LONDON \u2014 In the final days of 2020, the U.S. health insurer Centene made a swift incursion into Britain\u2019s prized National Health Service, one of the world\u2019s largest employers.<\/p>\n

A Centene subsidiary, Operose Health, took over nearly three dozen medical practices in London \u2014 gateways for NHS care \u2014 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.<\/p>\n

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 \u2014 amid pandemic restraints \u2014 when official business in London gave way to fizzy cocktails and quiet glad tidings.<\/p>\n

Within weeks, the acquisition set off alarms for Louise Irvine, an NHS doctor, who called it \u201cprivatization of the NHS by stealth.\u201d 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.<\/p>\n

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.<\/p>\n

Then there was this: The corporation faced legal problems and had paid fines, <\/a>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<\/a>. It faces investor lawsuits as well as overbilling allegations from several more states. Centene, based in Missouri, has denied wrongdoing.<\/p>\n

Centene\u2019s \u201csuitability\u201d 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.<\/p>\n

\u201cIt was covid time,\u201d Irvine, now retired, said with some frustration about the public meeting. \u201cWe believe NHS should be a public service, and it is being gradually eroded.\u201d<\/p>\n

Centene did not respond to requests to discuss its U.K. strategy. By July 2021, Centene\u2019s interests also acquired Circle Health Group, a private health care group based in London with 50 hospitals.<\/p>\n

Earlier this year, a judge ruled that the 2020 public meeting was conducted lawfully. The judge questioned the relevance of raising Centene\u2019s liabilities; she noted the American company\u2019s counsel had documented that its \u201cfinancial position was strong\u201d and that the insurer \u201ccontinues to operate successfully in the U.S. health care market.\u201d<\/p>\n

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.<\/p>\n

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<\/a>. The clinic was left with too few doctors, the Islington Tribune reported<\/a>, and patient appointments had dropped by 270 a week, representing a \u201chuge hole\u201d in care since the acquisition. The NHS\u2019 decision followed a BBC report in June<\/a> about Operose staffing<\/a>, in which clinic employees said the practice was short eight doctors and that less qualified workers, called physician associates, filled the gaps.<\/p>\n

Operose spokesperson Stephen Webb, in an email, said the Hanley practice \u201cis currently rated as \u2018Good\u2019 by the national regulator\u201d and the contract would be reviewed next year. On its website, Operose calls the BBC report \u201csensational.\u201d It adds that \u201cwe have a strong track record of performance, recruitment and investment in our staff and services.\u201d<\/p>\n

The Hanley decision is a small validation for Irvine and others who warned that efficiencies would degrade the quality of care.<\/p>\n

\u201cThe whole ethos of the American system, well, it is fundamentally different than how we view care in the U.K.,\u201d Irvine said. \u201cOur values are free and accessible health care for all.\u201d<\/p>\n

Cultivating Ties in Government<\/strong><\/p>\n

Centene was eyeing the British health system in winter 2011, when it hosted health advisers from across Europe to tour its facilities in Spain\u2019s seaside region of Valencia.<\/p>\n