Taking on healthcare waste, fraud an unexpected midterm chance for GOP

David L. Cannon

Submitted photo/InsideSources.com

For lawmakers seeking issues that resonate beyond traditional partisan fights, tackling healthcare waste and fraud offers both good policy and good politics. Reforming Medicare Advantage would show voters that the GOP is willing to confront abuse, lower costs and make the healthcare system work better for everyone.”

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OPINION — Republicans face an uphill battle in the 2026 midterms. The party in power usually loses ground, and voters are increasingly frustrated with rising costs and a healthcare system that feels broken. 

However, Republican officials and GOP congressional candidates could boost the party’s popularity with voters by tackling an unlikely issue: healthcare fraud. New polling shows that 81% of voters are more likely to support candidates who prioritize cracking down on healthcare waste, fraud and abuse.

Among the clearest opportunities to show voters that Republicans are serious about tackling healthcare abuse is taking on Medicare Advantage, a program increasingly plagued by wasteful incentives and overbilling.

Medicare Advantage, a hybrid program offering customized private plans to Medicare patients, is rife with waste and fraud due to bad incentives that encourage insurers to overbill patients. 

Medicare Advantage is more vulnerable to waste and fraud than traditional Medicare because private insurers like UnitedHealthcare and BlueCross BlueShield — not the Centers for Medicare & Medicaid — act as middlemen, determining risk scores that dictate how much the government pays them. 

Patients with higher risk scores generate larger reimbursements. Without stronger oversight and safeguards, that system makes it easy for insurers to inflate diagnoses and risk scores in order to secure larger government payouts.

And insurers do more than inflate risk scores. They also manufacture diagnoses to make patients seem sicker than they are. A common tactic is sending representatives to patients’ homes for “health-risk assessments,” questionnaires that patients take after treatment. Insurance companies will bill the government for medical conditions described only in these assessments, or change diagnoses of previously established conditions. 

When companies “upcode” patients like this, everyone loses. Millions more American patients will enroll in Medicare Advantage by 2030, and each new enrollee is another opportunity for fraud and waste that taxpayers will ultimately fund. 

Voters are tired of watching large healthcare institutions exploit loopholes while taxpayers absorb the costs.

While big insurers are becoming the central villain among voters, the administration and Congress have been slow to combat their fraud, even as evidence of abuse continues to emerge publicly. Just last year, Kaiser Permanente paid the Department of Justice $500 million for overcharging on their Medicare Advantage plans. From 2009 through 2018, Kaiser added a half-million diagnoses that generated about $1 billion in improper payments to the health plan.

These penalties punish insurers only after they’ve defrauded patients and taxpayers. Republicans now have the chance to crack down on insurers before they get the chance to overcharge their way to financial success. 

Centers for Medicare & Medicaid Administrator Mehmet Oz has announced department-wide initiatives to crack down on waste and fraud. So far, reimbursement rates have remained unchanged. CMS can ban outdated medical coding terms, and revising the insurance risk-score formula could prevent insurers from gaming the system. 

CMS action would help deliver on promises to hold big insurance accountable and lower costs for taxpayers.

Congress, too, should move quickly on the No UPCODE Act, which would crack down on inflated Medicare Advantage risk scores and overpayments driven by aggressive coding practices. Measures like these could finally have the momentum needed to cross the finish line.

For lawmakers seeking issues that resonate beyond traditional partisan fights, tackling healthcare waste and fraud offers both good policy and good politics. Reforming Medicare Advantage would show voters that the GOP is willing to confront abuse, lower costs and make the healthcare system work better for everyone.

David L. Cannon is an orthopedic surgeon in Tennessee. He wrote this for InsideSources.com. Please submit comments at yourvalley.net/letters or email them to AzOpinions@iniusa.org. We are committed to publishing a wide variety of reader opinions, as long as they meet our Civility Guidelines.