Category Archives: Medicare Advantage

Is Health Insurer Criticism Justified?

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, ACA, ACA Premiums, Access & Quality of Healthcare, Health Insurance Coverage Adequacy, Health Insurance Denial, Health Insurance Industry, Health Policy, Healthcare Reform, Medicare Advantage, Profit, Profit Margin, Profit Model, Profit Motive, Underinsured, Uninsured • Tagged , , , , • Leave a comment
Is Health Insurer Criticism Justified?

Since the murder of UnitedHealth executive Brian Thompson in New York City December 4, 2024, attention to health insurers has heightened. National media coverage has been brutal. Polls have chronicled the public’s disdain for rising premiums and increased denials. Hospitals and physicians have amped-up campaigns against prior authorization and inadequate reimbursement. For many health insurers, no news is a good news day. Here’s ChatGPT’s reply to how insurers are depicted:

“Media coverage of US health insurers focuses heavily on the challenges consumers face due to high costs, coverage denials, and complicated policies, often portraying insurers as profit-driven entities that hinder care access. Investigations reveal insurers using technology to deny claims and push for denials during prior authorization, while other reports highlight market concentration and the increasing influence of large companies like UnitedHealth Group and Centene. Media also covers the marketing efforts of insurers, particularly for Medicare Advantage plans, and public frustration with the industry. “

In some ways, it’s understandable. Insurance, by definition, is a bet, especially in healthcare. Private policyholders—individuals and employers– bet the premiums they pay pooled with others will cover the cost of a condition or accident that requires medical care. In the 1960’s, federal and state government made the same bet on behalf of seniors (Medicare) and lower-income or disabled kids and adults (Medicaid). But they’re bets.

But the rub is this: what healthcare products and services costs and their prices are hard to predict and closely-guarded secrets in an industry that declares itself the world’s best. Claims data—one source of tracking utilization—is nearly impossible to access even for employers who cover the majority of U.S. population (56%).

Spending for U.S. healthcare is forecast to increase 54% through 2033 from $5.6 trillion to $8.6 trillion— the result of higher costs for prescription drugs and hospital stays, medical inflation, technology, increased utilization (demand) and administrative costs (overhead). Insurers negotiate rates for these, add their margin and pass them thru to their customers—individuals, employers and government agencies. It’s all done behind the scenes.

The public’s working knowledge of how the health system operates, how it performs and what key players in the ecosystem do is negligible. For most, personal experience with the system is their context. We understand our personal healthiness if so inclined or fortunate to have a continuous primary care relationship. We understand our medications if they solve a problem or don’t. We understand our hospitals if we or a family member use them or occasionally visit, and we understand our insurance when we enroll choosing from affordable options that include the doctors and hospitals we like and when we’re denied services or billed for what insurance doesn’t cover.

Today, corporate names like UnitedHealth Group, Humana, Cigna, Elevance, CVS Aetna and Centene are the health insurance industry’s big brands, corralling more than 60% of the industry’s private and government enrollment with the rest divided among 1,149 smaller players. Today, the public’s perception of health insurers is negative: most consider insurance a necessary evil with data showing it’s no guarantee against financial ruin. Today, it’s an expensive employee benefit for employers who are looking for alternative options for workforce stability. And only 56% of enrollees trust their health insurer to do what’s best for them.

Ours is a flawed system that’s not sustainable: insurers are part of that problem.  It’s premised on dependence: patients depend on providers to define their diagnosis and deliver the treatments/therapeutics and enrollees depend on insurers to handle the logistics of how much they get paid and when. At the point of service, patients pay co-pays and after the fact, get an “explanation of benefits” along with additional out of pocket obligations. Hospitals and physicians fight insurers about what’s reasonable and customary compensation, and patients unable to out-of-pocket obligations are handed off to “revenue cycle specialists” for collection. Wow. Great system! Mark it up, pass it thru and let the chips fall where they may—all under the presumed oversight of state insurance commissioners who are tasked to protect the public’s interests.

Do insurers deserve the animosity they’re facing from employers, hospitals, physicians and their enrollees?  Yes, but certainly some more than others. Facts are facts:

  • Since 2020, health insurance premium costs have increased 2-4 times faster than household necessities and wages for the average household. Affordability is an issue.
  • Denials have increased.
  • Enrollee trust and satisfaction with insurers has plummeted.
  • And industry profits since 2023 have taken a hit due to post-pandemic pent-up demand, pricey drugs including in-demand GLP-1’s for obesity and increased negotiation leverage by consolidated health systems.

Most Americans think not having health insurance is a bigger risk than going without. But most also think healthcare is fundamental right and the government should guarantee access through universal coverage.

Having private insurance is not the issue: having insurance that ensures access to doctors and hospitals when needed reliably and affordably is their unmet need.

In the weeks ahead, employers will update their employee health benefits options for next year while facing 9-15% higher costs for their coverage. States will decide how they’ll implement work requirements in their Medicaid programs and assess the extent of lost coverage for millions. Insurers who sponsor market place plans suspended by the Big Beautiful Bill will raise their individual premiums hikes 20-70% for the 16 million who are losing their subsidies.

Medicare Advantage (Medicare Part C) insurers will skinny-down the supplements in their offerings and raise premiums alongside Part D increases, And, every insurer will inventory markets served and product portfolio profitability to determine investment opportunities or exit strategies. That’s the calculus every insurer applies every year, adjusting as conditions dictate.

Most private insurers pay little attention to the 8% of Americans who have no coverage; those inclined tend to be smaller community-based plans often associated with hospitals or provider organizations.

Most are concerned about continuity of care for their enrollees: they know 12% had a lapse in their coverage last year, 23% are under-insured and 43% missed a scheduled appointment or treatment due to out-of-pocket costs involved.

And all are concerned about the long-term financial viability of the entire health insurance sector: margins have plummeted since 2020 from 3.1% to 0.8%%, medical loss ratio’s have increased from 98.2% in 2023 to 100.1% last year, premiums increase grew 5.9% while hospital and medical expenses grew $8.9% and so on. The bigger players have residual capital to diversify and grow; others don’t.

Criticism of the health insurance industry is justified for the most part but the rest of the story is key. The U.S. system is broken and everyone knows it. But health insurers are not alone in bearing responsibility for its failure though their role is significant.

