary.

Pledging To Fix the Process

The Trump administration announced this summer that dozens of private health insurers agreed to make sweeping changes to the prior authorization process. The pledge includes releasing certain medical services from prior authorization requirements altogether. Insurers also agreed to extend a grace period to patients who switch health plans, so they won’t immediately encounter new preapproval rules that disrupt ongoing treatment.

Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said during a June press conference that some of the changes would be in place by January. But, so far, the federal government has offered few specifics about which diagnostic codes tagged to medical services for billing purposes will be exempt from prior authorization — or how private companies will be held accountable. It’s not clear whether Lyme disease cases like Kovitch’s would be exempt from preauthorization.

Chris Bond, a spokesperson for AHIP, the health insurance industry’s main trade group, said that insurers have committed to implementing some changes by Jan. 1. Other parts of the pledge will take longer. For example, insurers agreed to answer 80% of prior authorization approvals in “real time,” but not until 2027.

Andrew Nixon, a spokesperson for the U.S. Department of Health and Human Services, told KFF Health News that the changes promised by private insurers are intended to “cut red tape, accelerate care decisions, and encourage transparency,” but they will “take time to achieve their full effect.”

Meanwhile, some health policy experts are skeptical that private insurers will make good on the pledge. This isn’t the first time major health insurers have vowed to reform prior authorization.

Bobby Mukkamala, president of the American Medical Association, wrote in July that the promises made by health insurers in June to fix the system are “nearly identical” to those the insurance industry put forth in 2018.

“I think this is a scam,” said Neal Shah, author of the book “Insured to Death: How Health Insurance Screws Over Americans — And How We Take It Back.”

Insurers signed on to President Donald Trump’s pledge to ease public pressure, Shah said. Collective outrage directed at insurance companies was particularly intense following the killing of UnitedHealthcare CEO Brian Thompson in December. Oz specifically said that the pledge by health insurers was made in response to “violence in the streets.”

Shah, for one, doesn’t believe companies will follow through in a meaningful way.

“The denials problem is getting worse,” said Shah, who co-founded Counterforce Health, a company that helps patients appeal insurance denials by using artificial intelligence. “There’s no accountability.”

Cracking the Case

Kovitch’s bill for her clinic appointment was $238, and she paid for it out-of-pocket after learning that her insurance company, Anthem, didn’t plan to cover a cent. First, she tried appealing the denial. She even obtained a retroactive referral from her primary care doctor supporting the necessity of the clinic visit.

It didn’t work. Anthem again denied coverage for the visit. When Kovitch called to learn why, she said she was left with the impression that the Anthem representative she spoke to couldn’t figure it out.

“It was like over their heads or something,” Kovitch said. “This was all they would say, over and over again: that it lacked prior authorization.”

Jim Turner, a spokesperson for Anthem, later attributed Kovitch’s denials to “a billing error” made by MaineHealth, the health system that operates the walk-in clinic where she sought care. MaineHealth’s error “resulted in the claim being processed as a specialist visit instead of a walk-in center/urgent care visit,” Turner told KFF Health News.

He did not provide documentation demonstrating how the billing error occurred. Medical records supplied by Kovitch show MaineHealth coded her walk-in visit as “tick bite of left lower leg, initial encounter,” and it’s not clear why Anthem interpreted that as a specialist visit.

After KFF Health News contacted Anthem with questions about Kovitch’s bill, Turner said that the company “should have identified the billing error sooner in the process than we did and we apologize for the confusion this caused Ms. Kovitch.”

Caroline Cornish, a spokesperson for MaineHealth, said this isn’t the only time Anthem has denied coverage for patients seeking walk-in or urgent care at MaineHealth. She said Anthem’s processing rules are sometimes misapplied to walk-in visits, leading to “inappropriate denials.”

She said these visits should not require prior authorization and Kovitch’s case illustrates how insurance companies often use administrative denials as a first response.

“MaineHealth believes insurers should focus on paying for the care their members need, rather than creating obstacles that delay coverage and risk discouraging patients from seeking care,” she said. “The system is too often tilted against the very people it is meant to serve.”

Meanwhile, in October, Anthem sent Kovitch an updated explanation of benefits showing that a combination of insurance company payments and discounts would cover the entire cost of the appointment. She said a company representative called her and apologized. In early November, she received her $238 refund.

But she recently found out that her annual eye appointment now requires a referral from her primary care provider, according to new rules laid out by Anthem.

“The trend continues,” she said. “Now I am more savvy to their ways.”

