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Private Insurers Bilked Taxpayers Out of More than a Half-Trillion Dollars Between 2007 and 2023

Harvard/CUNY/Public Citizen Analysis Details Decades-Long Pattern of Medicare Advantage Schemes to Boost Profits by Avoiding Ill Seniors and Inflating Diagnoses

WASHINGTON, D.C. — According to a new analysis featured today in JAMA Internal Medicine, privatized Medicare Advantage plans have raised Medicare’s costs by $612 billion since 2007, including $82 billion last year alone.

The authors — physicians affiliated with Harvard Medical School, the City University of New York’s Hunter College, and the Public Citizen Health Research Group — analyzed data from Congress’ official Medicare Payment Advisory Commission (MedPAC), Medicare’s Trustees, and other sources to estimate how much Medicare would have saved if enrollees in privatized Medicare plans had instead remained in traditional Medicare, and how much Medicare Advantage plans used for their administrative overhead, from 2007-2023.

The researchers found that the insurers pocketed 97% — $592 billion — of Medicare’s overpayments for their overhead and profits, which consume 14% of their total revenues, seven-fold more than the 2% overhead in the traditional Medicare program.

The authors call privatized Medicare a “failed experiment” that should be abolished, noting that the savings should be used to expand benefits and lower out-of-pocket costs for all Medicare beneficiaries.

“Medicare Advantage is a bad deal for taxpayers,” said lead author Dr. Adam Gaffney, a Harvard pulmonary and critical care physician practicing at the Cambridge Health Alliance. “Money that could be used to eliminate all copayments or shore up Medicare’s Trust Fund is instead lining insurers’ pockets. And the private insurers keep Medicare Advantage enrollees from getting needed care by erecting bureaucratic hurdles like prior authorizations and payment denials.”

The JAMA IM article, “Less Care at Higher Cost — The Medicare Advantage Paradox,” details how private insurers have exploited loopholes in Medicare’s complex payment rules for decades to extract overpayments. The federal government pays insurance companies a lump sum for each patient its Medicare Advantage plans sign up, with the amount of the lump sum based on enrollees’ “risk scores,” which the government calculates from diagnosis codes that the plans submit. The risk scores are meant to predict how much care enrollees will need. But research has repeatedly shown that the private plans game the system by cherry-picking the healthiest seniors to enroll, and then exaggerating how sick they are by so-called “upcoding,” i.e. padding enrollees’ medical charts with long lists of diagnosis codes that do not require specific treatment, jacking-up the risk score and hence the government’s lump-sum payment to the plan.

According to the JAMA IM article, privatized Medicare plans often refuse to cover providers that high-cost patients need, such as specialized cancer hospitals or psychiatrists; restrict access to drugs and treatments; and pressure patients’ doctors to curtail expensive care. As a result, the privatized plans spend, on average, 9% less on medical services (including the extra benefits they promise) than traditional Medicare spends for comparable patients.

“Medicare Advantage plans have, in effect, stolen hundreds of billions from taxpayers,” says David Himmelstein, a study co-author who is a Distinguished Professor at CUNY’s Hunter College, a lecturer at Harvard Medical School, and a Research Associate at Public Citizen. “And the private plans’ schemes also raise seniors’ Part B Medicare premiums. Even seniors who don’t choose to enroll in Medicare Advantage are subsidizing the private plans’ profits.”

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“Less Care at Higher Cost — The Medicare Advantage Paradox,” Adam Gaffney, MD, MPH; Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD.  JAMA Internal Medicine. 2024.