Medicare Advantage: A By-the-Numbers Look at This Profit-Seeking Healthcare Scam

The quasi-privatized system called “Medicare Advantage,” otherwise known as Part C, was created in 2003 as a means of expanding the role of private sector corporations in the publicly-funded Medicare system. Proponents claimed it would lower costs and improve health care for seniors. It has achieved neither of those goals; instead, MA has become a wildly profitable scheme for private insurance giants, who have become adept at taking advantage of Medicare’s billing model to claim exorbitant profits. At this point, MA is more profitable for many companies than their conventional insurance businesses.

And the program continues to grow. Medicare Advantage now has more enrollees than traditional Medicare, thanks in no small part to aggressive public relations campaigns that sell seniors on the idea that the plans cut costs and increase choice. Congress has simultaneously failed to plug the holes in traditional Medicare, pushing seniors towards MA to avoid high out-of-pocket costs. Policymakers can fill these gaps and guarantee true comprehensive coverage simply by redirecting the overpayments to MA insurers into Medicare.

Numerous studies and media investigations have documented the problems with Medicare Advantage. What follows is a collection of some of the most notable figures documenting the high costs of this failed experiment in privatizing Medicare.

$88-$140 billion
The amount that the federal government overpaid private insurers under Medicare Advantage in 2022, according to the Physicians for a National Health Program (PNHP).

$612 billion
The amount that Medicare Advantage plans overcharged the federal government due to upcoding and favorable selection between 2007 and 2023, according to the Medicare Payment Advisory Commission (MedPAC), an independent congressional agency established to advise Congress on issues affecting the Medicare program.

$600 billion
According to one study, this is the projected excess spending between 2023 to 2031 due to the ways that Medicare Advantage plans use ‘upcoding,’ the process of classifying beneficiaries as being sicker than they really are in order to increase payments.

$35 billion
The amount that MedPAC estimates taxpayers will overpay MA insurers this year through ‘favorable selection,’ the practice of targeting healthy seniors for their plans.

$4.2 billion
The amount that MA insurers received for questionable home visit health risk assessments (and related chart reviews) in 2023, according to an October 2024 report from the Department of Health and Human Services.

80 percent
The percentage of mental health providers in a sample of MA plans that were determined to be “ghosts” (meaning they were unreachable, not accepting new patients, or not in-network), according to a recent Senate investigation.

1.8 million
Estimated number of Medicare Advantage customers whose health plans will be canceled in 2025.

167 percent
The amount that drug deductibles will increase for roughly two-thirds of all Medicare Advantage enrollees next year.

55.7 percent
The increase in MA care denials from 2022 to 2023, according to research from the American Hospital Association.

54 percent
The increase in the denial rate for long-term acute care hospitals in Humana’s Medicare Advantage plans from 2020 to 2022 (Senate Majority Staff Report, 10/17/24).

$660 million
The amount of taxpayer money that CVS/Aetna stashed away in 2018 by denying Medicare Advantage patients’ claims for treatment at inpatient facilities (Senate Majority Staff Report).

78 percent
The percentage of physicians in a 2023 American Medical Association survey who said that Medicare Advantage’s prior authorization processes caused a recommended treatment for a patient to be abandoned.

$6 billion
One estimate of the amount spent in 2022 on the marketing companies that work to attract new subscribers in Medicare Advantage plans.

556,068
The number of English-language TV commercials touting Medicare Advantage that aired during the seven-week open enrollment period in 2022.

$50 billion
The amount that the Wall Street Journal estimates private insurers received between 2018 and 2021 for “hundreds of thousands of questionable diagnoses that triggered extra taxpayer-funded payments.”

$2,329
The amount that MA insurers receive per beneficiary above the estimated costs of Medicare.

$1,730
The gross profit margin posted by MA companies in 2021 – more than double their profit margin on the individual market.

$172 million
The amount that Cigna agreed to pay in 2023 to “resolve allegations that it knowingly submitted and failed to withdraw inaccurate and untruthful diagnosis codes for its Medicare Advantage Plan enrollees to increase its payments from Medicare.” The Justice Department continues to investigate similar allegations involving other MA providers.