Yves here. This post provides an important, detailed takedown of the travesty known as Medicare Advantage. If you are in the US and watch what I call old people TV (syndicated classics and crime shows), you’ll be bombarded by Medicare Advantage come-ons at this time of year. The fact that Medicare Advantage is profitable enough to support close to blanket-level commercials should tell you that not enough of the premium dollars are going for health care.
Medicare Advantage is serving as a second-tier scheme for budget-stressed Social Security recipients, since many plans are nominally “no fee,” as in there is no deduction from Social Security payments, unlike for Medicare B (doctor coverage) and D (prescription coverage). But since there is no such thing as a free lunch, the lack of premiums is recouped via skimpier coverage.
But even worse, the health insurance industry hopes to increase the market share of Medicare Advantage and eventually displace traditional Medicare, and it has far too many supporters in Congress and the Administration.
Please circulate this post widely, particularly to those of Medicare age. And in particular, exhort recipients to contact their Congresscritters and support legislation (“The Medicare for All Act of 2023” House Bill, (H.R. 3421, and Senate Bill S. 1655, which would end Medicare Advantage, as well as the stealth private insurer takeover of traditional Medicare via Direct Contracting Entities and REACH plans, described in detail below.
Also note the shout out to Michael Hudson!
By F. Douglas Stephenson, LCSW, is a retired psychotherapist and former instructor of social work in the University of Florida Department of Psychiatry. He is a member of Physicians for a National Health Program. Cross posted from Common Dreams
Wendell Potter, a New York Times bestselling author, highly respected healthcare and campaign finance reform advocate, and authority tackling corporate and special interest propaganda, alerts us to the dangers of Medicare Advantage plans now offered by the private health insurance industry.
“In just a few weeks,” says Potter, “we’re once again going to be bombarded with ads featuring healthy and happy-looking seniors playing tennis and telling us how wonderful their Medicare Advantage plan is and how much of a no-brainer it is to shun traditional Medicare and opt instead for a plan operated by a big corporation like Humana and Cigna. We’ll hear insurers’ shills tell us about the extra benefits we’ll get, like discounts on gym memberships; $900 for groceries; and some coverage for dental, vision, and hearing. They’re short on details of course, and we never hear that coverage for those extra things can be pretty meager.”
Potter adds, “We also never hear about the potentially deadly side effects of Medicare Advantage plans. Make sure that insurers’ pitchmen—like ‘Broadway Joe’ Namath—are more forthcoming about what we’ll be getting ourselves into if we do as he suggests. Why should he be allowed to leave out important (Medicare Advantage) details we better know about before we sign on the dotted line?”
How Medicare Advantage Plans Differ From Conventional Medicare
- They are owned and operated by for-profit, private insurance corporations;
- Unlike traditional Medicare, Medicare Advantage plans often refuse to pay for treatments and medications physicians prescribe;
- Unlike traditional Medicare, many physicians, other healthcare professionals, and hospitals will be off-limits to patients because Medicare Advantage companies create their own proprietary and often skimpy “networks” of healthcare providers;
- If patients go out of network, they could be on the hook for thousands of dollars out of their own pocket; and
- They likely will have to pay extra—often a lot extra—for some of those extra benefits.
Private Health Insurance Industry Dominates
The for- profit, private insurance industry thoroughly dominates our national health insurance system and defines the basic concept and purpose of health insurance . The U.S. private business model of health insurance defines insurers as commercial entities, and maximize profits by mainly limiting benefits, maximizing health policy premiums, or by not covering people with health problems. Like all businesses, their goal is to make money. Under the business model, the greed of casual inhumanity is built in and the common good of the citizens and nation is ignored; excluding the poor, the aged, the disabled, and the mentally ill is sound business policy since it maximizes profit.
Political Support for Private Health Insurance Industry
Because our government permits private health insurance companies to exact large profit from its citizens, Wall Street banks and investors who back Big Insurance turn public money into a bonanza of private riches. High health insurance costs are the result of a political decision to essentially allow Big Insurance to do what they want and charge whatever they want. It’s no wonder so many beholden members of Congress want to protect the interests of their donors, Big Insurance and Big Pharma, industries that spent $371 million on lobbying in 2017.
The website/blog The Lever reported that The Better Medicare Alliance, an advocacy group for Medicare Advantage plans,
spent $570,000 lobbying Congress in the first quarter of this year, nearly double the $330,000 spent in the prior quarter. All told, the four major publicly traded health insurance companies that operate Medicare Advantage plans, as well as the insurance lobby America’s Health Insurance Plans, spent nearly $19 million on federal lobbying in the first quarter of 2023, a 66% increase from the prior quarter, according to a Lever analysis of data from OpenSecrets.
U.S. political and oligarch support for privatization of health insurance is grounded in the philosophy espoused by University of Chicago economist the late Milton Friedman. Friedman said, “The corporations should not take into account the public interest,” and added that “the government itself should not take into account the public interest. The job of the government is to simply let everybody make as much money as they can, however they can.”
