District-by-District Breakdown on the Effects of Repealing Health
For further information, follow one of the links below or scroll down the
private medicare: too much for taxpayers, too
little for beneficiaries
When Medicare was created in 1965 over 50% of everyone 65 or older
had no health insurance. Private insurance failed to meet their
needs. Medicare, on the other hand, is a success. It increased the
number of insured older adults to 95%. In 1972 Medicare coverage was
extended to people with significant disabilities. But Medicare's
success in providing access to health care for millions of people is
in danger. Ironically, the threat comes from private insurance
plans. Funded by windfall subsidies from taxpayer dollars,
privatization is jeopardizing the cost-effective, dependable
Since 2003 the number and
costs of private Medicare plans have increased exponentially as a
result of the design of Medicare Part D and "Medicare Advantage".
Unlike plans to privatize Social Security, which were debated and
largely rejected by lay people and professionals alike, the
privatization of Medicare is well underway and has occurred largely
without public knowledge or discussion. Medicare privatization and
the billions of dollars being spent to subsidize private plans
threaten the future of Medicare and the health and economic security
the Medicare public program has provided for America’s older and
disabled people and their families.
Medicare wasn't broken, but because of the ever-increasing private
Medicare options, it is breaking. The myriad private plans are
creating confusion and barriers to care for real people. The Center
for Medicare Advocacy is contacted everyday by people who were
inappropriately marketed to, people who did not understand what they
were getting into, people who have been unable to get the health
care services they need from their Medicare Advantage (MA) plan, and
people who are "locked into" their MA plan. Further, the Center gets
calls for help from people who thought they had MA "on top of" their
regular Medicare and/or Medigap and are surprised to find out that
is not true when the service or provider they need is not covered by
their MA plan.
Medicare privatization costs taxpayers approximately $15 billion a
year, while it hurts many people with Medicare and strangles the
traditional Medicare program. Consider these stories from just a few
of the Center’s clients:
Mrs. P is a 67 year
old woman who was diagnosed with ALS three years ago. She
contacted the Center for help because her private Medicare plan
cut off all her home care, saying she was "stable" and no longer
needed home health services. CMS said the coverage decision was
up to the plan and would not intervene. The Center for Medicare
Advocacy filed a case in federal court seeking continued
coverage for Mrs. P. The Court ordered Medicare to cover Mrs.
P.’s home care; she was therefore able to stay at home with the
health care she needs. Without Medicare coverage and this
necessary home care, Mrs. P. would have been forced to enter a
A Congressman called
the Center to obtain help for a constituent who he met at a
local town hall meeting. Mr. B and his wife were members of a
Medicare Advantage plan in Connecticut. They went to Florida
for vacation where Mrs. B fell and was sent to the hospital to
treat her injuries. Tests at the hospital showed that,
unbeknownst to Mrs. B, she had a brain tumor. Doctors determined
she needed treatment immediately. Because Mr. B is frail
himself and the couple’s daughter in Utah is a nurse, they
decided to go there for Mrs. B’s chemotherapy. Upon receiving
the chemotherapy, however, Mrs. B had a life threatening
reaction that resulted in her being in the Intensive Care Unit
for days. She ultimately died. The hospital bill came to
$100,000 and was completely denied by the Medicare Advantage
plan because Mrs. B was "out of network". The Center appealed.
Finally, after an administrative hearing most of the bill was
paid in recognition that the care received after Mrs. B’s
reaction to treatment were emergency services.
Mrs. W called us with
a Medicare Advantage (MA) problem. She went from a hospital to a
nursing home and was being billed for $13,000 because the
nursing home was out of her MA plan’s network. She had been
told by both the hospital and nursing home staff that original
Medicare would cover her nursing home stay, even though she had
an MA plan. This is not true. The beneficiary herself is
extremely confused and was unable to answer any of the Center
The Center has a case
pending for an individual who is in an MA plan in Connecticut
and went out of network for doctor’s services. He was billed
$5,000 for these services. This individual is functionally
illiterate and did not understand that he could only see
providers in the plan’s network when he signed up for the MA
plan. He says he did not receive any booklets or anything in
writing from the MA plan regarding the network’s providers. Even
if he did, he likely wouldn’t have been able to read the
information or comprehend the concept of a network.
A Center attorney
received a call from a woman with significant MA concerns. She
and her husband were visited by an MA marketing representative
for a Private Fee For Service Plan (PFFS). He came door to door
and was absolutely not invited. The woman told our attorney
that both she and her husband suffer from brain injuries and
previous strokes and that they were both distressed when the
agent came into their home. He told them that he wanted to talk
to them about a "new kind of Medicare." She said that she
listened but did not understand and that he gave too much
information too fast. She said she filled out the form he had
and said yes to all of his questions just to get him to leave
her home; this all happened in January, 2007.
