Jayapal, DeLauro, Schakowsky Lead Effort to Reform Medicare Advantage

WASHINGTON – U.S. Representatives Pramila Jayapal (WA-07), Rosa DeLauro (CT-03), and Jan Schakowsky (IL-09) today are leading 70 lawmakers in calling on the Centers for Medicare and Medicaid Services (CMS) to implement reforms to Medicare Advantage (MA) to improve health care for seniors and people with disabilities. Unlike traditional Medicare, MA plans are administered by private insurers and in recent years have been found to be fraught with waste, fraud, and abuse, too often putting corporate interests over patient outcomes.

“Although at its inception the MA program was expected to reduce Medicare spending, MA plans in the aggregate have never produced savings for Medicare. Additionally, inappropriate care delays and denials within MA are harming seniors and people with disabilities,” wrote the lawmakers. “Medicare is a foundational piece of the U.S. healthcare system and must be protected. We urge you to eliminate the barriers caused by MA care delays and denials and restricted provider networks, stop overpayments to MA, and reinvest the savings of time and money into care for Medicare beneficiaries.”

In the letter, the lawmakers support CMS’s proposed rule that prohibits MA plans from imposing any additional burdensome criteria for prior authorization approvals and urge CMS to build on that action and continue to reform MA.

Private insurers in the MA system consistently overcharge Medicare, while inappropriately delaying and denying care for patients. Half of the top 10 providers have been accused of fraud by the U.S. government and eight of the 10 have submitted inflated bills. Under changes requested by the lawmakers to cut down on waste, fraud, and abuse, Medicare could see up to $46.5 billion in annual savings.

“Medicare Advantage was supposed to reduce costs through better managed care. Instead, the program has become a shameless profiteering scheme for health insurance corporations and is driving up Medicare spending by at least tens of billions of dollars a year. And too many Medicare Advantage plans are wrongly denying and delaying claims and care to people deserve so much better. This letter is proof of the growing recognition of these problems among the public and in the halls of Congress. President Biden and Congress need to do everything in their power to protect folks on Medicare and taxpayer dollars, and the ideas in this letter are a great start,” said Ady Barkan, Founder and co-Executive Director of Be a Hero.

“Bad actors in Medicare Advantage are delaying and denying care that patients desperately need. CMS has the power to hold these bad actors accountable and level the playing field between Medicare Advantage and traditional Medicare. Seniors and people with disabilities are counting on CMS to take action. We thank Reps. Jayapal, DeLauro, Schakowsky, and their colleagues for fighting for Medicare beneficiaries,” said Alex Lawson, Executive Director, Social Security Works.

“Medicare Advantage is neither Medicare, nor an advantage. It is however a cash cow for big insurance and riddled with abuse. I am grateful for the leadership of Congresswomen Jayapal, Schakowsky and DeLauro for pushing these much-needed reforms of a program in desperate need of reform,” said Wendell Potter, President, Center for Health and Democracy.

“For far too long Medicare Advantage plans have bilked seniors and the Medicare program by focusing on profit instead of patients. We join with Reps. Jayapal, Schakowsky, DeLauro and the other signers of this letter in demanding improved accountability for insurers who reap massive profits while, among other things, delaying and denying care, maintaining narrow provider networks, using misleading advertising, and cherry-picking healthier seniors while pushing sicker seniors and people with disabilities back to traditional Medicare to get the care they need. It is time to put seniors before profits by enhancing protections, clawing back insurers’ ill-gotten gains and reinvesting that money to improve the Medicare program,” said Eagan Kemp, Healthcare Policy Advocate, Public Citizen.

“People’s Action members have been organizing to expand Medicare through our Health Care for All campaign for years. We applaud Congresswomen Jayapal, DeLauro, and Schakowsky for taking on Medicare Advantage, a health care scam that increases costs while failing to deliver the care people need. It’s time to crack down on Medicare Advantage profiteering and instead work to expand Medicare, a program that we know works,” said Sulma Arias, Director of People’s Action.

