The process shows the need for healthcare reform
I am not the biggest fan of MedPAC, the congressional Medicare policy arm. For example, I have taken issue with what I think is its slanted views on Medicare Advantage (MA) overpayments. But recently, I did give it some credit on its look at hospital financial health when MA penetration increases. It was a balanced look and concluded that MA penetration is not tied to financial instability as some hospital lobbies suggest. Empirical analyses conducted by MedPAC staff showed no evidence of a significant association between MA market penetration and all-payer margins of hospitals, skilled nursing facilities (SNFs), and home health agencies. Negative impacts do not appear to be the case in rural markets, either. That is Chapter 3 of the MedPAC report (link at end of the blog). I will likely write more about this soon.
My real reason for writing today is on Chapter 2 of the recent MedPAC report. As a backdrop to the remainder of the blog, as many of you know I am a former state budget director/management secretary and veteran health plan executive. For the better part of 20 plus years I have been on the inside of health plans or supporting them with core technology. So, I understand what insurance is and how it operates.
First, a confession here: sometimes health insurance and open enrollment even confuses me. I learn something new every day. I am mystified sometimes by the effort I have to put in to figure out my benefits and coverage as well as navigate preparing for operations, procedures, or open enrollment. And my family has even been victimized by surprise bills (gulp).
Second, I just cannot imagine what the general public and especially seniors go through in sorting out their healthcare journeys each year. Because of the mess that is healthcare in America, to give back I counsel family, friends, and even referrals from outsiders to help solve some of their perplexing insurance woes, especially during open enrollment. I have tried to limit my so-called portfolio of free clients, but the caseload continues to be robust given the crushing affordability crisis. Many cases, especially when someone has a complex condition or is going through cancer treatment, are both tragic and mind-boggling. You can read my last entry on open enrollment here: https://www.healthcarelabyrinth.com/this-years-open-enrollment-stories-tell-you-just-how-unaffordable-things-really-are/
That is why I was delighted to see MedPAC’s Chapter 2 of its report recently on the absolute monstrosity that is enrollment and ongoing decision-making for Medicare beneficiaries. It does a good job of examining all the complexity. That we force seniors and those with disabilities through this very opaque and labyrinthine process each year speaks volumes about the dysfunction of American healthcare more generally. As MedPAC outlines, here are the decision points people have to make:
- Initial enrollment upon qualification
- Understanding several enrollment periods annual and the ability to change coverage
- The link up to Social Security enrollment – or not as the retirement age increases
- Late enrollment penalties as people work longer and/or do not have other coverage
- Parts A and B qualification
- Part B premuims now over $200 per month per person and more for higher incomes
- Ensuring you have both Part A and B (or Part C) and Part D drug coverage
- Enrolling in either Medicare fee-for-service (FFS) with a standalone Part D plan OR Medicare Advantage (MA) with Part D
- Weighing financial protection vs. various limitations in MA
- Choosing an MA or PDP plan that best meets your health needs
- Medicare Supplement if in Medicare FFS
- Though regulated, many Medicare Supplement options
- The confusing process and potential bars from obtaining Medicare Supplement if switching from MA back to FFS
- While choices have eroded, understanding the multiple options for MA plans and PDPs
- The impact of eroding choices and little time to understand remaining options
- An incredibly complex cost-sharing structure in FFS and even in MA
- Navigating prior authorization (PA), appeals, grievances and more in MA, as well as FFS coverage criteria (and perhaps some PA) in FFS
- Understanding supplemental benefits in MA
- Understanding various MA product types, including HMOs, PPOs, and more
- Understanding network limitations in MA
- Navigating the diffuse FFS system on your own
- The Medicare Savings Program (MSP) in Medicaid (what?)
- How retiree, veterans’ and other coverage function with Medicare
- The Low Income Subsidy Program (LIS)
- Despite best efforts, Medicare.gov’s Plan Finder remains overwhelming
- Agent and broker networks that may not have your best interest in mind
- Limited governmental funding for advocacy support
- Advocating for yourself whether in FFS, PDPs, or MA
Most concerning is the fact that a great deal of information on enrollment can be extremely misleading and biased, driven by shadowy deals between plans and a subset of unscrupulous agents and brokers. But beneficiaries can be none the wiser until that big healthcare bill comes in.
So, this is the system we have built. It cries out for reform.
Chapter 2 of MedPAC Report to Congress: https://www.medpac.gov/wp-content/uploads/2026/06/Jun26_MedPAC_Report_To_Congress_SEC.pdf
#medicare #medicareadvantage #coverage #healthcare #partd #pdp #medicaresupplement
— Marc S. Ryan