The urgent need is for a roadmap to a system of health where the healthiness and well-being of the entire population is true north to its ambition. It’s a system that’s comprehensive, connected, cost-effective and affordable. Protecting turf between sectors, blame and shame rhetoric and perpetuation of public ignorance are non-starters.

PS: Two important events last week weigh heavily on U.S. healthcare’s future:

In Verona, WI, the Epic User Group Meeting showcased the company’s plans for AI featuring 3 new generative AI tools — Emmie for patients, Art for clinicians and Penny for revenue cycle management. Per KLAS, the private company grew its market share to 42% of acute care hospitals and 55% of acute care beds at the end of 2024.

In Jackson Hole, WY, the Federal Reserve Bank of Kansas City’s annual economic symposium where Fed Chair Jay Powell signaled a likely interest rate cut in its September 16-17 meeting and changes to how the central bank will assess employment status going forward.

Healthcare is labor intense, capital intense and 26% of federal spending in the FY 2026 proposed budget. The Fed through its monetary policies has the power and obligation to foster economic stability. Epic is one of a handful of companies that has the potential to transform the U.S. health system.  Transformation of the health system is essential to its sustainability and necessary to the U.S. economic stability since healthcare is 18% of the country’s GDP and its biggest private employer.

Medicare Advantage plans pay physicians less than original Medicare

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Health Policy, Healthcare Reform, Medicare Advantage, Medicare Reimbursement, Physician Compensation, Physician Fee Schedule • Tagged , , , , • Leave a comment

https://www.healthcarefinancenews.com/news/medicare-advantage-plans-pay-physicians-less-original-medicare

MA pays 10% to 15% less than what is paid by the government in original Medicare, report says.

A new study confirms what the American Medical Association and other medical groups have long been saying about physician pay: Medicare reimbursement is not keeping up with inflation.

In original Medicare, doctors are paid one-third less than a decade ago, the report said. Medicare reimbursement rates for outpatient procedures have decreased every year since 2016, for an overall decline of 10%.

Over the same period, inflation has risen by almost 30%, according to the report.

The report also sheds light on Medicare Advantage reimbursement. Medicare Advantage plans pay physicians an estimated 10% to 15% less than what is paid by the government in traditional Medicare, according to the 2025 Omniscient Health Physician Medicare Income Report. 

This can create negative margins for physicians considering MA plans take roughly twice as long to reimburse providers compared to original Medicare along with factoring in prior authorization and denials, the report said. 

An estimated 54% of Medicare beneficiaries are enrolled in a MA plan.

WHY THIS MATTERS

The MA reimbursement gap is driving shifts in network participation. A 2024 survey by the Healthcare Financial Management Association found that 19% of health systems have stopped accepting at least one MA plan, with another 61% planning to do so or actively considering it, according to the Omniscient report.

“Despite the rising demand for care from an aging U.S. population, the financial strain is forcing physicians to rethink whether they will continue serving Medicare patients,” said Meade Monger, CEO of Omniscient Health, a healthcare data science company. “High-volume Medicare practices, especially those in primary care and rural areas, are increasingly unable to sustain operations under current revenue structures.”

The federal government’s push toward streamlining and speeding up the prior authorization process and requiring an electronic process over paper represents improvement, the report said. Some insurers have announced plans to decrease the number of procedures that require prior auth.

But payment rates need to change, said Omniscient, which recommends policymakers index Medicare reimbursement rates to inflation and set payment standards for MA plans. 

THE LARGER TREND

On Tuesday, the American Medical Association released what it called flawed proposals in the Centers for Medicare and Medicaid Services’ physician payment rule released in July.

Despite getting a 3.6% payment boost after five consecutive years of cuts, physician pay, after adjusting for practice-cost inflation, has plummeted since 2001, the AMA said.

The proposed 2026 Medicare Physician Fee Schedule includes a 2.5% cut in work relative-value units (RVUs, which measure a physician’s time, technical skill, mental effort, decision-making and stress) and physician intraservice time for most services, the AMA said. This reduction would affect 95% of the services that doctors provide. 

The cut is based on an assumption of greater efficiency and less time involved for each service, an assumption that is not grounded in new data or physician input, the AMA said. 

CMS also proposes a reduction in practice-expense RVUs, which are the costs of running a practice, such as staff, equipment, supplies, utilities and overhead.

The bottom line, the AMA said, is that physician payment for services performed in a facility will drop overall by 7%.

CMS is accepting comments on its proposed rule until Sept. 12.

Inside the Midyear Panic at UnitedHealth

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Health Insurance Coverage Adequacy, Health Insurance Denial, Health Insurance Industry, Health Insurance Pre Authorization, Health Insurance Premiums, Health Policy, Healthcare Reform, High Premiums, Medical Loss Ratio (MLR), Medicare Advantage, Medicare Advantage Denials, Medicare Advantage Overpayments, Out of Network, Out of Pocket Expenses, Profit, Profit Margin, Profit Model, Profit Motive, UnitedHealth Group, UnitedHealthcare • Tagged , , , , • Leave a comment

https://healthcareuncovered.substack.com/p/inside-the-midyear-panic-at-unitedhealth

Imagine you’re facing your midyear performance review with your boss. You dread it, even though you’ve done all you thought possible and legal to help the company meet Wall Street’s profit expectations, because shareholders haven’t been pleased with your employer’s performance lately.

Now let’s imagine your employer is a health insurance conglomerate like, say, UnitedHealth Group. You’ve watched as the stock price has been sliding, sometimes a little and on some days crashing through lows not seen in years, like last Friday (down almost 5% in a single day, to $237.77, which is down a stunning 62% since a mid-November high of $630 and change).

You know what your boss is going to say. We all have to do more to meet the Street’s expectations. Something has changed from the days when the government and employers were overly generous, not questioning our value proposition, always willing to pick up the tab and pay many hidden tips, and we could pull our many levers to make it harder for people to get the care they need. 

Despite government and media reports for years that the federal government has been overpaying Medicare Advantage plans like UnitedHealth’s – at least $84 billion this year alone – Congress has pretended not to notice. There is evidence that might be changing, with Republicans and Democrats alike making noises about cracking down on MA plans. 

