Warning Signs: Potential Congressional Investigations in Healthcare

Few sectors are more consistently in the crosshairs of congressional oversight than healthcare. In the 119th Congress, Republican committee chairs have pursued investigations into group purchasing organizations (GPOs), pharmacy benefit managers (PBMs), Affordable Care Act (ACA) plans, healthcare fraud, insurance costs, data breaches, drug pricing and hospital systems through hearings, detailed information requests and subpoenas. With the exception of ACA-focused inquiries, these same issues have long drawn scrutiny from Democratic lawmakers, underscoring the bipartisan nature of oversight risk in this space.

If Democrats gain a majority in one or both chambers, companies should expect these core lines of inquiry to continue alongside potential investigations tied to the Trump Administration that could introduce additional layers of scrutiny. Democratic members and staff have already begun laying the groundwork for such efforts, including issuing document retention letters that, while not legally binding, signal investigative priorities, preserve evidence and establish predicates for future compulsory process. With prior experience of executive branch resistance, staff are increasingly focused on private sector actors, where exposure in a congressional investigation may be more immediate.

This Holland & Knight alert examines the issues most likely to shape future healthcare investigations and highlights specific areas of focus emerging from Democratic oversight planning.

Perennial Congressional Oversight Matters

Affordability

Following years of price increases across sectors and bipartisan interest in healthcare costs, the issue of affordability is likely to be a central focus of congressional oversight. In the healthcare sector particularly, affordability will be a central theme as committees launch inquiries into drug price strategies, PBM rebate and formulary practices, GPOs, insurance premiums and cost-sharing, and surprise medical billing. Beyond a stand-alone issue, affordability will serve as a unifying narrative used to justify cross-cutting investigations across multiple healthcare sectors. This is likely to be a focus regardless of which party controls the House or Senate.

Private Equity in Healthcare

Building on the theme of affordability and quality of care, congressional Democrats are likely to examine the role of private equity in the healthcare sector. This would likely include investigations into the acquisition of hospitals, nursing homes, physician groups and drug and device startups by private equity firms, with an examination of consumer prices, patient outcomes, quality of care, staffing levels, and the financial and operational impacts of ownership structures, including debt and potential changes to service offerings.

Hospital Consolidation

Hospitals that have recently merged into larger healthcare systems and those healthcare systems themselves are possible targets for congressional investigations from multiple angles and committees. Committees with jurisdiction over public and private healthcare spending – such as the House Committee on Ways and Means and House Committee on Energy and Commerce – are possible sources of inquiry, as are committees with jurisdiction over antitrust or oversight more broadly, such as the House Committee on the Judiciary and House Committee on Oversight and Government Reform. Likely topics include reduced competition, post-consolidation price increases, quality measures, labor impacts, facility closures or service line reductions, and cross-market consolidation.

Medicare Advantage

Democratic chairs are likely to continue scrutiny of insurers participating in Medicare Advantage on issues such as marketing practices, risk adjustment and upcoding, denial of care and prior authorization practices, and the relationship between quality ratings and federal reimbursement.

Algorithmic Decision-Making

In addition to ongoing concerns about the use of artificial intelligence (AI) in healthcare, there is growing attention to algorithmic bias against vulnerable populations, the use of AI to deny or limit care, and related data sharing between healthcare providers, insurers and Big Tech. Committees may also examine transparency, validation and governance of AI tools, as well as data sharing practices between healthcare entities and technology companies.

Surprise Billing and Medical Debt

Emphasizing the theme of affordability, congressional committees may conduct oversight of compliance with the No Surprises Act, including efforts to circumvent its provisions, as well as the role of medical debt and debt collection in consumer financial distress.

FDA-Regulated Industries

U.S. Food and Drug Administration (FDA) and U.S. Department of Health and Human Services (HHS) activities in this administration have drawn the ire of Congress. Expect topics such as use of the FDA Commissioner's National Priority Voucher (CNPV) program, supply chain issues, safety of new products and use of AI in healthcare to be the focus of oversight. In addition, with the pending reauthorization of user fee programs for prescription drugs, generic drugs, medical devices and biosimilars, Congress will have built-in opportunities to raise these issues. 

Prior Authorization and Utilization Management

Congressional committees are likely to increase scrutiny of prior authorization practices across public and private payers, including the role of automation and evidence-based review tools. Emerging utilization management models, including the Wasteful and Inappropriate Services Reduction (WISeR) Model, are likely to face significant congressional scrutiny. Oversight efforts are likely to focus on whether these models contribute to inappropriate denials or restricted access to services.

Targets Related to the Trump Administration

Conflicts of Interest

Several Democratic leaders have expressed concerns over potential conflicts of interest by appointees and special government employees in the second Trump Administration. Likely congressional oversight will include information requests for communications, financial disclosures, and recusal or ethics compliance documentation to former and current employers of these individuals, examining alleged favoritism, the investments of current and former officials, and other matters related to perceived conflicts of interest.

Negotiations with the Trump Administration

In the eyes of many congressional Democrats, any "behind closed doors" negotiations between industry and the Trump Administration are inherently suspect and worthy of oversight efforts. This will very likely lead to investigations into a wide variety of negotiations, including U.S. Department of Justice matters and pharmaceutical manufacturer discussions related to TrumpRx and most-favored-nation (MFN) pricing arrangements, particularly where pricing concessions, access implications or negotiation processes lack transparency. The ongoing litigation risk surrounding MFN policies – particularly related to the Global Benchmark for Efficient Drug Pricing (GLOBE) and Guarding U.S. Medicare Against Rising Drug Costs (GUARD) models – further elevates their profile as a likely target for congressional oversight.  Related is the relationship between these company-specific pricing agreements and FDA regulatory decisions.

These congressional inquiries often proceed alongside or lead to parallel scrutiny from state attorneys general and plaintiffs' bar litigation.

The Calm Before the Storm: Preparing for Increased Congressional Scrutiny

With midterm elections still months away, congressional Democrats have already begun laying the groundwork for potential investigations through document retention requests, engagement with watchdog groups and the press, and other preparatory activity. Rather than waiting until the new Congress is sworn in on January 3, 2027, entities potentially in the crosshairs can use this period to assess risk, mitigate exposure and develop action plans, including targeted internal assessments, document retention and communication reviews, and coordination across legal, policy and communications functions.

Congressional investigations present a distinct challenge. They are neither traditional lobbying efforts nor conventional white collar matters but operate in a highly visible environment that creates legal, reputational and policy risk if not managed effectively. 

Holland & Knight's Congressional Investigations Team brings together top former congressional investigators and oversight committee chairs, experienced healthcare attorneys, seasoned white collar lawyers and litigators, and public policy professionals to support clients across all aspects of congressional engagement. We work with clients to assess exposure, strengthen internal processes and develop practical strategies to respond effectively to congressional inquiries while maintaining focus on business objectives. If you have any questions or need assistance, contact the authors or another member of the team.

Information contained in this alert is for the general education and knowledge of our readers. It is not designed to be, and should not be used as, the sole source of information when analyzing and resolving a legal problem, and it should not be substituted for legal advice, which relies on a specific factual analysis. Moreover, the laws of each jurisdiction are different and are constantly changing. This information is not intended to create, and receipt of it does not constitute, an attorney-client relationship. If you have specific questions regarding a particular fact situation, we urge you to consult the authors of this publication, your Holland & Knight representative or other competent legal counsel.