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Massive changes are afoot in Medicare, and the media keeps missing the story

Massive changes are afoot in Medicare, and the media keeps missing the story

Picture of Trudy  Lieberman
(Photo by Justin Sullivan/Getty Images)
(Photo by Justin Sullivan/Getty Images)

In late July, sponsored content appeared sandwiched between paragraphs of legitimate journalism in Politico Pulse, the outlet’s daily health care newsletter. Humana, the country’s second-largest seller of Medicare Advantage (MA) plans, told readers that “with Medicare Advantage, seniors save an average of $1,640 in annual out-of-pocket spending compared to fee-for-service Medicare.” Humana added that it was “committed to affordable quality care,” echoing that shopworn slogan from the marketing pitch used to sell Obamacare in 2009.

Humana also referred readers, who undoubtedly include Congressional staffers and possibly their bosses, to a report from the Better Medicare Alliance, an industry-financed lobbying group for MA plans, released earlier this year. The report, the “2021 State of Medicare Advantage,” predictably lauded these plans, noting that 98% of beneficiaries were satisfied with their coverage; 97% were “specifically satisfied” with their network of physicians, hospitals, and specialists; and that “Medicare Advantage’s overall satisfaction rate rises to 99% among minority beneficiaries.” The lobbying group also applauded 70 members of Congress from both sides of the aisle who had sent a letter to the Secretary of Health and Human Services in support of MA plans. The group then took to Twitter to single out individual members of Congress such as Alabama Rep. Terri Sewell, thanking her for co-signing the letter and for “expressing strong support for Medicare Advantage.” Such gestures are like valentines, a lobbyist once told me, to flatter legislators into supporting a group’s agenda.

Flattery seems to have worked! Congress has given Medicare Advantage plans every advantage over traditional Medicare in an ongoing effort to diminish that program in favor of a privatized version of Medicare. The underlying goal, I have long argued, is to shift more of the cost of medical care to seniors themselves, relieving the financial pressure on the federal government to pay for their health needs. Over the years, the government has overpaid Medicare Advantage plans to encourage their growth. In addition plans have been able to get more money by overstating the severity of their beneficiaries’ illnesses.

All this money has enabled Medicare Advantage plans to entice new members with goodies like dental, vision, and hearing benefits, free transportation to doctors’ offices, and two weeks of meals after a hospital stay. MA plans are allowed to offer those benefits, which the traditional Medicare program and Medigap policies that accompany it usually do not offer. With such a government-sanctioned edge, no wonder MA plans have been able to bring 42% of the Medicare population into their fold.

There’s a dark side, though, to the rising popularity of Medicare Advantage plans, which the public does not see, since the media has largely taken a pass on covering the story. Academic research, however, is beginning to reveal that thousands of Medicare beneficiaries, taken in by over-the-top poll results from the Better Medicare Alliance and ubiquitous TV commercials featuring Joe Namath may not be so delighted with their plans after all. People are enticed by cheaper premiums and lots of benefits, but they often don’t go beyond the premiums to understand how the plans’ cost-sharing and provider networks really work.

“These findings suggest that Medicare Advantage members in rural areas are experiencing limited access to care,” Sungchul Park, an assistant professor at Drexel’s Dornsife School of Public Health, told me. “They may realize that staying in an Advantage plan is not good for them, and they switch.”

In March, the policy journal Health Affairs published a significant study that offers strong warnings for Medicare Advantage members, particularly those living in rural areas. The study found that while switching from traditional Medicare to MA plans was not common for beneficiaries in either rural or urban areas, those living in rural areas were twice as likely (10.5%) to leave an MA plan as people who live in urban or suburban areas (5%). In other words, more beneficiaries who had chosen Advantage plans in rural areas were dissatisfied with their coverage. About one-fifth of beneficiaries in rural areas who were dissatisfied with the ease of getting to their doctor or getting care at the same location switched to traditional Medicare.

