The television ads show seniors playing tennis, golfing and riding motorcycles. In others, celebrity pitchmen seniors will know – such as actor William Shatner, NFL star Joe Namath and former Republican Arkansas governor Mike Huckabee – promise new benefits alongside pictures of government-issued ID cards.
All of these are ads for Medicare Advantage and if Donald Trump wins the White House, Americans might be seeing a lot more of them.
That’s because one of Republicans’ only healthcare policy specifics involves further privatizing the program – selling more plans that commercials just like these advertise.
“We groan when we see [Medicare] Advantage as insurance,” said Dr Karen Kinsell, the only doctor in Fort Gaines, Georgia, a rural community where more than a third of the population lives below the poverty line.
Medicare Advantage is private insurance paid for by the federal government, a program authorized in 1997 amid concerns about Medicare’s cost. Insurance companies promised cheaper plans with better benefits.
One of the most important differences for patients is the imposition of “networks” in Medicare Advantage plans, or a limited number of doctors and hospitals a patient can see at a discounted rate. Traditional Medicare does not include networks – 98% of providers in the US participate. However, traditional Medicare has a monthly cost – most people pay a standard rate of $174.70.
Medicare Advantage plans can be enticing because they often include food or transportation cards, $0 monthly premiums and hearing, vision and dental benefits – none of which are included in traditional Medicare.
Kinsell notes that the problems usually start when people get sick.
“Patients have been unable to get into rehab, or stay,” she said. Others were charged $50 a day for rehab when the service is normally free for a short period in traditional Medicare.
“We’ve spent a lot of time in our district office with seniors who got hoodwinked by these corporate insurance plans,” said Democratic US representative Pramila Jayapal of Washington state. Jayapal has called for “urgent reforms” and consumer protections to be added to Medicare Advantage.
“They took the name – so seniors actually think they’re signing up for Medicare,” she said.
Despite complaints from doctors and patients, fraud investigations, allegations insurers used artificial intelligence models to deny care to seniors, and a pile of evidence that Medicare Advantage costs taxpayers more, Republicans have continued to boost the program. The most specific healthcare policy proposals are set forth by Project 2025, the conservative playbook by the Heritage Foundation.
Amid a thicket of gripes about vaccine mandates and no less than 199 mentions of abortion, the document also proposes further privatizing Medicare through Medicare Advantage.
Medicare Advantage “provides beneficiaries with a wide range of competitive health plan choices – a richer set of benefits than traditional Medicare provides and at a reasonable cost”, Project 2025 argues. Republicans should make it the default enrollment option and “remove burdensome policies that micromanage” plans, the document said.
The document also proposes to “give beneficiaries direct control of how they spend Medicare dollars”, which Democrats argue describes a voucher program, something Republicans tried to push in the Trump administration.
“That has been the playbook for privatization of Medicare really since these corporate Medicare ‘dis-Advantage’ plans – that’s what I call them – started,” said Jayapal. “It was their in-road.”
That, like a lot of Donald Trump’s proposals, is likely to cost the federal government a lot of money.
“The federal government is significantly overpaying Medicare Advantage plans in relation to what it spends on an individual and traditional Medicare – without corresponding significant gains to show for it,” said David Lipschutz, co-director of the Center for Medicare Advocacy.
Studies show Medicare Advantage plans will cost the federal government an estimated $83bn more than traditional Medicare in 2024 without corresponding improvements in health, according to the congressionally commissioned nonpartisan research agency Medicare Payment Advisory Council. Using default enrollment could increase that cost to an additional $2tn over 10 years, according to the left-leaning Center for American Progress.
The stakes for private health insurers are equally huge. One of the largest Medicare Advantage providers, United Healthcare, earned 46% of its $281bn in total revenue from Medicare Advantage enrollees, even though they represent only 15% of the company’s beneficiaries, an Accountable.US analysis found. The analysis was shared exclusively with the Guardian.
“The fact this is becoming something conservatives are trying to push as a universal model is alarming, because it’s a way to just increase profits for insurance companies,” said Tony Carrk, Accountable.US executive director.
Problems with the program are so acute that, at one point in 2022, eight of the 10 largest insurance companies selling Medicare Advantage plans were defendants in federal fraud or whistleblower lawsuits.
“Part of the problem of having private plans involved in Medicare, or really any healthcare space, is the promise they could provide better care more efficiently,” Lipschutz said. “And neither has happened.”
Although the Republican deficit hawks of yesteryear might balk at such a cost, the proposal to further privatize Medicare goes to a long-held Republican philosophy that survived Trumpism: the government is inherently untrustworthy and regular people need a financial reason to do the right thing.
“The problem with the left is they don’t think in economic terms,” said John Goodman, an economist who has advised nearly every Republican presidential candidate on health since George W Bush. He said he is currently working with America First Policy Institute, a pro-Trump thinktank.
Philosophically, Goodman believes Americans need “economic incentives” to do the right thing.
For patients, for example someone who is diabetic, that might mean low-cost insulin (a carrot) and the specter of a big bill if you don’t manage your diabetes and end up in the hospital (a stick). For doctors, it might mean jumping through bureaucratic hoops to get approval for a procedure, called prior authorization, to avoid being wasteful.
Critics argue debates about “economic incentives” mask what are in fact “catastrophic” health costs. Medicare Advantage plans are allowed to require patients to spend as much as $13,300 per year for out-of-network providers in 2024. More than one-third of all Medicare Advantage enrollees live on less than $10,000 per year, according to the Commonwealth Fund. Nearly 95% of all seniors have a chronic health condition, and more than 78% have two or more, according to the National Council on Aging.
Although Trump has disavowed Project 2025, he has deep ties to its authors. Its health proposals were written by Roger Severino, his own former director of the Office of Civil Rights in the Department of Health and Human Services.
Notably, Goodman thought Project 2025 was a “poor document” whose many references to abortion would turn voters off. But he agrees with proposals on Medicare.
In the 2024 GOP Platform, Trump pledged to, “not cut one penny from Medicare”, but does not provide further specifics. That comports with the Project 2025 plan – which would require a lot more money to expand Medicare Advantage enrollment.
For Goodman, there is at least one piece of humor in this branch of health policy – the idea that the left would propose a health system where people don’t have to pay for healthcare.
“In fact, the Bernie Sanders types do not think economic incentives should play any role in healthcare,” Goodman said.