In contrast, classical economist Michael Hudson notes that Big Insurance doesn’t want any kind of anti-monopoly legislation:
Essentially you have what is called a free market, as advocated by Milton Friedman. A free market means the wealthiest people dominate the market and the supply of credit, the management of the economy that allocates credit, and who gets what shifts from Washington to Wall Street. It shifts from the government to the private financial sector, and allows the financial sector to do the planning. One problem with this is the financial sector lives in the short run. So, it means that they only look for the next three months, the next year’s balance sheet, because the free market is so complex you don’t know what’s going to happen. Well, of course, since you’re managing it from Wall Street you in reality do know what’s going to happen, but you don’t want to tell people exactly what’s going to happen.
Big Insurance Profiteering Statistics
Wendall Potter reports on recent profiteering by Medicare Advantage plans:
- Big Insurance revenues and profits have increased by 300% and 287% respectively since 2012 due to explosive growth in the insurance companies’ pharmacy benefit management (PBM) businesses and the Medicare replacement plans called Medicare Advantage.
- The for-profits now control more than 70% of the Medicare Advantage market. In 2022, Big Insurance revenues reached $1.25 trillion and profits soared to $69.3 billion. That’s a 300% increase in revenue and a 287% increase in profits from 2012, when revenue was $412.9 billion and profits were $24 billion.
- Big insurers’ revenues have grown dramatically over the past decade, the result of consolidation in the PBM business and taxpayer-supported Medicare and Medicaid programs.
- What has changed dramatically over the decade is that the big insurers are now getting far more of their revenues from the pharmaceutical supply chain, Medicare, Medicaid, and from taxpayers as they have moved aggressively into government programs. This is especially true of Humana, Centene, and Molina, which now get, respectively, 85%, 88%, and 94% of their health-plan revenues from government programs.
- The two biggest drivers are their fast-growing pharmacy benefit managers (PBMs), the relatively new and little-known middleman between patients and pharmaceutical drug manufacturers, and the privately owned and operated Medicare replacement plans marketed as Medicare Advantage.
- Huge strides in privatizing both Medicare and Medicaid have been made. More than 90% of health-plan revenues at three of the health industry companies come from government programs as they continue to privatize both Medicare and Medicaid, through Medicare Advantage in particular. Enrollment in government-funded programs increased by 261% in 10 years.
Voters Don’t Matter
The voters don’t matter because the American definition of democracy is oligarchy, where a small group exercises control especially for selfish purposes. Polls have shown large popular support by citizens for Medicare for All, but neither political party nor Wall Street donors have supported it. Michael Hudson writes that by “conquering the brains of a country by shaping how people think, you can twist their view into ‘unreality economics’ and make them think you are there to help them and not to take money out of them, then you’ve got them hooked.” This is how Big Insurance and Big Pharma maintain control of U.S. health insurance. Our system is privatized, financialized, and unregulated so that private, big insurance companies can make money.
The assumption that whatever the market produces is rational and functional is the bedrock of Western economies. “And it’s wrong,” says Hudson, “because It negates the fact that you really need some government power strong enough to override the self-serving special interests of oligarchs and other 1% corporate interests. And that takes a very strong government, which is why the free market /privatization people have always opposed strong government and why their economic models don’t give any acknowledgement for government investment in infrastructure that Biden wants or any government activity that is able to override that of the 1% rentier class, the financial class, the property-owning class, and the corporate monopolists. That’s the problem we have.”
Private profit “Medicare Advantage” and “REACH” plans present new threats to Traditional Medicare.
1. What Is Medicare Advantage?
Medicare Advantage is a program offering private health insurance plans as options to replace traditional Medicare. Medicare Advantage plans differ from traditional Medicare in that they are paid with capitation (per member), they are required to limit enrollees’ out-of-pocket spending, and can offer extra benefits (e.g. gym memberships, $900 worth of groceries, dental benefits). They almost always offer prescription drug coverage and use a defined and often restricted network of providers that can require enrollees to pay more for out-of-network care. Utilization management techniques are used, such as prior authorization, and they can also fund special programs such as rewards for beneficiaries to encourage healthy behaviors. The hope is that these differences will lead to improved care at lower cost compared to Traditional Medicare.
In reality, “Medicare Disadvantage” is a better, more accurate name for the programs however, as insurance companies push Congress to corporatize all of Medicare, yet keep the name for the purposes of marketing, deception, and confusion.
Dismantling Medicare With Medicare Advantage: Over 50% of Medicare beneficiaries now have for-profit corporations in charge of their care through Medicare Advantage (MA). Insurance companies are paid handsomely for these plans, and much of that money goes to corporate profits instead of care. The companies running MA plans want to take over Medicare entirely, leaving patients with no option but to give their money to private insurers.
Denying Treatment: Investigations into claim denials in MA found that insurers were inappropriately denying treatments and tests that should be covered under Medicare. Physician surveys show that these practices often cause patients to suffer unnecessarily, and can even be life-threatening. In some cases, MA insurers were found to spend just seconds on each claim, and even denied claims using artificial intelligence instead of medical experts.
Deceiving Patients and Taxpayers: Reports from journalists, researchers, and government agencies have shown that health insurance companies like UnitedHealth and Cigna overcharge Medicare by giving patients exaggerated or entirely false diagnoses. Several companies have been fined, or sued, and agreed to large settlements. MA insurers are taking citizens’ tax dollars for conditions they aren’t even treating.
