Chapter 4 — Why Medicare Advantage Critics Get It Wrong: The data behind the debate

1. Why We Need to Address the Negative Narratives

Let me be direct about something. Throughout my Medicare career, I’ve watched Medicare Advantage (Part C) evolve from a niche option to the choice of 54% of all Medicare beneficiaries. That’s 32.8 million Americans who have actively chosen Medicare Advantage plans over Original Medicare, including millions of veterans who discovered these plans work perfectly with their military benefits. We’re talking about $462 billion in federal spending.

Yet despite this massive endorsement from actual Medicare beneficiaries, critics continue spreading outdated information and misleading narratives about Medicare Advantage. You’ll hear claims that these plans “restrict access to care,” “deny necessary treatments,” or “trap people in narrow networks.” These criticisms aren’t just wrong. They’re dangerous. They prevent veterans from accessing better coverage and benefits they’ve earned.

(Source: KFF.org, https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-enrollment-update-and-key-trends/)

Here’s what bothers me most. Many critics work for organizations that profit when people stay in Original Medicare and buy expensive Medigap policies. They’re not exactly unbiased observers.

Let me be clear about our approach. My team and I provide Medicare Supplements too (Plan G, N and sometimes others). In fact, when I first entered the industry, Medicare Supplements were the primary programs I offered. Original Medicare with a Medicare Supplement is a fantastic way to receive healthcare coverage, but for veterans it usually involves redundant coverage with their military benefits and becomes very expensive.

We absolutely recommend and provide Medicare Supplements when they’re the best fit for a veteran’s specific needs. For civilians without military benefits, Medicare Supplements often make perfect sense. But as you’ll see from the data, veterans with VA or TRICARE benefits typically have better options available through Medicare Advantage plans.

So let’s examine the actual data. Not opinions, not scare tactics, not theoretical concerns. The real numbers from 2024 and 2025 that show what’s actually happening with Medicare Advantage plans.

2. The Prior Authorization Reality: Numbers Don’t Lie

Prior authorization is the biggest weapon critics use against Medicare Advantage. You’ll hear horror stories about “denied care” and “bureaucratic barriers.” But let’s look at what actually happened in 2023.

The Real Numbers

Medicare Advantage insurers processed 49.8 million prior authorization requests in 2023. Of those, 46.6 million were approved. That’s a 93.6% approval rate. Let me say that again: over 93% of prior authorization requests were approved.

The denial rate was just 6.4%, and here’s the kicker. That’s actually an improvement from 7.4% in 2022. So while enrollment in Medicare Advantage is growing, denial rates are going down.

For veterans, this data is especially important. Too many veterans avoid Medicare Advantage plans because they’ve heard these prior authorization horror stories. But the numbers show these fears are largely unfounded.

But what about appeals? Critics love to point out that 81.7% of denied requests get overturned on appeal. They claim this proves the system is broken. What they don’t tell you is that only 11.7% of denials were actually appealed.

(Source: KFF.org, https://www.kff.org/medicare/issue-brief/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/)

Think about that. If Medicare Advantage plans were really denying necessary care left and right, wouldn’t more people appeal? The low appeal rate suggests that most denials involved incomplete paperwork or requests that providers didn’t feel strongly enough about to pursue.

The current system is already working well, but it’s about to get even better.

The 2026 Improvements

Critics never mention that the system is getting even better. Starting in 2026, new CMS rules require Medicare Advantage plans to respond to prior authorization requests within 7 calendar days instead of 14. That’s cutting wait times in half.

Beginning in 2026, plans must implement automated systems and publish their average response times on their websites. These aren’t small tweaks. They’re major improvements that directly address legitimate concerns about timing.

(Source: CMS.gov, https://www.cms.gov/newsroom/press-releases/cms-finalizes-rule-expand-access-health-information-and-improve-prior-authorization-process)

The Variation Reality

Not all Medicare Advantage plans handle prior authorization the same way. Some of the most efficient plans averaged just 0.5 requests per enrollee in 2022, while others averaged 2.9 requests. Denial rates show even wider variation, ranging from as low as 4.2% at some plans to as high as 13% at others.

This variation proves an important point. Prior authorization experiences aren’t universal across Medicare Advantage. The wide differences between plans show that blanket criticisms of the entire Medicare Advantage system aren’t fair or accurate.

Bottom Line for Veterans

Prior authorization isn’t the boogeyman critics make it out to be. Over 93% of requests get approved, denial rates are improving, and the system is getting faster and more transparent.

Don’t let outdated horror stories prevent you from accessing Medicare Advantage plans that could save you thousands while enhancing your military benefits.

3. The Network “Limitation” Myth: Choice Is Actually Expanding

One of the most common concerns I hear about Medicare Advantage plans is network limitations. Veterans worry that these plans will “trap you in narrow networks” or “restrict your doctor choices.” This concern made sense years ago, but the landscape has changed dramatically.

The PPO Revolution

43% of Medicare Advantage beneficiaries are now enrolled in PPO (Preferred Provider Organization) plans that cover out-of-network care at higher cost-sharing levels. That’s a massive shift from 2017, when PPOs made up only 24% of enrollment.

This means that contrary to what critics say about network limitations, many Medicare Advantage beneficiaries have plans with significant flexibility to see providers outside their networks, throughout the United States. Yes, they may pay more for out-of-network care, but they often have more choice than critics suggest. And for veterans with TRICARE for Life, TFL is still required to pay all deductibles, copays and coinsurance for out-of-network services that civilian retirees would have to pay entirely on their own.

(Source: KFF.org, https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-enrollment-update-and-key-trends/)

For veterans, this network flexibility is especially important. Many veterans split their time between VA facilities and civilian providers, travel frequently, or live in areas where having backup options matters. PPO plans give you that flexibility while still working seamlessly with your existing military benefits.

The vast majority of our veteran clients choose PPO plans specifically because they want this flexibility. These plans work perfectly with their military benefits. Whether they’re traveling to see grandkids, living part-time in different states, or just want local options when the VA is too far away, PPO plans give them the freedom they’ve earned.

Geographic Reality

99.7% of Medicare beneficiaries have access to at least one Medicare Advantage plan, and the average beneficiary can choose among 43 different plans in 2024. Rural enrollment has quadrupled since 2010, with 40% of eligible rural beneficiaries now choosing Medicare Advantage.

If Medicare Advantage plans were really “cherry-picking” only profitable urban markets like critics claim, how do you explain this massive expansion into rural areas? Rural veterans especially benefit from this growth because it gives them local options when VA facilities are far away.

Take a veteran living in rural Wyoming, 120 miles from the nearest VA facility. His Medicare Advantage PPO plan gives him access to the local hospital and clinic in his town, plus specialists in the regional medical center. When he needs VA care for service-connected conditions, he uses the VA. When he needs urgent care or wants a second opinion, he has local options. Critics call this “network limitation,” but veterans call it choice.

Network Quality vs. Network Size

Critics obsess over network size. How many doctors are included in each plan? But what matters more is whether you can get the care you need when you need it.

Many high-performing integrated healthcare systems operate with focused networks while achieving superior health outcomes through better care coordination. A smaller network of well-coordinated providers often delivers better care than a massive network of disconnected doctors who don’t communicate with each other.

Medicare Advantage plans must meet CMS network adequacy standards for time, distance, and provider-to-beneficiary ratios. These aren’t suggestions. They’re enforced requirements that ensure reasonable access to care.

For veterans, network adequacy often means having both civilian options and continued access to VA care. The best Medicare Advantage plans don’t interfere with your ability to use VA facilities. They give you additional options when the VA can’t meet your needs or when you want civilian care for convenience.

Bottom Line for Veterans

The “narrow network” criticism doesn’t match today’s reality. With 43% of Medicare Advantage enrollees in PPO plans that cover out-of-network care, and rural access expanding rapidly, veterans have more choices than ever.

The real question isn’t whether Medicare Advantage plans limit your choices. It’s whether you’re working with someone who knows which plans give you the most flexibility while maximizing your veteran benefits.

4. Quality Measures: Medicare Advantage Outperforms Original Medicare

Throughout my Medicare career, I’ve encountered countless veterans who believe Medicare Advantage plans are somehow “second-class” healthcare compared to Original Medicare. This misconception costs veterans real money and better health outcomes. The actual data reveals something completely different. Medicare Advantage plans consistently deliver superior care across virtually every quality measure that matters.

Let me break this down in terms that matter to you as a veteran.

The Reality: Medicare Advantage Leads in Quality

The Centers for Medicare & Medicaid Services publishes comprehensive Star Ratings each year to measure healthcare quality. In 2025, approximately 62% of Medicare Advantage enrollees are in plans rated four stars or higher. Plans earning four or more stars qualify for quality bonus payments, which totaled $11.8 billion in 2024.

(Source: CMS.gov, https://www.cms.gov/newsroom/fact-sheets/2025-medicare-advantage-and-part-d-star-ratings)

(Source: KFF.org, https://www.kff.org/medicare/issue-brief/medicare-advantage-quality-bonus-payments-will-total-at-least-11-8-billion-in-2024/)

For veterans, this means you’re not just getting Medicare coverage. You’re getting coverage that’s been proven to work better than the traditional system, and it enhances your existing military benefits rather than competing with them.

Prevention and Screening Excellence

Medicare Advantage plans excel at providing comprehensive preventive services that help detect health problems early. This includes screenings for cancer, diabetes, cardiovascular disease, and other chronic conditions that, when caught early, can save your life.

(Source: CMS.gov, https://www.cms.gov/medicare/coverage/preventive-services-coverage)

Think about this from a veteran’s perspective. You might have routine care through the VA, but what happens when you’re visiting family in another state? Or if you live in a rural area where the nearest VA facility is hours away? Medicare Advantage plans provide immediate access to preventive screenings wherever you are.

Recent studies show Medicare Advantage beneficiaries with diabetes who received in-home clinical visits had remarkable results. 9% reduction in hospitalizations, 28% reduction in readmissions, and 19% reduction in hospital stays. Even better, they showed a 7% increase in physician office visits to address gaps in care.

(Source: Better Medicare Alliance, https://bettermedicarealliance.org/publication/prevention-care-and-screening-in-medicare-advantage/)

Hospital Avoidance and Better Outcomes

The hospital avoidance data is particularly compelling for veterans. Analysis shows emergency room visits were 20-25% lower among Medicare Advantage enrollees, and inpatient days were 25-35% lower than Original Medicare.

For a veteran living far from VA facilities, this coordination can prevent emergency situations requiring expensive, long-distance medical transport. In multi-state studies, Medicare Advantage enrollees had 9-22% lower odds of preventable hospital admissions compared to Original Medicare, with readmission rates 13-20% lower.

Independent Specialists Make the Difference

When we work with veterans on Medicare decisions, we don’t just look at Star Ratings in isolation. We evaluate how high-quality plans work with your existing military benefits. As independent specialists, we’re not bound by company quotas. We can objectively compare quality metrics across ALL available plans in your area.

As specialists who work exclusively with veterans, we analyze which high-quality plans specifically excel in areas that matter most to you. How they work with military benefits, nationwide networks for travel, and strong chronic disease management programs.

What This Means for Your Decision

The quality data translates into real benefits for veterans:

• Better preventive care: More comprehensive screenings and early detection
• Reduced hospitalizations: Care that keeps you healthier
• Improved chronic disease management: Systematic approaches to ongoing conditions
• Enhanced integration: Medicare works seamlessly with your military healthcare
• Financial protection: Quality bonuses often mean better benefits and lower costs

The bottom line is straightforward. Medicare Advantage plans that earn high Star Ratings do so by delivering measurably better care. For veterans who understand the value of coordinated, mission-focused healthcare through military service, Medicare Advantage quality metrics prove you’re getting that same level of excellence in your civilian healthcare benefits.

5. Financial Reality: Medicare Advantage Saves Money

Let’s cut through the political noise and talk about what matters most to veterans on fixed incomes: your money. I’ll show you the actual numbers, using real examples, so you can make an informed financial decision.

The 2025 Cost Reality

Medicare Part B costs $185 per month in 2025, which equals $2,220 annually. For veterans living on Social Security and military retirement, that’s a significant expense.

32% of Medicare Advantage plans now offer Part B premium reductions. Many offer $100 or more in monthly savings.

(Source: KFF.org, https://www.kff.org/medicare/issue-brief/medicare-advantage-2025-spotlight-a-first-look-at-plan-premiums-and-benefits/)

Even better, 75% of Medicare Advantage enrollees pay no additional premium beyond their Part B costs. The average Medicare Advantage premium in 2025 is just $17 per month.

(Source: KFF.org, https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-premiums-out-of-pocket-limits-supplemental-benefits-and-prior-authorization/)

Real Money: Dad Wallace’s Example

My father, Wallace Duncan, is an 81-year-old Vietnam-era veteran who receives a $175 monthly Part B premium refund from his Medicare Advantage plan. That’s $2,100 back in his pocket every year.

Dad takes 8 medications regularly. As a priority 8 veteran at the VA, he pays copays based on the VA’s tiered system: $5 for preferred generics (Tier 1), $8 for non-preferred generics (Tier 2), and $11 for brand names (Tier 3) per 30-day supply. With his mix of medications across different tiers, his monthly VA medication costs would run approximately $50-70.

Here’s the critical detail: While the VA caps annual medication copays at $700 for veterans in Priority Groups 2-8, that’s still $700 out of pocket every year.

Instead, Dad has the VA transfer his prescriptions to his local pharmacy. His Medicare Advantage plan includes Part D prescription coverage at no additional premium, and he gets those same medications with a $0 copay through his plan’s formulary.

Dad’s total annual savings: $2,100 in premium refunds plus $700 in prescription savings (the maximum he’d pay at the VA) equals $2,800 in real money back every year.

This isn’t just about the money. It’s about choice and convenience. Dad can use any pharmacy in his plan’s network, including the one two blocks from his house, instead of driving to the VA facility or waiting for mail-order prescriptions.

(Source: VA.gov, https://www.va.gov/health-care/copay-rates/)

Prescription Drug Flexibility

Now your copay may vary, but with the extra coverage that’s included, you get more choice in where to fill your prescriptions, giving you the best possibility of lowering your costs. In addition, the VA’s formulary doesn’t include every possible prescription. If Part D is included in your Medicare Advantage plan and you’re prescribed a drug that the VA won’t cover, your Part D may cover it.

The 2025 Inflation Reduction Act caps Part D out-of-pocket costs at $2,000 annually. Veterans have additional advantages because VA drug coverage is creditable for Part D purposes, meaning you avoid late enrollment penalties.

Premium Refund Reality

Our veteran clients average $110 monthly in Part B premium refunds. That’s $1,320 annually, or $13,200 over 10 years in premium refunds alone.

Compare that to Original Medicare, where you pay the full $185 monthly ($2,220 annually) and get basic coverage with significant gaps.

Out-of-Pocket Cost Protection

Original Medicare has no annual limit on what you can spend. Medicare Advantage plans are required to cap your annual out-of-pocket spending. In 2024, the average maximum was $4,882 for in-network services.

(Source: KFF.org, https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-premiums-out-of-pocket-limits-supplemental-benefits-and-prior-authorization/)

Additional Benefits Value

Medicare Advantage plans receive an average of $2,329 per enrollee in government funding above basic Medicare costs, allowing substantial additional benefits at no extra charge.

Common benefits include:

• Comprehensive dental coverage
• Vision benefits with frames
• Hearing aids
• Fitness memberships

Many veterans receive substantial annual benefit value while paying nothing extra for their Medicare Advantage plan.

The 10-Year Financial Impact

For a veteran with our average $110 monthly premium refund:

• Annual premium refunds: $1,320
• 10-year premium refunds: $13,200*

*Note: This calculation uses today’s refund amount, but as Medicare Part B premiums increase over time, many Medicare Advantage plans increase their premium refunds proportionally. This means your actual 10-year savings could be significantly higher as both the Part B premium and your refund amount grow.

This doesn’t include the value of additional benefits like dental, vision, hearing, and fitness coverage. Many plans have actually increased their premium refunds over time, both to keep pace with Part B premium increases and to remain competitive in the marketplace.

The Bottom Line

The financial advantages are measurable and immediate:

• Monthly premium refunds that reduce or eliminate Part B costs
• Annual out-of-pocket limits that protect against catastrophic expenses
• Comprehensive additional benefits that address coverage gaps
• Prescription drug flexibility that can reduce medication costs

These are documented financial benefits that thousands of veterans receive every month. The choice is between paying full price for basic coverage with gaps, or receiving money back plus comprehensive benefits while maintaining all your military healthcare rights.

The math speaks for itself.

6. The Care Coordination Advantage Critics Can’t Explain Away

This is where the anti-Medicare Advantage argument completely falls apart. Original Medicare operates as a claims processor that pays bills after you get care, but provides no mechanism for coordinating that care between providers.

How Integration Actually Works for Veterans

Medicare Advantage plans operate as integrated healthcare systems where your providers can coordinate your treatment plan. For veterans who often see multiple specialists for service-connected conditions while maintaining routine care through Medicare, this coordination prevents dangerous gaps.

When you have multiple chronic conditions common among veterans (diabetes, heart disease, PTSD), this coordination can be the difference between effective treatment and dangerous drug interactions or conflicting therapies.

Proactive vs. Reactive Care Management

Many Medicare Advantage plans now provide remote monitoring technology and care management that enables early intervention when readings indicate potential problems. Instead of waiting for a medical crisis, care coordinators can initiate virtual consultations, adjust medications, or schedule preventive appointments.

For veterans managing multiple conditions, this proactive approach complements your VA care by providing additional oversight and coordination when you’re using civilian providers or traveling away from VA facilities.

Original Medicare has no mechanism for this kind of proactive care management. It’s purely reactive. It pays for services after health problems develop.

Disease Management Programs

Medicare Advantage plans implement coordinated protocols for managing diabetes, heart disease, COPD, and other chronic conditions common among veterans. These programs track patient outcomes across multiple providers and adjust treatment based on real-world results.

Under Original Medicare’s fee-for-service structure, every provider makes independent decisions with no central coordination or shared accountability for outcomes. This fragmented approach often leads to conflicting treatments or missed opportunities for better health management.

The Veteran Advantage

For veterans with existing relationships with VA providers, Medicare Advantage care coordination doesn’t replace your VA team. It enhances your overall care by providing civilian backup with systematic oversight. Whether you’re managing service-connected disabilities alongside age-related conditions or need coordinated care while traveling, integrated Medicare Advantage plans provide the kind of mission-focused healthcare coordination that veterans understand and value.

Critics of Medicare Advantage can’t explain away this fundamental difference. Coordinated care simply works better than fragmented care, especially for veterans managing multiple conditions across different healthcare systems.

7. Special Populations: Where Medicare Advantage Excels

The data tells a compelling story. Populations with the most complex healthcare needs choose Medicare Advantage at the highest rates. For veterans, this reveals why coordinated care consistently outperforms fragmented care.

Racial and Ethnic Minorities

Over 30% of Medicare Advantage beneficiaries are racial or ethnic minorities, compared to 18% in Original Medicare. These communities often have complex healthcare needs and benefit from coordinated care approaches.

(Source: KFF.org, https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-enrollment-update-and-key-trends/)

Special Needs Plans

6.6 million Medicare Advantage beneficiaries are enrolled in Special Needs Plans (SNPs) designed specifically for people with chronic conditions, dual Medicare-Medicaid eligibility, or institutional care needs.

Veterans with service-connected disabilities often qualify for Special Needs Plans that coordinate both their Medicare and VA benefits more effectively than Original Medicare’s fragmented approach. These plans provide highly specialized care coordination that’s impossible under Original Medicare’s structure, with demonstrated success in managing high-risk populations while reducing costs and improving outcomes.

Rural Communities

Medicare Advantage enrollment in rural areas has quadrupled since 2010. Rural veterans face unique challenges. Long distances to VA facilities, limited civilian provider networks, and complex coordination between military and civilian care.

Medicare Advantage plans address these challenges through:

• Nationwide networks that work whether you’re near a VA facility or not
• Telehealth services that provide immediate access to specialists
• Care coordination that bridges VA and civilian providers
• Transportation benefits that help with long-distance medical travel

Rural veterans, who often live hours from VA facilities, particularly benefit from Medicare Advantage telehealth and care coordination when VA services are geographically inaccessible.

The Veteran Population Reality

Veterans represent a significant portion of these special populations:

• Many veterans live in rural areas where VA facilities are distant
• Veterans have higher rates of service-connected disabilities requiring specialized care
• Minority veterans need culturally competent care coordination
• Veterans often qualify for dual Medicare-Medicaid benefits through VA disability ratings

What This Proves

The evidence is clear. Populations with the most complex healthcare needs, including rural veterans, disabled veterans, and minority veterans, consistently choose Medicare Advantage because coordinated care simply works better than fragmented care.

If Medicare Advantage were really inferior to Original Medicare, these populations wouldn’t be choosing coordinated care at such dramatically higher rates. The data speaks for itself. When healthcare needs are most complex, coordination matters most.

8. Market Competition: Driving Continuous Improvement

Critics paint Medicare Advantage as a monolithic system controlled by big insurance companies. The reality is much more competitive and dynamic, and this competition directly benefits veterans in ways that Original Medicare simply can’t match.

When my team and I evaluate Medicare Advantage plans for veterans, we’re not limited to one or two options. We can choose from plans offered by an average of 8 different insurers in most areas. While the two largest national companies collectively enroll 47% of Medicare Advantage beneficiaries, regional and smaller plans successfully compete by targeting specific populations, including veterans, or offering innovative benefits that larger companies can’t match.

This competition creates a powerful dynamic that works in veterans’ favor. Plans that don’t satisfy beneficiaries lose enrollment during annual Open Enrollment periods. For veterans, this means insurers actively compete for your business by offering better Part B premium refunds, more comprehensive benefits, and services that complement your military coverage.

(Source: KFF.org, https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-enrollment-update-and-key-trends/)

How Competition Benefits Veterans Specifically

Competition really pays off for veterans. Nearly all Medicare Advantage plans now cover dental, vision, or hearing services not available in Original Medicare or TRICARE for Life. While the VA provides dental coverage for veterans with 100% disability ratings and certain other qualifying conditions, most veterans don’t have access to comprehensive dental benefits through the VA. Even our clients with 100% disability who have VA dental coverage often use both their VA dental benefits and the dental benefits in their Medicare Advantage plans. They appreciate the additional choice, especially when the VA dental clinic has long wait times or limited appointment availability.

These benefits exist because plans compete for enrollment by providing value beyond basic medical coverage. For veterans who already have strong medical coverage through the VA or TRICARE for Life, these extra benefits fill gaps that military coverage doesn’t address. Original Medicare can’t innovate in this way due to its statutory structure. It’s locked into providing only the basic benefits defined by law.

The competition for veteran business has been particularly intense. Most of our veteran clients choose PPO plans specifically because competition has driven insurers to offer nationwide networks that work whether you’re near a VA facility or traveling across the country. Veterans have unique needs. They travel to see family, they split time between different states, they need backup coverage when VA care isn’t available. Competition has pushed plans to address these specific situations.

Veterans Voting with Their Feet

Medicare beneficiaries have an annual opportunity to switch between Medicare Advantage and Original Medicare with no penalties or restrictions. If Medicare Advantage plans were really inferior, people would switch back to Original Medicare.

Instead, enrollment continues growing, and disenrollment rates remain low. Most beneficiaries who change plans during Open Enrollment switch between Medicare Advantage plans rather than returning to Original Medicare. They’re not leaving the system. They’re finding better options within the system.

For veterans specifically, this annual choice creates tremendous leverage. When a plan reduces its Part B premium refund or cuts benefits, veterans can vote with their feet and choose a competitor. This keeps plans honest and ensures they continue earning veteran business through superior value, not market manipulation.

When we conduct annual reviews with veterans during Open Enrollment, we’re often able to find plans with higher premium refunds or better benefits that weren’t available the previous year. That’s competition working exactly as it should. Driving continuous improvement that benefits veterans directly.

The Independence Advantage in a Competitive Market

This competitive environment is exactly why working with independent specialists like my team makes such a difference for veterans. Generic advisors tied to specific insurance companies can only show you their company’s offerings. They can’t take advantage of the full competitive landscape.

As independent specialists, we can evaluate all available plans from all competing insurers to find the best Part B premium refunds, the most veteran-friendly networks, and the benefits that best complement your existing military coverage. Competition only benefits you if you have access to all the competitors, not just the ones your advisor is authorized to recommend.

This is why our veteran clients consistently get better outcomes. We’re not limited by corporate relationships or sales quotas. We can leverage the full competitive marketplace to find the plans that offer veterans the maximum value from companies that are actively competing for your business.

9. Who’s Really Behind the Anti-Medicare Advantage Campaign

Let me be blunt about something. Many of the loudest Medicare Advantage critics have financial interests in keeping people in Original Medicare.

The Medigap Industry

Organizations that provide Medicare Supplement (Medigap) insurance benefit when people choose Original Medicare because that’s the only way their products make sense. If everyone chose Medicare Advantage plans with built-in out-of-pocket maximums, the Medigap industry would largely disappear.

Some of the most vocal “consumer advocacy” groups receive funding from companies that profit when people avoid Medicare Advantage. That’s not objective analysis. It’s biased advocacy disguised as consumer protection.

What makes independent Medicare specialists different is that we provide Medigap coverage when it’s appropriate for someone’s situation. We’re not anti-Medigap or pro-Medicare Advantage. We’re pro-whatever works best for each individual based on comprehensive analysis, not financial bias toward one product type.

Provider Revenue Models

Some provider organizations prefer Original Medicare’s fee-for-service payment model because it allows them to bill for individual services without accountability for outcomes or cost-effectiveness.

Medicare Advantage plans’ focus on value-based care and outcome accountability threatens traditional revenue models based on service volume rather than health results.

Academic and Think Tank Bias

Many policy researchers and think tanks have ideological opposition to private involvement in Medicare, regardless of outcomes or beneficiary satisfaction. Their criticism of Medicare Advantage often reflects philosophical positions rather than objective evaluation of performance data.

10. The Congressional Budget Office Reality Check

The Congressional Budget Office projects that Medicare Advantage enrollment will reach nearly two-thirds of Medicare beneficiaries by 2034. This isn’t speculation. It’s their official forecast based on demographic trends and program performance documented in their 2024 health insurance projections.

If Medicare Advantage were really as problematic as critics claim, would enrollment be projected to continue growing for the next decade? Would millions of Americans annually choose inferior coverage when they have better alternatives? The CBO projections reflect what my veteran clients experience every day. Medicare Advantage plans provide better value, more comprehensive benefits, and superior care coordination compared to Original Medicare for most beneficiaries.

(Source: Congressional Budget Office, https://www.cbo.gov/publication/60383)

11. What the Critics Can’t Explain

Critics can never adequately answer these questions:

Why do satisfaction surveys consistently show high ratings for Medicare Advantage plans? The 2024 J.D. Power study found Medicare Advantage customer satisfaction scored 652 points (on a 1,000-point scale) and was 87 points higher than commercial health plans, with top satisfaction drivers being ease of finding care, low out-of-pocket costs, and provider choice.

(Source: J.D. Power, https://www.jdpower.com/business/press-releases/2024-us-medicare-advantage-study)

Why do beneficiaries continue choosing Medicare Advantage at increasing rates when they can switch back to Original Medicare? Enrollment has grown steadily for two decades, with 76% of Medicare Advantage members now choosing 4+ star rated plans, up ten percentage points since 2015. Why do rural communities and minority populations choose Medicare Advantage at higher rates if it’s inferior coverage? Rural enrollment has quadrupled from 11% in 2010 to 40% in 2023, while Medicare Advantage enrolls a disproportionate share of people of color compared to Original Medicare.

(Source: KFF.org, https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-enrollment-update-and-key-trends/)

Why do Medicare Advantage plans achieve better outcomes on preventive care and chronic disease management? Studies show Medicare Advantage plans deliver 21% higher spending on preventive services, 46% higher breast cancer screening rates for dual eligible beneficiaries, and 29% lower rates of potentially avoidable hospitalizations compared to Original Medicare. Why do independent quality measures show Medicare Advantage outperforming Original Medicare on key health metrics? Research demonstrates that Medicare Advantage beneficiaries experience 23% fewer inpatient stays, 33% fewer emergency room visits, and consistently better outcomes on chronic disease management measures.

(Source: RISE Health, https://www.risehealth.org/insights-articles/medicare-advantage-achieves-cost-effective-care-and-better-outcomes-for-beneficiaries-with-chronic-conditions-relative-to-fee-for-service-medicare/)

The data speaks for itself. Medicare Advantage isn’t perfect, but it consistently outperforms Original Medicare on measures that actually matter: health outcomes, financial protection, and comprehensive benefits.

12. The 2026 Regulatory Improvements

Rather than acknowledging Medicare Advantage’s success, critics often claim that any problems are unfixable. Recent CMS regulatory improvements prove otherwise, delivering meaningful prior authorization and patient protection enhancements.

Prior Authorization Improvements

The CMS Interoperability and Prior Authorization Final Rule, effective beginning in 2026, requires Medicare Advantage plans to:

• Respond to prior authorization requests within 7 calendar days for standard requests (down from 14)
• Respond within 72 hours for expedited/urgent requests
• Provide specific denial reasons from standardized industry criteria for all denials
• Implement automated Health Level 7 FHIR Prior Authorization APIs by 2027
• Publicly report prior authorization metrics annually starting March 31, 2026

(Source: CMS.gov, https://www.cms.gov/newsroom/press-releases/cms-finalizes-rule-expand-access-health-information-and-improve-prior-authorization-process)

Inpatient Care Protections

The Contract Year 2026 Medicare Advantage Final Rule strengthens patient protections by requiring:

• Plans cannot retroactively deny previously approved inpatient admissions except for fraud or obvious error
• All coverage decisions during or after an inpatient stay must be treated as formal determinations, granting enrollees full appeal rights
• Plans must notify both providers and enrollees of all coverage decisions
• Beneficiaries cannot be held financially responsible until a claims payment determination is made

(Source: CMS.gov, https://www.cms.gov/newsroom/fact-sheets/contract-year-2026-policy-and-technical-changes-medicare-advantage-program-medicare-prescription-final)

Dual-Eligible Integration

For veterans who qualify for both Medicare and Medicaid, CMS is finalizing new requirements for dual eligible special needs plans to provide integrated member ID cards and conduct integrated health risk assessments by 2027, reducing bureaucratic complexity.

These targeted reforms address specific areas for improvement while preserving Medicare Advantage’s ability to coordinate care and control costs. The prior authorization improvements alone are estimated to generate $15 billion in administrative savings over ten years while improving patient access to timely care.

Quality Measurement Evolution

Starting in 2026, the Star Ratings system is fundamentally shifting toward outcome-based measurement that prioritizes actual health improvements over administrative processes. CMS is reducing Patient Experience measures from 4x to 2x weight while reintegrating Health Outcomes Survey measures for physical and mental health improvement.

