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The government’s inability to crack down on Medicare Advantage overpayments is a product of major lobbying campaigns by the industry. (Bill Clark / CQ Roll Call via Getty Images)
The health insurance behemoth Humana enjoyed a banner 2022. The Louisville, Kentucky–based insurer made $2.8 billion in profits last year, while paying out $448 million in dividends to shareholders and more than $17 million in compensation to its CEO.
The main driver of those earnings? The federal government spent $20.5 billion overpaying Humana and other private insurers for the Medicare Advantage plans they manage on behalf of seniors and people with disabilities. If not for those overpayments, Humana could have suffered a nearly $900 million loss in 2022, according to a Lever analysis.
Humana is the most prominent example of how insurers have built a major cash cow out of systematically overbilling Medicare Advantage, the private Medicare program operated by private interests. These overpayments are symptomatic of a broader profit-driven policy agenda that seeks to completely privatize Medicare, one of the nation’s most popular social programs, and lock program recipients into subpar private insurance plans, even when they get sicker and need the best care possible.
Medicare Advantage plans have higher claim denial rates and more prior authorization restrictions than traditional Medicare plans. Last year, regulators found that nearly one in five payment requests rejected by Medicare Advantage plans in 2018 were wrongfully denied, representing an estimated 1.5 million claims.
And while Biden administration proposals could have helped slow the for-profit takeover by tightening the screws on Medicare Advantage overpayments, insurers recently led a fierce lobbying campaign to dissuade the government from fully cracking down on the practice.
At the root of Medicare Advantage overpayments is “upcoding” by insurers, a scheme by which the companies systematically overbill the public as if their patients are sicker than they really are. Companies have offered bottles of champagne and bonuses to entice doctors to add diagnoses to patients’ records, according to government lawsuits reviewed by the New York Times.
In total, these practices led to $20.5 billion total excess payments to Medicare Advantage insurers in 2022, according to a March report from the Medicare Payments Advisory Commission (MedPAC), a federal body tasked with overseeing Medicare. In the coming years, the overpayment problem could get substantially worse. A November 2021 study suggested that Medicare costs from 2023 to 2031 will be $600 billion higher than if Medicare Advantage beneficiaries were instead enrolled in traditional Medicare.
Because of such overpayments, big insurers like Humana have become highly dependent on Medicare Advantage. Humana, for example, earned more than 80 percent of its revenue from Medicare last year, and now has nearly five million Medicare Advantage customers. Wall Street loves this business model: Humana’s stock has outperformed the S&P 500 by 23 percent over the past five years.
Humana isn’t alone in benefiting from Medicare Advantage overpayments. The other major for-profit insurers — UnitedHealth, Centene, and CVS Health, which owns Aetna, would have seen major hits to their 2022 profits had the government eliminated the overpayments.
UnitedHealth Group would have seen its profits deteriorate by more than one-third, from $14.4 billion to less than $8.8 billion, according to an analysis by the Lever. CVS Health would have seen its profits cut by more than half, from $4.1 billion to $1.9 billion. And Centene would have seen its profits deteriorate by more than one-quarter, from $3.4 billion to $2.4 billion.
Experts say the enormous sums of money going toward overpayments endanger the overall financial stability of Medicare as a whole.
Experts say the enormous sums of money going toward overpayments endanger the overall financial stability of Medicare as a whole.
“It’s threatening the solvency of our Medicare trust fund,” said Ana Malinow, a physician active in pro–Medicare for All groups. “The trust fund is made up of payments that people make throughout their entire working lives. If you are working, you’re paying into Medicare every two weeks with your paycheck. Instead of money going to pay for health care for seniors and people with disabilities, it’s going to UnitedHealth and Humana.”
Cutting back Medicare Advantage overpayments could be transformative for the social program, said David Lipschutz, associate director of the Center for Medicare Advocacy, which lobbies for a robust Medicare system. “These are huge amounts of money that could be directed to shoring up Medicare’s finances,” said Lipschutz. “Or expanding benefits for everyone, not just in Medicare Advantage plans.”