Bottom Line: Medicare Advantage is not the same Medicare program that Americans have come to know and love. The private insurance industry has spend millions on advertising in order to hide the ugly truth: Their MA plans raid taxpayer funds and routinely fail to deliver the care that patients expect and deserve.
Terminate Medicare Advantage: Physicians for a National Health Program, concludes that the Center for Medicare Services (CMS) should terminate the Medicare Advantage program. It would be far more cost-effective for CMS to improve traditional Medicare by capping out-of-pocket costs and adding improved benefits within the Medicare fee-for-service system than to try to indirectly offer these improvements through private plans that require much higher overhead and introduce profiteers and perverse incentives into Medicare, enabling corporate fraud and abuse, raising cost to the Medicare Trust Fund, and worsening disparities in care. These problems are not correctable within the competitive private insurance business model, and the Medicare Advantage program should be terminated.
2. What Is a ‘Direct Contracting Entity’ and ‘REACH’?
This program hands traditional Medicare to Wall Street by inserting a profit-seeking middlemen in Traditional Medicare to “manage” care for seniors and people with disabilities, allowing companies to keep up to 40% of what they don’t spend on care as overhead and profit. Beneficiaries are assigned. without their knowledge or consent. automatically to a ‘Direct Contracting Entity’ (DCE) if their primary care physician has joined one. The only way for beneficiaries to opt out is to find a different primary care physician.
Profits Over Patient Care: Profits are put ahead of patient care by virtually any type of company to be a Direct Contracting/REACH middleman, including commercial insurance companies, private equity investment firms, and other Wall Street profiteers. DCE’s expand profiteering to all of Medicare. Direct Contracting companies have already enrolled 1.8 million beneficiaries, with plans to take over all of Traditional Medicare in the next decade.
Terminate DCE’S and REACH: It would be far more cost-effective for CMS to improve traditional Medicare by capping out-of-pocket costs and adding improved benefits within the Medicare fee-for-service system than to try to indirectly offer these improvements through private plans that require much higher overhead and introduce profiteers and perverse incentives into Medicare, enabling corporate fraud and abuse, raising cost to the Medicare Trust Fund, and worsening disparities in care. These problems are not correctable within the competitive insurance business model, and the DCE/REACH program should be terminated.
Free Ourselves From Profiteers
We now have several decades of experience with the conversion of health and mental healthcare into a business. Our healthcare is being rationed, with care guidelines determined by profitability and secrecy decided in private Wall Street corporate boardrooms. To realize large profits demanded by Wall Street investors, our health system must attract the healthy and turn away the sick, disabled, the poor, many of the old, and the mentally ill.
To maintain corporate control of U.S. healthcare insurance, our system is privatized and unregulated. Private, big insurance companies are in the business of making money, not providing full healthcare, and when they undertake the latter, it is likely not to be in the best interests of patients or to be efficient. Administrative costs (and immense profiteering) are greater in the private healthcare insurance system, and even Medicare itself is weakened by having to work through the private system.
The USA is a country where health insurance for medical and mental healthcare is a function of socioeconomic status. Everyone knows that this inhumane system should have been corrected long ago. We must immediately end our moral crime of having the greatest health system in the world, but only for those who can afford it. We must support the common principles that healthcare is a human right, must be free from corporate profit, and must be achieved through national legislation.
Let’s never forget that universal Medicare for All is a solid investment in all citizens of our country by simply promoting a social service for universal access to affordable healthcare insurance for all. Aren’t we a society that cares enough to see that everyone receive the healthcare they need? That’s the basic purpose of Medicare for All. The history of our most successful national health insurance program, Medicare, provides one of the best arguments for expanding the program to cover everyone. It’s time to end inadequate and dangerous health insurance programs. Insist on real health insurance reform essential for individuals and families.
Contact your legislators asking them to oppose and end Medicare Advantage, DCE’s, and REACH plans . Most importantly, ask them to strongly support new legislation now filed in Congress, “The Medicare for All Act of 2023” House Bill (H.R. 3421) and Senate Bill (S. 1655) that would establish this badly needed reform.
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My first thought when seeing all of the commercials for these plans is they must be big money makers.I’m retired and part of my retirement package was my employer paying for my medicare . Twice a year they send me a check. They have gradually forced people to give up their traditional medicare for an Advantage plan. This year the didn’t offer a supplemental medicare option but only an Advantage plan. I really had no choice. It was take what they offered or pay for traditional Medicare. I believe forcing this on people will eventually create our next health care crises. it is only a matter of time before these Advantage plans cost destroy them. Then only very healthy people will be able to afford health care.
Jackie, file this in the “who the hell am I category”, but I had the same predicament. School district offered various plans but I hesitated and sought counselling from a Medicare counsellor. She was paid by the feds so had no conflicts of interest in nudging me to an A’plan. I’m not sure, but there was a window wherein a person could switch to trad. M’care from an A plan. Perhaps check into a counselor in your area and see if it’s possible. They are free and my person answers questions, promptly any time of year – even if it’s a simple technical question regarding a service or fee. None of the “dial 1 for hardware, dial 2 for Mike in the basement, dial 3 to be directed where to dial” …… Take “Advantage” if you can. Peace Out!
