Troy Miller: We don't need more Medicare Advantage champions

Almost everyone has heard of “Medicare Advantage,” the program offering Medicare benefits administered by corporate health insurers. Maybe you’ve seen the endless stream of commercials with celebrities like Joe Namath, William Shatner or Jimmy Walker. Maybe a parent or grandparent has recently enrolled in one of the dozens of Medicare Advantage plans offered in West Virginia.

Or maybe you saw that Sen. Joe Manchin, D-W.Va., was recently hailed as a “Medicare Advantage Champion.”

West Virginians do not need senators who are champions of private health insurers. These insurers are profiting by overcharging the federal government for their services, while delaying and denying care to patients. West Virginians need heroes in the Senate who will hold private insurance accountable when they fleece Medicare and patients.

Then again, many people might not realize that Medicare Advantage programs are failing to meet the needs of people with costly and complex conditions, draining the Medicare Trust Fund, and driving up costs for everyone who pays into Medicare — especially current Medicare recipients.

A New York Times examination of Medicare Advantage reported that “eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud. The fifth company, CVS Health, which owns Aetna, told investors its practices were being investigated by the Department of Justice.”

Unfortunately, our government is currently expanding the role of for-profit insurers in Medicare, instead of holding them accountable. ACO REACH, a Trump-era health care experiment, is allowing insurers, private equity firms and other entities to control access to care for older and disabled Americans in traditional Medicare.

People might not even realize that the government is enrolling them in ACO REACH. If a patient is using a primary care provider who works for an entity participating in ACO REACH, the Centers for Medicare and Medicaid Services will enroll that patient into the ACO REACH experiment — without their consent.

People should receive a written notice of their enrollment, but the notice does not disclose that their physicians will have a powerful financial incentive to delay needed care and steer them to low-cost providers. ACO REACH entities can pay their primary care doctors more money when their patients receive less care.

People have a right to opt out. But, the only way they can opt out is if they change primary care physicians and jeopardize their continuity of care.

Insurers have long exploited Medicare Advantage at the expense of quality patient care, and the ACO REACH model is similar.

As with Medicare Advantage plans, the Centers for Medicare Service pays ACO REACH entities a flat, upfront amount to cover their enrollees’ medical and hospital care needs. As with Medicare Advantage, ACO REACH entities profit more the less money they spend on care. ACO REACH entities can keep up to 40% of the money the Centers for Service pays them that they don’t spend on care.

We know from two recent Health and Human Services Office of the Inspector General reports that Medicare Advantage plans can profit wildly by denying care. And because the Centers for Service does not have the tools or the resources to oversee them adequately and hold them accountable for their bad acts, they can profit wildly without so much as a slap on the wrist.

Older and disabled West Virginians need representatives in Congress who speak out against insurers and other entities that deny their members needed care, and ensure that they are held accountable for their bad acts.

In September, the West Virginia Democratic State Executive Committee passed a resolution urging President Joe Biden and Health and Human Services Secretary Xavier Becerra to protect patients who rely on Medicare by ending the ACO REACH experiment. If Manchin wants to be a real champion, he should stand with his constituents and fellow Democrats.