When the woman called the marketing representative to disenroll
the representative told her to just send a letter to the plan
and that would effectuate disenrollment. She did so in January
but had not been disenrolled when she contacted the Center six
months later. During that time, she and her husband needed and
received medical services, for which they were billed and sent
to collection. The husband requires injections from an
oncologist which cost $3000 each; he needed three during this
period. Other services received during the period included
doctors’ visits, a hospital CT scan, neurologist visits, and
N, one of the Center’s clients had traditional Medicare along
with a Medigap supplemental policy. He was approached by an MA
plan while at his dialysis unit, which is now a marketing
violation. He was told that the MA plan and the Medigap policy
together would cover all his expenses. Mrs. N called the Center
because they are now receiving bills for the balance of what the
MA plan did not cover. When she contacted the Medigap
representative, he told her that because she now is in an MA
plan, the Medigap won't cover the balance. Mrs. N then called
the MA plan to disenroll because she is worse off than before
joining the MA. They told her she
couldn't disenroll at this time.
The Center is working to retroactively disenroll Mr. N from the
MA plan based upon the misinformation that he was given by the
marketing representative. Hopefully, if the retroactive MA
disenrollment is granted, the Medigap policy will provide
retroactive coverage for the past bills.
A Center attorney
received a call from the daughter of a beneficiary who speaks
very little English. Apparently an agent from an MA plan in
Hartford, CT came door-to-door without being invited (which is a
marketing violation), visited this woman's mother and got her to
sign an application. The representative told the mother that
everything would be "free". The daughter called the plan and
was able to get her mother disenrolled. But, Social Security is
still deducting the monthly premium for the MA plan from her
mother's Social Security check so she called the Center to get
help with the premium problems. Her mother needs the money.
The Center was contacted by the daughter of a woman who signed
up for an MA plan. Apparently representatives from the MA plan
called and asked if they could come to the mother's home. She,
and the daughter, visited with the representatives and made it
very clear that what they were looking for 100% coverage of the
mother's dialysis treatments. The representatives told them
that if she signed up her dialysis treatments would be covered
100%. It soon became clear to the mother and daughter that the
plan only covers 80% of dialysis treatments, the same as
traditional Medicare. In addition, it became clear that the
plan never should have offered to sign her up in the first place
because she has ESRD which precludes her from signing up for
Another gentleman called the Center. He was visited by an MA
plan and was told that the plan was "free" - which it is not.
He received a letter from Social Security stating that $46.00
would be deducted from his Social Security check. This is how
he found out that the plan was not "free.""
"Medicare Advantage" is starving the successful traditional Medicare
program and hurting beneficiaries. Studies by MedPAC, the
Congressional Budget Office, and the Commonwealth Fund and numerous
scholars confirm that taxpayers are spending between 12% – 19% more
on private plans than it would cost to serve the same people in the
traditional Medicare program. Meanwhile, private Medicare has
proven far less able to provide secure health insurance and a wide
choice of doctors and other health care providers for older people
and people with disabilities.
Medicare was enacted in 1965 because private industry failed to
insure more than 50% of older people. It would be ironic if
privatization condemned Medicare now, returning older and disabled
people to the vagaries of the private, for-profit insurance
solution for the Medicare crisis is not to increase the eligibility
age or decrease benefits, but to stop privatizing it at the expense
of older people and taxpayers.
Judith Stein • Center for Medicare Advocacy, Inc.
October 15, 2008
DON'T "FIX" MEDICARE OUT OF
Much of the current talk about the problems of Medicare
misses the point. The proposals could end up "fixing"
a successful program out of existence. Before supporting any fix, remember:
Medicare has been a success
Medicare assures the elderly and people with
disabilities that neither they nor their families will have to
bear the full burden of their health care costs.
Seniors and people with disabilities
appreciate Medicare and the uniform benefits it provides to
everyone, regardless of income or where they live.
Medicare became necessary in the first place
because health insurance companies were not meeting the needs of
the elderly; that's why it was enacted
by Congress in 1965.
Today, over forty years later, private
insurance companies still aren't
interested in serving the elderly and disabled. HMOs have pulled
out of markets, increased premiums, and cut benefits - despite
evidence that they are paid more than enough.