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El programa está diseñado para eliminar servicios considerados innecesarios o de “bajo valor” y representa una expansión federal del proceso llamado autorización previa, una práctica impopular que exige a los pacientes o a los médicos la aprobación del seguro antes de realizar ciertos procedimientos y exámenes médicos, o de escribir recetas.

Afectará a beneficiarios de Medicare, así como a los médicos y hospitales que los atienden, en Arizona, Ohio, Oklahoma, Nueva Jersey, Texas y Washington, a partir del 1 de enero y hasta 2031.

La medida ha generado preocupación entre políticos y expertos en políticas públicas. La versión tradicional de Medicare —que cubre a personas de 65 años en adelante y a algunas personas con discapacidades— ha evitado en general el uso de la autorización previa.

Sin embargo, las aseguradoras privadas la usan ampliamente, en especial en el mercado de Medicare Advantage.

El momento del anuncio también sorprendió: el programa piloto se anunció a finales de junio, pocos días después de que la administración Trump presentara una iniciativa voluntaria para que las aseguradoras privadas redujeran el uso de autorizaciones previas, práctica que, según Mehmet Oz, administrador de los Centros de Servicios de Medicare y Medicaid (CMS, en inglés), provoca “retrasos significativos” en la atención.

“Esto debilita la confianza del público en el sistema de salud”, dijo Oz a los medios. “Es algo que no podemos tolerar en esta administración”.

Pero algunos críticos, como Vinay Rathi, médico e investigador de políticas públicas en la Universidad Estatal de Ohio, acusan al gobierno de Trump de enviar mensajes contradictorios.

Por un lado, dijo Rathi, el gobierno quiere imitar estrategias del sector privado para reducir costos. “Por el otro, los regaña públicamente”.

“Es hipócrita decir una cosa y luego lo contrario”, dijo Suzan DelBene, legisladora demócrata de Washington. “Es muy preocupante”.

Pacientes, médicos y otros legisladores también han criticado lo que consideran tácticas para retrasar o negar atención médica, lo que puede causar daños irreparables o incluso la muerte.

“Las compañías de seguros tienen como mantra recibir el dinero de los pacientes y luego hacer todo lo posible para no entregárselo a quienes brindan la atención”, señaló Greg Murphy, legislador republicano de Carolina del Norte y urólogo. “Eso sucede en todas las juntas directivas de las aseguradoras”.

Las aseguradoras han defendido durante años que la autorización previa reduce el fraude, el gasto innecesario y posibles daños. La indignación pública por la negación de coberturas dominó los titulares en diciembre, cuando el asesinato del CEO de UnitedHealthcare hizo que muchos consideraran al presunto asesino como un héroe popular.

Y el rechazo público es generalizado: casi tres de cada cuatro personas encuestadas en julio por KFF dijeron que la autorización previa era un problema “grave”.

Por su parte, Oz afirmó en su conferencia de prensa de junio que la “violencia en las calles” llevó a la administración Trump a abordar la reforma de las autorizaciones previas en el sector privado.

Aún así, el gobierno está ampliando su uso en Medicare. Un vocero de los CMS, Alexx Pons, dijo que ambas iniciativas “tienen el mismo objetivo: proteger a los pacientes y a los fondos de Medicare”.

Preguntas sin respuesta

El programa piloto, llamado WISeR —siglas de Reducción de Servicios Inadecuados y Despilfarro— evaluará el uso de un algoritmo de IA para tomar decisiones de autorización previa en algunos servicios de Medicare, como sustitutos de piel y tejidos, implantes de estimuladores eléctricos de nervios y artroscopías de rodilla.

El gobierno federal sostiene que estos procedimientos son particularmente vulnerables al “fraude, despilfarro y abuso”, y que la autorización previa podría contener su uso excesivo.

Podrían agregarse más procedimientos a la lista. Sin embargo, los servicios de hospitalización, atención de emergencia o aquellos cuya demora represente un riesgo considerable para el paciente no estarán sujetos al modelo de IA, según el anuncio federal.

Aunque el uso de inteligencia artificial en seguros de salud no es nuevo, Medicare ha tardado en adoptar herramientas del sector privado. Hasta ahora, solo ha utilizado la autorización previa de forma limitada, a través de contratistas que no tienen incentivos para negar servicios. Pero expertos que han estudiado el plan creen que el plan piloto federal podría cambiar esa dinámica.

