Summary: A JAMA viewpoint published in December advocated Medicare Advantage for All, ignoring the sordid record of Medicare Advantage plans. Those plans extract tens of billions in profits, avoid and eject unprofitable patients, decrease funds available for medical care, have a worrisome quality record, and constrain patient choice of providers. Inserting private insurers into Medicare for All would fatally undermine such reform.
Letter to the Editor, JAMA, April 26, 2022, by Drs. Adam Gaffney, David Himmelstein, and Steffie Woolhandler
[A recent JAMA viewpoint by Zahner et al advocates] Medicare Advantage (MA) for all over single payer reform. Zahner acknowledges that Medicare Advantage plans raise Medicare’s costs but offers no estimate of the excess expense (and waste) entailed in subcontracting universal coverage to private insurers. The 2020 national health expenditure estimates, coincidentally released the day before this Viewpoint, offer insight into this waste.
In 2020, private insurers’ overhead totaled $301.4 billion, vs. $236.6 billion in 2019. Privately administered Medicare plans accounted for $63.4 billion of the total (up 41.2% from 2019); $55.5 billion (up 64.9%) went for overhead of privately administered Medicaid plans. Overhead consumed 15% of Medicare Advantage premiums in 2020, eight-fold higher than traditional-Medicare’s 1.9% overhead, implying that subcontracting to private plans raised Medicare’s overhead by $55 billion.
Medicare Advantage plans’ high overhead explains the paradox that they cost 4% more, yet pay-out less to doctors and hospitals than traditional Medicare. While profits per se account for some excess overhead, much reflects the bureaucracy erected to garner profits – e.g. network management, utilization review and referral restrictions – bureaucracy that cuts both high- and low-value services. Additional billions go for upcoding and other schemes that Medicare Advantage plans have used to outmaneuver CMS’ risk adjustment efforts for decades, belying Zahner’s prediction that tweaks to risk adjustment will eliminate overpayments.
Zahner asserts that Medicare Advantage plans offer better quality, citing an exploratory study encompassing mainly lower-cost services and patients, a profitable group that Medicare Advantage plans structure their benefits to attract. Yet MedPAC cautions that the lack of data precludes definitive quality comparisons. Moreover, the exodus from Medicare Advantage of patients needing high-cost services like dialysis, skilled-nursing or home care, offers “revealed-preference” evidence that Medicare Advantage poorly serves unprofitably-ill patients.
Patients want good coverage and unrestricted choice of doctors and hospitals, not – as Zahner suggests – choice of which insurance plan processes the bill. Traditional Medicare offers virtually unrestricted choice, but its coverage, which leaves many with large uncovered bills, needs improvement. The Congressional Budget Office estimates that an expanded and upgraded version of traditional Medicare could provide universal, first-dollar coverage, while achieving administrative savings that would reduce overall costs, even while expanding clinical spending and patients’ choices. In contrast, Medicare Advantage for all would perpetuate the upward spiral of healthcare spending, divert more medical resources to insurers and restrict choice.
Far from looking to Medicare Advantage as a model for reform, we should question whether it should play any role at all.
By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.
Private insurers now get the majority of their total premium revenues from Medicare Advantage (MA) and Medicaid managed care. And their overhead from those programs is enormous; in 2020, MA overhead averaged $2,256 per enrollee. Because that overhead is pushing the 15% limit mandated by the Affordable Care Act, MA insurers have been shifting profits to the provider groups and prescription management firms they own, whose profit/overhead is not capped; UnitedHealthcare, the biggest MA insurers, also controls more than 60,000 clinicians and paid $90 billion to its non-insurance subsidiaries in 2021. They are further boosting income and profits through diagnostic upcoding.
So expect to hear a rising chorus of calls (orchestrated by the private insurance industry) to expand Medicare Advantage and similar programs. CMS has is already implementing one such program, Direct Contracting Entities, although protests by patients and providers forced it to rebrand that program as “REACH”. REACH would auto-assign (without their knowledge or consent) most remaining traditional Medicare enrollees to managed care plans, many of them owned by the same firms that dominate MA. HJM has critiqued REACH, most recently here.
Health reform must eject the insurance middlemen who are draining resources from care.