Employers have complained for ages about constantly rising premiums, but they’ve sucked it up, knowing they could pass much of the increase onto their workers – and make them pay thousands of dollars out of their own pockets before their coverage kicks in. Now, at least some of them are realizing they don’t have to work with the giant conglomerates anymore.

Doctors and hospitals have complained, too, about burdensome paperwork and not getting paid right and on time, but they’ve largely been ignored as the big conglomerates get bigger and are now even competing with them.

UnitedHealth is the biggest employer of doctors in the country. But doctors and hospitals are beginning to push back, too. 

Since last fall, UnitedHealth and its smaller but still enormous competitors have found that “headwinds” are making it harder for them to maintain the profit margins investors demand. That is mainly because, despite the many barriers patients have to overcome to get the care they need, many of them are nevertheless using health care, often in the most expensive setting – the emergency room. They put off seeing a doctor so long because of insurers’ penny-wise-pound-foolishness that they had some kind of event that scared them enough to head straight to the ER. 

It’s not just you who is dreading your midyear review. Everybody, regardless of their position on the corporate ladder, and even the poorly paid folks in customer service, are in the same boat. And so is your boss. Nobody will put the details of what has to be done in writing. They don’t have to. Your boss will remind you that you have to do your part to help the company achieve the “profitable growth” Wall Street demands, quarter after quarter after quarter. It never, ever ends. You know this because you and most other employees watch what happens after the company releases quarterly financials. You also watch your 401K balance and you see the financial consequences of a company that Wall Street isn’t happy with. And Wall Street is especially unhappy with UnitedHealth these days.

And when things are as bad as they are now at UnitedHealth’s headquarters in Minnesota, you know that a big consulting firm like McKinsey & Company has been called in, and that those suits will recommend some kind of “restructuring” and changes in leadership to get the ship back on course. You know the drill. Everybody already is subject to forced ranking, meaning that at the end of the year, some of your colleagues, regardless of job title, will fall below a line that means automatic termination. You pedal as fast as you can to stay above that line, often doing things you worry are not in the best interest of millions of people and might not even be lawful. But you know that if you have any chance of staying employed, much less getting a raise or bonus, you have to convince your superiors you are motivated and “engaged to win.” No one is safe. Look what happened to Sir Andrew Witty, whose departure as CEO to spend more time with his family (in London) was announced days after shareholders turned thumbs down on the company’s promises to return to an acceptable level of profitability. 

If you are at UnitedHealth, you listened to what the once and again CEO, Stephen Hemsley, and CFO John Rex, who got shuffled to a lesser role of “advisor” to the CEO last week, laid out a new action plan to their bosses – big institutional investors who have been losing their shirts for months now. You know that what the C-Suite promised on their July 29 call will mean that you will have to “execute” to enable the company to deliver on those promises. And you know that you and your colleagues will have to inflict a lot more pain on everybody who is not a big shareholder – patients, taxpayers, employers, doctors, hospital administrators. That is your job. And you will try to do it because you have a mortgage, kids in college and maxed-out credit cards.  

Here’s what Hemsley and his leadership team said, out loud in a public forum, although admittedly one that few people know about or can take an hour-and-a-half to listen to:

  • Even though UnitedHealth took in billions more in revenue, its margins shrank a little because it had to pay more medical claims than expected.
  • Still, the company made $14.3 billion in profits during the second quarter. That’s a lot but not as much as the $15.8 billion in 2Q 2024, and that made shareholders unhappy.
  • Enrollment in its commercial (individual and employer) plans increased just 1%, but enrollment in its Medicare Advantage plans increased nearly 8%. That’s normally just fine, but something happened that the company’s beancounters couldn’t stop.
  • Those seniors figured out how to get at least some care despite the company’s high barriers to care (aggressive use of prior authorization, “narrow” networks of providers, etc.)

To fix all of this, Hemsley and team promised:

  • To dump 600,000 or so enrollees who might need care next year
  • To raise premiums “in the double digits” – way above the “medical trend” that PriceWaterhouseCoopers predicts to be 8.5% (high but not double-digit high)
  • Boot more providers it doesn’t already own out of network
  • Reduce benefits

Throughout the call with investors (actually with a couple dozen Wall Street financial analysts, the only people who can ask questions), Hemsley and team went on and on about the “value-based care” the company theoretically delivers, without providing specifics. But here is what you need to know: If you are enrolled in a UnitedHealth plan of any nature – commercial, Medicare or Medicaid or VA (yes, VA, too) – expect the value of your coverage to diminish, just as it has year after year after year.  

The term for this in industry jargon is “benefit buydown.”

That means that even as your premiums go up by double digits, you will soon have fewer providers to choose from, you likely will spend more out-of-pocket before your coverage kicks in, you might have to switch to a medication made by a drug company UnitedHealth will get bigger kickbacks from, and you might even be among the 600,000 policyholders who will get “purged” (another industry term) at the end of the year.

Why do we and our employers and Uncle Sam keep putting up with this?

Yes, we pay more for new cars and iPhones, but we at least can count on some improvements in gas mileage and battery life and maybe even better-placed cup holders. You can now buy a massive high-def TV for a fraction of what it cost a couple of years ago. Health insurance? Just the opposite. 

As I will explain in a future post, all of the big for-profit insurers are facing those same headwinds UnitedHealth is facing. You will not be spared regardless of the name on your insurance card. If you still have one come January 1. Pain is on the way. Once again. 

DOJ Questions UnitedHealth Doctors Re: Medicare Advantage Upcoding

Posted on by • Posted in Dept of Justice (DOJ), Health Insurance Industry, Medicare Advantage, Medicare Advantage Overpayments, Physician, Physician Diagnosis, Profit, Profit Margin, Profit Model, Profit Motive, UnitedHealthcare, Upcoding • Tagged , , , , • Leave a comment
https://healthcareuncovered.substack.com/p/doj-questions-unitedhealth-doctors?utm_source=post-email-title&publication_id=255152&post_id=167915638&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

I’ve been at this for so long and have seen so much. And it’s hard to overstate how significant the latest revelations from The Wall Street Journal are. According to its reporting, the U.S. Department of Justice’s criminal health care-fraud unit is questioning former UnitedHealth Group employees about the company’s Medicare billing practices regarding how the company records diagnoses that trigger higher payments from taxpayers.

