⚡️ NIMITZ HEALTH NEWS FLASH ⚡️ 

“Medicare Advantage: Past Lessons, Present Insights, Future Opportunities”

House Ways & Means Health and Oversight Subcommittees

July 22nd, 2025 (recording linked here)

WITNESS & TESTIMONY

• Ms. Dawn Maroney: CEO of Alignment Health Plan and President of Alignment Health

• Dr. Brian Miller, M.D., M.B.A., M.P.H.: Associate Professor of Medicine, Johns Hopkins University; Practicing hospital medicine physician

• Dr. David A. Basel, M.D.: Vice President of Clinical Quality and Population Health Officer, Avera Health

• Dr. Sachin Jain, M.D., M.B.A.: CEO, Senior Care Action Network (SCAN) Health Plans

• Dr. Matthew Fiedler: Joseph A. Pechman Senior Fellow – Economic Studies Center on Health Policy, Brookings Institution

HEARING HIGHLIGHTS

MEMBER OPENING STATEMENTS

• Health Subcommittee Chair Buchanan (R-FL) opened by praising Medicare Advantage (MA) as a popular and cost-effective option that serves millions, including over 100,000 in his district. He highlighted MA’s added benefits like dental, vision, and fitness programs, along with high satisfaction rates. Buchanan acknowledged concerns over prior authorization delays and outdated financial incentives. He called for reforms to improve transparency, reduce provider burden, and ensure the program remains strong.

• Health Subcommittee Ranking Member Doggett (D-TX) criticized MA for failing to save taxpayer money and instead driving up costs, citing $84 billion in overpayments this year. He shared stories of delayed care and administrative burdens, and warned of poor provider reimbursement. Doggett promoted bipartisan bills to ensure fair payment and close costly loopholes affecting veterans and the VA. He urged swift legislative action to curb waste and protect Medicare’s long-term future.

• Oversight Subcommittee Chair Schweikert (R-AZ) said he supports managed care in theory but stressed that current incentives in MA are misaligned. He warned that the Medicare trust fund could be depleted in seven years and emphasized the need to act. Schweikert noted his subcommittee has gathered thousands of pages of data from MA plans to investigate risk scoring and payment practices. He called for bipartisan reform to realign incentives and reduce long-term costs.

• Oversight Subcommittee Ranking Member Sewell (D-AL) warned that recent healthcare cuts would harm millions, especially in rural and underserved communities. She said MA’s rising costs and opaque practices demand oversight and reform. Sewell expressed concern about high denial rates and the impact of AI on care access. She called for bipartisan cooperation to ensure MA meets its promise without limiting care.

WITNESS OPENING STATEMENTS

• Ms. Maroney described Alignment’s approach to whole-person, tech-enabled care that proactively supports high-risk seniors. She shared a story of preventing a costly hospitalization with a $30 meal, illustrating their patient-first model. Maroney emphasized that Alignment keeps denial rates low and has earned high satisfaction and quality ratings. She urged policymakers to support innovation, competition, and reforms that remove barriers to care.

• Dr. Miller highlighted MA’s role in serving lower-income and minority seniors who can’t afford Medigap plans. He pushed for reforms to prior authorization and clinical data processes, including ending reliance on outdated technology like fax machines. He proposed loosening Stark Law restrictions for managed care and encouraged better data comparisons between MA and fee-for-service Medicare. Miller stressed the need for smarter reform grounded in real-world evidence.

• Dr. Basel said MA plans are creating rising administrative burdens that hurt rural hospitals, especially through denials and discharge delays. He shared examples where MA policies extend hospital stays, raise patient costs, and reduce reimbursement. Basel called out inconsistent definitions and payment standards that diverge from traditional Medicare. He urged reforms that ensure fairness, reduce burdens, and prioritize patient well-being.

• Dr. Jain emphasized that Medicare Advantage fills major gaps left by traditional Medicare, particularly for low- and middle-income seniors. He shared stories of how MA provides vital services like transportation and chronic care management. Jain acknowledged the need for reform but warned against ignoring MA’s value in promoting prevention, stability, and dignity. He called for improvements focused on transparency and patient-centered outcomes.

• Dr. Fiedler reported that MA costs 20% more per enrollee than traditional Medicare, largely due to flawed risk adjustment and favorable selection. He explained that only about half of the extra spending benefits patients, with the rest likely going to profits and marketing. Fiedler proposed aligning MA payments with traditional Medicare to save billions without cutting coverage. He stressed that meaningful reform could improve Medicare’s sustainability without increasing the uninsured rate.