The government’s inability to crack down on Medicare Advantage overpayments is a product of major lobbying campaigns by the industry. Two Biden administration proposals that would have tightened the screws on Medicare Advantage overpayments by enhancing audits and cutting the growth of payments to Medicare Advantage plans were both scaled back in the face of aggressive industry lobbying and TV campaigns.
Instead, while there will likely be some cutbacks, the Medicare Advantage gravy train will continue. The number of people enrolled in Medicare Advantage is set to outpace traditional Medicare for the first time ever this year, with more than thirty million beneficiaries.
In February, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, proposed a rule that would have reined in upcoding abuses by reducing extra payments that insurers receive for certain diagnoses, including diabetes “with complications” and a rare form of malnutrition. But in the face of widespread industry lobbying, the agency settled on a weaker three-year phase-in effort.
Even the original proposed rule might not have been enough to address Medicare Advantage overpayments. MedPAC called the initial proposal “insufficient” in a comment letter, and said that Secretary of Health and Human Services Xavier Becerra had “not taken significant action” in response to MedPAC’s analyses of fraudulent billing in Medicare Advantage.
Another way to crack down on upcoding schemes would be to limit government payments to Medicare Advantage plans, since it would send a message to Medicare Advantage providers that overall program costs are far too high. Last December, CMS did so by proposing increasing payments to Medicare Advantage plans by just 1 percent, compared to the 8.5 percent payment increase it approved last year.
In response, the Better Medicare Alliance, an advocacy group for Medicare Advantage plans, spent at least $13.5 million on ads pressuring the administration to increase the planned rate hike.
The group also spent $570,000 lobbying Congress in the first quarter of this year, nearly double the $330,000 spent in the prior quarter. All told, the four major publicly traded health insurance companies that operate Medicare Advantage plans, as well as the insurance lobby America’s Health Insurance Plans, spent nearly $19 million on federal lobbying in the first quarter of 2023, a 66 percent increase from the prior quarter, according to a Lever analysis of data from OpenSecrets.
The government’s inability to crack down on Medicare Advantage overpayments is a product of major lobbying campaigns by the industry.
That lobbying paid off: instead of a 1 percent increase in payments to Medicare Advantage — which the insurance industry cast as a reduction because the growth rate had slowed dramatically — CMS announced a 3.3 percent payment increase at the end of March.
“The industry’s aggressive lobbying campaign showcases that they clearly want to protect their profit stream,” said Lipschutz. “Their disingenuous campaign tried to paint some very minor payment adjustments as being catastrophic to the Medicare Advantage program. They tried to ‘Medi-scare’ beneficiaries into contacting their elected officials to get CMS to back off — which CMS did to a certain extent.”
While industry analysts have said that this modest rate increase will strain insurers’ prodigious profits, the bond ratings agency Moody’s declared in April that “we believe [Medicare Advantage] will continue to be a growth driver for the industry and will take further market share from traditional Medicare.”
Medicare Advantage payment increases like Joe Biden’s 3.3 percent hike will result in higher dividends to shareholders at the expense of the solvency of traditional Medicare.
The insurance industry also took aim at a recently proposed rule to claw back years of inflated risk adjustment payments, which are made to incentivize Medicare Advantage plans to accept riskier patients.
Initial proposals floated by CMS included retroactive audits of risk adjustment payments going back to 2011. Instead, the final pared-back proposal released in March only included retrospective audits going back to 2018.
Lipschutz said he does give the administration some credit for the audit rule change and the smaller rate hike for Medicare Advantage insurers relative to the prior year.
“On the other hand, it can be seen as far too little too late,” he said, adding that federal policy being so weighted toward Medicare Advantage plans at the expense of traditional Medicare is a “serious imbalance that is long overdue for course correction.”
