The Case Against Medicare Advantage

Medicare Advantage plans have significant restrictions on provider choice and a capricious pre-approval process.

It is once again open season for selection of a Medicare plan and the airwaves are insulated with advertisement urging people to select Medicare Advantage over traditional Medicare.  The advertisement campaigns for Medicare Advantage are as ubiquitous and as misleading as the advertisements for a political candidate in the closing days of a campaign.

Some Medicare Advantage plans provide good comprehensive health insurance, but some plans are inadequate and the selection of Medicare advantage over traditional Medicare always creates substantial limitations in health care choices and financial risk.

A recent Wall Street Journal article describes the potential catastrophic impacts of the choice of Medicare Advantage on people who choose Medicare Advantage over traditional fee-for-service Medicare.  One applicant enrolled in a Medicare Advantage plan found he could not obtain adequate treatment after being diagnosed with prostate cancer and was unable to both switch to a combination of traditional Medicare and Medigap because the best time to purchase a Medigap policy is immediately upon turning 65.

Several government studies, academic papers, and news reports show many Medicare Advantage plans provide limited access to doctors and hospitals.

  • This article discusses Vanderbilt Health dropping some Medicare advantage plans in Tennessee. 
  • This article discusses the exclusion of some Medicare Advantage plans by a health system in Oregon.
  • Research summarized here found that Medicare Advantage enrollees in rural areas of California had difficulty obtaining access to specialists. 

Another difference between Medicare Advantage and traditional Medicare is that Medicare Advantage plans often require prior authorization for treatments or even to see a specialist while Medicare does not.

A recent survey conducted by the American Medical Association (AMA) found that 94 percent of doctors found prior authorizations delay care, 80 percent of respondents found that prior authorization could lead to patients abandoning a prescribed course of treatment, and one third of doctors stated that prior authorizations led to an adverse medical outcome.

report by the office of the inspector general from the Department of Health and Human Services found that 13 percent of denials of denials of prior authorization requests by Medicare Advantage plans would have been automatically approved under standard Medicare guidelines. The auditor found in some cases a claim of inadequate documentation by the Medicare Advantage plan was incorrect.  Medicare Advantage plans appear to be routinely denying requests for services that the provider deems medically necessary.

Many individuals choose Medicare Advantage plans over traditional Medicare plans to lower premiums and obtain extra benefits.  The Biden Administration is finalizing rules  targeting misleading advertisements for Medicare Advantage plans. 

However, misleading advertisements are not the major problem in this industry.  Honest Medicare Advantage advertisement lacks information about the risks inherent to narrow-network health insurance which restricts access to specialists and hospitals and denies requests for medically necessary procedures.  

There is considerable support for Medicare Advantage on both side of the political aisle because these plans lower costs to taxpayers and enrollees.  Donald Trump signed an executive order expanding Medicare Advantage plan.  Medicare Advantage plans were a central feature of the health care reform plan offered by Vice President Harris when she was a candidate for president.

Go here for a better way to balance the need to control costs and provide comprehensive quality health insurance coverage.

Many doctors warn their patients about the risk associated with Medicare Advantage plans but the warnings are drowned out by a barrage of advertisements. 

People are making their choice of Medicare plan based on advice from commercials and salespeople rather than health professionals capable of weighing relative risks.  Perhaps the best advice on the question of whether one should select a Medicare Advantage plan would be the same advice given by Nancy Reagan to teenagers considering drugs — “Just Say No.” 

Authors Note:  The author of this newsletter has examined several financial topics including student debt,  interest ratesthe use of 529 plans to fund a Roth IRA, and the need for people near retirement to prioritize elimination of the mortgage.  Please subscribe to Insightful Memos.

2020 Policy Questions: Health Care

Progressives believe that revisions to the ACA would not substantially improve health insurance.  Centrists believe Medicare for All is fiscally unsustainable and could lead to unforeseen outcomes.  Guess What! They both might be right.

Questions for Centrists:  State health exchange markets created by the Affordable Care Act provides health insurance to roughly 5 percent of the working-age population.  Employer-based health insurance remains the dominant provider of health insurance to this segment of the population.   Do you favor reforms that would substantially expand the role of state exchanges in providing health insurance to more workers, especially workers at small firms? Would you acknowledge that a reform program that modestly increases the role of state exchanges but leave employer-based insurance as the dominant health insurance market will have a relatively modest impact on health insurance problems?

Many people have inadequate health insurance. Many health insurance policies have high deductibles and high out-of-pocket limits.  Many health insurance policies only provide benefit in a narrow geographic area have narrow networks and often do not cover services rendered by an out-of-network provider working in an in-network facility. These problems with existing health care plans leave many people with unanticipated health care debt, cause some people to reduce retirement savings and cause other people to forego necessary medical procedures and prescribed medicines.  What does your health plan do to improve coverage for people who currently have a comprehensive health plan?

Questions for Progressives:

The Medicare for All bill is entirely tax financed.   Under Medicare for All, health care expenditures directly impact the budget.  How would this program be insulated from budgetary pressures?

  • The Medicare for All bill creates a universal Medicare care trust fund?  What is the purpose and what are the limitations of this trust fund?  Have there been simulations of the long-term solvency of the universal health care trust fund?
  • Would general tax revenue and funds raised from bonds be automatically used to cover health care expenditures if funds in the trust fund did not cover all benefits?
  • Won’t future Congresses consider adjustments to health care expenditures and provider compensation rates based on the annual budget?   Shouldn’t Congress be more concerned about the overall deficit and the trend of the debt to GDP limit than the status of the trust fund?
  • Could the Secretary of HHS in a fiscally conservative Administration reduce benefits and compensation rates?
  • What would happen to Medicare for All benefits when there is a government shut down or a debt limit problem?    Who gets paid first people who need health care or people who own government debt?  

The current bill exempts Medicare for All from the Hyde amendment. What would prevent a future Administration and Congress from applying the Hyde Amendment to Medicare for All; thereby eliminating all insurance payments for abortion services?

People who want to learn more about how these issues are playing out in the 2020 contest should go here.

https://medium.com/@bernstein.book1958/how-should-centrists-respond-to-senator-warren-on-health-care-e82967734384?source=friends_link&sk=26049a4353e9ac170e9ec0323cef64aa