PNHP

Consensus Statement on Expanding Prior Authorization in Traditional Medicare

Consensus Statement on Expanding Prior Authorization in Traditional Medicare

Aug. 5, 2025

We, the undersigned organizations and individuals, issue the following consensus statement regarding the Wasteful and Inappropriate Services Reduction (WISeR) model recently proposed by the Center for Medicare and Medicaid Innovation to begin January 1, 2026.

Background

The WISeR model proposes to implement prior authorization for at least 17 additional services in traditional Medicare (TM) in six states. The model will solicit applications from private companies that currently administer prior authorizations for private health insurers, including Medicare Advantage (MA) plans. The model will run for 6 years.

Shared Perspective

As former government officials, providers, policy experts, researchers, and patients, we are concerned about the design of the model and recommend it not be initiated. Our specific concerns are outlined below.

1. Participant payment model: The WISeR model proposes to compensate the private companies participating “based on a share of averted expenditures.” This payment structure immediately creates an incentive for companies to avert more expenditures by denying more prior authorization requests in order to increase their compensation. Evidence from government agencies and experts across the political spectrum has demonstrated that MA prior authorization, which also results in additional retained revenue when care is denied, very often improperly denies care. (1,2) A participant payment model that mirrors the current incentives in MA is likely to fall victim to the same misaligned incentives and lead to delays and denials of needed care.

2. Participant selection: The model intends to allow participants who are currently administering prior authorization processes for private payers, including MA companies. Currently, the Medicare Administrative Contractors (MACs) that administer prior authorizations in TM have an accuracy rate of over 98%. (3) Further, MAC prior authorization decisions are overturned less than half as frequently (roughly 35%) as decisions made by private companies administering MA prior authorization with an 81.7% overturn rate. (4) Thus, the participants desired for the WISeR model have demonstrated inferior performance in making accurate prior authorization decisions, which have resulted in serious harm and death to patients. (5) These same bad actors should not be given the ability to make these decisions in TM.

3. Prior authorization protocols: The lack of transparency in MA prior authorization makes it impossible to justify expanding these processes into TM, based on evidence of their accuracy or benefit to patients and providers. MA insurers do not report prior authorization decisions based on type of service, contract, or reason for denial. Additionally, the protocols used to review prior authorizations in MA are not disclosed to patients, providers, or policymakers. Given that prior authorization in MA is a black box with documented adverse effects on patients and moral injury to providers, expanding the process without a full public audit of how it is currently conducted with recommendations for improvement is risky. (6)

4. Use of enhanced technology: The model references the use of enhanced technologies for prior authorization review. However, these technologies, particularly the use of artificial intelligence (AI) systems, have been associated with significantly higher rates of care denials. For instance, internal documents from MA insurers demonstrate that denials for post-acute care services rose sharply following the implementation of AI-driven review processes administered by naviHealth, a subsidiary of UnitedHealth Group. (7) Often these denials in MA are inappropriate as the Department of Health and Human Services Office of the Inspector General and whistleblowers have demonstrated. (8,9) This, combined with the lack of transparency into the methodologies behind the enhanced technologies used by private insurers (the intended model participants) could result in delays and denials of needed care for seniors and people with disabilities enrolled in TM.

Signed,

Center for Health and Democracy
Physicians for a National Health Program
Public Citizen
Center for Medicare Advocacy
Robert Berenson, MD, Former Commissioner of the Medicare Payment Advisory Commission
Donald Berwick, MD, Former Administrator, CMS
Andrea Ducas, MPH, Vice President for Health Policy, Center for American Progress
Clifton Gaus, ScD, Former Administrator of Agency for Health Care Policy and Research (now AHQR)
Richard Gilfillan, MD, Former Director, Center for Medicare and Medicaid Innovation
Ed Weisbart, MD, National Board Secretary, Physicians for a National Health Program
Bruce C. Vladeck, Administrator, Health Care Financing Administration, 1993-1997, Board Chair Emeritus, Medicare Rights Center
Judy Feder, Professor and former Dean, McCourt School of Public Policy, Georgetown University

This statement was sent to the U.S. Department of Health and Human Services, the Centers for Medicare and Medicaid Services, and the Congressional staff members on Aug. 5, 2025.

References

  1. U.S. Department of Health and Human Services, Office of Inspector General, Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care, report no. OEI-09-18-00260, April 2022, https://oig.hhs.gov/reports/all/2022/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/.
  2. Jeannie Fuglesten Biniek, Nolan Sroczynski, Meredith Freed, and Tricia Neuman, “Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Determinations in 2023,” KFF (January 28, 2025), https://www.kff.org/medicare/issue-brief/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/.
  3. U.S. Centers for Medicare & Medicaid Services, Prior Authorization and Pre‑Claim Review Program Statistics for Fiscal Year 2023, January 17, 2025, https://www.cms.gov/files/document/pre-claim-review-program-statistics-document-fy-23.pdf
  4. Jeannie Fuglesten Biniek, Nolan Sroczynski, Meredith Freed, and Tricia Neuman, “Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Determinations in 2023,” KFF (January 28, 2025), https://www.kff.org/medicare/issue-brief/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/.
  5. Jennifer Lubell, When Prior Authorization Blocks Lifesaving Treatments, American Medical Association (April 7, 2025), https://www.ama-assn.org/practice-management/prior-authorization/when-prior-authorization-blocks-lifesaving-treatments.
  6. U.S. American Medical Association, 2024 AMA Prior Authorization (PA) Physician Survey (American Medical Association, 2024), https://www.ama-assn.org/system/files/prior-authorization-survey.pdf
  7. U.S. Senate Permanent Subcommittee on Investigations, Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post‑Acute Care, Majority Staff Report (October 17, 2024), https://www.hsgac.senate.gov/wp-content/uploads/2024.10.17-PSI-Majority-Staff-Report-on-Medicare-Advantage.pdf
  8. U.S. Department of Health and Human Services, Office of Inspector General, Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care, OEI‑09‑18‑00260 (April 2022), https://oig.hhs.gov/reports/all/2022/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/.
  9.  Casey Ross and Bob Herman, “UnitedHealth Pushed Employees to Follow an Algorithm to Cut Off Medicare Patients’ Rehab Care,” STAT (November 14, 2023), https://www.statnews.com/2023/11/14/unitedhealth-algorithm-medicare-advantage-investigation/.