Pons afirmó a KFF Health News que ninguna solicitud de Medicare será rechazada sin antes ser revisada por “un profesional clínico calificado” y que los proveedores “tienen prohibido recibir pagos vinculados a tasas de negación”.

Sin embargo, el anuncio federal señala que los proveedores recibirán “un porcentaje de los ahorros generados por evitar atención innecesaria o inadecuada como resultado de sus revisiones”.

“Los acuerdos de ahorros compartidos implican que los proveedores se beneficien financieramente cuando se brinda menos atención médica”, y crea una estructura que puede incentivar la negación de atención médicamente necesaria, dijo Jennifer Brackeen, directora de asuntos gubernamentales de la Asociación de Hospitales del Estado de Washington.

Pero según médicos y expertos en políticas de salud, ese no es el único problema.

Rathi señaló que el plan “no está completamente desarrollado” y se basa en criterios “ambiguos y subjetivos”. El modelo, explicó, depende en última instancia de que los contratistas evalúen sus propios resultados, lo cual podría comprometer la validez de las conclusiones.

“No estoy seguro de que sepan, siquiera, cómo van a determinar si esto está ayudando o perjudicando a los pacientes”, dijo.

Pons aseguró que el uso de IA en este piloto estará “sujeto a supervisión estricta para garantizar transparencia, rendición de cuentas y cumplimiento con las normas de Medicare y la protección de los pacientes”.

“Los CMS siguen comprometidos con garantizar que las herramientas automatizadas apoyen —y no reemplacen— decisiones clínicas sólidas”, dijo.

Los expertos coinciden en que, en teoría, la inteligencia artificial podría agilizar un proceso que se caracteriza por retrasos y negaciones que afectan la salud de los pacientes. Las aseguradoras argumentan que la IA elimina errores y sesgos humanos, y reduce costos al sistema de salud. También insisten en que son personas, no algoritmos, quienes revisan las decisiones finales sobre cobertura.

Pero algunas investigaciones cuestionan que eso ocurra realmente.

“Creo que también hay ambigüedad sobre qué significa exactamente ‘revisión humana significativa’”, señaló Amy Killelea, profesora investigadora en el Centro de Reformas del Seguro de Salud de la Universidad de Georgetown.

Un informe de 2023 publicado por ProPublica reveló que, durante un período de dos meses, médicos de Cigna dedicaron en promedio 1,2 segundos para revisar cada solicitud de pago.

Justine Sessions, vocera de Cigna, dijo a KFF Health News que la compañía no utiliza inteligencia artificial para negar atención o reclamos. La investigación de ProPublica, explicó, se refería a “un proceso simple, impulsado por software, que ayudó a acelerar pagos a médicos para pruebas y tratamientos comunes y de bajo costo. No está impulsado por IA” y “no se utilizó para autorizaciones previas”, agregó Sessions.

Sin embargo, demandas legales colectivas presentadas contra grandes aseguradoras alegan que sus modelos de IA fallan al considerar las necesidades individuales de los pacientes y contradicen las recomendaciones médicas, obligando a algunas personas a asumir el costo de su atención.

Una encuesta realizada en febrero por la American Medical Association reveló que el 61% de los médicos cree que la IA está “aumentando las negaciones de autorización previa, agravando daños evitables a los pacientes y generando un despilfarro innecesario ahora y en el futuro”.

Chris Bond, vocero de AHIP, el grupo que representa a las aseguradoras, dijo a KFF Health News que la organización está “totalmente enfocada” en cumplir los compromisos asumidos con el gobierno. Entre ellos, reducir el alcance de la autorización previa y garantizar que las comunicaciones con los pacientes sobre negaciones y apelaciones sean fáciles de entender.

“Es un programa piloto”

El programa piloto de Medicare pone en evidencia las preocupaciones sobre la autorización previa, y agrega nuevas inquietudes.

Si bien las aseguradoras privadas han sido poco transparentes sobre cómo utilizan la IA y hasta qué punto aplican la autorización previa, investigadoras en políticas públicas creen que estos algoritmos suelen programarse para negar automáticamente la atención costosa.

“Cuanto más caro es el servicio, más probable es que se niegue”, afirmó Jennifer Oliva, profesora de la Facultad de Derecho Maurer de la Universidad de Indiana-Bloomington, experta en regulación de IA y cobertura médica.

En un artículo reciente para Indiana Law Journal, Oliva explicó que cuando un paciente tiene una expectativa de vida limitada, las aseguradoras tienden a apoyarse en el algoritmo. A medida que pasa el tiempo y el paciente o su médico apelan la negación, aumentan las probabilidades de que esa persona fallezca antes de que el seguro cubra el tratamiento. Cuanto más largo es el proceso de apelación, menos probable es que la aseguradora tenga que pagar, dijo.

