The Scam We Have vs The Future We Deserve

The Medicare open enrollment window just slammed shut, which means a whole lot of older and disabled folks just spent the last few weeks being carpet-bombed with ads.

You know the ones:
soft lighting, a retired athlete you vaguely recognize, a phone number flashing at the bottom of the screen like it’s a prayer line.

“Call now and you could get more benefits—vision, dental, hearing, a gym membership, even money back in your Social Security check!”

If you’re already living in a country that treats healthcare like a game show, this sounds… pretty good. Of course people sign up. Half the time you can’t even tell where “Medicare” ends and “Medicare Advantage™️” begins. That’s not an accident. That’s the business model.

Because here’s the uncomfortable truth:
Medicare Advantage is not an improvement on Medicare. It’s the privatization of Medicare.
It’s a big siphon stuck into a public program.

Let’s strip out all the jargon and rainbow brochures and look at the mechanics.

That’s it. That’s the “innovation.”

They make money two ways:

Not “harder” like “fill out an extra form.”
Harder like: you need prior authorization for basic stuff, your specialist is suddenly “out of network,” your rehab days get cut short, and you don’t find out until you’re already in a hospital bed.

If traditional Medicare tried half the tricks these companies do, it would be a national scandal.

When private insurers do it, it’s called “cost control.”

You see it in:

The timing is brutal. People get hit with the worst restrictions when they’re the least able to fight back: post-surgery, in a crisis, at the end of life. Nobody has the energy to wage a paperwork war while they’re trying not to die.

But again: that’s the point. The more people who quietly go without care or give up fighting about a denial, the better the quarterly earnings look.

On the other side of the ledger, there’s the coding hustle.

Medicare pays more for people who are medically complex. So what do Medicare Advantage plans do? They suddenly discover that everyone is suspiciously complex.

You go in with mild high blood pressure, you come out with a stack of chronic condition codes that make you look ready to keel over. A handful of aches and pains turn into “multiple comorbidities.”

Sometimes you don’t even know this is happening. The coding is between the plan and the government. But the billings pile up, and the company gets to say, “Wow, look at all the sick people we heroically cover! Better reimburse us more.”

That “risk adjustment” system was supposed to protect sicker patients. Instead, it turned into a legal way to upcode and fleece Medicare.

One of the big hooks for Medicare Advantage is the add-ons: dental, vision, hearing, maybe a “free” gym membership if you promise to stay alive long enough to justify it.

Those are real benefits. People actually need them. That’s why they’re dangled like candy.

But they’re also cheap compared to serious medical care. A couple of dental cleanings and a vision exam cost the plan a lot less than a hospital stay or a course of cancer treatment.

So the trade basically looks like this:

It’s like a landlord who lets you paint the walls whatever color you want, but reserves the right to lock the bathroom at random.

Who loses?

Medicare Advantage takes a public guarantee—“you paid in your whole working life, and we’ve got you”—and turns it into a casino where the house always wins.

Next up: how to fix this mess by making the thing we actually need—real, comprehensive Medicare for All—so universal and solid that Medicare Advantage has no reason to exist at all.

Dear Mao,

My partner is actually uninsured. Not “bad plan,” not “high deductible.” No insurance.

Any time something’s wrong—chest tightness, dizziness, coughing at night—they say they’ll “wait it out” or “Google it.” I’ve paid for urgent care twice, and both times I felt like I was swiping my card to buy a slightly smaller chance of them dying.

They say the ER is a scam. They’re not wrong. But I’m the one lying awake listening to them wheeze and doing the math in my head: rent, food, surprise four-figure bill.

I don’t want to parent them. I don’t want to resent them either. But right now it feels like I’m the only thing standing between their body and the American healthcare system.

Am I being controlling, or am I just the one holding the clipboard?

— Pre-Approved for Panic

Dear Pre-Approved for Panic,

You’re not controlling. You’re just doing a job this country offloaded onto you.

Your partner has learned the basic rule of U.S. healthcare:
Getting help is dangerous. Not medically—financially.

They’re not “laid back.” They’re scared.
They’ve just converted that fear into stubborn avoidance.

Meanwhile, you’ve been quietly drafted as their insurance plan:
You pay, you worry, you Google, you watch their chest rise and fall at 3 a.m.

