Providing for Congressional Disapproval Under Chapter 8 of Title United States Code, of the Rule Submitted By the Centers for Medicare Medicaid Services of the Department of Health and Human Services Relating to ``Medicare Program; Implementation of Prior Authorization for Select Services for the Wasteful and Inappropriate Services

Floor Speech

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Mr. WYDEN. 447, S.J. Res. 198.
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Mr. WYDEN. Mr. President, colleagues, at the beginning of this year, the Trump administration empowered unaccountable AI companies to delay and deny certain types of care in traditional Medicare.

Now, Donald Trump promised--promised--that he would not touch Medicare, and, today, it is clear that that Trump promise has been broken.

Seniors paid into Medicare out of every paycheck during their working years, and they did so with an expectation they would have an ironclad guarantee of affordable healthcare.

Today, seniors in six States across America are discovering that care their doctor has recommended for them has been slowed or halted by a shadowy AI-driven third party.

The consequences are not abstract. Seniors with severe back pain have to wait weeks for relief, upending their lives and leaving them suffering because of the bureaucracy of healthcare.

The types of care that are subject to these restrictions are not frivolous: knee arthroscopies, nerve stimulations, steroid injections, cervical fusion. These types of procedures are the care that seniors rely on to stay mobile and pain-free in the aging process.

Now, decisions between doctors and patients are overridden by for- profit AI contractors. The Trump administration's only defense of this model has been to point to the rapid rise of skin substitute procedures to justify their flawed experiment.

The Trump administration's work doesn't pass the smell test. First, the Centers for Medicare and Medicaid Services already have now lowered payment rates for this procedure; in doing so, closed the loophole driving the dramatic increase.

(Mrs. CAPITO assumed the Chair.)

Second, the skin substitute procedures only account for a tiny fraction of care under the model. In the case of Oregon's neighbor to the north, Washington State, skin substitutes account for less than 1 percent of services--less than 1 percent of the services, Madam Chair-- subject to the prior authorization under this model. So the excuses hold no water.

Prior authorization has run rampant in the American healthcare system. For-profit insurance companies are increasingly using this business tactic to block and deter care in order to increase their profits.

I want to put a fine point on this. In 2024, insurance companies that sell Medicare Advantage plans denied more than 4 million prior authorization requests--just think about that: 4 million prior authorization requests. Of those denials, only 1 in 10 were appealed by a senior or their doctor. But when the denial was appealed, it was overturned 8 times out of 10. What this tells me is that prior authorization is being used to deny legitimate care, often acting as a bureaucratic hurdle meant to discourage seniors and their doctors from pursuing a course of treatment that might impact insurance company's bottom line.

It is bad enough that this is the state of affairs in Medicare Advantage, but now the Trump administration is trying to import insurance company tactics into traditional Medicare. And that would mean that seniors who selected it precisely because they don't want to deal with the headaches and complexity of an insurance company would suffer.

This is not a partisan issue. Many of my Republican colleagues have expressed concern about prior authorizations and the state of Medicare Advantage. I hope that they will stand with those of us today who want to tell the Trump administration to abandon an ill-advised experiment that seniors don't want. They didn't ask for it. It doesn't make sense.

There is a lot of work to be done to improve both traditional Medicare and Medicare Advantage for seniors that count on the Medicare guarantee.

And I have been working on that Medicare guarantee since the days when I was a codirector of the Oregon Gray Panthers. Let's work on that together, and we can start by ending this AI-driven prior authorization experiment. It is a mistake. We can't run the risk of it being sent to other parts of the healthcare system. I urge a ``yes'' vote.

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Mr. WYDEN. Madam President, we don't take a back seat to anybody in terms of fighting inefficiency, fighting fraud. We have been working on those issues, as the chair of the Finance Committee knows, together wherever possible.

Unfortunately, what we have seen in this experiment is that we are not dealing with inefficiency and fraud. We are forcing patients to come back again and again and again. That just defies common sense.

And on the issues like skin substitutes, that has been addressed through a payment process, payment policy reform, to get at the incentives and wasteful utilization.

So on the points that the minority is making, the reality is patients are not going to get care, and we are not going to make sensible changes as we have in other areas to deal with fraud and inefficiency.

That is why we ought to be voting for what we are trying to do today on the Democratic side.

I yield back and hope we will have a bipartisan vote.

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Mr. WYDEN. Fortunately, for--let me say to Senator Murray that I so appreciate your presentation, and particularly talking about the algorithms. And, also, the fact is that under what you have described very clearly, the big winner under this flawed experiment is a bunch of middlemen who are trying to profit off denials, and not the people who really desperately need care.

So I very much appreciate it, and Oregon is proud to be a partner with Washington State in leading the country to get rid of this very flawed idea. And I thank you for your remarks.
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Mr. WYDEN. Madam President, I would ask consent to start the 1:30 vote now.

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