2025-11-04 07:15:00
2025年10月30日，纽约市布鲁克林区Flatbush社区的一家杂货店门口出现了电子福利卡（EBT）标识。这则新闻出现在《The Logoff》每日简报中，该简报旨在帮助读者了解特朗普政府的动态，同时避免政治新闻占据过多生活。欢迎阅读《The Logoff》：经过数日的不确定性，特朗普政府将维持食品援助发放，但仅限于当月的一半时间。目前，由于政府停摆，补充营养援助计划（SNAP）资金在周末暂停，影响了近4200万美国人（其中许多是儿童）的基本食物援助。尽管资金有望很快恢复，但受助者将面临失去福利和不确定恢复时间的双重困扰。
背景是什么？SNAP资金暂停本可避免。截至10月初，美国农业部（USDA）网站上曾有计划说明如何使用应急资金维持SNAP运作，但该计划随后被删除，取而代之的是“资金已枯竭”的信息，并将责任归咎于民主党国会。接下来SNAP会怎样？政府目前动用的应急资金只能覆盖11月上半月，之后资金可能再次中断。如果政府停摆持续，SNAP援助可能完全停止。这在一定程度上是因为特朗普政府拒绝探索其他维持资金的方案。上周，一位波士顿的联邦法官曾建议利用关税收入，但政府表示无意动用。
大局如何？随着停摆持续，特朗普政府采取了极端措施维持部分优先事项的资金，如移民执法和军人工资。而像食品援助这样的项目，政府则需要被强制资助，且态度消极。
至此，是时候结束阅读了。读者们，临别前想说，我读到一篇关于社区互助帮助SNAP受助者的NPR报道，非常感人，尽管背景令人担忧。如果你想要远离新闻循环的内容，Futurism上一篇关于让经典游戏《Doom》在欧洲航天局卫星上运行的文章或许适合你，非常有趣。一如既往，感谢阅读，祝你度过美好夜晚，我们明天再见！
This story appeared in The Logoff, a daily newsletter that helps you stay informed about the Trump administration without letting political news take over your life. Subscribe here.
Welcome to The Logoff: After days of uncertainty, the Trump administration will keep food assistance flowing — but only for part of the month.
What’s happening? Funding for the Supplemental Nutrition Assistance Program, or SNAP, is likely to resume in the near future, after the Trump administration said Monday it would comply with a federal judge’s order to spend about $5.5 billion in contingency funds (essentially, cash the program can draw on to keep operating in emergencies).
SNAP funding lapsed over the weekend as a result of the ongoing government shutdown, interrupting vital food aid for nearly 42 million Americans, many of whom are children. While funding should start flowing again soon, the interruption will hurt SNAP recipients who have to deal with not only lost benefits but also uncertainty about exactly when they will resume.
What’s the context? This interruption in SNAP funding didn’t need to happen. Until early October, the Department of Agriculture (USDA) had a plan on its website outlining the use of contingency funding to keep SNAP benefits flowing. It was subsequently removed from the USDA site and replaced with a message saying, “The well has run dry,” and blaming congressional Democrats.
What’s next for SNAP? The contingency funds the administration is drawing on will only cover about half of November before benefits once again lapse. If the government remains shut by then, benefits are likely to dry up altogether.
That is partially due to the Trump administration’s refusal to explore alternatives to keep SNAP funding flowing past the middle of the month. Last week, a different federal judge in Boston pointed to tariff revenue as an option, but the administration has said they don’t intend to draw on it.
What’s the big picture? As the shutdown drags on, the Trump administration has gone to extraordinary measures to keep funding some of its priorities, such as immigration enforcement and military paychecks. Others, like food assistance, it has to be compelled to fund — and then, only begrudgingly.
Hi readers, before you go: I thought this NPR story about how communities are coming together to help neighbors who need it as SNAP benefits run dry was touching — even if the surrounding context is grim.
If you want something a little more removed from the news cycle (who can blame you?), this Futurism story about getting the classic video game Doom to run on a European Space Agency satellite might be for you. It’s a delight.
As always, thanks for reading, have a great evening, and we’ll see you tomorrow!
