Something still haunts Ed Weisbart, MD, from his days in the health insurance business.
It was 1999, and Weisbart was the medical director of a Chicago medical group that managed care for more than 140,000 people. The enterprise was running like a well-oiled machine — until one day, a man presented with a rare blood clotting disorder that would cost the company $1 million a year to treat. At that sum, one of its regional offices would likely go out of business.
Weisbart caught himself entertaining dark thoughts. What if the company just gave this guy the cold shoulder? Could they simply not answer his calls? These were "paper records days," he said — in theory, the company could lose his medical records. If he showed up at the office to meet with anybody, maybe they could make him wait an hour or two.
"And then, what? He would complain to us, and say this used to be a good office, and it's not anymore – I'm going to go somewhere else," Weisbart said. "And I would be thinking, I won."
Weisbart never acted on any of these impulses, he said, nor did he tell anybody about those thoughts until years later. The office didn't go out of business, either, and the man received his treatments. But the temptation toward corruption left a deep impact.
"It's haunted me ever since," Weisbart said. "I consider myself a generally ethical patient advocate, and yet, I was so corrupted by the finances of the system that I was actually developing schemes to make a very sick person not want to get health care with us. And isn't the point of a health care system that you should want to get health care?"
Today, Weisbart is the national secretary for Physicians for a National Health Plan (PNHP), an advocacy group representing more than 25,000 physicians who support a national health insurance plan and oppose a profit-driven health insurance system in which companies can choose profits over patients. That system's interests are at the heart of a stunning Medicare proposal in Project 2025, the Heritage Foundation’s 900-page right-wing agenda for a second Trump administration that experts say would harm patients while enabling insurance companies to funnel billions of dollars in desperately needed funds from the Medicare program.
"It's kind of shocking, when it comes to how irresponsible it is," Andrea Ducas, vice president of health policy at the Center for American Progress, told Salon of Project’s 2025 proposed change to Medicare. "It's emblematic of a desire to, essentially, increase corporate power."
Project 2025 proposes making Medicare Advantage, as opposed to traditional Medicare, the default plan for all enrollees. Medicare Advantage has been around for decades; it was signed into law in 1997 as part of a bipartisan reform bill to balance the federal budget. Under Medicare Advantage, insurance companies offer plans that cover Medicare benefits. In turn, Medicare pays the insurance companies based on an estimate of an individual's annual health care costs.
In theory, the Medicare Advantage program was supposed to help the government benefit from the private sector's efficiencies. In practice, many insurers overcharge the federal government hundreds of billions of dollars in inflated estimates, often by adding diagnosis codes that make individuals appear sicker on paper than they are in reality. MedPac, a nonpartisan Congressional advisory committee, estimates that in 2024, inflated estimates will translate to $50 billion in overpayments. An analysis from PNHP, published in 2023, estimates that Medicare overpays insurers by as much as $140 billion per year.
In one analysis of Medicare Advantage data, The Wall Street Journal found that between 2019 and 2021, individuals enrolled in Medicare Advantage through UnitedHealth were roughly 15 times as likely to be diagnosed with diabetic cataracts than traditional Medicare beneficiaries. Payments to insurers for diabetic cataracts totaled $700 million in that period; most diagnoses were added by the insurers.
"The plans will get more for people who are more sick, so there's significant incentive for the plans to make their enrollee population appear as sick as possible," David Lipschutz, co-director of the Center for Medicare Advocacy, told Salon.
According to an analysis from Lever, an investigative newsroom, the private insurance giant Humana — one of the largest providers of Medicare Advantage plans — recorded $2.8 billion in profits in 2022. Without federal government overpayments into Medicare Advantage plans, though, Humana may have lost nearly $900 million that year.
"We overpay them to kill people"
Outside those abuses, Medicare Advantage doesn't offer a better patient experience. In many instances, it can be worse.
Medicare Advantage beneficiaries are often limited to a smaller provider network, deal with more prior authorizations and are more often "inappropriately denied approval for necessary health care," according to PNHP. In 2022, KFF found that those enrolled in Original Medicare were more often treated in higher-rated specialty healthcare facilities than those in Medicare Advantage.
Those consequences don't exist in a vacuum: Medicare Advantage patients undergoing surgeries for certain liver, pancreas and stomach cancers had higher mortality rates than similar patients on Original Medicare, according to PNHP.
"We've created a system where we've invited for-profit corporations to drain the Medicare Trust Fund . . . and we overpay them to kill people," Weisbart said.
A broader implication for the conservative movement
That Medicare Advantage's patient harms are so well-documented, and that Project 2025 recommended that the plan replace Original Medicare, may belie a core truth of the modern American conservative movement, Kim Phillips-Fein, a historian and professor at Columbia University, told Salon.
"A lot of the less-visible parts of the project are going to wind up reinforcing economic inequality," Phillips-Fein said of Project 2025. "They talk one way, but are very likely to govern another."
Much of today's modern conservative movement is rooted in the business community's antagonism against the New Deal, Phillips-Fein said, which ushered in what corporate stakeholders saw as a large labor movement that threatened business interests. But by promoting a health care plan proven to harm individuals, Project 2025’s Medicare Advantage proposal — as well as the broader Project 2025 agenda — suggests that corporate interests aren't just a component of the American conservative movement. Rather, it suggests that those interests are at the core of the movement — even at the known harm of the American worker.
"It's just telling that you've got an authoritarian playbook that sort of, at every pass, seems to be more focused on driving up corporate profits at the expense of the American people," Ducas said.
Reinvesting "the giant bag of cash" in traditional Medicare
Medicare Advantage was pitched as a private market solution to traditional Medicare. It exists because of the flaws of traditional Medicare. But experts say Medicare Advantage's own shortcomings present a timely opportunity for the program to reign in fraudulent spending and reinvest funds into the original program.
"We can take these significant and wasteful overpayments, reinvest them into the Medicare program . . . and that rising tide would help all Medicare beneficiaries, because that would then become a new baseline," Lipschutz said.
One badly needed reform? Adding an out-of-pocket cap to traditional Medicare plans. With no limit on out-of-pocket spending, beneficiaries can spend more than $5,000 per year on premiums. In 2018, those enrolled in traditional Medicare spent an average of $6,168 per year on premiums and services.
Another area ripe for reform: covering vision, dental and hearing under traditional Medicare, Ducas said. Under the current program, Medicare enrollees have to purchase a supplementary plan that covers the above health care as well as an extra plan known as Medigap, which reduces out-of-pocket costs associated with Medicare and the supplemental coverage. On average, Medigap monthly premiums can range from $50 to more than $300.
Without reform to Medicare Advantage, the broader Medicare program is projected to overpay insurers by more than $7 trillion over the next ten years, according to the Department of Health and Human Services.
"As it would happen, there is a giant bag of cash we are, right now, throwing every year at Medicare Advantage plans," Ducas said. "If we took that waste out . . . you could get to that reform future. That's what excites me."
