Medicare Advantage Myth-Busting – OpEd

This year, the majority of Americans eligible for Medicare coverage chose to enroll in private Medicare Advantage (MA) plans rather than Traditional Medicare. Insurance companies that run these MA plans spend significant sums of money to blanket seniors with marketing that highlights the supposed advantages of MA like low upfront costs, supplemental coverage, and other unique perks like subsidizing gym memberships. However, the ads leave seniors in the dark on the downsides of MA like heavily restricted networks that damage one’s choice of provider along with dangerous delays and denials of necessary care. At the same time, both the Biden Administration and many members of Congress from both parties have voiced support for the further privatization of Medicare through growing Medicare Advantage.

In this article, we will debunk several pervasive myths about MA that proponents and insurance giant owners push in their effort to continue privatizing Medicare at the expense of patients.

Myth #1: Medicare Advantage Is Medicare

The inclusion of the term Medicare in Medicare Advantage — otherwise known as Medicare Part C — is incredibly misleading, as the program is de facto government-subsidized private insurance.

Traditional Medicare is public insurance, where tax revenues are directly used to cover healthcare for seniors and some disabled people. It employs a fee-for-service (FFS) payment model, where the Centers for Medicare and Medicaid Services (CMS) directly pays for each covered service by a healthcare provider.

In contrast, MA consists of thousands of different plans mostly provided by health insurance giants like UnitedHealthcare and Humana. Seven large insurance companies accounted for 84% of MA plan enrollment in 2023. Rather than directly covering care as needed, the federal government pays lump sum Medicare dollars, known as capitated payments, to these private insurers for each patient. MA plans make money by spending as little as possible on patient care in order to keep as much of the leftover taxpayer money as possible.

In other words, MA is private insurance supported by government subsidies, and it is a form of managed care by health insurance companies. MA is not a government-managed public health insurance program like Traditional Medicare.

Myth #2: Medicare Advantage Saves Money

Medicare Advantage has never saved taxpayers money as a substitute for Traditional Medicare. In fact, according to the Medicare Payment Advisory Commission (MedPAC), taxpayers have spent more on financing MA than they would have if everyone was covered under Traditional Medicare.

In fact, Congress and CMS have been working to try to stop MA companies from gaming the system to steal taxpayer money. A 2023 study by the Physicians for a National Health Program (PNHP) estimates that CMS overpaid MA plans between $88-$140 billion in 2022 alone through various practices like pretending patients were sicker than they were along with targeting healthier, less costly seniors to enroll in their plans. Overpayments have also caused all Medicare beneficiaries to pay billions in higher Medicare Part B premiums.

Through taking taxpayer subsidies, MA has been significantly more profitable for insurance companies than the private plans offered to the rest of Americans. In 2021, MA companies had a gross profit margin of $1,730 per enrollee, which is more than double their profit margin on the individual market ($745). In 2023, Humana ended its entire commercial insurance business in order to entirely focus on government-funded programs like MA.

Some who claim MA saves money point to how MA spending is growing at a slower rate than Traditional Medicare. However, their point assumes that people enrolled in MA and Traditional Medicare share the same characteristics, which is false. MA targets andenrolls people who are healthier, less likely to use medical services, and, thus, less expensive to cover than those in Traditional Medicare.

Myth #3: Medicare Advantage Is Necessary To Save Beneficiaries Out-of-Pocket Spending

One of the primary appeals of Medicare Advantage is the idea that it saves beneficiaries money. However, this is highly dependent on how much care someone needs. The extent to which MA does save money for patients is not a natural result of its supposed superiority; it is due to intentional political sabotage and decision making.

Patients in both MA and Traditional Medicare have to pay a monthly premium for Medicare Part B ($174.40 in 2024). Then, Traditional Medicare covers 80% of costs for outpatient services. Beneficiaries are responsible for paying the remaining 20%, with no limit on out-of-pocket (OOP) payments. However, Traditional Medicare fully covers inpatient services such as hospitalization after a patient meets a deductible ($1,632 in 2024). For prescription drug coverage, Traditional Medicare beneficiaries pay a monthly premium for a Medicare Part D plan run by a private insurer ($40 average in 2023).

Traditional Medicare beneficiaries can purchase a supplemental Medigap insurance plan to cover most OOP spending (average monthly premium of $139 in 2023), which a plurality (41%) did in 2021. Eighty-nine percent of people in Traditional Medicare had some form of supplemental coverage in 2023, such as through Medicaid (19%) or their employer/union (31%).

In MA, premiums, coinsurance rates, and deductibles vary across the thousands of different plans. However, the average monthly premium is very low ($18.50 estimate for 2024), and many plans have $0 premiums. Additionally, CMS mandates that MA plans have an OOP spending limit. The average limit for in-network services was $4,835 in 2023; when accounting for both in- and out-of-network services, the average limit was $8,659. Ninety-seven percent of MA beneficiaries are in plans that incorporate drug coverage, and the average premium is $10 per month (73% of enrollees had no premiums for drug coverage).