Any efforts to reform Medicare should
Preserve a guaranteed set of benefits for all
beneficiaries and include prescription drugs and long-term care
Provide plain and simple information about
what Medicare covers, how to get necessary services, and what to
do when individuals don't get the Medicare coverage or services
Recognize the limits of private health
insurance and managed care: they come and go depending on their
economic interests. They are currently reducing access to
services to Medicare beneficiaries, often leaving whole
communities without a managed care option.
We must strive to make Medicare work for all by building on
its established track-record of providing guaranteed benefits. Policy makers
should make choices that keep Medicare a strong program with uniform
benefits available to all beneficiaries.
Preserving a Structurally Sound Program for Tomorrow
A Position Paper from the Undersigned Organizations*
The Medicare program is a success story. It reflects our
national commitment to the concept of social insurance by providing one health
insurance system with a defined set of benefits for our nation’s elderly and
disabled. Any discussion of reforms to the Medicare program and responses to the
Medicare Commission must begin with understanding this important commitment.
As stated by Nancy-Ann Min DeParle, Administrator of the
Health Care Financing Administration (HCFA), United States Department of Health
and Human Services:
Medicare is clearly a success story, an achievement of
social insurance. And yet, as the millennium approaches, the program faces
challenges that cannot be ignored. While the Balanced Budget Act of 1997
extended the solvency of the Medicare Part A Trust Fund, the broader, longer
term challenge of meeting the complex health needs of an aging society is
not diminished. The number of elderly is growing and their life expectancy
is lengthening. In addition, the traditional Medicare benefit package,
reflective of average indemnity plans in 1965, is less generous than most
large employer sponsored fee-for-service plans. Gaps in coverage contribute
to high out of pocket expenses relative to income for many seniors,
particularly those with low incomes. Indeed, only about half of the
elderly’s health care costs are paid for by Medicare. (Preface, A Profile of
Medicare May, 1998)
Basic Tenets and Principles that
Must be Observed
Medicare should continue to be a health care
delivery and financing program provided and overseen by the
United States government and not a mere set of payment
The Medicare program must include a secure,
guaranteed, defined set of benefits.
Medicare should continue to provide one
community of interests among the healthy and frail, rich and
poor. It should not separate these beneficiaries into separate
groups with distinct and varying interests by creating benefit
options and delivery systems that differ depending upon the
ability to pay or the beneficiary’s health status.
The Medicare program must provide equal
access to appropriate and high quality services for all
The needs of beneficiaries who have chronic,
long-term conditions and disabilities must be formally
recognized by the Medicare program and must be met by its
coverage and payment structures.
The Medicare program must be administered
fairly, efficiently, and consistently.
The Medicare program must be comprehensible
to beneficiaries. An appropriate, ongoing education campaign
should be developed that makes Medicare understandable to the
Organizations providing Medicare managed care
services must be required to provide full and clear information
regarding their plans, their benefits, all the rights of
participants, and all the costs related to the care.
The Medicare program must provide a full and
fair appeals system which guarantees due process to
beneficiaries if their health care services are denied, reduced,
or terminated. The system must include access to the courts and
an opportunity for attorneys fees in order to ensure that
beneficiaries can obtain proper representation.
Medicare must provide an effective
independent quality review system to ensure access and quality
of care and services.
Concerns and Cautions
In considering programmatic change, planners
should learn from the recent experience of implementing the
Medicare+Choice program; beneficiaries were [ARE] confused by
the Medicare+Choice program and unsure of its reliability as a
set of health care delivery options.
Policy makers should remember that managed
care plans have discontinued their Medicare managed care
products in many markets, identifying lack of profitability and
program uncertainty as reasons for leaving the Medicare market.
Deliberations about Medicare reforms should
take into consideration the realities of beneficiaries who have
lost services (or who have been unable to obtain services) as a
consequence of new, more restrictive Medicare payment systems
such as the Interim Payment System (IPS) for Medicare covered
home health care.
The Medicare program should be structured so
that "Medigap" insurance policies are unnecessary. If Medigap
insurance does continue to be necessary, the policies must
provide comprehensive, affordable coverage.
Policy makers should identify, address and
monitor the scope of services provided and treatment options
available to women and racial and ethnic minorities, and assure
that Medicare reform efforts address the special needs of these
Outpatient prescription drug coverage should
be a Medicare benefit. This would not only provide for a
critically needed benefit, it would also give beneficiaries a
better opportunity to choose between managed care plans and
"original" Medicare, since many individuals join managed care to
obtain prescription coverage. Careful attention must be paid,
however, to what is required in order to obtain this benefit.