Medicare and Medicaid at 60

The contribution of Medicare and Medicaid to American life cannot be overstated. Almost one in four Americans is on Medicaid, including over 40% of children.

By Walter Tsou, M.D., M.P.H.
The Philadelphia Inquirer, July 30, 2025

Sixty years ago today, President Lyndon Johnson signed into law the two most consequential health programs in U.S. history — Medicare and Medicaid. Both Medicare (Title 18) and Medicaid (Title 19) were added to the Social Security Act with benefits directed at seniors.

For seniors no longer in the workforce and those who were chronically disabled, Medicare, along with Social Security, were the programs that allowed the elderly not to fall into abject poverty at a time when their health worsened.

Medicaid was created from the federal-state partnership of the 1960 Kerr Mills Act, but Congress expanded the age limits of eligible low-income populations to include families with children, people with disabilities, and the blind.

Wilbur Cohen, undersecretary of the Department of Health, Education and Welfare under Johnson, is considered the father of these two essential programs. Cohen envisioned a national health insurance program for America, but, given the power of the medical and insurance lobby, had to settle for Medicare for seniors and Medicaid for low-income citizens. He likened the final legislation to the salami approach, where he would accept one slice at a time until he could get the whole salami.

Sixty years later, we are still waiting.

The contribution of Medicare and Medicaid to American life cannot be overstated. Today, all seniors with 40 quarters of Medicare taxes paid, those with chronic disabilities, ALS, and patients on dialysis, are covered by Medicare. We only need to imagine if coverage had not been expanded, what a difference it would make to family finances, work productivity, or premature mortality.

Almost one in four Americans is on Medicaid, including over 40% of children. The proposed work requirements and new paperwork verifications needed to retain Medicaid —thanks to the recently enacted “big, beautiful bill” — will make our current bureaucratic and dysfunctional approach to healthcare financing even worse — actually far worse.

In Arkansas, a work requirement cost the state $26 million without any increase in employment or volunteer time. Even worse, more than 18,000 lost health insurance coverage. Now multiply the new unfunded mandate on each state government that must verify this new onerous paperwork requirement, and add the millions who are predicted to lose their health insurance, and you realize that we are moving dramatically away from the original intent of Medicare or Medicaid.

Despite the belief that markets are more efficient, in healthcare, it makes it much more cumbersome and dysfunctional.

In 1948, the Universal Declaration of Human Rights was adopted by the U.N., including the United States. Article 25 states that “everyone has the right to a standard of living adequate for the health and well-being of himself and of his family.” Two points should be emphasized. Everyone means that if you can breathe, regardless of your position in life, a society has a basic level of care that is provided to you. Second, universal health insurance or access to care is essential for health.

Beyond the recognition that healthcare is a human right, it is a necessity for a productive society. Our taxes are dependent on people well enough to work, play, and worship. Keeping people insured keeps them well. Keeping them well keeps our society productive.

We have unfortunately believed that market forces can solve all that is wrong in healthcare. Some think we can solve our labor shortages by forcing the few “able-bodied” to be required to work or by denying emergency care to immigrants.

Meanwhile, we ignore the real “waste, fraud and abuse” in the system by the tens of billions overcharged by Medicare Advantage plans or the private equity schemes that bankrupted Crozer Chester and Taylor hospitals or Hahnemann.

The “big, beautiful bill” was supposed to cover only the original intent of the Medicare and Medicaid program. Instead, it will destroy the fragile infrastructure of healthcare.

Maybe we need a new guiding principle on this anniversary: Healthcare is a public good, not a market commodity, and we should finally get that big salami.

Dr. Walter Tsou is a former health commissioner of Philadelphia and a national board adviser to Physicians for a National Health Program.

https://www.inquirer.com…

Looming ACA Premium Hikes … A Political Hot Potato

Enhanced tax credits for ACA exchange plans will expire this year, leaving 20 million people facing premium hikes of 75% ($1000). The GOP, which delayed their Medicaid cuts to try to avoid voter backlash, has a new problem not of their making. What will they do?

Individual market insurers requesting largest premium increases in more than 5 years, Peterson-KFF Health System Tracker, July 18, 2025, by Jared Ortaliza, et al.

… The costs of health care services like hospitalizations and physician care, as well as prescription drug costs tend to go up every year, and insurers often raise premiums to cover their increased costs. For 2026, insurers commonly say the underlying cost of health care (medical trend) is similar to last year’s reported 8%. …

Another change expected for next year is the enhanced [ACA] tax credits are set to expire. … For the last five years, enhanced premium tax credits have increased the amount of financial assistance enrollees in ACA Marketplace coverage receive, lowering their monthly premium payments. If Congress takes no action to renew these enhanced tax credits, enhanced subsidies will expire at the end of 2025, which will cause premium payments for subsidized enrollees to increase by over 75% starting in January 2026. Insurers expect a large share of enrollees to leave the market, and that those enrollees will be healthier on average, thus leaving the risk pool sicker on average.