For years, independent policy experts and *some* regulators have warned that the private Medicare Advantage program has become a breeding ground for upcoding and tax dollar waste. The tactic being scrutinized by the DOJ is called “upcoding.” Essentially, Medicare Advantage companies have an incentive to “find” new illnesses — even among patients who might not need additional treatment because the more serious the diagnoses, the bigger the government payouts to the company.

According to the Journal, prosecutors, FBI agents, and the Health and Human Services Inspector General have been asking ex-employees about special training for doctors, software that flags profitable conditions, and even bonuses for physicians who recode patient files. One former UnitedHealth doctor told the Journal that prosecutors inquired about pressure to use certain diagnosis codes and bonus pay for certain health care decisions that financially favored UnitedHealth. 

The Journal’s data shows that UnitedHealth’s members received certain lucrative diagnoses at higher rates than patients in other Medicare Advantage plans — billions of extra dollars that ultimately come from taxpayers. In one example, they reportedly pulled in about $2,700 more taxpayer dollars per patient visit when nurses went into seniors’ homes to hunt for additional conditions.

In a statement, UnitedHealth insists they “remain focused on what matters most: delivering better outcomes, more benefits, and lower costs for the people we serve.”

This latest criminal investigation joins at least two other DOJ probes into UnitedHealth’s billing and potential antitrust violations. And it’s yet another reminder that the Medicare Advantage program — which, much to many advocates alarm, now covers more than half of all Medicare enrollees – is desperately in need of real oversight.

If there’s any silver lining, it’s that courageous former employees are speaking up. They know what I know: This “profit-maximizing” through “upcoding” and “favorable selection” drains billions that could be better spent on actual patient care and pad Wall Street profits.

The Fox Guards the Hen House – Translating AHIP’s Commitments to Streamlining Prior Authorization

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, America's Health Insurance Plans (AHIP), Electronic Pre Authorization, Health Insurance Industry, Health Insurance Pre Authorization, Lobbyist, Medicare Advantage, Medicare Advantage Denials, Prior Authorization, Unnecessary Pre Authorizations • Tagged , , , , • Leave a comment
https://healthcareuncovered.substack.com/p/the-fox-guards-the-hen-house-translating?utm_source=post-email-title&publication_id=255152&post_id=166732339&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

“We urge the Administration to consider the timing of these policies in the context of the broader scope of requirements and challenges facing the industry that require significant system changes.”

  • AHIP, March 13, 2023 (in a letter to CMS Administrator Chiquita Brooks-LaSure responding to CMS’s proposed rule on Advancing Interoperability and Improving Prior Authorization Processes, proposed Final Rule, CMS-0057-P)

“Health insurance plans today announced a series of commitments to streamline, simplify and reduce prior authorization – a critical safeguard to ensure their members’ care is safe, effective, evidence-based and affordable.”

  • AHIP, June 23, 2025 (press release announcing voluntary prior authorization reforms)

What a difference two years make.

After lobbying aggressively to delay implementation of the PA reforms proposed by the previous administration (successfully delayed one year and counting), AHIP, the big PR and lobbying group for health insurers, now claims the mantle of reformer, announcing a set of voluntary commitments to streamline prior authorization.

So naturally, the industry’s “commitments” deserve closer scrutiny. Let’s unpack them. As a former health insurance industry executive, I speak their language, so allow me to translate. AHIP, which has no enforcement power, by the way, claims that 48 large insurers will:

  1. Develop and implement standards for electronic prior authorization using Fast Healthcare Interoperability Resources Application Programming Interfaces (FHIR APIs).Translation: CMS is already requiring all insurers to do this by 2027. We might as well take credit preemptively.
  2. Reduce the volume of in-network medical authorizations. Translation: We already demand hundreds of millions of unnecessary prior authorizations for thousands of procedures and services, so cutting a few (who knows how many?) should be a layup and won’t cut into profits.
  3. Enhance continuity of care when patients change health plans by honoring a PA decision for a 90-day transition period starting in 2026.Translation: We’re already required to do this in Medicare Advantage. And since we delayed implementation of e-authorization until 2027, we’re in the clear until then anyway.
  4. Improve communications by providing members with clear explanations for authorization determinations and support for appeals. Translation: We’re already required by state and federal law to do this. We’ll double-check our materials.
  5. Ensure 80% of prior authorizations are processed in real time and expand new API standards to all lines of business. Translation: We had to promise to hold ourselves accountable to at least one measurable goal. We will set the denominator – we’ll decide which procedures and medications require PA – so we’ll hit this goal, no problem, and we might even use more non-human AI algorithms to do it.
  6. 6. Ensuring medical review of non-approved requests. Translation: People will be relieved we’re not using robots. And we’ll avoid having Congress insist that reviews must be done by a same-specialty physician, as proposed in the Reducing Medically Unnecessary Delays in Care Act of 2025 (H.R. 2433).

Of course, I wasn’t in the room when AHIP drafted these commitments, so take my translations with a grain of salt. But let’s be honest: These promises are thin on specifics, short on accountability, and devoid of measurable impact.

They also follow a familiar script, blaming physicians for cost escalation by “deviating from evidence-based care” and the “latest research”, while positioning PA as a necessary safeguard to protect patients from “unsafe or inappropriate care.” And largely ignoring how PA routinely delays necessary treatment and harms patients.

It’s also rich coming from an industry still reliant on something called the X12 transaction standard – technology that is now over 40 years old – to process prior authorization requests, while simultaneously pointing the finger at providers for outdated technology and being slow to adopt modern systems. Many insurers did not start accepting electronic submissions of prior authorization until roughly 2019, nearly 20 years after clinicians started using online portals such as MyChart in their regular practice. The claim that providers are the ones behind on technology is another ploy by insurers to dodge scrutiny for their schemes.

We shouldn’t settle for incremental fixes when the system itself is the problem. Nor should we allow the industry that created this problem – and perpetuates it in its own self-interest – to dictate the pace or terms of reforming it.

