Our nation is graying rapidly. Every day, 10,000 baby boomers, members of one of the largest generations in U.S. history, hit the traditional retirement age of 65. This will keep up for the next several years.

This has and will put huge strains on the U.S. health care system and how individuals and the country pay for the medical treatment of this giant group of older patients. While major attention gets paid to looming shortfalls with the safety net of Social Security, experts also are sounding salarms about Medicare and its coverage for the medical services for tens of millions of Americans 65 and older.

This month, we’re focusing on the program called Medicare Advantage or Advantage Medicare. These are:

1. Privately run Medicare plans which have proven popular among seniors, now covering about half of all those over 65.

2. But since they’re private, they’re subject to the profit-focused practices of Big Insurance. And that’s something that patients, doctors and hospitals have sometimes had big problems with.

Bottom line (and more detail below): Consumers turning 65 are under a lot of pressure to make quick decisions about whether they will be covered by traditional Medicare or one of the Advantage plans. Patients often don’t realize their choices will dog them for years. So … that makes it important to learn the pros and cons so good choices can be made.

Let’s compare the promises of Advantage with the “Yes, But” realities.

Advantage proponents contend that they can curb fee-for-service and other problematic health care approaches by enrolling more of the privately insured older Americans into programs more akin to now-familiar Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). These, in theory, can better coordinate and manage or control medical treatment, eliminating wasteful, inconvenient, intrusive, and painful care.

YES, BUT: As patients young and old have discovered, medical care outside of insurers’ preferences comes with potentially significantly higher “out of network” costs. HMO patients, especially those in Advantage plans, may not get referred to expensive specialists without running a bureaucratic and practical gauntlet, with prior authorization typically required, critics say. Further, those in Advantage PPOs hit similar roadblocks. They also complain that their provider choices can be highly constrained.

Patients have been infuriated by insurers’ widespread practice of shoving them into “narrow” provider networks that too often exclude well-known specialists and other respected medical experts, especially those who practice in big hospitals or major academic centers.

Insurers say these practitioners and facilities rack up too-high charges. But the specialists, big hospitals, and academic medical centers defend their costs, noting that a substantial number of their patients have complex, chronic, and difficult conditions, or injuries. They also say they treat a disproportionate number of poor, underinsured, or uninsured patients.

Advantage patients also complain that they can fall outside of insurer networks and into more expensive care if they travel often or spend time in different locations (for example, living as snowbirds who move part of the year from cooler to warm climes and vice versa). As patients age and their health conditions become chronic and more complex, their needs for specialist care can increase — and get snarled by Advantage programs’ constraints.

Some Advantage programs help patients with government-required premiums they must pay monthly, as with nutrition (food aid), and even housing. Critics have assailed Congress and multiple U.S. Administrations for failing to update Medicare and match benefits offered by private insurers.

YES, BUT: Patients may soon see the disappearance of Advantage benefits broader than those offered in original Medicare.

With the fears of the coronavirus pandemic fading, patients are rushing back for medical care, big time. Insurers are struggling to keep up with rising costs, even in options like HMOs and PPOs. Big companies like Cigna, United Healthcare, and Humana have struggled with and shed parts of their Advantage coverage due to cost and profitability concerns.

Insurers, as an array of their actions indicate, always put a premium on maximizing profits. They have spent big on advertising for Advantage programs — causing consternation and crackdowns by regulators concerned about the marketers’ truthfulness — and they have made huge inroads in signups for this coverage. Insurers still are struggling now to reap the money they once did.

Patients also may be unaware of how insurers have wrung every buck they could out of Advantage plans. As medical economists and watchdog journalists have noted, federal regulators have sued multiple big insurers in the field. They stand accused of sketchy billing practices, notably in “upcoding.” Regulators say that insurers leverage their insider knowledge and experience with complex medical records and bills to make patients seem sicker than they are and to take a bigger piece of the U.S.-provided payments for older patients’ care by using the most expensive treatment codes, or in failing to document serious diagnoses. In brief, critics say, insurers defraud taxpayers with this practice, a claim the industry denies.

Critics recently have assailed large insurers over another disturbing practice — employing computer algorithms and artificial intelligence to pore over masses of health records to determine how to deter patients from making claims at all. Those who are targeted, critics say, are among the oldest and sickest. By identifying them, then denying or delaying authorization and treatments for them, insurers save money. But this harms patients, doctors say.

Even before the algorithm scandals erupted, doctors and hospitals were ripping insurers for taking far too long to authorize in advance an increasing range of medical tests, procedures, and medications. They expressed exasperation at the harm patients suffer, as well as the economic consequences to their operations, due to insurers denying coverage and failing to provide sound medical reasons for doing so.