“Lo primero que hacen es dificultar al máximo el acceso a servicios de alto costo”, aseguró.

Dado el crecimiento previsto del uso de IA en seguros de salud, los algoritmos de las aseguradoras representan “un punto ciego en la regulación” que exige mayor supervisión, dijo Carmel Shachar, directora del Centro de Innovación en Derecho y Políticas de Salud de la Facultad de Derecho de Harvard.

Según Shachar, el programa WISeR es “un paso interesante” para asegurarse de que los fondos de Medicare se utilicen en atención de calidad; pero la falta de detalles hace difícil saber si realmente funcionará.

Los políticos también se hacen esas preguntas.

“¿Cómo se va a probar este sistema? ¿Cómo van a asegurarse de que funciona y no está negando atención o generando más rechazos?”, preguntó DelBene, quien firmó una carta en agosto junto a otros demócratas exigiendo respuestas sobre el programa de IA.

Pero no solo los demócratas están preocupados.

Murphy, copresidente del Caucus de Médicos Republicanos de la Cámara de Representantes, reconoció que muchos médicos temen que el programa piloto WISeR interfiera con la práctica médica si el algoritmo niega tratamientos recomendados por profesionales.

Mientras tanto, miembros de ambos partidos en la Cámara de Representantes apoyaron recientemente una propuesta de Lois Frankel, demócrata de Florida, para bloquear el financiamiento del piloto en el presupuesto del Departamento de Salud y Servicios Humanos para el año fiscal 2026.

La IA llegó para quedarse en el sistema de salud, dijo Murphy, pero aún está por verse si el piloto WISeR ahorrará dinero a Medicare o empeorará los problemas ya existentes por la autorización previa.

“Es un programa piloto, y estoy dispuesto a ver qué ocurre con esto”, agregó Murphy, “pero siempre, siempre me inclinaré por confiar en que los médicos saben lo que es mejor para sus pacientes”.

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The pilot program, designed to weed out wasteful, “low-value” services, amounts to a federal expansion of an unpopular process called prior authorization, which requires patients or someone on their medical team to seek insurance approval before proceeding with certain procedures, tests, and prescriptions. It will affect Medicare patients, and the doctors and hospitals who care for them, in Arizona, Ohio, Oklahoma, New Jersey, Texas, and Washington, starting Jan. 1 and running through 2031.

The move has raised eyebrows among politicians and policy experts. The traditional version of Medicare, which covers adults 65 and older and some people with disabilities, has mostly eschewed prior authorization. Still, it is widely used by private insurers, especially in the Medicare Advantage market.

And the timing was surprising: The pilot was announced in late June, just days after the Trump administration unveiled a voluntary effort by private health insurers to revamp and reduce their own use of prior authorization, which causes care to be “significantly delayed,” said Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services.

“It erodes public trust in the health care system,” Oz told the media. “It’s something that we can’t tolerate in this administration.”

But some critics, like Vinay Rathi, an Ohio State University doctor and policy researcher, have accused the Trump administration of sending mixed messages.

On one hand, the federal government wants to borrow cost-cutting measures used by private insurance, he said. “On the other, it slaps them on the wrist.”

Administration officials are “talking out of both sides of their mouth,” said Rep. Suzan DelBene, a Washington Democrat. “It’s hugely concerning.”

Patients, doctors, and other lawmakers have also been critical of what they see as delay-or-deny tactics, which can slow down or block access to care, causing irreparable harm and even death.

“Insurance companies have put it in their mantra that they will take patients’ money and then do their damnedest to deny giving it to the people who deliver care,” said Rep. Greg Murphy, a North Carolina Republican and a urologist. “That goes on in every insurance company boardroom.”

Insurers have long argued that prior authorization reduces fraud and wasteful spending, as well as prevents potential harm. Public displeasure with insurance denials dominated the news in December, when the shooting death of UnitedHealthcare’s CEO led many to anoint his alleged killer as a folk hero.

And the public broadly dislikes the practice: Nearly three-quarters of respondents thought prior authorization was a “major” problem in a July poll published by KFF, a health information nonprofit that includes KFF Health News.

Indeed, Oz said during his June press conference that “violence in the streets” prompted the Trump administration to take on the issue of prior authorization reform in the private insurance industry.

