Without Consent, Medicare Advantage Enrollment is Wrong

by Twila Brase, RN, PHN, President and Co-founder of Citizens’ Council for Health Freedom

Photo by Annabel Podevyn on Unsplash

Frances Walter broke her left shoulder in a fall and underwent surgery. During her recovery, her Wisconsin Medicare Advantage plan relied on an algorithm to set a strict limit of 16.6 days in a nursing facility. When day 17 arrived, coverage stopped, even though medical records showed she was still unable to dress herself, use the bathroom without help, or control her pain.

A federal judge later criticized the decision as “at best, speculative.” But by that point, Frances had already exhausted her savings to qualify for Medicaid. She passed away in December 2022, after spending her final years fighting for the care she needed.

Now, the Trump administration and Republicans in Congress want to automatically place every new Medicare recipient into a plan just like the one that denied Frances—for three years. Without consent.

These private health plans under government contract follow different rules than Original Medicare, allowing denial of care per health plan criteria, not treatment per doctor’s orders.

H.R. 3467, introduced by Congressman David Schweikert (R-AZ) in May 2025, would place every new Medicare beneficiary without their consent into the lowest-premium Advantage plan in their ZIP code at enrollment.

The bill includes an opt-out option but provides no specifics on when the opt-out option ends, how seniors will be informed it exists, or what it would take a senior to switch from Medicare Advantage (MA) enrollment to Original Medicare.

It appears that anyone who does not opt out may be locked in for three years — unable to switch plans or return to Original Medicare unless the federal government determines they qualify for a hardship exemption. But since there is no opt-out language in the bill, we do not know how it would ultimately work.

Now, the Trump administration is weighing a similar policy through executive action, potentially spurred on by the fact that Medicare is projected to be insolvent by 2033 — just seven years from now. Trump’s Medicare administration may also be influenced by the auto-enrollment recommendation in the Heritage Foundation’s Project 2025, which states on page 465: “Make Medicare Advantage the default enrollment option.”

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Medicare Advantage does not function like Original Medicare. Original Medicare, sometimes called “fee-for-service Medicare” (because payment is based on each service provided), rarely requires prior authorization, the lengthy process that often leads to denials of care.

Instead, the doctor determines what care is medically necessary for the patient, the Medicare administration pays its allotted portion, and the patient pays the rest. In short, Original Medicare is the “freedom version” of Medicare. Patients can go to any doctor, hospital, or facility anywhere that takes Medicare. This includes about 98% of all doctors and facilities.

Medicare Advantage is an entirely different operation. The Medicare Administration pays these government-favored health plans a fixed monthly amount to manage each enrollee’s care, otherwise known as “per member, per month” or PMPM payments, approximately $1,000 to $1,200 per member per month, per KFF, or around $12,000 to $14,000 per year.

As Donald Berwick, MD, MPP, and former administrator of the Centers for Medicare & Medicaid Services (CMS) once put it:

“For-profit Medicare Advantage is mostly accountable to its investors and shareholders, not to patients.”

Despite three government reports issued since 2015 by the HHS Office of Inspector General on rationing by Medicare Advantage plans, the denial of medically necessary, Medicare-approved care continues. The 2018 report found if denials are appealed, 75% of the denials are overturned, but only 1% of denials are appealed because it’s a burdensome process. It turns out that denying medically necessary care is a lucrative strategy.

Now, consider the possible damage from auto-enrolling seniors into Advantage plans.

Seniors may fail to opt out in time to get the care they need. According to Keith Armbrecht, founder of Medicare on Video, the lower the premium, the more restrictive the plan tends to be. This means smaller networks, fewer hospitals, and tighter controls on what gets approved. Furthermore, health plans often require ‘step therapy’ – forcing patients to try (and fail) cheaper treatments first, before it will finally cover the treatment that works, causing added expense, additional office visits, and delayed care. Health plans also restrict which doctors and hospitals a patient may use. Seniors who see specialists outside the plan network may get stuck with the entire bill.

UnitedHealth Group is currently facing a federal lawsuit brought in part by the estate of Gene Lokken, a 91-year-old who fractured his leg and ankle in May 2022. His Medicare Advantage plan cut off physical therapy coverage after 19 days. His family paid approximately $150,000 to continue the care his doctor had ordered. He died in July 2023. The lawsuit alleges UnitedHealth used an artificial intelligence (AI) tool with a 90% error rate to make coverage decisions — and kept using it knowing that only 0.2% of patients ever appeal a denial of care.