That’s the real triangle here:

So stop arguing about whether the ER is a scam. Everyone’s right about that.

Talk about the part you actually control:

You’re not asking them to be “better with doctors.”
You’re asking them to be a partner in survival.

If their answer is to double down on “I’ll just tough it out,” then they’re not sharing a life with you.
They’re outsourcing risk to you.

And you don’t have to be somebody’s unpaid catastrophic coverage.

Love can move mountains.
It is not obligated to move hospital billing codes.

— Mao
Care is mutual. Cost-sharing should be, too.

Medicare Advantage only exists because the original Medicare program was deliberately left incomplete.

No dental.
No vision.
No hearing.
No long-term care.
Gaps in drug coverage.
Out-of-pocket costs that can still mess you up if you’re on a fixed income.

Leave enough holes in a public program and—surprise—private companies show up to sell you “plug-ins.” That’s all Medicare Advantage is: a giant, heavily subsidized patch pack marketed as an upgrade.

So when we talk about Medicare for All, we’re not just talking about “put everyone on the current version of Medicare and call it a day.”

We’re talking about finishing the job.

A serious M4A system—the kind people have in mind when they chant it at rallies—wouldn’t just toss you a gym membership and a dental coupon.

It would cover:

In other words: the things Medicare Advantage waves in your face as add-ons would just be… standard. Ordinary. Normal parts of a functioning health system.

The arbitrage opportunity disappears. There’s no gap to monetize. No “value proposition” for private plans except “we could make your life slightly more annoying for no reason.”

Here’s the thing every industry lobbyist tries to bury under 400 pages of jargon:

Traditional Medicare runs on low single-digit administrative costs.

Private insurers? By the time you add up all the salaries for people whose entire job is to stall, deny, appeal, audit, market, litigate, and report to shareholders, you’re easily in the mid-teens or higher. That’s before we even get into profit margins.

All of that overhead isn’t “innovation.”
It’s friction.

Every dollar that goes into that machine is a dollar not going into actual care.

Medicare for All doesn’t magically eliminate bureaucracy—nothing does—but it takes the sprawling, redundant, corporate mess we have now and replaces it with one set of rules and one payer.

Your doctor spends less time arguing with eight different insurers and more time treating you like a human being instead of a series of billing codes.

“Parasitic” isn’t a spicy insult here; it’s a description of how the industry works.

A parasite:

Private health insurance:

Wall Street openly talks about “utilization” as a risk. That’s code for: if too many people actually use their insurance, profits go down.

You staying healthy? Neutral.
You needing care? Bad for the stock price.
You dying quickly and cheaply? Honestly, that’s not the worst outcome for them.

That is not a moral glitch. That’s the business model.

You’ll hear this a lot: “We don’t need Medicare for All, we just need to regulate insurers more strictly.”

We’ve tried that. We’re still trying that. The problem isn’t that the rules are slightly off. It’s that the incentives are.

An insurance company has to do three things to keep Wall Street happy:

How do you square that with the basic ethics of medicine, which say:
If someone needs care and we can provide it, we should?

You don’t. You fudge. You deny. You delay. You “review.” You “manage utilization.” You rely on the fact that people will get tired, confused, intimidated, or die trying to fight you.

No amount of clever regulation makes those goals compatible. As long as care is a profit center, sick people are raw material.

Just to head off the scare stories:

Medicare for All is public financing for care delivered by the same mix of providers we already use: private practices, community health centers, big hospital systems, etc.

You still pick your doctor. You still go to the same clinic. The difference is you’re not constantly wondering:

You show your card. You get care. The bill goes to one place, and you’re not the profit margin.

This is why Medicare Advantage freaks out so hard at any mention of Medicare for All: their entire existence depends on Medicare staying broken and incomplete.

Fill in the gaps.
Make the coverage comprehensive.
Take the profit motive out of deciding who gets a ventilator and who gets a bill.

Suddenly, there is no compelling reason for an extra corporate layer to sit in between us and the care we already paid for with our labor and our taxes.

A grown-up country doesn’t need private companies to run a toll booth on its healthcare system.

We don’t need “advantages.” We need guarantees.

And that’s the real choice on the table:
Do we keep letting an industry skim off the top of a broken system, or do we fix the system and tell the skimmers they’re done?