Inflation Reduction Act Health Insurance Subsidies: What is Their Impact and What Would Happen if They Expire?, KFF, July 26, 2024, by Jared Ortaliza, et al.

Memo advises GOP to extend ACA tax credits, The Hill, July 22, 2025, by Alejandra O’Connell-Domenech, et al.

A new memo from Plymouth Union Public Research … advises Republicans that the best way to fend off attacks from the left about Medicaid cuts is to extend ObamaCare’s enhanced premium tax credits. …

The memo notes that all benefits [to taxpayers] from tax cuts will be nullified because of premium increases if the subsidies are not extended.

PUP Research is the sister group to PUP Advocacy, a conservative advocacy organization.

Extra subsidies that help people afford ObamaCare premiums that were put in place during the coronavirus pandemic are set to expire at the end of the year, and there are few signs Republicans are interested in tackling the issue at all.

If Congress takes no action, premiums for subsidized enrollees are projected to increase by more than 75 percent starting in January 2026, according to health research group KFF.

There is broad bipartisan and public support for extending the subsidies, and the memo cited recent polling from Trump pollster Fabrizio Ward that showed Republicans losing support in the most competitive districts if the tax credits expire.

But if Republicans extend them, the poll showed they can gain an advantage against Democrats in the midterms. The Republican candidate that supports extending the tax credits would lead the Democrat on the generic ballot by 6 points overall.

Comment:

By Jim Kahn, M.D., M.P.H.

The recently passed federal budget bill imposes massive cuts to Medicaid and Medicare, close to $1.5 trillion. The Medicaid cuts, mainly in eligibility criteria, start only after the Congressional mid-terms, shielding Republicans from voter backlash. The Medicare cuts arise from budget shortfalls caused by the massive tax cuts (tilted to the rich, of course).

Also happening through inaction is the expiration of COVID-era strengthening of ACA exchange plan subsidies (premium tax credits). As shown in the figure below, ACA enrollment rose sharply from 2020 to 2024, reaching 20 million subsidized individuals. The credits are set to expire in 2025. This will leave tens of millions of people in the lurch: experiencing a massive increase in costs – 75% higher premiums, about $1000, according to KFF analyses above. This will happen before the 2026 midterms, and be blamed on the GOP, likely exacting a significant toll at the ballot box

Republican strategists have noticed – as reported by The Hill, above. So of course they are encouraging a (short) extension of the subsidies. Which would place the Democrats in a political pickle – support the right policy, even if may hurt you in the next election.

No political party wants the hot potato of cutting insurance benefits, so they try to avoid credit (actually, blame). Wouldn’t it be spectacular if we were all covered, with the same cradle-to-grave universal health plan? Generous and efficient. Fairly funded. Single payer.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Medical funding should be a social good

By Henry Kahn, M.D.
The Atlanta Journal-Constitution, Letters, July 28, 2025

As explained by Mike King in his AJC Opinion piece, “Why a beloved hospital failed – and why it doesn’t have to be this way,” July 20, the Atlanta Medical Center came to its end because it couldn’t survive in our country’s environment of profit-oriented medical care.

King is correct. The United States stands out among all wealthy societies as the only place where health and medical care are supposed to exist as businesses. In other wealthy countries, it’s presumed that health is – and should be – a social good, not a commercial product.

Those societies pay for their doctors, nurses, clinics, hospitals and public health services through progressive taxation plans that save money for the population. They don’t permit high overheads, lobbying or skimming profits off every collected dollar. Their medical coverage is essentially universal (everybody included in the same plan) because that’s the ethical and less expensive solution.

Medical funding in Georgia and the U.S. Is in a gloomy place right now. A bright spot can be found among the younger doctors, nurses and trainees who won’t accept the commercial distortion of their duty to deliver care where it’s needed. It’s time for our politicians and bean counters to follow the lead of the more Idealistic, coming leadership.

https://ajc.com…

When Doctors Suffer Too: The Hidden Crisis of Moral Injury in U.S. Healthcare

By Brenda Gazzar
Code Wack Podcast, July 28, 2025

Most of us know that our profit-driven healthcare system results in moral injury. How is moral harming physicians? And how is it harming patients? Dr. Diljeet Singh is an integrative gynecologic oncologist and the president of Physicians for a National Health Program. She’s leading a powerful new project with the Robert Wood Johnson Foundation to find out.

By gathering stories from doctors and patients across the country, her team is uncovering how corporate control and financial pressures are fueling moral injury in medicine—and what it will take to make things right. From physicians losing autonomy to entire communities losing access to care, the stakes are real—and deeply personal. This is the second episode in a two-part series.

Check out the Transcript and Show Notes for more!

https://heal-ca.org…

The “Bright Side” of America’s Health Insurance System

By Jay Brock, M.D.
FXBG Advance, July 22, 2025

Not that long ago I happened to run into someone who was running as a candidate in a primary election for Congress. The conversation soon turned to the American health insurance system, including a number of points regarding the gaping insufficiencies of our current system.

We ended up discussing the most startling example of how our current health insurance system has failed the American people—each year, 70,000 Americans die prematurely because they cannot afford to pay for timely medical care.

The candidate’s response? In a nation of 350 million, having only 70,000 die each year as a direct result of a failed health insurance system seemed to be quite a low number.

I guess that’s one way to look at it.

(The candidate happened to be a veteran, and I still wonder what his reaction would have been if I stated that having only 70,000 American troops die in battle every year due to gross mismanagement—and indifference about their welfare—was also quite a low number. In any case, he didn’t get the nomination.)

But maybe he had a point. Let’s look at the bright side of our health insurance system.