Privatize everything is the neoliberal mantra. When talking to friends I am always amazed that they don’t complain about the medical system. I hear terrible stories from them about access and treatment care or lack thereof, and for some reason they don’t see the fault with the system. One friend has to keep waiting months for a 15 minute visit with the neurologist. They are totally used to a dysfunctional medical system and seem to accept it.
As a soon to be 65er, am getting daily mailers from all the advantage parasites.
From what I can deduce, part A (hospital) is covered by SS. No cost except deductible. If you made payroll contributions to Medicare for at least 10 years.
Part B (drugs) is covered by SS also, but there is a monthly premium of $164.90, for most people.
Is this accurate?
Yes, I’m in the same boat as you the only difference may be that as I signed up for SS at 62, I was automatically signed up for Medicare where they auto entered me into Part B, a very annoying and I thought inappropriate move by SS. Since I have to now actively reject Part B (have husband and other supplemental coverage for now) I will still have to pay for one month of B even though I didn’t want it at all.
My other point about this topic, why was Medicare Advantage allowed to use the word “Medicare”? It is a huge confusion for a lot of people – intentional I’m sure – who think the government manages it. If the name was changed, people would have an instant heads up it’s not coming from the government.
Thanks for the reply.
Trying to wait until full retirement age to enroll for SS.
Does anybody have any recommendations as to accessing SS.
Is it easiest/best to use, phone, web or visit SS office in person?
Start 4 months before you think you are eligible.
They would dearly love for you to just apply online and if your case is simple, it can shoot right through.
If you can find a SS office that will let you through the door, try that, but take a mask because you may wait a long time just to see someone. Who may help you or just give you a phone appointment.
Ten years after my late husband died, I became eligible for a widow’s benefit and went to a local Social Security office to apply. The help they gave me was absolutely wonderful. The agent constantly assured me the “Social Security wants make sure you’re getting the best benefits you qualify for.” That attitude had disappeared entirely by about ten years ago. I had a simple question and had to travel to three different Social Security offices in the area before I could even see a human being who could answer it.
Carla, on 7/15/23, in links, you said you had cataract surgery scheduled, did you have it? I’ve had mine and the results are amazing. I can read again!
Agree with ‘earthling.’ Start early, I’d suggest six months early. Here in the North American Deep South, I figured out that I had better luck calling ahead and setting an appointment to see an actual physical person.
The online portal can be a proctological pain. For one thing, they contract out to a credit reporting agency for “authentication” of your identity. Any time a third party becomes involved, the complexity and “pain” of using a system increases exponentially.
Also, have all of your paperwork in order when you go in. I had to apply for a ‘replacement’ social security card because my original card, from a grade school exercise, was laminated in plastic by the teachers when it was issued to us. Covering the Social Security card with any ‘foreign’ substance is now forbidden. Those old, laminated in plastic cards are not accepted at the Social Security offices any more.
Stay safe.
Somehow, I still have my original SS card, scrawled with my schoolboy signature 50 years later.
It did not get laminated so should be good to go.
What other paperwork should I need?
Birth certificate and DL I presume.
Here are the Social Security Administration’s own words on that issue.
See: https://www.ssa.gov/benefits/retirement/planner/applying5.html
Getting a copy of my original birth certificate from London was a story all in itself. [It turned out to be easier than I had feared.]
As many here have said, start early and expect some foul ups.
“We’re from the Government and we’re here to help you.”
Good luck!
Go to the nearest SS office to enroll. You can make an appointment.
Using the word, Medicare, to name the Medicare Advantage plans is by design and agreed upon by Medicare/HHS. Insurance companies banked on the fact, that most people will not understand the difference between traditional Medicare and the commercial version of that. It’s been working flawlessly, especially with the full support by the Congressional critters. As they say, “The fish start to smell from its head”, or the critters in Congress in this case.
The article don’t mention, that once someone gets a Medicare Disadvantage plan, it’s not so easy to return to traditional Medicare. One can, but not without consequences. For example, other than CT, MA and NY states it is hard to get a Medicare Supplemental plan, that pays the 20% of claim after Medicare pays 80%. There might be Medicare Supplemental plans in the other 47 states, but they are heavily underwritten, a.k.a. pre-existing conditions are not covered.
Commercial health insurance company used pay more for procedures than Medicare. That had changed during the last 10 years, where insurance companies pay 100% of the Medicare allowed amount and now, they are moving to 80% just like Medicare does. In another work, Commercial insurances aren’t that much different from Medicare Disadvantage plans, with their limited provider networks, pre-approval for procedures, deny claims frequently, etc.
Medicare supplemental plans have been crapified as well — a process that is ongoing.
Yes, and their premiums keep going up significantly each year. My wife and I live in one of the “good” states (NY), yet the costs for our Medicare supplemental plan are getting to the point where those “no cost” Advantage plans that saturate the TV (and our mailbox) are getting our attention. Now I am fully aware of the nature of the Advantage scam as noted in this article, so there is no danger of us switching to it. But as long as we are relatively healthy my wife and I are paying a lot of money (for us) for almost nothing. In addition, because my wife takes several prescription drugs (including an expensive asthma inhaler) she was pretty much forced to sign up for the prescription drug coverage. What a scam. The only thing worse is no coverage at all. I can easily see why it is such a significant part of their profit margins these days.