Traditional Medicare operates on a fee-for-service basis. This means that doctors and hospitals are paid directly by Medicare for the services they provide. Private plans have operated as part of Medicare since just after the program was launched in 1965, but typically did so on a very limited basis. That changed in 2003, when Congress substantially increased subsidies for plans to enter the market, after intense industry lobbying.
While the traditional Medicare model is not without problems — Medicare only covers 80 percent of expenses, which means that seniors need either Medicaid or a Medigap insurance plan to get full coverage — it has major benefits relative to Medicare Advantage.
The principal benefit of traditional Medicare is that there is not a profit-driven insurer attempting to limit the scope of care that a patient needs.
The principal benefit of traditional Medicare is that there is not a profit-driven insurer attempting to limit the scope of care that a patient needs.
Medicare Advantage “seems like a good idea,” said Ted Doolittle, the State Health Care Advocate for Connecticut. That’s because Medicare Advantage plans often offer expanded benefits like dental, vision, or wellness. They also eliminate the need for a potentially expensive Medigap plan if a senior isn’t eligible for Medicaid coverage.
But then, said Doolittle, “The scholarship shows that when patients get sick, they try to go back to traditional Medicare.”
According to Doolittle, most people who are either Medicaid eligible or who could afford a Medigap plan would balk at signing up for Medicare Advantage plan “if folks had adequate information about the nature of Medicare Advantage versus traditional Medicare, and the higher denial rates and the prior authorizations required for care in Medicare Advantage.”
Doolittle pointed out that there’s a key barrier to patients to getting full medical coverage if they try to switch back to Medicare once they become sick: in most states, Medigap insurers are allowed to discriminate against seniors on the basis of preexisting conditions if they are already enrolled in Medicare Advantage, something that is prohibited when seniors first become eligible for Medicare three months prior turning sixty-five.
This problem is amplified by the rapid growth of Medicare Advantage. In 2010, a little over one-quarter of Medicare beneficiaries were in Medicare Advantage. By 2016, it was still less than one-third. But this year, a majority of Medicare beneficiaries will be on the private plans.
And the exorbitant government costs of Medicare Advantage are not limited to just overpayments related to upcoding. This year, Medicare Advantage plans will receive taxpayer rebates averaging $196 per participant. These rebates have more than doubled since 2018.
The total cost of the rebates could be as high as $75 billion this year, according to analysis by Bill Kadereit, president of the National Retiree Legislative Network.
“The extra $196 is spent on fringe benefits, and only on fringe benefits that go towards Medicare Advantage beneficiaries,” Kadereit said. “The other 30 million people in traditional Medicare get nothing. When Joe Manchin in West Virginia says ‘I like sending money to the Medicare Advantage plans, give them more,’ well, 40 percent of his people in West Virginia are not on Medicare Advantage, so they don’t get a nickel.”
Expanded attention to Medicare Advantage abuses has led some members of Congress to speak up and pressure the Biden administration to rein in the industry, even in the face of aggressive lobbying.
In February, seventy lawmakers, led by Congressional Progressive Caucus chair Pramila Jayapal (D-WA), sent a letter to the Biden administration pointing out that “as enrollment in [Medicare Advantage] grows, spending per beneficiary has grown faster in [Medicare Advantage] than original Medicare, and that spending is being funneled into corporate profits under the guise of operating costs instead of into care for patients.”
That said, there is no voice in Congress advocating for the phasing out of Medicare Advantage and allocating expanded benefits equally to all Medicare beneficiaries, which is by far the most cost-effective option.
And the larger Medicare Advantage becomes, the more politically difficult it will be to rein in, noted Doolittle.
“As Medicare Advantage keeps getting more embedded in Medicare, the situation keeps getting worse,” he said. “It’s gotten up to a real critical mass at this point, which makes it very hard to stop.”
You can subscribe to David Sirota’s investigative journalism project, the Lever, here.
