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LONDON — In the final days of 2020, the U.S. health insurer Centene made a swift incursion into Britain’s prized National Health Service, one of the world’s largest employers.

A Centene subsidiary, Operose Health, took over nearly three dozen medical practices in London — gateways for NHS care — in a deal worth tens of millions of dollars. The subsidiary became the largest private supplier of general practice services in the United Kingdom, with 67 practices accounting for 570,000 patients.

A local health commission, records show, signed off after a nine-minute review in a virtual hearing held the week before Christmas. Centene was not mentioned. Not a question was asked. It was the time of year — amid pandemic restraints — when official business in London gave way to fizzy cocktails and quiet glad tidings.

Within weeks, the acquisition set off alarms for Louise Irvine, an NHS doctor, who called it “privatization of the NHS by stealth.” Irvine, other practitioners, and residents supported a crowdfunded legal challenge to the takeover of AT Medics Holdings, the U.K. primary care company under contract to the NHS.

Centene is the largest privately managed care provider in the U.S. that offers government-sponsored insurance, such as Medicaid and Affordable Care Act plans, as well as health care to seniors, prisoners, military members, and veterans. Britons who protested its expansion saw a for-profit outsider with ambitions that could weaken the NHS. They worried Centene would decide on staffing to suit its bottom line. NHS contracts with doctors at set rates, and assistants are paid less; critics questioned whether the Centene deal would reduce more highly trained staff.

Then there was this: The corporation faced legal problems and had paid fines, since 2013, over noncompliance with state or federal Medicaid contracts or rules. By mid-2021, as its legal battle intensified in London, Centene was grappling with allegations of overbilling Medicaid for pharmacy services. It has since paid about $657 million to settle the accusations of 15 states. It faces investor lawsuits as well as overbilling allegations from several more states. Centene, based in Missouri, has denied wrongdoing.

Centene’s “suitability” for doing business with the NHS was not discussed in the virtual hearing. And because of technical limitations, members of the public could review the decision only through an audio recording, released online a day later.

“It was covid time,” Irvine, now retired, said with some frustration about the public meeting. “We believe NHS should be a public service, and it is being gradually eroded.”

Centene did not respond to requests to discuss its U.K. strategy. By July 2021, Centene’s interests also acquired Circle Health Group, a private health care group based in London with 50 hospitals.

Earlier this year, a judge ruled that the 2020 public meeting was conducted lawfully. The judge questioned the relevance of raising Centene’s liabilities; she noted the American company’s counsel had documented that its “financial position was strong” and that the insurer “continues to operate successfully in the U.S. health care market.”

Advocates for market-based efficiencies, including former NHS chiefs who were hired by Centene-related businesses, portray the managed-care titan as a change agent that can innovate and trim costs.

In October, an NHS care commission declined to renew a Centene contract for Hanley Primary Care Center in north London, which was part of the 2020 deal. The clinic was left with too few doctors, the Islington Tribune reported, and patient appointments had dropped by 270 a week, representing a “huge hole” in care since the acquisition. The NHS’ decision followed a BBC report in June about Operose staffing, in which clinic employees said the practice was short eight doctors and that less qualified workers, called physician associates, filled the gaps.

Operose spokesperson Stephen Webb, in an email, said the Hanley practice “is currently rated as ‘Good’ by the national regulator” and the contract would be reviewed next year. On its website, Operose calls the BBC report “sensational.” It adds that “we have a strong track record of performance, recruitment and investment in our staff and services.”

The Hanley decision is a small validation for Irvine and others who warned that efficiencies would degrade the quality of care.

“The whole ethos of the American system, well, it is fundamentally different than how we view care in the U.K.,” Irvine said. “Our values are free and accessible health care for all.”

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Cultivating Ties in Government

Centene was eyeing the British health system in winter 2011, when it hosted health advisers from across Europe to tour its facilities in Spain’s seaside region of Valencia.

In March 2011, and again in 2015, representatives from Centene’s subsidiary Ribera Salud promoted its “pioneering approach” to caregiving at hospitals and treatment centers through a public-private partnership, according to an NHS advisory report.

Like Britain, Spain faces an aging population. The subsidiary promised a model for “efficient and effective healthcare” for patients who are government-supported or pay out-of-pocket. The government paid the provider a flat rate per patient each year, and Ribera Salud operated the sites and managed staff.

The approach intrigued British politicians and advisers, conservatives as well as liberals, eager to manage health care costs by encouraging competition.

Centene cultivated its image and relationships, launching the subsidiary Centene UK in 2016. Within months, it was hiring NHS administrators for its executive ranks. Among the highest-profile recruits: Samantha Jones, a nurse and the NHS England director of “new care models,” who had championed Centene’s work in Spain.

By 2019, Jones was named CEO of Centene UK. In 2021, she left to work for Prime Minister Boris Johnson as “an expert adviser for NHS transformation and social care.”

As Johnson’s premiership came under pressure, Jones was named chief of operations at No. 10 Downing St. She left when he resigned in July.