Not signing up for Part D (drug coverage) will incur a penalty for every month you are absent. BTDT. Pay the premium; mine is $10/month.
Let me say something about Medicare supplemental plans. Since they only cover the 20% above the 80% of Medicare payments some think the premium is too expensive. Especially if you’re healthy now. If you are ever admitted to a hospital (and their big expenses–BTDT) you will understand that the supplemental premium was cheap insurance against medical bankruptcy.
There is no way to survive financially in the US if you get sick. Eat right, exercise, and stay healthy—it’s worth it!
I understand, which is why we pay for it. My parents both had multiple illnesses in their late years. I’m well aware of the costs; they would have been wiped out in months without Medicare + supplemental insurance. It’s still a form of despicable rent extraction by unnecessary intermediaries covering unnecessarily excessive costs by other rent-extracting providers. It’s only “cheap” in comparison to life without it in the good ol’ US of A.
> Medicare supplemental plans have been crapified as well — a process that is ongoing. [Carla, 9:43 a.m.]
Hardly a surprise, given that they’re run by the same companies with MA plans. And when you go to their websites for information, they do a side-by-side “comparison” between their medigap plans and their MA plans, and gee, guess which comes out looking like the better option for seniors on a limited budget? Adding to the confusion, CMS includes MA/”Part C” with supplemental Medicare. Even though they explicitly point out that MA isn’t the same as medigap — that you can have one or the other but not both — it’s really not that helpful, especially given that when you punch in your zip code to see available plans in your area, the lists for the various “letter plans” and the MA plans are virtually indistinguishable.
This just keeps getting scammier and scammier.
BTW, have you had your cataract surgery yet? How did it go?
Don’t forget the added advantage – when those Senior Citizens start to feel the iron hand in the velvet glove tightening around their necks through those zero benefits then they will blame “Medicare” and the Gummit. Not the Vultures on Wall Street or the “Medicare Advantage” company CEOs. This plan is currently ongoing to high acclaim at the NHS.
You’re right, they should not be able to call themselves “Medicare” in any way, because it misleads. But, it’s not inaccurate, in that they are paid, by the Federal Treasury, whatever the government planned to spend on your real Medicare. Then they ration out your health care to you by “administering” it. Whatever health care you don’t use, or that they cheat you out of, they get to keep as profits. And your average Murcan has no idea this is the business model.
“You’re right, they should not be able to call themselves “Medicare” in any way, because it misleads. ”
fwiw,
https://khanna.house.gov/media/press-releases/khanna-pocan-schakowsky-introduce-bill-strengthen-medicare-define-alternative
The “Save Medicare Act” will not going to pass this year, or ever for number of reasons. One is that 50% Medicare eligible people already have Medicare Advantage plans. It will be hard to argue against that these people will be confused and the name should not change.
The other is financial reason, more accurately, campaign finance issues. The Better Medicare Alliance, representing Medicare Advantage insurances, close to double their lobbying to $570K in the 1stQ, when compared to last year’s Q as stated by this article. Do you really believe that the Medicare alliance throwing that money around to support that bill? I don’t….
Part B is for provider services, outpatient care, and some medical devices. Part D is for drugs. Some differences for insulin coverage. $164.90 is the 2023 premium for part B (may be more depending on income).
https://www.medicare.gov/what-medicare-covers
Premiums and deductibles for A, B, D:
https://www.medicare.gov/Pubs/pdf/11579-medicare-costs.pdf
Thanks for the correction.
I mentioned this to Jackie, above. Find a Medicare counsellor in your area. They are free, paid by the feds, unbiased and will meet with you and spend an hour (or more) helping you with specifics such as you ask. I told my first person I was not interested at all in an “A” plan but he was essentially a salesman so I found another, and she listened, answered directly and has answered questions for a couple years within a day. Don’t try to navigate on your own, molto complicato.
I think, actually, Medicare itself does NOT pay for counselors to advise you on plans, and anyone who tells you he or she is paid by Medicare to advise you is stretching the truth – they are insurance agents getting paid by fees from Advantage Plans as commissions and calling those payments “Medicare money” because those private companies are paid a per person fee for each person enrolled, up to $ 1,200 a year. However, there ARE truly unbiased advisors in every state, volunteers, called SHIP or SHIBA volunteers, which are citizens trained to understand all the ins and outs of the various plans. These volunteers are supported by professional staffs paid usually by state Office of Insurance Commissioner offices – ie paid support staff but the advising is done by voilunteers who have been trained. When you get the Medicare Handbook each year, or when you are about to turn 65, there is a SHIP or SHIBA number on the back cover page. You can arrange a telephone or in-person counseling session to answer any questions you may have. The people advising you have no dog in the hunt, so to speak, as regards choosing traditional Medicare of Medicare Advantage, nor can they promote any specific solution. Rather, they provide advice and assistance in registering for Medicare and then information about the various plans offered. I work as a SHIBA volunteer in Washington State, have for about a year. I signed up to learn this stuff because I wanted to know what I was going to get into myself when I enrolled in Medicare. If I can save someone else from the stress and fear when facing sign-up that I experienced then I have had a good day. To become a SHIBA counselor takes at least 500-750 hours of study, training, and work with a mentor. Call your SHIP or SHIBA office if you have concerns.
Isn’t or wasn’t Fresno Dan one such ‘counsellor?’
