“It is the best choice for the individual and the best for society.”
Medicare’s open-enrollment period (Oct. 15-Dec. 7) is approaching fast. Seniors must decide whether to choose traditional Medicare ( the original, largely public version) or one of the more recent Medicare Advantage plans (the privatized, for-profit version).
I have carefully and thoroughly studied the differences between them. I would advise choosing traditional Medicare— as I have always done. To put it succinctly, the Medicare Advantage insurers have devised strategies to extract maximum profits from the system that harm everyone else.
The Medicare Advantage plans confine you to restrictive networks of care providers; traditional Medicare does not.
The networks limit choice, and they are unstable. All over the country, hospitals and medical practices are withdrawing from the networks. These facilities cite prior authorization requirements and disputes over payments. In Maine last year, Northern Light Health withdrew from Humana’s network, citing “delayed and denied payments for medically necessary care.”
As patients, we develop trusting relationships with our care providers. With Medicare Advantage, these relationships can be severed with little warning. Imagine how it would be if you had to start over with a new doctor or if you no longer had access to the nearest hospital.
Medicare Advantage also disadvantages care providers.
Unlike traditional Medicare (except in unusual circumstances), Medicare Advantage plans require prior authorization for many tests, medicines and procedures, placing an onerous burden on clinicians. Many practices must hire personnel who spend all their time dealing with prior authorization applications and appeals. We all end up paying for this inefficiency.
With Medicare Advantage, decisions about the care a patient may receive are made by insurance company employees, often with the assistance of artificial intelligence. In no way do these decisions resemble a qualified second opinion. They are an insult to the clinician, who, unlike the insurance company, knows their patient’s condition intimately and cares personally about their patient’s well-being. All of this contributes to the increasingly common burnout and moral injury suffered by the medical profession.
Of course, traditional Medicare does not cover everything and will deny certain claims. But everything is transparent and predictable. Doctors and patients know in advance what is covered and what isn’t, or they can easily find out. Thus, there is no delay in diagnosis and treatment, and the attendant risk to the patient is avoided. And there are no surprise bills with traditional Medicare.
There is also a fundamental conflict of interest. With commercial insurance, making profits and meeting patient needs will always be inversely related: you can enhance one only by diminishing the other.
If profit objectives are not being met this quarter, you boost profits simply by issuing more denials. And this happens frequently. Patients might be happy with their Medicare Advantage plans and realize savings in the short term when they are still healthy, but when they become seriously ill, they often discover that their insurance isn’t there when they need it most. Statistics and countless anecdotes attest to this.
Medicare Advantage also disadvantages the taxpayer.
A report last year by MedPAC, the Medicare Payment Advisory Commission — a nonpartisan government agency that advises Congress on Medicare payments — showed that Medicare spends an estimated 22% more for Medicare Advantage enrollees than it would spend if those beneficiaries were enrolled in traditional Medicare, a difference that translated into a projected $83 billion in 2024.
Where does that $83 billion go? A small part goes to additional benefits like hearing aids, eyeglasses and basic dental care, but most is wasted on bureaucratic overhead and company profits.
The insurance company is a costly and unnecessary middleman.
It is far more efficient for the government to pay providers directly, and — as providers can appreciate — the U.S. government is one of the most reliable payers in the world.
The Medicare Advantage insurers, of course, do everything they can think of to maximize the payments they receive from the government/taxpayer. One device they employ is upcoding — the recording of spurious diagnoses to make a patient look sicker than they really are, thereby increasing the patient’s risk score and the payment the plan receives. Patients become unwitting accomplices to a fraud.
There are other devious practices, and we all pay the salaries of those employed to invent them and administer them. We should not tolerate this.
I would recommend that seniors think long term, ignore the enticing and misleading ads for the Medicare Advantage plans — which we all pay for — and enroll instead in traditional Medicare. It is the best choice for the individual and the best for society.
By Michael Bacon, Westbrook, Maine
A similar version of this essay appeared in the Op-Ed section of the Portland Press Herald on September 24, 2025