For about six months in 1911, on that long finger of land pointing southward from Mexico’s Pacific Coast, an international band of fellow travelers attempted revolution. The rebels seized Baja California border villages like Mexicali, Los Algodones, and Tijuana, conducting a number of their raids from the backs of hijacked trains. Over the roar of […]
It’s hard to know how much harm is done to the millions of women across the US and the world who must combine the stress and emotion of childbirth with inadequate health care. (Diego Cerro Jimenez / Getty Images)
Two years apart, I gave birth to two children in two cities, New York and London. During my first pregnancy, I was living on the Upper East Side of Manhattan, settling into our new duplex apartment when I received a phone call asking me whether I wanted to book myself in for a hospital tour. For me, the idea that you would tour a hospital before giving birth — as if it were a hotel into which you were deliberating checking in — sounded absurd. What could I possibly need to see? I was raised in Britain during a period in which the National Health Service (NHS) was still well funded, and a “one-size-fits-all” approach in which hospitals provided everyone with the best possible service predominated. Surrounded by the glitz and the glamour of American private health care, my European sense of bewilderment soon gave way to excitement at having the power to influence the delivery process of my first child.
As we walked around Mount Sinai West — an imposing ten-story building on Tenth Avenue on the West Side of Manhattan — the tour guide delivered a pitch. The hospital, she told me, was ranked highly for maternity outcomes, and the labor suite was designed with creating a comfortable family environment in mind.
This certainly seemed better than being told by a doctor which underfunded hospital to deliver at in Britain, as was the experience of my peers in the UK who had recently given birth. What the tour guide didn’t realize was that she didn’t need to go so hard on her sales pitch — the hospital, with its sparkling white floors and spacious bathrooms, spoke for itself. The look of the place made it that much easier to picture our first moments as a family of three. The cost of giving birth in the hospital equivalent of the Ritz-Carlton was, unsurprisingly, not cheap: staying over would cost me a hefty $900 a night, excluding all of the other costs for the delivery and aftercare.
Two years later, amid a pandemic, I stood inside a bathroom in Chelsea and Westminster Hospital barely large enough for me to swing my arms around. The building in which I waited for my first appointment looked dated; it had none of the glitz of Mount Sinai West. I was weeks away from giving birth and had decided to stay put in the UK, where my immediate family lived. My husband and I could not fathom the idea of managing an energetic toddler and a newborn between us.
As I lay on the bed to be examined, I was horrified when the midwife pulled out a tape measure to do a growth check. I felt like I had gone back in time: Wasn’t there anything less analog that could do the job? Prior to this, I was used to having a routine scan for all of my appointments. I was shocked to learn that in England, on average, patients received merely two ultrasound scans over the course of a pregnancy. This was a huge contrast to New York, where my pregnancy was completely managed by a doctor I had found after hours of research, reading reviews and comparing qualifications.
Since I delivered Mohsin vaginally, I had presumed that I would do the same the second time around. The first had been straightforward, so this time would be absolutely fine. Women, poorer and much less healthy than I was, used to routinely birth eight, nine, or even ten children without the assistance of drugs. What did I have to worry about? However, as the birth date approached, I recalled that I had previously incurred something known as a fourth-degree tear after giving birth to my first child. A piece of paper, which had been crumpled up or filed away, held this information. It was six weeks after I gave birth to Mohsin, during my postpartum checkup, that I learned of the injuries I had sustained during childbirth. Certainly, I had no recollection of anyone in New York sitting me down to discuss the related long-term implications.
In London, as my midwife looked over my pregnancy history, she paused when she realized the extent of my injury. Gently, she reassured me that my notes would be discussed with a team of doctors. A day later, I was called by an anxious registrar explaining that they wanted to urgently do a scan to assess how much tearing had taken place. This would be the best way to assess whether a vaginal delivery would be safe. Upon hearing this, I was very surprised that such a scan existed. If it did, then why had the team under a private system not mentioned it? In the UK, despite the health care system being heavily underfunded, the principle that guided whether doctors performed scans was the needs of the patient. In the United States, in contrast, it was the demands of the patient for the right kind of customer service, and the coverage of their health care plan, that decided what procedures they received.
