Medicare Advantage Keeps Gaming The System, New Data Reveals
Artwork by medicareresources.org
Over the years, we’ve have talked a lot about the disadvantages of Medicare Advantage (MA). These plans — which have become a gold mine for profit-oriented insurers and their Wall Street backers — cover over half of Medicare beneficiaries, and are sold as a cheaper alternative to traditional Medicare. New reporting confirms that these private plans are bleeding taxpayers for billions of dollars more than traditional Medicare would cost for comparable enrollees.
Fresh reporting by MedPage — drawing from data provided by the Medicare Payment Advisory Commission (MedPAC) — highlights MA’s broken promises.
Despite reforms like the V28 risk adjustment model, MA payments still will exceed traditional Medicare by 14% per enrollee this year. Of the projected $76 billion overage, $22 billion stems directly from “upcoding” – where insurers exaggerate patients’ diagnoses in order to reap higher payments from the government.
Medicare Advantage insurers have been cited for exaggerating patients’ diagnoses & denying care
Our policy team sounded the alarm on these abuses in a March 2024 comment letter, in which NCPSSM President Max Richtman called out insurers’ nefarious practices. The letter demanded better oversight by the Center for Medicare and Medicaid Services (now led by Trump-appointee Dr. Mehmet Oz). Richtman urged the agency to take action to protect Medicare’s integrity, such as tougher coding standards and a ban on ‘abusive health risk assessments.’
“Systematic upcoding reduces the accuracy of MA payments by making the enrollee population appear sicker and costlier.” – Max Richtman, President and CEO, NCPSSM
The upcoding has become so egregious that even some Republicans have started to scrutinize major insurers. Last year, staffers for Iowa Republican Senator Chuck Grassley (who appears in our new Social Security documentary) were granted access to over 50,000 pages of United Health Care (UHC) documents. Their findings — which were released earlier this month — exposed UHC’s commitment to what Senator Grassley called “gaming the system and abusing the risk adjustment process to turn a steep profit.”
While United Health Care has emerged as the worst offender, it’s abundantly clear that many MA insurers are engaged in these shady practices. Look no further than insurers’ reliance on prior authorizations for procedures and treatments that normally would be automatically covered in traditional Medicare. This includes denying skilled nursing care that jeopardizes older patients who have nowhere else to turn.
Sen. Chuck Grassley (R-IA) accused Medicare Advantage insurers of “gaming the system.”
Patients can appeal non-coverage rulings from the prior authorization process. Appeals are triggered when patients receive Notices of Medicare Non-Coverage (NOMNC), effectively denying them care. It was reported that one patient received 12 non-coverage notices — even after winning previous appeals.
Last week, Acentra Health exposed how the prior authorization process specifically targets seniors receiving skilled nursing care. After combing through 25,000 appeals, Acentra found that 83% of coverage denials involved skilled nursing care patients. Of those, a staggering 93% related to Medicare Advantage patients, despite that group representing roughly half of the Medicare market. While it’s long overdue that the federal government crack down on these abuses by MA insurers, it’s also important to remember that seniors can avoid denials of care (and other MA-related headaches) by enrolling in traditional Medicare instead.
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Read our comment letter from 2024 here
Read more about the disadvantages of Medicare Advantage here
Listen to our podcast here.
Trump & Musk Created a Culture Where Social Security Data Could be Abused
AP/Getty Images
New reporting that DOGE abused Americans’ private Social Security data should come as no surprise. We have warned from the beginning that DOGE had no business accessing this data and that no good could come of it. Last June, the Supreme Court overturned a lower court order that barred DOGE from accessing Americans’ Social Security data. This gave DOGE carte blanche to misuse Americans’ personal information that it never should have had in the first place.
Now, the Trump administration is attempting to single-out and scapegoat two DOGE staffers because of the latest breach. No doubt, any DOGE employees who misused Americans’ personal Social Security data (in this case, reportedly by promising to share it with a third-party in order to ‘overturn election results’) should be held accountable for their actions. But this reported malfeasance was enabled by a culture created by the Trump Administration, Elon Musk, and DOGE soon after the president took office — a culture of recklessly interfering in the legitimate functions of the federal government with questionable intent and zero accountability.
ProPublica
DOGE’s supposed mission, as directed by the White House, was to root out alleged ‘fraud’ at the Social Security Administration. It found no significant fraud but hobbled SSA’s ability to serve the 70 million people who rely on Social Security — by slashing the workforce and erecting new hurdles for beneficiaries simply trying to access their earned benefits.
“The reported abuses of Social Security data are part of this relentless attack on the functioning of the Social Security Administration, under the phony cover of hunting for ‘waste, fraud, and abuse’ at what was among the most efficient federal agencies,” says NCPSSM president and CEO Max Richtman.