QUESTION AND ANSWER SUMMARY

• Rep. Buchanan (R-FL) questioned on the nation’s reactive healthcare spending model, citing growing obesity and chronic illness. Dr. Jain responded by emphasizing the need for earlier intervention and lifestyle support, describing SCAN’s approach to proactive chronic care. Dr. Miller advocated for CMS to promote specialized, customizable MA plans, including those for institutionalized and dual-eligible patients, which could better prevent disease and manage costs.

• Rep. Doggett (D-TX) criticized deceptive ads opposing MA reform and asked how reducing overpayments could benefit both traditional and MA enrollees. Dr. Fiedler stated that correcting MA’s inefficiencies could raise base Medicare benefits and improve plan benchmarks, potentially making both systems stronger.

  Rep. Doggett then pressed for improvements to risk adjustment, including adoption of MedPAC’s DESE model. Dr. Fiedler supported insurer-specific coding intensity adjustments but warned of tradeoffs with selection incentives.

  Rep. Doggett also questioned the true value of MA supplemental benefits; Dr. Fiedler responded that offerings like dental are often limited and not worth the cost of current overpayments.

• Rep. Smith (R-MO) highlighted strong consumer interest in MA and asked about upcoding risks. Ms. Maroney emphasized the need for transparency and targeted reforms without undermining the program’s value, especially for fixed-income seniors.

  Rep. Smith also raised concerns about rural access and prior authorization burdens; Dr. Basel discussed how transportation is a major barrier in rural areas and praised MA's potential to innovate in addressing it. Dr. Miller proposed real-time, automated approvals integrated with EHRs, while also calling for better provider documentation tools to reduce denials and inefficiencies.

• Rep. Sewell (D-AL) asked how Alignment keeps its denial rate under 2%; Ms. Maroney credited auto-approvals and early member assessments.

  Rep. Sewell then raised a case of a hospital facing lengthy appeals despite prior authorization, and questioned whether AI would worsen the problem. Dr. Basel suggested AI could help if aligned with provider needs, but agreed that biased algorithms could do harm. Dr. Fiedler noted that MA’s denial patterns create uneven financial stress, particularly for vulnerable hospitals.

• Rep. Smith (R-NE) emphasized the importance of rural access to MA. He asked how Avera succeeds in rural areas; Dr. Basel credited tight care coordination made possible by Avera’s dual role as provider and plan. He urged CMS to support small plans by addressing network adequacy and selectively targeting aggressive coding practices, rather than applying broad payment reductions.

• Rep. Fischbach (R-MN) focused on how prior authorization policies impact rural hospitals and patient discharge planning. Dr. Basel explained that delays in approving skilled nursing facility transitions lengthen hospital stays, limit bed availability, and increase costs. He noted that recent federal streamlining efforts have not improved the trend and that denial rates continue to rise. On supplemental benefits, he stated that while fitness perks are underused, dental and vision coverage have the most tangible impact, especially in rural areas where care access is limited.

• Rep. Thompson (D-CA) warned that Republican-backed healthcare cuts threaten hospital solvency and access to care, especially for low-income seniors. Dr. Fiedler responded that canceling automatic enrollment in Medicare Savings Programs will make it harder for eligible seniors to afford premiums and cost-sharing, potentially reducing care access.

  Rep. Thompson concluded that without hospitals and clinicians in place, insurance coverage alone is meaningless.

• Rep. Kelly (R-PA) highlighted how bureaucratic delays in treatment approvals undermine patient care. He expressed bipartisan support for fixing these operational inefficiencies and asked for solutions. Dr. Basel called for standardized, electronic prior authorization processes, noting that some payers still require phone dictation. Dr. Miller agreed, urging collaboration among hospitals, payers, and regulators to implement automated, real-time systems.

• Rep. Moore (R-UT) emphasized the success of MA in Utah, where over 60% of Medicare beneficiaries are enrolled, and asked how to preserve the program’s value while addressing flaws. Dr. Jain underscored that MA’s predictability and financial protection are especially attractive to seniors without retirement savings, and urged that reforms avoid undermining these strengths.

  Rep. Moore also asked how plans can better serve rural areas; Dr. Jain highlighted supplemental benefits and social supports like food delivery and transportation as effective tools. Dr. Basel agreed and stressed that CMS must remove regulatory barriers that hinder such innovations.

• Rep. Yakym (R-IN) raised concerns about administrative burdens from prior authorizations under MA plans, particularly for rural providers. Dr. Basel responded that while prior authorization can help avoid unnecessary procedures, excessive requirements delay necessary care. He noted that rural facilities lack the specialized staff to manage the complexities of these processes and called for streamlined systems that better predict which procedures are likely to be approved, reducing unnecessary denials.