The Biden Administration hopes to quell this fury by cracking down on insurers and their processes and timelines for authorization and approvals starting next year. Though insurers were taking high heat over these practices, they have flipped and say they support the administration’s moves. States also have jumped into the fray, responding to their citizens’ complaints about pokey insurers.

Under the original program, patients pay Part B costs, plus, if they choose to buy it, for prescription drug coverage. They also may pay for other Medigap or supplemental coverage, about which the financial services site Nerd Wallet explains: “All Medigap policies have premiums. The least expensive plans for a 65-year-old might cost as little as $30-$40 per month. For older beneficiaries and plans with more coverage, monthly premiums can cost hundreds of dollars. Generally speaking, you’ll pay the lowest premiums for plans with less coverage …. Conversely, a plan that covers more … tends to have a higher premium.”

Medigap plans can be expensive to some. But they are vital in dealing with a big difference between original and Advantage plans. The Advantage plans, by law, have caps on patients’ out-of-pocket costs, while the original coverage does not. Consumers can shield themselves from costly out-of-pocket expenses by buying gap coverage. Experts also note that patients in both original and Advantage plans must be wary of deductibles and co-pays, knowing that those on tight budgets can find these out-of-pocket costs difficult to manage.

YES, BUT: For those who are reading along and struggling to understand the dollars-and-cents of original versus Advantage plans for seniors, a critical financial fundamental, of course, cannot be ignored. It’s the $361 billion paid by taxpayers (in 2021 alone) to private insurers to support Advantage coverage. As the Kaiser Family Foundation explains this amount, which works out to about $12,000 per Advantage customer annually:

“Medicare pays insurers a set amount per enrollee per month, which varies depending on the county in which the plan is located, the health status of the plan’s enrollees, and the plan’s estimated costs of covering Medicare Part A [hospitalization] and Part B [doctor and other medical] services. The plans use these payments to pay for Medicare-covered services, and in most cases, also pay for additional benefits and reduced cost sharing. Plans are required to meet federal standards, including providing an out-of-pocket limit.”

Here is the problem, however, as reported by the conservative financial hawks at the Peter G. Peterson Foundation:

“In 2021, Medicare Advantage was 4% more expensive per enrollee than if those same individuals were enrolled in traditional Medicare and increases in cost per enrollee are expected to continue. That increase in cost per enrollee is not explained by the health of Medicare enrollees versus Medicare Advantage enrollees. Furthermore, beyond beneficiaries having a treatment plan, prescription review, and a regular doctor or place of care, there is limited evidence to suggest [Advantage] plans are delivering better quality and access to care.

“Medicare Advantage is more expensive for the government than traditional Medicare because the cost-saving areas of MA [predominantly] benefit the private plans rather than the government. [Advantage] was structured to incentivize innovation of efficient care management and, subsequently, to lower costs. That has proven effective: for 2022, the average bid from Medicare Advantage plans was 15% less than what fee-for-service Medicare would spend.

“However, a shortcoming is that the government does not realize most of those savings, largely because of inflated risk scores skewing (numbers that account for diagnoses and expected medical costs of a beneficiary) the benchmark. The more qualifying diagnoses a member has (i.e., higher risk score), the more Medicare pays to the [Advantage] plan for that enrollee. Because of that, private plans are incentivized to identify and submit all possible diagnoses to [the government] whether the insured are actively being treated by providers or not, which inflates scores and thus payments to private plans in comparison to what a similar individual would cost under Medicare.”

The foundation is not alone in warning that lawmakers, policy experts, and federal regulators should be working urgently to deal with problems in both original and Advantage coverages. Medical care in the wealthiest nation in the world must be a right, not a privilege for the rich few. But our senior population — needing affordable, accessible, reliable, and safe medical services — is growing significantly. Health coverage for older Americans requires rigorous oversight to ensure it does not put unnecessary cost burdens on the taxpayers of today and tomorrow.

And the right time to do it is months before consumers hit the big six-five birthday.

Thanks to the internet, good information is available from the likes of AARP, Consumer Reports, the New York Times and the Wall Street Journal. The federal government has its own site with extensive Medicare information.

Older folks should start their research months before being pushed by federal law to make Medicare decisions. Patients should consider the state of their health, notably if they have chronic conditions or disabilities. If they require specialized treatment or medical services, they may find it important to choose their doctors, specialists, hospitals, and other medical providers.

As they consider plan options, they should look closely at their medical provider choices, and which are considered “in” or “out” of insurer networks. How do they feel about delays or denial of care, and, more fundamentally, about the need for insurer authorizations for a wide range of tests, procedures, drugs, and medical equipment and devices?

If you travel often or even live in various parts of the country for periods of time during the year, pay special attention to your plan’s coverage. By law, those with original Medicare are supposed to receive medical services anywhere in the U.S. that doctors and hospitals treat Medicare patients. This is not true for Advantage patients.

