---
type: source
title: "An Economic History of Medicare Part C"
author: "McWilliams et al. (Milbank Quarterly / PMC)"
url: https://pmc.ncbi.nlm.nih.gov/articles/PMC3117270/
date: 2011-06-01
domain: health
secondary_domains: []
format: paper
status: unprocessed
priority: high
tags: [medicare-advantage, medicare-history, political-economy, risk-adjustment, payment-formula, hmo]
---

## Content

### Historical Timeline (synthesized from multiple search results including this paper)

**1966-1972: Origins**
- Private plans part of Medicare since inception (1966)
- 1972 Social Security Amendments: first authorized capitation payments for Parts A and B
- HMOs could contract with Medicare but on reasonable-cost basis

**1976-1985: Demonstration to Implementation**
- 1976: Medicare began demonstration projects with HMOs
- 1982 TEFRA: established risk-contract HMOs with prospective monthly capitation
- By 1985: rules fully implemented; enrollment at 2.8% of beneficiaries

**1997: BBA and Medicare+Choice**
- Medicare trustees projected Part A trust fund zero balance within 5 years
- Political pressure → BBA 1997: cost containment + expanded plan types (PPOs, PFFS, PSOs, MSAs)
- Reworked TEFRA payment formula, established health-status risk adjustment
- Created annual enrollment period to limit mid-year switching
- **Unintended consequences**: plans dropped from 407 to 285; enrollment fell 30% (6.3M→4.9M) between 1999-2003
- 2+ million beneficiaries involuntarily disenrolled as plans withdrew from counties

**2003: MMA and Medicare Advantage**
- Republican control of executive + legislative branches
- Political shift from cost containment to "accommodation" of private interests
- Renamed Medicare+Choice → Medicare Advantage
- Set minimum plan payments at 100% of FFS (was below)
- Created bid/benchmark/rebate framework
- Payments jumped 11% average between 2003-2004
- Created Regional PPOs, expanded PFFS, authorized Special Needs Plans

**2010: ACA Modifications**
- Reduced standard rebates but boosted for high-star plans (>3.5 stars)
- Created quality bonus system that accelerated growth

**2010-2024: Growth Acceleration**
- 2010: 24% penetration → 2024: 54% penetration
- From 10.8M to 32.8M enrollees
- Growth driven by: zero-premium plans, supplemental benefits, Star rating bonuses

### Political Economy Pattern
Each phase follows a cycle:
1. Cost concerns → restrictions → plan exits → beneficiary disruption
2. Political backlash → increased payments → plan entry → enrollment growth
3. Repeat with higher baseline spending

The MMA 2003 was the decisive inflection: shifted from cost-containment framing to market-competition framing. This ideological shift — not just the payment increase — explains why MA grew from 13% to 54%.

## Agent Notes
**Why this matters:** The full legislative arc reveals MA as a political creation, not a market outcome. Each payment increase was a political choice driven by ideology (market competition) and industry lobbying, not evidence of MA's superior efficiency. The system we have now — 54% penetration with $84B/year overpayments — was designed in, not an accident.
**What surprised me:** The BBA 1997 crash (30% enrollment decline, 2M involuntary disenrollments) is the counter-evidence to the narrative that MA growth is driven by consumer preference. When payments were constrained, plans exited. "Choice" is contingent on overpayment.
**KB connections:** [[proxy inertia is the most reliable predictor of incumbent failure because current profitability rationally discourages pursuit of viable futures]], [[industries are need-satisfaction systems and the attractor state is the configuration that most efficiently satisfies underlying human needs given available technology]]
**Extraction hints:** Claims about: (1) MA growth driven by political payment decisions not market efficiency, (2) the BBA-MMA cycle as evidence that MA viability depends on above-FFS payments, (3) the ideological shift from cost containment to market accommodation as the true inflection

## Curator Notes
PRIMARY CONNECTION: [[the healthcare attractor state is a prevention-first system where aligned payment continuous monitoring and AI-augmented care delivery create a flywheel that profits from health rather than sickness]]
WHY ARCHIVED: Essential historical context — you can't evaluate where MA is going without understanding the political economy of how it got here.
EXTRACTION HINT: The 1997-2003 crash-and-rescue cycle is the most extractable insight. It demonstrates that MA's growth is policy-contingent, not demand-driven.