We’re #1 in the world in healthcare spending per person. We may get worse results than all other advanced nations, and unaffordable healthcare may be the #1 kitchen table issue for most Americans for multiple election cycles, but no other nation can say they spend as much as we do. We’re still #1!

Only 25 million Americans don’t have health insurance—but 325 million do!

And of the 325 million with health insurance, if 60 million are by definition considered “underinsured” (they cannot afford to use their insurance due to onerous out-of-pocket costs) then 265 million Americans aren’t considered underinsured.

On the other hand, 3/4 Americans still worry that they won’t be able to afford to pay their medical bills if they get sick. The bright side, of course, means that one in four Americans don’t worry. Imagine: nearly 90 million Americans DON’T worry about being able to afford to pay their medical bills if they get sick! A remarkable success!

Only a half-million Americans endure a medical bankruptcy each year. That means 349,500,000 Americans don’t endure a medical bankruptcy in any given year. Of course, medical bankruptcy is not a usual occurrence in other advanced nations, but when it comes to medical bankruptcy we’re #1! And likely to stay there unless and until we get a different health insurance system. (Don’t hold your breath.)

That means that since 2000, some 12 million Americans (most with health insurance) have endured a medical bankruptcy. But who’s counting! (Certainly not Congress.)

Is the Big, Beautiful budget Bill recently passed by Republicans in Congress (not a single Democrat voted for it) another “bright side” of our health insurance system? Let’s see: the bill will cut about one trillion dollars from healthcare —especially Medicaid—over the next decade in order to provide huge tax breaks for the wealthiest Americans.

Though spending cuts will be directly affecting mostly the poor and disabled—the people on Medicaid—eventually even rich folk will be harmed by this bill when hundreds of local hospitals (that don’t serve just poor and disabled people on Medicaid) start closing their doors as a result of these dramatic cuts to healthcare spending.

But the bright side is that the wealthiest Americans will keep getting huge tax breaks!

Maybe they should have called this the “Big Beautiful Bright Side of Health Insurance Bill!”

Republicans are defending this trillion dollar cut to healthcare funding by claiming that they will save Medicaid for those who really need it. Their prime example: if you can work but aren’t, this program isn’t for you…unless you jump through numerous government-mandated hoops to prove that you really are deserving of health insurance.

It’s as if there are two groups of folks: those who deserve healthcare, and those who don’t. (In case you haven’t already noticed, this is remarkably representative of our current entire system, where rich Americans can afford great healthcare but non-rich Americans struggle.)

Republicans saying these huge funding cuts are actually saving Medicaid for those who really need it is reminiscent of American military spokesmen during the Vietnam War claiming that they needed to destroy a village in order to save it.

What Republicans aren’t saying is that mandating work requirements to be eligible for Medicaid doesn’t work. The overwhelming majority of those on Medicaid are in fact eligible, but the new bureaucratic paperwork requirements are so burdensome that many deserving enrollees will be thrown off the program, saving money to pay for those tax cuts for the wealthiest Americans.

Even worse, some states spend more on enforcing their eligibility requirements than they do on healthcare for these enrollees.

But who’s counting!

https://fxbgadvance.com…

Responding to Anti-Universal Care Social Media

Health insurance industry opponents of universal coverage have invested heavily in social media to sow doubt about the benefits of health policies and to undermine public trust in government and evidence. Effective response requires understanding the public’s values and a multi-pronged communication strategy.

Generating Opposition to universal healthcare policies the United States: An analysis of private health industry advertising on Meta platforms, PLOS Global Public Health, July 16, 2025, by Kendra Chow, et al.

Abstract

In 2019, the Partnership for America’s Health Care Future (PAHCF), a private health industry lobby group, launched a campaign across Meta platforms (Facebook, Instagram) to generate opposition to universal health care policies in the United States. This study investigates the content and the themes prevalent in PAHCF’s campaign and how these might shape public discourse and perceptions around universal health care policies. Using qualitative content analysis, 1675 advertisements were examined on Meta platforms within PAGCF’s campaign. Inductive methodology was applied to develop a coding framework. Details of campaign spend and number of impressions advertisements received were also collected. The qualitative coding strategies identified three overarching foci: policy targets, claims and themes, and targeted appeal groups. These elements were found to strategically and mutually reinforce one another to generate the narrative that proposed universal health care policies will be detrimental to public health, the economy, and society. Analysis identified that PAHCF engages in strategies common among unhealthy commodity industries. Social media in this instance powerfully perpetuated PAHCF messages that undermined universal health care efforts and contributed to the commercial determinants of health impacts of this industry. These findings indicate that the private health care industry is participating in wider commercial determinants of health activities, acting to protect their profits to the detriment of public health. Like other campaigns by unhealthy commodity industries, PAHCF’s campaign is designed to increase doubt in the benefits of health policies, undermine public trust in government and evidence, and promote public alignment with their own messaging and preferred solutions. To counter such tactics, public health professionals need to gain a better understanding of the strategies unhealthy commodity industries utilize to deflect attention from their underlying health-harming intentions, especially through more novel platforms like social media.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

This study shows that anti-insurance reform forces are aggressively exploiting the power of social media, our era’s central tool for disseminating ideas. The Partnership for America’s Health Care Future social media campaign cleverly crafts negative (and misleading) perceptions of a universal health care system.

Those of us advocating for universal, comprehensive, affordable health care have faced intense opposition, often from organizations like PAHCF. Such opposition has not relied solely on social media. Other avenues include political parties (both Republican and Democratic) and large media networks such as Fox News. These strategies have been all too successful at creating resistance and fear about an insurance approach that is functioning and appreciated around the world.

