How a second Trump term could destroy Medicare as we know it

Project 2025’s section on Medicare and other health care initiatives is not getting the attention it deserves.

As soon as Project 2025, the right-wing blueprint for a second Trump administration, began to receive significant negative publicity earlier this month, the former and perhaps future president quickly denied all knowledge of it. “I know nothing about Project 2025,” he said on Truth Social, adding he believed that (unspecified) ideas in the proposal are “abysmal.”

He’d certainly like us to believe that. But that statement shouldn’t be the end of the matter, and not simply because more than two dozen former Trump administration officials are involved in Project 2025. It’s because many of its planks read like a continuation of his first term. That includes the section on Medicare and other health care initiatives, which is not getting the attention it deserves.

While he was in office, each of Trump’s budgets called for Social Security and Medicare cuts.

Project 2025 recommends making Medicare Advantage — the private insurance offering in Medicare — the default option for enrollment. Currently, there is no default option, though what’s called “Original Medicare” is presented first. That may sound like a minor change, particularly if you’re not familiar with Medicare’s offerings. But this plan, should it come to fruition, will likely degrade not only Medicare, but health care for all Americans, no matter our age.

Ever since he announced his first presidential run, Trump has promised to “save Medicare, Medicaid and Social Security without cuts.” That was a lie. Even before he became president, his own staff and supporters were saying it wasn’t true. While he was in office, each of Trump’s budgets called for Social Security and Medicare cuts. Trump himself encouraged enrollment in Medicare Advantage, while his Department of Health and Human Services, the agency responsible for the program, sent out promotional emails during one sign-up period with headlines like “Get more benefits for your money.”

This statement is, again, a lie.

Medicare Advantage costs the government billions of dollars more annually than the traditional offering, while delivering less in the way of necessary care. Giant health care insurers game the Medicare system, profiting at the expense of taxpayers and patients alike. The government pays insurers a minimum fee per enrollee based on each enrollee’s health — something done to discourage companies from cherry-picking the healthy. But insurance companies do their darndest to make their enrollees appear as sick as possible to the federal government, so they can collect more money for them. As a result, the government spends more than 20% more for people enrolled in Medicare Advantage than they do the traditional program.

But all this upcoding doesn’t mean Medicare Advantage enrollees receive more in the way of care. In traditional Medicare, patients can see almost any doctor and few services need prior authorization. Neither is true under Medicare Advantage. Medical networks are narrow and limited, while everything from an MRI of the aching knee to chemotherapy for recommended cancer treatment -- not to mention doctor-recommended nursing home and rehab stays -- can be subject to insurance company second-guessing. While only a little more than 10% will appeal if they do not receive pre-authorization, if they do, four out of five will see the decision overturned.

Why, in 2024, does Medicare Advantage cover more seniors than the traditional offering? Trump, to be clear, is far from the only reason. Traditional Medicare can seem complicated, and most experts recommend its users also purchase Medigap insurance, which covers some of the out-of-pocket costs Medicare pushes to the user.

Many conservatives have a way of going quiet about government spending when it fattens the bottom lines of big corporations.

That combo can be more expensive up front for seniors, many of whom are cash-strapped. Medicare Advantage plans seem simpler, and also frequently offer enticements like gym memberships and dental care. The downsides aren’t as obvious until the enrollee needs lifesaving medical care — when it can be cost-prohibitive to seniors to switch back to the traditional government program. Given that lifesaving care is hardly an uncommon need for the elderly, it’s little wonder the program has acquired the nasty nickname “Medicare Disadvantage.”

You would think an outfit like the Heritage Foundation, which complains regularly about both the federal budget deficit and supposed restrictions on economic freedom, would want to do the exact opposite of a program that increases government spending and reduces Americans’ choices.

But many conservatives have a way of going quiet about government spending when it fattens the bottom lines of big corporations. And Medicare Advantage is excellent at that. Insurers are so flush with profits that they’re using this excess federal money to create vertical monopolies, hoovering up everything from physician practices to pharmacy benefit managers and stymying competition by steering their customers to their own, not infrequently higher priced, offerings. The result is that the worse care and reduced choice of Medicare Advantage spills over to the rest of America.

All of these issues could worsen if Medicare Advantage is made the default option. “Pushing people into Medicare Advantage is a recipe for further enriching corporate health insurers at the expense of older adults, destroying Medicare as we know it. It compounds health inequities. Vulnerable Americans are likely to lose access to their choice of doctors and face barriers to getting the care they need,” says Diane Archer, president of Just Care USA.

This isn’t just impacting the millions of Americans on Medicare. It’s running up all our bills. If you are trying to save the government money while offering up better care for the money spent, pushing Medicare Advantage is the exact opposite of what the doctor ordered.

Helaine Olen is a managing editor at the American Economic Liberties Project and a reporter in residence at the Omidyar Network. She is the author of "Pound Foolish: Exposing the Dark Side of the Personal Finance Industry" and a co-author of "The Index Card: Why Personal Finance Doesn't Have to Be Complicated." She has been a columnist for The Washington Post and Slate, and her work has also appeared in numerous other publications, including The New York Times and The Atlantic.