Analysis

Randall Mason

The Marden Companies

Every fall, millions of older Americans are flooded with commercials, mailers, and phone calls urging them to choose Medicare Advantage. The promises of extra benefits and lower premiums sound enticing. But there’s a large gap between the sales pitch and the reality of obtaining needed care.

The uncomfortable truth is that the government does not provide beneficiaries with the information they need to choose the most appropriate Medicare Advantage plan. Seniors are left sorting through fantastic claims, well-meaning advice from friends, and, ultimately, frustration when serious health needs arise.

The problem begins with the Medicare “Star Ratings,” the main tool used to compare Medicare Advantage plans. These ratings look reassuring — neat, simple, and displayed everywhere from Medicare.gov to plan brochures. But they measure the wrong things. They focus on preventive screenings, customer service surveys, and administrative accuracy.

Important, yes — but irrelevant when you need an MRI approved, therapy authorized, or access to a specialist who takes your insurance.

What Star Ratings don’t measure are the factors that determine whether you receive timely, appropriate care when you’re seriously sick, such as:

– How quickly a plan approves treatment

– How often it denies or delays medically necessary services or discharges early

– Whether your doctors, hospitals and other providers accept the plan

– Whether home health, therapy, or skilled nursing are truly available at the plan’s reimbursement rates

These realities are not abstract. They are experienced every day by hospitals, home health agencies, therapists, and nursing facilities. Providers are the ones who must call insurers repeatedly, file appeals, and fight to secure care that should be routine. They see which plans cooperate and which ones throw up roadblocks.

So why doesn’t the government capture or share this critical information? It comes down to political incentives, structural limitations, and industry pressure.

First, Medicare doesn’t have access to real-world provider data by design. It cannot see how long authorizations take, how often claims are downcoded, or how frequently plans refuse rehabilitation. Only providers see that. Without the ability to independently audit these behaviors, Medicare cannot legally include them in official ratings.

Second, Medicare Advantage insurers are politically powerful. They collectively earn tens of billions in annual revenue directly from federal Medicare payments. With that revenue, they donate heavily to campaigns, lobby aggressively, and exert enormous influence over the committees that oversee Medicare.

This lobbying power creates extraordinary access to policymakers, all but eliminating meaningful reform originating within Medicare.

Third, both political parties have spent two decades promoting Medicare Advantage as a modern, efficient alternative to traditional Medicare. Acknowledging the program’s weaknesses would be politically awkward, especially as enrollment continues to rise.

Finally, CMS is not a consumer-protection agency. It does not regulate advertising the way the FTC oversees commercial products. If insurers meet basic guidelines, they are free to run the celebrity-filled commercials and misleading “Medicare helpline” ads that have become so common.

The result? Beneficiaries choose plans based on incomplete information, leaving them vulnerable after a fall, a surgery, or a new diagnosis. Many discover too late that the care they expected is subject to delays, denials, and narrow networks they thought they understood.

Seniors deserve a rating system that reflects reality. A system that tells them which plans approve care promptly, support rehabilitation, maintain strong provider networks, and work cooperatively with the clinicians who care for them. A system grounded in the real-world experiences of doctors, therapists, hospitals, skilled nursing facilities, and home health agencies.

Since the government will not create such a system, seniors are left to gather information on their own by talking with local providers about how plans behave when care is required.

Calling a few providers to ask which plans they work well with can tell you more than hours of online research.

But this burden should not fall on seniors. Collecting usable information should be the responsibility of a government that spends roughly $500 billion per year in taxpayer dollars on Medicare Advantage.

Medicare Advantage is not going away, and it shouldn’t. Many people benefit from it. But seniors deserve honesty. They deserve transparency. They deserve a system that protects them not just when they’re healthy, but when they’re at their most vulnerable — and they deserve real value for the $500 billion invested on their behalf.