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"There's every reason to expect the Trump administration to block these proposed rules from moving forward," warned Public Citizen co-president Robert Weissman.
The Biden administration on Tuesday unveiled a new rule aimed at reining in privatized Medicare Advantage plans, which have drawn growing federal scrutiny for denying coverage claims en masse—sometimes using artificial intelligence—and overbilling the government to the tune of tens of billions of dollars per year.
But the proposal could soon be fed through the buzzsaw of the incoming Trump administration, which is likely to have an outspoken Medicare Advantage supporter, Mehmet Oz, at the helm of the Centers for Medicare and Medicaid Services (CMS).
Biden's CMS said in a fact sheet released Tuesday that the new rule would ensure MA companies make enrollees aware of their right to appeal coverage denials. CMS pointed to data showing that MA plans, which now cover more than half of the Medicare-eligible population, "overturn 80% of their decisions to deny claims when those claims are appealed."
"These data also show that a low percentage of denied claims are appealed, meaning many more could potentially be overturned by the plan if they were appealed," CMS added.
The rule would also look to constrain MA plans' deceptive marketing practices and "use of inappropriate prior authorization." Prior authorization is a byzantine process under which providers must demonstrate that a proposed treatment is medically necessary before the insurer will cover it.
"The big question, of course, is what will the Trump administration do with these rules? Will they side with patients needing treatment or care-denying big insurers?"
Robert Weissman, co-president of the consumer advocacy group Public Citizen, welcomed the new rule as a "common-sense" measure that would "limit" some of the damage inflicted by MA plans, which are notorious for denying patients necessary care.
"The big question, of course, is what will the Trump administration do with these rules? Will they side with patients needing treatment or care-denying big insurers?" Weissman continued. "Unfortunately, despite its populist pretensions, there's every reason to expect the Trump administration to block these proposed rules from moving forward. Dr. Mehmet Oz, Trump's nominee to run the Centers for Medicare and Medicaid Services, is a major proponent of expanding privatized Medicare, with nary a worry about privatized Medicare's rampant abuses and rip-offs of taxpayers."
Sen. Ron Wyden (D-Ore.), chair of the Senate Finance Committee, vowed Tuesday that he will "be watchdogging the incoming Trump administration to ensure there is no backsliding on these critical consumer protections and coverage improvements."
Oz, a long-time television personality known for hawking unproven treatments, has been characterized as a "shill" for MA, a program funded by taxpayers and run by for-profit insurance companies.
As recently as August, Oz boosted Medicare Advantage on his YouTube account, as New York magazine reported earlier this week:
In August, Dr. Mehmet Oz's official YouTube account posted a video titled "Get $0/Month Medicare Coverage: What You Need to Know," in which Oz lays a sales pitch on his viewers. "Which of these items can you get for zero dollars?" he says, pointing to images of a coffee cup, a pack of gum, and a newspaper, as if quizzing a toddler on the pictures in a children’s book. "Or how about a health insurance plan?" he says. If you've ever watched daytime television, you know how the next part goes: Oz reveals he was, indeed, talking about the health insurance plan, and the studio audience erupts into applause. He then brings out an insurance agent to paint a rosy portrait of Medicare Advantage before ending with a call to action, encouraging any seniors in the audience to call in to a special phone number or visit a website to learn more and enroll.
During his 2022 bid for a U.S. Senate seat, Oz campaigned on a proposal he called "Medicare Advantage for All"—while owning stock in UnitedHealth Group, the nation's largest MA insurer.
Oz's support for Medicare Advantage aligns with the Project 2025 agenda, which calls for making MA the default enrollment option for U.S. seniors—an existential threat to traditional Medicare. Such a sweeping change would hugely benefit UnitedHealth and other private insurance giants.
"Project 2025's plans for Medicare, seconded by Dr. Oz, will end Medicare as we know it, and leave seniors to the tender mercies of dishonest and debased private insurance plans," The American Prospect's Robert Kuttner warned Tuesday. "What's insidious is that none of these changes require legislation. The best we can hope for is that the sunlight of exposure of these schemes will act as a disinfectant."
