The Wall Street Journal’s Editorial Board vs. The Wall Street Journal’s Newsroom.

The paper that exposed Medicare Advantage’s $50 billion overbilling scheme is now urging the government to make it the default for every senior in America.

During my two decades working for Big Insurance, I learned what industry spin looks like. I know what it sounds like. And I know that when a major newspaper’s editorial board publishes a piece defending an industry that has spent millions cultivating its editorial goodwill, the result often reads exactly like the Wall Street Journal’s editorial yesterday, “The Truth About Medicare Advantage.”

The piece is a masterclass in selective evidence. But what makes it remarkable is that the most damning rebuttal to it doesn’t come from me, or from Medicare Advantage’s many critics, or from the political left. It comes from the Wall Street Journal’s own newsroom.

In the fall of 2022, a team of Journal reporters did something extraordinary. They negotiated a data-sharing agreement with the Centers for Medicare and Medicaid Services, gaining access to 1.6 billion Medicare Advantage records over a 12-year period — every prescription filled, every doctor visit, every hospitalization. The investigation that followed was among the most rigorous pieces of health care journalism in years.

What they found was damning. Medicare Advantage plans received roughly $50 billion in payments between 2018 and 2021 for diagnoses that were questionable — conditions added to patients’ records not by their doctors, but by the insurers themselves. The Pulitzer Prize committee called it a series showing how health insurers gamed the Medicare Advantage program to collect billions for nonexistent ailments while shunting expensive cases onto the public.

The Journal’s editorial board was apparently not paying attention to its own reporters. Because in its editorial yesterday, the board cites a study funded by Elevance Health — one of the largest Medicare Advantage insurers in the country — to argue that private MA plans reduce Medicare spending. It calls opposition to Medicare Advantage “ideological, no matter the facts.”

“No matter the facts” certainly applies to the Journal’s editorial.

The central fact the editorial board cannot afford to acknowledge — because the entire argument would collapse if it did — is the ongoing Medicare Advantage overpayment scandal. MedPAC, the independent congressional agency that advises Congress on Medicare, projects that for 2026, Medicare Advantage payments will run $76 billion — or 14% — above what traditional Medicare would spend on the same beneficiaries, after accounting for health status, coding differences, and geographic factors. Note that the $76 billion in overpayments is just for this year. Looking back over the history of the Medicare Advantage program and the total likely would grow to nearly a trillion dollars if not more.

This is not a partisan number. MedPAC is a nonpartisan body. The methodology accounts for the very factors the industry argues should be included. And the conclusion is unambiguous: the federal government spends substantially more of our tax dollars per person under Medicare Advantage than it would under traditional Medicare. That $76 billion overpayment is not a rounding error. It is more than the entire annual budget of the Department of Education.

The Journal’s editorial board also ignores what that overpayment costs seniors who never chose a private plan. The Journal’s own reporting detailed how MA overpayments translated into roughly $13.4 billion in additional Part B premium costs in 2025 alone — costs borne by every Medicare beneficiary, including those in traditional Medicare who never signed up for a private Medicare replacement plan, which is what Medicare Advantage is. Every senior paying Part B premiums is, in effect, subsidizing the insurers the editorial board is championing.

The editorial argues that Medicare Advantage reduces the incentives for hospitals to upcode patients to a higher level of complexity. This would be a compelling point if the Journal’s own investigation had not spent years documenting how MA insurers themselves are the upcoding problem.

The Journal’s investigation found that coding intensity in Medicare Advantage runs 20% higher than in traditional fee-for-service Medicare. Of the 17 audits the Department of Health and Human Services Office of Inspector General has conducted since 2019, there was no support for nearly 69% of diagnoses that Medicare Advantage plans used for risk adjustment, leading to more than $100 million in overpayments to MA plans from upcoding alone. That’s not a rounding error either.