I’ll send out a query on the Pink Bunny Slippers Radio Network.
I thought he was also.
Haven’t seen him around lately, hope all is well with him.
Hopefully, getting married to La Senyora has done him a world of good. He probably has a lot of more important things to do with his time than he used to.
Stay safe. Stay focused.
Actually, I agree, Medicare itself does not pay for counselors. On the other hand, most states and/or organizations have senior citizen services that performs this function. The quality of service varies widely, mainly due to the fact, counseling about Medicare is not their primary function.
Part B covers outpatient things (e.g. visits to your doctors’ office), but does not cover drugs. If you want drug coverage, you have to pay for Medicare Part D.
They sell these plans chiefly on “free” vision and dental coverage — without noting that their networks, particularly for these services, are so narrow as to be either unacceptable (you wouldn’t open your mouth for that Medicaid-mill dentist or wouldn’t travel that distance for eye glasses) and that the “free benefits”, such as unnecessary dental x-rays, are often little more than a come-on for uncovered services.
And for most of these plans it’s back to referrals from a PCP, whose appointment may be months away, to get access to their much narrower specialist network, compared to actual Medicare. This can be life-threatening.
Medicare Advantage manages to rip off both government and consumer. As such, it has wide Congressional support.
A cardiologist I know told me that she’d seen first hand one of the dangers of MA – patients had generalist MDs handle conditions that should have been referred to specialists, reducing the insurers cost but risking seriously bad outcomes. As to Medicare itself, she’s a fan because Medicare pays promptly.
Thank you for this post.
I have several comments to make:
1) A lot of the problems with Medicare Advantage are the same problems with Obamacare plans — limited networks, denial of referrals, and denial of treatment. As I have mentioned previously on NC, I have been stuck in Obamacare hell trying to help a relative get the treatment she needs. I could make a whole post just on this awful, inhumane experience. (IM Doc has also written about the horrors of Obamacare.) Hours on the phone and we do not have answers. Still waiting for an EOB for a doctor visit at the beginning of July. We are at the point where we are about to get some signs and picket outside the local insurance office. (Or put a video out on social media that hopefully would go viral.)
2) I joined Physicians for a National Health Program because it was the only organized effort I found fighting for Medicare for All.
3) Wendell Potter wrote about disintermediation, a term that keeps an insurance CEO up at night:
https://www.huffpost.com/entry/disintermediation-a-big-w_b_2522075
4) There is an argument to be made for getting rid of the insurance companies . You only need to look at large companies and institutions and you will find that they self-insure. They found out long ago that it’s cheaper. They only use insurance companies for billing and administration. We need to self-insure as a country.
Thank you,Yves, for your coverage of this topic. I wish I lived in a civilized country.
My hope is that some enterprising state attorney general goes after the insurance companies for fraud — people pay for insurance, but they don’t get the treatment they are supposed to get.
Well I can dream, can’t I?
I’ve been reading posts and comments about the Medicare Advantage scam on NC for some time, and though I don’t disagree, I’m in a position where MA works so much better for me, at least for now. I have campaigned for a real public health program for years, but Medicare is not that by a long shot. With relatively good health, my major out of pocket is going to be for dental, vision, hearing and occasionally drugs to treat an infection, none of which are covered by regular Medicare. I’m living on a skimpy SS check and a little freelance and part-time work (I bring in just enough to not qualify for Medicaid), so having these expenses covered has worked for me for almost 10 years now. My regular dentist and audiologist are in-network, and most of the local specialists and family practices, since our medical center has bought them all up over recent decades. Being on regular Medicare would mean expensive supplementals that are run through the private insurance companies anyway. I will probably regret this later when I may have an emergency or develop a serious condition, but I am also seeing Medicare getting chipped away at and by that time it may not really be around anymore.
> Being on regular Medicare would mean expensive supplementals that are run through the private insurance companies anyway.
Yep. When I switched from MA to traditional Medicare in March, which I did over the phone through CMS, I was required to sign up for a drug plan, a.k.a. “Part D.” Only later did I find out that the plan the CMS rep recommended to me was through Aetna. Someone else please correct me if I’m wrong, but apparently all Part D plans are private insurance. Also, something not mentioned in the article, MA is known as “Medicare Part C.”
As you point out, some of us need vision and especially dental insurance, the latter of which is prohibitively expensive for anyone on a limited budget. What many people don’t know, and my main objection to the rigid opinions on NC about MA, is that you are NOT locked in permanently. You actually can work the system to your advantage, if you know how. At some point when I get a break from the avalanche of crises and interruptions, I will write a full report, which indeed includes some MA horror stories, a lot that I haven’t seen addressed elsewhere. The nutshell version:
I did eventually manage to get a crown for a hole in my mouth I’d had for four years, with $0 out-of-pocket, at one of the best dental clinics in my area. I did it by switching from a truly execrable MA plan during the end of year enrollment period, which I believe is October to the first week in December. Coverage starts on Jan 1. I chose the new plan specifically because that clinic was in the network, and the plan allowed up to $2,000 a year for preventive and restorative work (at reimbursement rates set by the plan, so the dentist has to agree to accept these rates and not bill patients for the balance). Before Jan. 1, 2023, I went to the clinic, explained my situation, gave them the ID number on the new plan so that they would know the work would be covered, and set up appointments to make sure that the work was all done before the last week in March — because here’s what they don’t tell you: You are allowed to change plans ONCE between Jan. 1 and March 31. In those 3 months, they not only installed the crown, but they also filled a broken front tooth –and there was still enough left in the allowance for one cleaning. With less than a week to spare, I called CMS and switched to traditional Medicare.