For healthy individuals without need of expensive healthcare services and products, MA saves money due to its low premiums. However, while Traditional Medicare users with a Medigap plan spend more money upfront due to higher premiums, they can save thousands of dollars for expensive care that would reach their OOP limit if they were enrolled in MA.

However, many seniors simply cannot afford purchasing a Medigap plan, so they have little choice but to enroll in MA. In 2023, 52% of MA beneficiaries earned annual incomes around $25,000. Income limitations disproportionately lead Blacks (65%) and Latinos (69%) to choose MA compared to Whites (48%), as 78% and 81% of Black and Latino MA beneficiaries earn less than 200% of the federal poverty level, respectively.

Traditional Medicare beneficiaries without any form of supplemental coverage (11% of Traditional Medicare users in 2021) most certainly have to pay more for healthcare due to Part A deductible and the lack of any OOP cap. However, the lack of an OOP cap in Traditional Medicare is entirely a result of politics and can be changed. While CMS requires MA plans to have an OOP cap, policymakers have elected not to create one for Traditional Medicare. Congress could legislate a $5,000 OOP cap for Traditional Medicare; this would cost just $39 billion annually or just 28-44% of the overpayments made to MA plans in 2022.

Considering the fact that MA has never saved taxpayer money, the history of billions of dollars in overpayments to MA plans, and the fact that Congress could cost-efficiently lower costs for those in Traditional Medicare, it is a myth that MA is necessary to save patients money.

Myth #4: Medicare Advantage Improves Health Outcomes

Through incentivizing the use of preventative care, Medicare Advantage’s capitated payment model should supposedly increase the health of its beneficiaries. However, there is not sufficient evidence to prove this. Additionally, the sickest patients opt for Traditional Medicare and low reimbursement rates decrease the willingness of healthcares providers to accept MA patients.

The Kaiser Family Foundation (KFF) reviewed existing studies and found that there is not strong evidence of widespread significant differences in health outcomes between Americans enrolled in MA versus Traditional Medicare. MA plans push patients to more preventative care visits, and they also incentivize beneficiaries to take on healthy habits like getting and using a gym membership. In contrast, Traditional Medicare is more likely to send its beneficiaries to higher-rated cancer facilities, nursing facilities, and home health agencies. Issues with data quality and differences in the populations who choose MA versus Traditional Medicare also render direct comparisons between the two programs quite weak.

Incentivized to spend as little as possible, MA plans pay healthcare providers less than Traditional Medicare. As a result, an increasing number of doctors and providers are declining to accept MA patients, further restricting MA networks and access to care. Additionally, lower payments can prevent doctors from providing the best quality care. In comparison, around 99% of non-pediatric physicians accept Traditional Medicare.

Medicare Advantage is a great option for relatively healthy beneficiaries who do not expect to need intensive care for serious illnesses and injuries. Capitated payments do incentivize MA insurance companies to save money by investing in healthy, preventative care and programs. At the same time, the model also incentivizes MA plans to avoid covering the highest quality care for the people most in need.

To restrict care that beneficiaries would otherwise receive in Traditional Medicare, MA companies delay and deny care throughprior authorizations (PAs) and payment denials. In 2021, patients and their providers had to file 35 million PA requests in order to receive medical care. MA companies denied 2 million of these requests. People only bothered to appeal 11% of the time; however, those that did had a 82% success rate. In 2022, 94% of physicians surveyed by the American Medical Association reported experiencing PAs which caused delays to necessary care; 56% reported this occurring always or often. Eighty percent reported that PAs caused the abandonment of recommended treatment, and 33% reported that they caused a serious adverse event for their patients.

There are many reasons for poor health outcomes in the United State: lack of healthcare access, high costs, low income, poor diet, and lack of exercise to name a few. The strategy of giving lump sums of money — mostly to insurance giants — and incentivizing them to spend as little as possible is not supported with evidence of improved health outcomes and does not directly tackle these greater issues.

Myth #5: Medicare Advantage Offers Benefits That Traditional Medicare Simply Cannot Match

A primary selling point of MA plans is that they offer supplemental benefits — mainly coverage for dental, vision, and hearing care — that Traditional Medicare does not provide. While this is true, it is misleading because it does not reveal the quality of this coverage.

While the vast majority of MA plans offer supplemental benefit coverage, there isn’t evidence that their beneficiaries actually utilize dental, hearing, and vision services much more than people enrolled in Traditional Medicare. In fact, there is some evidence to the contrary regarding dental care. This is because MA supplemental “coverage” does not protect patients from having to spend significant sums of money out of their own pockets.

Most MA plans have high coinsurance rates along with low annual caps on how much insurance will cover. So, MA coverage predominantly doesn’t help patients with expensive dental, hearing, or vision treatments. This prevents many seniors from being able to afford care even though they technically have coverage. Ultimately, MA plans constantly advertise that they offer supplemental coverage, but they leave Americans in the dark on how little financial help they will actually receive.

