I receive emails from a senior citizen’s organization urging me to sign a petition to protect Medicare Advantage (MA) nonmedical benefits. After reading and deleting the first one, I ignored subsequent ones for two reasons.
First, since CMS, the federal agency that administers Medicare, allowed private insurers to provide these benefits, their cost grew by over 800 percent. CMS intended these benefits to improve elder health, but this was not codified, and the companies used them for marketing. In 2025, CMS decided to determine which benefits were used and to what extent, to eliminate those with little or no use. This consideration prompted the petition, likely encouraged by the insurers.
Second, CMS unwisely structured the benefits’ budget so that whatever was not spent could be kept as profit, possibly from insurer influence. This encouraged providers to limit benefit promotion to members and make requesting them difficult, resulting in low overall use. CMS has encouraged insurers to increase advertising and simplify the application process, but have they done so?
In August, I attended a presentation on what seniors wanted from Medicare. Unsurprisingly, they desired many services and low costs. These were the goals of British citizens for the National Health Service (NHS) at its inception and presently. Today, the NHS absorbs about 40 percent of the national budget; despite service reductions, individuals have to purchase private health insurance for additional care. Other NHS nations have the same difficulties. Presently, health care consumes about 18 to 20 percent of our national budget, and we are already experiencing service reductions.
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A major plank in the 2024 Democratic platform was a promise to improve health care, but what they meant was to increase Medicare enrollment. Many midterm Democratic candidates are using the same plank. However, adding people to a dysfunctional system will only hasten its collapse, decreasing availability and quality for everyone. Some experts predict that without major change, our health care system could collapse in a decade. Adding members, with no other change, will cause failure sooner.
The dysfunction has been developing for decades. Those with the power to correct it have done nothing, as the present system is too profitable for its for-profit participants. State and federal legislators are lobbied extensively to maintain the status quo and personally benefit as well. They make minor, often cosmetic changes that accomplish nothing and do not affect any business’s profits.
Beyond lobbying, MA providers use other profit-increasing strategies, some of which cross legal or ethical lines. At worst, if they are caught, they receive a fine and a rebuke, as they are too influential for more serious consequences.
One tactic is their misuse of prior authorizations (PAs). These have made headlines of late because of notable care denials. Their original intent was to reduce overused, unnecessary, and/or low-value tests and procedures. The MA companies used them to deny care and increase profits.
Another tactic is upcoding, in which the insurance company categorizes a condition’s seriousness as greater than it really is to increase their government subsidy. Alternatively, they add minor, noncontributory diagnoses, like toenail fungus, to a patient’s list of conditions, as more diagnoses increase a patient’s complexity for the same purpose.
There are also administrative costs. Does it really cost private insurers six to seven times more than CMS to administer Medicare? My favorite is their constant whining to the government that they need a funding increase, or they will have to withdraw from the MA market as unprofitable. Nonetheless, almost quarterly, they announce profits greater than expected.
Virtually every facet of health care is becoming corporatized by entities whose primary interest is revenue, not patient care. Studies of different areas of health care, from hospitals to physician practices to nursing homes, have all demonstrated that once a facility or service becomes for-profit, prices increase and quality decreases; staff is reduced, lower-quality and less expensive supplies are used, and other “economies” are employed.
As structured, our health care system is very vulnerable to fraud, and many people and corporations take advantage of this. Inspection and control are difficult, but with increasing computer use, patterns should be more easily detected. The British NHS recoups hundreds of millions of pounds yearly, which is about 50 percent of its annual fraud loss, and I expect that we recover even less.
Even some nonprofit hospitals act like for-profits. Traditionally, any excess funds these organizations make are used for charity care, facility upgrades, or service expansion. Lately, some nonprofits, at least, have been secreting tens of millions of dollars offshore in countries that do not disclose information to our government.
Increased coverage is necessary, but without major system reform it will be worthless. Most likely, we will continue to administer care through for-profit companies. However, stricter regulations and oversight are necessary to ensure that quality, equity, and availability of care are prioritized, not revenue. We should consider health care a quasi-public utility and the companies that administer it as semi-governmental agencies whose rates and profits are controlled. The companies and their shareholders will oppose reform, but change is required for public benefit. We can learn from the errors made by NHS systems so that we can avoid them, although inevitably we will face the same benefits/cost dilemma they do, as money is finite. I am pessimistic that we will take any positive steps until the system collapses and years of chaos ensue, and that even then we will proceed slowly rather than take the necessary radical action.
M. Bennet Broner is a medical ethicist.