Gotta run…
The private supplemental plans are controlled and monitored by CMS.
Well, now, that’s reassuring. /s
Medicare Advantage, a.k.a. Medicare “Part C,” is a Medicare supplemental plan. Do a search for “Medigap,” and you’ll see it on the list. Thanks to an ongoing FOIA investigation by KHN/KFF HN, we have a pretty good idea how well CMS is controlling and monitoring MA/Part C** — “pretty good,” as opposed to “knowing exactly,” because even a FOIA hammer isn’t enough to knock current data out of CMS. IIRC from the KHN series, the latest audits they were able to get from CMS were from 2011.
Anyone who feels better knowing that CMS is monitoring and controlling private supplemental plans should have no problem at all with MA.
** Lambert has been on top of that series and linked ASAP whenever they published a new report.
I have the same situation/experience.
I think it’s a statistical thing, where the two of us represent deadbeats within the MA business model, where they will be satisfied to gut at some later time, as nature takes its course.
Tucson, where I live, seems to have a big population of retirees with little/no money. Hence, most of the providers and facilities are part of the MA networks. As long as people like us stay relatively healthy MA will work for us; their bet, which is the better one, is that our good health is not going to continue.
The way this thing games out is that MA will become increasingly miserly as pure medicare competition is legislatively eviscerated. In 5-10 years, or whenever we personally hit some condition that is hardly unusual or unexpected given our age, they cash in.
The question I need to pursue is how to (maybe) get back onto traditional Medicare. But, the reality is that there’s nowhere to hide from the fate that ultimately awaits us with any of these plans, since the powers that be see an opportunity and that is you and I….
Matlock and The Father Dowling Mysteries are my favorites. Also an old movie series from the 30s – 40s with a character “Number 1 Son’.
I thank NC and it’s commentariat for educating me so that I chose Traditional Medicare when I was 65, several years ago. I have never regretted that decision. Particularly now that I am entering the “surgery season” where I will have rotator cuff surgery next Friday, then a partial knee replacement when sufficiently recovered from the shoulder surgery.
Be sure to give us an update in three months. You will not have recovered physically, but the EOB’s from Medicare should be arriving by that time.
I would advocate for Medicare for All, but we live in the real world, and have to make the best decisions we can for our situation. My husband has health issues (heart, cancer) and is on part B and a Medigap policy. The Medigap policy is not cheap –running almost $450/mo. I am on Medicare Advantage (I know, I know it has many problems, although I think that a portion are related to the agreement between the government and the providers.). I am not ill, and am certainly taking a chance on not needing significant medical care that woukd not be covered very well. (My mother lived to 93 and had nothing wrong ever except some mobility issues and dementia, so I can hope.). Over the past 8 years, we have saved quite a lot of money, comparing my Medicare Advantage plan with my husband’s Medigap policy. I do think your comment above about no deductions from Social Security for Medicare Advantage plans is not correct. My statement for income tax purposes from Social Security shows about $2000 deducted. Also, I would comment that I have asked around and most senior citizens I know are on Medicare Advantage; none has reported any significant problems with getting treatments. Perhaps this area is better for some reason.
According to my information, there are several Advantage options,
Part A, B and D
Part A, B, D + MedSupp
Part A, D + MedSupp
Part C and D w/drugs
Part C w/o drugs
Part C w/o drugs and stand-alone Part D
So further reading identifies Part C as Medicare Advantage
The mind boggles
The MA plans sell themselves by having no/low costs, but in a given locale, you may well have to pay something that will be deducted from your monthly ss ck.
Correct. You pay the premium and then get to decide how to customize your “access to care.”
For seniors and most disabled people, if your income doesn’t exceed a monthly benchmark — I believe it’s something like $1,667 in 2023 — you may qualify for a federal subsidy that pays your Part B premium (not sure if it depends on which state you live in). I was alerted to this program through my county Dept of Social Services. If you’re eligible for SNAP, there’s a good chance you qualify for the Medicare help, and if I’m not mistaken, being eligible for Medicaid automatically qualifies you. The DSS letter confirming my recertification also noted that the program not only pays the Part B premium, but it now covers deductibles and copays (a concession for throwing all the poors off Medicaid?). I haven’t tested this out yet and so don’t know if it actually works as advertised. Just throwing it out there as info for financially strapped readers facing gut-wrenching healthcare decisions.
If your county DSS has an office on aging, or equivalent, they might also be able to help. That said, not everything they told me was 100% accurate or complete.
This recent backgrounder from the KFF may be of interest:
https://www.kff.org/medicare/issue-brief/a-snapshot-of-sources-of-coverage-among-medicare-beneficiaries/
One more thing to note about Advantage plans is that the end users benefits are front loaded (lower costs and seemly expanded services) when you’re first choosing a plan and likely to be healthy and active but higher costs and less care as you age. The lock-in after your first year of cover makes it very hard to switch to a gap plan unless your local plan “leaves the market”. If you have a pre-existing condition, declining health, or need/want to travel stick with a gap plan.