2025-11-04 06:45:00
在尼日利亚的村庄Ngarannam，12月19日遭到博科圣地破坏后，两名女孩被拍摄在武装士兵身后。| Florian Gaertner/Photothek via Getty Images
进入本周，特朗普面临的重大外交政策问题之一是美国是否会发动军事打击针对委内瑞拉。尽管这一问题仍未解决，但特朗普同时威胁要对另一个大西洋彼岸的国家——尼日利亚采取军事行动，誓言如果该国政府未能阻止对基督徒的迫害，将派军队“枪炮齐发”进入尼日利亚。这再次表明，这位诺贝尔和平奖提名者和“美国优先”外交政策的倡导者，愿意动用军事威胁来实现其外交目标，并干涉他国的内政，只要这符合其国内政治利益。从这个角度看，对尼日利亚的威胁与对委内瑞拉的威胁类似，但后者更有可能被实施。在两种情况下，特朗普似乎都在违背他一贯反对军事干预的立场，但这些干预都与他的政治基础的优先事项相关：一方面是为了阻止毒品和移民进入美国，另一方面是为了保护基督徒。
实际上，尼日利亚的情况确实令人担忧。自2009年以来，极端伊斯兰恐怖组织博科圣地及其分支一直在北部地区发动残酷的武装叛乱，造成多起高调的屠杀和绑架事件，包括2014年奇博克女学生被绑架事件，引发了全球媒体关注。此外，近年来西北和中北部尼日利亚也出现了穆斯林牧民与基督徒农民之间的冲突。尽管尼日利亚军队多年来一直在与叛乱分子作战，但总统博拉·阿赫米德·蒂努布被指责忽视基督徒的困境，而军事行动也受到广泛腐败和人权侵害的阻碍。此外，尼日利亚的一些州拥有世界上最为严苛的亵渎法，这些法律被批评者认为主要针对基督徒。尽管如此，穆斯林和非洲传统宗教信徒也遭受了迫害。
特朗普对尼日利亚的关注可能更多源于华盛顿的发展，而非尼日利亚本身发生的特定事件。近年来，尼日利亚基督徒的困境成为美国福音派基督徒关注的焦点。2022年，我曾前往华盛顿会见前尼日利亚总统穆罕默德·布哈里，当时活动多次被抗议者打断。在Truth Social上，特朗普引用了国际基督教人权组织Open Doors的报告，指出2024年全球有4476名基督徒因信仰被杀害，其中3100人来自尼日利亚。这并非特朗普首次关注该问题。在2020年特朗普的第一个任期期间，当布哈里访问白宫时，特朗普曾尖锐地问：“你们为什么在尼日利亚杀害基督徒？”此外，特朗普政府在2020年将尼日利亚列入国务院“特别关注国”名单，以抗议其对宗教自由的侵犯。然而，拜登政府在2021年将其从该名单中移除，就在安东尼·布林肯访问尼日利亚之前，尼日利亚被视为美国重要的反恐伙伴和非洲地区的重要政治经济力量。
因此，特朗普在周五发布的一条Truth Social帖子，宣布将尼日利亚重新列入“特别关注国”名单并不令人意外。美国国际宗教自由委员会（USCIRF）——一个由国会和白宫任命的跨党派监督机构——曾敦促他这么做，参议员泰德·克鲁兹（R-Tex.）也提出了相关立法。USCIRF委员Mohamed Elsanousi告诉Vox，委员会欢迎特朗普的声明，但希望他也能提到其他同样遭受迫害的群体，如穆斯林和非洲传统宗教信徒。
然而，特朗普周六的帖子则显得更加出人意料，他威胁要让美军“枪炮齐发”进入尼日利亚，以彻底消灭那些实施恐怖行为的伊斯兰极端分子，并指示国防部为可能的行动做准备。他说：“如果我们发动攻击，那将迅速、猛烈且甜美，就像那些恐怖分子攻击我们珍视的基督徒一样！”国防部长彼得·海格塞思在推特上回应称：“是的，先生。”
当被问及是否意味着美军将直接派兵或进行空袭时，特朗普回答：“可能是，还有其他事情。我设想了很多可能。”然而，特朗普的威胁实际执行的可能性似乎不大。虽然他并非和平主义者，但更倾向于快速、低风险的干预行动。而尼日利亚的情况显然不符合这一模式。尼日利亚政府因拒绝接受被驱逐的移民以及批评以色列在加沙战争中的行为，而受到特朗普政府的不满。此外，讨论是否应派美军地面部队参与西非反恐斗争，似乎有些不合时宜。事实上，美国军队已经在西非国家，包括尼日利亚，参与了二十年的训练和援助行动。然而，随着该地区更多国家转向与俄罗斯建立安全伙伴关系，以及美国对外援助削减，这些行动的未来变得不确定。
值得注意的是，今年8月，美国政府批准向尼日利亚出售价值3.46亿美元的武器，而如今却指责尼日利亚政府允许基督徒大规模被杀并实施人权侵害。有充分理由认为，美国应重新考虑对尼日利亚的安全援助策略，因为该策略显然未能有效遏制博科圣地的叛乱。但同样，单边的美国军事干预可能也不会更有效。特朗普本人似乎也意识到这一点。他在5月沙特阿拉伯的讲话中批评了过去政府对复杂社会的干预，认为他们并不真正理解这些社会。他在9月向军事指挥官讲话时誓言要恢复“保卫祖国是军队首要任务”的基本原则，并认为“只有在最近几十年里，政客们才开始认为我们的职责是去警察肯尼亚和索马里的偏远地区，而美国却正面临内部入侵”。
然而，如今他却威胁要将美军投入一个美国几乎不了解的非洲国家，卷入一场极其复杂的民族冲突。这进一步证明，尽管特朗普强调“美国优先”，但他本质上仍是一个全球主义者，认为美国在世界舞台上扮演着不可或缺的角色，应该参与解决全球危机，包括那些与美国狭义的国家安全利益无关的问题。但与之前的自由派国际主义者或新保守派不同的是，特朗普的对外干预更紧密地与他的国内政治优先事项相挂钩。这可能意味着支持美国友好的政党在阿根廷选举中，或在巴西支持盟友的审判；也可能意味着重新调整美国难民政策，以主要帮助白人南非人；还可能意味着在委内瑞拉发起一场以毒品和移民政策为口号的政权更迭运动。在尼日利亚，这意味着重新提出“人道主义军事干预”的概念，但只在这一行动符合特朗普重要选民群体的利益时才会实施。
过去，像苏丹埃尔法舍尔的惨状可能会引发关于美国是否需要军事干预的讨论。但在今天的华盛顿，这种讨论似乎已经不再存在。
The big Donald Trump foreign policy question heading into this week looked like it was going to be when and if the US was going to launch military strikes against Venezuela. That’s still a live question, but in the meantime, the president has threatened to attack an entirely different country on the other side of the Atlantic, vowing to send troops “guns-a-blazing” into Nigeria if that country’s government fails to prevent the persecution of Christians.
