U.S. House Speaker Mike Johnson, R-La., talks with reporters during a press conference on Wednesday, Dec. 10, 2025. Also pictured are, from left, Republican Conference Chairwoman Lisa McClain of Michigan, Majority Whip Tom Emmer of Minnesota and Majority Leader Steve Scalise of Louisiana. (Photo by Jennifer Shutt/States Newsroom)

WASHINGTON — U.S. House Republicans released a health care bill Friday evening they hope will help curb rising costs, though the measure doesn’t have the level of Democratic support needed to get through the Senate. 

The 111-page bill will likely move to the House floor next week, where Speaker Mike Johnson will need nearly every one of his members to vote to pass the legislation, an uphill battle given the vastly different views among centrists and far-right members of the party on health care issues. 

The Louisiana Republican said in a statement the bill offers “clear, responsible alternatives that will lower premium costs and increase access and health care options for all Americans.”

Democrats have been pressing for a three-year extension of the enhanced tax credits for people who purchase their insurance through the Affordable Care Act marketplace. 

So far, House and Senate Republican leadership hasn’t gotten on board with any extension of those subsidies, arguing they have led to a sharp rise in the cost of health insurance. 

GOP lawmakers have instead pursued their own legislation, but without at least some backing from Democrats, no bill will make it through the Senate’s 60-vote procedural hurdles. 

Senate Republicans tried to advance a bill earlier this week from Louisiana Sen. Bill Cassidy and Idaho Sen. Mike Crapo but fell short of the votes needed. 

Democrats were also unsuccessful trying to move their bill to extend the ACA marketplace tax credits for three years. 

The House Republican bill, sponsored by Iowa Republican Mariannette Miller-Meeks, is unlikely to break the logjam in Congress over the rising cost of health insurance and health care, potentially leaving the issue as one the parties can debate leading up to next year’s midterm elections. 

Targeting ‘real drivers’ of cost increases

Johnson rebuked Democrats in his statement for enacting the Affordable Care Act during President Barack Obama’s first term, saying the law hasn’t made health care cost less. 

House Republicans’ new legislation, Johnson said, will address “the real drivers of health care costs to provide affordable care, increase access and choice, and restore integrity to our nation’s health care system for all Americans.”

The bill would require Pharmacy Benefit Managers “to provide employers with detailed data on prescription drug spending, rebates, spread pricing, and formulary decisions—empowering plans and workers with the transparency they deserve,” according to a summary in Johnson’s release. 

Starting in 2027, the legislation would appropriate funding for cost sharing reduction payments that the summary said would reduce health insurance premiums and stabilize the individual market. 

The House Rules Committee is scheduled to prepare the bill for floor debate on Tuesday by considering whether to allow any amendments to be considered on the floor. 

The full House will then debate the legislation later in the week before departing for the two-week holiday break. 

Trump wants direct payments

President Donald Trump, speaking from the Oval Office shortly after the bill was released, reiterated his preference that the federal government send payments directly to Americans.

“We want to give the money to the people and let the people buy their own great health care, and they’ll save a lot of money, and it’ll be great,” he said.

But Trump also appeared to signal he is going to stay out of negotiations in Congress, saying, “I leave it to them and hopefully they’re going to put great legislation on this desk right here.”

Sen. Bill Cassidy, R-La., answers questions from reporters after chairing a hearing of the Senate Health, Education, Labor and Pensions Committee on Sept. 17, 2025. (Photo by Jennifer Shutt/States Newsroom)

WASHINGTON — U.S. Senate Republicans announced Tuesday they will hold a vote on their own health care proposal later this week to counter a Democratic bill that would extend enhanced tax credits for Affordable Care Act marketplace plans for three more years.

The 32-page GOP bill would not address the expiring ACA marketplace tax credits but would send payments to certain Americans through Health Savings Accounts to cover some of the cost of health care. 

Neither measure has the 60 votes needed to advance under that chamber’s rules. That would leave the ACA marketplace subsidies to expire at the end of the year and dramatically spike the cost of health insurance for the millions of people enrolled in those plans. 

Senate Majority Leader John Thune, R-S.D., said Democrats’ bill to simply extend the enhanced ACA marketplace tax credits to offset the costs Americans pay for that insurance was unacceptable. 