This week’s reports of DOGE malfeasance are not isolated. In August, DOGE team members were found to have uploaded the personal information of hundreds of millions of Americans to a ‘vulnerable cloud server’ without any credible explanation.
The disclosure mirrors what Chuck Borges, the former chief data officer at the SSA, said in his whistleblower complaint, warning that the private data of more than 300 million Americans was at risk after DOGE employees uploaded a copy of the Social Security Administration’s database to a cloud environment. – MarketWatch, 1/21/26
“We stand with Congressmen John Larson (D-CT) and Richard Neal (D-MA) in demanding ‘a full criminal investigation into DOGE leaks of private Social Security data to Elon Musk’s associates and immediate congressional action to safeguard Americans’ privacy,'” says Richtman.
Elon Musk recently donated $10M to Kentucky GOP Senate candidate & Trump supporter Nate Morris (AP/Mark Humphrey)
“If people can’t trust Social Security to keep their privacy inviolate, confidence in the entire program may well be shattered,” writes L.A. Times columnist Michael Hiltzik. “Sadly, that would be consistent with conservatives’ long war against this most popular and important government program, but maybe that’s what Trump has wanted all along.”
It is probably not coincidental that the two DOGE staffers reportedly promised to share Social Security data with an unnamed political advocacy group, ostensibly to challenge election results. Their ultimate boss, Donald Trump, is still peddling the lie that he won the 2020 elections; their former boss and ex-leader of DOGE, Elon Musk, just donated a whopping $10 million to the campaign of a Trump-supporting Senate candidate in Kentucky, who was endorsed by the late Charlie Kirk last year. (Musk, the world’s richest man, was the biggest donor in the 2024 election cycle — spending $300 million, mostly on behalf of Trump.)
The Social Security Administration claims to have had no knowledge of the data abuse by DOGE employees. The Department of Justice refuses to investigate DOGE, only the two employees in question. Meanwhile, anyone with a Social Security number has reason to be alarmed that their data has been leveraged by the unholy convergence of DOGE’s phony efficiency campaign and the radical political agenda of Trump and Musk.
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Listen to our podcast interview with former Social Security Commissioner Martin O’Malley on the Trump administration’s devastating actions at the Social Security Administration.
Conservatives Won’t Stop Dividing the Generations over Social Security, Medicare
Americans of all ages face a crushing affordability crisis. Rather than blame the billionaire class and their political servants – or wealth inequality in general – conservatives have continued trying to pit the generations against each other.
Look no further than this week’s misleading op-ed in the Los Angeles Times,The Financial Engine Behind Millennial and Gen Z Malaise. This is only the latest in a gaggle of mainstream media pieces blaming younger adults’ economic struggles on older people – otherwise known as the “greedy geezer” myth.
These screeds barely ever mention that the rising cost of college tuition, mounting student debt, and unaffordable housing could be mitigated by more progressive federal policies that favor everyday people instead of financial elites. See: almost every other Western-style democracy. Instead, it’s all supposedly older people’s fault.
“Medicare programs are paying for golf balls, greens fees, social club memberships, horseback riding lessons, and pet food,” writes columnist Veronique de Rugy of the right-leaning Mercatus Center at George Mason University.
In reality, Medicare covers medically necessary services like doctor visits, hospital stays, and preventive care… not luxury goods. Far from living in luxury, most seniors are reliant on Social Security to cover some or all of their living expenses. In fact, without Social Security, some 40% of seniors would fall into poverty!
Conservative think tanks are trying awfully hard to divide the generations
The Mercatus-authored piece also mirrors Koch-funded groups like the American Enterprise Institute (AEI) by claiming that retirees are receiving “37% more in Social Security benefits than they paid in (payroll) taxes.”
This statement completely ignores the true nature of Social Security. It was never designed to be an investment program or to generate profits for contributors, nor was it designed to pay out only as much as a worker contributed.
“Social Security is social insurance and like any insurance program, it spreads risk among those who contribute. If you have home insurance, you don’t expect to get your premiums back if your house doesn’t burn down, but you do expect to collect much more than you contributed if disaster strikes.” – Maria Freese, NCPSSM senior Social Security policy expert
With Social Security, you contribute during your working years so you have a source of income if you become disabled, your family is protected if you die, and you can maintain some level of standard of living if you are fortunate enough to enjoy a long life. Once you qualify for benefits, they last as long as you live – benefits don’t stop at an arbitrary number tied to your contributions.
What’s more, Social Security benefits are progressively structured — meaning lower-income seniors receive higher proportional benefits than their wealthier counterparts.
