- Has Medicare been successful?
- How does Privatization affect Medicare and Medicare beneficiaries?
- What core values should be addressed in any Medicare "reform" plan?
- What are real solutions for Medicare reform?
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The Medicare program is a success story. It was designed and enacted in 1965 as a social insurance program because private companies failed to insure older people. It was intended to provide basic coverage through one health insurance system, with a defined set of benefits. Reforms to Medicare should honor and maintain its core values to ensure its continued success for future generations.
As stated by Nancy-Ann DeParle, a former Administrator of the Health Care Financing Administration (HCFA, now CMS):
Few 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 should continue to be a national health insurance program, not a set of independent private plans and payment options.
- Medicare should include a mandatory, secure set of defined benefits.
- Medicare should continue to provide one community of interests among the healthy and frail, rich and poor. It should not separate beneficiaries into separate groups with distinct and varying interests by creating multiple cost-sharing levels, benefit options, and delivery systems that differ depending upon the ability to pay or an individual’s health.
- Medicare should provide equal access to appropriate and high quality health services for all beneficiaries, including those with chronic, long-term, and mental health conditions.
- Private Medicare plans should be carefully monitored by CMS to ensure they provide full Medicare coverage and rights to their enrollees.
- Medicare should provide an accessible, meaningful appeals process that guarantees due process to all beneficiaries. Medicare coverage decision-makers, at all levels, should be independent from CMS and should be required to make coverage decisions based on the law and regulations.
The public should listen carefully to the many proposals being considered that would dramatically change Medicare under the guise of reform, modernization, and deficit reduction. Many of these proposals would abandon Medicare’s core values and increase expensive privatization. Medicare can be strengthened and preserved for future generations if an informed public demands it.
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 Medicare program.
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 billions of dollars every 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 nursing home.
- 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 was 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 attorney’s questions.
- 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 endocrinologist visits.
- Mr. 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 this plan.
- 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 industry.
The 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.
Center for Medicare Advocacy, Inc.
October 15, 2008
- 04/21/10 – White House Health Care Reform Timeline
- 3/26/10 – Download the full text of the Patient Protection and Affordable Care Act.(Note: Large .pdf file approximately 900 pages.)
- External Link: "Ryan's Medicare Plan Would Leave Many Seniors Stranded" by Peter Orszag, Bloomberg News, in the Tampa Bay Times
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- Privatization: Not Right for Medicaid, Not Right for Medicare April 25, 2013
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- The Impact of the President’s Budget on People Who Depend on Medicare and Social Security April 11, 2013
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- Protect Medicare: Reject Paul Ryan’s Budget Proposal March 14, 2013
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- Center for Medicare Advocacy Testifies on Medicare Redesign February 26, 2013
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- Medicare Facts and Fiction: Costs and Spending Edition January 10, 2013
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- Warning: Medicare Payment Limits Are Bad for Health! December 13, 2012
- Special Report – Independence of Medicare Administrative Law Judges Threatened by Office of Inspector General’s Recommendations December 6, 2012
- Annual Medicare Payment Limits for Home Health – Even Worse Than Co-Pays for Beneficiaries December 5, 2012
- Raising the Medicare Eligibility Age: A Costly and Dangerous Proposal November 29, 2012
- Deficit Reduction and Medicare: Save Money Without Harming Beneficiaries November 15, 2012
- The Affordable Care Act Moves Forward: What’s Up for 2013 November 8, 2012
- Medicare and ACA Facts and Updates; Jimmo Update November 1, 2012
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- How the Ryan Budget (and Republican Platform) Would Hurt Current Nursing Home Residents August 30, 2012
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- Center for Medicare Advocacy Director Judith Stein Refutes Claims that ACA Hurts Medicare August 30, 2012
- The $700 Billion Medicare Myth August 16, 2012
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- Happy Birthday, Medicare! July 26, 2012
- House Votes for 33rd Time to Repeal Health Reform July 12, 2012
- Good News for Medicare: Supreme Court Upholds Affordable Care Act July 5, 2012
