HJBR Jan/Feb 2026

HEALTHCARE JOURNAL OF BATON ROUGE I  JAN / FEB 2026 13 I also learned how the war we waged on Mom’s behalf is one that frighteningly few Medicare Advantage plan members like her bother fighting when companies like Humana deny coverage. In 2023 alone, 3.2 million (6.4%) requests for prior authori- zation were denied by MedicareAdvantage plans. Nearly 12% (11.7%) of denials were appealed in 2023, and 81.7% of appeals were partly or fully successful. 10 While the data illustrate how difficult it is for ailing Davids to fight off Goliath’s heel from their frail necks, the overturn rate screams how wrong the denials are in the first place. Privatized Medicare has undergone many tweaks since the foundation was laid decades ago, all under the guise of sav- ing taxpayer money and delivering better healthcare to seniors. Yet, despite all the tweaks and soaring enrollment, they’ve never saved Medicare a dime. According to the Commonwealth Fund, the government has paid more to private Medicare Advan- tage plans for enrollees than their costs would’ve been under traditional Medicare. 11 It’s my argument that ever since the Soviet Union broke up, the unofficial tag- line of American healthcare has been “Cap- italism: If it was good enough to beat the Commies, it’s good enough to fix Grandma.” More than a century earlier, Charles Dar- win’s theory of evolution inspired the con- cept of “survival of the fittest” as a way of explaining the mechanism of natural selec- tion. In short, you either adapt or die in an unforgiving world. In the decades after Darwin published On the Origin of Species in 1859, proponents of capitalism repeatedly cited his evolution- ary theory of natural selection as valida- tion of free market competition for limited resources. 12 If you can’t turn a profit, you die off in an economic jungle, especially in the corporate age. This is the eat-or-be-eaten environment in which American healthcare is forced to operate. There’s no room for human com- passion on the ledger sheet. Stockholders want dividends, not sob stories. When it comes to insurers, denial = profit. 13 As the lawsuits assert, these private companies make “a clear financial wind- fall in the form of policy premiums with- out having to pay for promised care.” The faceless nature of this tactic makes it too tempting not to squeeze a few more bucks out of sick people. In 1961, President Dwight D. Eisenhower gave a memorable farewell address that called attention to the country’s rapidly growing armaments industry, which only existed on a small scale before World War II. 14 The last general elected to leadAmerica warned us about the “grave implications” of the military-industrial complex gaining unwarranted influence. It’s a shame no one with Ike’s guts and standing ever bothered to warn us about the rise of the medical-industrial complex. The system is not designed to make sick people healthy so much as it’s designed to enrich the operators of the system and their stock- holders. It’s like a factory where workers are told to keep the line moving by not worry- ing about some of the human units because they cost too much to repair. New Developments, Same Old Song Originally, I hoped InHumana would encourage beneficiaries to stick with tradi- tional Medicare to avoid AI-driven denials of prior authorization in Medicare Advan- tage. Thanks to recent developments in Washington, DC, however, that argument may soon become moot. On June 27, 2025, CMS announced it was launching the Wasteful and Inappropri- ate Service Reduction (WISeR) Model to bring artificial intelligence–powered prior authorization to traditional Medicare. 15 Two months later, The New York Times reported the new pilot programwas set to begin Jan. 1, 2026, in six states. 16 As a result, millions of traditional Medicare beneficiaries in Texas, Oklahoma, Arizona, Washington, Ohio, and New Jersey will be subjected to the scourge of AI-driven denials for a host of treatments. The NewYork Times article reported how WISeR was already drawing opposition from lawmakers, former Medicare officials, physician groups, and others. Critics have deemed the program “AI death panels” for seniors, particularly because CMS’ corpo- rate partners stand to directly profit from the denials, according to The Times . “The A.I. companies selected to oversee the program would have a strong financial incentive to deny claims,” The Times wrote. “Medicare plans to pay them a share of the savings generated from rejections.” It’s important to note that, while CMS has characterized WISeR as a “voluntary” program, “the voluntary element applies to technology vendors,” which CMS defines as “‘participants,’ rather than to healthcare providers,”according to the consulting firm Applied Policy. 17 “Although providers are not required to submit prior authorization requests,”the firm reported inAugust, “pay- ment for the designated services cannot be secured without either prior authorization approval or successful passage through pre- payment review.” Since the pilot program requires zero congressional approval, WISeR represents the slow-boil method of achieving one of Project 2025’s main goals: making Medi- careAdvantage plans the default enrollment option. 18 U.S. Sen. Patty Murray, D-Washing- ton, aptly described it as a “backdoor move” to privatize Medicare in a way that draws minimal attention. 19 Weeks later, in early November, six mem- bers of Congress (including two physicians) announced that they’d “introduced legisla- tion to protect seniors from new red tape the Trump administration is implement- ing in traditional Medicare.” The Seniors Deserve SMARTER (Streamlined Medical Approvals for Timely, Efficient Recovery) Care Act would repeal the WISeR model, according to a news release from U.S. Rep. Rick Larsen, D-Washington. 20 As of this writing in December, SMARTER was still in committee. 21 Around the same time WISeR began to make a smattering of headlines, I had a bit of a “name your demon”moment while lis- tening to an episode of the “Code WACK!”