It’s the latest example of how the Nobel Peace Prize aspirant and advocate of “America First” foreign policy is more than willing to use the threat of military force to accomplish his foreign policy goals, and to interfere in the domestic affairs of other countries, when doing so aligns with his domestic political priorities.
In this sense, the threat against Nigeria is similar to that against Venezuela, although the latter appears far more likely to actually be carried out. In both cases, the president appears to be contradicting his frequently expressed opposition to military interventionism, but these are interventions linked to the priorities of his political base: in one case, keeping drugs and migrants out of the US. In another, protecting Christians.
As we get deeper into Trump’s second term, it’s becoming increasingly clear that MAGA is not immune from the temptation to go abroad in search of monsters to destroy.
The problem Trump is talking about here is a real one. The hardline Islamist terror group known as Boko Haram and its offshoots have waged a brutal insurgency against the Nigerian state in the northern part of the country since 2009, committing numerous high-profile massacres and kidnappings, including the 2014 Chibok schoolgirl abduction that attracted a global media campaign. This isn’t the only religious conflict going on. Recent years have also seen a wave of clashes and attacks between predominantly Muslim herders and predominantly Christian farming communities in Northwest and Northcentral Nigeria. The Nigerian military has been fighting the insurgency for years, but President Bola Ahmed Tinubu has been accused of ignoring the plight of Christians, in particular, and the military campaign has been hampered by widespread corruption and alleged human rights abuses.
In addition, several Nigerian states have some of the world’s most draconian blasphemy laws, which critics say are disproportionately enforced against Christians. Atheists and members of minority Muslim sects have been persecuted as well, though.
Trump’s sudden interest in Africa’s most populous country was likely motivated less by any particular event there — these are all longstanding issues — than by developments in Washington. Though it doesn’t get a ton of mainstream media attention, the plight of Christians in Nigeria has been a galvanizing issue for evangelical Christians in the US in recent years. When I went to see former Nigerian President Muhammadu Buhari speak in Washington in 2022, the event was repeatedly interrupted by protesters. On Truth Social, Trump cited numbers from a report from the international Christian rights NGO Open Doors stating that of the 4,476 Christians killed for their faith globally in 2024, 3,100 were in Nigeria.
This also isn’t the first time Trump has taken an interest in the issue. When Buhari visited the White House during Trump’s first term in 2020, the president pointedly asked him, “Why are you killing Christians in Nigeria?” During Trump’s first term, the US added Nigeria to the State Department’s list of Countries of Particular Concern for violations of religious freedom. The Biden administration controversially removed Nigeria from the list in 2021, just before a visit by Secretary of State Antony Blinken to the country, which is viewed by the US as both an important counterterrorism partner and a major political and economic player in Africa.
So it was not surprising to see Trump’s initial Truth Social post on Friday, that he was returning Nigeria to the CPC list.
The bipartisan US Commission on International Religious Freedom (USCIRF), a bipartisan federal watchdog appointed by Congress and the White House, had been urging him to do so, as had recent legislation introduced by Sen. Ted Cruz. (R-Tex.), who has been consistently outspoken on the issue.
Mohamed Elsanousi, one of the USCIRF commissioners, told Vox that the commission welcomed Trump’s announcement and his highlighting of the killing of Christians, but added, “there are also violations and killings of Muslims and African traditional religion practitioners. So we would have loved for the President to mention all the other communities that are facing the same kind of persecutions as well.”
But Trump’s post on Saturday was more of a surprise, saying that the US military:
…may very well go into that now disgraced country, “guns-a-blazing,” to completely wipe out the Islamic Terrorists who are committing these horrible atrocities. I am hereby instructing our Department of War to prepare for possible action. If we attack, it will be fast, vicious, and sweet, just like the terrorist thugs attack our CHERISHED Christians!