The new report was released as allies of Republican nominee Donald Trump push to make privatized Medicare Advantage plans the default enrollment option for U.S. seniors.
An inspector general report published Thursday estimates that the U.S. federal government delivered around $7.5 billion in potentially improper payments to for-profit Medicare Advantage companies last year, a finding that came as allies of Republican nominee Donald Trump are pushing to make privatized MA plans the default enrollment option for the nation's seniors.
The new report from the Office of Inspector General (OIG) for the U.S. Department of Health and Human Services focuses specifically on health risk assessments (HRAs) and chart reviews, mechanisms that MA companies use to gauge enrollees' health and help determine the size of payments the insurers receive from the federal government.
The OIG report characterizes MA companies' use of HRAs and chart reviews as "questionable," noting that the program's insurers have a history of making patients appear sicker than they are to receive larger payments from Medicare.
"Diagnoses reported only on enrollees' HRAs and HRA-linked chart reviews, and not on any other 2022 service records, resulted in an estimated $7.5 billion in MA risk-adjusted payments for 2023," the report states. "The lack of any other follow-up visits, procedures, tests, or supplies for these diagnoses in the MA encounter data for 1.7 million MA enrollees raises concerns that either: (1) the diagnoses are inaccurate and thus the payments are improper or (2) enrollees did not receive needed care for serious conditions reported only on HRAs or HRA-linked chart reviews."
The report raises particular concern about the validity of HRAs and chart reviews conducted at patients' homes "because these tools are often administered by MA companies or their third-party vendors and not enrollees' own providers."
Last year, according to the OIG report, "in-home HRAs and HRA-linked chart reviews generated 63% of the estimated $7.5 billion in risk-adjusted payments."
"Any inaccurate diagnoses from these in-home HRAs and associated chart reviews may have resulted in overpayments to the MA companies," the report states. "For diagnoses that were accurate, enrollees may have gone without needed care."
Diane Archer, senior adviser on Medicare at the progressive advocacy group Social Security Works, told Common Dreams that "we need to stop paying MA insurers more for their sickest patients when they don't provide them with needed care."
"We need to penalize them in meaningful ways for ripping off taxpayers and harming their patients," said Archer. "We need to stop assuming that the insurers are managing people's care. They are overcharging the government and denying needed care, sometimes indiscriminately, to boost their profits."
"If Trump's plan takes effect, the number of Medicare Advantage policies UnitedHealth controls is expected to reach 15.6 million."
Medicare Advantage, a privately run program funded by the federal government, has faced growing scrutiny in recent years as enrollment in the program has surged. More than half of the Medicare-eligible population in the U.S. is enrolled in a Medicare Advantage plan, according to KFF, resulting in massive profits for insurance giants.
The new OIG report found that just 20 MA insurers—including UnitedHealth, Cigna, and Humana—accounted for 80% of the $7.5 billion in government payments stemming from HRAs and chart reviews last year.
"One top MA company, UnitedHealth Group, Inc., stood out from its peers, especially in its use of in-home HRAs and HRA-linked chart reviews to generate risk-adjusted payments," the report says.
UnitedHealth is one of the insurance behemoths that stands to benefit most from a plan crafted by Trump allies that would funnel more seniors into MA plans, which are notorious for denying necessary care and overcharging Medicare to the tune of tens of billions of dollars per year.
People's Action estimated in a report published last week that UnitedHealth could see its revenue from Medicare Advantage double to $274 billion annually if Trump wins next month's election and enacts Project 2025's proposal to make the privatized plans the default enrollment option for new Medicare beneficiaries.
Democratic nominee Kamala Harris, for her part, has called for an expansion of traditional Medicare to cover home health services as well as hearing and vision—benefits that are key selling points of MA plans.
Sulma Arias, executive director of People's Action, warned in an op-ed for Common Dreams on Thursday that Trump's "only plan for healthcare in a second term is to privatize."