As we argued in our recent piece, Congress should act to significantly curtail the use of prior authorization, limiting it to a narrow, evidence-based set of high-risk use cases. Insurers should also be required to rapidly adopt smarter, lower-friction cost-control methods, like gold-carding trusted clinicians (if it can be implemented with integrity and fairness), without compromising patient access or clinical autonomy.

Letting the fox design the hen house’s security perimeter won’t protect the hens. It’s time for Congress to build a better fence.

Republicans Are Turning on Medicare Advantage

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Health Insurance Industry, Health Policy, Healthcare Reform, Medicare Advantage, MedPAC • Leave a comment
https://healthcareuncovered.substack.com/p/republicans-are-turning-on-medicare?utm_source=post-email-title&publication_id=255152&post_id=166131637&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

UnitedHealth Group and the other insurance giants running the Medicare Advantage (MA) program might want to start paying attention to something they haven’t worried much about before: growing skepticism from Republicans.

Until recently, efforts to reform MA — a privatized version of Medicare now covering more than half of all beneficiaries — came mostly from Democrats and independent policy experts.

No longer. The latest skepticism is not coming from a liberal think tank or a progressive PAC. It’s coming from two Republican doctors who have spent decades treating patients and sit on powerful House committees overseeing health care. It’s coming from a former Republican congressman who was an author of the law that established Medicare Advantage two decades ago. And it’s coming from right-leaning organizations and policy experts who are now demanding major changes to MA. Their position marks a dramatic and important shift that could lead to meaningful reforms being enacted in a Congress controlled by Republicans.

An Architect of MA Speaks Out

In an op-ed published by The Hill Sunday, former Republican Rep. Jim Greenwood of Pennsylvania — who helped write the Medicare Modernization Act that created Medicare Advantage — said plainly: “The program no longer lives up to [its] promise.”

Greenwood wrote that he had once believed private competition would drive innovation and efficiency. But today, he says, MA has been overtaken by “a handful of massive insurers who are gaming the rules for profit.” Overpayments, cherry-picking, and risk-score manipulation, he said, are now “endemic.”

“It pains me to say this, but the system we helped create is being abused. And it’s not just hurting taxpayers. It’s hurting patients.”

“Seniors… are too often finding out — at the worst possible time — that their plan won’t cover what they need.”

While Greenwood still believes there is a place for private-sector involvement in Medicare, he now calls for rigorous oversight, transparency, and enforcement. He also warns against insurers’ predictable scare tactics whenever reform is on the table.

“I never imagined that Medicare Advantage would become a vehicle for such waste and abuse,” Greenwood concluded. “It’s time to fix it.”

Republican Congressional Docs Say Medicare Advantage Is Broken

Another recent op-ed, written for The Washington Times by two conservative Republicans, Rep. Greg Murphy of North Carolina and Rep. John Joyce of Pennsylvania – both physicians and co-chairs of the GOP Doctors’ Caucus — draws the same conclusion: Medicare Advantage veered too far off course, and it’s time to rein it in. They wrote: 

“Profit-driven insurance companies have destroyed [Medicare Advantage’s] model.”

“These plans must stop seeing rewards for delaying or altogether denying care to beneficiaries that need it.”

They called out insurers for “upcoding” — the practice of exaggerating how sick patients are to collect more taxpayer dollars — and for using prior authorization as a weapon to delay or deny necessary care to America’s seniors.

These aren’t unsubstantiated complaints. Recent media investigations found that MA plans regularly reject claims that would be approved under traditional Medicare. The Department of Health and Human Services Inspector General has raised alarms, and the U.S. Justice Department has set its sights on UnitedHealth Group’s Medicare business in particular.

And according to the Medicare Payment Advisory Commission (MedPAC), MA is now costing taxpayers 22% more per beneficiary than traditional Medicare — a difference that translates to $83 billion in overpayments to private health insurers last year alone.

Now, Republicans like Murphy and Joyce are saying the quiet part out loud: MA is making insurance company executives and investors rich at the expense of seniors, people with disabilities and taxpayers.

Conservative Advocacy Voices Are Speaking Up, Too

Phil Kerpen, president of the conservative group American Commitment, warned in an op-ed for the Daily Times that Medicare Advantage — which he said was once a “highly innovative and successful” option — is now “becoming increasingly costly and unstable.”

Kerpen pointed to the Department of Justice’s criminal investigation into UnitedHealth as a wake-up call and criticized the monopolistic consolidation of insurers buying up doctors, hospitals, and pharmacies. He called out opaque billing practices, delays in care, and an “unfair burden on taxpayers.”

“If ever there were a government program in need of DOGE-like accountability, competition, and transparency, Medicare Advantage is it.”

He called for reforms many — including myself — have long demanded: stronger disclosure rules, better tools for plan comparison, and serious action on prior authorization abuse. To save the program, he said, President Trump and Congress must be willing to “take on the big insurers and reform it. And quickly.”

Cracks in the Wall of Insurance Influence

There was even a last-minute push, led by Senate HELP Committee Chair Bill Cassidy (R-Louisiana), a doctor, to include MA reforms in Trump’s “One Big Beautiful Bill.” While that effort reportedly failed, Republican critics of the program are vowing to work on a bipartisan basis to enact changes the insurance lobby has fought for years. Upgrade to paid

I spent years in the executive suites of Cigna and Humana — historically big players in Medicare Advantage — and I can tell you this: Republican lawmakers and conservative thought leaders demanding reforms to  MA is no small thing. Private insurance corporations have long counted on bipartisan cover to operate with minimal oversight. If they start losing support from Republicans and conservative media, that protective wall begins to crack.

For years, industry lobbyists succeeded in casting Medicare Advantage as politically untouchable — “too complicated,” “too entrenched,” or “too popular to fix.” But as more members of Congress hear from their constituents about denied care, inadequate provider networks, rising out-of-pocket costs, and profiteering by insurance corporations, that illusion is dissipating.

With GOP leaders like Murphy, Joyce, Kerpen — and now Greenwood — stepping forward, it’s clear the tide is turning. Medicare Advantage reform is no longer a partisan issue — it’s an American issue. And for the sake of patients, taxpayers, and the solvency of the Medicare Trust Fund, it’s time Washington acts like it.