“Yes sir,” tweeted Secretary of Defense Pete Hegseth in response. Asked on Air Force One on Sunday if this could mean boots on the ground or airstrikes, Trump replied, “Could be. I mean, other things. I envisage a lot of things.”
It would be very surprising if Trump actually follows through on his threat. While hardly a pacifist, Trump prefers quick interventions that promise decisive victories and carry little risk of quagmire or US casualties. None of that applies in Nigeria. It’s probably relevant that the Nigerian government is not viewed particularly favorably by the Trump administration for a number of reasons, including its refusal to accept deported migrants from the US and its criticism of Israel over the war in Gaza.
It’s also a little strange to be debating whether “boots on the ground” would be the decisive factor in turning the tide against jihadists in West Africa. US troops have been involved in training and assistance missions with Western African countries, including Nigeria, for two decades now. Though the future of those missions is uncertain as more countries in the region turn toward security partnerships with Russia and as US foreign aid cuts hamper US efforts to try to stabilize countries where insurgencies are thriving.
It’s worth pointing out that in August, the administration approved $346 million in arms sales to the government it is now accusing of allowing the wholesale killing of Christians and of perpetrating its own human rights abuses. There are very good reasons to suggest the US should rethink a strategy of security assistance to Nigeria — it has plainly failed to put down Boko Haram’s insurgency — but little reason to believe a unilateral US military intervention would be much more effective.
Trump’s own statements suggest that he also believes this. In his speech in Saudi Arabia in May, he criticized past administrations for “intervening in complex societies that they did not even understand themselves.” Addressing military commanders in Quantico in September, he vowed to restore “the fundamental principle that defending the homeland is the military’s first and most important priority” and argued that “Only in recent decades did politicians somehow come to believe that our job is to police the far reaches of Kenya and Somalia, while America is under invasion from within.”
And yet, now he is threatening to put the US military into the middle of a dizzyingly complex ethnic conflict in an African country that few in the US really understand.
It’s yet more evidence that for all his America First messaging, Trump is essentially a globalist: someone who believes the US plays an indispensable role on the world stage, and should play a role in solving global crises, including those with little relevance to America’s narrowly defined national security interests. But the big difference between Trump and the liberal internationalists or neoconservatives who came before him is the degree to which his foreign interventions are aligned with his domestic political priorities.
That can mean throwing US economic might behind a MAGA-friendly party in an Argentinian election or the trial of an ally in Brazil. It can mean revamping US refugee policy so that it predominantly helps white South Africans. It may soon mean a regime change campaign in Venezuela couched in the rhetoric of drug and migration policy. And in the case of Nigeria, it means reviving the supposedly discredited notion of humanitarian military intervention — but only in a case where it aligns with the priorities of one of Trump’s important constituencies.
In previous years, the grisly scenes emerging from El Fasher, Sudan, might have prompted a debate about the necessity of American military intervention. Don’t count on it in today’s Washington.
2025-11-04 03:40:00
20世纪70年代，心理学家迪安娜·德鲁什在使用合成器进行实验时，发现了一种奇怪的现象。她回忆道：“我当时觉得仿佛进入了一个不同的宇宙，或者自己疯了，世界仿佛颠倒了！”德鲁什偶然发现了音频形式的错觉，她称之为“八度错觉”，并意识到这并非偶然现象，而是大脑处理声音的重要机制。我们的大脑会编辑我们听到的声音，我们所感知的声音并不是耳朵直接传来的实时信号，而是大脑对声音的推测。正如丹·波利教授所说：“大脑无法直接接触物理世界，我们所感知的意识都是大脑活动构建的。”在《听觉屏障》这一由Unexplainable制作的四集特别系列中，我将探讨人类听觉的极限以及如何突破这些限制。从那些被幻听困扰的人，到试图弄清楚“寂静”究竟听起来像什么，再到能够“聆听”太空的天文学家。新一集将在11月3日起每周一、三更新。第一集《听觉屏障》探讨了听觉的神话，大脑的编辑能力不仅让我们能够处理听到的声音，还能通过耳蜗植入物帮助失聪者重新听到世界。诺姆采访了一位失去听觉后，通过使用小熊维尼来重新训练大脑，从而重新聆听他最喜欢的音乐《波莱罗》的人。
In the 1970s, psychologist Diana Deutsch was experimenting with a synthesizer, when she heard something strange. “It seemed to me that I’d entered another universe or I’d gone crazy or something…the world had just turned upside down!” Deutsch recalls.
Deutsch had stumbled across an illusion in audio form — she called it the “Octave Illusion” and you can listen to it here — and she realized it wasn’t just a quirk. It was telling her something essential about how our brain processes sound.
Our brain edits the world we hear. What we hear isn’t a direct real-time feed coming from our ears. It’s our brain’s best guess. “Because the brain doesn’t have direct contact with the physical world,” says professor Dan Polley, “Everything that we perceive as consciousness is constructed from the activity of the brain.”