Analyze prospective costs with diligence. Advantage plans may seem not only cheaper but also full of alluring benefits. But can you live with the constraints in coverage? And, based on your health, will your needs change — soon or in the future? If your existing conditions worsen or you are felled by serious illness or injury, will you be unhappy that you might not find specialists or specialized care facilities in your affordable network? If you’re OK with an Advantage plan because at least one or two of its providers suit you, what happens to you if those doctors, specialists, or hospitals get dropped, move, or retire?

With Big Pharma pounding all patients with relentless cost increases, older Americans need to consider their medication needs now and in the future. That may mean talking with the doctor, her staff, or a friendly pharmacist. Or it could be that consumers pull out their prescription lists and compare it with insurers’ rosters of what drugs are covered under which plans.

Many people find their heads start to spin when they try to sort out their post-65 coverage choices. Many turn to brokers for help. The Wall Street Journal says 1 in 3 Americans seek this assistance. They should do so with care, the newspaper reported:

“Brokers can be extremely helpful, but routinely neglect to tell their customers that they are paid $400 to $500 per enrollee by insurers, often to sell more expensive plans, which creates a fundamental conflict of interest in the advice they provide. So, if you go down this path, make sure to ask them questions about their incentives, the plans they’re not telling you about and whether the discounts they are offering you will dry up in a year or two.”

The New York Times reported this about another option:

“You will find plenty of information on the Medicare.gov website, including the Part D plan finder, where you can input the drugs you take and find which plan gives you the best and most economical coverage. The toll-free 1-800-MEDICARE number can also assist you. Perhaps the best resources, however, are the federally funded State Health Insurance Assistance Programs, where trained volunteers can help consumers assess both Medicare and drug plans. These programs ‘are unbiased and don’t have a pecuniary interest in your decision making,’ said David Lipschutz, the associate director of the Center for Medicare Advocacy. But their appointments tend to fill up quickly …”

Caveat emptor, folks. Make those Medicare decisions carefully and with due diligence starting at age 65. If patients eventually want to change plans, it can get messy and complicated.

Both original Medicare and Advantage programs have open periods annually when most customers can make changes. For original Medicare, open enrollment runs from mid-October to early December. It is different for Advantage plans, whose open periods span Jan. 1 to March 31.

Patients unhappy in Medicare Advantage, experts say, likely will find smoother going if they switch to another Advantage plan. It varies by geography, but consumers in most regions of the country will find several dozen plans and multiple insurers to choose from. They may swap Advantage plans because their preferred doctors, specialists, or hospitals are no longer part of their insurers’ network. Their prescription drugs, wrapped into their Advantage coverage, may have been dropped or spiked in cost. They may be unhappy with increases in premiums or reductions in benefits.

In a five-year span scrutinized by one researcher, half of those studied and in Advantage plans switched. Experts are digging deeper to see how much discontent is reflected in that metric.

Recent news articles say consumer unhappiness is driving Advantage customers to want to change over to original Medicare. The disgruntled complain that as they have grown older and sicker and need more and specialized care, the Advantage plans don’t fill their needs. They grow weary over constant battles over approvals and denials of treatments their trusted doctors recommend. They say they feel gulled by their earlier choice for Advantage plans, which they find deceiving in their seemingly favorable costs and benefits.

But it’s not easy to switch back to original Medicare after patients make an initial Advantage choice at age 65, and a big part of the complication is due to later issues with Medigap plans. At the outset and for six or so months after, those picking original Medicare can seek gap plans and insurers cannot deny them coverage based on preexisting conditions, and companies are limited in premium increases (adjustments) for these enrollees.

But those who pick Advantage plans, then want to switch to original Medicare later, mostly lose the preexisting condition protections in gap coverage. They may find it harder to find suitable gap plans and may pay hefty charges accordingly.

Those who have original plans and then switch to Advantage should be advised that they, too, will give up their gap coverages and preexisting condition protections. This can make it difficult for them to return to original Medicare.

Those switching from Advantage to original plans should carefully calculate the costs for their change. Besides determining (in advance, please) what they might pay for gap coverage, they also may want to add a prescription drug plan, determining which of their medications qualify in which plans.

While making important coverage decisions, consumers may consult federal ratings — rankings using stars — for help. As the Wall Street Journal reported, however:

“The government tries to help reduce the complexity of Medicare choices with its star ratings of plans, but research has shown that high star ratings do not tell us whether a plan will improve our survival or not. This makes choosing a plan in Medicare very hard to understand and manage. It’s even harder for people who have dementia, or are in a nursing home, or both. All this information means more work. But ensuring you’re properly protecting your health — and your pocketbook — is worth the effort.”