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Bankrupt Healthcare
Medicare Enrollees Routinely Denied Coverage

Just because you have Medicare, it doesn’t mean your insurer will cover your health services. About 16 million people are covered by private Medicare Advantage plans (30 percent of Medicare enrollees), and another 23 million people participate in Medicare prescription drug plans. New federal audits of the insurers who cover both of those groups have found that insurance companies routinely disregard the rules that are supposed to guarantee that the program’s enrollees get an adequate coverage. Here are some of the key points, according a NYT report on the audits:

• In more than half of all audits, “beneficiaries and providers did not receive an adequate or accurate rationale for the denial” of coverage when insurers refused to provide or pay for care.

• When making decisions, insurers often failed to consider clinical information provided by doctors and failed to inform patients of their appeal rights.

• In 61 percent of audits, insurers “inappropriately rejected claims” for prescription drugs. Insurers enforced “unapproved quantity limits” and required patients to get permission before filling prescriptions when such “prior authorization” was not allowed.

• Medicare plans frequently missed deadlines for making decisions about coverage of medical care, drugs and devices requested by doctors and patients.

These findings come fast on the heels of a Department of Health and Human Services report on that other government health care program, Medicaid. The HHS report found that Medicaid enrollees often have trouble accessing health services despite being “insured,” and are often forced to wait months or travel long distances to get the care they need. Now these new audits suggest that Medicare recipients face massive obstacles of their own in translating government aid into actual access. Both Medicaid and Medicare, then, extend access in name to poorer or older Americans, while providers, insurers, and other actors in the health care system find ways to ration care in practice.

Those who praise these programs should re-examine how they work on the ground level, where many are excluded from care despite being “covered.” The left would presumably conclude that these failures are just budgetary, and we could pour more money into these otherwise promising programs, everything would be swell. But this is just tinkering around the edges of an outdated health system. Rationing care will always be a part of health care. It can be more or less severe depending on how much it costs to provide care. If politicians and health policy makers make health care cheaper, rationing—whether through prices in the private health care market or through government programs for those enrolled in them—will be more bearable.

There are already many promising ideas out there for making care more affordable, and we could no doubt find many others if we devoted the same attention to that problem as we do to debating various changes to Medicaid and Medicare’s payment and coverage systems.

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  • rheddles

    If politicians and health policy makers make health care cheaper

    And if pigs fly…

    Get real. Government doesn’t make anything cheaper. Competition and free markets make things cheaper. The more government gets out of interfering with a market, the cheaper transactions become. The more the government interferes, the more inefficient the market becomes.

    Rationing healthcare is not bearable if you’re the one rationed out.That’s why people work harder, to avoid being rationed out of as many transactions as possible.

  • Boritz

    “Insurers enforced “unapproved quantity limits” and required patients to
    get permission before filling prescriptions when such “prior
    authorization” was not allowed.”

    The Justice Department should jump on selective enforcement by insurers.

  • Andrew Allison

    It would be really useful if TAI would get it’s facts right when pontificating about health insurance in general and Medicare in particular. The problems described are, guess what, with the PRIVATEe insurance companies which provide Medicare Parts C and D insurance whose only interest is in profit. These problems are, in fact an argument for single-payer insurance. In order to prevent knee-jerks, let me emphasize that we’re talking about insurance, not the delivery of health care.

  • lhfry

    Angies List had an article a few months ago about the difficulty of finding a gp who will take a new Medicare patient. If you move from one part of the country to another, this can be a problem. The only provider that we would care to visit in rural Virginia that would take a new MC patient is an urgent care center. As Medicare squeezes payments, this situation will get worse. Medicaid recipients also face this problem.

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