By Rep. Pramila Jayapal (D-Wash.) and Dr. Diljeet Singh
The Hill, November 17, 2023
Physicians and policymakers are, in different ways, both responsible for the health and well-being of patients. While physicians care for patients to the best of their ability, policymakers ensure that the structures that make up the health care system are effective and equitable. Whenever and wherever there is a threat to these goals, both groups have a role to play in recognizing and combating it. That is why we are speaking out on the need to make fundamental changes to the Medicare Advantage (MA) program.
MA as it exists today is a threat to patient care, to health equity, and indeed to the integrity of our public health infrastructure. A new report from Physicians for a National Health Program, an organization of doctors working to reform the health care system, shows that for-profit, corporate MA insurers are overpaid anywhere from $88 to $140 billion a year. That’s money coming out of patients’ and taxpayers’ pockets.
MA is the privately-run version of the traditional government-administered Medicare program. Instead of paying directly for care, the government instead pays insurers to “manage” patients’ needs. Enrollment in this program has grown significantly over the past two decades, with over 50 percent of eligible beneficiaries opting for an MA plan in 2023. Unfortunately, growth in the program has not led to better care for beneficiaries or a better deal for taxpayers — just the opposite, in fact. Tens of billions of taxpayer dollars are being siphoned off as profit by insurance companies that don’t even provide necessary care. That money doesn’t just cost our government, it costs seniors. For example, premiums paid for Medicare Part B, which covers most medical services outside of hospitalization, totaled $131 billion in 2022. With the amount of extra money that corporate insurers get from the government, we could totally eliminate Part B premiums and still have money left over.
Where is all this money coming from? It’s complicated, the result of a tangled web of loopholes, policies, and practices that are difficult for an individual beneficiary or physician to see. Even so, scholars and regulators have identified a few major factors that lead to overpayments. For example, insurance companies in MA tend to enroll patients that are healthier and therefore cost less than average but still get paid as if their patients were much sicker. This is called favorable selection, and by some estimates, it could cost as much as $75 billion a year in extra payments.
Because Medicare gives additional money to MA insurers for patients with more severe or more numerous diagnoses, another source of overpayments are all the irrelevant or old conditions that insurers record on patient charts. This practice is known as upcoding; these conditions aren’t being actively treated, so they don’t cost the insurance company anything, but they do lead to as much as $20 billion in extra payments. These methods only scratch the surface of all the ways in which MA insurers take advantage of the system, but the bottom line is clear: these companies are pocketing billions of dollars that belong to Medicare beneficiaries.
Of course, it isn’t just about the money; it’s also about patient care. Medicare Advantage plans tout their low premiums and extra benefits, but often these are only worth it as long as you’re healthy. If you get sick and need complex or significant care, plans start to show their true colors. Difficult authorization processes and narrow networks can make getting treated under an MA plan a nightmare. In fact, high-need patients with chronic conditions and patients in their last year of life are substantially more likely to switch out of MA and back to traditional Medicare, tired of having to justify each and every needed procedure or medication to their insurance company.
In our roles as a member of Congress and a practicing physician, we see different but equally concerning manifestations of these problems. Constituents call in with stories of being lured into an MA plan, and then denied care or prevented from seeing their doctor. Cancer patients, for whom an early diagnosis and treatment plan is imperative to survival, face weeks of delay because of onerous pre-authorization requirements. In fact, some of these patients have ended up needing emergency surgery or aggressive radiation that could’ve been avoided if insurers hadn’t gotten in the way. MA doesn’t just take billions in taxpayer dollars; it makes it harder for doctors to do their jobs, and harder for patients to get well.
With the money that we spend on corporate giveaways, we could entirely fund Medicare’s prescription drug benefit, establish an out-of-pocket maximum in traditional Medicare, or even provide dental, hearing, and vision benefits to everyone on Medicare and everyone on Medicaid. This doesn’t need to be a partisan issue. We should all agree that programs paid for by the people should benefit the people. It’s time to crack down on overpayments in MA and use those resources to improve Medicare for all patients.
Pramila Jayapal represents Washington’s 7th District. Dr. Diljeet K. Singh is a women’s health advocate and an integrative gynecologic oncologist in clinical practice since 1999. She currently serves as vice president for Physicians for a National Health Program.