How Upstate Retirees Fought Privatized Health Care And Won

Goehler worked for the Cortland County Public Defender’s office for 17 years. Now in his late 60s, he’s entitled to the county’s retirement benefits — including its health coverage, a combination of traditional Medicare and a supplemental plan paid for by the county. Goehler’s wife and 23-year-old son also receive health insurance through his retirement plan, which he said works well for the three of them. If the county forced its retirees onto an Advantage plan and he preferred to stay on traditional Medicare, he would have to opt out of his retiree health plan, and his wife and son would lose their coverage. If that had happened last year, Goehler says, it would have disrupted “serious” appointments for his wife’s eye treatments. When he received the county’s letter last summer, he convened a group of retirees to figure out what they should do.

Many had heard Medicare Advantage horror stories of patients being forced to switch doctors or providers needing to wait for insurers’ approval to prescribe urgently needed medication. Traditional Medicare, they knew, was accepted just about everywhere in the United States, no questions asked, while private plans typically restrict you — to some degree — to providers in their network. Advantage plans, they had heard, also require prior authorization, which can sometimes delay or deny care to patients who need it.

After several informational sessions, the county legislature held a procedural subcommittee meeting in mid-August about the planned switch, which turned tense when retirees in attendance voiced their concerns. Representatives from the Broome County Purchasing Alliance, which buys Advantage plans on behalf of counties and localities, gave a slideshow presentation assuring the audience that their product, a UnitedHealthcare Medicare Advantage plan, was the best on the market. (Comparing it to the plan that New York City retirees rejected, a representative said it was “totally apples and nuts, not even apples and oranges.”) As retirees asked questions, a common refrain emerged: They thought this was happening too quickly, and wanted the legislature to at least slow down and give them time to understand the new plan. (UnitedHealthcare did not respond to requests for comment.)

Instead, the legislature put its foot on the gas. It moved up a planned vote and passed the resolution, 10-6, nine days after the subcommittee meeting. (County legislators who supported the switch to Medicare Advantage did not respond to interview requests.) The retirees would be on the new plan by January 2024, less than six months after they received that first letter.

“The subcommittee members watched the slideshow and listened to the salesmen and all go, ‘Yep, sounds good!’” Goehler said. In his view, the county’s part-time legislators were outclassed by the for-profit insurance industry, which dazzled them with claims that the county could provide its retirees with better health care along with new perks like vision and dental coverage, all while cutting costs.

Inspired by the New York City retirees, Goehler put together a lawsuit. Working pro bono, he contacted as many of the county’s retirees as he could find, some of whom had moved out of state or were in poor health and unaware that the change was even happening. The county has 376 retirees, but its retiree health plan covers 564 people, including spouses. Goehler drove around collecting signatures, often meeting up with retirees in parking lots.

Sharon Oursler, a 78-year-old who worked for 34 years in the county’s Planning Department, had to get a notary to come to her house because she was recovering from a broken knee. (Would the new plan disrupt her care? she wondered.) “It almost felt like there was nothing we could do about it,” Oursler said. “They were going to switch us over. Nobody really wanted it. Nobody was for it.” Racing the clock, Goehler filed the lawsuit with more than a hundred signatures, with retirees still calling him to see if they could add their names.

“The only way to stop it was a lawsuit,” he said. “They weren’t gonna stop. They weren’t gonna listen to us.”

Generally, they’ve served those investors well, particularly in the cases of UnitedHealthcare and Humana, which together control almost half of the Medicare Advantage market. In their rush to get a piece of the pie, insurers have targeted not just individuals, but also public sector employers and the dwindling number of companies that still provide pensions, emphasizing the possible savings to create a sense of urgency around the switch.

In Cortland, that rushed timeframe — coupled with what they saw as an air of secrecy around the initial negotiations — alarmed retirees. Moving everyone over to the new plan would take a few months, they were told, but then why not wait until next year to start the process and give everyone time to get comfortable with it? If they did that, some county legislators argued, the county would miss out on a year of savings. Cortland County, like many employers that offer health coverage to retirees, pays for a supplemental plan to round out coverage provided by traditional Medicare, which covers 80 percent of most services. In switching to an Advantage plan, the county would no longer have to pay for the supplement, and could effectively shift more of the cost onto the federal government, which would then pay UnitedHealthcare a certain amount per Advantage enrollee. Sweetening the deal, New York state would also offer a one-time match for the first year of savings through its County-Wide Shared Services Initiative, which encourages local governments to cut costs through collaboration.

Even some county legislators, though, were confused by the sense of urgency, including Beau Harbin, who voted “no” on the change and said that legislators were still scrambling to understand the new plan when the resolution was on the floor. To retirees, the frantic nature of it all seemed intentional. “They didn’t want to give us a minute to think about it,” Oursler said.

Doug Bulman, the Broome County Purchasing Alliance’s founder, attributes the timeline to UnitedHealthcare’s October 1 deadline, but blames the county for not spending more time educating its retirees on the plan.

This wasn’t the only time that Bulman’s group has rushed this change through a county legislature, though. In nearby Lewis County, the switch to Medicare Advantage unfolded over almost the exact same timeline last year, with sales presentations in August followed quickly by a vote. Seniors there also protested the change was happening too fast, though they did not mount a lawsuit in time to stop it. In 2021, Tioga County had followed a similar timeline for its switch to Medicare Advantage as well.

Still, Bulman insisted that the over 20 municipalities he has sold his plans to have had “not one grievance,” and claims the typical Medicare Advantage problems that Cortland seniors highlighted in their lawsuit do not apply to his plans. “Not one of those accusations the Cortland County retirees made was true about our plan,” he said, pointing out that his own parents are on one of his plans. “Not one.”

His plan, he said, utilizes UnitedHealthcare’s “passive PPO,” meaning it has a more expansive coverage network than a typical Advantage plan. If a provider accepts traditional Medicare, Bulman said, they’ll accept his plan, even if they’re out of network. Thus, Cortland retirees likely wouldn’t have to change doctors — though “never say never,” Bulman said. As for prior authorization, Bulman pointed out that it is also used by the Cortland seniors’ current Excellus supplemental plan. “It is a hassle,” he admitted, “but it’s there to lower costs.”

To the retirees, that all sounded too good to be true, and prior authorization proved a sticking point. Advantage plans issue millions of prior-authorization denials per year, and in a 2022 report, the Office of the Inspector General found 13 percent of them were for procedures that met Medicare coverage rules. If prior authorization wasn’t a big deal, Cortland seniors wondered, then why wouldn’t UnitedHealthcare provide a list of procedures that would require it under the new plan until after the county had already committed to joining? When the retirees finally got ahold of the list, it contained dozens of procedures ranging from routine tests to colonoscopies to rehabilitative care.