“The way that the program is structured, the money goes straight to the insurance companies,” Thune said. “And the way that we think this ought to work is you ought to come up with a way in which you can deliver the benefit to the patients and not to the insurance companies.”

Thune said the Democratic bill lacks an income cap for ACA marketplace tax credits and allows $0 premiums for health insurance plans — guaranteeing the measure will fail.

Senate Democratic Leader Chuck Schumer, of New York, called the GOP proposal a “nonstarter” that would lead to “junk insurance.” He said the only way to avoid a dramatic increase in health insurance costs next year is to extend the enhanced ACA tax credits. 

“Their phony proposal is dead on arrival,” Schumer said. “The bill not only fails to extend the tax credits, it increases costs, adds tons of new abortion restrictions for women, expands junk fees and permanently funds cost-sharing reductions.”

Multiple plans

Senate Republicans have debated for weeks whether to hold a vote on a GOP plan to show the party has something to offer toward reducing health care costs. Thune promised Democrats a vote on a health care bill of their choosing in exchange for votes to end the government shutdown. 

Schumer announced last week that Democrats would hold the vote on a three-year extension of the enhanced ACA tax credits as they exist now. 

Several GOP senators, including Maine’s Susan Collins and Ohio’s Bernie Moreno, have released plans that would include an extension of the expiring tax credits while beginning to transition away from those subsidies. 

But Republican leaders ultimately decided to hold a vote on a proposal released earlier this week by Health, Education, Labor and Pensions Committee Chairman Bill Cassidy, R-La., and Finance Committee Chairman Mike Crapo, R-Idaho. 

The Cassidy-Crapo legislation would have the Department of Health and Human Services deposit money into Health Savings Accounts for people enrolled in bronze or catastrophic health insurance plans purchased on the ACA marketplace in 2026 or 2027, according to a summary of the bill. 

Health Savings Accounts are tax-advantaged savings accounts that consumers can use to pay for medical expenses that are not otherwise reimbursed. They are not health insurance products.

ACA marketplace enrollees who select a bronze or catastrophic plan and make up to 700% of the federal poverty level would receive $1,000 annually if they are between the ages of 18 and 49 and $1,500 per year if they are between the ages of 50 and 64. 

That would set a threshold of $109,550 in annual income for one person, or $225,050 for a family of four, according to the 2025 federal poverty guidelines. The numbers are somewhat higher for residents of Alaska and Hawaii.  

The funding could not go toward abortion access or gender transitions, according to the Republican bill summary. 

Proposal modeled on Trump comments

Cassidy and Crapo outlined how their proposal would work during afternoon floor speeches, where they also aired their grievances with how the Affordable Care Act has affected Americans’ health care costs. 

Crapo rebuked Democrats for establishing the enhanced ACA marketplace tax credits during the coronavirus pandemic and scheduling them to sunset at the end of this year. 

“The pattern has become clear: Democrats respond to rising premiums by throwing taxpayer dollars at the problem,” Crapo said. “Their supposedly short-term fixes only drive premiums higher and make the problem harder to solve. Leaving us with apparently no choice other than to do the same thing again and again and again.”

The GOP plan, he said, was modeled off President Donald Trump’s request to send funding directly to Americans to spend on their health care. 

“Families can use that money to cover costs not handled by their insurance policy without having to wait for insurance companies to approve their treatment decisions,” Crapo said. “Because families want the best value for their money, they will seek out the most appropriate treatment. Over time this will result in lower health care costs as providers compete for patients.”

Cassidy said the bill would not subsidize health insurance premiums but would help some Americans pay for doctor exams, dentist visits, glasses and prescriptions. 

Once eligible ACA marketplace enrollees receive that funding in their Health Savings Accounts, he said, they will shop around for better prices, including on x-rays, which are often used to determine if someone has broken a bone. 

“She’s going to say, ‘Wait a second, the x-ray is $150 here and $500 there. I’m going to where it’s cheaper, not more expensive,’” Cassidy said, giving an example. “And I can tell you when that begins to happen, the people who are more expensive begin to lower their price.”