For a Wall Street Lifeline, UnitedHealth Is Throwing Brokers Overboard

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In a concession to Wall Street investors, starting this summer, UnitedHealth will stop paying commissions to agents and brokers for some new enrollees in nearly 200 UnitedHealthcare Medicare Advantage plans across 39 markets.

And it’s happening not because UnitedHealth can’t afford to pay. As we’ve published previously, the company reported $9.1 billion in profits during the first quarter of 2025 — up from $7.9 billion the year before. But that wasn’t enough to satisfy Wall Street, which punished UnitedHealth with the steepest one-day stock drop in 26 years — a $110 billion free fall in market value — after the company revised its full-year profit guidance downward.

Why the drop? 

Because UnitedHealth admitted it may not squeeze quite as much profit from taxpayers this year as expected — mainly due to unexpectedly high care utilization from some of the new Medicare Advantage enrollees it brought on during the last open enrollment period. Particularly enrollees who, as then-CEO Andrew Witty described, came from other insurers exiting the market and hadn’t been properly coded. Yawn.

For Now, Brokers Are UNH’s Patsy

This recent commission cut is less about operational efficiency and more about damage control. UnitedHealth is signaling to investors that it’s willing to shrink its Medicare Advantage footprint — at least temporarily — if that helps preserve profit margins. And Wall Street analysts are eating it up, seeing it as a way to slow the flow of high-cost members and stabilize earnings, according to BarChart.

Off Wall Street, the move has already come under fire. As the National Association of Benefits and Insurance Professionals put it, UnitedHealth is “cutting off the very people best equipped to help” seniors — especially low-income and rural enrollees who depend on brokers to explain their options.

While we would warn seniors against enrolling in a Medicare Advantage plan in the first place – without brokers, many beneficiaries will be left to fend for themselves in a system that’s already infamously confusing, expensive and deadly.

A Strategic Retreat Disguised as a Cost-Containment Strategy

The problem is the perverse incentive structure UnitedHealth and other insurers helped build — one that rewards risk-coding gamesmanship more than it rewards delivering care. For years, the company thrived by maximizing revenue through “coding intensity” and by acquiring everything from doctors’ offices to behavioral health firms to control more of the health care ecosystem.

Now, UnitedHealth is responding the way Wall Street expects: by slashing anything that isn’t bolted down – including brokers.

So here we are: 

UnitedHealth is still wildly profitable, still drawing billions from taxpayer-funded programs like Medicare and Medicaid — and now it’s cutting out the professionals who presumably help seniors navigate a convoluted health care system. All this, mind you, to appease jittery investors. And despite UnitedHealth’s current wobbly share price, analysts expect it to rebound, especially with a continuation of share buybacks on the horizon.

During the first quarter of this year alone, the company bought back $3 billion worth of its own shares. Over the past year, buybacks totaled more than $12 billion. When you factor in dividends, the company said it “returned” more than $16 billion to shareholders in 2024. That’s how you keep investors at least partially satisfied.

Medicare Advantage Is Ripe for an Overhaul 

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Accountable Care Organization (ACO), Competitive Bidding, Health Insurance Industry, Health Policy, Healthcare Reform, Medicare, Medicare Advantage, Risk Adjustment, Standardized Benefits • Leave a comment
Medicare Advantage Is Ripe for an Overhaul 

As the Senate eyes alternative or additional cost-saving provisions to those included in the House-passed reconciliation bill, some Republicans are considering reforms to Medicare. That is a promising development because overhauling Medicare Advantage could lower federal costs in ways that even many Democrats have advocated (although it is certain the overall bill will receive no Democratic support due to myriad other provisions).

Medicare Advantage, or MA, is Medicare’s private insurance option.

Beneficiaries can get their coverage through these plans in lieu of the traditional, government-managed program. Medicare pays MA sponsors a per-person monthly fee, which they use in turn to pay providers for the services their enrollees need. Enrollment in MA surged after Congress amended the payment formula in 2003. According to the 2024 Medicare trustees report, in the last decade alone, MA enrollment increased from 16 million people in 2014, or 30 percent of total enrollment, to 34 million people in 2024, or one out of every two program beneficiaries.

MA is growing because the plans usually offer more generous coverage than the traditional program without charging substantially higher premiums. In fact, many MA enrollees get free prescription drug coverage and much lower cost-sharing for hospital and physician services. They also sometimes get limited dental and vision care protection. MA enrollees usually do not pay for Medigap insurance, which can be expensive.

Critics argue MA plans can offer added benefits only because they are overpaid – a contention credible research confirms, including as conducted by the Medicare Payment Advisory Commission (MedPAC). At the same time, other data shows MA plans are often more efficient at delivering services than the traditional program because the plans scrutinize claims more carefully. High MA enrollment is also associated with positive spillover effects in the traditional program.

MA reforms should incentivize efficiency and high-quality care without needlessly overpaying the plans. The Senate should pull together a reform plan that gradually restructures the MA market so that it operates more efficiently and with lower costs for taxpayers. The following general principles should guide what is developed.

  • Competitive Bidding.
  • MA plans submit bids under the current formula, but Medicare’s payment is a combination of those bids and benchmarks that are set administratively. The Senate should amend the formula to rely strictly on bidding, with a transition to prevent abrupt changes in what is offered to enrollees. The payment could be based on the average bid weighted by enrollment. The new system could be phased in over five years by gradually increasing its influence on the formula (20 percent in year one, going up to 100 percent in year five, for instance).
  • Standardized Benefits.
  • Competitive bidding should be combined with standardization of the coverage MA plans are offering. Without such rules, it is difficult for individual beneficiaries to compare their options on an apples-to-apples basis. The Senate should require CMS to develop a standard MA offering that is comparable in value to the traditional benefit (it may be necessary to add catastrophic protection to the traditional program to ensure the competition is fair). MA plans would then submit their bids based on this standardized offering, and all Medicare beneficiaries would have the option of opting for such coverage. Further, the Senate should direct CMS to develop a small number of standardized supplemental benefits that could be purchased by beneficiaries with additional premium payments. These offerings could focus on the most popular add-ons in the MA market.
  • Risk Adjustment.
  • There are many criticisms of the current system of providing payment adjustments to MA plans based on the varied health risks of their enrollees. The current system has several flaws that might be addressed, but the basic problem is too much reliance on the data submitted by the plans which can lead directly to higher revenue. That design of course invites abuse. The Senate should put into law a requirement that CMA is to determine a final annual risk score for the plans based on submitted information, and any needed refinements by the government to ensure the fairest possible comparisons across plans.
  • ACOs as MA Plans. 
  • The Medicare program would benefit from robust provider-driven MA plans that can effectively compete with the insurer-led MA offerings now dominating the market. CMS should work with interested Accountable Care Organizations (ACOs) on building out functions they would need to become viable alternatives in the MA insurance market.