In the early years of private Medicare plans, insurers went to great lengths to sign up only the healthiest seniors and to run off the seniors when they got sick. It was called “cherry picking” and “lemon dropping.” I saw it up close in the early ‘90s when I was at Humana, one of the first insurers to get into the private Medicare replacement business. It was so prevalent in the industry that in 2003 Congress passed legislation to authorize the government to pay insurers more for signing up less-healthy seniors. So for two decades now, insurers have been paid more for sicker patients, which means they have powerful financial incentives to make patients look sicker on paper — but not to pay for treatments they supposedly would need. The Journal’s reporters found that among Medicare Advantage beneficiaries who had an HIV diagnosis added to their record by their insurer, just 17% received any treatment for the disease. Among beneficiaries diagnosed with HIV by their own physician, 92% received treatment. Diagnoses without treatment are not better care. They are extra revenue.

The editorial’s most revealing sentence may be this one: “The opposition to Advantage is ideological, no matter the facts.” This is a tell. It reframes data as politics, and politics as bias — a classic spin move designed to preempt legitimate criticism by impugning the critic’s motives.

But the criticism of Medicare Advantage is most certainly not ideological, and it is not coming only from Democrats. Sen. Chuck Grassley of Iowa, a Republican, wrote to UnitedHealth Group’s CEO arguing that the “apparent fraud, waste, and abuse at issue is simply unacceptable and harms not only Medicare beneficiaries, but also the American taxpayer.” The Trump administration’s Department of Justice opened a criminal investigation into UnitedHealth Group’s Medicare Advantage billing practices (which the Journal reported as a scoop). The Senate Judiciary Committee, which Grassley chairs, published a 104-page report on MA overbilling.

Another senior Republican, Sen. Bill Cassidy, who chairs the Senate Health, Education, Labor and Pensions (HELP) Committee, is the lead sponsor of a bill that would crack down on upcoding. It’s called The No UPCODE Act. These are not the actions of ideologues. They are the actions of Republican legislative leaders and committee investigators who read the Journal’s own reporting and followed up.

The editorial’s timing is no coincidence. Trump’s Medicare director, Chris Klomp, recently confirmed that the administration is actively considering a policy that would automatically enroll new Medicare beneficiaries into private Medicare Advantage plans — a proposal straight out of the Project 2025 blueprint. The editorial reads, at least in part, as advance justification for that policy.

Under current law, seniors who enroll in Medicare are automatically covered by traditional Medicare unless they affirmatively choose a private plan. Under a default enrollment scheme, the reverse would be true: seniors who fail to make an active choice would be placed into a private plan, with the option to switch back – but not for three years. Seniors would be locked in a plan that the government chose for them, that has a limited network of doctors and hospitals, that makes them pay the entire bill for services they might receive outside of that network, and that denies coverage for medically necessary care far more than traditional Medicare – for three years.

The consequences of getting automatic enrollment in MA wrong are severe and often irreversible. The vast majority of states do not require Medigap insurers to sell supplemental coverage to beneficiaries who want to switch back from Medicare Advantage to traditional Medicare outside of limited time windows. For many seniors, once they are in, they are in. The editorial board does not mention this.

And the program is hardly the stable backstop the board describes. A Johns Hopkins Bloomberg School of Public Health analysis found that approximately 10% of Medicare Advantage enrollees — roughly 2.9 million seniors — are being forced to find new coverage in 2026 as insurers exit markets, a tenfold increase in the forced disenrollment rate compared to just two years ago. The board wants to make this the default destination for every new senior in America, just as the private market is demonstrating it cannot sustain its current commitments.

Let’s return to the study the editorial board cites as evidence that Medicare Advantage saves money. The board presents it as peer-reviewed fact. What it does not say is that the researchers are affiliated with Elevance Health — formerly Anthem — one of the largest Medicare Advantage insurers in the country. Industry-funded research is not automatically wrong, but it requires disclosure and scrutiny that the editorial board does not provide. I know from personal experience that industry-funded research is typically rigged to support conclusions the funder wants to convey – to policymakers, the business community, the media and the public – and that any data that do not support the funder’s business objectives never make it into the final report.

In the communications business, we used to call this kind of thing a “third-party validator” — research that carries the appearance of independence while advancing the funder’s interests. I helped produce the playbook. I know how this works.

