Scamming the Government for Fun and Profit

The cancer that is Medicare Advantage

There are so many ways to make money that I’ve never considered. You could be a doctor, for example. Doctors can make a lot of money. Sometimes students tell me they want to be doctors. When I ask why, the answer is frequently because the salaries are high.

Kids being what they are, they don’t consider all the years you have to study to be a doctor. They don’t consider the prohibitive expenses of medical school. They don’t consider the grades they may need, or the selectivity of medical schools. The last thing they don’t consider is the one that primarily swayed me from medical school—Do they have any talent for science or medicine? I sure don’t.

But that doesn’t sway American businesspeople, who are making a bundle off of Advantage plans. This piece suggests that Advantage providers pulled in a cool 50 billion from taxpayers for assigning diseases to patients that paid more. It didn’t matter that these patients were never treated for these maladies. In fact, it didn’t even matter that these patients did not actually have the diseases. Gloria Lee’s Advantage plan sent a nurse to her house, free of charge. Nice, huh?

The finding was good news for Lee’s insurer, a unit of United Health.

Medicare pays insurers more for sicker patients. In the case of someone like Lee with diabetic cataracts, up to about $2,700 more a year at that time. 

But the retired accountant doesn’t have diabetes, her own doctor later said, let alone the cloudy vision sometimes caused by the disease.

So it’s a WIN-WIN! Lee gets a free nurse visit, and United Health gets a few thousand bucks for no reason. Of course, a few thousand here, a few there, and a thousand more thousands elsewhere, and it begins to mount up. You know, a billion here, a billion there…

Instead of saving taxpayers money, Medicare Advantage has added tens of billions of dollars in costs, researchers and some government officials have said. One reason is that insurers can add diagnoses to ones that patients’ own doctors submit. Medicare gave insurers that option so they could catch conditions that doctors neglected to record. The Journal’s analysis, however, found many diagnoses were added for which patients received no treatment, or that contradicted their doctors’ views.

Well, hey, this is a business, isn’t it? And businesses have to make money one way or the other. One thing I like about real Medicare is that my doctors make decisions about my care. Slave insurance provider Aetna doesn’t get to add diagnoses for no reason other than their bottom line. More importantly, it doesn’t get to to deny us vital care so their shareholders benefit.

For my money, Aetna is a parasitical entity. So are all health insurance companies. We’d all be better off if we removed the profit motive from medical care. I had a few experiences that molded my opinion. Forgive me if I’ve mentioned them in the past, but they’re on my mind now.

When I was much younger, a friend’s mom died, leaving massive medical bills for Dad. Dad sold his house and moved into the basement of his son’s house. One Christmas Eve in that basement, he took a gun and blew his brains out.

I recall working as a musician and opening for a more well-known band one Sunday in Pennsylvania. I hung out and ate with that band’s banjo player.

You can likely surmise that playing the banjo is not the most lucrative of jobs. This banjo player had no health insurance. The following day, Monday, he had chest pains. He decided to save the thousands of dollars the ER would have cost him. On Tuesday, he was dead. If he were in Canada, France, or a whole lot of other countries, he’d have health care that wouldn’t bankrupt him. (So would the person who sold you your burger at Wendy’s.)

My father fought in the Battle of the Bulge. Toward the end of his life, he deteriorated quite a bit and needed round the clock care. He had a catastrophic insurance policy, but it didn’t remotely cover the costs of the facilities he was in. When he finally passed, his wife was in desperate negotiations to place him in Medicaid so she wouldn’t lose her home.

Our national lack of health care for all is a disgrace. Like a whole lot of things American, it’s rooted in not only greed, but racism too. (Read The Sum of Us if you want chapter and verse.) For years and years we’ve avoided biting the bullet and making sure we helped one another. Obamacare is not great, but it’s a whole lot better than the nothing Donald Trump planned for us if he’d overturned it.

Medicare Advantage is an absolute step backward from what we have now. There are a whole lot of other cute things MA does. They can…

…make your benefits tailored to be unpleasant and unsustainable for people who are sick and expensive. So don’t approve rehab care, which Medicare traditional pays for, but the Medicare Advantage plans usually don’t. So if someone needs that rehab care, they’re really pushed to choose to go back to traditional Medicare.

Great, huh? And some states make it very tough to get back into real Medicare. Medicare pays 80%, but you have to cover the other 20. I don’t suppose I have to tell you how expensive that is. And that can be problematic too.

Be aware that under federal law, Medigap policy insurers can refuse to cover your prior medical conditions for the first six months. A prior or pre-existing condition is a condition or illness you were diagnosed with or were treated for before new health care coverage began.

Wow. That sucks. Imagine being stuck in Medicare Advantage, having a surgery they won’t cover, and being unable to treat if for six months. Sometimes people can’t wait that long. Imagine living in a state other than NY, and learning your decision to use Advantage was veritably irrevocable.

An oncologist I know told me she had patients who needed chemo right now, but often had to wait precious weeks before she was able to treat them. She told me, no matter what the cost, to stick with real Medicare.

Real Medicare is in even more danger. Last time Trump was in office, he laid out a plan to further privatize Medicare. Project 2025 seeks to make Medicare Advantge the default program for Americans (use a private window to see the linked story). It’s pretty clear real Medicare could simply wither away under another Trump presidency.

Meanwhile, it’s incumbent upon us to pressure our union leaders to do more than pay lip service to saving Medicare for city retirees. If Michael Mulgrew really wants to take a stand, we need more than words.

Mulgrew’s words won’t help us if we lose the case against his BFF Eric Adams in NY State Supreme Court. Mulgrew needs to cash in every chip he, as UFT President, has ever collected. He needs to make sure a state or city bill passes to guarantee our health care.

Otherwise, his words are just that. He made this happen.

It’s high time he did something to correct it.