Still, the administration is expanding the use of prior authorization in Medicare. CMS spokesperson Alexx Pons said both initiatives “serve the same goal of protecting patients and Medicare dollars.”

Unanswered Questions

The pilot program, WISeR — short for “Wasteful and Inappropriate Service Reduction” — will test the use of an AI algorithm in making prior authorization decisions for some Medicare services, including skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy.

The federal government says such procedures are particularly vulnerable to “fraud, waste, and abuse” and could be held in check by prior authorization.

Other procedures may be added to the list. But services that are inpatient-only, emergency, or “would pose a substantial risk to patients if significantly delayed” would not be subject to the AI model’s assessment, according to the federal announcement.

While the use of AI in health insurance isn’t new, Medicare has been slow to adopt the private-sector tools. Medicare has historically used prior authorization in a limited way, with contractors who aren’t incentivized to deny services. But experts who have studied the plan believe the federal pilot could change that.

Pons told KFF Health News that no Medicare request will be denied before being reviewed by a “qualified human clinician,” and that vendors “are prohibited from compensation arrangements tied to denial rates.” While the government says vendors will be rewarded for savings, Pons said multiple safeguards will “remove any incentive to deny medically appropriate care.”

“Shared savings arrangements mean that vendors financially benefit when less care is delivered,” a structure that can create a powerful incentive for companies to deny medically necessary care, said Jennifer Brackeen, senior director of government affairs for the Washington State Hospital Association.

And doctors and policy experts say that’s only one concern.

Rathi said the plan “is not fully fleshed out” and relies on “messy and subjective” measures. The model, he said, ultimately depends on contractors to assess their own results, a choice that makes the results potentially suspect.

“I’m not sure they know, even, how they’re going to figure out whether this is helping or hurting patients,” he said.

Pons said the use of AI in the Medicare pilot will be “subject to strict oversight to ensure transparency, accountability, and alignment with Medicare rules and patient protection.”

“CMS remains committed to ensuring that automated tools support, not replace, clinically sound decision-making,” he said.

Experts agree that AI is theoretically capable of expediting what has been a cumbersome process marked by delays and denials that can harm patients’ health. Health insurers have argued that AI eliminates human error and bias and will save the health care system money. These companies have also insisted that humans, not computers, are ultimately reviewing coverage decisions.

But some scholars are doubtful that’s routinely happening.

“I think that there’s also probably a little bit of ambiguity over what constitutes ‘meaningful human review,’” said Amy Killelea, an assistant research professor at the Center on Health Insurance Reforms at Georgetown University.

A 2023 report published by ProPublica found that, over a two-month period, doctors at Cigna who reviewed requests for payment spent an average of only 1.2 seconds on each case.

Cigna spokesperson Justine Sessions told KFF Health News that the company does not use AI to deny care or claims. The ProPublica investigation referenced a “simple software-driven process that helped accelerate payments to clinicians for common, relatively low-cost tests and treatments, and it is not powered by AI,” Sessions said. “It was not used for prior authorizations.”

And yet class-action lawsuits filed against major health insurers have alleged that flawed AI models undermine doctor recommendations and fail to take patients’ unique needs into account, forcing some people to shoulder the financial burden of their care.

Meanwhile, a survey of physicians published by the American Medical Association in February found that 61% think AI is “increasing prior authorization denials, exacerbating avoidable patient harms and escalating unnecessary waste now and into the future.”

Chris Bond, a spokesperson for the insurers’ trade group AHIP, told KFF Health News that the organization is “zeroed in” on implementing the commitments made to the government. Those include reducing the scope of prior authorization and making sure that communications with patients about denials and appeals are easy to understand.

‘This Is a Pilot’

The Medicare pilot program underscores ongoing concerns about prior authorization and raises new ones.

While private health insurers have been opaque about how they use AI and the extent to which they use prior authorization, policy researchers believe these algorithms are often programmed to automatically deny high-cost care.

“The more expensive it is, the more likely it is to be denied,” said Jennifer Oliva, a professor at the Maurer School of Law at Indiana University-Bloomington, whose work focuses on AI regulation and health coverage.

Oliva explained in a recent paper for the Indiana Law Journal that when a patient is expected to die within a few years, health insurers are “motivated to rely on the algorithm.” As time passes and the patient or their provider is forced to appeal a denial, the chance of the patient dying during that process increases. The longer an appeal, the less likely the health insurer is to pay the claim, Oliva said.

“The No. 1 thing to do is make it very, very difficult for people to get high-cost services,” she said.