The Wall Street Journal’s newsroom has done some of the most consequential health care journalism of the past decade. Its reporters negotiated extraordinary data access. They documented, with precision, how the insurance industry has extracted billions from Medicare through practices that the Pulitzer committee described as gaming the system. They named names and they showed their work. And you can be certain that every word they wrote was carefully fact-checked and vetted by the Journal’s legal team.

The editorial board is in the same building as the Journal’s newsroom. I know because I’ve been in those rooms. I know and have worked with many of the reporters who cover the health insurance business, going back to my days in the industry. I can assure you that the Journal’s reporters are among the best in the business and, unlike the editorial writers, most certainly are not motivated by ideology.

The newspaper’s editorial board owes readers the same fidelity to evidence that its reporters have demonstrated. Instead, it has produced a piece of advocacy that reads like it was drafted in a health insurance industry communications shop — cherry-picked studies, industry talking points, and a dismissal of critics as ideologues “no matter the facts.”

I have spent the years since leaving the insurance industry trying to help people understand how spin works – how it is produced, how it travels, and how it takes hold even in institutions that should know better. The Journal editorial board’s Medicare Advantage advocacy is a case study.

This should be studied in every journalism school in America: The paper that exposed Medicare Advantage’s overbilling scheme is now urging the government to make it the default plan for every senior in America. Someone needs to explain that to the reporters who spent three years proving why that is a terrible idea.

Even as CMS documents improper denials, ghost networks and unlawful out-of-pocket charges, enforcement remains weak with just $3 million in fines levied in early 2025 against billion-dollar insurers.

Enrolling in Traditional Medicare means paying more upfront to protect against catastrophic costs because Traditional Medicare lacks an out-of-pocket cap, but in return, you get the care your treating physicians recommend you need. In stark contrast, enrolling in Medicare Advantage typically means allowing a for-profit insurer to second-guess your treating physician and inappropriately delay or deny the care you need, forcing you to gamble with your health and, sometimes, your life. What’s worse is that our federal government is rarely willing or able to punish Medicare Advantage insurers for their bad acts. Consequently, Medicare Advantage insurers too often can get away with restricting access to specialists and specialty hospitals and not covering the treatments their enrollees are entitled to.

Penalties on Medicare Advantage insurers that deprive their enrollees of the care they need are few and far between. In the first four months of 2025, the Trump administration imposed more penalties on the insurers in Medicare Advantage than they faced during the entire four years of the Biden administration. Still, it only imposed about $3 million in penalties, reports Rebecca Pifer Parduhn for HealthcareDive. That is tiny relative to the billions in profits of the big insurers.

Most of the penalties the Centers for Medicare & Medicaid Services (CMS) has imposed in the last few years for Medicare Advantage insurer violations are under $50,000. Penalties imposed were for serious offenses, including improper insurer delays and denials of care and insurers requiring people to spend more out of their own pockets than allowed under the law. Centene was hit with the largest penalty of $2 million for charging its enrollees above the out-of-pocket maximum permitted to be charged, in violation of 42 C.F.R. Part 422, Subpart C.

Molina received the second largest penalty of just over $285,000 for its failure to comply with prescription drug coverage requirements. CMS said that Molina’s failure was “systemic and adversely affected, or had the substantial likelihood of adversely affecting, enrollees because the enrollees experienced delayed access to medications, paid out-of-pocket costs for medications, or never received medications.” It’s hard to believe that Molina didn’t substantially benefit financially from its violations even after paying the $285,000 fine.

Susan Jaffe reports for KFF News that over a seven-year stretch between 2016 and 2022, CMS, under both Trump and Biden, did almost nothing to ensure network adequacy for Medicare Advantage enrollees. Moreover, it did very little to penalize the Medicare Advantage insurers CMS identified as operating Medicare Advantage plans with inadequate networks.

After KFF made a Freedom of Information Act request regarding enforcement actions against Medicare Advantage insurers with inadequate networks, CMS turned over just five letters to insurers regarding seven MA plans with inadequate provider networks. Given the widespread reporting of network inadequacy in Medicare Advantage, it’s inconceivable that only seven MA plans had inadequate networks. When questioned as to why CMS took action in so few instances, the agency explained that it is not overseeing all of the more than 3,000 Medicare Advantage plans but conducting “targeted” reviews of Medicare Advantage plan provider networks.