So what are we actually hearing, when we’re hearing?
In The Sound Barrier, a special four-part series from Unexplainable, I explore the limits of our sense of hearing and how we can break through. From people trapped by phantom sounds in their heads, to the quest to find out what silence actually sounds like, to astronomers who have figured out a way to listen to space.
New episodes will be released every Monday and Wednesday, starting November 3.
The brain’s editing superpower doesn’t just allow us to process the world we hear — it allows people with hearing loss to hear the world again by using a cochlear implant. Noam speaks to someone who lost his hearing and then retrained his brain — using Winnie the Pooh, believe it or not — to relisten to his favorite piece of music, “Bolero.”
2025-11-03 23:00:00
三分之一的美国人计划在2025年接受心理治疗。如果你是其中之一，可能会发现：弄清楚保险是否能覆盖心理治疗需要一些努力。判断保险计划是否涵盖心理治疗，或者在多个计划中选择以期获得覆盖，这种过程可能让人感到不知所措。根据2024年的一项调查，超过一半的受访者表示心理治疗费用是获取心理健康服务的主要障碍，而四成的人则认为心理治疗提供者数量不足是主要障碍。三分之一的心理学家根本不接受保险，即使通过工作获得保险的人，也常常需要找不在保险网络内的心理治疗师。对于美国人来说，保险覆盖身体健康的状况已经很复杂，而心理健康治疗则更加困难，正如美国精神疾病联盟（NAMI）的首席倡导官Hannah Wesolowski在给Vox的电子邮件中所写的那样：“我们等待的时间更长，支付的费用更高，选择的治疗师也更少。”因此，了解如何利用保险计划中的心理健康福利尤为重要。
自15年前以来，美国已有法律要求大多数健康保险计划提供的心理健康覆盖与身体健康覆盖相当。该法律禁止保险公司对心理健康治疗的访问收取更高的费用，或限制其访问次数。然而，这项规定并未真正改善消费者的体验。保险公司通常向其网络内的心理健康治疗师支付很低的费用，因此许多治疗师选择不与保险公司合作。此外，一些保险计划的“网络”目录看似丰富，但实际很多治疗师并不接受新患者。这意味着，很多人需要联系四到五位治疗师才能找到一位在保险网络内的。如果找不到合适的治疗师，很多人就会放弃治疗。2024年9月通过的一项法律旨在解决网络稀少的问题，可能在未来几年迫使保险公司扩大其治疗师网络。
在尝试让保险覆盖心理治疗时，人们通常会遇到一些术语，了解这些术语对选择合适的保险计划很重要：
治疗师与患者之间的“契合度”是影响治疗效果的重要因素，因此拥有多种人格类型和治疗方式可供选择对患者来说是件好事。然而，保险公司通常限制你只能访问一定数量的治疗师，以较低费用获得治疗。如果你想开始治疗，可能会遇到困难：是先找一位治疗师，然后看看他是否在你的保险网络内？还是先选择一个有良好心理健康覆盖的保险计划，再从该计划的网络中寻找合适的治疗师？其实没有对错之分，这取决于你最看重什么以及你手头的资源。如果你最关心的是费用，那么先选择一个有良好心理健康覆盖的保险计划，再寻找合适的治疗师会更明智。如果你已经确定要与某位特定的心理健康治疗师合作，那么最好先询问该治疗师接受哪些保险计划。记住，不要只凭保险公司的名字，要确认具体的计划名称。
如果你没有保险，可以考虑是否符合政府资助的保险计划，如医疗补助（Medicaid）或医疗保障（Medicare），或者是否能负担得起通过工作、州级《平价医疗法案》（ACA，也称奥巴马医改）或保险经纪人购买的保险。如果你无法获得健康保险，仍然有其他选择。如果你需要心理治疗，可以选择全额自费。通常，每次治疗的费用在100到200美元之间。一些治疗师提供按收入比例收费的方案，即收入较低的人可以支付较少的费用，因此值得询问。许多仅提供在线服务的治疗师也接受自费客户（有些也接受特定保险），并且效果可能很好。乔治亚州立大学的心理学家兼教授Jeff Ashby表示：“疫情改变了我们对远程医疗的看法。我们发现，许多问题都可以通过远程医疗来治疗，这与以往的研究结果一致。”此外，还有低成本或免费的心理治疗选择。NAMI的全国热线负责人Megan Rochford建议寻找提供心理治疗培训的大学研究生项目，这些项目通常提供免费治疗。虽然很多人认为谈话治疗和药物是心理健康治疗的核心，但还有其他方式可以获取帮助和支持，比如团体治疗，通常比个体治疗便宜，对某些人来说效果也相当。美国团体心理治疗协会（AGPA）有一个网站，可以搜索附近的认证团体治疗师。自助小组和支持小组在许多情况下也有所帮助，你可以在这里和这里找到一些支持小组的列表。一些人可能还会发现同伴支持、疗愈圈和社区护理方法非常有用。此外，还有许多免费且保密的心理健康“温暖热线”（warmlines），提供电话帮助。NAMI运营着一个全国热线，许多州也有自己的温暖热线。这些热线与988等危机热线不同，它们更侧重于帮助人们连接未来的资源，而不是在危机中提供即时支持。NAMI和心理健康美国（Mental Health America）的网站上有大量资源，帮助人们寻找低成本的心理健康支持。无论你选择哪种方式获取帮助，都请记住，你并不孤单。更新：2023年11月3日，东部时间上午10点：本文最初于2023年发布，此后多次更新以包含最新数据。
One in three Americans resolved to make 2025 the year they get therapy. If you were one of them, you may have discovered: Figuring out how to get your insurance benefits to cover therapy can take some legwork.
