Dive Brief:
- Eight major health insurers are being subpoenaed by House Republicans after allegedly failing to comply with a committee’s request to share information about potential Affordable Care Act fraud.
- House Judiciary Committee Chairman Jim Jordan, R-Ohio, and the chairmen of the regulatory and oversight subcommittees sent the subpoenas on Monday to publicly traded insurers CVS, Elevance, Centene and Oscar, along with nonprofits Health Care Service Corporation, Kaiser Permanente, Blue Shield of California and GuideWell.
- The subpoenas request additional documents and information from the insurers, and suggest House Republicans are considering legislation to combat what they view as rampant fraud in the ACA exchanges.
Dive Insight:
Republicans say they are very worried about ACA fraud, particularly stemming from more generous subsidies for plans in the exchanges put in place during the coronavirus pandemic to keep more Americans insured. The conservative Paragon Institute issued a report last year finding millions of ACA members generated no claims in 2024, suggesting tens of millions dollars in annual subsidies were being pocketed by insurers for the “phantom enrollees.”
Though health policy experts and the insurance industry dispute that report, other research also suggests fraud exists, albeit on a smaller scale. In an investigation released in December, the Government Accountability Office found it’s easy to circumvent guardrails in the exchanges meant to prevent improper enrollments, by successfully signing almost 20 fake individuals up for coverage.
The GOP cited worries about fraud when the party allowed enhanced ACA subsidies to expire on Dec. 31, setting more than 20 million Americans up for steep premium hikes this year.
And now, Jordan and his colleagues Reps. Scott Fitzgerald, R-Wis., and Jeff Van Drew, R-N.J., are subpoenaing major ACA insurers to get more information, as the House Judiciary committee’s interest in exchange fraud continues into the new year.
Jordan first initiated the investigation in December, following the GAO report. Each of the eight insurers that received subpoenas on Monday responded to that initial inquiry, but were not as forthcoming as the House Judiciary chairman liked, according to the letters.
The subpoenas ask for more information, particularly around the insurers’ fraud prevention measures, according to a press release from the Judiciary Committee. Insurers must respond by Feb. 23.
When reached for comment, Centene, CVS, Kaiser Permanente, GuideWell and Blue Shield of California said they were fully cooperating with the House Judiciary’s requests for information, while HCSC said it was “committed” to fighting fraud, including by working with state and federal officials.
Elevance and Oscar did not respond to a request for comment.
Jordan’s letters also cite a controversial rule released by the Trump administration in June, provisions of which were stayed by a judge later that summer. The rule would have heightened verification and enrollment standards for ACA plans, ostensibly to tackle fraud. But it would also have made it much harder for Americans to sign up for the coverage, according to health policy experts.
The Maryland district judge found that the Trump administration had violated the Administrative Procedure Act in promulgating the rule. The Trump administration has appealed that decision.
But “the Committee is investigating whether the APA needs to be reformed so as to ensure that important healthcare fraud prevention measures can be swiftly implemented and are not unreasonably burdened by administrative procedural requirements,” according to Jordan’s letters to insurers.
Any such reform would align with the Trump administration’s rejection of established administrative procedures as it seeks to pursue its agenda. In early 2025, the HHS said it would no longer seek out public comment on a wide variety of actions, sparking controversy from critics who viewed the change as an attempt to restrict transparency into the department’s actions.
The subpoenas come as Republicans embrace an increasingly contentious relationship with health insurers, blaming them for sky-high premium increases this year. Meanwhile, health insurers note that premium hikes are based on increases in underlying costs for medical items and services.
Still, that hasn’t prevented a barrage of criticism against major insurers, including in hearings on the Hill. Health insurers were also targeted in President Donald Trump’s “Great Healthcare Plan” released earlier this year.
