Comment by CalChris | Hacker News Reader

Comment by CalChris | Hacker News Reader

Medicare has a similar issue. When you sign up at 65, you have to make a first big decision, Traditional Medicare (yay!) or private Medicare Advantage (boo!).

Traditional Medicare consists of Part A (hospitals), Part B (doctors) and Part D (drugs). Part A+B don't cover everything so you have a Medigap plan. I have Plan G which has very little paperwork. All up, I spend about $400/mo and I'm very happy with A+B+G+D.

With Medicare Advantage you sign over your Medicare rights+benefits to a private insurer. This may save you some money, especially early on. In fairness, not really a lot and the $0/mo plans are a scam. With Medicare Advantage, you will then have to argue with an insurance company for the rest of your life. You'll have to deal with preauthorizations and a restricted network.

With Traditional Medicare, what's covered is spelled out pretty clearly ahead of time. Docs know it. You know it. There's literally an app for that. With Medicare Advantage, medically necessary is at the discretion of the private insurance company.

Here is the scenario from a relative: he had a heart event which ended up needing a stent. He had to argue with Kaiser while this was going on. Kaiser is 240,000 people. He is one.

Medicare Advantage is very profitable.

It is possible to switch back from MA to TM which really revolves around your Medigap plan. You are guaranteed issue for Medigap plans for about 3 months before/after you turn 65. After that, you will have to undergo medical underwriting.

Yes.

"Medicare Advantage" = HMO. All the usual HMO problems.

The best Medigap plan is Plan F, which is no longer available to new subscribers. "Discontinuation of Medicare Plan F was a strategic decision aimed at promoting responsible healthcare spending and ensuring the financial sustainability of the Medicare program." It covers just about everything Medicare doesn't pay, including the various deductibles Medicare has. If Medicare covered Medicare's part, the Plan F provider has to pay their part. They don't get to question it. I don't even see hospital bills, just statements that it's been paid for.

Plan G is one step down from that.

MA is not necessarily an HMO. It's up to the operator. Some are HMOs, some are PPOs, some are neither.

> "Medicare Advantage" = HMO. All the usual HMO problems.

Not on Medicare, but I switched to an HMO over 10 years ago at work, and have never been happier.

There are fantastic and crappy PPOs, and fantastic and crappy HMOs.

I’m 40, on Social Security Disability Insurance and recently became eligible for Medicare.

After years on Kaiser because of familiarity, when I became eligible for Medicare, I had to make a choice between original Medicare or Medicare Advantage.

It’s incredible expensive to buy into adequate coverage if you’re under 65 and on disability and want original Medicare, but after the mixed experience I had with Kaiser, I wouldn’t have it any other way.

As I have some serious health conditions, I signed up with Plan G Extra and a high coverage tier for Part D. It’s going to cost about $1300/mo plus an additional $202.90/mo for part B, but it’s better than having to worry about future health issues putting me in financial ruin.

Nice to preserve choice being responsible for at most a $283 deductible per year on top of the monthly cost.

I had a 3 day hospital stay in December 2024 that was $75,000 and I didn’t have to pay for it, so it was worth it to have good coverage.

The theory behind Medicare Advantage is that it would cost the government less than traditional Medicare because the private insurer would be more efficient. Guess what happened.

I think the logic of running a more efficient company is true - they are making more money operating them than the government can/is.

The insurers are such behemoths and so largely vertically integrated it is controlling the system instead of improving it.

Notice how there is rarely ever any new competition in the health insurance space to drive down pricing.

Well the only ways to make any sort of insurance pool (whether it's run by the government or a private organization, for or non profit) more efficient is to deny more payouts or aggressively select for a less risky risk-pool. Medicare insures everyone over age 65, so the second option doesn't work. You can't just leave half the elderly uninsured because they're fat and likely to run up $100,000 in knee replacements. So you have to deny more claims.

Insurance is brutally simple. Money in, money out. Trying to make your back office more lean with tech and automation has extremely limited returns, because the back office is such a small portion of the total cost structure. 95-100% of costs in any given insurance operation are claims. So everything to do making things more efficient and reducing costs has to do with reducing claims.

It's not that simple. Something like a quarter of all healthcare procedures aren't justified on an evidence-based medicine basis and do nothing to improve patient outcomes. Higher quality care actually costs less. But there's a huge amount of waste and mismanagement at all levels of the system.

I agree and making insurance more efficient involves aggressively policing that activity and denying associated claims.

In fact, MA costs the government more per person than does TM. MA may have been lobbied for as a cost saving measure. It is, in fact, a profit center for insurance companies.

https://www.kff.org/medicare/higher-and-faster-growing-spend...

Ah, yes, nothing cuts costs like, er, inserting a middleman?

I've no idea how anyone ever thought this could work.

If you look at any health insurers profit split right now they are making all of their gains on medicare advantage.

Reply on news.ycombinator.com