On January 22nd, the House of Representatives held back-to-back hearings on healthcare affordability, featuring CEOs from five of the largest insurance companies.
The hearings took place with the backdrop of ongoing Congressional debates on how to address the now-expired enhanced Affordable Care Act subsidies. We have heard from ACG Governors about patients canceling appointments and delaying care, due to the significant premium increases for 2026 ACA marketplace plans.
Members of the House Energy & Commerce and Ways & Means committees heard testimony from the following CEOs: Stephen Hemsley (UnitedHealth Group). David Joyner (CVS Health), Gail Boudreaux (Elevance Health), David Cordani (The Cigna Group) and Paul Markovich (Ascendiun). The members of Congress grilled the executives on topics like competition, vertical integration, PBMs, prior authorization, the patient-provider relationship, and the use of AI in prior authorization decisions.
In addition, the GOP Doctors Caucus invited ACG to submit questions for the record, which you can review here. Several of our suggested topics and lines of questioning were echoed throughout the day from members in both committees and on both sides of the aisle.
Here are our top 5 must-see moments from the hearings:
1. W&M Chairman Smith (R-MO): The Largest Insurers Aren’t Just Insurers – They Control Everything
Rep. Smith: By a show of hands: which of your companies own or control a health insurance division?
CEOs: *Raise hands*
Rep. Smith: Please keep your hand up if you also employ health care providers or own clinics, specialty pharmacies, or any other kind of medical practices or pharmacy.
CEOs: *Raise hands*
Rep. Smith: Please keep your hand up if you also own or control a pharmacy benefit manager.
CEOs: *Raise hands*
Rep. Smith: And please keep your hand up if you lead a publicly traded company at which you have a legal responsibility to maximize shareholder value.
CEOs: *Raise hands*
Rep. Smith: So, we’ve established – on the record – that the largest health companies are not just insurers. They are also medical providers and pharmacies – diagnosing and deciding treatment for patients. They are also PBMs, another form of middlemen managing drug benefits. They are increasingly controlling every aspect of our health care system.
2. Rep. Troy Carter (D-LA): Should We Trust the Patient’s Physician or an Insurance Algorithm?
Rep. Carter: Should a licensed physician who knows the patient be trusted over an insurance algorithm when determining the most appropriate treatment, instead of forcing patients through a step therapy requirement that delays care and oftentimes increases suffering and even cost?
Stephen Hemsley: No, I think there are appropriate times for step therapy, but in the situation you describe, I would not.
Rep. Carter: And Mr. Joyner?
David Joyner: Yeah, I agree. Step therapy is an opportunity for one to introduce a savings opportunity for the consumer and member as well.
Rep. Carter: But respectfully, oftentimes it’s not a savings. It’s a nuisance, because the physician is saying this doesn’t work for my patient. The patient goes to the pharmacy and is told, ‘you can’t get this because the insurance company won’t approve it, because you haven’t tried this,’ and the patient says, ‘but I have tried it, it doesn’t work. There are horrible side effects, but now I’ve paid a 30, a 60, day 90 day co-pay for it, and they won’t let me do it again.’ Isn’t that unfair to a patient whose doctor not an algorithm, but whose doctor has stated that this medicine doesn’t work?
3. Rep. Greg Murphy, MD (R-NC): “I’d Turn All of You Guys Into Dust”
Rep. Murphy: Nothing you’re going to say to me today is going to change that you have put profits above patients, and you put profits above those who care for patients. You’re sitting here blaming hospitals, pharmaceutical companies, even physicians. There is blame to go around here, but you have squarely abused your privilege of authority to deliver healthcare to patients.
…
I don’t agree with Mark Cuban often, but we do agree that what needs to happen is that you guys need to be broken up. The vertical integration has destroyed competition in this country, and again, if I had my way, I’d turn all of you guys into dust.
We’d start back from scratch. We’d have competition in the industry. We’d have associated health plans, and we would have non-profit hospitals, rather than profit being put over patients. Sadly enough, I’m not naive enough to believe that anything that’s been said today is going to change boardroom behavior.
I don’t think it will happen. The bottom line is profit, and that’s what’s happened in this country, and this is where the American Medical System, compared to the rest of the world, is sad comparatively.
4. Rep. Mike Thompson (D-CA): AI in Prior Authorizations
Rep. Thompson: Prior Authorization increases administrative burden and for our doctors. It’s bad for our patients. And that’s something that I believe you can do something about. So I have a question for all of you. Prior authorization is causing these problems, and many of your companies use AI algorithms to categorically deny care that must then be appealed without the input of a physician. I want to know what you’re doing about that and how you can address it.
CEOs: *All CEOs said their companies do not use AI for prior authorization denials*
Rep. Thompson: There’s a disconnect, because the doctors that I talk to and hospitals I talk to are telling me something a little bit different. So I’d welcome the opportunity to work with you to figure this out and see if we can fix it.
5. Rep. Kat Cammack (R-FL): When Delays Happen, Patients Suffer – But Your Bottom Line Doesn’t
Rep. Cammack: Raise your hand if an executive at your company takes a financial penalty when a patient is armed due to an insurer cause delay or wrongful denial.
*No CEOs raise their hand*
Rep. Cammack: Okay, so no one at the company bears any responsibility for denial of care or patient outcomes. Raise your hand if an overturn, denial or appeal negatively impacts executive compensation at your company.
*No CEOs raise their hand*
Rep. Cammack: Not one. That right there is the problem when denials and delays and appeals – which happen every single day – occur the patient and their families are the ones that get hurt, not your bottom line.
Bonus! Rep. Alexandria Ocasio-Cortez (D-NY): “I Think This Model Works Very Well For CVS”
Rep. Ocasio-Cortez: I was following one of CVS’ recent investor calls where they really laid out quite clearly what this means if you are a patient. This is what’s known as a “captive strategy.”
And CVS in the investor call used the example themselves of a patient known as Kate. Kate has an Aetna health insurance plan, right here and which is owned by CVS Health. She then goes to a CVS pharmacy. She’s connected to an Oak Street Health medical clinic. She sees a doctor at Oak Street Health who prescribes her medication. And then she goes to fill that prescription at the CVS Pharmacy. So the price Kate pays for that medication is dictated by Aetna, CVS Caremark, and they also own the drug manufacturer, Cordavis.
Mr. Joyner this is quite a bit of market concentration. Wouldn’t you agree?
David Joyner: No I wouldn’t agree that it’s market concentration. I would suggest it’s a model that works really well for the consumer.
Rep. Ocasio-Cortez: Yeah. I think it works very well for CVS.