In the television commercials, seniors can be seen playing tennis, golfing and riding motorcycles. In others, prominent senior pitchers — such as actor William Shatner, NFL star Joe Namath and former Republican Arkansas Gov. Mike Huckabee — will know they promise new benefits alongside images of government-issued IDs.
All of these are Medicare Advantage ads, and if Donald Trump wins the White House, Americans may see a lot more of them.
That’s because one of the Republicans’ only health policy specialties is to further privatize the program – to sell more plans that commercials like this promote.
“We groan when we see it [Medicare] Advantage as insurance,” said Dr. Karen Kinsell, the only doctor in Fort Gaines, Georgia, a rural community where more than a third of the population lives below the poverty line.
Medicare Advantage is private insurance funded by the federal government. It is a program approved in 1997 due to concerns about Medicare costs. Insurance companies promised cheaper rates with better benefits.
One of the most important differences for patients is the introduction of “networks” in Medicare Advantage plans, or a limited number of doctors and hospitals that a patient can see at a discounted rate. Traditional Medicare does not include networks – 98% of providers in the U.S. participate. However, traditional Medicare insurance comes with a monthly cost – most people pay a standard rate of $174.70.
Medicare Advantage plans can be tempting because they often include grocery or transportation cards, $0 monthly premiums, and hearing, vision, and dental benefits—none of which are included in traditional Medicare insurance.
Kinsell points out that problems usually start when people get sick.
“Patients were unable to get into or stay in rehab,” she said. Others were charged $50 a day for rehab, when the service is typically free for short periods in the traditional Medicare system.
“We have spent a lot of time in our district office with seniors who have been deceived by these corporate insurance policies,” said Democratic U.S. Representative Pramila Jayapal of Washington state. Jayapal has called for expanding Medicare Advantage to include “urgent reforms” and consumer protections.
“They adopted the name — so seniors actually think they’re signing up for Medicare,” she said.
Despite complaints from doctors and patients, fraud investigations, allegations that insurers used artificial intelligence models to deny care to seniors, and a mass of evidence that Medicare Advantage is costing taxpayers more, Republicans have continued to push the program. The most concrete health policy proposals are laid out in Project 2025, the Heritage Foundation’s conservative guide.
Amid a thicket of complaints about vaccine mandates and no fewer than 199 mentions of abortion, the document also proposes further privatization of Medicare through Medicare Advantage.
Medicare Advantage “offers beneficiaries a wide range of competitive health insurance options – a more comprehensive benefits package than traditional Medicare, at a reasonable cost,” argues Project 2025. Republicans should make it the default enrollment option and “eliminate burdensome policies that limit plans to the limit.” manage the smallest detail,” the document says.
The document also proposes “giving beneficiaries direct control over how they spend Medicare dollars,” which Democrats say describes a voucher program, something Republicans tried to push through in the Trump administration.
“That’s actually been the playbook for privatizing Medicare since these corporate Medicare deprivation plans, that’s what I call them, started,” Jayapal said. “It was her introduction.”
Like many of Donald Trump’s proposals, this is likely to cost the federal government a lot of money.
“The federal government is significantly overpaying for Medicare Advantage plans compared to what it spends on private individuals and traditional Medicare programs—without showing significant corresponding profits,” said David Lipschutz, co-director of the Center for Medicare Advocacy .
Studies show that Medicare Advantage plans will cost the federal government an estimated $83 billion more in 2024 than traditional Medicare plans without corresponding health care improvements, according to the congressionally mandated nonpartisan research agency the Medicare Payment Advisory Council. According to the left-leaning Center for American Progress, the cost of standard registration could rise to an additional $2 trillion over 10 years.
There is just as much at stake for private health insurers. One of the largest Medicare Advantage providers, United Healthcare, generated 46% of its $281 billion in total revenue from Medicare Advantage enrollees, even though they make up just 15% of the company’s beneficiaries, an analysis by Accountable.US found. The analysis was shared exclusively with the Guardian.
“The fact that this is becoming something that conservatives are trying to push as a universal model is alarming because it is just a way to increase insurance company profits,” said Tony Carrk, chief executive of Accountable.US.
The problems with the program are so acute that in 2022, eight of the 10 largest insurance companies that sold Medicare Advantage plans were defendants in federal fraud or whistleblower lawsuits.
“Part of the problem with including private health insurance in Medicare, or really any health care setting, is the promise that they could provide better care more efficiently,” Lipschutz said. “And neither happened.”
While yesterday’s Republican deficit hawks might balk at such costs, the proposal to further privatize Medicare is based on a long-held Republican philosophy that has outlasted Trumpism: Government is inherently untrustworthy and ordinary people need it a financial reason to do the right thing.
“The problem with the left is that they don’t think in economic terms,” said John Goodman, an economist who has advised nearly every Republican presidential candidate since George W. Bush on health care. He said he is currently working with the America First Policy Institute, a pro-Trump think tank.
Philosophically, Goodman believes Americans need “economic stimulus” to do the right thing.
For patients, for example diabetics, that could mean inexpensive insulin (a carrot) and the specter of a big bill if you don’t get your diabetes under control and end up in the hospital (a stick). Avoiding waste could mean for doctors to jump through bureaucratic hurdles to get approval for a procedure, known as “prior authorization.”
Critics argue that debates about “economic incentives” obscure the truly “catastrophic” health costs. Medicare Advantage plans will be allowed to require patients to spend up to $13,300 per year on out-of-network providers in 2024. According to the Commonwealth Fund, more than a third of all Medicare Advantage enrollees live on less than $10,000 a year. According to the National Council on Aging, nearly 95% of seniors have one chronic condition and more than 78% have two or more.
Although Trump has distanced himself from Project 2025, he is closely linked to its creators. The health care proposals were written by Roger Severino, his former director of the Office for Civil Rights at the Department of Health and Human Services.
In particular, Goodman considered Project 2025 to be a “bad document” whose many references to abortion would turn off voters. But he agrees with the Medicare proposals.
In the 2024 GOP platform, Trump promised “not to cut a penny from Medicare” but gave no further details. That’s consistent with the Project 2025 plan — which would require much more money to expand enrollment in Medicare Advantage.
For Goodman, there is at least some humor in this area of health care policy — the idea that the left would propose a health care system in which people don’t have to pay for health care.
“In fact, the Bernie Sanders guys don’t think economic stimulus should play any role in health care,” Goodman said.