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- Champions for Medicare Beneficiaries Applaud Supreme Court Ruling June 28, 2012
- Cut Through the Rhetoric: Questions to Ask After the Supreme Court ACA Decision June 22, 2012
- MedPAC Reviews Blending Medicare and Medicaid June 21, 2012
- A Reporter’s Checklist for the Impending Obamacare Ruling June 15, 2012
- Center for Medicare Advocacy in Congress, Voicing Concerns on Behalf of Beneficiaries May 10, 2012
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- Fact vs. Fiction: Medicare is Not Going “Bankrupt” April 26, 2012
- Toby Edelman Statement to Senate Committee Regarding Antipsychotic Drugs in Nursing Facilities April 19, 2012
- Home Health Face-to-Face Physician/Practitioner Requirement Challenges April 12, 2012
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- The Second Anniversary of Health Care Reform is Good News Will There be a Third? March 21, 2012
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- The President’s Proposed 2013 Budget: Impact on Medicare February 17, 2012
- Investing in Our Future: Strengthening Medicare for 2012 and Beyond February 9, 2012
- Protecting Medicare and the Middle Class: Themes from the President’s State of the Union Speech January 25, 2012
- Payroll Tax Extension Includes Important Provisions for Medicare Beneficiaries December 29, 2011
- Forcing Dual Eligibles Into Private Health Plans is No Quick Fix November 22, 2011
- Supercommittee Update November 17, 2011
- Health Care Reform Update: Where Are We, and What’s Up for 2012? November 10, 2011
- Breaking Good News for Medicare Beneficiaries October 27, 2011
- “Skin in the Game,” Health Equity and Deficit Reduction October 13, 2011
- Medigap – Fact & Fiction October 13, 2011
- The President’s Plan for Economic Growth and Deficit Reduction: A First Look at the Impact on Medicare September 29, 2011
- Next Steps for Some Beneficiaries In Medicare Special Needs Plans September 15, 2011
- CMS to Begin Round Two of Its Competitive Bidding Program for the Provision of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) September 1, 2011
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- Amended Appeal Rules for Employer and Individual Health Plans August 11, 2011
- Medicare Facts & Fiction: 3 Quick Lessons to Combat Medicare Spin August 9, 2011
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- New Initiatives to Improve Services for Dual Eligibles July 15, 2011
- House Plans Vote to Slash Medicare and Social Security through Balanced Budget Amendment July 15, 2011
- Recommendations for Beneficiary Protections In Models Approved by CMMI July 15, 2011
- Lower-Premium Pre-Existing Condition Insurance Plans Take Effect in Many States July 7, 2011
- Real Solutions to Save Medicare Dollars in Skilled Nursing Facilities June 30, 2011
- First Appellate Court Rules on Health Reform Law, Holds it Constitutional June 29, 2011
- Why Medicaid Matters to People with Medicare June 16, 2011
- So, What Would You Do? Real Solutions for Medicare Solvency and Reducing the Deficit June 9, 2011
- New Rules for Medicare Advantage and Part D Plans June 2, 2011
- Many Uninsured Individuals with Pre-Existing Conditions Will Find It Easier to Obtain Coverage June 2, 2011
- Combating Fraud, Waste and Abuse in Health Care May 26, 2011
- 2011 Medicare Trustees Report May 19, 2011
- Send Us Medicare Summary Notices (MSNs) May 19, 2011
- Preserve Medicaid – Share Your Story! May 19, 2011
- Proposed Notice Requirements About Quality of Care: Endorsement, with Concerns May 5, 2011
- New Hospice Face-to-Face Requirement: Help or Hindrance? April 28, 2011
- Senators Kerry and Snowe, with Representatives Courtney and Latham, Introduce Legislation to Ensure Skilled Care for Seniors April 26, 2011
- Health Care Changes: Challenges to Medicare April 25, 2011
- What Happens to Current Nursing Home Residents if the House Budget Resolution Becomes Law? April 21, 2011
- 25 Years of Medicare Advocacy, and Hope for 25 More April 14, 2011
- Keeping Medicare and Medicaid Strong? April 7, 2011
- Why Medicaid Matters to Medicare Beneficiaries and Their Families April 1, 2011
- Happy Anniversary, Health Care Reform March 23, 2011
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- The Burden of Out-of-Pocket Costs on Medicare Beneficiaries February 24, 2011
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- Center for Medicare Advocacy Submits Testimony to House Ways & Means Committee: The Affordable Care Act Strengthens the Medicare Program and Retains Its Guaranteed Benefits February 9, 2011
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- New Home Health and Hospice Face-to-Face Physician/Practitioner Encounter Requirement January 13, 2011
- New Medicare Home Health Regulations: Improvement is Not Required to Obtain Coverage December 30, 2010
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- Center for Medicare Advocacy Urges Policy-Makers to Rethink Medicare Cuts December 3, 2010
- Health Care Reform Does Not Cut Medicare Benefits October 28, 2010
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- Extended Observation Stays in Acute Care Hospitals: Criticism, Legislation and Discussion August 26, 2010
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- The Right to Visit Partners and Others In Medicare Participating Hospitals June 22, 2010
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For older articles, please see our archive.