U.S. Senate Minority Leader Chuck Schumer, D-N.Y., and House Minority Leader Hakeem Jeffries, D-N.Y., speak with reporters during a press conference in the U.S. Capitol building in Washington, D.C., on Wednesday, Dec. 3, 2025. (Photo by Jennifer Shutt/States Newsroom)

WASHINGTON — U.S. Senate Democratic Leader Chuck Schumer announced Thursday the chamber will vote next week to extend enhanced tax credits for three years for people who purchase their health insurance from the Affordable Care Act marketplace, though the plan seems unlikely to get the bipartisan support needed to advance. 

While it would typically be difficult for the minority leader to schedule a floor vote, Senate Majority Leader John Thune, R-S.D., agreed that Democrats could bring up a health care bill of their choosing in exchange for voting to end the government shutdown.

Schumer told reporters in recent days to “stay tuned” for details about the legislation while maintaining all Senate Democrats were united around the proposal. The three-year plan he previewed during his floor speech appears identical to one House Democratic leaders have been pressing for in that chamber. 

“Any Republican who claims to care about premium increases on January 1 has only one realistic path, and that’s to support our bill for a simple, clean, three-year extension,” Schumer said. “If Republicans block our bill, there’s no going back. We won’t get another chance to halt these premium spikes before they kick in at the start of the new year.” 

The vote will take place next Thursday, Schumer said. 

Clock ticking on solution

Health care costs have surged to the forefront of the national conversation in recent months, with both Democrats and Republicans in Congress pledging to find solutions. Both agree much more time is needed to make larger, structural changes. 

The Senate committee in charge of health care policy held a hearing Wednesday where senators began to coalesce around extending the enhanced tax credits beyond the end-of-December sunset date. But a bipartisan bill has not yet been introduced in that chamber on that subject. 

Health, Education, Labor and Pensions Chairman Bill Cassidy, R-La., said just after the hearing wrapped up there will likely be a GOP bill, or even a bipartisan one, to counter Schumer’s bill. 

“Yeah, absolutely,” Cassidy said. “I’d like to have a plan that both sides can vote for. But there will be a Republican plan if I have anything to do with it.”

Congress has an especially brief time frame to find a short-term resolution on the expiring tax credits, which would lead the cost of ACA marketplace plans to rise by hundreds or thousands of dollars. 

Open enrollment for ACA marketplace plans ends at different times throughout the country, with some states finishing on Dec. 15. Residents of other states are able to sign up through varying dates in January, but with their coverage starting later in the year. Lawmakers are set to leave Capitol Hill on Dec. 19 for their winter holiday break. 

A poll released Thursday by the nonpartisan health organization KFF showed nearly 60% of ACA marketplace enrollees could not cover the costs of a $300 annual increase in their premiums, while an additional 20% said they couldn’t afford a $1,000 jump in prices per year. 

Gottheimer, Kiggans unveil House bipartisan bill

At the same time Schumer was speaking on the Senate floor, a bipartisan group of House lawmakers, led by New Jersey Democratic Rep. Josh Gottheimer and Virginia Republican Rep. Jen Kiggans, introduced a bill they said could address some of the short-term issues facing ACA enrollees. 

“Although we may have different opinions over the long-term solutions for reforming marketplace health care or if there are even better and cheaper options for publicly available health insurance, we agree on the many aspects of the short-term solutions,” Kiggans said. 

The legislation — which needs to pass a floor vote, make it through the Senate and garner President Donald Trump’s signature — would extend the enhanced ACA marketplace tax credits with new income caps, “guardrails for waste, fraud and abuse” and an overhaul of the pharmacy benefit manager, or PBM, system, Kiggans said. 

The bipartisan group of representatives would then move on to the second part of their plan, not included in the bill, where they would try to make more structural changes to the entire country’s health care system. 

Those bills, Kiggans said, would address hospital billing transparency, implement Health Savings Accounts and advance the Give Kids a Chance Act “to accelerate pediatric cancer treatments and expand access to life-saving therapies for children battling rare diseases.”

Gottheimer said the group wants House leaders to put their bill up for a vote before members leave town for the two-week, end-of-year break. 

“In the last month, families have seen their health insurance premiums surge as they’ve shopped for insurance during open enrollment because enhanced premium tax credits are set to expire, as we all know, at the end of the year,” Gottheimer said. “In fact, because of this, for millions of families on the ACA, their health premiums will rise an average of 26% next year. 

“In Jersey, where we live, it could be even rougher with a 175% increase. That’s $20,000 for a family of four. And that’s why we’re all here together to try to solve this problem, do something about it, and avoid a massive new tax on hard-working families,” he said.

