By Jessica Glenza
The Guardian, Oct. 26, 2024
The television ads show seniors playing tennis, golfing and riding motorcycles. In others, celebrity pitchmen seniors will know â such as actor William Shatner, NFL star Joe Namath and former Republican Arkansas governor Mike Huckabee â promise new benefits alongside pictures of government-issued ID cards.
All of these are ads for Medicare Advantage and if Donald Trump wins the White House, Americans might be seeing a lot more of them.
Thatâs because one of Republicansâ only healthcare policy specifics involves further privatizing the program â selling more plans that commercials just like these advertise.
âWe groan when we see [Medicare] Advantage as insurance,â said Dr Karen Kinsell, the only doctor in Fort Gaines, Georgia, a rural community where more than a third of the population lives below the poverty line.
Medicare Advantage is private insurance paid for by the federal government, a program authorized in 1997 amid concerns about Medicareâs cost. Insurance companies promised cheaper plans with better benefits.
One of the most important differences for patients is the imposition of ânetworksâ in Medicare Advantage plans, or a limited number of doctors and hospitals a patient can see at a discounted rate. Traditional Medicare does not include networks â 98% of providers in the US participate. Most people pay a standard monthly rate of $174.70 for both Medicare and Medicare Advantage.
Medicare Advantage plans can be enticing because they often include food or transportation cards, $0 monthly premiums for drugs benefits, and hearing, vision and dental benefits â none of which are included in traditional Medicare.
Kinsell notes that the problems usually start when people get sick.
âPatients have been unable to get into rehab, or stay,â she said. Others were charged $50 a day for rehab when the service is normally free for a short period in traditional Medicare.
âWeâve spent a lot of time in our district office with seniors who got hoodwinked by these corporate insurance plans,â said Democratic US representative Pramila Jayapal of Washington state. Jayapal has called for âurgent reformsâ and consumer protections to be added to Medicare Advantage.
âThey took the name â so seniors actually think theyâre signing up for Medicare,â she said.
Despite complaints from doctors and patients, fraud investigations, allegations insurers used artificial intelligence models to deny care to seniors, and a pile of evidence that Medicare Advantage costs taxpayers more, Republicans have continued to boost the program. The most specific healthcare policy proposals are set forth by Project 2025, the conservative playbook by the Heritage Foundation.
Amid a thicket of gripes about vaccine mandates and no less than 199 mentions of abortion, the document also proposes further privatizing Medicare through Medicare Advantage.
Medicare Advantage âprovides beneficiaries with a wide range of competitive health plan choices â a richer set of benefits than traditional Medicare provides and at a reasonable costâ, Project 2025 argues. Republicans should make it the default enrollment option and âremove burdensome policies that micromanageâ plans, the document said.
The document also proposes to âgive beneficiaries direct control of how they spend Medicare dollarsâ, which Democrats argue describes a voucher program, something Republicans tried to push in the Trump administration.
âThat has been the playbook for privatization of Medicare really since these corporate Medicare âdis-Advantageâ plans â thatâs what I call them â started,â said Jayapal. âIt was their in-road.â
That, like a lot of Donald Trumpâs proposals, is likely to cost the federal government a lot of money.
âThe federal government is significantly overpaying Medicare Advantage plans in relation to what it spends on an individual and traditional Medicare â without corresponding significant gains to show for it,â said David Lipschutz, co-director of the Center for Medicare Advocacy.
Studies show Medicare Advantage plans will cost the federal government an estimated $83bn more than traditional Medicare in 2024 without corresponding improvements in health, according to the congressionally commissioned nonpartisan research agency Medicare Payment Advisory Council. Using default enrollment could increase that cost to an additional $2tn over 10 years, according to the left-leaning Center for American Progress.
The stakes for private health insurers are equally huge. One of the largest Medicare Advantage providers, United Healthcare, earned 46% of its $281bn in total revenue from Medicare Advantage enrollees, even though they represent only 15% of the companyâs beneficiaries, an Accountable.US analysis found. The analysis was shared exclusively with the Guardian.
âThe fact this is becoming something conservatives are trying to push as a universal model is alarming, because itâs a way to just increase profits for insurance companies,â said Tony Carrk, Accountable.US executive director.
Problems with the program are so acute that, at one point in 2022, eight of the 10 largest insurance companies selling Medicare Advantage plans were defendants in federal fraud or whistleblower lawsuits.
âPart of the problem of having private plans involved in Medicare, or really any healthcare space, is the promise they could provide better care more efficiently,â Lipschutz said. âAnd neither has happened.â
Although the Republican deficit hawks of yesteryear might balk at such a cost, the proposal to further privatize Medicare goes to a long-held Republican philosophy that survived Trumpism: the government is inherently untrustworthy and regular people need a financial reason to do the right thing.
âThe problem with the left is they donât think in economic terms,â said John Goodman, an economist who has advised nearly every Republican presidential candidate on health since George W Bush. He said he is currently working with America First Policy Institute, a pro-Trump thinktank.
Philosophically, Goodman believes Americans need âeconomic incentivesâ to do the right thing.
For patients, for example someone who is diabetic, that might mean low-cost insulin (a carrot) and the specter of a big bill if you donât manage your diabetes and end up in the hospital (a stick). For doctors, it might mean jumping through bureaucratic hoops to get approval for a procedure, called prior authorization, to avoid being wasteful.
Critics argue debates about âeconomic incentivesâ mask what are in fact âcatastrophicâ health costs. Medicare Advantage plans are allowed to require patients to spend as much as $13,300 per year for out-of-network providers in 2024. More than one-third of all Medicare Advantage enrollees live on less than $10,000 per year, according to the Commonwealth Fund. Nearly 95% of all seniors have a chronic health condition, and more than 78% have two or more, according to the National Council on Aging.
Although Trump has disavowed Project 2025, he has deep ties to its authors. Its health proposals were written by Roger Severino, his own former director of the Office of Civil Rights in the Department of Health and Human Services.
Notably, Goodman thought Project 2025 was a âpoor documentâ whose many references to abortion would turn voters off. But he agrees with proposals on Medicare.
In the 2024 GOP Platform, Trump pledged to, ânot cut one penny from Medicareâ, but does not provide further specifics. That comports with the Project 2025 plan â which would require a lot more money to expand Medicare Advantage enrollment.
For Goodman, there is at least one piece of humor in this branch of health policy â the idea that the left would propose a health system where people donât have to pay for healthcare.
âIn fact, the Bernie Sanders types do not think economic incentives should play any role in healthcare,â Goodman said.