Some Discover That Medicare Advantage Is to Their Disadvantage

When the Affinity salesman came to the door of 70-year-old Marcolina Sanchez's New York City apartment, he persuaded her to sign up for a Medicare Advantage private health insurance plan.

"He promised her better coverage [than traditional Medicare]," said Mrs. Sanchez's daughter, Catherine Santiago. "But when she went to see her regular doctor at her local clinic, she was told she couldn't go there anymore. She had to go to someone in the company's network. But why would my mother want to change doctors? No one told her that would be necessary.

Lincoln Richards, 75, of Palm Bay, Florida, had a similar experience after being persuaded to switch from regular Medicare to HealthFirst, another Medicare Advantage provider. Mr. Richards is still reeling from his discovery that HealthFirst would not cover the emergency care he needed when he fell in the street and injured his spine. Now, Mr. Richards has bills from the anesthesiologist and the hospital that he is unable to pay.

"The policy says I'm not insured to be seen outside their group, but I didn't even think of that then. I'm worried sick. I don't have that kind of money," he said. "It's hard enough to pay the premiums every month."

For both Mrs. Sanchez and Mr. Richards, and many others like them across the country, the problems with their new Medicare Advantage coverage have caused them and their families emotional distress and weeks of bureaucratic wrangling to disengage from the plans.

Medicare private health plans, called Medicare Advantage, have grown fast since 2003 when the Bush administration began showering them with increased subsidies to entice seniors to leave the traditional Medicare program. Thanks to the extra government money, these plans can offer seniors attractive benefits not found in traditional Medicare, like dental coverage. But sales agents rarely explain the network restrictions that prevent enrollees from receiving care from any Medicare provider, as they did before. In addition, Medicare Advantage enrollees often discover that they are incurring charges like co-pays for doctor visits that they wouldn't pay under traditional Medicare.

For Medicare advocates and many health professionals who work with the elderly, beneficiaries like Mrs. Sanchez and Mr. Richards are the real-world victims of the zeal to privatize the Medicare program, and their experiences are a cautionary tale for Medicare beneficiaries everywhere.

Rampant Marketing Abuses

The idea behind the federal subsidies for Medicare Advantage plans was that eventually the investment would pay off because the private plans would lower costs through competition and managed care. So far, the hoped-for payoff hasn't arrived; to the contrary, the plans have required the infusion of more and more cash over the years just to keep them from exiting the market. The plans currently receive between 12 percent and 19 percent more in federal financing than do traditional Medicare providers, amounting to a total subsidy of $5 billion a year.

Because the amount of federal money a Medicare Advantage plan receives is based on how many enrollees it has, in the last few years these plans have been working overtime to persuade as many traditional Medicare beneficiaries as possible to switch to their plan. Today, nearly 8.3 million of the 43 million Americans with Medicare have signed on with a private Medicare plan. But this growth has been accompanied by widespread reports of marketing abuses.

Gladys Cruz [not her real name] crossed paths with a HealthFirst representative in front of her New York City drug store, where, she claims, the salesman blocked her way and harassed her into buying. The salesman also offered her a drug store card that would enable her to get $600 worth of medicine free for signing up -- one of HealthFirst's most popular inducements.

"I hear those private insurance salesmen promise the world, and later the people find out they've got a huge co-pay or they can't see their usual doctor," said an office assistant at the geriatric medical practice where Mrs. Cruz is a patient. (Like Mrs. Cruz, the office assistant also requested anonymity.)

HealthFirst's vice president of external affairs, George Hulse, denies that his representatives harass elderly customers or confuse them by hiding restrictions.

"We are here to improve the quality of life for seniors, not to hurt them in any way," Hulse says. "We do not hard sell or cold call, and we have a verification line where an expert goes over everything with the seniors to ensure they understand all their options

For the Medicare Advantage plans, the extra federal money and marketing have proven to be enormously lucrative. In 2005, according to the Government Accountability Office, their profits were $1.14 billion more than projected.

Double the Amount of Paperwork

Discontent about Medicare Advantage plans has spread to health professionals as well. Elizabeth Oram, a geriatric nurse practitioner at St. Vincent's Hospital in New York City, has seen the havoc the new plans have wrought in her outpatient clinic.

"The best thing about working in geriatrics was that everyone had Medicare, so there were no concerns about how a patient would pay; I could see everyone," Oram said. "The new private Medicare plans have changed all this. The other day a woman arrived in a wheelchair, but I couldn't see her. She had a private policy, and we couldn't take it. These new plans have turned our department upside down, and given supervisors double the amount of hassles and paperwork."

Aggressive and deceptive marketing by Medicare Advantage plans has been the subject of hearings on Capitol Hill in recent months. In response, the Bush administration proposed new marketing rules for these plans. Among other provisions, the rules would prohibit cold-calling, door-to-door marketing and unsolicited selling in places such as waiting rooms and senior centers. However, many lawmakers and consumer advocates say that the federal Centers for Medicare and Medicaid Services (CMS), which oversees the Medicare program, lacks the manpower to enforce any new rules and that states must be given enforcement authority.

However, Congress in a single vote may already have done more than any regulation could do to curb marketing abuses. On July 16, 2008, it overrode President Bush's veto of a bill delaying a 10.6 percent pay cut to doctors who treat Medicare patients. The delay will be financed by a sizeable reduction in payments to Medicare Advantage plans -- $14 billion over five years. This could go a long way toward eliminating what the New York Times characterized in a May 21, 2008, editorial as "the root cause of the problem: the high subsidies that prop up these plans and make them so attractive to high-pressure marketers."

For critics of the playing field tilted to the advantage of the Medicare Advantage plans, the real issue is preserving one of the most popular government programs ever.

"It's about the future of Medicare," says Paul Precht, director of policy and communications at the Medicare Rights Center. "Paying out to companies more than it would cost under traditional Medicare only hastens the insolvency of Medicare and leads to its destruction."

For Marcolina Sanchez, it will be enough just to be able to see her regular doctor again.

For information on a Medicare Rights Center report, Too Good To Be True: The Fine Print in Medicare Private Health Care Benefits, click here.

For more on the Medicare program, click here.