Senators don’t see future in bipartisan House bill

Schumer and other Senate Democrats didn’t appear to take the bipartisan House plan seriously when pressed about it during an early afternoon press conference, asking reporters in the room whether Speaker Mike Johnson, R-La., would actually put it on the floor for a vote. 

“As for whatever House proposals there are, we’ll always look at something, but I don’t even see 15 Republicans supporting it right now,” Schumer said. “Sure an individual or two or three people can say this or that. It’s not going to solve the problem.”

Schumer maintained Senate Democrats’ three-year extension, which does not come with income caps or other changes to the tax credits proposed by centrist Republicans, is the best path forward.

He appeared frustrated when reporters asked him why he didn’t include changes that could have swayed at least some GOP senators to vote for the bill. 

Schumer said it wasn’t worth it for Democrats to put together a bill that a few Republicans might support when he doesn’t expect Speaker Johnson to put the bill on the floor in that chamber given strong opposition to the enhanced tax credits by “half his caucus.”

“Come on,” he said. “The fault is there, not with us.”

Louisiana Republican U.S. Sen. Bill Cassidy talks with reporters in the Dirksen Senate office building on Wednesday, Dec. 3, 2025. (Photo by Jennifer Shutt/States Newsroom)

WASHINGTON — The U.S. Senate committee that oversees health care started coalescing around an approach to lower costs for Americans during a Wednesday hearing, though several hurdles lay ahead.

Republicans and Democrats on the panel appeared to accept that enhanced tax credits for people who purchase their health insurance from the Affordable Care Act marketplace should not expire at the end of the year. Just days are left for open enrollment and premiums are expected to greatly increase. 

The bipartisan momentum among a select group of senators will need to build significantly in the days ahead if an extension of the subsidies is going to speedily garner the 60 votes needed to advance in the Senate and then move through the GOP-controlled House. 

It will also need President Donald Trump’s signature to become law, and he has so far not signaled support for an extension.

“I’m hoping that we can find a bill that can get 60 votes, that can fix the problem with the exchanges for January 1, 2026,” Health, Education, Labor and Pensions Committee Chairman Bill Cassidy, R-La., said. “It shouldn’t be a Republican solution. It shouldn’t be a Democratic solution. It should be an American solution.”

Cassidy cautioned lawmakers on the panel from pressing for “grandiose ideas,” saying Congress must “have a solution for three weeks from now.”  

A ‘political problem’ seen for the GOP

But extending the ACA marketplace subsidies, possibly with tweaks, is just a short-term solution that senators on the committee agreed will need to be followed up with an overhaul of the American health care system. 

Any efforts on larger-scale legislation will bump up against the deeply entrenched politics of the Affordable Care Act, well-funded lobbyists and next year’s midterm elections, none of which will make the process easy. 

Vermont independent Sen. Bernie Sanders, the ranking member on the panel, said he appreciated Cassidy’s “sentiment about wanting to do something quickly,” but said Republicans should have focused on the expiring ACA tax credits earlier in the year, instead of leaving it until now.  

“The reason for this hearing, to be frank, is that my Republican friends understand they’ve got a political problem,” Sanders said. “Their political problem is that all over America today, people on the Affordable Care Act are opening up packages coming from the insurance companies, and guess what? Their premiums on average are doubling and in some cases in my state are tripling or quadrupling.”

Sanders said Congress should extend the enhanced ACA marketplace tax credits for another year, or two, or three, while lawmakers sort through larger, structural issues around health care costs. 

“Yes, the current system is broken. Yes, we need to create a new system,” Sanders said. “But unfortunately, we aren’t going to do it in two weeks.”

Sanders suggested the committee hold a series of hearings in the months ahead featuring leaders from other developed countries that provide health care to all of their residents.

Extensions of tax credits debated

Maine Republican Sen. Susan Collins said “there’s a limit to what we can do in this first year” and that lawmakers are “going to need a two-year plan.”

Collins indicated that she wants to see “reasonable” income caps to limit eligibility for ACA marketplace tax credits in any short-term extension that Congress may pass. 

Washington state Democratic Sen. Patty Murray said Republicans who are serious about addressing the spike in costs for ACA marketplace enrollees should work with Democrats to pass a “clean, one-year extension” of the enhanced subsidies. 