The drudgery of figuring out whether and how your insurance plan covers therapy — or choosing between plans in the hope of getting therapy covered — can feel overwhelming. In a 2024 poll, more than half of Americans surveyed said mental health treatment costs were a major barrier to care, while four in 10 people said the scarcity of providers was a big obstacle. A third of psychologists don’t take insurance at all, and even people who get health insurance through their jobs often have to go out of network for their mental health care.
As complicated as it is for Americans to get physical health care covered by insurance, “people with mental health conditions get the short end of the stick,” Hannah Wesolowski, chief advocacy officer at the National Alliance on Mental Illness (NAMI), wrote in an email to Vox. “We wait longer, we pay more, and we have less choice for providers.”
That makes it especially important to understand how to navigate the mental health benefits insurance plans offer. Here’s what you need to know.
For more than 15 years, the US has had a law — the Mental Health Parity and Addiction Equity Act — that requires most health insurance plans to provide mental health coverage that’s as good as their physical health coverage. In particular, the law forbids insurance companies from charging more for visits to a mental health care provider than for other visits, or from limiting the number of those visits its plans cover.
However, this regulation hasn’t exactly created a consumer utopia. Insurance companies often pay super low rates to mental health providers in their networks, so many therapists simply opt out of partnering with insurance plans. People seeking in-network care are also often faced with “ghost networks,” provider directories that seem robust at first before you find out that many of the providers aren’t actually taking new patients, says Wesolowski. That means many people often end up having to contact four or more providers before finding an in-network therapist. People who struggle to find a covered therapist often end up going without.
A law passed in September 2024 takes aim at the sparse network problem, and may force health insurance companies to expand their provider networks in the next few years.
People trying to get therapy covered by their insurance typically run into a few different types of charges that it’s helpful to understand:
If you’re evaluating a health plan to determine how it covers therapy, look at the section of the plan document on mental health, under the “outpatient” subsection. Look for language describing visits to a therapist: This might include language like “office visits,” “individual, family, or group psychotherapy,” “medication management,” and “virtual care” or “telehealth.”
Some plans may require you to pay full price for therapy visits until you reach your deductible, then kick in some percentage of the visits’ cost until the end of the year. Alternately, you might have to pay a co-pay for every visit, while the plan covers the rest. Still other plans may fully cover a certain number of visits before you start paying out of pocket.
In most insurance plans, getting care from the plan’s network of providers will likely cost you less than care from out-of-network providers. Many plans will pay some percentage of the total cost for providers in their network, and a lower percentage (or nothing) for providers out of network. Read through the plan carefully and call your insurance company (the 800 number on your insurance card) if you have questions.
Lastly, the plan should also note the number of visits it will cover in one year, something like the “calendar year maximum.” Most plans are now required to cover unlimited visits, but there are a few exceptions.
Once you start therapy, many therapists will give you the bill directly, which you pay and then submit to your insurer for reimbursement.
One of the key predictors of how helpful therapy will be is whether you “click” with your therapist — so having a range of personality types and approaches to choose from is good for consumers. But, insurance companies limit the number of therapists you can access at a lower cost. If you want to start therapy, it can be challenging to figure out whether to choose a therapist first and then see if they fall under an insurance plan, or choose an insurance plan first, then find a therapist from the plan’s list of in-network providers.
There’s no wrong choice here — how you approach this really depends on what you value most and the resources you have at hand. If it’s most important to you to keep costs down, it makes sense to find an insurance plan with decent therapy coverage first, and steel yourself to do some digging for a therapist match once you’re covered. (We’ve got some tips on finding a provider who’s a good fit here.)
However, if you’re set on working with a particular mental health practitioner, it might make more sense to ask the provider which insurance plans they work with. (If you choose this route, make sure you know exactly which plans the provider accepts — it’s not enough to know the insurance company’s name.)
If you’re uninsured, it’s worth checking whether you qualify for government-sponsored insurance programs like Medicaid or Medicare — or can afford to buy your own insurance, either through your job, from your state’s Affordable Care Act exchange (also known as the ACA, or Obamacare), or from an insurance broker.
If you can’t get health insurance, you still have options. If you want therapy, paying full price out of pocket may be an option. It’s costly, typically ranging from $100 to $200 for a session. Some providers offer therapy on a sliding scale — which means lower costs for people with less ability to pay — so it’s worth asking.