It’s their first year, but a friend has switched to a MA plan and is pleased right now. I figure there may be some awakening unless the plan is smart because it is located out of the state they are in the process of moving to permanently. But they will be spending several months in this state to close up and finally sell their apartment here. They have several health issues and are very likely to need medical care while doing that. This state is vastly more expensive then where they are relocating. I hope for their sake I am wrong, but I think they are going to find that their network is far more limited than they were led to believe. And so are the benefits.
Have them contact their new state Medicare help center ASAP. You have a one year grace period when you can switch back to real Medicare+gap without penalty but their timing may be tight.
https://www.medicarehelp.org/state-health-insurance-assistance-programs-ship/
Once again, I want to publicly thank NC for steering me the [family blog] away from Medicare Disadvantage.
I’m almost 66, and I’m a healthy old cuss. To the point where I haven’t needed to use my traditional, classic rock Medicare plan. Not even once.
Here’s what I really like about Medicare: If you don’t need to use it, it simply leaves you alone.
Oh, yes, I get those Medicare emails about this procedure, that test, or some shot. And I simply squash them beneath my delete key.
Much like yourself I’m a healthy old cuss, think I’ll just roll with Part A for now and reassess in a few years.
If you do expect to need meds at some future time, look closely at Part D. There is a big “gotcha” built in for Plan D. The longer you wait to sign up for a Plan D plan, the higher the monthly premiums go, inexorably and steadily. It looks like someone figured out the “younger is healthier, thus less cost to the Plan,” and the “older costs the Plan more,” situation and decided to design the system so that the Plans have guaranteed ‘average’ income streams in general.
The caveat here is that a Government run all encompassing system would be cheaper, socially, and much more reliable. The private Plan D offerings change their formularies every year. That can be a real waste of the ‘consumer’s’ time and resources.
Be safe, make no hasty decisions.
Rather than pay that lifelong penalty for not having it, I did sign up for Part D. It’s my way of paying tribute to the Pharma Cartel, even though I don’t consume their products.
My repub mom has accused poor people of “knowing the system” to get all kinds of govt benefits that middle class people don’t. So when these commercials say “we get the benefits you are entitled to”, that’s what they’re playing off of.
Well, in all fairness to Mom, when you have little or nothing, why not “work the system” to get something, anything at all? The Big Everythings of the Business and Financial World do so. Follow the Alchemist’s Creed: “As above, so below.”
Realpolitik used to be a respectable position to take. Now, it’s all ideologies, all the time.
IMO, the health care extortion racket in the US is the most important issue most people will face.
As other comments have outlined, many US denizens are simply unaware, misinformed, and/or confused about “health care” and especially Medicare and related issues.
In the US, cheating and scamming senior citizens is a big industry, and part of the culture. It is disgusting and corrupt, but that’s the way it is until enough people say “ya basta” We aint gonna stand for it no mo!
This should be a no-brainer if we compare the systems, expenditures and health outcomes of other OECD countries The data is there, books have been written about it. Yet health outcomes and average life expectancy continue to decline (unless you are in the upper-income brackets)
I notice a couple of comments that claim everything is fine: you must be wealthy or naive, or both to think that. Either that or some people have collective Stockholm Syndrome. Time to do some homework.
I agree: Medicare for All is what we have needed for decades. If I recall, Richard Nixon had a plan for a universal health system in the US, but Congress criminals shot it down. The US does not have a health care system, but it does have a private patchwork of extortion rackets.
At this point, there should be no controversy or debate. We need to abolish private health extortion and initiate a real health care system. Medicare for All would be a great start.
In my opinion, Universal Health care should be the goal. And the first thing to do is re-label it so that it is NOT affiliated or has none of the baggage of Medicare, Medicare Advantage, Medicaid.
First rule: the notion of Insuring a Mortal being is absurd. We are talking about regulating costs / charges for a utility that everyone should have access to as a basic human right. Eff Executive pay, stock options, and bone-us ez.
The Congress, VA, Federal Employee and Medicare plans should be consolidated, and rolled out to all, cradle -to- grave.
“Americare. Good enough For Mitch, Nancy, Mark Milley–good enough for you! “
Link to who did and didn’t cosponsor H.R. 3421. Looks like only Democrats.
https://www.congress.gov/bill/118th-congress/house-bill/3421/cosponsors?s=2&r=1&q=%7B%22search%22%3A%5B%22h.r.3421%22%5D%7D
A big problem with this post is the “call your Congressman” prescription for a solution to this problem. There is no benefit to your Congressman from listening to their own constituents’ complaints when they are being paid by Big Pharma and Big Insurance. By no means am I trying to discourage people from doing this, but that has been tried for decades now to no effect.
What we need in this country is a General Strike. Rather, a series of general strikes, French style, until it is in certain targeted oligarchs’ best interests to capitulate. I advocate that free at-the-point-of-service health care should be number one on the list of demands for any general strike, although by no means not the only one.
Until the oligarchs buying Congress people begin telling them to start a universal free health system, nothing is going to change, short of outright revolution.
👍🏼 Agreed ! Thanks for the information.