EP510: The Impact on You of Medicare Advantage Goings-on (2026 Edition), With Betsy Seals
Medicare Advantage 2026: Stabilization, Retrenchment, and a Back-to-Basics Playbook with Betsy Seals
In Episode 510, Stacey Richter interviews Medicare Advantage (MA) consultant Betsy Seals about the 2026 state of MA and its broader impact, including taxpayer value, seniors' access to care, and cost shifting to commercial employers when vertically integrated carriers negotiate MA rates while employers pay higher ASO rates.
Seals describes MA as in a stabilization/retraction phase with market exits, regulatory and administration shifts, and benefit pullbacks that can affect beneficiaries depending on whether plans cut "flashy" enrollment perks versus outcome-focused care. Her "back to basics" guidance emphasizes avoiding profiteering and compliance risks (e.g., upcoding, problematic AI-driven prior authorization), focusing on populations a plan can truly serve well (including chronic SNP strategies), and improving STARS through real health outcomes rather than box-checking.
They discuss high prior-authorization denial overturn rates on appeal, downstream provider incentives, and the need for stronger process reform and regulatory "teeth," while noting confidence in MA's long-term viability.
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP510
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00:00 Introduction to this episode.
00:43 Past episodes on profiteering: EP481 with Benjamin Schwartz, MD, MBA, and EP495 with Mick Connors, MD.
01:25 How Medicare Advantage is relevant to everyone.
06:15 A preview of today's conversation.
07:49 The "state of the state" of Medicare Advantage plans.
08:49 Video by Eric Bricker, MD, on the financial performance of the U.S. healthcare system.
09:32 Does Medicare Advantage's losses matter to the patients?
10:29 A recap of Betsy's insights so far.
11:19 The underlying strategic through line that needs to be considered.
13:04 The impact of Goodhart's Law.
14:12 What the players that are succeeding right now are doing.
14:22 The first pillar of a back-to-basics strategy: Don't get caught with your hand in the cookie jar.
16:07 EP463 with Betsy Seals.
16:50 Why short-term strategies don't work.
18:26 Stats report on prior authorizations serving the beneficiary.
19:32 EP482 with Preston Alexander.
19:38 Why prior authorization needs change.
21:28 The better strategy to use.
21:43 EP462 with Scott Conard, MD.
23:17 The second pillar of a back-to-basics strategy: Focus on the beneficiaries you actually serve well.
24:37 What it looks like to implement this focus on the beneficiaries you serve well.
25:29 How special needs plans play into this.
27:43 The third pillar of a back-to-basics strategy: Think about how STARS in clinical programs improve health.
30:04 The ethical component to implementing a Medicare Advantage program.
31:04 Betsy's advice for independent practices dealing with prior authorizations.
33:37 STAT article by Bob Herman about the effectiveness of Medicare Advantage lobbying on policy.
34:08 Betsy's final notes for all players impacted by what's currently happening.
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