Ideas for Further Study and Exploration
Policy makers should explore some new cost
sharing provisions which do not adversely affect low to moderate
income beneficiaries, and some new employer and/or employee
contributions. New cost sharing and contribution mechanisms may
be necessary, and may well be acceptable to the public, if the
public understands that the alternative is the loss of a
Medicare program to which everyone contributes and from which
Policy makers should explore the advantage of
combining Medicare Parts A and B, restructuring the Medicare
premium, and lowering the eligibility age so that the risk pool
includes individuals who will need less care and services while
contributing premiums to the program. Similarly, efforts to
raise the age of eligibility should be examined carefully to
determine true cost savings, and to consider the likely impact
these efforts would have on increasing the number of uninsured
persons, decreasing access to services, and diminishing the good
health and longevity of those who no longer qualify.
A significant portion of the budget surplus
should be dedicated to help fund the Medicare program. If we
have saved as a nation, we should use our savings for the
nation’s future; the health care needs of our increasingly aged
population must be a priority.
Medicare should explore strategies for
incentive purchasing with providers who demonstrate a history of
delivering appropriate access to high quality services.
The public should be informed of the dramatic changes
envisioned by the Medicare Commission and should be given an opportunity to
consider seriously whether they want these changes. As we continue the dialogue
about Medicare solvency and reform, we must remember that the Medicare program
is sound, and that it has served our nation’s elderly and disabled well. Again,
as HCFA Administrator, Nancy-Ann Min DeParle, has stated:
[f]ew programs in the history of the United States have
brought as much benefit to society as Medicare. Since its enactment in 1965,
Medicare has provided access to quality health care for those Americans
least likely to be attractive to private insurers – those over age 65,
disabled, or with end stage renal disease. Medicare has also prevented many
Americans from slipping into poverty. The elderly’s poverty rate has
declined dramatically since Medicare was enacted – from 29 percent in 1966
to 10.5 percent in 1995. Medicare also provides security across generations:
it has given American families assurance that they will not have to bear the
full burden of health care costs of their elderly or disabled parents or
relatives at the expense of their young families. (Preface, A Profile of
Medicare, May 1998.)
Medicare must remain a strong and reliable program with
specific benefits. It must be available to all eligible persons, irrespective of
health or financial status. This must be our commitment. This must be our
Center for Medicare Advocacy, Inc.
National Senior Citizens Law Center
Consumer Coalition for Quality Health Care
National Academy of Elder Law Attorneys (NAELA)
American Federation of State, County and Municipal Employees (AFSCME)
National Council of Senior Citizens
Connecticut Association of Area Agencies on Aging, Inc.
Medicare Advocacy Project, Greater Boston Legal Services
Legal Assistance to the Elderly (San Francisco)
Tennessee Justice Center
Samuel Sadin Institute on Law, Brookdale Center on Aging, Hunter College (NY)
Vermont Senior Citizens Law Project
Vermont Medicare Advocacy Project
Council of Vermont Elders
Connecticut Legal Services
Greater Upstate Law Project, Inc. (NY)
Neighbor to Neighbor
Northern California Lawyers for Civil Justice
Coalition of Wisconsin Aging Groups/Elder Law Center
National Health Law Program
*Authored by the Center for Medicare Advocacy, Inc., the National Senior
Citizens Law Center, and the Consumer Coalition for Quality Health Care.
The Bipartisan Commission on Medicare completed its work on
March 16, 1999 without reaching agreement on a recommendation to Congress about
the future of Medicare. Having missed its initial deadline, the Commission
declared itself unable to come to consensus on a set of recommendations.
The Commission’s only proposal, the Breaux-Thomas proposal,
known as a "Premium Support" or "Voucher" program, creates great concern among
both current and future Medicare beneficiaries because it:
Increases the age of eligibility from 65 to
Does not strengthen the financial health of
the Medicare program for the future, particularly for the "Baby
Does not limit out-of-pocket expenses that
beneficiaries would have to pay when the premium support voucher
is not enough to buy necessary health coverage;
Does not guarantee a defined and dependable
Does not provide a stable and affordable
premium structure for beneficiaries;
Does not set aside budget savings for
Medicare solvency as requested by the President.
We must move on! Medicare remains a vital and successful
program. Now is the time for dialogue and action. The debate has just begun, and
we must help lead it.
We are left with an important opportunity to:
Further the health care financing debate;
Offer meaningful solutions;
Secure a complete, vital Medicare program for
our families and loved ones.
Participate in this critical discussion. Help preserve
Medicare as a national program which promotes the important value of ensuring
basic health care for all of our elders.
For further information contact:
Alfred J. Chiplin, Esq. or Vicki Gottlich, Esq.
Center for Medicare Advocacy, Inc.
1025 Connecticut Ave., NW Suite 709
Washington, DC 20036, (202) 293-5760
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