“And if their call for reforming tax credits is serious, we should look at that. We can talk about those reforms ahead of the 2027 year,” Murray said. “But I have to say, I’m not optimistic that most Republicans are serious about this because they refused to talk about this problem before right now, and I’ve been down this road before.”

Murray also rebuked Cassidy for not focusing the committee’s attention on the expiring tax credits earlier in the year by taking a swipe at his vote to confirm Health and Human Services Secretary Robert F. Kennedy Jr.

“This is about as serious as expressing concern about RFK Jr.’s anti-vax crusade after voting to make him the most powerful public health official in the country,” Murray said.

‘Reasonable caps’ backed

Alaska Republican Sen. Lisa Murkowski said members of the committee need to focus on what the next few months and years look like for Americans’ health care costs. 

“I think we’re going to need to have a short-term extension. But I think we can put reasonable caps on. I think that we can put some of the parameters that we have been talking about. There’s no great secret sauce here to how we’re going to deal with this particular dilemma that we’re in,” Murkowski said. “But we’ve got to be looking longer term to — how do we ultimately reduce these costs of care?”

Murkowski said she was also concerned about a decrease in funding for public health and prevention initiatives, before asking the witnesses appearing before the committee what their top recommendations would be for “prevention-type programs that have the strongest evidence for reducing long-term costs.”

Joel White, president of the Council for Affordable Health Coverage in Washington, D.C., said Congress should allow “premium discounts in the individual market for wellness programs,” which he said is currently illegal.

Marcie Strouse, owner and partner at Capitol Benefits Group in Des Moines, Iowa, suggested lawmakers open up health savings accounts “to allow for more holistic and preventive services.” She also said Congress could highlight “direct primary care and making sure people are actually getting the care that they need.”

Dr. Claudia M. Fegan, national coordinator at Physicians for a National Health Program in Chicago, suggested enhanced primary care and screening people for diseases like cancer that can be easier to treat when caught early. 

Wisconsin Democratic Sen. Tammy Baldwin said the hearing clearly demonstrated that there is “underlying agreement that this system needs a lot of reform.”

But, she said, Congress needs to take a look at the entire health care system, not just the Affordable Care Act. 

“I want to make a point that just under 50% of Americans get their health insurance through employers or group insurance, 20% are on Medicaid, 15% on Medicare, 1% on TRICARE or VA, and just over 6% are in this market,” Baldwin said. “There are problems with this market. But I have to say that abandoning the ACA … is not going to solve the system as a whole.”

Ohio Republican Sen. Jon Husted appeared supportive of a short-term extension of the enhanced ACA tax credits to provide Congress more time to address larger issues with health care affordability.

“We can freeze the subsidies where they’re at right now for a temporary period of time. I don’t know if that’s one year or two years to help give some relief,” he said. “And by the way, just because we continue those tax credits does not drive down the cost. It transfers the burden to the taxpayer and future generations. But it is a little help right now that we both can agree on. And then we’ve got to fix it.” 

Husted said there are easily a dozen bills that Congress could take up individually to start bringing down health care costs. 

Hawley offers plan for health costs tax exemption

Missouri Republican Sen. Josh Hawley also appeared to side with extending the enhanced ACA marketplace tax credits in the short term.

“We are looking at a massive crisis unless Congress acts and acts soon,” Hawley said. “And my message is to the leadership of this body — to the leaders of the House, the leaders of the Senate —maybe it’s time we all locked ourselves in a room and got to a solution here.”

Halwey pitched a bill he just introduced to exempt health care from taxes. 

“If you pay premiums, you ought to be able to deduct that from your taxes. If you have out-of-pocket medical expenses, you ought to be able to deduct every dollar off of your taxes. You want to lower the cost of health care immediately. Do that. No taxes on health care for any American,” Hawley said. “And you set an upper limit so you don’t have rich people gaming the system. I get it. That’s fine. But let’s think about working people in this country who cannot afford health care.”

Hawley said it should be allowed whether an American itemizes on their taxes or not. 

All three panelists seemed initially supportive of the idea. 

Redoing tax credits in 2026

Cassidy said after the two-hour hearing he’s working to get support from lawmakers in both political parties for an integrated approach for next year.