“These findings suggest that Medicare Advantage members in rural areas are experiencing limited access to care,” Sungchul Park, an assistant professor in the department of health management and policy at Drexel’s Dornsife School of Public Health and the lead study author, told me. “They may realize that staying in an Advantage plan is not good for them, and they switch.”

“If you’re living in an area with few providers to begin with, you might have access to an even smaller number of providers in your network,” said David Meyers, an assistant professor of health services policy and practice at Brown University and another of the study’s authors.

What makes these results even more noteworthy is that so many rural beneficiaries were willing to leave their Advantage plans even though most of them can’t buy a supplemental insurance (Medigap) policy to fill in traditional Medicare’s coverage gaps. Many seniors have health problems that make them uninsurable at this point. But without a Medigap policy, they must pay the 20% of a bill that Medicare does not pay. People in traditional Medicare usually buy Medigap policies, which cover things like coinsurance, copayments and deductibles, when they first become eligible for Medicare. Depending on which of the 10 standardized Medigap plans they buy, they may have negligible out-of-pocket expenses. However, only four states — New York, Connecticut, Maine, and Massachusetts — allow people to return to traditional Medicare and buy a Medigap policy without an insurer taking into consideration their health after their initial enrollment period. That makes it more likely in other states for an insurer to deny someone a Medigap plan — coverage is not guaranteed. But staying in an MA plan may mean they cannot access certain doctors to treat their condition. They’re stuck in a bind.

Meyers and his colleagues have recently published other studies, which raise more questions about the care minorities receive in Medicare Advantage plans. In January, one study published in the Journal of General Internal Medicine found that MA plans with higher premiums, higher enrollment, and higher market share tended to have wider networks. The study also found “substantial racial/ethnic disparities in access to wider MA networks when it came to primary care, psychiatry, and mental and behavioral health” care for Hispanic and Asian beneficiaries. This June, another Health Affairs study found that as of 2018, 47% of Hispanics, and 37% of Blacks were in MA plans, compared to 26% of whites. The study concluded that the biggest increases in MA enrollment were among Black enrollees and those who lived in the poorest neighborhoods.

There’s a dark side, though, to the rising popularity of Medicare Advantage plans, which the public does not see, since the media has largely taken a pass on covering the story.

“Racial and ethnic minorities tend to concentrate in specific plans that may be lower in quality than the plans white beneficiaries are enrolling in,” Meyers said. “Hispanic and Black beneficiaries also tend to enroll in low-premium plans, and we’ve found lower premiums may be associated with narrower networks.” Meyers added that it’s well-established by existing research that Black and Hispanic enrollees experience poorer outcomes in the Medicare Advantage program than white enrollees.  

Given such findings and the zeitgeist of the moment, it is disappointing to see the media take a pass reporting on Meyers’ research, which is significant for millions of Americans of color and those living in rural areas. That’s hardly surprising, since as I have pointed out in this space, journalists barely cover Medicare these days, despite its importance to so many Americans. The Health Affairs press office picked up only 12 stories about its March report on rural Americans leaving MA plans. All appeared in trade or health-related news outlets. It picked up only five stories — four in the trade press and one in a fitness magazine — discussing the findings of the Health Affairs study published in June. The AARP Bulletin, which reaches 35 million readers, including those in rural areas heavily targeted by Medicare Advantage sellers, did not run a story about Meyer’s findings, according to an AARP spokesperson.

So where can journalists, people on Medicare, and those about to join actually learn objectively what their options are? The best source of such information about the limitations of Medicare Advantage plans Meyers and his colleagues have pointed out is their State Health Insurance Assistance Program, or SHIP, for short. The SHIPs were set up by Congress in 1990 to help Medicare beneficiaries, who were confronting a confusing marketplace long before there were Advantage plans.

