The Center for Medicare Advocacy has long pointed out the structural imbalances that favor the private Medicare Advantage (MA) program at the expense of traditional Medicare. A recent JAMA Viewpoint article titled “Steering, Switching, and the Medicare Advantage ‘Trap’”
Lawrence P. Casalino, MD, PhD, Amelia M. Bond, PhD, MS, and Dhruv Khullar, MD, MPP (March 17, 2025) explores some of these imbalances. The authors note that when Medicare beneficiaries are choosing between traditional Medicare and MA:
Many beneficiaries are unaware of 2 key features of MA enrollment that may steer them into the program and keep them there for life. First, health insurers give agents and brokers from whom many beneficiaries seek assistance strong incentives to steer beneficiaries to MA. Second, it is very difficult for most beneficiaries, once enrolled in MA, to switch to traditional Medicare.
With respect to the first issue – agent and broker incentives – CMS tried to address some of these enticements through rules published in 2024. As discussed in this Commonwealth Fund Blog titled “A New Rule to Protect Medicare Beneficiaries Against Inappropriate Sales Tactics Is Stuck in the Courts” (Jan. 16, 2025) authored by Center for Medicare Advocacy attorneys, these efforts are on hold due to litigation. With respect to switching from MA back to traditional Medicare, the JAMA article notes:
by enrolling in MA, [beneficiaries] are making what is likely to be an irreversible, lifelong decision […] Beneficiaries who would like to switch from MA to traditional Medicare may find that no [Medigap] plan in their state will issue them a policy or that policies offered to them are prohibitively expensive, especially if they are in poor health.
Another structural imbalance that favors MA enrollment is the significant payments plans get compared that what traditional Medicare spends on a given beneficiary.
MedPAC Continues to Highlight MA Overpayments
The independent, non-partisan Medicare Payment Advisory Commission (MedPAC) has, for several years running, highlighted concerns about bloated payment to MA plans. MedPAC recently released its annual “Report to Congress: Medicare Payment Policy” (March 13, 2025); also see accompanying Press Release. As summarized in the Press Release:
The Commission estimates that Medicare spends approximately 20 percent more for MA enrollees than it would spend if those beneficiaries were enrolled in FFS Medicare, a difference that translates into a projected $84 billion in 2025. That difference varies by MA organization and stems largely from two factors: favorable selection of beneficiaries into MA and coding intensity. “Favorable selection” refers to the tendency of beneficiaries with lower spending than predicted by their risk score to enroll in MA. We estimate that, in 2025, favorable selection will increase MA payments by roughly 11 percent above what the program would have paid under FFS Medicare. “Coding intensity” refers to the tendency for MA plans to record more diagnosis codes for their enrollees, which causes risk scores and Medicare payments to be higher. We estimate that, due to higher coding intensity, MA risk scores will be about 10 percent higher than risk scores for similar FFS beneficiaries, even after accounting for the annual CMS coding adjustment.
The Commission acknowledges that a portion of these increased payments to MA plans are used to provide more generous supplemental benefits and better financial protection for MA enrollees. However, the benefits from MA’s higher cost relative to FFS are subsidized by the taxpayers and beneficiaries who fund Medicare, increasing fiscal strain on the program. The Commission estimates that Part B premiums, paid by all Medicare beneficiaries, will be about $13 billion higher in 2025 because of higher MA spending [emphasis added].
Even Dr. Oz Agrees that MA Plans are Overpaid
As discussed in a recent CMA Alert (March 13, 2025), the Senate Finance Committee held a confirmation hearing last week for Dr. Mehmet Oz, President Trump’s nominee to be the Administrator of the Centers for Medicare & Medicaid Services (CMS). While Dr. Oz has considerable financial ties to the Medicare Advantage (MA) industry and has been a proponent of “Medicare Advantage for All”, under questioning, he admitted that “We pay more for Medicare Advantage than we’re paying for regular Medicare, so it’s upside down,” and pledged to “go after” MA upcoding if confirmed. He also addressed the rampant use of prior authorization by MA plans as a “pox on the system” but proposed using AI to streamline the MA prior authorization process, despite AI being used in recent years to instead inappropriately deny care.
Conclusion
A key question about the future of Medicare Advantage – and the Medicare program as a whole – is posed in the title of a recent KFF publication: “Will the Trump Administration Fast Track the Privatization of Medicare?” by Tricia Neuman, Jeannie Fuglesten Biniek, and Meredith Freed (March 13, 2025). The authors note that “[t]he privatization of Medicare has been taking place without much public debate – a trend that has implications for the 68 million people covered by Medicare, health care providers, Medicare spending, and taxpayers.”
As the public awaits the Trump Administration’s first significant policy issuances regarding Medicare Advantage, including the final Rate Notice and final Part C and D rule for CY2026, we urge policymakers to resist privatization and instead protect and strengthen the traditional Medicare program.
March 20, 2025 – D. Lipschutz