Next year, seniors and families will have more stringent and more unaffordable health coverage thanks to new AI-driven prior authorizations in Medicare and loss of subsidies in the ACA.
The New Year is just two weeks away, and when Americans wake after clinking champagne and kissing at midnight, the health care landscape in the United States will be in worse shape than it was in 2025. There is a growing list of why that’s true, but here are a couple of developments that will make it harder for many of us to get the care we need:
- The December 31 expiration of the Affordable Care Act enhanced subsidies, which will lead to millions of Americans losing coverage and make premiums barely affordable for millions of others; and
- CMS’s January 1 implementation of a new pilot project that will put private, for-profit contractors using AI-powered prior authorization in traditional Medicare.
Unless policymakers change course, many Americans will be ringing in 2026 with higher costs, less access and a nasty health care hangover.
WISeR strikes at 12
As we’ve reported, the implementation of the Wasteful and Inappropriate Service Reduction (WISeR) model’s will mark the first time in traditional Medicare’s 60-year history that for-profit companies will decide whether seniors receive certain medical services their doctors recommend. Six companies — many with deep ties to Big Insurance and insurer-backed venture capital — will suddenly have the power to say yes or no to 17 procedures that never required prior authorization before. And for these companies, the more the denials, the bigger the profits.
As Dr. Seth Glickman documented after sitting through CMS’s own WISeR webinar, the rollout has been vague on details and confusing to providers and patients. CMS even admitted during the webinar that the vendors chosen to administer the model were selected in part based on their “success” of using prior authorization in the private Medicare Advantage program, which is notorious for denials, delays and life altering decisions.
Some lawmakers in Washington have taken notice. A coalition of Democrats introduced the Seniors Deserve SMARTER Care Act, warning that WISeR creates “a dangerous incentive to put profits ahead of patients’ health.” Imposing prior authorization in traditional Medicare “will kill seniors,” said Rep. Mark Pocan, one of the bill’s sponsors.
Kiss subsidies goodbye
While WISeR threatens seniors’ access to care, millions of working families are facing a different New Year’s surprise: the expiration of enhanced ACA marketplace subsidies, which Congress has (so far) failed to extend or replace. As Rachel Madley, PhD wrote in October, families will have to gamble when they pick a health insurance plan. She added:
The enhanced premium subsidies being debated in Congress right now are a lifeline for so many of us and must continue in the short term, but they don’t fix the underlying problem: Private insurers extract value rather than control costs or provide access to necessary and affordable care. Decades of experience show that when profits rule health insurance, families face financial ruin no matter which plan they pick during open enrollment.
But as we’ve noted before, this isn’t an existential crisis for Big Insurance. ACA marketplace plans are not where insurers make their real money. Their profits flow increasingly from taxpayer-funded programs like Medicare Advantage and Medicaid managed care — the same universe WISeR is quietly expanding.
One proposal to “solve” the subsidy issue, endorsed by President Donald Trump and HELP Chairman Bill Cassidy, would not extend the tax credits but put $1000 to $1500 into government-sponsored health savings accounts (HSAs). HSAs can be helpful if you you have crappy insurance – or are rich and need an additional place to put your money to avoid taxes – but not a meaningful solution to the millions of Americans facing a 75% hike in premiums or finding themselves priced out of coverage altogether in 2026. The supporters of this approach claim it would somehow take money away from health insurers, but it would just reroute federal dollars to those same companies. For instance, UnitedHealth Group, which owns the nation’s biggest HSA custodian, could grab even more of our tax dollars than they already do. Meanwhile, families would still be exposed to unaffordable premiums and massive out-of-pocket costs. Champagne dreams.
Thanks to these changes in health care: The hangover on January 1, 2026, won’t only be from the previous night’s festivities – and it won’t be cured with some water and Advil. Cheers.
HENRY KOTULA 