I called three SHIP programs in rural states asking about options for a hypothetical relative. They all suggested the person make an appointment to see a counselor, but gave me a bit of information when I asked about ease of seeing physicians. In Indiana, a counselor said a doctor can leave an Advantage plan “for any reason they see fit. It’s definitely not uncommon.” A North Dakota counselor noted, “there aren’t a lot of doctors in rural areas, and they (people) have to travel to bigger areas. Original Medicare might be a better option because it is accepted nationwide. It’s more broad.” In Georgia, a counselor advised, “Each option works for some, but it doesn’t work for others.”

This spring a rare and excellent Medicare story appeared, this one in Kaiser Health News and picked up by some of Kaiser’s media partners. Fred Schulte reported that Humana had overcharged Florida seniors on Medicare nearly $200 million in 2015 by overstating how sick they were. The Health and Human Services Office of the Inspector General said this would be “by far the largest” audit penalty ever imposed on a Medicare Advantage company if finalized. Humana told KHN it disputed the findings. I sent an email to the company asking for an update and Humana did not respond to the request. Schulte is a veteran journalist who has covered this issue for years and is one of the rare reporters to write critically about Medicare Advantage plans, let alone cover Medicare in the first place. He reported that despite their popularity, MA plans have been the target of many government investigations, Medicare audits, and Department of Justice and whistleblower lawsuits.

Schulte’s dogged pursuit of Advantage plan overcharges and the health researchers’ findings about network shortcomings in rural areas and for Americans of color should be reason enough to revive media interest on this neglected beat. You can bet when Joe Namath is back in the fall hawking Medicare Advantage plans, he won’t be talking about narrow networks, lack of access to doctors, or overcharging the government. But someone should.

Veteran health care journalist Trudy Lieberman is a contributing editor at the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care column.

Comments

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I originally signed up for the regular Medicare insurance only to discover that I had an annual upfront deductible that I had to pay out of pocket before the insurance started to pick up part of my costs. That $200 annual fee actually kept me from seeing my doctor for treatment. A friend clued me in that there were medicare advantage plans and our Not For Profit Local Hospital did in fact offer several advantage plans. I was able to sign up for one that actually didn't cost any monthly premium. I'm still with this provider but have changed plans as I meet the criteria of using a PCP who is one of the hospital's doctors and with that consideration I have no monthly premium. Our hospital also has medical offices in the more rural areas of the state.

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Why senior citizens enroll in Medicare Advantage plans

Consider the household budget of a senior citizen who is not a homeowner with assets whose retirement income is above the Medicaid level and below 300% of the poverty level. The average Social Security check in Washington State is about $1600 per month. Then consider the rising cost of rent and the cost of food, household essentials and automobile repairs.

Now factor in the cost of health insurance premiums. Add about $150 per month for Medicare Part B. With a zero premium Medicare Advantage plan, such as AARP United Health Care, the only additional budget item for health care cost is an optional $38 per month in dental insurance and any dental copays beyond exams and fillings. Compare this with the cost of Medicare Part D and supplement plans. In Washington State, considering the soaring cost of rent, a senior citizen risks homelessness by not enrolling in zero premium Medicare Advantage.

The main reason Medicare Advantage plans are popular is that they can be combined with federal charity care, the federal program that covers deductibles and co-insurance for patients below 300% of the poverty level. Patients below 300% of the poverty level combine zero premium Medicare Advantage with federal charity care. The only cost for health care is the Medicare Part B premium in the range of $150 per month.

Financially, low income senior citizens risk homelessness by not enrolling in zero premium Medicare Advantage.

It is true that HMO models are increasingly dominating Medicare Advantage plans. In 2021, AARP United Health Care in Washington State drastically reduced out-of-network benefits in all plans and restructured its offerings into four HMOs and one PPO. It is true that the choice of doctors is restricted in low cost Medicare Advantage plans.
But consider what the networks and the choices are.

In Washington State, the University of Washington Medical Center health care system is in-network, with its broad range of specialty clinics and three major hospitals. The providers are professors and the doctors they hire are often the residents and students they trained. In a large university health care system, there are quality controls and checks and balances to minimize the risks for patients. Another example of a major network operating in Washington State is Kaiser.