The Congressional Budget Office (CBO) estimates the House bill will increase deficits by $3.0 trillion over ten years when net interest is in the calculation. Medicare reforms could help the Senate produce a more fiscally responsible bill. If an MA bidding system led to a reduction in payments comparable to a 10 percent cut (which is realistic based on MedPAC’s research), the savings over a decade would be close to $500 billion.

Medicare Advantage Is Failing Its Mission. Here’s How Washington Could Finally Fix It

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Bipartisan voices are calling for reforms to end waste and gaming in MA. Solutions are on the table — if policymakers choose to act.

In the first half of 2025, we have heard many leaders share their concerns with the current results of the Medicare Advantage (MA) program and the need for changes. Dr. Mehmet Oz, administrator of the Centers for Medicare and Medicaid Services, spoke multiple times about issues with upcoding in MA during his confirmation hearing. Lawmakers on both sides of the aisle have also been vocal about the need for reform in MA, including the co-chairs of the GOP Doctors Caucus, Reps. Greg Murphy and John Joyce, and Democratic Rep. Alexandria Ocasio-Cortez. Most recently, CMS Deputy Administrator Stephanie Carlton spoke about these issues at the recent annual conference of the Association of Health Care Journalists in Los Angeles.

Carlton noted that the original intent of MA was “better outcomes for patients” and “better value for taxpayers,” but that the current program is not achieving those goals.

She specifically mentioned research from the Medicare Payment Advisory Commission and other groups showing that “MA is more expensive than fee-for-service”. Fee-for-service, in which health care providers are paid for each service provided to patients, is used in traditional Medicare. Carlton went on to describe the need to “course correct” the program. We wholeheartedly agree. 

Luckily, there are solutions to these issues within MA that both the executive branch and Congress can address. CMS has the authority to address upcoding, where insurers add more codes to a patient’s record to increase their reimbursement from the government, in multiple ways.

First, CMS should continue the changes to the risk-scoring system initiated under the Biden Administration, which removes codes that CMS determines are abused within the Hierarchical Condition Category system. Researchers have found that this method could largely eliminate current overpayments going to insurers, which total tens of billions of dollars a year. CMS also has the authority to increase the coding intensity adjustment, which is the factor by which risk scores are adjusted by the agency to account for greater coding intensity by MA insurers.

The coding intensity adjustment used by CMS is currently 5.9%, which is the statutory minimum. Research shows that the true coding intensity adjustment should be more than 20%; increasing it to this level would reduce Medicare spending by more than $1 trillion over 10 years. There are ways to achieve these savings while also promoting competition, which is why Republicans created Medicare Advantage in the first place, and not compromising quality. Finally, CMS should exclude codes added to a patient’s record from home health risk assessments (HRAs) performed by insurers. That’s because insurers have used HRAs to add codes for diagnoses that patients were never treated for, enabling them to pocket billions of taxpayer dollars. 

Carlton also shared her commitment to plans recently announced by CMS to substantially increase both the pace and the scale of Risk Adjustment Data Validation (“RADV”) audits of MA plans. CMS implemented changes in 2023 to increase the scope of audits and recoupment of overpayments from insurers beginning with 2018 audits, but progress has been painstakingly slow, with CMS originally slated to begin issuing 2018 audit findings in 2026. The intensified efforts will require needed investments in technology and people. 

Another issue diluting the value of MA to taxpayers is the excessive use of supplemental benefits of questionable utility, including things like gym memberships, which serve mainly as marketing tools for insurers. The money spent on such benefits has more than doubled over the past five years. 

Congress can also take action to reform MA in meaningful ways. First, Congress should work with the HHS Secretary and CMS Administrator and provide oversight and accountability to ensure necessary changes to the risk-adjustment methods and processes, including audits and recovery of overpayments.  It is also important to ensure that insurers and their downstream vendors are compliant with applicable CMS rules and regulations, both in terms of clinical and documentation requirements and the payments they receive for these activities. 

Congress could also pass legislation to develop a new risk adjustment system that prevents gaming by insurance companies.

This system could base risk scoring on data from patient encounters with their medical providers rather than just diagnostic codes. This would ensure that patients are treated for any diagnosis used in their risk scores, to ensure that extra diagnoses are not added that patients are not being treated for. Additional scrutiny of how MA rebates are being used and a re-evaluation of permissible benefits are also needed. Further, Congress could implement a cap on out-of-pocket (OOP) expenses for traditional Medicare beneficiaries. Currently, only MA plans offer a cap on OOP expenses, which reduces competition between MA plans and traditional Medicare. Adding an OOP cap to TM would level the playing field between MA and TM, likely resulting in MA plans improving their coverage and benefits, and focusing less on upcoding and withholding care. This would improve the quality of care and competition within the Medicare and MA programs. 

Insurance companies running MA plans have created a system in which taxpayers and patients are not getting the value they pay for.

It is promising that leaders in the current administration and on both sides of the political aisle in Congress are expressing a desire to change this system for the better. There are many solutions to the issues within MA that can be enacted quickly and effectively to improve care and value for seniors and people with disabilities who are enrolled in those plans.

The GOP Budget: Tax Cuts for the Wealthy and More Medical Debt for Everyone Else

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, ACA, Bankruptcy, Credit Ratings, Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, Medicaid, Medicaid Cuts, Medical Debt, Medicare, Medicare Advantage, Medicare Cuts, Pass the Buck, Underinsured, Uninsured • Leave a comment
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The GOP’s reconciliation bill, the “One Big Beautiful Bill Act” (yes, it’s actually called that), is a cruel exercise in slashing benefits for the poor, the elderly, and the sick to free up fiscal space for yet more tax cuts for the rich. Compounding the harm, these benefit cuts are nowhere near enough to pay for the bill’s tax cuts for the wealthy.