• Rep. Chu (D-CA) pressed on why Medicaid work requirements fail to detect fraud, while MA plans benefit from billions in improper payments due to upcoding and opaque AI systems. Dr. Fiedler confirmed that work requirements primarily result in coverage loss for eligible individuals and that MA plans receive tens of billions in overpayments with limited beneficiary benefit.

  Rep. Chu also previewed legislation requiring transparency and physician oversight for AI-based coverage decisions, which Dr. Fiedler said would be necessary to ensure accountability.

• Rep. Murphy (R-NC), a physician, voiced support for well-managed MA plans but lambasted large insurers like UnitedHealthcare for corrupting the system through upcoding and mass denial strategies. Dr. Miller agreed that the MA star rating system lacked value, suggesting that it should apply to fee-for-service Medicare and include downside risk.

  On the viability of private practice under MA, Dr. Miller emphasized that independent physicians are being crowded out by tax-exempt hospital systems and that reforms should support practice ownership.

• Rep. Bean (R-FL) promoted his "Apples to Apples" bill, which would require CMS to release complete comparative data between MA and fee-for-service Medicare. Ms. Maroney asserted that MA offers value through low premiums and high satisfaction, though she admitted there was room for improvement in transparency. Dr. Miller agreed with the bill's intent but criticized current comparisons as statistically flawed. Dr. Basel supported greater transparency and noted that his organization's MA patients often receive higher-quality care, but also stressed the need for uniform quality metrics.

• Rep. Evans (D-PA) shifted focus to “food as medicine” and criticized recent SNAP cuts that undermine health and increase costs. He asked about the role of MA in addressing food insecurity. Dr. Fiedler explained that while some MA plans offer food-related supplemental benefits, core solutions like SNAP are more efficient. He recommended both policy domains—healthcare and food assistance—be aligned to address social determinants of health.

• Rep. Hern (R-OK) expressed concern that Biden administration policies have reduced the financial resources available for MA supplemental benefits. Dr. Jain explained that recent CMS changes, particularly to the risk adjustment model and star ratings, have cut MA revenue and led to reduced benefits. He criticized the star rating methodology as distorted, citing a lawsuit his plan filed against CMS over an unfair rating penalty. Dr. Miller then called for automated physician-coded diagnoses and full transparency in data to enable accurate comparisons between MA and fee-for-service Medicare.

• Rep. Moran (R-TX) emphasized the strain of prior authorizations on rural providers in his district. Dr. Miller acknowledged that prior authorization adds administrative burden and contributes to burnout, but said the solution lies in using AI to automate approvals and clarify criteria. Dr. Basel added that inconsistency across plans creates challenges, especially when providers feel compelled to deliver care at their own financial risk while awaiting authorization.

  Rep. Moran then asked about increasing transparency for beneficiaries. Ms. Maroney recommended public data from CMS on supplemental benefits and prior authorization rates to foster competition and informed consumer choice.

• Rep. DelBene (D-WA) criticized the inefficiency of MA prior authorization, noting that over 80% of denials are eventually approved—wasting time and delaying care. Dr. Fiedler said appeals consume significant administrative time and cost, diverting resources from patient care.

  Rep. DelBene warned that CMS’s new Wiser model could worsen access by rewarding contractors for denying care in traditional Medicare. Dr. Fiedler agreed the model risks creating harmful incentives and is unlikely to improve care access for seniors.

• Rep. Miller (R-WV) highlighted rural challenges with MA, including provider exits due to low reimbursements and prior auth burdens. Dr. Basel emphasized the need to streamline processes and reduce admin friction to help rural systems. He supported telemedicine as a partial solution to network adequacy issues. Dr. Miller noted that prior auth processes in MA are more burdensome than traditional Medicare, especially for rural practices lacking admin support, and urged more automation to ease the load.

• Rep. Van Duyne (R-TX) backed reforms to modernize prior auth, sharing stories of delayed care affecting stroke and end-of-life patients. Ms. Maroney stressed her organization’s efforts to ensure continuity of care and denied seeing the delays others reported. Dr. Miller confirmed such delays strain hospitals and patients alike, though occasionally prolonged stays have benefits. Dr. Basel reported that MA plans often downcode rehab needs, placing stroke patients in lower-intensity settings against medical advice.

• Rep. Davis (D-IL) condemned HR 1 for slashing over $1.5 trillion from healthcare programs, warning of long-term harm to low-income families, seniors, and safety-net providers. Dr. Fiedler affirmed that loss of coverage leads to worse financial outcomes, including medical debt, evictions, and lower credit access, particularly for the uninsured who face catastrophic costs without Medicaid protection.

