“It’s nothing,” Tom, a retired firefighter from rural Texas, thought when he had persistent stomach pain.
After shedding 30 pounds in three weeks, his family physician ordered a CT scan. Tom was not concerned — after all, the 65-year-old had gotten Medicare Advantage earlier that year.
Like millions, Tom switched his insurance after he was solicited by a broker who promised low premiums and a gift card. Absent from the sales pitch was the fact that Medicare Advantage plans — privately run and separate from government-funded traditional Medicare — often delay and deny coverage.
One of us met Tom nearly three months after his CT scan, and his doctor discovered the abdominal mass. The job as the first oncologist he had been able to see after months of jumping through hoops was to get initial scans, identify an in-network provider, wait for further referral and approval processes and finally schedule and complete a biopsy.
The delays became a death knell. Tom was diagnosed with Stage 3 pancreatic cancer.
Tom’s first question was, “It’s going to be fine, right?”
Despite the urge to reassure him, Tom’s life and treatment options were not up to a doctor. They were up to his insurance. The same insurance that delayed urgent testing and care.
By definition, Medicare Advantage is meant to support elderly medical care and increase efficiencies; in function, it is a business model that allows the American government to decrease its liability for sick seniors.
Instead of absorbing and managing costs, the responsibility is outsourced to third-party operators, such as UnitedHealth Group, Humana and CVS Health.
While Medicare Advantage provides excellent coverage if you never get sick, this insurance can quickly become a precursor to medical bankruptcy if the patient develops a deadly disease, a highly probable outcome when you consider that nearly 40 percent of Americans get cancer in their lifetime.
After nearly two decades of experimentation and $450 billion of taxpayer money, Medicare Advantage has proven porous in terms of corruption, fraud and abuse. Yet, 32.8 million elderly Americans (54 percent of the eligible Medicare population) are currently enrolled in Medicare Advantage.
In 2023 alone, Medicare Advantage plans fully or partially denied 3.2 million prior authorization requests.
No one, especially among folks facing the daily drudgery of fighting cancer, truly understands how the cogs within the insurance machine work. Few of our elderly patients fight the goliath institution, and many succumb to poorer health outcomes in their quest for lifesaving treatment.
Last year, countrywide and across disease groups, 79 percent of patients who experienced a delay or denial of coverage paid out of pocket for medication at least sometimes. Unsurprisingly, more than 100 million Americans are in medical debt.
Of those who appealed between 2019 and 2023, over 80 percent were approved, implying that the initial claims were valid. This game of attrition directly contradicts Medicare Advantage’s promise to provide efficient, patient-centered healthcare.
These denials are not just medically dangerous because they enable deadly diseases to progress unchecked. They are also emotionally erosive.
Daily, we see patients shrink in the face of denials, unable to emotionally navigate the complex Medicare system and the immense pain, isolation and depression resulting from this behemoth that stands between their disease and their hope to be free of it.
During one of Tom’s chemo visits, with thousands of dollars worth of IVs in his veins, his skin pale and translucent, he realized he was begging his insurance at every turn to support him.
Stories like Tom’s reveal the truth: Medicare Advantage is unapologetically failing its elderly cancer patients. Sick American seniors deserve more than insurance coverage in name only.
We advise our patients to avoid Medicare Advantage. The better choice is traditional Medicare, plus a secondary or supplemental insurance.
Often, people do not enroll in supplemental insurance because they do not understand its importance, believe they will never get sick, miss the deadline for approval without a medical exam (you must do this within three months before or after your 65th birthday), or think it is too expensive.
Although supplemental insurance costs nearly $500 a month (exact amounts vary based on age and income), choosing this add-on — and paying roughly $6,000 a year — is much more affordable than Medicare Advantage’s yearly out-of-pocket (potentially adding up to $8,500) and fighting for approvals for basic treatment.
On Medicare Advantage, Tom quickly reached his maximum yearly out-of-pocket of $8,500, but then it reset on Jan. 1. After four months of treatment, he was responsible for paying $17,000 for 16 months of care, on top of his insurance premiums, simply to receive standard care.
Of course, if you are one of the fortunate few to have never experienced illness — and we hope you are — Medicare Advantage can be a cheaper option. The question is, how can we make Medicare Advantage advantageous for the vulnerable?
There is a bipartisan opportunity to change the narrative around this insurance model. During his confirmation hearing as the head of the Centers for Medicare and Medicaid Services, Mehmet Oz criticized Medicare Advantage insurers for some of their practices.
Strategic change — omitting out-of-pocket costs for cancer patients, curbing insurance companies’ rights to deny claims submitted by doctors and speeding up the process — along with more rigorous oversight of the program are worthwhile goals the Trump administration and Congress should take on.
While Democrats and Republicans disagree on many issues, we believe we can all agree that people like Tom — and the millions of other Americans enrolled in Medicare Advantage — deserve comprehensive and just care.
Dr. Pramod Pinnamaneni, MD, MBA, and Dr. Nitya Thummalachetty, DrPH, are founders of the Nau Project, a start-up dedicated to helping everyday Americans navigate the complexities of our healthcare system.
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