Consider cancer care in Washington State. Seattle Cancer Care Alliance and its research arm, Fred Hutchinson Cancer Research, have always been associated with the University of Washington, and the full consolidation was just completed. Seattle Cancer Care Alliance is in-network with AARP United Health Care and other Medical Advantage plans.

Joining a Medicare Advantage plan gives patients access to some of the top cancer care in the world. When patients have access to health care at one of the world’s top cancer treatment centers, of course they are satisfied with their doctors and their network. They don’t have to depend on yelp reviews because the doctors were screened by a university human resources process.

Claims that providers exaggerate their patients’ illnesses to overbill Medicare do not match the actual practices of large health care systems. For example, most cancer care follows the NCCN flow charts. Insurance companies rely on test results and everything is standardized. University medical centers have ethics. There are extensive reports of doctors all over the country minimizing and disregarding women’s complaints of pain and distress, not exaggerating women’s medical conditions.

Access to health care in rural areas is a serious problem. Living near a bus route to a major medical center is one of the main factors any senior citizen must consider in choosing where to retire. The University of Washington has free shuttle service to several of its hospitals. Anyone who can get to one of the main medical centers can get to most of the others.

The problem in rural areas comes down to transportation. Seattle Cancer Care Alliance serves the entire state. People from Alaska also fly to Seattle and stay in SCCA’s housing for treatment. Construction for a light rail is underway in King County, and it will meet many people’s needs. But ubiquitous transportation to health care, especially in rural areas, is a serious, unsolved problem.

Government and non-profit initiatives to build more housing near transit and health care can provide more senior citizens with basic shelter, however imperfect, so that they can access health care.

One of the main problems causing dissatisfaction in the health care system is that of languages. Large medical centers have more than 100 languages to interpret. Hospitals strive to hire staff members from diverse backgrounds so that someone is available as an interpreter. There are full time interpreters for some languages. Private doctors can have two or three staff members with different languages, but foreign language speakers have the best chance of having their needs met at a university.

Another source of dissatisfaction with insurance is the denial of benefits for a requested procedure and irrational restrictions of preferred prescription lists and formularies for medicines. There is no indication of how this would change with termination of Medicare Advantage.

Universal health care is desirable, but it is also important to understand why the structure of Medicare Advantage combined with federal charity care is successful in providing high quality care to senior citizens. When people praise the success of Medicare Advantage plans, it is not the result of an insurance company public relations campaign or corporate influence on Members of Congress. The integrity of Members of Congress who listen to their constituents should not be disparaged. They are not being influenced by corporate donations. Congresswoman Terri Sewell is a person of considerable education and high integrity.

Eliminating Medicare Advantage without an alternative to preserve zero premiums and zero deductibles and copays would throw hundreds of thousands of senior citizens into both medical insecurity and housing insecurity.

- Linda Seltzer writes and curates information about Medicare issues in progressive Health Care Policy Discussion on Facebook.

Picture of Gloria  Keith

I wanted very much to have the healthcare that I was able to combinate for our mother. I found loopholes in UHC which allowed us to establish a private plan for our mom through UHC and Mom's Supplement Resources. After mother's death, UHC hired the mother's Case Manager. The loopholes were filled to the brim. I have tried UHC several times. Yet, it hasn't stayed true to its contract with me or the contract, I thought I had with UHC. Several reasons keep me continuing with Traditional Medicare and my state supplements.