As the use of AI by health insurers is poised to grow, insurance company algorithms amount to a “regulatory blind spot” and demand more scrutiny, said Carmel Shachar, a faculty director at Harvard Law School’s Center for Health Law and Policy Innovation.

The WISeR pilot is “an interesting step” toward using AI to ensure that Medicare dollars are purchasing high-quality health care, she said. But the lack of details makes it difficult to determine whether it will work.

Politicians are grappling with some of the same questions.

“How is this being tested in the first place? How are you going to make sure that it is working and not denying care or producing higher rates of care denial?” asked DelBene, who signed an August letter to Oz with other Democrats demanding answers about the AI program. But Democrats aren’t the only ones worried.

Murphy, who co-chairs the House GOP Doctors Caucus, acknowledged that many physicians are concerned the WISeR pilot could overreach into their practice of medicine if the AI algorithm denies doctor-recommended care.

Meanwhile, House members of both parties recently supported a measure proposed by Rep. Lois Frankel, a Florida Democrat, to block funding for the pilot in the fiscal 2026 budget of the Department of Health and Human Services.

AI in health care is here to stay, Murphy said, but it remains to be seen whether the WISeR pilot will save Medicare money or contribute to the problems already posed by prior authorization.

“This is a pilot, and I’m open to see what’s going to happen with this,” Murphy said, “but I will always, always err on the side that doctors know what’s best for their patients.”

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It took years, a chain of conflicting decisions, and a health insurer switch before she finally won approval. She started treatment in January and now channels time and energy into helping other patients fight denials.

“One of the things I tell people when they come to me is: ‘Don’t panic. This isn’t a final no,’” said Nix, 55, of Statesville, North Carolina.

To control costs, nearly all health insurers use a system called prior authorization, which requires patients or their providers to seek approval before they can get certain procedures, tests, and prescriptions.

Denials can be appealed, but nearly half of insured adults who received a prior authorization denial in the past two years reported the appeals process was either somewhat or very difficult, according to a July poll published by KFF, a health information nonprofit that includes KFF Health News.

“It’s overwhelming by design,” because insurers know confusion and fatigue cause people to give up, Nix said. “That’s exactly what they want you to do.”

The good news is you don’t have to be an insurance expert to get results, she said. “You just need to know how to push back.”

Here are tips to consider when faced with a prior authorization denial:

1. Know your insurance plan.

Do you have insurance through your job? A plan purchased through healthcare.gov? Medicare? Medicare Advantage? Medicaid?

These distinctions can be confusing, but they matter a great deal. Different categories of health insurance are governed by different agencies and are therefore subject to different prior authorization rules.

For example, federal marketplace plans, as well as Medicare and Medicare Advantage plans, are regulated by the U.S. Department of Health and Human Services. Employer-sponsored plans are regulated by the Department of Labor. Medicaid plans, administered by state agencies, are subject to both state and federal rules.

Learn the language specific to your policy. Health insurance companies do not apply prior authorization requirements uniformly across all plans. Read your policy closely to make sure your insurer is following its own rules, as well as regulations set by the state and federal government.

2. Work with your provider to appeal.

Kathleen Lavanchy, who retired in 2024 from a job at an inpatient rehabilitation hospital in the Philadelphia area, spent much of her career communicating with health insurance companies on behalf of patients.

Before you contact your health insurer, call your provider, Lavanchy said, and ask to speak to a medical care manager or someone in the office who handles prior authorization appeals.

The good news is that your doctor’s office may already be working on an appeal.

Medical staffers can act as “your voice,” Nix said. “They know all the language.”

You or your provider can request a “peer-to-peer” review during the appeals process, which allows your doctor to discuss your case over the phone with a medical professional who works for the insurance company.

3. Be organized.

Many hospitals and doctors use a system called MyChart to organize medical records, test results, and communications so that they are easily accessible. Similarly, patients should keep track of all materials related to an insurance appeal — records of phone calls, emails, snail mail, and in-app messages.

Everything should be organized, either digitally or on paper, so that it can be easily referenced, Nix said. At one point, she said, her own records proved that her insurance company had given conflicting information. The records were “the thing that saved me,” she said.

“Keep an amazing paper trail,” she said. “Every call, every letter, every name.”

Linda Jorgensen, executive director of the Special Needs Resource Project, a nonprofit offering online resources for patients with disabilities and their families, has advised patients who are fighting a denial to specifically keep paper copies of everything.

“If it isn’t on paper, it didn’t happen,” she said.

