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MEDICARE GETS A LOT of criticism these days. Some view it as socialized medicine. Others fret over the hospital trust fund, which covers Medicare Part A and is expected to run out of money by 2036.
Meanwhile, some policymakers want to cut back on traditional Medicare and promote privatization through Medicare Advantage plans, otherwise known as Part C. That reflects the philosophy that health care costs, access and quality will be improved if we obtain health care as we do other goods, by shopping for the best deal and choosing from among many competitors.
I vehemently disagree. Health care isn’t like obtaining and paying for other goods and services. The current system is working well.
Connie and I have been enrolled in Medicare since January 2010. Over the past 14 years, we’ve been admitted to both public and private hospitals, gone to labs and imaging centers, and seen both primary care physicians and specialists.
I’ve had one surgery since 2010, while Connie has received several types of surgery, both on an inpatient and outpatient basis. One procedure required her to continue treatments in Massachusetts while we were on vacation. She received highly specialized treatment for an eye injury when we self-referred to Wills Eye Hospital in Philadelphia. Over the past 14 years and through various treatments:
From this patient’s point of view, Medicare works very well. It’s not socialized medicine or government-run health care. Instead, it’s government-run, taxpayer-funded insurance.
This is not to say there are no problems. It’s a bureaucracy, after all, and its ability to control costs is limited. But it works for more than 60 million Americans like Connie and me.
No doubt many players in the health care system and some individual providers would not share my positive sentiments, especially regarding Medicare’s fees, rules, regulations and requirements. Yet similar issues are true of private insurance as well.
Medicare isn’t cheap, especially if you’re subject to the premium surcharges known as IRMAA, or income-related monthly adjustment amount, that apply to higher-income people. And, as noted earlier, I must buy a Medigap policy to supplement our Medicare coverage.
For many, the cost of health care coverage after age 65 will likely be higher than it was with their pre-retirement employer-funded coverage. Some try to save money with Medicare Advantage, or Part C. More than 50% of Medicare-eligible beneficiaries enroll in Part C. The attraction is lower out-of-pocket costs and added benefits. Maybe.
The question that often isn’t asked is, how can a Part C plan charge a modest or no premium, add extra benefits and still make money? It can’t—not without some significant differences from original Medicare. Part C plans employ various forms of managed care. Here are three examples:
Limited network. Unlike traditional Medicare, which allows you to visit any doctor or hospital accepting Medicare, Medicare Advantage plans often restrict your network to contracted providers. This might limit your choice of doctors and specialists.
Prior authorization. Certain Medicare Advantage plans require prior authorization before specific treatments or procedures are covered. This can lead to delays in care.
Less flexibility. Switching doctors or plans mid-year can be more cumbersome with Medicare Advantage compared to original Medicare.
While Medicare Advantage is popular and growing, behind the scenes there are issues. The Department of Justice and the Office of the Inspector General have been looking into Medicare Advantage plans, including concerns that some plans use prior authorization requirements to limit care and deny claims.
If you don’t mind playing by all the rules, a Medicare Advantage plan can be a good deal. Yet, having managed various forms of health plan during my career, including health maintenance organizations, I’m sticking with original Medicare. If you decide differently, take a close look at your choices before you enroll.
Richard Quinn blogs at QuinnsCommentary.net. Before retiring, Dick was a compensation and benefits executive. Follow him on Twitter @QuinnsComments and check out his earlier articles.
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Richard:
YOUR article is fantastic and does great job of describing the benefits of Traditional Medicare.
The mere fact that Medicare Advantage is being recommended by the government should be enough to cause people to know it is not in their best interests. Why do you think they are paying actors to sell this too you will falsehoods about “more benefits, cheaper costs, etc.?
The bottom line is this…THE ONLY PEOPLE THAT SHOULD BE ENROLLED IN MEDICARE PART C are those who truly cannot afford Traditional Medicare and Plan G premiums. (MY OPINION.)
Unless you are too poor for Traditional Medicare and the G Plan, then Medicare part C is your only option…but know this…in the long run, it will be more restrictive and more expensive.
Now are there going to be some exceptions based on states and coverages? Sure…but in general, MA will never be as comprehensive as Traditional Medicare with Plan G (and Medicare D for drugs.)
And starting in 2025, Plan D for Drugs, will be offering better premiums and coverage.
I had to learn by experience, but the price was cheap. Since I got a cancer diagnosis within my first months “free look” after age 65, I was still able to change my Medicare Advantage plan back to traditional medicare WITH a supplement–I chose the high deductible plan G supplement.
In hindsight, I forgot that insurance is for when you need it, not when you don’t. When I needed it, traditional medicare was so much better!
What did it cost me? One unreimbursed MRI at $600 and a totally ignored appeal. That was a cheap education, although I was a slow learner.
Interesting! I also got the ‘C’ diagnose and had an expensive operation but only had a hospital fee to pay for something but it was less than $100.
I have United Health Advantage and am very satisfied . . so far. I have an eye exam next month, I won’t have to give them my cash at all. So, I wonder what is best but will keep what I have.
“It’s not socialized medicine or government-run health care. Instead, it’s government-run, taxpayer-funded insurance.” Sounds like an issue with syntax, not the substance. Medicare IS socialized medicine, and thank Goodness for it! Celebrate what you have!
As a retired Primary care doc ( now on straight MC) I can offer the following thoughts based on years of being on the other end, caring for patients on Medicare Advantage.
In a nutshell MA plans are a disaster for MDs and patients. As noted the plans are paid more for more “complex” patients( doctors usually aren’t ) but CMS did a poor job defining complex; it basically relates to the total number of coded diagnoses.
That is the reason for the house visits from a MA nurse, to find any possible diagnosis and add many codes to otherwise simple things. low thyroid becomes an autoimmune disease, hypertension morphs into kidney and heart disease, etc. $$$ up go the payments the Feds are forced to pay to the plan, every year. This money has nothing to do with the care someone receives, it is gaming the system.
Some MA in places with great stable hospital system ( usually at least a duopoly) are OK as they have not choice to use the big University hospital for complex specialties. But it may not be the one you want.
Even in CT my MA patients were frequently told they could not go to Yale for heart surgery but had to go to a community hospital with a marginal record.
MA plans place a huge burden on MDs and staff who have to jump through hoops to get care plans approved, and many times they are denied without reason, by a clerk.
Unless you cannot possible afford traditional MC, stay away from MA. Once you sign up with a MA traditional Medicare will take you back during open enrollment, but the insurance companies running the supplement (paying for 20%) do not have to take you on or can charge you much higher premiums.
Good explanations. Thanks! That inability to try MA and then switch back without penalty (the supplemental is not avail. or is much higher) is the only thing that has kept us in MA. Congress: FIX THIS!
Just to be clear you can switch to back ton from Medicare Advantage to traditional plans during the first year of eligibility and have guaranteed issue at the premium level that would have been charged at initial enrollment in Medicare. This is a trial year.
After the first year you will most likely have to go through underwriting and either be denied by insurance companies or pay (significantly) higher premiums.