"If Trump's plan takes effect, the number of Medicare Advantage policies UnitedHealth controls is expected to reach 15.6 million," Arias wrote. "One out of every three Medicare Advantage policyholders is denied care by private insurers like United every year. Under Trump's plan, UnitedHealth alone would deny care to as many as 5.2 million people."
"This ability to deny care," Arias added, "is what makes Medicare Advantage plans far more profitable to private insurers than any other plans they offer."
A right-wing coalition's proposal to make Medicare Advantage the default enrollment option would be a "clear handout to the private insurance industry," said one critic.
A right-wing coalition that's been laying the policy groundwork for another Trump presidency has developed a plan to further privatize Medicare by making fraud-riddled Medicare Advantage "the default enrollment option" for newly eligible beneficiaries.
The plan, highlighted Monday by Rolling Stone's Andrew Perez, is outlined about halfway through Project 2025's 920-page playbook for the first six months of a conservative presidency.
Republican administrations and right-wing groups have long advocated funneling people who are newly eligible for Medicare into Medicare Advantage plans, which are funded by the federal government and run by for-profit insurers. During his first White House term, former President Donald Trump took steps to actively encourage seniors to choose Medicare Advantage plans over traditional Medicare and expanded the benefits that the privately run plans are allowed to offer.
Those efforts have had an impact. As Perez noted, "Last year, for the first time ever, a majority of Americans eligible for Medicare were on privatized Medicare Advantage plans."
"If Republicans win the presidential race this year," he wrote, "the push to fully privatize Medicare, the government health insurance program for seniors and people with disabilities, will only intensify."
Every year, new and existing Medicare recipients have an opportunity to enroll in Medicare Advantage plans, which engage in aggressive and often highly deceptive advertising practices to lure seniors who are often seeking out benefits not currently offered by traditional Medicare, such as vision and dental care.
"Donald Trump and his MAGA Republican cronies plan to totally privatize Medicare if they win in November's election."
Once enrolled in Medicare Advantage plans—which offer limited networks of doctors and overbill the government to the tune of $140 billion a year—patients often feel trapped and are subjected to care denials and other deep flaws in the program that have drawn growing attention from lawmakers in recent years.
If Project 2025, which is led by the right-wing Heritage Foundation, gets its way, Medicare Advantage providers would be given even greater power over the critical government insurance program. The Trump administration embraced many of the Heritage Foundation's policy recommendations during its first year in power.
"Donald Trump and his MAGA Republican cronies plan to totally privatize Medicare if they win in November's election," the progressive advocacy group Social Security Works wrote in response to Rolling Stone's reporting. "Hell no. Hands off our earned benefits."
Philip Verhoef, president of Physicians for a National Health Program, told Rolling Stone that Project 2025's plan to make Medicare Advantage the default enrollment option would be "disastrous."
"To do so would be really just a clear handout to the private insurance industry," Verhoef said.
Project 2025 has said that it doesn't "speak for any presidential candidate," but Trump's reelection campaign has relied on parts of the coalition's proposed agenda for second-term planning.
Trump's team has faced backlash over some of Project 2025's work, including draft executive orders that would use the Insurrection Act to deploy the U.S. military against demonstrators. As The Washington Postreported in December, Trump campaign senior adviser Susie Wiles complained privately to Project 2025's director and asked the coalition to "stop promoting its work to reporters."
Seth Schuster, a spokesperson for President Joe Biden's reelection campaign, warned in a statement Monday that "if Donald Trump wins this November, he and Republicans will continue their push to end Medicare as we know it for millions of Americans."
"Trump will leave millions of seniors with fewer benefits and less access to doctors—all to benefit his big insurance donors," said Schuster. "In Trump's America, the special interests win and seniors and working families lose. Worse care, broken promises, and higher costs—that's Trump's plan for seniors and working families."
In addition to making Medicare Advantage the default enrollment option for Medicare, Project 2025 is calling for the revival of the Global and Professional Direct Contracting Model, a Medicare privatization scheme that the Biden administration rebranded as ACO REACH and slightly modified—to the dismay of physicians, healthcare campaigners, and progressive lawmakers who called for the repeal of the Trump-era pilot program.