“You could use the income that would be used to extend the subsidies, apply them to the bronze plan, because the bronze plan is so much less expensive. You could then put that balance into the health savings account,” Cassidy said, referring to coverage levels in plans on the ACA marketplace. “So it does continue the support using the existing mechanisms we have, but integrates the HSA, which gives first dollar coverage and could potentially lower the net deductible.”

Cassidy said Congress could extend the open enrollment period for the ACA marketplace and then fund the Health Savings Accounts, which are tax-advantaged savings accounts, before the end of March. 

“People would save their receipts and submit them for payment,” he said. “People do that all the time.”

As states continue to curb health insurers’ use of artificial intelligence, patients and doctors are arming themselves with AI tools to fight claims denials, prior authorizations and soaring medical bills. (Photo by Anna Claire Vollers/Stateline)

As states strive to curb health insurers’ use of artificial intelligence, patients and doctors are arming themselves with AI tools to fight claims denials, prior authorizations and soaring medical bills.

Several businesses and nonprofits have launched AI-powered tools to help patients get their insurance claims paid and navigate byzantine medical bills, creating a robotic tug-of-war over who gets care and who foots the bill for it.

Sheer Health, a three-year-old company that helps patients and providers navigate health insurance and billing, now has an app that allows consumers to connect their health insurance account, upload medical bills and claims, and ask questions about deductibles, copays and covered benefits.

“You would think there would be some sort of technology that could explain in real English why I’m getting a bill for $1,500,” said cofounder Jeff Witten. The program uses both AI and humans to provide the answers for free, he said. Patients who want extra support in challenging a denied claim or dealing with out-of-network reimbursements can pay Sheer Health to handle those for them.

In North Carolina, the nonprofit Counterforce Health designed an AI assistant to help patients appeal their denied health insurance claims and fight large medical bills. The free service uses AI models to analyze a patient’s denial letter, then look through the patient’s policy and outside medical research to draft a customized appeal letter.

Other consumer-focused services use AI to catch billing errors or parse medical jargon. Some patients are even turning to AI chatbots like Grok for help.

A quarter of adults under age 30 said they used an AI chatbot at least once a month for health information or advice, according to a poll the health care research nonprofit KFF published in August 2024. But most adults said they were not confident that the health information is accurate.

State legislators on both sides of the aisle, meanwhile, are scrambling to keep pace, passing new regulations that govern how insurers, physicians and others use AI in health care. Already this year, more than a dozen states have passed laws regulating AI in health care, according to Manatt, a consulting firm.

“It doesn’t feel like a satisfying outcome to just have two robots argue back and forth over whether a patient should access a particular type of care,” said Carmel Shachar, assistant clinical professor of law and the faculty director of the Health Law and Policy Clinic at Harvard Law School.

“We don’t want to get on an AI-enabled treadmill that just speeds up.”

A black box

Health care can feel like a black box. If your doctor says you need surgery, for example, the cost depends on a dizzying number of factors, including your health insurance provider, your specific health plan, its copayment requirements, your deductible, where you live, the facility where the surgery will be performed, whether that facility and your doctor are in-network and your specific diagnosis.

Some insurers may require prior authorization before a surgery is approved. That can entail extensive medical documentation. After a surgery, the resulting bill can be difficult to parse.

Witten, of Sheer Health, said his company has seen thousands of instances of patients whose doctors recommend a certain procedure, like surgery, and then a few days before the surgery the patient learns insurance didn’t approve it.

In recent years, as more health insurance companies have turned to AI to automate claims processing and prior authorizations, the share of denied claims has risen. This year, 41% of physicians and other providers said their claims are denied more than 10% of the time, up from 30% of providers who said that three years ago, according to a September report from credit reporting company Experian.

Insurers on Affordable Care Act marketplaces denied nearly 1 in 5 in-network claims in 2023, up from 17% in 2021, and more than a third of out-of-network claims, according to the most recently available data from KFF.

Insurance giant UnitedHealth Group has come under fire in the media and from federal lawmakers for using algorithms to systematically deny care to seniors, while Humana and other insurers face lawsuits and regulatory investigations that allege they’ve used sophisticated algorithms to block or deny coverage for medical procedures.

Insurers say AI tools can improve efficiency and reduce costs by automating tasks that can involve analyzing vast amounts of data. And companies say they’re monitoring their AI to identify potential problems. A UnitedHealth representative pointed Stateline to the company’s AI Review Board, a team of clinicians, scientists and other experts that reviews its AI models for accuracy and fairness.