Many online-only providers provide services to people paying out of pocket (some also accept certain insurance plans) and can be very effective. “The pandemic changed the way we thought about telehealth,” says Jeff Ashby, a psychologist and professor at Georgia State University who researches stress and trauma. “What we discovered — consistent with previous research — is that a whole lot of issues can be treated using telehealth.”
There are also low- and no-cost therapy options out there. Megan Rochford, who oversees NAMI’s national helpline, suggests looking for universities with graduate programs training people to provide psychotherapy; these often offer treatment for free.
Although many people may think of talk therapy and medications as the cornerstones of care, there are other ways to get help and support from other people. Group therapy is typically less expensive than individual therapy, and for some people, is just as effective. The American Group Psychotherapy Association has a website where you can search for certified group therapists near you.
Self-help and support groups can also be helpful in lots of situations; you can find a few lists of support groups here and here. Some people may also find peer support, healing circles, and other community care approaches very useful.
In addition, there are lots of free and confidential mental health “warmlines” that provide help over the phone: NAMI runs a national helpline, and many states run their own warmlines. These are different from hotlines like 988 in that they’re geared less toward supporting people through a crisis and more toward connecting people with resources for future care.
NAMI and Mental Health America have websites with troves of resources for people seeking low-cost support for mental health concerns: Check out their page on community care, their directory of helplines, and other resources.
However you choose to get help, it’s worth remembering that you’re not walking alone.
Update, November 3, 10 am ET: This story was originally published in 2023 and has been updated multiple times to include the latest data.
2025-11-03 23:00:00
牙科保险其实并不是真正的保险，更像是一种有限的折扣计划，而且有年度最高限额。一旦超过这个限额，患者就要自己承担所有费用，通常数额相当可观。在美国的医疗体系中，牙科一直被视为一个被忽视的“小角色”。尽管有大量证据表明口腔健康与整体健康密切相关，比如对怀孕结果和心脏健康的影响，但美国医疗体系并不将牙科视为基本服务。牙科教育、监管和实践一直与整体医疗体系分离。
美国牙科协会（ADA）指出，超过三分之一的美国成年人没有牙科保险。虽然牙科保险可以覆盖部分清洁和检查费用，但一旦涉及更复杂的治疗，保险覆盖的金额就会减少，患者需要自行承担大部分费用。例如，一些计划的年度最高限额在1000到2000美元之间，超过这个限额后，保险不再提供任何帮助。
ADA的首席经济学家马克·武吉奇（Marko Vujicic）指出：“从牙科保险的模式来看，它并没有保护患者免受财务风险，反而相反。一旦保险额度用完，所有费用都由患者承担，这实际上是保护了保险公司，限制了他们的财务风险。”
尽管如此，牙科保险并不是完全没有价值。一些研究表明，获得牙科保险可以促使更多人定期看牙医，尤其是低收入人群通过医疗补助（Medicaid）获得牙科保险后，确实增加了看牙的频率。然而，改变现状却面临诸多阻力，包括牙科行业本身的反对。牙科协会（ADA）曾反对一项为所有 Medicare 受益人提供牙科保险的提案，认为应优先考虑低收入老年人。
此外，牙科保险行业监管较松，许多牙科保险公司希望保持现状。例如，医疗损失比率（MLR）规定保险公司必须将至少80%的保费用于医疗支出和改善医疗质量，但牙科保险并未受到类似监管。一些州如马萨诸塞州在2022年通过了要求牙科保险公司至少将83%的保费用于患者护理的提案，但牙科界对此反应冷淡。
牙科保险的结构使得患者在选择保险时面临诸多挑战。牙科保险更像是亚马逊Prime这样的会员服务，患者支付费用，保险公司则在市场中寻找牙医并为其提供折扣。然而，一旦保险额度用完，患者就不得不自己承担费用，这在牙科治疗中尤为明显。
对于患者而言，理解牙科保险的局限性非常重要。一些牙科保险计划的年度最高限额已经无法覆盖现代牙科治疗的费用。例如，40年前1500美元可以购买很多牙科服务，而如今同样的金额可能只能支付一次简单的治疗。
牙科保险的复杂性使得患者难以自行判断其价值。有些人可能每年只做一次清洁和检查，而牙科保险的费用可能比这些服务的费用更高。此外，一些牙科保险计划在复杂治疗上的报销比例很低，甚至不报销。
牙科保险的现状导致患者在面对牙科问题时常常感到无助。他们需要提前规划，甚至希望不会需要太多治疗。然而，这种模式并不理想，尤其对那些最需要帮助的人群来说。
牙科保险的复杂性和局限性使得患者难以做出明智的决策。牙科保险的结构和监管体系需要改革，这可能需要立法行动，例如扩大 Medicare 和 Medicaid 的牙科覆盖范围。尽管这可能面临阻力，但一些专家认为，双方或许可以找到一个折中的方案。
总的来说，牙科保险的现状并不理想，它更像是一个有限的折扣计划，而不是真正的保险。患者在选择牙科保险时需要仔细阅读条款，了解其实际价值。同时，牙科行业和保险公司也需要反思，是否可以通过更合理的结构和更高的监管来改善这一现状。
The thing about dental insurance is that it isn’t really insurance — it’s more like a half-helpful discount plan with a maximum. And once you reach the maximum, you’re on your own, often to the tune of hundreds and thousands of dollars. As though going to the dentist needed to be less fun.