Support for universal health programs derives from a belief in social justice: everyone should have access to comprehensive health care that is kept affordable through progressive taxes. Opponents place a high value on each person being individually responsible for funding their own care, with a minimized role of government. The centrist consensus (GOP & Dem alike) is that free market dynamics and limited government programs like Medicaid will assure efficiency and (limited) generosity. However, anyone who has studied recent US health policy knows that the market model fails – neither efficient nor generous. The current system increases the wealth of investors by depriving lower-income individuals of needed care.

Could individuals across the political spectrum assemble to calmly devise a system that works of all of us? It appears not. Those supporting single payer, which requires funding based on the ability to pay, will never win the support of individuals who deem it unfair to require them to pay more, no matter how wealthy they are. In an age of billionaires, there seems to be rising inflexibility on this issue.

Ok, much education and persuasion is needed before we can gather to devise a functioning universal approach. Could we build this support through expanded social media? It certainly must be a central part of the strategy.

However, before we dive into persuasive techniques, let’s explore what substantive arguments might work. Both of us really like AI LLMs (large language models) for the ability to frame issues. Thus, to structure our thinking, we asked ChatGPT.

Let’s all ponder and critique this framework. In coming weeks we’ll refine these AI comments and build the persuasive arguments.

Prompt:

What factors make a person decide that society should support an equitable, universal financing system for health care that enables everyone to receive the health care that they should have, as opposed to the view that each person should be individually responsible for providing the funds that are needed to pay for their own health care, whether by direct payment or payment through insurance?

ChatGPT said:

The decision to support an equitable, universal financing system for health care versus an individual responsibility model is shaped by a mix of moral, cultural, economic, and practical considerations. Here are the major factors that influence which viewpoint a person adopts:

1. Moral and Ethical Values

Belief in health care as a human right: People who see health care as a fundamental human right often favor universal systems, believing that access should not depend on wealth or employment.

Empathy and social solidarity: Those who place a high value on community welfare, fairness, and compassion tend to support systems that ensure no one is left behind.

Views on individualism vs. collectivism: In cultures or families that emphasize individual responsibility, people may lean toward self-financed health care. Conversely, collectivist values emphasize shared responsibility.

2. Economic Perspectives

Risk pooling and efficiency: Some recognize that universal systems spread risk across society, lowering overall costs and avoiding the inefficiencies of fragmented, for-profit insurance systems.

Concerns about personal cost: People who believe they can afford their own care (or have good insurance) may resist universal systems because they fear higher taxes or subsidizing others.

Awareness of market failures: Those who understand that health care markets don’t function like regular markets (due to emergencies, unequal information, and lack of consumer choice) may see universal financing as more rational.

3. Personal Experiences

Encounters with medical bills or gaps in coverage: A personal or family experience with medical bankruptcy, denial of care, or lack of insurance often shifts people toward supporting universal care.

Positive or negative experiences abroad: Exposure to universal health care systems in other countries can strongly influence perceptions.

Trust in existing insurance or employer coverage: People satisfied with their private insurance may feel less incentive to support systemic change.

4. Knowledge and Awareness

Understanding of how health care is financed: People who learn that even private care is heavily subsidized (through tax breaks, public programs, etc.) may be more open to universal financing.

Evidence of better outcomes elsewhere: Awareness that countries with universal health care often achieve better health outcomes at lower costs can sway opinions.

Misinformation or myths: Some oppose universal systems due to beliefs that such systems mean “rationing,” poor quality, or lack of choice, even when evidence suggests otherwise.

5. Political and Ideological Beliefs

Role of government: People who trust government and view it as a vehicle for public good are more likely to support universal systems. Those who distrust government often favor private solutions.

Perception of fairness: Some believe it’s unfair to require healthy or wealthy individuals to pay for others’ care, while others see universal care as a fair use of shared resources.

Influence of political parties and media: Political messaging significantly shapes opinions, with universal care often framed differently depending on ideological leanings.

6. Social and Cultural Factors

Sense of social safety nets: In societies where public education, roads, and policing are accepted as communal goods, people are more likely to see health care in the same way.

Cultural attitudes toward poverty and illness: Societies that view illness as a personal failing may favor individual responsibility, while those that see it as largely random and unavoidable lean toward shared financing.

7. Fear of Economic Insecurity

Job-based insurance concerns: People who fear losing health coverage due to unemployment or changing jobs may prefer universal financing for stability.

Desire for protection against catastrophic costs: Recognition that anyone can face unexpected illness can lead to support for collective risk-sharing.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Betrayal, Burnout & Moral Injury: Doctors and the Financialization of Medicine

By Brenda Gazzar
Code Wack Podcast, July 21, 2025

What happens when doctors feel forced to act against their own moral compass? When financial barriers—not clinical judgment—determine the care a patient receives?

We’re talking about moral injury in medicine—how it’s affecting physicians, harming patients, and why it’s getting worse under our profit-driven healthcare system.

Joining us is Dr. Diljeet Singh, an integrative gynecologic oncologist and president of Physicians for a National Health Program. She shares powerful stories from her own practice—and from the front lines of American healthcare—that reveal a deeper crisis than just burnout. This is the first episode in a two-part series.

Check out the Transcript and Show Notes for more!

https://heal-ca.org…

The Failure of Neoliberalism in Health Care

Two new articles by Hayden Rooke-Ley explain how neoliberal economics and the largely private insurance system it created have failed patients by maximizing profits at the expense of patient care. It’s time for a public-driven approach.