According to the American Medical Association, 29% of physicians have watched this kind of denial lead to a patient’s hospitalization, disability, or death.

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Despite claims that health plans reduce costs, these corporate health plans do not save money. Medicare is projected to spend $76 billion more on Medicare Advantage enrollees this year than it would if those same patients were enrolled in Original Medicare — a 14% overpayment funded by taxpayers.

This raises Medicare premiums for every senior. Medicare recipients, including those who choose Original Medicare, pay approximately $175 more per year in Medicare Part B premiums because Congress overpays MA plans. KFF’s graphics show how much more costly MA really is.

One way health plans pad their own pockets is through a fraudulent practice called upcoding. Plans add extra diagnosis codes to make patients appear sicker on paper (riskier to the plan’s bottom line), which increases how much the government pays them under the Affordable Care Act (ACA) programs called “risk adjustment” and “risk corridors.”

Eight of the 10 largest Medicare Advantage organizations were found to be coding at higher rates than expected in 2024. The U.S. Department of Justice is now investigating UnitedHealth Group for possible fraud tied to these practices. Previously, Sutter Health Inc. paid $90 million to resolve allegations of submitting unsubstantiated, higher-risk diagnosis codes.

Thus, American workers and Medicare recipients are spending more every year on a program that gives seniors less access to care — and that access is shrinking by the day. For example, hospitals and health systems across the country are dropping Medicare Advantage plans, leaving patients with fewer doctors, fewer hospitals, and fewer real choices.

This reduced access has real consequences. Medicare Advantage cancer patients with complex diagnoses are 1.5 to 2 times more likely to die within 30 days of surgery compared to patients in Original Medicare, according to 2022 study published in the Journal of Clinical Oncology by researchers at City of Hope.

Let’s look at what could happen if Congressman Schweikert’s bill (H.R. 3467) becomes law.

A senior citizen auto-enrolled on January 1 who discovers in February that her oncologist is out of network will likely not be allowed to switch plans, and she will likely not be allowed to switch to fee-for-service, go-to-any-doctor Original Medicare until October. She may be forced to wait up to three years, unless she can prove a qualifying hardship or unless yet unwritten federal regulations allow it. We have no idea what kind of regulations might be written.

Rep. Schweikert himself acknowledged at a July 2025 House hearing that MA has become a “bastardized” program, with lawmakers from both parties calling out the industry for upcoding and care denials.

So why on earth would Congress pass H.R. 3467 to auto-enroll seniors into this same program and close the door behind them? Is the purpose to lock the door and leave seniors trapped in Medicare Advantage for at least three years?

This is the camel’s nose under the Original Medicare tent. Ultimately, the goal is to collapse Original Medicare and force every senior into the care-denying MA program.

This is not a free-market proposal. Free markets require the ability to choose and to leave. Auto-enrollment with a three-year lock removes both.

If President Trump and Congress want to stop the race into Medicare insolvency, why not let seniors voluntarily opt out of Medicare and purchase real health insurance, the affordable major medical indemnity policies that pay solely for catastrophic and insurable events?

Today, seniors are essentially forced to stay in Medicare due to a 1993 Clinton policy that ties access to Social Security benefit with enrollment in Medicare Part A.

Congress should set seniors free. Their lives depend on it.

Photo by Richard Sagredo on Unsplash

What You Can Do

Read Citizens’ Council for Health Freedom’s Medicare How-To Guide, which contains information and analysis found nowhere else, including how to avoid 10 Medicare traps.

Contact U.S. Representative David Schweikert (R-AZ) at 202-225-2190. Contact the House Committee on Ways and Means at 202-225-3625. Tell your own U.S. Representative and U.S. Senator to oppose H.R. 3467 and any proposal that defaults senior citizens into MA plans or locks them in for any period of time. Freedom demands exit ramps, not locked doors.

Freedom also demands independent doctors that work for patients, not payers. Whether you are in Medicare, privately insured, or uninsured, find an independent, cash-based physician that works for you at JoinTheWedge.com.

Frances Walter and Gene Lokken deserved better. We cannot allow America’s seniors to be locked into a program which threatens their lives with no way out.