Another Ominous Default Swap: Medicare Advantage as the Default for Older Adults

The healthcare landscape for older adults is quietly undergoing a seismic shift. Medicare Advantage (MA), once an optional alternative to Original Medicare, will increasingly become the default choice for millions of elders. While marketed with enticing extras and promises of comprehensive care, a closer look reveals a system rife with financial incentives for insurers that come at the expense of patient care.

Extra Benefits: An Anemic Lure

One of the primary selling points of Medicare Advantage plans is the array of extra benefits not covered by Original Medicare, such as dental, vision, gym memberships, and even meal delivery services. These offerings sound appealing, especially to older adults on fixed incomes. However, the value of these extras is overstated.

For instance, dental benefits cover only basic cleanings and exams, leaving patients to pay out-of-pocket for more extensive care like crowns or root canals. Similarly, vision benefits might only include an annual eye exam and a small allowance for glasses, far from the comprehensive care many older people need. These benefits are marketing tools more than substantive healthcare improvements, luring elders into plans that limit access to necessary medical services.

AI and Algorithms: Reducing Care to Maximize Profits

Behind the scenes, Medicare Advantage plans increasingly rely on artificial intelligence and algorithms to manage care. These tools analyze patient data to predict healthcare needs and costs. While such technologies hold potential for improving efficiency, they also are used to minimize insurer expenses rather than enhance patient outcomes.

Algorithms flag patients as low-risk to justify denying or delaying care. For example, an elder flagged as “low priority” for a specialist referral might face weeks or months of delays, worsening his condition. This strategic use of technology prioritizes profit margins over patient well-being, subtly but effectively rationing care.

The Art of Risk Management: Deny and Delay

The risk management practices employed by Medicare Advantage plans have become an art form—an art that often leaves elders underserved. Insurers are incentivized to deny or delay expensive treatments to bolster their bottom lines. Even when patients meet all clinical criteria for a procedure or medication, they encounter roadblocks like prior authorization requirements or endless appeals processes.

These tactics disproportionately affect the most vulnerable elders, such as those with complex medical conditions. By denying or delaying care, insurers shift the financial burden onto patients and their families while ensuring that shareholders reap the benefits.

Locking Out Medigap: A Costly Loophole

For elders who opt out of Medicare Advantage and stick with Original Medicare, Medigap policies offer critical supplemental coverage to help with out-of-pocket costs. However, the availability of these policies is severely limited by a little-known loophole. Federal law guarantees elders the right to purchase a Medigap plan without medical underwriting only during the first six months after enrolling in Medicare Part B.

After this window closes, insurers in most states can deny coverage or charge exorbitant premiums based on pre-existing conditions. Only four states—Connecticut, Maine, Massachusetts, and New York—mandate guaranteed issue rights beyond this initial period. This leaves elders effectively locked out of affordable supplemental coverage, locking them into Medicare Advantage plans that may not meet their needs.

The Bigger Picture

The transformation of Medicare Advantage into the default option for elders is not happening by accident. It is the result of calculated policy shifts and marketing strategies designed to funnel seniors into plans that maximize insurer profits. While the system offers some benefits, it also raises significant concerns about equity, access, and the quality of care.

For policymakers and advocates, the challenge lies in pushing back against these trends. Strengthening regulations around Medicare Advantage, closing Medigap loopholes, and ensuring that AI and algorithms serve patients rather than profits are essential steps toward a more equitable healthcare system for America’s elders. I do not see that happening in 2025.

For beneficiaries, talk to an unbiased and competent person before locking into anything. Understanding the risks and benefits is crucial--before aging into Medicare and during the annual open enrollment period each year. Take time to evaluate options with a knowledgeable advisor to make informed decisions that align with personal healthcare needs and financial circumstances.

For everyone, be aware of the push toward this default swap in 2025. It is all part of Project 2025 and is the national agenda!