The Same Script: Value-Based Payment, Managed Care, and Neoliberalism, The Law and Political Economy Project, July 15, 2025, by Hayden Rooke-Ley

Ultimately, the private rationing of managed care and value-based payment is an abdication of governance – a failure of policymakers to wield the public authority required to equitably and efficiently administer a public health care program. A post-neoliberal health care agenda, by contrast, would contain costs through proper price administration and cutting private-sector administrative waste – the true drivers of overspending. It would directly reimburse physicians and other clinicians and nurture their professional autonomy, rather than empowering corporate executives and financiers to control them. It would use savings to make Medicare and other insurance programs more affordable for patients, and to properly pay overworked and underpaid caregivers. Now is the time to depart from the four-decade experiment with managed care and to structure financing policy to serve the interests of clinicians, patients, and their local communities.

Delays and Denials in Medicare Advantage, JAMA, June 25, 2025, by Hayden Rooke-Ley et al.

The growth of privatized Medicare is increasing the rates of prior authorizations and claim denials creating barriers to care, increasing administrative waste, and demoralizing clinicians. At the core of this problem lies a conflict of interest: the Medicare Advantage (MA) insurance companies that profit from denials are entrusted to make neutral determinations of medical necessity as they apply Medicare’s coverage rules. They do not. Unsurprisingly, MA plans serve their financial interests first.

Privatized Medicare was not supposed to work this way. MA plans are mandated by law to cover the same benefits as Traditional Medicare (TM) and follow Medicare coverage rules. However, MA insurers often refuse to follow them.

For decades, observers have raised concerns about denials in managed care, researchers proposed various solutions, and regulators have promulgated rules to clamp down on certain conduct. However, these solutions stop short of addressing the core conflict of interest. Fortunately, a solution lies in plain sight. TM uses third-party contractors, known as Medicare administrative Contractors (MACs), to implement coverage rules, engage in targeted prior authorization, and process and adjudicate claims. Although MACs are not perfect, they do have one major advantage over MA insurers: they are not biased toward denying care. MACs are paid a simple administrative fee. They are not at risk for medical costs and have no financial interest in denying services or payments. This process is efficient: CMS spends less than 2% on administrative costs, compared to 13% in MA.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

Health care in the United States is far costlier than in all other countries, and the performance of our system falls near the bottom of industrialized nations. As often discussed in HJM, we understand the functional reasons for this underperformance – grossly inefficient processes and massive financial access gaps.

In these two publications, Hayden Rooke-Ley digs deeper to explore underlying causes. He cogently critiques our neoliberal economic approach, which places blind faith in private sector mechanisms to optimize system performance. The fundamental problem is: optimize for whom? The private sector-dominated insurance system prioritizes creating wealth for investors at the cost of depriving consumers of the medical care they should have. He finds a defective nexus of managed care, value-based payments, prior authorizations, and denial of care and/or care payments.

These highly detrimental dynamics could be resolved by applying a sound policy principle: return control of decisions that affect patients to individuals who have no financial stake in the decisions. These are public guardians and their agents, interacting directly with medical providers. Remove the profit-seeking intermediaries. This would also help us end other faulty policies such as narrow provider networks and excessive patient cost-sharing should.

Hayden Rooke-Ley has also written about how to transform the provider side – i.e., how the harm from private equity could be mollified by the revitalization of public provisioning of medical resources.

Both of these papers are well worth downloading to be fully consumed. And to be used to explain to others why our system is functioning so poorly considering its high costs. They can serve as a springboard to a system that would be affordable and work well for all of us: a single payer national health program.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Sunlight Report on UnitedHealth Group

Center for Health & Democracy, July 16, 2025

Shining a light on a giant

The Sunlight Report on UnitedHealth Group is a first-of-its-kind look at the nearly 2,700 acquisitions and internally created subsidiaries that make up UnitedHealth Group, the largest health care conglomerate in the world.

Named for its mission to bring light to UnitedHealth’s vast and often opaque business structure, this project compiles and analyses publicly available data in an accessible way,  allowing the public to more clearly grasp the scope of the company’s reach.

Introduction

UnitedHealth Group has evolved from a small U.S. health insurer into a massive health care conglomerate through decades of strategic acquisitions and vertical integration. It provides health insurance and related services globally and is broadly divided into its insurance arm (UnitedHealthcare) and another major division (Optum), which provides other health care-related services. As of the fourth quarter of 2024, UnitedHealth operated in almost every country in the world, had more than 400,000 employees, and reported 2024 revenue of $400 billion. Through its vertical integration and acquisitions, it now employs or has close contractual ties with more than 90,000 doctors (nearly 10% of the entire U.S. physician workforce) and commands 15% of the U.S. health insurance market. As a result of this vertical integration strategy, almost 30% of total company revenue is now generated by internal business entities. 

(The relevant accounting term to further explain the significance of that percentage is “intercompany eliminations.” In its financial disclosures, UnitedHealth must report intercompany eliminations to avoid double counting. This is because the company is paying itself in many instances, i.e., UnitedHealthcare, the insurer, increasingly is paying health care providers (grouped under Optum) that it owns or otherwise controls. In 2010, before UnitedHealth had acquired most of its clinical assets and when the company’s revenues were $94.2 billion, eliminations totaled $18.3 billion, or approximately 16% of total revenue. In 2024, after hundreds of acquisitions of physician practices and other clinical assets and when the company’s revenues totaled $400.3 billion, eliminations had reached $150.9 billion, or 27.4% of total revenue. Here’s another way of looking at this: The eliminations in 2024 represented nearly 60% of Optum’s total revenues.)