By then, Centene had a substantial U.K. foothold and other former NHS administrators had joined its top ranks. Contacted through LinkedIn, Jones said she was “not available to do any interviews.”

For consumers intent on preserving Britain’s national health care — or just understanding who owns what and where — Centene is difficult to track. It’s the same in the U.S., where the company has more than 300 subsidiaries. Names there typically lean into local iconography such as Peach State Health Plan of Georgia and Buckeye Community Health Plan of Ohio — with no mention of Centene.

In England, Jenny Shepherd, 72, has written about Centene and its subsidiaries for years. She set up a hyperlocal news site in 2012 to track public services amid government budget restraints. She soon focused on NHS. When Centene’s operations in Spain were being floated as a model for reform, Shepherd saw little coverage of it. “Journalism was lacking,” she said.

Shepherd scours regulatory filings for her posts, published under “NHS Matters.” Over years, she has documented a flowchart of sorts of Centene’s businesses. She said the company routinely recasts its corporate profile. From 2016 to 2018 alone, subsidiary names, addresses, and company directors changed often, she noted.

In 2018, Centene UK was listed as controlled by a Centene subsidiary, MH Services International Holdings. In November 2019, according to regulatory filings, Centene UK formally changed its name to Operose Health.

The practices acquired in 2020, however, were still identified in March 2021 as part of AT Medics Holdings. That filing, in U.K. government records, lists Operose Health as a board member.

Centene’s stake in Circle Health was laid out in December 2021 regulatory filings. Circle Health’s parent company in the U.K. is MH Services International (UK) Ltd., “with the ultimate parent being Centene Corporation,” records show.

Centene aims to wring profit from government-guaranteed payments, Shepherd said: “The English NHS is as big as the Chinese army, and it was clear that the Americans wanted to get their hands on it.”

Such guarantees have diminished, however, as health care costs have increased. The pandemic has propelled a two-year backlog for some treatments. For the first time in history, NHS nurses in England, Wales, and Northern Ireland went on strike in December, largely over pay. Ambulance drivers and paramedics in England and Wales followed suit. Military personnel were readied to take over some services.

‘Closer to the American Model’

The rise of for-profit providers within the British NHS has sparked incendiary debates, with brute questions about costs and motives. How much is spent on patients? How much is spent on services? And could market forces plow the national health landscape into a tiered system of care?

“We are seeing a shift in care access and waiting times, and a big rise in the number of people moving toward a private system,” said Chris Thomas, principal health fellow at the Institute for Public Policy Research think tank in London. “Britain already has the largest number of private patients in the G-7, and that brings us closer to the American model.”

Centene has been welcomed by some as a way “to ease burdens within a chronically overworked NHS,” Thomas said. “But it doesn’t seem optimal to have a corporation — a for-profit organization — coming in.”

Centene has seen limits to government guarantees, particularly in Spain.

Even as British health advisers visited Ribera Salud in 2011, the Spanish press was documenting financial missteps in the venture. Fees per patient, meant to cover access to universal care, had to be renegotiated. Directors and administrators moved between public-sector jobs and Ribera through what appeared to be an unchecked revolving door.

Anne Stafford, a finance professor at University of Manchester, examined the numbers behind the Ribera model. The rhetoric of savings never matched reality, she said, with no clear comparison offered of labor costs, financing, wage demand, and patient ratios between Spain and Britain.

Debates over how best to deliver care often lack rigor and consistency, she added. “People say they love their NHS, but they have no concept of how it is funded or how it operates,” she said. “That allows people with an agenda to get into the market.”

British politicians have seen health care as ripe for privatization since the late 1990s, she said, but “there is very little proper accountability” for whether “the private sector, in fact, is delivering value for money.”

NHS advisers also have questioned whether the two systems could be effectively compared: Invented after World War II, the NHS was so celebrated that in 2012 doctors and nurses marched in the opening ceremony of the London Olympics. Spain’s national health care emerged in the 1980s, after the death of dictator Gen. Francisco Franco, and it struggled with costs within its first decade. The Centene model in Valencia, reliant on bank financing, was implemented in 1999.

The report found differences in size and staffing of facilities as well as how care systems were integrated. Measuring possible cost savings was difficult and, the report said, “there are risks that these benefits may be hard to replicate.”

By December 2021, it was clear that Centene no longer regarded its Ribera operations as a moneymaker. It announced it would divest “non-core assets” to improve its profit margin.

Centene executives pointed investors to two international assets: Circle Health and Ribera.

Within months, the Spanish subsidiary was sold for an undisclosed figure, bundled with other health and diagnostic groups, to Vivalto Santé, the third-largest private hospital company in France. The acquisition was completed in November.

Centene, in a statement, described its excising of Ribera, with 10 hospitals, 1,650 beds, and 71 primary care and outpatient clinics, as a “significant milestone in our value creation plan.”

For now, it’s steaming ahead with its Circle Health venture. Its 1,900 beds delivered two-thirds of more than $2 billion in annual revenue, according to investor guidance in December 2021. It’s now the largest private hospital care provider in England.

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