Additionally, taxpayers and Traditional Medicare beneficiaries are effectively subsidizing these additional benefits. Not only has MA never saved taxpayer money, it is further depleting the Medicare Trust Fund and raising Part B premiums for all Medicare beneficiaries. These higher premiums and taxpayer overpayments allow MA companies to market supplemental benefits along with the aforementioned low premiums which attract healthier and lower-income seniors.

Instead of enriching MA companies, Traditional Medicare could provide dental, hearing, and vision benefits for less than $42 billion in 2025, which is 30-48% of the overpayments taxpayers made to MA in 2022. Unlike in MA, this coverage would not be limited to restricted provider networks.

Myth #6: Medicare Advantage Is Necessary To Lower Healthcare Spending

Healthcare spending overall and Medicare spending specifically increase every year more than inflation. The United States spends more money per capita than any other country on healthcare. The average cost of healthcare per person in other wealthy nations is roughly half as much as the United States.

To lower Medicare spending, proponents of Medicare Advantage tout the benefits of “value-based” care compared to Traditional Medicare’s FFS model. Critics claim that FFS incentivizes wasteful spending and opportunities for doctors to become rich by billing Medicare for services unnecessary to patient health.

In contrast, “value-based” care involves CMS giving lump sums of money (capitated payments) to MA companies for each patient, supposedly incentivising efficient healthcare spending on preventative care. Through spending less and, ideally, keeping patients healthier, MA companies get to keep more money.

While there are case studies of mission-driven organizations succeeding with capitated payments, this does not hold true for the large, for-profit insurance giants that dominate MA. Rather, the major MA companies’ primary goal is to maximize profit. Therefore, they typically take as much taxpayer money as feasible by gaming the system while restricting care in order to spend less and keep as much as possible.

However, the entire premise that reducing healthcare usage with a more restrictive insurance policy is the best means to lower healthcare spending is baseless. The United States does not use healthcare services more than the other countries who spend far less, and the same is true for Medicare compared to similar foreign populations.

Then why is healthcare so expensive in the United States? Prices. Healthcare prices in the United States are significantly higher than other countries. This reality is a result of factors like market consolidation (lack of competition), patents, administrative waste, and more.

Rather than combat the large hospitals, pharmaceutical companies, private equity companies, insurance giants, and other powerful private interests who control armies of lobbyists and excesses of campaign cash, MA proponents provide a simple solution: make people get less care. This is a convenient solution which happens to also further enrich and get the blessing of dominant insurers like UnitedHealth Group.

All in All, Medicare Advantage Is a Scam

Congress created Medicare Advantage with the 2003 Medicare Prescription Drug Improvement and Modernization Act (MMA). After signing the bill into law, President George W. Bush boasted how MA would lower costs, expand benefits, afford seniors more choices, and improve quality of care. However, this supposed modernization of Medicare was really a scheme to privatize, gifting billions of dollars to insurance companies while seeking to end Traditional Medicare.

In reality, MA has never saved taxpayer money. Through gaming the system of capitated payments, MA insurance companies have reaped billions in overpayments — which have also increased the amount all Medicare beneficiaries pay in Part B premiums.

Through restricting care and taxpayer subsidies, MA plans do offer a lower cost alternative to Traditional Medicare, especially for beneficiaries who cannot afford a supplemental Medigap plan. Additionally, it can offer supplemental benefit coverage unavailable under Traditional Medicare, even if the quality of such coverage is poor and provides limited financial support. However, this reality is not because of its inherent design; it is a result of the political sabotage of Traditional Medicare. Congress can cap OOP expenses and provide supplemental coverage for Traditional Medicare with the same money it overpays to MA insurance giants lining their profit margins.

The only choices MA afforded seniors has been which private plan they want to choose. The program destroys beneficiaries’ choice of doctor due to restricted networks. Additionally, there is not sufficient evidence that MA significantly improves health outcomes while health providers are increasingly dropping MA plans due to low reimbursements, further limiting the number of providers MA patients can see. At the same time, current comparisons between MA and Traditional Medicare are unfair as long as policy makers refuse to fix the cost gaps in the latter.

Within both the Medicare and entire American populations, healthcare costs are rising at the same time as health outcomes are worsening, especially in comparison to peer nations. While MA is a convenient solution for insurance companies, it neither addresses the causes of high prices nor poor health outcomes.

MA proponents consistently point to the increasing share of beneficiaries who choose MA over Traditional Medicare as evidence of success. Along with millions of dollars spent on deceptive advertising by insurance companies, this is the consequence of policymaker’s failure to update Traditional Medicare.

It’s past time Medicare beneficiaries are given a real choice. Instead of overpaying insurance giants to the tune of hundreds of billions of dollars, Congress can cap OOP expenses at $5,000 annually and provide supplemental benefits in Traditional Medicare.

This article was published by CEPR