The sheer size and complexity of the organization, coupled with its rapid pace of acquisitions, makes it difficult for consumers, regulators, policymakers, employers and other group purchasers of health insurance to understand the inner workings of the organization. This is compounded by often insufficient granularity in UnitedHealth’s financial and regulatory reporting. For example, current financial reporting aggregates data from multiple entities and regions, often without clear delineation of contributions by subsidiary or geography. This makes it difficult to analyze the performance (and significance) of its many individual components. Similarly, corporate filings and disclosures often do not include information about entity-specific operations and people.

We believe these factors leave the public without critical information needed to understand how UnitedHealth’s size and structure affects health care access, quality, and affordability. The details of many of its acquisitions are not publicly disclosed, which, coupled with its byzantine structure, deters most people from learning more or understanding what is at stake.

That is why we undertook the massive project of helping the public understand this corporation, which has grown to become the fourth largest on the Fortune 500 list of American companies.

full report: https://sunlightreportinsurance.com…

UnitedHealth Has 2,694 Subsidiaries and Affiliates. Is It Too Big to Manage?

This behemoth conglomerate might just be too monstrous for its own good.

By Jarod Facundo and Patrick Rucker
The American Prospect, July 16, 2025

UnitedHealth Group executives have long argued that buying rival health care companies was the key to earning long-term profits, and investors who endorsed that strategy were rewarded for years.

Since UnitedHealth announced disappointing earnings in April, though, Wall Street has erased roughly half of the company’s stock value, and its “buy everything” business model has come under scrutiny.

A new report tallies UnitedHealth’s vast holdings and chronicles how the company both spawned new enterprises and went on a prolonged buying spree to grow. In all, UnitedHealth has a whopping 2,694 subsidiaries and affiliates.

The report gives a deal-by-deal accounting of how UnitedHealth ballooned, but it also implicitly asks a key question: Has it become too big to manage?

“United is shaping our health care system, and few people know the company’s scope,” said Wendell Potter, president of the Center for Health & Democracy, which published the Sunlight Report on UnitedHealth Group with financial support from Arnold Ventures.

The report shows how a vast national health care system largely feeds the bottom line of one giant enterprise.

In a statement, UnitedHealth said the company sought to streamline a medical system that is fragmented and inefficient.

“We’re helping to accelerate the transition of the U.S. health care system,” said Dr. Wyatt Decker, a UnitedHealth executive who described the company’s “value-based” model for paying doctors more when their patients become healthy rather than for the number of treatments they give.

UnitedHealth, he said, seeks to move “beyond a transaction-based health system to a model that is designed to be proactive to help keep people healthy over the course of their lifetimes.”

Whatever UnitedHealth’s stated ambitions, the company has become so complex that it is difficult for regulators and enforcers who would rein it in, said Reed Showalter, a senior fellow for the Vanderbilt Policy Accelerator, a think tank within Vanderbilt University. He calls it “weaponized complexity.”

“You end up with this game of whack-a-mole because these companies are so big and they can hide unfairness and harms in so many different ways through their subsidiaries.”

The Prospect has previously detailed UnitedHealth’s relentless, single-minded, half-century search for profits. One industry analyst describes how the company has used its vast store of wealth to pull more and more rivals under its control.

“This is not a care delivery ‘system,’” said Jeff Goldsmith, who has followed the company closely for decades. “United is a profit-mining enterprise. They used profits to buy profitable companies.” But Goldsmith cautioned that this merger spree has stopped, with uncertain implications for UnitedHealth’s future.

Acquiring Profits

Established in 1974 to handle overhead and doctor salaries for then-popular health maintenance organizations (HMOs), UnitedHealth set its sights throughout the 1980s on rival insurers as part of a drive toward horizontal integration, Goldsmith said. More recently, UnitedHealth targeted health care providers and health data systems as a way to vertically integrate.

The company sought out profitable links in the health care delivery chain and avoided low-margin businesses like hospitals.

Roughly 1 in 10 physicians work for UnitedHealth; the company controls about 20 percent of the prescription drug market through pharmacy benefit manager (PBM) Optum Rx, and collected $300 billion last year providing insurance for patients.

Besides the eye-popping number of subsidiaries, UnitedHealth has a staggering 400,000 employees.

“Most patients do not realize their physician might also be employed by their insurer. It raises trust and ethical issues. How does United balance tensions between controlling costs and quality? They don’t say,” said Seth Glickman, a former insurance and health system executive. He now is a researcher and advocate for reform in the health care finance space who helped author the Sunlight Report.

“Can the CEO or the board really understand all that is happening?” asked Lawton R. Burns, a professor of health care management at the Wharton School of Business at the University of Pennsylvania. “When you get to this size, you run into issues of governance.”

In the light of some transactions, UnitedHealth resembles a financial services company more than an insurer. Its Optum Bank lends to independent physician practices and has nearly $15 billion in deposits. Optum Ventures, its venture capital arm, has more than $2 billion in assets.

Potter’s Sunlight Report uncovered UnitedHealth’s disparate holdings by drilling through required filings to state insurance regulators, known as Schedule Y.

Buying Spree

In 2010, the company controlled just 149 individual entities. By 2023, that number had ballooned nearly twentyfold. Nearly 80 percent of the acquisitions over that period were health care providers, according to the report. The remaining 20 percent consisted largely of international acquisitions and administrative enterprises that helped consolidate UnitedHealth’s vast health data system and PBM, and specialty insurance providers offering coverage for everything from workers’ compensation to dental plans.

As the company’s holdings grew, so did revenue, and it seemed like the business plan was working. Beginning in 2010, total revenue increased from $94 billion to $400 billion, while net income rose from $4.6 billion to $15 billion, according to securities filings. Meanwhile, investors saw share prices skyrocket from $30 per share to $530 a decade later.