Meanwhile, the op-ed makes the claim that Social Security is the “biggest driver of our government debt.” This is another conservative trope. Social Security is self-funded and does not contribute to debt. (The program also is legally barred from borrowing money.) As conservative hero Ronald Reagan himself said, “Social Security has nothing to do with the deficit.”
President Reagan acknowledged that Social Security does not contribute to the federal debt
In fact, the biggest driver of federal debt is ‘tax expenditures’ — windfalls for the wealthy like the Trump/GOP tax cuts, which added some $3 trillion in red ink. Conservatives don’t seem to mind debt if it’s driven by tax breaks for the rich.
The L.A. Times piece also misleads readers with a “gotcha,” using the basic economic reality that Americans generally are worth more at the end of their lives than they are at the beginning or middle:
“American heads of households younger than 35 now have a median net worth of about $39,000 and an average net worth of more than $183,000`. Those over age 75 have a median net worth of roughly $335,000 and an average net worth exceeding $1.6 million.” – Veronique de Rugy, L.A. Times
Typically, Americans have built up wealth over their lifetimes as they save for retirement or pay off their home mortgages. And until recently, each generation tended to be wealthier than the ones before it. However, thanks to regressive economic policies, that trend has now been reversed.
Conservative narratives seem designed to pave the way for benefit cuts and privatization of Social Security. Although the Times op-ed does not explicitly mention means testing Social Security and Medicare – which would fundamentally alter these programs – the author strongly hints at it:
“Treating every elderly person, no matter how well-off, as a member of a protected class entitled to increasingly unaffordable benefits will eventually destroy a system that progressives in particular cherish.” – Veronique de Rugy, L.A. Times
These social insurance programs are earned benefits based (in part) on lifetime payroll contributions. They are not a ‘handout’ to seniors, people with disabilities, or their families. Implementing means-testing breaks this decades-long compact with workers, and would disproportionately target modest earners making $50,000-$70,000 annually.
This is all part of a broader, well-funded effort to turn generations against each other and soften the ground for degrading Social Security and Medicare. Framing seniors as “greedy geezers” living large on “boomer luxury communism” is designed to distract from the real culprits behind our affordability crisis.
GOP Senators Face Key Test on Health Care Affordability
Sen. Bernie Moreno (R-OH) is one of the bipartisan ‘gang’ of Senators working on an ACA tax credit compromise
Last week, the House of Representatives took a bold step towards averting huge increases in Americans’ health care premiums, passing a bill that would extend the Affordable Care Act (ACA) tax credits for three years. The measure succeeded thanks to YES votes from all House Democrats and 17 House Republicans, who openly defied GOP Speaker Mike Johnson.
In a press statement, NCPSSM Max Richtman applauded the House vote:::
“Kudos to members of the U.S. House for bucking Republican leadership and voting to extend crucial ACA tax credits… The House legislation would especially bring relief to older Americans, who are not yet eligible for Medicare and are subject to higher premiums than younger people.” – Max Richtman, President and CEO, National Committee to Preserve Social Security & Medicare
The legislation now heads to the Senate. Republican Senate Majority Leader John Thune has positioned the House bill to be “dead on arrival,” but signaled openness to a compromise under certain strictures. (Let’s not forget that Senate Republicans killed ACA tax credits once already.) Meanwhile, President Trump has indicated that he will veto any “clean extension” that comes to his desk.
Anne Montgomery, Senior Health Policy Expert with NCPSSM, explained that ACA subsidies are indispensable for millions of Americans, especially older ones who are not yet eligible for Medicare (aka “near seniors.”) Without the extended tax credits, many near seniors will be priced out of the ACA marketplace entirely.
“Taking away these tax credits essentially shuts people out of coverage at older ages. In less healthy (often red) states, premiums without extended tax credits could be 10 to 20 times higher,” said Montgomery.
A bi-partisan ‘gang’ of senators reportedly is working on a compromise bill that may offer a two-year extension of ACA tax credits, with new income caps and other restrictions.
Some Republicans continue to push their preferred alternative, enhanced Health Savings Accounts (HSAs). Republican Senators Cassidy (LA) and Crapo (ID) have led the charge with legislation that would put HSAs at the forefront, and replace ACA subsidies with block grants to states. The plan would unravel the ACA’s affordability framework and allow insurers to charge older adults even more than they already do.
“The Cassidy–Crapo bill walks away from what the ACA set out to do and the financial help people need for affordable coverage. Democrats will have to decide whether that compromise is good policy or, frankly, a piece of junk.” – Anne Montgomery, Senior Health Policy Expert, National Committee to Preserve Social Security & Medicare
Montgomery says that the benefit of simply enhancing HSA accounts would be minimal compared to extending the ACA tax credits. However, she says NCPSSM would support a balanced agreement that modestly expands the use of HSAs, as long as it preserves the integrity of the Affordable Care Act exchanges, the tax credit structure, and the principle of affordability for older adults.