What’s clear is that CMS does not begin to have the resources to oversee more than 3,000 Medicare Advantage plans to ensure they are in compliance with their contractual obligations and delivering the care they are required to. As a result, Medicare Advantage enrollees are left unprotected. Too often, Medicare Advantage plans have “ghost networks,” networks that look good in the provider directory but turn out to include physicians who are out of network. These MA plans might not have enough primary care physicians, mental health providers, specialists, hospitals, nursing homes, rehab facilities or mental health professionals in their networks.

Technically, CMS can prevent insurers with inadequate networks from marketing their Medicare Advantage plans, freeze enrollment, fine them or even terminate the Medicare Advantage plans. But it never has. In its June 2024 report, the Medicare Payment Advisory Commission (MedPAC) wrote: “CMS has the authority to impose sanctions for noncompliance with network adequacy standards but has never done so.” CMS often doesn’t even let Medicare Advantage enrollees know about the inadequacy of the provider network or allow enrollees the ability to disenroll.

For CMS to oversee Medicare Advantage plans effectively and impose sanctions where appropriate it would need far more resources than it currently has. Moreover, penalties would likely need to be non-discretionary or they would be subject to political interference. In addition, to simplify the process and reduce costs, insurers likely would need to be required to offer the same network for all their Medicare Advantage plans in a given community.

As lawmakers debate ACA subsidy extensions and HSAs tied to banks and insurers, the public’s appetite for a health care overhaul is stronger than at any time since the 2020 Democratic primaries.

Washington is running out of hours to address the health care crisis of their own making. There are just 23 days before the Affordable Care Act’s (ACA) enhanced subsidies expire and congressional leaders are still trading barbs and floating half-baked ideas as millions of Americans brace for punishing premium spikes.

Meanwhile, the public has grown frustrated with both congressional dysfunction, and private health insurance companies that continue to raise premiums and out-of-pocket costs at a dizzying pace. According to new KFF data, 6 in 10 ACA enrollees already struggle to afford deductibles and co-pays, and most say they couldn’t absorb even a $300 annual increase without financial pain.

And even as Congress flails, Americans are coalescing around a solution party leaders rarely mention: Medicare for All.

A dramatic rebound in popularity

After Senator Bernie Sanders bowed out of the presidential race in April 2020, Medicare for All faded to the background following political infighting, industry fearmongering and the lack of a national champion. But nearly six years later, the proposed policy solution has re-emerged as a top choice among frustrated voters.

A new Data for Progress poll found that 65% of likely voters (including 71% of independents and nearly half of Republicans) support creating a national health insurance program that would replace most private plans. What’s notable is that the poll shows that support barely budges – holding at 63% – even when voters are told Medicare for All would eliminate private insurance and replace premiums with taxes, a dramatic shift from years past when just 13% supported such a plan under those conditions.

These new polls show that Americans are not simply dissatisfied with the looming subsidy crisis. But instead, as I wrote last month, they’re losing faith in the current system that allows Big Insurance to collect record profits at the expense of Americans’ health and bank accounts.

The KFF poll shows that ACA enrollees lack confidence that President Trump or congressional Republicans will handle the crisis, with almost half of ACA enrollees saying a $1,000 cost spike would “majorly impact” their vote in 2026. More than half of ACA enrollees are in Republican congressional districts, which explains why Republicans representing swing districts are desperately trying to persuade their Republican colleagues — so far without success — to extend the subsidies.

Of course, Medicare for All still faces steep odds in Congress. Industry opposition remains powerful, Democrats are divided and Republicans are openly hostile. But the polling shift is significant and suggests the political terrain is changing faster than Washington is acknowledging — and that voters, squeezed by soaring premiums and dwindling subsidies, are being nudged toward policies previously attacked as too ambitious to pass.

And against this backdrop, Medicare for All’s revival feels less like a left-wing wet dream and more like a window into the public’s thinning patience. Americans are looking past the Affordable Care Act’s limits and past Big Insurance’s promises – and towards a solution that decouples Americans health from profit-hungry, Wall Street-driven corporate monsters. While Washington has met this moment with inaction, Americans seem ready to act.