Republicans Should Follow Voters’ Lead on Combatting Healthcare Fraud

Every election cycle, Washington promises to make healthcare more affordable. Democrats typically respond with larger government programs. Republicans, meanwhile, have increasingly embraced new regulations and structural interventions. Yet both parties often overlook one of the few areas where voters largely agree and where meaningful savings can actually be achieved: eliminating fraud, waste, and abuse in government health programs.

That may finally be changing.

A recent KFF Health Tracking Poll found that while healthcare costs remain Americans' leading economic concern, Republican voters rank fraud in government health programs as the health issue they most want candidates to address. Fifty-five percent say it is extremely important for candidates to address the issue, more than any other health issue. Most voters also believe fraud exists in government health programs and that reducing it would lower federal spending.

Republicans should seize this opportunity.

For decades, conservatives have championed responsible government and fiscal discipline. Healthcare reform offers perhaps the greatest opportunity to put those principles into practice. Instead of trying to manage healthcare markets through increasingly interventionist policies, Republicans should make program integrity the cornerstone of their healthcare agenda. That approach is not only philosophically consistent, it is one of the few reforms capable of lowering costs and preserving Medicare and Medicaid for those who truly depend on them.

One lesson I learned while overseeing Medicaid in Pennsylvania and Rhode Island is that protecting taxpayer dollars requires constant vigilance. Throughout my tenure, our agencies identified numerous categories of providers whose billing practices warranted closer scrutiny. Audits uncovered upcoding, unsupported claims, duplicate payments, and services billed at reimbursement levels that documentation did not justify. We did not allow those findings to sit on a shelf. My expectation was that irregularities would be addressed immediately.

When improper payments were identified, we worked to recover taxpayer dollars whenever possible and determine whether the cause was fraud, provider error, or a weakness in program controls. Suspected fraud was referred for investigation and enforcement; honest mistakes were corrected; and recurring vulnerabilities were addressed through corrective action plans. Most providers were honest professionals dedicated to serving patients. But a small number of bad actors — or persistent errors and weak controls — can cost taxpayers millions when government fails to respond.

Unfortunately, Washington has too often neglected this basic work of program integrity.

Instead of making fraud prevention and the reduction of improper payments a central priority, policymakers have increasingly turned their attention toward redesigning private healthcare markets. Some seek to break up physician practices, large healthcare organizations, or pharmacy benefit managers based largely on their size or corporate structure rather than evidence of unlawful conduct or consumer harm. Conservatives should be skeptical of that premise.

Breaking up private companies simply because they are large or vertically integrated substitutes government judgment for market competition and risks weakening the very negotiations and efficiencies that help control costs. Conservatives should resist replacing one form of government intervention with another. Instead, they should focus on making government perform the responsibilities it already has.

States should modernize eligibility verification by continuously comparing enrollment records against death records, employment databases, incarceration records, and residency information. Artificial intelligence can identify suspicious billing patterns long before traditional audits. Predictive analytics can detect emerging fraud schemes before millions of taxpayer dollars disappear. Provider enrollment standards should be strengthened for high-risk suppliers, and repeat offenders should face permanent exclusion from government health programs rather than cycling through years of administrative proceedings.

Congress should also require greater transparency regarding improper payment rates, fraud prevention efforts, recovery activities, and program integrity performance. What gets measured gets managed. Equally important, policymakers must distinguish fraud from honest mistakes. Program integrity should focus its toughest enforcement on intentional deception, not technical documentation errors or providers acting in good faith.

Republicans have long enjoyed greater credibility on government efficiency than on expanding government programs. Rather than attempting to compete with Democrats over who can better manage healthcare markets, Republicans should focus on what voters already expect them to do well: protecting taxpayer dollars and ensuring government programs operate with integrity.

Competent government is not inconsistent with limited government. In healthcare, it is one of its highest expressions. The cheapest dollar in healthcare is the one that is never stolen. Every fraudulent claim that is stopped before payment is a cost that taxpayers never have to absorb. Americans want lower healthcare costs, but they also expect government to safeguard the dollars they already send to Washington.

Before Congress writes another regulation, imposes another price control, or restructures another segment of the healthcare marketplace, it should first ensure that every taxpayer dollar is paying for legitimate care delivered to eligible patients.

That is not simply good policy. It is good government.

Gary D. Alexander is president and CEO of the Alexander Group. He previously served as Pennsylvania’s Secretary of Human Services and Rhode Island’s Secretary of Health and Human Services and Medicaid Director.

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