• Rep. Fitzpatrick (R-PA) asked how care coordination and Special Needs Plans impact outcomes. Ms. Maroney explained that team-based, risk-adjusted care planning with supplemental benefits like meals and fitness services led to reduced admissions and readmissions.

  Rep. Fitzpatrick raised concerns about step therapy and administrative burdens for independent providers. Dr. Miller recommended integrating formulary and prior auth data into EHR systems and automating submissions to reduce friction and redirect plan dollars toward improved processes.

• Rep. Miller (R-OH) flagged administrative burdens and delayed reimbursements, especially with large systems like Cleveland Clinic. Dr. Miller urged adoption of modern IT systems used in other industries to eliminate outdated practices like faxing. Dr. Basel stressed that transparency in both decisions and denials is as critical as efficiency, noting inconsistent standards between medical directors and AI-driven decisions.

• Rep. Suozzi (D-NY) asked each witness if MA “needed a tune-up” or a full overhaul. Responses ranged from minor improvements to structural reforms. On cost, most witnesses acknowledged MA could be made more efficient. On upcoding, responses varied: some saw it as a widespread issue, others as limited to certain plans. All agreed prior authorization needs improvement, and everyone supported more transparency—though Dr. Fiedler cautioned it won’t solve deeper structural issues alone.

• Rep. Moore (R-UT) questioned the abuse of in-home risk assessments and asked how to maintain accountability without discarding valuable services. Dr. Miller proposed automating diagnosis coding within EHRs and enabling point-of-care validation by physicians.

  Rep. Moore also asked how to improve the star rating system. Dr. Jain responded that ratings are poorly understood and inconsistently trusted, urging reforms to make differences more meaningful and relevant at the point of sale.

• Rep. Horsford (D-NV) criticized recent GOP-backed health cuts and asked how HR 1 could harm Medicare stability. Dr. Fiedler noted the bill rolled back efforts to expand cost-sharing assistance, potentially raising financial burdens for low-income beneficiaries.

  On supplemental benefits, Dr. Jain emphasized their real-life value for low-income seniors but warned of misleading availability. Dr. Fiedler suggested expanding traditional Medicare’s benefits would be more equitable than relying solely on MA to fill gaps.

• Rep. Sanchez (D-CA) criticized Republicans for cutting coverage while claiming to combat fraud. Dr. Jain could not comment on specific MA premium projections but acknowledged that broader payment pressures might lead to market stress. On transparency, Dr. Fiedler doubted quality bonuses are currently driving meaningful care improvements.

  Rep. Sanchez proposed tracking prior authorization overturn rates; Dr. Jain endorsed this idea, saying it would help patients better understand what they’re buying and improve plan accountability.

• Rep. Panetta (D-CA) raised concerns about “ghost networks” in Medicare Advantage, where outdated provider directories mislead patients and result in costly out-of-network care. Dr. Miller supported reforms to require accurate directories and advocated integrating them into the Medicare Plan Finder, enabling real-time comparisons between MA and traditional Medicare options.

  Rep. Panetta highlighted his bipartisan REAL Health Providers Act to mandate annual directory updates and agreed that transparency and consumer tools are critical to reducing surprise costs and improving plan choice.

• Rep. Moore (D-WI) emphasized her district’s high MA enrollment and asked how plans can maintain low prior auth denial rates. Ms. Maroney credited proactive care coordination and navigator support.

  Rep. Moore then questioned how MA plans upcode while favoring healthier enrollees. Dr. Fiedler explained that plans document additional diagnoses for relatively healthy patients while sicker individuals may opt for traditional Medicare due to easier access.

  Rep. Moore flagged racial disparities in MA enrollment and asked if more demographic data would improve oversight. Dr. Fiedler agreed, citing major CMS data gaps. He also warned that proposed federal cuts could severely impact both MA and traditional Medicare.

• Rep. Schweikert (R-AZ) raised concerns about Medicare’s unsustainable cost trajectory, upcoding in MA, and misleading marketing practices. He emphasized aligning incentives in managed care to improve outcomes and reduce spending. Dr. Miller endorsed using AI to streamline prior auth and called for regulatory reforms, including Stark Law adjustments, to level the playing field for independent physicians. Dr. Jain advocated for multi-year MA enrollment to encourage long-term investment in patient health and proposed repurposing broker commissions to support preventive care. Dr. Basel highlighted how telehealth and improved EMR interoperability are already expanding rural access.