July 24, 2024

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GOP leaders call for probes into alleged Affordable Care Act fraud

3 min read

House Republican leaders are asking government watchdogs to investigate health insurance sign-ups through the Affordable Care Act, citing reports that allege insurance brokers are fraudulently enrolling customers into some ACA health plans and that millions of Americans may be wrongly benefiting from federal insurance subsidies.

The House Energy and Commerce, Ways and Means, and Judiciary Committees requested Friday that the Government Accountability Office and the inspector general at the Department of Health and Human Services open investigations into the “astonishing level” of potential enrollment fraud, according to letters shared with The Washington Post.

“The scale of the problem suggests malicious intent,” Reps. Cathy McMorris-Rodgers (R-Wash.), Jason T. Smith (R-Mo.) and Jim Jordan (R-Ohio) wrote in their letters, requesting a “systemic review of enrollment” from the watchdogs. The three lawmakers are chairs of the Energy and Commerce, Ways and Means, and Judiciary Committees, respectively.

The allegations center on a report from the Paragon Health Institute, a conservative think tank, which concluded that as many as 5 million Americans may be wrongly receiving ACA insurance subsidies. The Paragon report compared census estimates on the number of Americans potentially eligible for such subsidies against the level of ACA enrollment.

The allegations also are driven by recent KFF Health News reports about unscrupulous brokers falsifying information to enroll customers or wrongly switching customers between plans without their knowledge or consent, a development that has stirred bipartisan anger.

The Centers for Medicare and Medicaid Services recently announced that the agency received about 90,000 complaints of unauthorized sign-ups or plan switches in the first quarter of 2024. While brokers benefit from the moves by receiving commissions, unauthorized plan enrollments or switches can harm consumers, and federal health officials have said they are cracking down on broker behavior.

Democrats share some concerns about possible fraud, with Sen. Ron Wyden (D-Ore.), chair of the Senate Finance Committee, recently demanding more enforcement to protect consumers from unscrupulous brokers.

The focus on potential ACA fraud comes as lawmakers continued to wrestle over the health law and how to fund its programs. Democrats have celebrated sign-ups through the ACA, with President Biden at Thursday night’s debate touting that more than 40 million Americans are covered through its insurance marketplaces and its Medicaid expansion.

Republicans have countered that the program’s purpose has been distorted, and that Democrats have been too generous in providing federal subsidies for private health insurance.

Under the American Rescue Plan Act and the Inflation Reduction Act, people who report income between 100 and 150 percent of the federal poverty line can receive enhanced subsidies that lower their premium to zero for a plan with very low out-of-pocket payments, also known as a zero-premium plan. A household of four people, for instance, could report income between about $30,000 and $45,000 to qualify for the enhanced subsidies. The enhanced subsidies are set to expire in 2025, and Republicans have balked at extending them, setting up a fight in Congress.

About half of the people who signed up for private health insurance in the recent ACA enrollment period reported incomes that qualified them for a fully subsidized plan or a zero-premium plan, up from about one-third before the enhanced subsidies became available. The Paragon report argues that individual enrollees, insurance brokers and private health insurers all have financial incentives to take advantage of those subsidies, and that no one has bothered to closely examine the reasons behind the spike in the subsidies’ use.

“It’s stunning how little has been done to date looking at these issues,” Brian Blase, Paragon’s president and a former Trump White House health policy official, said in an interview.

Other researchers and health policy experts have said they doubt Paragon’s conclusions.

Edwin Park, a research professor at the McCourt School of Public Policy at Georgetown University, said he supported federal investigations into broker behavior and other sources of potential enrollment fraud. But he cautioned that Republicans have repeatedly raised fraud allegations as a way to attack the Affordable Care Act and other health programs.

“Beneficiary fraud has always been a small part of any fraud and abuse in any of the programs like Medicaid,” Park said.

He also criticized the Paragon report for relying on “a relatively simplistic methodology” that didn’t account for critical differences between the census estimates and the ACA enrollment data.

Pressed on his report’s findings, Blase said he was confident in the conclusions.

“I don’t think they’re allegations. I think it’s data,” he said.


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