Health Insurers Under the Gun at House Hearing

 UnitedHealth Group is the "poster child for Medicare Advantage abuse," and the plan's practice of delaying or denying claims "looks like a business model" to increase profits, Rep. Kim Schrier, MD (D-Wash.), said Thursday at a House hearing on lowering healthcare costs.

Schrier began her comments by giving the example of a constituent who was hospitalized after suffering a stroke. "This patient had a UnitedHealth Medicare Advantage plan, and UnitedHealth refused to pay for that hospitalization because United decided that it was medically unnecessary, overriding the doctor's own medical decision," she said. "And so now we've got this senior who's in the hospital and can't go home, and is stuck with a huge bill."

"That is just unconscionable, and it is shameful that you're doing this to people on Medicare Advantage," she added, addressing UnitedHealth Group CEO Stephen Hemsley, one of the witnesses at the hearing, before noting that United eventually paid the claim more than a year later.

"This is why so many people hate their insurance companies, they pay a lot of money, they expect peace of mind, and then the insurance company leaves them high and dry," Schrier pointed out. "A lot of you run Medicare Advantage plans, but UnitedHealth is the poster child for Medicare Advantage abuse."

She asked Hemsley why United initially declined to pay the patient's bill. "I'm not familiar ... I'm very sympathetic to the situation that you described," Hemsley said. "They should get all the care that's appropriate for them."

Schrier was far from the only member of the House Energy & Commerce Health Subcommittee who verbally attacked Hemsley. Rep. Nanette Barragán (D-Calif.) mentioned a California family who ended up declaring bankruptcy after United's refusal to pay for treatment for their daughter's bladder tumor left them with $1 million in medical debt.

"We've seen that less than 1% of claims are appealed, but when they are, insurance reversed their decision 44% of the time," she said. "Why do your patients have to fight your company to get their claims covered?"

"I appreciate the subject," Hemsley said. "They shouldn't have to fight; we should make this much easier."

Barragán was not satisfied with that answer. "The way you're talking about this is not sympathetic. It's not compassionate," she said. "These are people's lives ... I hope that you all are going to do better."

For their part, the insurers on the witness panel had similar explanations for why health insurance costs are so high. "What's driving these costs is understood: greater demand for care, growing medical provider costs, and persistently high prices for hospital care and prescription drugs," said David Joyner, chairman and CEO of CVS Health. "Every day we are addressing the fragmentation and the underlying cost of care. It starts by making care for Americans accessible and affordable, and most importantly, simplifying the patient experience at every point." (In addition to pharmacies, CVS also owns the Aetna health insurance company, as well as CVS Caremark, a pharmacy benefit manager.)

"There's too many times when the participants in the healthcare system, health plans, hospitals, physicians, pharmaceutical companies, and others put profits ahead of patients and are complacent about how complex, inconvenient, and inefficient our current system is," said Paul Markovich, president and CEO of Ascendiun, the nonprofit parent company of California Blue Shield.

He had four suggestions for improving the system. "First, ensure every American has access to a comprehensive, real-time digital health record," Markovich said. "It can be used to personalize their healthcare [and takes] a lot of administrative costs out of the system. Second, break the 'do more, get paid more' fee-for-service model, and instead start paying for outcomes. Third, make prescription drugs accessible and affordable by eliminating kickbacks in the form of rebates, fees, and spread pricing. Finally, we need to put the entire healthcare system on a budget."

Rep. Buddy Carter (R-Ga.) focused on the insurance executives' high salaries, noting that Joyner and one of his C-suite colleagues were paid $41 million in 2024. "This is enough to cover the premiums for thousands of American families," Carter said. "How do you justify getting paid that much when so many of your patients struggle to afford skyrocketing premiums?"

"That was not my compensation -- my compensation was $17 million, of which $1.1 million was my base salary and the rest was long-term incentives and a bonus," Joyner said. "I think it's important to know ... I did return my bonus back to the Employee Relief Fund so the employees that were going through challenging, difficult times had the benefit of my bonus."

Rep. Marc Veasey (D-Texas) discussed the insurers' vaccine coverage in the wake of changes made by Health Secretary Robert F. Kennedy Jr. to the CDC's childhood immunization schedule. He asked each insurance company witness, "As a CEO, do you commit to covering [previously recommended] vaccines prior to Secretary Kennedy's reckless changes for plan year 2026?"

All five insurers -- CVS/Aetna, Cigna, UnitedHealth Group, Elevance Health, and California Blue Shield -- said that they would, although Hemsley said that at United, "we allow the consumer to make a choice as to how they want to proceed. So we provide comprehensive coverage, and then it is between the doctor [and the patient]" as to which ones will be given.

Gail Boudreaux, president and CEO of Elevance Health, said her company covers vaccines as required by law but also looks at recommendations from the CDC's Advisory Committee on Immunization Practices and the medical societies to make its decision.

Veasey seemed happy with the responses. "Let me just say thank you," he said. "I really appreciate that you're following the science behind all of this, and I'm glad that we can agree that children's lives are more important than politics."

The Affordable Care Act (ACA) also came up at several points during the hearing, with Republicans arguing that the ACA had increased healthcare costs, while Democrats praised it for reducing the number of uninsured patients and urged the Senate to approve a House-passed measure to extend the ACA's expanded premium tax credits.

Rep. Michael Rulli (R-Ohio) floated the idea of allowing patients to buy health insurance across state lines, which is currently illegal. "In my opinion, that could bring down the cost," he said.

https://www.medpagetoday.com/publichealthpolicy/washington-watch/119546