Picture of Linda Seltzer

Consider the household budget of a senior citizen who is not a homeowner with assets whose retirement income is above the Medicaid level and below 300% of the poverty level. The average Social Security check in Washington State is about $1600 per month. Then consider the rising cost of rent and the cost of food, household essentials and automobile repairs.
Now factor in the cost of health insurance premiums. Add about $150 per month for Medicare Part B. With a zero premium Medicare Advantage plan, such as AARP United Health Care, the only additional budget item for health care cost is an optional $38 per month in dental insurance and any dental copays beyond exams and fillings. Compare this with the cost of Medicare Part D and supplement plans. In Washington State, considering the soaring cost of rent, a senior citizen risks homelessness by not enrolling in zero premium Medicare Advantage.
The main reason Medicare Advantage plans are popular is that they can be combined with federal charity care, the federal program that covers deductibles and co-insurance for patients below 300% of the poverty level. Patients below 300% of the poverty level combine zero premium Medicare Advantage with federal charity care. The only cost for health care is the Medicare Part B premium in the range of $150 per month.
Financially, low income senior citizens risk homelessness by not enrolling in zero premium Medicare Advantage.
It is true that HMO models are increasingly dominating Medicare Advantage plans. In 2021, AARP United Health Care in Washington State drastically reduced out-of-network benefits in all plans and restructured its offerings into four HMOs and one PPO. It is true that the choice of doctors is restricted in low cost Medicare Advantage plans.
But consider what the networks and the choices are.
In Washington State, the University of Washington Medical Center health care system is in-network, with its broad range of specialty clinics and three major hospitals. The providers are professors and the doctors they hire are often the residents and students they trained. In a large university health care system, there are quality controls and checks and balances to minimize the risks for patients. Another example of a major network operating in Washington State is Kaiser.

Consider cancer care in Washington State. Seattle Cancer Care Alliance and its research arm, Fred Hutchinson Cancer Research, have always been associated with the University of Washington, and the full consolidation was just completed. Seattle Cancer Care Alliance is in-network with AARP United Health Care and other Medical Advantage plans.
Joining a Medicare Advantage plan gives patients access to some of the top cancer care in the world. When patients have access to health care at one of the world’s top cancer treatment centers, of course they are satisfied with their doctors and their network. They don’t have to depend on yelp reviews because the doctors were screened by a university human resources process.
Claims that providers exaggerate their patients’ illnesses to overbill Medicare do not match the actual practices of large health care systems. For example, most cancer care follows the NCCN flow charts. Insurance companies rely on test results and everything is standardized. University medical centers have ethics. There are extensive reports of doctors all over the country minimizing and disregarding women’s complaints of pain and distress, not exaggerating women’s medical conditions.

Access to health care in rural areas is a serious problem. Living near a bus route to a major medical center is one of the main factors any senior citizen must consider in choosing where to retire. The University of Washington has free shuttle service to several of its hospitals. Anyone who can get to one of the main medical centers can get to most of the others.
The problem in rural areas comes down to transportation. Seattle Cancer Care Alliance serves the entire state. People from Alaska also fly to Seattle and stay in SCCA’s housing for treatment. Construction for a light rail is underway in King County, and it will meet many people’s needs. But ubiquitous transportation to health care, especially in rural areas, is a serious, unsolved problem.
Government and non-profit initiatives to build more housing near transit and health care can provide more senior citizens with basic shelter, however imperfect, so that they can access health care.
One of the main problems causing dissatisfaction in the health care system is that of languages. Large medical centers will have more than 100 languages to interpret. Hospitals strive to hire staff members from diverse backgrounds so that someone is available as an interpreter. There are full time interpreters for some languages. Private doctors can have two or three staff members with different languages, but foreign language speakers have the best chance of having their needs met at a university.
Another source of dissatisfaction with insurance is the denial of benefits for a requested procedure and irrational restrictions of preferred prescription lists and formularies for medicines. There is no indication of how this would change with termination of Medicare Advantage.
Universal health care is desirable, but it is also important to understand why the structure of Medicare Advantage combined with federal charity care is successful in providing high quality care to senior citizens. When people praise the success of Medicare Advantage plans, it is not the result of an insurance company public relations campaign or corporate influence on Members of Congress. The integrity of Members of Congress who listen to their constituents should not be disparaged. They are not being influenced by corporate donations. Congresswoman Terri Sewell is a person of considerable education and high integrity.
Eliminating Medicare Advantage without an alternative to preserve zero premiums and zero deductibles and copays would throw hundreds of thousands of senior citizens into both medical insecurity and housing insecurity.

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