Bust up Big Insurance, curb Medicare Advantage, Republican says

Rep. Dr. Greg Murphy (R-N.C.) is a conservative who wants to rein in federal spending, and gets why big programs such as Medicaid and the health insurance exchanges make attractive targets for spending reductions. He's also a urologist and former hospital executive who has seen the value of access to healthcare firsthand.

That's why the trillions of dollars in healthcare cuts House Republicans are considering give him pause, even though he agrees with the direction House Speaker Mike Johnson (R-La.) and President Donald Trump want to take the federal government, Murphy said in a wide-ranging interview last week.

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Rather than simply rip massive amounts of money from major programs, Congress should be more focused and creative, said Murphy, who sits on the Ways and Means Committee, which has big influence over health policy because of its jurisdiction over Medicare.

Murphy draws on his experience inside the healthcare system to offer more nuanced, and perhaps unexpected, solutions.

The three-term congressman, whose district stretches from the Atlantic coast to Greenville, thinks lawmakers need to look at cracking down on overspending under Medicare Advantage, busting up vertically integrated healthcare conglomerates such as UnitedHealth Group and increasing doctor pay.

Murphy, who still sees patients, is particularly attentive to how new laws would affect hospitals, he said. Prior to entering electoral politics in 2015, Murphy was chief of staff at Vidant Medical Center in Greenville, the flagship hospital of University Health Systems of Eastern Carolina, known as ECU Health.

"First and foremost, I care about the patient in front of me, and that means access, that means affordability, that means the highest-quality care — period," Murphy said.

What it takes to achieve that, Murphy said, is "making sure that people who actually take care of the medicine or take care of the patient are taken care of — the doctors, the nurses, the physician assistants, nurse practitioners, everybody."

Trump tax cuts, Medicaid cuts

That would necessitate a tricky balancing act if Republicans remain committed to renewing the tax cuts on wealthy households and corporations Trump enacted in 2017, and which are due to sunset at the end of the year.

The Ways and Means Committee and Senate Finance Committee will take the lead on that effort. Murphy is a member of the Ways and Means Committee's and Veterans' Affairs Committee's health subcommittees and belongs to the GOP Doctors Caucus, the Primary Care Caucus, the Academic Medicine Caucus, the Kidney Caucus and the conservative Republican Study Committee.

Extending these tax policies would increase the federal debt by $4.6 trillion over 10 years unless Congress offsets the lost revenue with spending cuts or other tax increases, according to the nonpartisan Congressional Budget Office.

Murphy does not dismiss the substantial budget cuts that his colleagues are discussing. That includes taking $2.3 trillion out of Medicaid, which hospitals caution would have devastating consequences, particularly in rural areas like those Murphy represents.

From Murphy's point of view, there are savings to be found in healthcare programs, but lawmakers need to approach them with a scalpel, not an ax. Whatever Congress does, it must take into account how its policies impact patients and providers, not just the federal balance sheet, he said.

To reduce Medicaid spending, Murphy said, Congress should target providers that overtreat patients and bill the government and take steps to bring down enrollment. Murphy cited anecdotes of individuals he believes don't qualify for benefits but are enrolled, and pointed to work requirements as a means to shift people off Medicaid and onto job-based health plans.

"You're on Medicaid and you walk in the room fine, then there's somewhere you can work and get insurance," Murphy said. "There's plenty of savings that goes on with that. At the same time, I'm adamantly opposed to cutting anything that keeps our critical access hospitals, our rural hospitals alive."

'Cut the head off the snake'

Murphy also counts himself among the growing number of GOP lawmakers who look askance at the role of large, for-profit companies in the healthcare system. Rampant prior authorization demands, lack of competition among pharmacy benefit managers and other aspects of the health sector are ripe for change, he said.

"What they're doing is they're denying care to patients, making more expensive care to patients," Murphy said. "I don't mind profit. I don't. I'm very much a capitalist. But when you, on the end result, are not fulfilling your duty to allow me as a physician to take care of patients, to have them get the care that they need, and [when that's] in the face of unexplainable record profits, there is something wrong — morally, ethically and possibly legally."

UnitedHealth Group is the biggest offender, Murphy said. He would like the Trump administration to carry out the work the Federal Trade Commission began under President Joe Biden. That would ultimately lead, he said, to the disintegration of the company, which comprises the largest health insurer by membership in UnitedHealthcare, the second-largest PBM by market share in OptumRx and the largest employer of physicians in Optum.

Taking a hard line against UnitedHealth Group would make the rest of the industry fall in line, Murphy said.

"So many of the other companies do the same exact thing, but sometimes you have to cut the head off the snake to send a message that what they're doing is wrong — I truly believe immoral," Murphy said.

'Hundreds of billions' from Medicare Advantage

When it comes to Medicare Advantage — in which UnitedHealthcare is second in market share to Humana — Murphy and some other Republicans see too much profiteering and too much pressure on providers, even though the party has strongly supported the privatized version of Medicare for decades.

Medicare Advantage now covers more than half of Medicare-eligible people, a mark of success for the program created under President Bill Clinton and Speaker Newt Gingrich (R-Ga.) in 1997.

But what Murphy sees, he said, is far too many claims denials, shady marketing tactics and gaming the program to generate additional revenue. That means there's money on the table, he said.

"The upcoding is disastrous, and that will be hundreds of billions of dollars in savings," Murphy said. "These insurance companies using Medicare Advantage are taking advantage of the system, they're also upcoding and not providing the care."

Murphy is more traditional when it comes to the Affordable Care Act of 2010, in that he opposed it from the start. But enrollment in the law's health insurance exchanges surged to more than 24 million this year, spurred by enhanced premium tax credits Biden enacted that expire at the end of the year.

Like a number of other Republicans who are not fans of the law, however, Murphy did not just say the more generous subsidies should be allowed to disappear. He suggested that the tax credits are too generous and need to be rolled back. For instance, he noted that in rare cases families that earn up to $600,000 could qualify for at least some financial assistance if their medical expenses are more than 7.5% of their income.

"That's absurd, and so I think we'll take a good look at this," Murphy said. "We want our working poor, especially, to be able to get good, accessible healthcare. But again, we overshot," he said. "The adults are back in the room, and the adults are needing to balance the checkbook."

Raising doctor pay

At the same time, GOP lawmakers including Murphy have priorities that would require new spending. For instance, Murphy supports boosting Medicare reimbursements to physicians, who bemoan that rates haven't kept up with rising expenses. In December, Congress came close to undoing a 2.9% Medicare pay cut for this year but failed to see it through.

A new physician reimbursement system would cost many billions of dollars, but that's worth keeping doctors from leaving medicine or selling their practices to private equity investors or health systems, Murphy said. "The latter two are not the best care. It's less efficient, more expensive," he said.

The end-of-year spending package that didn't include a pay hike for doctors expires in March, and lawmakers are working on a "continuing resolution," or CR, to fund the government through the end of fiscal 2025. If the new bill doesn't address Medicare physician reimbursements, Murphy will oppose it, he said.

"I've had a guarantee from the Trump transition team to the speaker that this gets dealt with in the next CR," Murphy said. "it will be a red line for me, unless it gets dealt with. I cannot see the destruction of private practices."