The Battle of the Letters: Medicare Advantage

Occasional fistfights aside, most of our legislators make the choice to use their words when they’re angry, and a lot of those words go into public letters they write to presidents, officials, and even each other. Despite the fact that no one else in this country has written or read a letter in decades, the public comment letter is still popular with politicians, who have elevated this obscure literary genre to a competitive sport, using these letters to demonstrate their power, build alliances, and shape policy. Today we’re going to focus on one ongoing battle of letters over one of our favorite topics: the privatization of Medicare through a program known as Medicare Advantage. We’ll talk about how all the players in the debate about Medicare Advantage are engaging in that battle, and how it could impact our access to healthcare!

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Show Notes

We’ve recorded a bunch of episodes about Medicare Advantage!

Medicare Advantage was created as a private, for-profit alternative to traditional (or public) Medicare, was the promise of lower costs… which never happened. Surprise: Medicare Advantage plans are FAR more expensive to taxpayers than traditional Medicare for covering the same person, costing taxpayers $7 billion more per year than if everyone were just covered by traditional Medicare. (source)

It’s the healthcare Joe Namath, Jimmy JJ Walker, and Big Papi are selling to seniors with big promises of coverage for vision and dental care, transportation, groceries, and more – for $0 premiums. Free shit!

Private companies drain public money to provide generally substandard insurance. These companies are exploiting a legit problem in Medicare, where many seniors are forced to pay premiums for medigap plans to cover stuff like chewing and seeing.

If you can’t afford the premiums for Medigap coverage, but you need to chew or see, you might be forced into an Medicare Advantage plan just because that’s what you can afford month-to-month. And that could be fine… until you need care and find out that the copays and deductibles are too high, there are super limited networks, or the insurance company refuses to pre-authorize your treatment.

But many of these MA plans don’t come through on their wild promises, and in fact, seniors end up being pushed out of MA and back into original Medicare when they are sick and actually need care. Private insurance companies love collecting money,but they hate paying money for the service they’re supposed to provide. Go figure!

We put out a report about this! Taking Advantage

Who’s Who?

AHIP: “America’s Health Insurance Providers” is the trade organization for the health insurance industry. Unsurprisingly, they are big proponents of Medicare Advantage.

AHIP has written their own comment letters to CMS (the Center for Medicare and Medicaid Services) advocating for expansions to the MA program since at least 2015. Lately they also began coordinating their besties in the House and the Senate to write letters on their behalf. They claim that Medicare Advantage will expand the program to more seniors, and present some of their own research:

MA will bring more money into the Medicare system… because MA plan holders use less care. (nothing to brag about!)
MA is serving a diverse populatio
- “As of 2021, approximately 59% of Hispanic or Latino/a individuals and 57% of Black individuals eligible for Medicare choose Medicare Advantage plans. Overall, 54% of Medicare beneficiaries who belong to diverse populations choose Medicare Advantage.”
- Turns out if you set out to exploit a diverse demographic of people, you can!

In 2021, 70 members of congress signed “dear colleague” letter, initated by initiated by Reps. Val Demings (D-FL), Mike Gallagher (R-WI), Marc Veasey (D-TX), and Gus Bilirakis (R-FL).

In 2023 – 60 Senate signers – a good example of how this is insidiously bipartisan, John Fetterman signed right next to Ted Cruz

In 2024 – 60 Senators, but only 16 reps signed on to their version. That’s because of the OTHER letter, which Congresswoman Pramila Jayapal has been whipping up support for in the house.

The Good Guys

Organized resistance to Medicare Advantage is actually fairly new (last few years)! Just a couple of weeks ago a COUNTER letter was to Biden and the agencies that run Medicare calling for major reforms to Medicare Advantage and essentially pointing out that it sucks. The letter was led by three Reps – Jayapal, DeLauro, Schakowski – was ALSO signed by 70 Representatives, so suck on that AHIP! (P.S. there are 435 voting members of Congress, so most of Congress is taking the cowardly fence-sitting approach to Medicare Advantage) (source)

The letter makes four demands, one of which is already kinda sorta happening:

Ban Medicare Advantage plans from creating prior authorization barriers that can’t be used in traditional Medicare, such as “step therapy.” (Banned by Obama, un-banned by Trump, and… allowed under Biden. Grrr.)
Require Medicare Advantage plans to include all providers in their networks that are included in the public Medicare plan. One trick MA uses is to have extreme limited networks, so you might not be able to get certain types of care at all in your area.
Stop overpaying Medicare Advantage by preventing “upcoding” and paying them the accurate amount for the patients they cover
Finally, use all the savings to expand Medicare coverage for everyone: we could cover dental, vision, and hearing with money leftover; or we could reduce or eliminate the premiums and deductibles that Medicare enrollees still have to pay.

This last bit is particularly important, since it’s problematic to just end the MA program – this would require many low-income people to spend more to buy Medigap plans. They’d have much better coverage, but many can’t afford that better coverage.

There will be a separate Senate letter, but we don’t have details yet. (There’s still time to ask your Senator to sign on.)

What does the Other Letter mean? It’s a show of power in a legislature where it’s difficult to put progressive policy up for a vote and actual voting ends in gridlock. Based on the numbers, we can see the tides turning on Medicare Advantage.

Remember that even though these letters are important for signaling shifts in the balance of power, the real organizing happens at the grassroots level, not on Capitol Hill.

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