Central to this effort are massive cuts to Medicaid and the Affordable Care Act (ACA) marketplaces that, as I argued in my recent paper, will exacerbate our ongoing medical debt crisis.

The GOP reconciliation package that the Senate and House recently agreed to instructed the House Energy and Commerce Committee, which oversees spending on health-care programs including Medicaid and the Children’s Health Insurance Program (CHIP), to identify up to $880 billion in savings over the next 10 years.

Under the rules of the budget reconciliation process, Republicans need to offset any tax cuts they wish to make permanent with an equal dollar value in cuts to spending so as to remain deficit neutral. Trillions of dollars in tax cuts for the wealthier therefore necessitate trillions of dollars in cuts to spending that fall mostly on the social safety net.

Although they did not quite reach that target, the committee still returned a proposed package of deep cuts and changes to Medicaid and to the ACA marketplaces that would reduce federal medical spending by at least $715 billion over 10 years, with about $625 billion in reduced Medicaid spending.1

After public backlash, Republicans seem to have backed off some of their most radical plans for Medicaid (at least for now—one of the challenges of taking health care from people is that it’s terrible politics, so the precise details of the cuts are likely to remain a moving target until the bill passes).

But all options they are close to settling on would still do horrific damage to the well-being of working-class families.

This includes requiring all Medicaid recipients above the federal poverty line to “cost share” by paying (larger) premiums and copayments,2 cutting federal matching to states that provide public health insurance coverage to undocumented and perhaps documented immigrants (on their own dime), and imposing harsh work requirements on “able-bodied adults without dependent children.” This latter provision will cut federal Medicaid spending by roughly $300 billion over 10 years even though the vast majority (92 percent) of nondisabled, non-elderly adult Medicaid recipients are already working, studying full time, or serving as caregivers. This is because work requirements create burdensome reporting requirements to demonstrate compliance that will cause Medicaid recipients who are already employed to lose their insurance as well—blaming the victim for losing their health care, in essence.

The Congressional Budget Office estimates that the reconciliation bill would decrease Medicaid enrollment by 10.3 million in 2034 (the end of the reconciliation bill budget window).

According to this same analysis, most of these individuals would not obtain other insurance (e.g., through an employer) and would thus become uninsured.

When combined with the bill’s changes to the ACA marketplace and the expiration of the enhanced premium tax credits—a wildly successful policy that was introduced as part of the American Rescue Plan Act (ARPA) and one that Republicans have shown no inclination to extend—this would result in an additional 13.7 million uninsured individuals in 2034, a 30 percent increase, according to KFF estimates.

Republicans seem hell-bent on undoing the remarkable progress made in the 15 years since the passage of the ACA in reducing the non-elderly uninsured rate from 17.8 percent in 2010 to roughly 9.5 percent today (plus ça change).

But we’ve seen less focus on how this will affect the problem of underinsurance.

Republicans’ Medicaid cost-sharing requirements, the changes they have proposed to the ACA marketplaces, and their determination to let the ARPA premium tax credit enhancements expire will also worsen the problem of underinsurance, an area where we have made considerably less progress.

Taken together, this will worsen the ongoing medical crisis because medical debt is driven by uninsurance and underinsurance.

Medical debt is, unlike in most other countries, and despite the successes of the ACA, a major problem in the United States. KFF found that 20 million adults (almost 1 in 12) owed “significant” medical debt to a health-care provider.3 This number rises when we consider a more expansive definition of medical debt including credit card balances and bank loans used to pay medical providers. Under that definition, an estimated 41 percent of American adults (~107 million people) carried some form of medical debt and 24 percent of American adults (~62 million people) had medical debt that was past due or that they were unable to pay. Among those with medical debt using this more expansive definition, nearly half (44 percent) reported owing at least $2,500, and about one in eight (12 percent) said they owe $10,000 or more. The poor, the sick, the middle-aged, and Black and Hispanic individuals disproportionately bear the brunt of this problem.

The crisis of medical debt and underinsurance is so widely recognized by Americans that a state attorney general candidate can go viral just by talking about the reality of a GoFundMe health-care system millions of Americans face.

The consequences of all this debt are dire—and reflect a health-care system that heals people physically but leaves many permanently scared financially. In 2022, medical debt (using the narrow definition) made up an estimated 58 percent of all debts that had gone to collections, and 62 percent of bankruptcies were attributed in part to medical debt. Medical debt also damages credit scores, leading to a wide variety of negative impacts on financial well-being that can follow families for years.

A poor credit score means that families may be unable to obtain a mortgage or a car loan or may end up paying much higher interest rates.

Credit scores are commonly used by landlords to screen tenants and by employers as part of a background check during the hiring process. Even for those who manage to maintain their credit after taking on medical debt, there are real costs. For those with limited income and assets, debt service may displace spending on food, clothing, and other essentials, leading to material hardship. It can make savings impossible and limit economic mobility.

Medical debt is a problem largely generated by poor policy decisions including, as I argue in my paper, prioritizing and incentivizing health insurance coverage through the private market rather than through Medicaid and Medicare, which offer comprehensive coverage more cheaply. The problem would rapidly disappear if we could extend comprehensive health insurance coverage to the millions of uninsured and underinsured people who live with the constant risk that a sudden medical event could ruin their finances and constrain their futures.

But rather than fix the problem, the GOP plans to throw millions off Medicaid and saddle those who remain with higher costs and more limited coverage. The results of these poor policy decisions will be more sickness, more debt, and higher costs for everyone in exchange for on-paper “savings.” And all this in service of tax cuts for the wealthy they haven’t even bothered to justify.

If you ask Eleanor

“If the old people cannot afford their medical care under their own Social Security allowances, then the burden is going to fall on their children who are in their earning years. This will mean that just at the time when these children who may be having young children of their own and needing medical care, a young couple will also have to consider shouldering the burden for parents as well. This is not fair, and leads to both the children and the older people not getting full coverage, since both will try to shave a little off their needs in order not to make the burden impossible to carry.”

– Eleanor Roosevelt, My Day (May 23, 1962)