Episode Details

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

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