September in London was gloriously and surprisingly sunny. This was great, as it meant that Mohsin could continue to spend time outdoors, playing in Redcliffe Gardens or following my husband or mom around Chelsea and Fulham doing errands or meeting friends. Although there was a week to go before my due date, I was already preparing for the delivery. Mohsin was born a week early, and I didn’t want to be caught off guard.
Right on cue, exactly one week before my due date, my contractions became more frequent. I spent the day pacing the beautiful gardens in our building to ease the pain before my water inevitably broke. With my hospital bag already packed and ready to go, I picked up the phone and dialed the hospital. “My water just broke,” I calmly explained. I emphasize “calm” here because, although this was our second child, my husband still hadn’t realized that quite some time could pass between water breaking and giving birth. “Okay, we shall be expecting you shortly,” a softly spoken midwife replied.
In the UK, the principle that guided whether doctors performed scans was the needs of the patient. In the United States, it was the demands of the patient for the right kind of customer service, and the coverage of their health care plan.
As I hugged my mom goodbye, my husband hailed a cab despite the hospital being within walking distance. Unlike in New York, I did not have to carry a printout of a detailed birth plan. All I knew was that I wanted to give birth naturally, but the scan results had not yet arrived by the time I went into labor, so there was no way of knowing how safe it would be to do so.
I lay on the hospital bed with my jaws clenched as the hospital staff tried to determine how far dilated I was. The contractions worsened. I closed my eyes, muttering any prayers that came to mind. Suddenly, two doctors nervously appeared by my bedside. They told me that they had some test results to discuss with me. I glared at my husband to make them disappear, but they said that it was vital to discuss the results right then and there.
According to the scan, I had sustained a fourth-degree tear, the most extreme possible, during my last pregnancy, and another vaginal delivery could have serious lifelong implications for me. My head was spinning. All I could hear was that a C-section was strongly recommended. Ultimately, the doctors told me, it was up to the patient to make the decision. So I decided: no, I did not want to be cut open. The young, Australian registrar sighed as she looked at her colleague — they both agreed to give me some time to think about it.
When they came back ten minutes later, I had not budged. Time was ticking, and if a C-section was to be performed, I had to make the decision immediately. I looked at my husband, who remained quiet. His tense body told me what he feared. Was a natural delivery really going to make me a better mother? Or, for that matter, prove that I had given birth?
I shook my head and restated my decision to be allowed a vaginal delivery. It was my life, and I would ultimately suffer if things went wrong. A flashback of New York City came to mind; I had typed up in capital letters that I should not be given an epidural and that I wanted a very natural birth. Despite this, I recalled being challenged by the nurse on what I was trying to achieve, as she had not dealt with a patient who didn’t want to be alleviated of pain. While that was a much smaller-scale decision, I realized that, although elective C-sections were possible in the UK, funding constraints meant that doctors did not offer them unless they thought there were good reasons for doing so. I really did need a C-section, but when I declined, the nurses and doctors respected my decision.
An agreement was then made that an epidural would be essential in controlling the outcome. I lay on my side as an anesthesiologist directed me to tense my body as the needle went in. Fifteen minutes later, I couldn’t feel a thing. I dozed in and out of sleep as I envisioned the light at the end of the tunnel drawing closer. Within two hours of being admitted, I was fully dilated. The Australian registrar took it upon herself to ensure that she could control as much of the process as possible to get the baby out. Gravity would do its magic; all she asked me to do was to lie there and let the baby move down naturally as much as possible.
A part of me wondered whether I was taking up too much of the medical staff’s time. Surely they would need to move on to other patients? However, the other part of me admired the dedication the team demonstrated. I had gone against the advice that was given to me, and I was still at the center of care.