Jorgensen, who serves as a caregiver to an adult daughter with special needs, created a free form you can print to help guide you when taking notes during phone calls with your insurance company. She advised asking the insurance representative for a “ticket number” and their name before proceeding with the conversation.

4. Appeal as soon as possible.

The silver lining is that most denials, if appealed, are overturned.

Medicare Advantage data published by KFF in January found that nearly 82% of prior authorization denials from 2019 through 2023 were partially or fully overturned upon appeal.

But the clock is ticking. Most health plans give you only six months to appeal the decision, according to rules laid out in the Affordable Care Act.

“Don’t dillydally,” Jorgensen advised, especially if you’re sending a paper appeal, or any supporting documents, through the U.S. Postal Service. She recommends filing quickly, and at least four weeks before the deadline.

For the sake of speed, some people are turning to artificial intelligence for help crafting customizable appeal letters.

5. Ask your HR department for help.

If you get your health insurance through an employer, there’s a good chance your health plan is “self-funded” or “self-insured.” That means your employer contracts with a health insurance company to administer benefits, but your employer shoulders the cost of your care.

Why does that matter? Under self-funded plans, decisions about what is or isn’t covered ultimately rest with your employer.

Let’s say, for example, your doctor has recommended that you undergo surgery, and your insurer has denied prior authorization for it, deeming the procedure “not medically necessary,” a phrase commonly used. If your plan is self-funded, you can appeal to the human resources department at your job, because your employer is on the hook for your health care costs — not the insurer.

Of course, there’s no guarantee your employer will agree to pay. But, at the very least, it’s worth reaching out for help.

6. Find an advocate.

Many states operate free consumer assistance programs, available by phone or email, which can help you file an appeal. They can explain your benefits and may intervene if your insurance company isn’t complying with requirements.

Beyond that, some nonprofit advocacy groups, such as the Patient Advocate Foundation, might help. On the foundation’s website is guidance about what to include in an appeal letter. For those battling severe disease, foundation staffers can work with you one-on-one to fight a denial.

7. Make noise.

We’ve written about this before. Sometimes, when patients and doctors shame insurers online, denials get overturned.

The same holds when patients contact lawmakers. State laws regulate some categories of health insurance, and when it comes to setting policy, state lawmakers have the power to hold insurance companies accountable.

Reaching out to your legislator isn’t guaranteed to work, but it might be worth a shot.

Finally, if you’re interested in sharing your experiences with a journalist, fill out this form. We’d like to hear from you.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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During a typical shift, she shows up at her clients’ home at 10 p.m. She answers questions they may have about basic infant care and keeps an eye out for signs of postpartum depression.

After bedtime, she may feed the baby a bottle or wake the mother to breastfeed. She soothes the infant back to sleep. Sometimes, she prepares meals for the family in a Crock-Pot or empties the dishwasher.

She leaves the following morning and returns, often nightly, for two or three weeks in a row.

“I’m certified to do all of it,” said Oliver, of Hardeeville, South Carolina, who runs Compassionate Care Doula Services. It takes a village to raise a child, as the adage goes, but “the village is not what it used to be,” Oliver said.

Doulas are trained to offer critical support for families — before delivery, during childbirth, and in those daunting early days when parents are desperate for sleep and infants still wake up around the clock. While doulas typically don’t hold a medical or nursing degree, research shows they can improve health outcomes and reduce racial health disparities.

Yet their services remain out of reach for many families. Oliver charges $45 an hour overnight, and health insurance plans often don’t cover her fees. That’s partly why business “ebbs and flows,” Oliver said. Sometimes, she’s fully booked for months. Other times, she goes several weeks without a client.

That may soon change.

Two bipartisan bills, introduced in separate chambers of the South Carolina General Assembly, would require both Medicaid, which pays for more than half of all births in the state, and private insurers to cover the cost of doula services for patients who choose to use one.

South Carolina isn’t an outlier. Even as states brace for significant reductions in federal Medicaid funding over the next decade, legislatures across the country continue to pass laws that grant doula access to Medicaid beneficiaries. Some state laws already require private health insurers to do the same. Since the start of 2025, Vermont lawmakers, alongside Republican-controlled legislatures in Arkansas, Utah, Louisiana, and Montana, have passed laws to facilitate Medicaid coverage of doula services.

All told, more than 30 states are reimbursing doulas through Medicaid or are implementing laws to do so.

