During the initial 50 years of my working life, I was a net contributor to American health care. I reached 70 having spent only a single day in a hospital following an appendectomy at 17. Today that would have been a day surgery. Virtually all my adult life, I paid for medical insurance, with just a few short breaks when I ran “bare” while transitioning from one job to another. Whenever possible, I enrolled with Kaiser medical programs. Once Medicare eligible, I signed up for their Medicare Advantage plan.

Initially, Kaiser’s Colorado Advantage program was unique as the plan applied for an exception to the federal rules permitting them to operate on a “capitated” basis. Fiscally, Kaiser received a flat annual payment for each Medicare Advantage enrollee and, in turn, committed to providing all required health care for its patients. More than 500,000 Colorado seniors participate in Medicare Advantage programs, all of which offer some form of managed (HMO) care. For those who prize a lifetime relationship with and confidence in a specific physician or medical practice, their coverage is pretty much limited to signing up with the Advantage plan their provider contracts with.

During the early 1990s I traveled constantly by air, often taking four to six business flights a week. This experience introduced me to what was seemingly an entirely irrational pricing scheme which familiarized me with the word algorithm long before it became popular as an internet descriptor. Airlines adjust the cost of a ticket depending on how far away a flight date may be, the day of the week (even the time of day) a passenger is purchasing a ticket, how full the flight is at the time of your reservation together with factors unknown. The result is unless a couple purchases their tickets together, no two people seated in your row paid the same price for their trip. Health care costs can appear equally irrational.

During the 45 years since I served in the legislature, health care costs have exploded from less than 10% of national GDP to nearly 20%. Together with the financialization of the American economy by hedge funds and private equity, which has followed a similar trajectory, half our discretionary dollars now pass to either bankers or health care providers. Unlike airlines, where cutthroat competition tamps prices down, medical costs escape market forces for two reasons: first, costs are rarely transparent and, second, the entire sector is chock-a-block with middlemen of varying descriptions whose presence are opaque. As I would argue with Republican colleagues at the legislature in 1980, when health care costs were already a problem, medical care rarely behaves like a commodity.

When I recently faced cardiac bypass surgery, I wasn’t interested in identifying the low-cost provider, nor did I wish to serve as a novice surgeon’s first patient, although every young doctor has to have one. Call me selfish. Call me nervous. I wanted a cardiac practice with a sterling success record (99-plus-percent). Or, at a time when we still used yellow page directories, I would challenge market zealots, “If you break your leg and the bone is protruding through the skin will you take the time to call through and locate the cheapest orthopedist to set your leg?” Of course not. The nearest emergency room will do. And then, pray for no “out-of-network” surprise billings.

Writing in “The Big Newsletter”, Matt Stoller identifies much of the rising costs in American health care as “corporate sludge” — the source for why we pay twice as much as other advanced economies for often mediocre medical care. Medicare Advantage appeared in the mid 1990s as a work around for patients who had neither the time nor persistence to navigate Medicare’s approval hurdles. Eight years ago, my bilateral knee replacements cost me just $900 out of pocket, primarily for three nights at the hospital. This past July, my hip replacement, which is now a day surgery, cost $92 for miscellaneous expenses. I received far more than my money’s worth from 15 years of Kaiser’s Medicare Advantage plan, as the unbilled price of each surgery exceeded $125,000. That, of course, as with so much of current medical practice, is a somewhat fictitious number. Kaiser has negotiated reduced rates with its providers.

Despite their popularity, Advantage plans have been under attack for nearly their entire 30-year history. On the left, many critics are irritated by the fact insurance carriers have discovered a way to extract a few extra dollars from the Medicare program, while legislators on the right in Congress are now searching for opportunities to eliminate every possible dollar from the federal government’s health care budgets. Some wags have joked the U. S. government has become an insurance company with an Army. Nearly 70% of the federal budget is dedicated to Social Security, pensions and health care. Just as Willie Sutton, the Depression-era bank robber, is rumored to have explained he robbed banks because, “…that’s where the money is”, Congressional budget hawks turn to Medicaid and Medicare costs for appropriation savings.

As is predictable in Washington, a lobbying organization has emerged, a non-partisan, non-profit advocacy voice for the insured: the Medicare Advantage Majority, or MAM, dedicated to protecting and strengthening Medicare Advantage coverage. Among the 34 million Americans relying on these programs for managing their care, including many with chronic conditions requiring continuing care, their Advantage programs often pick up most, if not all, of drug costs. They also can cover benefits traditional Medicare has never offered, including vision, dental and transportation to appointments. “Medicare Advantage doesn’t just serve seniors, it supports the entire ecosystem of caregivers who treat them,” explains MAM spokesperson Darren Grubb. Ninety-two percent of providers and caregivers express their support for the role Advantage plans undertake in shepherding patients through their medical challenges.

Nonetheless, U.S. Sens. Bill Cassidy (R-Louisiana) and Jeff Merkley (D-Oregon) have reintroduced their failed 2023 bill that forbids “upcoding” of an initial diagnosis assigned to a Medicare client. This is a common and to be expected result of the progression in most chronic illnesses as well as many diseases. Most inexplicable is the bill’s slashing of funding for in-home care, which would drive-up eventual costs. The legislation is proffered as a remedy for the myth of medical waste, fraud and abuse. How is this supposed to occur? Let’s face it, patient fraud is virtually non-existent. Provider fraud is another matter, and a legion of investigators earn their keep by searching for it. My own hip surgery resulted from an upcoding of assumed sciatica to arthritic deterioration in the joint.

The Boston Globe has covered changes coming for Medicare Advantage plans in New England more than most other media, reporting on Oct. 19, “Tens of thousands of senior Massachusetts residents may find that (their) Medicare Advantage plans are charging higher premiums, shrinking provider networks, covering fewer drugs, and offering fewer perks (including transportation to appointments) as Medicare’s open enrollment period gets underway.” It’s not just Medicaid taking hits from Trump’s “Big, Beautiful Bill.” We should expect premium increases in 2026 for Colorado enrollees. Nonetheless, as MAM’s spokesman Darren Grubb observes, “Medicare Advantage saves caregivers time and money.” In my experience that can be a win-win solution.

Miller Hudson is a public affairs consultant and a former Colorado legislator.