The letter calls on CMS to make the following improvements: 

1. Finalize and strongly enforce the proposed prohibition on MA plans denying prior authorization requests for coverage of a Medicare covered item or service based on criteria not found in traditional Medicare coverage policies, and issue new guidance prohibiting the use of step therapy for Medicare Part B.
2. Require MA plans to cover services from any medical provider that accepts Medicare’s approved rate. At a minimum, require MA networks to cover care at the top 50 cancer hospitals in the country.
3. Stop overpayments by developing a more accurate risk-scoring model based on patient demographics and prohibiting the use of unscrupulous methods to increase care costs.
4. Reinvest the $46.5 billion annual savings from MA overpayments into lowering Medicare premiums, eliminating deductibles, expanding benefits to include dental, vision, and hearing, or otherwise improving medical care for all Medicare beneficiaries.

Jayapal, DeLauro, and Schakowsky led multiple previous efforts in 2022 urging immediate action to stop Medicare Advantage Organizations (MAOs) from improperly denying care to seniors. These calls for action followed a report published by the Department of Health and Human Services Office of the Inspector General (HHS OIG) revealing that MAOs wrongly denied as many as 85,000 medical prior authorizations,1.5 million payment requests, and a request for information from CMS on how to improve the MA program. 

The full text of the letter can be found here.

The letter was signed by Pramila Jayapal (WA-07), Rosa DeLauro (CT-03), Jan Schakowsky (IL-09), , Nanette Diaz Barragán (CA-44), Jamaal Bowman (NY-16), Cori Bush (MO-01), André Carson (IN-07), Troy Carter (LA-02), Greg Casar (TX-35), Kathy Castor (FL-11), Sheila Cherfilus-McCormick (FL-20), Judy Chu (CA-28), David N. Cicilline (RI-01), Yvette Clarke (NY-09), Steve Cohen (TN-09), Jasmine Crockett (TX-30), Henry Cuellar (TX-28), Danny K. Davis (IL-07), Chris Deluzio (PA-17), Mark DeSaulnier (CA-11), Debbie Dingell (MI-06), Adriano Espaillat (NY-13), John Garamendi (CA-08), Jesus “Chuy García (IL-04), Robert Garcia (CA-42), Sylvia Garcia (TX-29), Daniel Goldman (NY-10), Al Green (TX-09), Raúl M. Grijalva (AZ-07), Val Hoyle (OR-04), Sheila Jackson Lee (TX-18), Henry C. “Hank” Johnson, Jr. (GA-04), Sydney Kamlager-Dove (CA-37), Robin Kelly (IL-02), Ro Khanna (CA-17), Andy Kim (NJ-03), Raja Krishnamoorthi (IL-08), Barbara Lee (CA-12), Summer Lee (PA-12), Teresa Leger Fernández (NM-03), Mike Levin (CA-49), Ted W. Lieu (CA-36), Betty McCollum (MN-04), James P. McGovern (MA-02), Grace Meng (NY-06), Jerrold Nadler (NY-12), Grace Napolitano (CA-32), Eleanor Holmes Norton (DC), Alexandria Ocasio-Cortez (NY-14), Ilhan Omar (MN-05), Chellie Pingree (ME-01), Mark Pocan (WI-02), Katie Porter (CA-47), Ayanna Pressley (MA-07), Delia Ramirez (IL-03), Mary Gay Scanlon (PA-05), Robert C. “Bobby” Scott (VA) (VA-03), Brad Sherman (CA-32), Shri Thanedar (MI-13), Bennie G. Thompson (MS-02), Rashida Tlaib (MI-12), Jill Tokuda (HI-02), Paul Tonko (NY-20), Ritchie Torres (NY-15), Lori Trahan (MA-03), Nydia M. Velázquez (NY-07), Bonnie Watson Coleman (NJ-12), Nikema Williams (GA-05), Frederica Wilson (FL-24).

Issues: Health Care