And just like that, the controlled pushing started and stopped — Mustafa was born on Friday, September 10, at 4:10 a.m. My body had miraculously survived — with nothing more than some stitches. My eyes began to look at the newly renovated labor room in a different light.
In London, I stayed in the hospital for four nights after giving birth. During this time, I didn’t think at all about the costs I was incurring — there were none.
Looking back, the decision not to have a C-section was probably not my brightest one, and I was very fortunate that I dodged serious injury and lifelong health complications. However, the support and care that I received during the birthing process was beyond what I had imagined.
By the time I had showered and changed my gown, it was 8:30 a.m., and I started my move to the postpartum ward. One of my main reservations was having to share space with five other women and five newborns. I recalled struggling to share a room with one other mother at Mount Sinai West who was constantly shushing me anytime she felt inconvenienced. As I sat on the fresh new linen, the head nurse came over and introduced herself. She congratulated me and told me that every staff member was trained in helping new mothers with breastfeeding. When I asked her about being discharged, she looked puzzled. There was no urgency, she told me. I should stay until I felt comfortable and ready to leave.
At Mount Sinai, it had taken hours for a specialized lactation consultant to finally visit me, and when she eventually did, she spent only a brief time coaching me on what to do. She didn’t seem to understand that I was a new mom, I didn’t know how breastfeeding worked, and I had a raw body that was in an incredible amount of pain. Looking back, this explains some of the breastfeeding challenges I faced with my first child. I spent three months trying to combine breastfeeding with formula before finally giving up.
In London, I stayed in the hospital for four nights after giving birth. During this time, I didn’t think at all about the costs I was incurring — there were none. Instead, I focused my attention on getting well and being a mother. In the ward, I enjoyed three meals a day with a starter, main course, and dessert. Wasn’t this closer to a hotel experience than the glossy-floored New York hospital in which I gave birth to my first child? From doctors to nurses, there was a line of people available for support. The hallway had multiple showers that were cleaned on a daily basis. It was far from the chaos that I thought I had signed up for.
As we got ready to be discharged, I was given the charmingly outdated baby red book to record immunizations and health care records in. I chuckled to myself about how this red book system had not been updated to reflect the digital era we are now living in.
Discharged from the hospital in Chelsea, I thought back to the cold January in New York City when I dragged myself, limping, out of the house for Mohsin’s day-two pediatrician visit. I hadn’t realized that there was no concept of health care providers coming to you, as is the standard in the UK. Even today, as I discuss this with American friends of mine who are also mothers, they are surprised to hear that, across much of Europe, nobody is expected to take a newborn anywhere.
It’s hard to know how much harm is done to the millions of women across the United States and the world who must combine the stress and emotion of childbirth with inadequate health care.
Each time Mustafa was due for a visit, a nurse would call me in the morning to confirm a time window during which they would stop by. The system was genius. I was able to comfortably stay in my home, be observed feeding him, and ask anything about myself that I was concerned with.
It’s hard to know how much harm is done to the millions of women across the United States and the world who must combine the stress and emotion of childbirth with inadequate health care. The problem with low expectations is that they also deprive people of ways of thinking of alternatives. I was so impressed in New York by what I felt to be the best possible health care available, care that was better than that experienced by many other Americans. But so many basic services, such as a bed that I did not have to pay for, didn’t even occur to me as possibilities in the moment. It just felt normal. It was only after giving birth in the UK, a country with a functioning (albeit badly funded) public health care system, that I got to experience a genuine alternative. It made clear to me the value of publicly funded services: they free us from the terror of having to count the cost of our most basic needs.
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Do the emergence of a seemingly multipolar world and the declining power of the US (mainly its constant economic crises, falling rates of profit, recession, excessive debt, etc.) provide an opportunity for Puerto Rico and other nations to achieve self-determination?…
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