Older adults who are not yet eligible for Medicare may not be able to afford ACA premiums if Congress doesn’t act immediately
“There’s a big difference between allowing for more HSA products – and dismantling the Affordable Care Act exchange system,” noted Montgomery.
Time is critical now. Many ACA enrollees already have received notices of significantly higher premiums for the new year. Any reasonable legislation at this point would have to re-open the ACA enrollment period to allow people to sign up for plans with affordable premiums.
NCPSSM President Richtman warns lawmakers not to let the ACA tax credits expire, thrusting millions of Americans into a health care affordability crisis. He says that Republicans’ failure to cooperate will come back to haunt them in November’s mid-terms.
“We will help remind voters who had the backs of Americans struggling to keep up with soaring health care premiums — and who didn’t,” said Richtman.
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Read the Senate Finance Committee Democrats’ takedown of HSAs here.
Listen to our podcast with Florida Rep. Debbie Wasserman Schultz on ACA tax credits & Trump Medicaid cuts here.
Trump & DOGE Wreaked Havoc at SSA, New Reporting Confirms
As the year ends, new reporting confirms that customer service at the Social Security Administration (SSA) has tanked since Trump took office last January – despite the administration’s claims to the contrary. A new investigative report by the Washington Post — based on a thorough analysis of agency data and interviews — reveals that “long-strained customer services have become worse by many key measures.”
Commissioner Frank Bisignano has issued glowing — but bogus — reports touting ‘improvements’ at SSA, but basic common sense says that the scorched-earth tactics the agency implemented after Trump & DOGE took over could only have degraded service.
“Thousands of employees were fired or quit and hasty policy changes and reassignments left inexperienced staff to handle the aftermath,” write Post correspondents Lisa Rein, Meryl Kornfield, and Hannah Natanson. (SSA slashed its workforce at a time when staffing already was at a 50-year low, with 10,000 baby boomers hitting age 65 every day.)
Demonstrators in Baltimore protest DOGE interference at Social Security Administration (AP Photo)
Elon Musk and DOGE swept into SSA last winter, seizing Americans’ personal Social Security data and disrupting agency operations as part of a phony hunt for ‘fraud.’ (Never mind that actual Social Security fraud is statistically quite low.) Musk and Trump’s claims that 150 year-olds somehow collect benefits were part of this charade.
The 73 million people who depend on Social Security have paid the price. “Exaggerated claims of fraud have led to new roadblocks for elderly beneficiaries, disabled people and legal immigrants, who are now required to complete some transactions in person or online rather than by phone.”
Meanwhile, a New York Times report published just before Christmas revealed that DOGE’s crusade to cut government “waste, fraud, and abuse” was a sham.
“The group did not do what Mr. Musk said it would: reduce federal spending by $1 trillion before October. On DOGE’s watch, federal spending did not go down at all. It went up,” according to the Times report.
Musk quit DOGE last summer but left a toxic legacy
DOGE’s assault on the Social Security Administration exposed that the true goal was not to fight waste, but to dismantle crucial functions of the federal government that oligarchs like Trump and Musk find bothersome, such as a social safety net.
As Government Exec reported in September, Musk’s DOGE brats were “a bunch of people who didn’t know what they were doing, with ideas of how government should run — thinking it should work like a McDonald’s or a bank — screaming all the time.”
“The shock troops of DOGE were the advance guard in perhaps the most dramatic transformation of the U.S. government since the New Deal. And despite the highly public departure of DOGE’s leader, Elon Musk, that campaign continues today.” – Government Exec, 9/8/25
After Musk returned to the private sector last summer, subsequent news reports indicated that DOGE may have finally ceased operations. But soon after, Forbes reported that rumors of DOGE’s death may have been exaggerated. “DOGE isn’t dead—it’s been absorbed into the bloodstream of the government, federal employees say.”
Seniors and advocates can take heart that public pressure forced SSA and DOGE to walk back some of their more egregious proposals, but Trump’s campaign to destroy the workings of the federal government continues — with grave implications not only for the Social Security Administration, but for the Medicare and Medicaid programs as well. If recent reporting proves anything, it’s that the fight against Trump’s effort to rend the social safety net will continue into 2026.
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Listen to our podcast interview with former Social Security Commissioner Martin O’Malley here.
Listen to our podcast interview with SSA whistleblower Laura Haltzel here.
Watch our documentary about the history of Social Security here.