“Health plans are committed to responsibly using artificial intelligence to create a more seamless, real-time customer experience and to make claims management faster and more effective for patients and providers,” a spokesperson for America’s Health Insurance Plans, the national trade group representing health insurers, told Stateline.

But states are stepping up oversight.

Arizona, Maryland, Nebraska and Texas, for example, have banned insurance companies from using AI as the sole decisionmaker in prior authorization or medical necessity denials.

Dr. Arvind Venkat is an emergency room physician in the Pittsburgh area. He’s also a Democratic Pennsylvania state representative and the lead sponsor of a bipartisan bill to regulate the use of AI in health care.

He’s seen new technologies reshape health care during his 25 years in medicine, but AI feels wholly different, he said. It’s an “active player” in people’s care in a way that other technologies haven’t been.

“If we’re able to harness this technology to improve the delivery and efficiency of clinical care, that is a huge win,” said Venkat. But he’s worried about AI use without guardrails.

His legislation would force insurers and health care providers in Pennsylvania to be more transparent about how they use AI; require a human to make the final decision any time AI is used; and mandate that they show evidence of minimizing bias in their use of AI.

“In health care, where it’s so personal and the stakes are so high, we need to make sure we’re mandating in every patient’s case that we’re applying artificial intelligence in a way that looks at the individual patient,” Venkat said.

Patient supervision

Historically, consumers rarely challenge denied claims: A KFF analysis found fewer than 1% of health coverage denials are appealed. And even when they are, patients lose more than half of those appeals.

New consumer-focused AI tools could shift that dynamic by making appeals easier to file and the process easier to understand. But there are limits; without human oversight, experts say, the AI is vulnerable to mistakes.

“It can be difficult for a layperson to understand when AI is doing good work and when it is hallucinating or giving something that isn’t quite accurate,” said Shachar, of Harvard Law School.

For example, an AI tool might draft an appeals letter that a patient thinks looks impressive. But because most patients aren’t medical experts, they may not recognize if the AI misstates medical information, derailing an appeal, she said.

“The challenge is, if the patient is the one driving the process, are they going to be able to properly supervise the AI?” she said.

Earlier this year, Mathew Evins learned just 48 hours before his scheduled back surgery that his insurer wouldn’t cover it. Evins, a 68-year-old public relations executive who lives in Florida, worked with his physician to appeal, but got nowhere. He used an AI chatbot to draft a letter to his insurer, but that failed, too.

On his son’s recommendation, Evins turned to Sheer Health. He said Sheer identified a coding error in his medical records and handled communications with his insurer. The surgery was approved about three weeks later.

“It’s unfortunate that the public health system is so broken that it needs a third party to intervene on the patient’s behalf,” Evins told Stateline. But he’s grateful the technology made it possible to get life-changing surgery.

“AI in and of itself isn’t an answer,” he said. “AI, when used by a professional that understands the issues and ramifications of a particular problem, that’s a different story. Then you’ve got an effective tool.”

Most experts and lawmakers agree a human is needed to keep the robots in check.

AI has made it possible for insurance companies to rapidly assess cases and make decisions about whether to authorize surgeries or cover certain medical care. But that ability to make lightning-fast determinations should be tempered with a human, Venkat said.

“It’s why we need government regulation and why we need to make sure we mandate an individualized assessment with a human decisionmaker.”

Witten said there are situations in which AI works well, such as when it sifts through an insurance policy — which is essentially a contract between the company and the consumer — and connects the dots between the policy’s coverage and a corresponding insurance claim.

But, he said, “there are complicated cases out there AI just can’t resolve.” That’s when a human is needed to review.

“I think there’s a huge opportunity for AI to improve the patient experience and overall provider experience,” Witten said. “Where I worry is when you have insurance companies or other players using AI to completely replace customer support and human interaction.”

Furthermore, a growing body of research has found AI can reinforce bias that’s found elsewhere in medicine, discriminating against women, ethnic and racial minorities, and those with public insurance.

“The conclusions from artificial intelligence can reinforce discriminatory patterns and violate privacy in ways that we have already legislated against,” Venkat said.

Stateline reporter Anna Claire Vollers can be reached at avollers@stateline.org.