Does Medicare Advantage Funding Disparity Affect Managed Care Insurers’ Profitability? Evidence from Puerto Rico

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ID: 327599
2026
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Abstract
Abstract Introduction Puerto Rico's Medicare Advantage market operates under a persistent yet fluctuating federal funding disparity, with reported benchmark payments approximately 38% below those in United States states. Health insurance industry representatives have argued that this disparity constrains their financial margins, warranting measures to reduce healthcare benefits and demand more federal funds for Medicare. Methods This study assessed the relationship between Puerto Rico’s Medicare funding disparity and medical loss ratio, administrative loss ratio and profit margins within the Medicare Advantage market. We analyzed insurer financial statements filed with the Puerto Rico Insurance Commissioner Office and Plan C plan payment data from the Centers for Medicare and Medicaid Services using descriptive trends and regression models. Results The funding disparity was not significantly associated with medical loss ratio or profit margin, but was associated with higher administrative loss ratio. Profit margins exhibit abrupt fluctuations coinciding with external shocks affecting healthcare utilization and the healthcare market. Conclusion Annual variation in the funding disparity alone does not explain insurer financial performance. Efforts to increase federal Medicare Advantage payments to Puerto Rico should be accompanied by oversight regarding how additional revenues are allocated among medical care, administrative activities, and profits.
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Authors Sergio R. Rivera Rodriguez, Naomi Zewde, Alexandra C. Rivera‐González
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Journal Health Affairs Scholar
Year 2026
DOI
10.1093/haschl/qxag242
URL
https://doi.org/10.1093/haschl/qxag242
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