American health giant UnitedHealth made occasional unsuccessful forays into primary care in the UK in the 2000s, and more recently its Optum subsidiary has been picking up lucrative contracts for NHS support services including IT, number-crunching and back-office systems.

But so far it has shown little sign of any more serious effort to invade much more of the under-funded English health care system, least of all as an insurer. This is in stark contrast to UnitedHealth’s burgeoning expansion in the US, where, despite only minimal involvement in direct patient care, it has grown close to creating a “private single payer system.”

A detailed article published in August by The American Prospect magazine – Health Care’s Intertwined Colossus – explores the prolific growth and the scope of UnitedHealth’s powers in the US market, and helps explain why its bosses might regard England as offering comparatively slim pickings.

The article shows how the corporation’s growth has been intrinsically linked to the US system, where extensive lobbying and donations to both major parties has enabled the health care corporations to buy the connivance of US politicians at national and state-wide levels.

UnitedHealth began in the 1970s as a for-profit company managing a non-profit business in Minneapolis, and it has grown by utilising all of the loopholes and contradictions of the world’s most expensive and dysfunctional health care system, to become the fifth largest public company in the US, and one of the 30 largest in the world.

While it’s best known as an insurance company, UnitedHealth began as a health management company but has extended its tentacles of power in many more directions, becoming the largest employer of physicians in the US, but also buying up pharmacies, primary care clinics, surgical and urgent care centres, home health providers, mental health providers, hospices, an IT division, and more.

United has even set up its own bank, offering among other things pay day loans (at 35 percent interest) to independent physicians … waiting for payment of their invoices to UnitedHealth.

The corporation’s story has been a consistent one of seeking to generate profits at every level, from patients, independent providers and from the government. Its story began with the Nixon government’s encouragement of ‘health maintenance organisations’ (HMOs) as an alternative to fee for service. HMOs offered a reduced fee to patients, but limited their cover to hospitals and doctors they employed or contracted directly with: the decision-making in health care was increasingly handled by accountants and insurers rather than by doctors.

By the early 1980s United’s founder Richard Burke had spotted the additional profit stream to be made from managing the drugs available to HMO subscribers, and established the first Pharmacy Benefit Management company, which began to coin in profits … at the expense of higher prices for patients as more costly brand names were favoured over cheaper generics.

United began to acquire HMOs and other health insurers, and use its growing market power to force down prices from doctors and hospitals and undercut rival insurers. While the growth of HMOs was good for business, the 1990s saw increasing anger at the ways they could be seen denying patients treatment and giving doctors incentives to limit treatment. Nonetheless they became the only game in town: between 1989 and 1996 annual HMO transactions grew from $1 million to $13 billion.

Attempts to rein in the powers of the HMOs proved fruitless, even when 700,000 physicians joined forces in a class action suit against United and other HMOs in 2002, alleging fraud and racketeering.

George W Bush’s government created Health Savings Accounts (HSAs), allowing wealthier people to save in tax deductible funds against the risk of requiring health care – and United spotted the profitable opportunity to establish a bank offering HSAs, and is now the second largest in the field, holding £20 billion from millions of users.

The authors show how time and again UnitedHealth has been the first, most ruthless and most brazen in exploiting every opening; cornering 80% of the market in claims data management; buying up an “independent” think tank to influence government policies; pocketing billions in government subsidies for health information technology  and electronic health records systems; and even cashing in on the Obama administration’s effort to increase the “Medical Loss Ratio” – forcing health insurers to spend as much as 80-85% of their premium revenue on patient care. United’s response was to further expand, so that more premium income could pile up more profit.

More recently United’s emphasis has been on buying up groups of physicians, making them employees, but doing so one at a time to avoid scrutiny from regulators. The more physician practices they own, the more United can force down physician fees – and eliminate any competition.

United has also gone back into the PBM business, and its PBM OptumRx is predictably maximising its profits by fleecing stand alone drugstores and forcing independent pharmacists out of business. More recently it has bought up home health companies and hospices.

Time and again when caught in the wrong by the courts, United has paid sums as high as $890 million to settle cases. But the company has also been able to ride through other legal challenges.

The result has been poorer care and higher costs for patients: according to the Kaiser Family Foundation in June, United denies almost a quarter of all claims for treatment by independent doctors.

It’s become a beast too big for the US government or its weak regulators to tame or contain, and too powerful for its rivals to challenge. UnitedHealth Group gross profit for the quarter ending September 30, 2023 was $23.4 billion, a 17.22% increase year-over-year.

The authors point out, perhaps rather naively given the power of the medical industrial complex in the USA and the weakness and often compliance of Democrat administrations that:

“the fact that United is essentially running a private single-payer system, with more customers than most nations have citizens, could also be the answer to the problems United creates. …

“Under public utility regulation, premiums could be capped. The government could oversee United’s offerings so closely that it effectively serves as a public option. And conflicts of interest could be eliminated: … separating insurer financiers from owning health providers altogether.”

Nobody really believes this is a realistic prospect in the US in the foreseeable future. But from a selfish UK perspective perhaps that might ensure that United’s attentions remain focused on further milking its home market rather than attempting high risk ventures here or elsewhere in Europe.

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