Sunday, September 4, 2022

Medicare For All? Forget I said that.

I used to be a big proponent of Medicare for All. But I will be turning 65 in a few months, and now that I'm running the Medicare gantlet*, I have changed my mind. 

Nobody should have to do this -- certainly not anybody who has spent 40 or 50 years of their working life having their health insurance choices dictated to them by their employer. Medicare, as the system stands today, is overly complicated -- very possibly by design. It's also weighted toward private insurance companies. And if things keep going the way they've been going, Medicare as we've known it for generations will very likely cease to exist, only partly because it will "run out of money".

First, a quick primer. Everybody's eligible for Medicare once they turn 65. It has four parts:

  • Part A covers hospitalization. It's free, and everybody gets it.
  • Part B covers outpatient stuff like doctor visits. It is not free -- this year's premium is $170.10 per month -- and you don't have to get it. But most people do. Together, Parts A and B constitute "Original Medicare".
    • Parts A and B don't cover every expense, though, so a lot of people also pick up a Medicare Supplement (a.k.a. Medigap) plan. These are designated by letter (I'd like to get hold of the genius who decided that both Medicare's Parts and Medigap Plans should have letter designations), and while these plans are sold by private insurance companies, the government decrees what's covered under each lettered plan. In other words, if you buy a Plan G, no matter who you buy it from, it has to cover the same stuff as every other Plan G. Below is a chart that I cadged from Medicare and You, the handbook that the government will send you when you enroll. (Ignore Plans C and F; if you turned 65 after January 1, 2020, you can't get them.) Most folks go with either Plan G or Plan N. Now despite that the coverage in each plan is mandated by the feds, premiums vary -- sometimes by a lot. The highest premiums are usually charged by the companies that do a lot of advertising (AARP, I'm looking at you).

  • Part D (I'm going out of order intentionally) is drug coverage. It's provided by private insurance companies, and the premiums vary widely. Plus each company has its own formulary, or tiers of drugs they will pay for; just like with the drug coverage you have now, generics are cheapest and brand-name drugs can be hella expensive. has a search function where you can plug in your prescriptions and your favorite pharmacies, and it will generate a list of Part D plans available to you, which you can then sort by cheapest combined premium and drug costs. Most people who do Parts A and B also pick up a Part D plan.
You can see why people might get bewildered by the choices: You don't just get Medicare, poof! done! You get Parts A and (maybe) B, and (maybe) a Medigap plan, and don't forget your drug coverage. There are a lot of moving parts. Even folks whose employers served up a cafeteria plan might find this overwhelming.

There's another choice, though: You can leave all this confusion behind and go with Part C, a.k.a. Medicare Advantage. You've probably seen lots of ads for MA. It sounds like a terrific deal. Many policies include drug coverage, just like the insurance you have right now. Some policies include dental, hearing, and vision benefits, which Original Medicare doesn't cover even if you buy a Medigap plan. (I'd like to get hold of the genius who decided that Medicare shouldn't cover dentures and hearing aids.) You can even get a policy with a zero premium! How can that not be a great deal?

Well, here's how:

Medicare Advantage is regular old insurance. The vast majority of plans are either HMOs or PPOs, which means each plan has a network of doctors, hospitals, and other healthcare providers that they want you to see. Maybe your primary care doc is in-network, but what if she wants you to see a specialist? You're back to the game of "Do I need a referral?" and "Do they take my insurance?" -- games you don't have to play with Original Medicare.

There's also the matter of out-of-pocket costs. Your MA plan may not charge you a monthly premium, but your maximum annual out-of-pocket cost could be thousands of dollars higher than Original Medicare's -- to the tune of as much as $7,550 in-network or $11,000 out-of-network per year, compared to $233 per year for Original Medicare. (I saw this bullshit with Obamacare over the past couple of years. A whole lot of plans on the exchange have cheap premiums and insane annual deductibles.)

But here's the biggest problem with MA. You see, Original Medicare pays per service: Your doctor provides your care, and Medicare pays the doctor a set price for that care. But MA insurers are paid by the government per customer. Most are for-profit insurance companies, so they have an incentive to pocket as much of that fee as they can -- which means they have an incentive to deny care, sometimes even care that would have been covered without question under Original Medicare. Also, the government pays more for customers with certain diagnoses -- the more diagnoses, the better. So these insurers have been discovered combing customers' health histories and having their customers complete "health risk assessments" to find diagnoses to add to their charts, thereby bilking the government out of $12 billion in 2020 (and, by the way, making their customers look sicker than they are). All of this came out in a hearing held in July by the House Energy and Commerce Subcommittee on Oversight and Investigations. The subcommittee also heard evidence that many MA customers in their last year of life switch to Original Medicare -- an indication that MA plans aren't providing the best care for their sickest customers.

In addition, Sen. Ron Wyden (D-Oregon), who chairs the Senate Finance Committee, is looking into possible deceptive advertising practices by insurers that provide MA plans. Wyden says the federal government received twice as many complaints about MA plans in 2021 as it had in 2020. He's seeking information from 15 state governments about complaints they've received about MA plans.

The percentage of older Americans enrolled in MA plans is expected to top 50 percent within the next couple of years. MA was supposed to save the government money on senior healthcare. But some MA plans cost the government more than they should, and some aren't providing the level of care that Medicare requires them to provide. 

I'm mindful of the fact that conservatives have wanted for years to get rid of Medicare (and Social Security). And my inner conspiracy theorist is urging me to say that it's no accident that Original Medicare is so confusing while MA plans seem so simple. My rational mind is holding my inner conspiracy theorist back. But I will say this: I've set up a spreadsheet for my Medicare choices, and none of them are MA plans.

And when I said before that Americans should have Medicare for All? What I meant was single-payer insurance -- like Medicare's Parts A and B, but better.


There are a ton of websites and YouTube videos purporting to help you through this process. This video has a good summation of the pros and cons with MA plans, but in linking to it, I'm not endorsing her company in any way.


*Before somebody says I misspelled gauntlet: A gauntlet is a type of glove. A gantlet is the thing where people form two lines and have you run between the lines while they try to beat the crap out of you -- which is a pretty accurate description of the process of picking Medicare coverage.


These moments of bloggy clarification have been brought to you, as a public service, by Lynne Cantwell. Stay safe out there!

No comments: