The $83 Billion Scam Hidden Inside Medicare (And the Economist Who Proved It)
Economics Matters with Laurence KotlikoffShow Notes
What if the system designed to protect your health in retirement was actually engineered (from the inside) to profit from keeping you confused, underserved, and locked out of the care you've already paid for?
You've spent decades paying into Medicare. You've done everything right. And yet, as you approach the years when healthcare matters most, the system greeting you on the other side is riddled with hidden traps, gaming, and a funding crisis that Washington refuses to look at directly. In this episode, Professor Kotlikoff talks with his Boston University colleague Dr. Randy Ellis, one of the world's foremost health economists and the architect of the very risk-adjustment formula that determines how much the government pays your Medicare Advantage plan. He literally built it. And he's saying it's being exploited in ways that are costing taxpayers $83 billion a year, with your care hanging in the balance. Time Stamped Learnings: [8:27] Why Medicare Advantage plans are paid billions more than they should be, and how insurance companies game the diagnostic coding system to pocket the difference [9:00] The "cherry-picking" crisis nobody in Washington wants to admit: how private health plans are specifically designed to attract healthy enrollees and quietly push sick ones back into traditional Medicare [10:24] Why the formula running your Medicare payments is 30 years old (built in the 1990s, implemented in 2002, and barely updated since) while insurance companies have decades of new data and technology to exploit every loophole [23:00] What Europe is doing right, and why countries like the Netherlands, Germany, and Belgium are delivering better health outcomes at nearly half the cost per GDP [41:14] The age-65 cliff that's trapping older Americans in jobs they don't want, just to hold onto insurance before Medicare kicks in, and a smarter way to phase that transition [39:16]The Ellis Plan: a bold, practical reimagining of how America could restructure its entire healthcare system (without starting a political war) [48:38] Why your kids and grandkids are the ones who will ultimately pay for every year we delay fixing this, and what the math actually looks like [54:46] The risk adjustment fix that could make insurance companies actually want to enroll sick people AND save Medicare billions in the process
Featured Guest Dr. Randy Ellis is a Professor of Economics at Boston University, Past President of the American Society of Health Economists, and author of more than 150 academic papers and reports. With over 11,000 Google Scholar citations, he is best known for developing the HCC Risk Adjustment Formula — the model used to calculate Medicare Advantage (Part C), Medicare Part D, and Obamacare marketplace payments. His current research, developed alongside collaborator Dr. Arlene Ash, proposes a modernized risk adjustment framework that could save the Medicare program $83 billion annually. What You Walk Away With America spends over 18% of its GDP on healthcare, and is on a trajectory toward 20%. Sweden spends 11% and ranks 4th in the world for health outcomes. We rank 21st. This is policy failure compounded by decades of inaction, gaming, and a political culture too proud to look abroad for better answers. If you're approaching Medicare age, actively enrolled, or simply trying to understand why your premiums keep rising faster than inflation — this conversation is essential listening.
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