Medicare’s open enrollment period occurs each year from mid-October to early December. In this window, private insurers deluge seniors with ads for their privatized versions of Medicare, called Medicare Advantage plans. Rather than allowing more and more seniors to enroll in these slickly marketed for-profit plans, they should be eliminated because they undermine Medicare and our health care system with fraud and other schemes that reduce health care quality while overbilling the federal government. Roughly half of the Medicare population, almost 30 million seniors, are now enrolled in this privatized version of Medicare.
(Note: If you find my posts too much to read on occasion, please just read the bolded portions. They present the key points I’m making.)
Medicare was created in 1965 when people over 65 found it virtually impossible to get private health insurance coverage. It made health care a universal right for Americans 65 and over. It improved the health and longevity of older Americans, as well as their financial security. Initially, Medicare consisted solely of a public insurance program that included all seniors.
Today, a mixed public-private health insurance market exists under Medicare. The Medicare-eligible population has been able to enroll in private health insurance plans since the 1980s. The private, for-profit health insurance industry pushed hard for a privatized option under Medicare; they wanted the opportunity to sell insurance to the large, population of seniors. They claimed they could deliver better quality services at lower cost due to their efficiencies, thereby saving Medicare money. However, these promised efficiencies never materialized and it became clear that the private insurers were simply looking for a way to increase their profits. For example, the typical administrative overhead for Medicare Advantage plans, including profits, is around 15% – 20% of premiums paid, while for traditional, government-operated Medicare it’s around 2%.  
Medicare Advantage plans should be eliminated for the following four reasons:
- They have become very skillful at paying as little as possible for enrollees’ health care services in order to maximize profits for themselves. They attract seniors by offering low or no premiums and special benefits (such as dental or vision coverage, or a subsidized health club or gym membership). However, they typically have high out-of-pocket costs, restrictive networks of providers, and requirements for pre-authorization of services. Through their marketing, they work to attract healthier-than-average enrollees to minimize their costs; this is called cherry-picking. By restricting or denying access to care, they cut costs and often drive sicker enrollees to leave, further lowering their costs; this is referred to as lemon-dropping.
- They game the reimbursement system by over-reporting the seriousness or even the number of illnesses or health conditions of their enrollees; this is called “upcoding”. It makes the enrollees appear to be sicker than they are and therefore eligible for more or higher reimbursements from Medicare. For example, knee pain can be reported as arthritis and an episode of distress can be reported as major depression, even if no services are provided for the more serious diagnosis. Efforts by Medicare to police upcoding result in significant administrative costs and a cat and mouse game where the private insurers find new ways to game the system as old ones are brought under control. Multiple studies and investigations have documented rampant, fraudulent upcoding. Estimates of its cost to Medicare range from $10 to $25 billion a year. (This is enough money to pay for adding vision and hearing coverage for everyone eligible for Medicare.) Almost every major insurer has been charged with upcoding fraud by the government or a whistleblower.
- They have been very effective at limiting regulation and enforcement by contributing money to members of Congress, spending significantly on lobbying, and using the revolving door to move people back and forth between jobs at the insurance companies and at the government agencies that oversee Medicare. For example, U.S. Representative Richard Neal (D – MA), Chair of the House Ways and Means Committee, which oversees all government spending, has received $3.1 million in campaign contributions from the insurance industry.
- Their profit motive inevitably provides perverse incentives to skimp on enrollees’ care and engage in fraud to maximize payments from Medicare. One study found that insurers make twice as much profit on Medicare Advantage plans as they do on other types of insurance. Medicare Advantage was supposed to lower Medicare spending and save the government money; instead, it costs the government substantially more per enrollee than traditional Medicare.
Furthermore, a mixed public-private health insurance system can’t achieve the efficiencies and quality of traditional Medicare because private insurers:
- Fragment the pool of insured people undermining the basic theory and efficiency of insuring large groups of diverse individuals,
- Have no financial incentive to maintain the long-term health of their enrollees, and
- Spend a large portion of premiums on overhead and profits. (See this previous post for more details.)
(Previous posts provide more details on Medicare Advantage and why it can’t work and needs to be eliminated.)
Bills have been introduced in Congress to reduce payments to Medicare Advantage insurers, to increase regulation and oversight, and to end Medicare Advantage (and a related, even more insidious pilot program, called ACO REACH, which puts seniors into privatized plans without their consent or knowledge). Furthermore, a bill has been introduced to ban private insurers from using the term “Medicare” in the titles and ads for their plans.  This would reduce confusion for seniors and curb misleading advertising. In particular, this would reduce the confusion between Medicare Advantage plans and Medicare Supplemental Insurance (often called Medigap insurance) that covers health care not covered by traditional Medicare (i.e., it fills “gaps” in Medicare, such as coverage for dental, vision, and hearing care). Medigap insurance is also sold by private insurers and adds coverage on top of Medicare, while a Medicare Advantage plan is a replacement for Medicare.
I urge you to contact President Biden and your U.S. Representative and Senators to ask them to eliminate Medicare Advantage because it is a rip off of Medicare and undermines our health care system. You can email President Biden at http://www.whitehouse.gov/contact/submit-questions-and-comments or you can call the White House comment line at 202-456-1111 or the switchboard at 202-456-1414. You can find contact information for your US Representative at http://www.house.gov/representatives/find/ and for your US Senators at http://www.senate.gov/general/contact_information/senators_cfm.cfm.
 Rogers, S., 8/25/22, “Comment on Request for Information: Medicare Advantage program,” Physicians for a National Health Program (https://pnhp.org/system/assets/uploads/2022/08/PNHPMedicareAdvantageComment_Aug2022.pdf)
 Stancil, K., 10/9/22, “ ‘Straight up fraud’: Data confirms private insurers use Medicare Advantage to steal billions,” Common Dreams (https://www.commondreams.org/news/2022/10/09/straight-fraud-data-confirms-private-insurers-use-medicare-advantage-steal-billions)
 Johnson, J., 10/14/22, “New bill would ban private insurance plans from using ‘Medicare’ name,” Common Dreams (https://www.commondreams.org/news/2022/10/14/new-bill-would-ban-private-insurance-plans-using-medicare-name)
4 thoughts on “MEDICARE ADVANTAGE IS A PRIVATIZATION FRAUD”
Hi John, thanks for your thoughtful work. I have Tufts advantage, and luckily I can get the doctors I want and quality care. Admittedly, the referral system is awkward sometime, but overall I am thrilled with the program. It is unfortunate there appears to be a sinister undercurrent to the program. I guess I should consider myself lucky. Bob Connor
Bob, I’m glad it’s working well for you. There is a sinister, privatization, profit-making undercurrent to Medicare Advantage plans, unfortunately. In general, I think there’s problem with for-profit health care b/c the perverse incentives are very strong.
Hi John,Thank you very much for this information! I am still covered by employer-based primary health insurance, but I am very glad to have this information before I have to decide what to do when I retire someday!!Thanks again,Carolyn
You’re more than welcome! The Medicare landscape is confusing and complicated enough without throwing in a privatization scheme like Medicare Advantage.