Notably, these coverage requirements align with one of the goals of Project 2025, whose “Mandate for Leadership” report, published in 2023 by the conservative Heritage Foundation, offered a blueprint for President Donald Trump’s second term. The document calls for increasing access to doulas “for all women whether they are giving birth in a traditional hospital, through midwifery, or at home,” citing concerns about maternal mortality and postpartum depression, which may be “worsened by poor birth experiences.” The report also recommends that federal money not be used to train doctors, nurses, or doulas to perform abortions.

The Heritage Foundation did not respond to an interview request.

Meanwhile, the idea that doulas can benefit babies, parents, and state Medicaid budgets by reducing costly cesarean sections and preterm birth complications is supported by a growing body of research and is gaining traction among conservatives.

A study published last year in the American Journal of Public Health found that women enrolled in Medicaid who used a doula faced a 47% lower risk of delivering by C-section and a 29% lower risk of preterm birth. They were also 46% more likely to attend a postpartum checkup.

“Why wouldn’t you want somebody to avail themselves of that type of care?” said Republican state Rep. Tommy Pope, who co-sponsored the doula reimbursement bill in the South Carolina House of Representatives. “I don’t see any reason we shouldn’t be doing that.”

Pope said his daughter-in-law gave birth with the assistance of a doula. “It opened my eyes to the positive aspects,” he said.

Amy Chen, a senior attorney with the National Health Law Program, which tracks doula reimbursement legislation around the country as part of its Doula Medicaid Project, said lawmakers tend to support these efforts when they have a personal connection to the issue.

“It’s something that a lot of people resonate with,” Chen said, “even if they, themselves, have never been pregnant.”

Conservative lawmakers who endorse state-level abortion bans, she said, often vote in favor of measures that support pregnancy, motherhood, and infant health, all of which these doula reimbursement bills are intended to do.

Some Republicans feel as if “they have to come out in favor of that,” Chen said.

Health care research also suggests that Black patients, who suffer significantly higher maternal and infant mortality rates than white patients, may particularly benefit from doula care. In 2022, Black infants in South Carolina were more than twice as likely to die from all causes before their 1st birthday as white infants.

That holds true for women in rural parts of the country where labor and delivery services have either closed or never existed.

That’s why Montana lawmakers passed a doula reimbursement bill this year — to narrow health care gaps for rural and Indigenous communities. To that end, in 2023, the state enacted a bill that requires Medicaid to reimburse midwives for home births.

Montana state Sen. Mike Yakawich, a Republican who backed the Democratic-sponsored doula reimbursement bill, said pregnant women should have someone to call outside of a hospital, where health care services can be costly and intimidating.

“What help can we provide for moms who are expecting? My feeling is, it’s never enough,” Yakawich said.

Britney WolfVoice lives on the Northern Cheyenne Indian Reservation in southeastern Montana, about two hours from the closest birthing hospital. In early July, she was seven months pregnant with her fourth child, a son, and said she planned to have a doula by her side for the second time in the delivery room. During WolfVoice’s previous pregnancy, an Indigenous doula named Misty Pipe brought cedar oil and spray into the delivery room, rubbed WolfVoice’s back through contractions, and helped ensure WolfVoice’s husband was the first person their daughter saw.

“Being in a hospital, I felt heard for the very first time,” WolfVoice said. “I just can’t explain it any better than I felt at home. She was my safe place.”

Pipe said hospitals are still associated with the government forcibly removing children from Native American homes as a consequence of colonization. Her goal is to help give people a voice during their pregnancy and delivery.

Most of her clients can’t afford to pay for doula services out-of-pocket, Pipe said, so she doesn’t charge anything for her birth services, balancing her role as a doula with her day job at a post office.

“If a mom is vulnerable, she could miss a prenatal appointment or go alone, or I can take time off of work and take her myself,” Pipe said. “No mom should have to birth in fear.”

The new state law will allow her to get paid for her work as a doula for the first time.

In some states that have enacted such laws, initial participation by doulas was low because Medicaid reimbursement rates weren’t high enough. Nationally, doula reimbursement rates are improving, Chen said.

For example, in Minnesota, where in 2013 lawmakers passed one of the first doula reimbursement bills, Medicaid initially paid only $411 per client for their services. Ten years later, the state had raised the reimbursement rate to a maximum of $3,200 a client.

But Chen said it is unclear how federal Medicaid cuts might affect the fate of these state laws.

Some states that haven’t passed doula reimbursement bills, including South Carolina, might be hesitant to do so in this environment, she said. “It’s just a really uncertain time.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).