While the overall growth numbers have been impressive, more and more UnitedHealth revenue has come from the company doing business with its own subsidiaries.

In 2010, roughly $18.3 billion of Optum revenue came from businesses it owns, according to SEC filings. Today, that number has increased nearly tenfold to $151 billion, according to an analysis of securities filings..

Unmanageable

With its vast and sprawling network of medical interests, it’s not just UnitedHealth’s size that worries Goldsmith, but its unmanageability.

“To create real synergies in this space, you have to make it easier for doctors to practice medicine and improve the patient’s experience. That hasn’t happened,” he said, noting that UnitedHealth has a net negative view among consumers.

“You have all these moving parts,” he said. “But the nerve endings are not reaching all the way to the fingers and toes.”

There is a fine line between a business that operates profitably at a large scale and one that struggles to manage its distinct parts, said Professor Burns at Wharton.

“The country has over 60 years of business history with conglomerates, and that history isn’t very glowing,” he said, noting that health care is particularly difficult to scale nationally.

“There is a reason that the largest hospital groups and provider networks are regional and not national,” he said. “It turns out, when it comes to health care, people prefer a local-based culture.”

Goldsmith put it more bluntly. “United does a terrible job providing services,” he said. “If you can’t meet my needs as a patient and if you can’t connect with all those talented docs that you acquired, you don’t have anything. You just have a bunch of assets that are depreciating in value. That is a recipe for a shrinking company.”

In response, UnitedHealth’s Dr. Wyatt Decker said, “Optum aligns with and employs physician practices to advance solutions to expand access to care, improve affordability, enhance the care experience and achieve better health outcomes.”

Medicare Profits

Regulators and investors are beginning to ask whether UnitedHealth’s vast provider network wrongly boosted its popular insurance program for seniors.

UnitedHealth controls roughly 30 percent of the Medicare Advantage market, and it enrolls more seniors than any other operator. Many of UnitedHealth’s acquisitions have solidified the company’s power to not only treat ailing seniors but also determine how sick they are for the purposes of reimbursement.

Roughly one-third of the acquisitions tallied in the Sunlight Report are related to a single deal: UnitedHealth’s $5.4 billion acquisition of home health provider LHC Group in 2022.

UnitedHealth has used home wellness visits and medical codes in health records to exaggerate the poor health of seniors, which boosts payout from the government, The Wall Street Journal reported last year. Medicare Advantage patient evaluations are known as “risk adjustments,” and UnitedHealth has defended the integrity of the practice and its Medicare Advantage program generally.

The company continues to do so. “[Medicare Advantage] plans are regularly audited for accuracy and compliance, and we consistently perform at the industry’s highest levels. We have advocated that CMS conduct audits for every plan, every year, and remain supportive of that proposal,” said UnitedHealth’s Dr. Decker.

The Journal followed up with a report in May of this year that the Justice Department is now investigating whether UnitedHealth engaged in criminal Medicare fraud. On July 9, the Journal reported that federal agents interviewed former UnitedHealth doctors and a nurse practitioner about the training and software used to capture lucrative medical conditions.

If UnitedHealth did use its vast provider network to boost its Medicare Advantage revenue, that business model could now be under threat. For now, UnitedHealth must try to squeeze efficiencies out of a disparate provider network and try to mollify doctors who might chafe under UnitedHealth’s control.

“You can try to get all these doctors on the same reporting system and have them help develop a business strategy,” Goldsmith said. “But United is still dealing with a pretty disaffected workforce.”

Bigger Is Better?

Some investors who are unfazed by UnitedHealth’s stock sell-off said they still believe in the company’s strategy, particularly the practice of acquiring health care providers.

“If you own providers, you have more touch points to keep the patient out of hospitals. That’s how you can control spend,” said one hedge fund manager whose portfolio is 20 percent health insurers, including UnitedHealth.

Insurers have traditionally paid doctors for the care they deliver, a model called fee-for-service. UnitedHealth has been a proponent of value-based care, which pays providers more when they can prove the patient got better after the treatment.

“These guys are positioned for the adaptation of value-based care,” said the hedge fund manager, who declined to be named discussing investment strategy.

Value-based care has principally been limited to Medicare Advantage plans. “But it will increasingly be adopted on the commercial side,” the hedge fund manager said, referring to employer-funded health insurance.

Some analysts disagree and argue that UnitedHealth’s buying binge has only created a bloated, unmanageable company. Yet UnitedHealth’s strategic vision remains the same.

“Our strategy and structure are the right ones for this era,” Stephen Hemsley told investors on the day he took over for his second stint as CEO this May, after Andrew Witty stepped down. “We have made meaningful progress through value-based care approaches … I believe and expect we can also be in the forefront of modernization and innovation across the health system.” (Hemsley, while UnitedHealth’s chair, reportedly sold tens of millions of dollars in stock right after the Justice Department informed the company of an antitrust investigation in 2023, and right before it was disclosed in the media.)

Future Unclear

One reason for UnitedHealth’s earnings shock was a sudden uptick in medical expenditures among Medicare Advantage members. “The medical costs of many Medicare Advantage beneficiaries new to UnitedHealthcare remained higher than expected,” the company acknowledged in May.

“It’s unclear whether United simply mispriced their insurance book or made other correctable errors, or whether there are more structural issues from a business perspective,” said Hayden Rooke-Ley, a senior fellow at the Brown University School of Public Health and the American Economic Liberties Project. UnitedHealth’s drive to control more health care providers might not lower costs for consumers or improve health outcomes, but it can still be profitable, he said.

“Whether this playbook will continue to be successful will have a lot to do with whether policymakers and regulators continue to encourage this vertical consolidation—or start to question it.”

https://prospect.org…