Medicare Advantage in crosshairs as GOP Congress eyes new rules

Modern Healthcare – Tuesday, July 22, 2025
By Michael McAuliff

Republicans may be falling out of love with Medicare Advantage, a program the party has long championed.

Medicare Advantage needs an overhaul and the health insurance companies that administer benefits for more than half of Medicare enrollees need to be reined in if the privatized system is to be preserved, GOP lawmakers said at a House hearing Tuesday.

Republican after Republican on the Ways and Means Committee’s oversight and health subcommittees, which jointly staged the hearing, hailed the promise of Medicare Advantage. They also pointed to growing discontent, suggesting a willingness to legislate.

Related: Where UnitedHealthcare, Humana rule the Medicare Advantage market

Most often, Republican lawmakers singled out practices such as “upcoding” Medicare Advantage enrollees to make them appear sicker, thus generating higher payments, and prior authorization requirements that hamper access to care and boost insurance company profits.

“Patient enthusiasm for the program is exactly — exactly — why we should ensure its integrity,” Ways and Means Committee Chair Jason Smith (R-Mo.) said. “We know of concerns about MA plans inflating a patient’s level of sickness, resulting in higher reimbursements from the plan at taxpayer expense, and an estimated $40 billion in 2025 alone.”

“We have heard many stories that excess prior authorization negatively impacts patients,” Health Subcommittee Chair Vern Buchanan (R-Fla.) said.

Oversight Subcommittee Chair David Schweikert (R-Ariz.) recalled that the original promise of Medicare Advantage was saving taxpayers money compared to fee-for-service Medicare. That’s not what’s happening, he said.

Democrats have made the same criticisms for decades, but President Donald Trump’s Republican Party has demonstrated it will not defend Medicare Advantage as vigorously as the GOP used to, even as they remain committed to its existence.

UnitedHealth Group subsidiary UnitedHealthcare, Humana and CVS Health subsidiary Aetna, the top Medicare Advantage carriers, caught flack at the hearing, which featured Alignment Healthcare President Dawn Maroney and Scan Health Plan President and CEO Dr. Sachin Jain as witnesses.

“I applaud you all for doing it right,” Rep. Dr. Greg Murphy (R-N.C.), who has called for UnitedHealth Group to be broken up, said to the insurance executives.

“What I’d like to see are UnitedHealthcare, Humana and Aetna sitting in front of us because they have bastardized the system and they have ruined Medicare Advantage,” Murphy said.

Murphy pointed to the murder of UnitedHealthcare CEO Brian Thompson in December as a sign of how deep the problems go.

“That’s the outrage that we’re seeing,” Murphy said. “We have to correct this, and this is a bipartisan issue. We can’t throw away a good program, but we can throw away bad actors.”

Exactly what the GOP-led Congress may do and when they may do it are not clear, not least because lawmakers already face a packed health policy agenda after passing $1.1 trillion in healthcare cuts this month.

Over the past several years, Republicans and Democrats have supported a number of Medicare Advantage bills that failed to advance and could resurface. That includes proposals on prior authorization, “upcoding” and price transparency.

It’s also not clear how many votes any of those measures could garner in Congress.

Many Republicans remain protective of Medicare Advantage and while Democrats may support some of the legislation, they have broader political considerations in the wake of Trump enacting his “One Big Beautiful Bill.”

Democrats have signaled less willingness to cooperate with Republicans after the majority forced that tax-and-spending-cuts bill and other legislation through Congress without input from the minority party.

The Better Medicare Alliance, which represents health insurance companies, warned Congress to tread carefully.

“We urge policymakers to prioritize thoughtful reforms that strengthen Medicare Advantage while protecting the affordability, benefits and coordinated care that beneficiaries rely on,” Better Medicare Alliance President and CEO Mary Beth Donahue said in a news release Tuesday.

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