GOP leaders demand investigation into Affordable Care Act fraud

House Republican leaders are asking government watchdog agencies to investigate health insurance enrollment under the Affordable Care Act, citing reports that insurance brokers are fraudulently enrolling customers in some ACA health plans and that millions of Americans are improperly taking advantage of federal insurance subsidies.

The House Energy and Commerce, Ways and Means, and Judiciary committees on Friday requested that Government Accountability Office And this Inspector General of the Department of Health and Human Services According to letters shared with The Washington Post, an investigation should be launched into the “astonishing level” of potential enrollment fraud.

“The scale of the problem suggests malign intent,” Reps. Cathy McMorris-Rodgers (R-Washington), Jason T. Smith (R-Mo.) and Jim Jordan (R-Ohio) wrote in their letters, urging watchdogs to conduct a “systematic review of the nomination.” The three lawmakers are chairmen of the Energy and Commerce, Ways and Means, and Judiciary committees, respectively.

The allegations center on Report The Paragon Health Institute, a conservative think tank, concluded that more than 5 million Americans are incorrectly receiving ACA insurance subsidies. The Paragon report compared census estimates on the number of Americans potentially eligible for such subsidies against ACA enrollment levels.

The allegations are also prompted by recent reports from KFF Health News that unscrupulous brokers have provided false information to get customers to enroll or have wrongly switched between plans without the customer’s knowledge or consent, a development that has sparked widespread public outcry. sparked bipartisan outrage,

The Centers for Medicare & Medicaid Services recently announced the The agency received nearly 90,000 complaints of unauthorized sign-ups or plan switches in the first quarter of 2024. While brokers benefit from these 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 potential fraud, with Senator Ron Wyden (D-Ore.), chairman of the Senate Finance Committee, recently saying Demand for more enforcement for consumer protectionS from dishonest brokers.

The focus on potential ACA fraud comes as lawmakers continue to deliberate on how to fund the health law and its programs. Democrats have celebrated sign-ups through the ACA, with President Biden saying in Thursday night’s debate 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 incomes between 100 and 150 percent of the federal poverty line can receive an increased subsidy that reduces their premium to zero for a plan with a very low out-of-pocket payment, also known as the Inflation Reduction Act. Zero Premium PlanFor example, a family of four could report an income between about $30,000 and $45,000 to be eligible for the increased subsidy. The increased subsidy is set to expire in 2025, and Republicans have refused to extend it, setting up a fight in Congress.

About half of 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, compared with about a third before the increased 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 no one has bothered to closely examine the reasons behind the rise in subsidy use.

“It’s amazing how little work has been done on these issues so far,” 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 are skeptical of Paragon’s findings.

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

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

He also criticized the Paragon report because it relied on a “relatively simple methodology” that did not take into account significant differences between census estimates and ACA enrollment data.

When pressed on the findings of his report, Blaise said he was confident in the conclusions.

“I don’t think these are allegations. I think these are statistics,” he said.


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