Clinical outcomes like diabetes control and preventing avoidable hospitalizations receive increased emphasis. This transformation ensures Medicare Advantage plans focus on what matters most. Demonstrably keeping beneficiaries healthy through coordinated, effective care delivery.

(Source: Press Ganey, https://info.pressganey.com/press-ganey-blog-healthcare-experience-insights/health-outcome-surveys-2026)

13. Key Takeaways

✓ Medicare Advantage approval rates for prior authorization exceed 93%, with denial rates declining as enrollment grows

✓ Nearly half of Medicare Advantage beneficiaries have PPO plans that cover out-of-network care, contrary to “network limitation” claims

✓ Medicare Advantage consistently outperforms Original Medicare on preventive care and chronic disease management measures

✓ Beneficiaries save an average of $2,541 annually with Medicare Advantage compared to Original Medicare plus Medigap

✓ Care coordination and proactive health management in Medicare Advantage prevent hospitalizations and improve outcomes

✓ Special populations choose Medicare Advantage at high rates: minorities, rural communities, and people with chronic conditions

✓ Market competition drives continuous innovation in benefits and service delivery

✓ CMS regulatory improvements address legitimate concerns while preserving Medicare Advantage’s structural advantages

✓ Anti-Medicare Advantage criticism often comes from organizations with financial interests in Original Medicare and Medigap sales

✓ Congressional Budget Office projects Medicare Advantage enrollment will reach 64% by 2034, reflecting sustained consumer preference

14. The Bottom Line

After examining comprehensive data from 2024 and 2025, the case against Medicare Advantage critics is overwhelming. They’re promoting outdated narratives that ignore current reality, often driven by financial interests rather than beneficiary welfare.

The evidence is clear. Medicare Advantage plans deliver 93.6% prior authorization approval rates, with nearly half of beneficiaries in PPO plans that cover out-of-network care. Among our veteran clients, the vast majority choose Medicare Advantage PPO plans specifically for this network flexibility. Beneficiaries save an average of $2,541 annually compared to Original Medicare plus Medigap while receiving better preventive care and chronic disease management.

The 2026 regulatory improvements address every major criticism while preserving Medicare Advantage’s care coordination advantages. Medicare Advantage isn’t perfect, but continued oversight and the Star Ratings evolution toward health outcomes ensure constant improvement.

When critics attack Medicare Advantage, ask yourself: Do their claims match the actual data? Are they acknowledging the 2026 improvements and regulatory reforms? Do they have financial interests in Original Medicare and Medigap sales?

Most importantly, 32.8 million Americans have chosen Medicare Advantage over Original Medicare. The Congressional Budget Office projects enrollment will reach 64% by 2034. These aren’t confused or misled beneficiaries. They’re making informed decisions based on actual experience.

I’m not arguing Medicare Advantage is right for everyone, but it’s a very good option for many, especially veterans. Having both options is important. I’m not trying to persuade anyone away from Original Medicare, but rather pointing out why Medicare Advantage is popular among the 54% of Medicare beneficiaries who choose it.

For veterans specifically, Medicare Advantage offers unique advantages that generic critics ignore. Enhancement of military benefits, veteran-friendly plan designs, and opportunities like Part B premium refunds that can put real money back in your pocket.

The data proves Medicare Advantage critics need to update their talking points or admit their real objection isn’t to program performance, but to private sector involvement in Medicare delivery. The next chapter reveals how veterans can access these often-overlooked financial benefits that you’ve already earned through decades of service and Medicare contributions.

What’s Coming Next

Now that you’ve seen why Medicare Advantage critics’ arguments don’t hold up against the data, you’re probably wondering: “What specific benefits am I missing?”

For veterans, there’s one benefit that stands out above all others: Medicare Part B premium refunds.

In Chapter 5, you’ll discover how certain Medicare Advantage plans actually send money back to you every month. My dad Wallace receives $175 monthly through his plan. Our clients average $110 in monthly refunds.

You’ll learn why veterans are perfect candidates for the highest refunds available, and how these refunds work alongside your VA benefits without interfering with them.

Ready to discover money you didn’t know you were entitled to?

Ready to explore your Medicare Advantage options? Call 888-960-8387 (VETS) to experience what WE SPEAK VETERAN™ really means.

For educational content about Medicare strategies and the latest developments in Medicare Advantage, you can find us on:

YouTube: https://www.youtube.com/@ChrisDuncan-WeSpeakVeteran
Facebook: https://facebook.com/veteransadvantagefinancial
Instagram: https://www.instagram.com/wespeakveteranchrisduncan/
X/Twitter: https://x.com/wespeakveteran
TikTok: https://www.tiktok.com/@christopherduncanvaf