In the realm of all things health care, dental exists as a sort of overlooked stepchild. The American medical system doesn’t really consider dental care an essential service, despite mounds of evidence linking a healthy mouth to the well-being of the rest of the body, from better pregnancy outcomes to a healthier heart. Dentistry has always been siloed off.
Dental coverage has been off in its little — largely unregulated — corner, too. According to the American Dental Association, more than one-third of US adults don’t have any benefits at all. (For comparison, just 8.2 percent of Americans lack health insurance.) Many patients put off dental care and cite cost as the main reason they don’t go to the dentist — including those who are insured.
Even if you do have dental benefits, they’re often less than beneficial. Insurers may cover 100 percent of a cleaning or a checkup, but once you get into other more complicated services, they start to cover less, so patients have to pick up some or much of the cost. Plans have annual maximums ranging between, say, $1,000 to $2,000, after which the insurance covers nothing.
“When you look at the dental insurance model, it doesn’t protect the patient from financial risk. It’s the opposite,” said Marko Vujicic, chief economist and vice president of the Health Policy Institute at the American Dental Association. “Once the benefit runs out, the $1,400 or whatever it is, all of that financial burden is on the patient. So it protects the insurer, they’re limited on their exposure.”
Imagine being told your health insurer will only pay for 50 percent of your heart bypass surgery, and that it only covers $10,000 of all your health services each year. That would be considered unacceptable in this day and age. But that’s what would happen if I needed a crown — my insurance covers half, and it only pays out $1,500 total all year. My dentist screwed up on a filling last year. It didn’t take long before I hit my limit.
Open enrollment, the set time period for picking health benefits for the coming year, is a moment when millions of people come face-to-face with the complexity of American health insurance.
Our goal is to help you make choices about your own health — and understand how the health system got this way. Here are the questions you should ask yourself while picking a health plan, and here’s why health care in America is tied to your job in the first place. Here’s how dental insurance and flexible spending accounts came to be, and why even most Medicare beneficiaries get insurance through private companies.
Is there a better way to do this? Judge for yourself: In 2020, Vox explored the upsides and downsides of health insurance systems in Taiwan, Australia, the Netherlands, and the United Kingdom.
None of this is to say you should nix dental insurance and just go it alone. Insurers are often able to get patients better prices for services than patients would get on their own, and a $1,500 help on dental costs isn’t nothing. It’s just hard not to look at the landscape and wonder whether it can’t be better.
To back up a bit and then some, dentistry was for centuries performed by barber surgeons, which is pretty much what it sounds like — the guy who cut your hair also pulled your rotten tooth (and did a lot of procedures you’d probably prefer your hairdresser not get into anymore). Dentistry wasn’t recognized during the establishment of medical schools in the US in the 1700s and 1800s. Eventually, the country’s first dental school was founded in 1840.
“From the beginning of the modern era, there has been debate about dentistry’s proper place in the wider health system, but what has evolved is clear: Dental education, regulation, and practice are isolated from the rest of health care,” wrote Elizabeth Mertz, associate director of research at Healthforce Center at the University of California, San Francisco, in a 2016 paper on the dental-medical divide.
In the 1960s and 1970s, she notes, consumers largely paid their own dental costs, while most of the public had some sort of hospital or surgical insurance for medical care. A prepaid dental plan should incentivize dental visits, since it at least covers some of the costs. But it became a valid business model for insurers only after they realized that not everyone would take advantage of the benefit — people and employers would pay for the insurance but not necessarily go.
So today, America’s got a system where we separate out dental care into its own separate little realm. We then do the same with dental insurance and treat it like it serves a different purpose.
“Medical is structured to help you most when you’re sickest,” said Michael Adelberg, executive director of the National Association of Dental Plans, a trade group representing dental insurers. “Dental insurance is focused more on preventative care and helping people — many of whom are not naturally inclined to go to the dentist — get to the dentist by being most generous on preventative care and regular checkups.” Even though, again, having dental insurance doesn’t always equate to taking those biannual recommended trips to the dentist.
Medicaid and Medicare, designed in the 1960s, excluded dental services from coverage and continue to do so.
Dental isn’t included in regular Medicare, except for in specific circumstances where it’s considered part of some other medical procedure (like certain cardiac or organ transplant procedures). While 90 percent of Medicare Advantage plans offer some sort of dental coverage, the quality of that coverage can vary greatly. Patients often don’t realize the limitations on those add-on plans when signing up, so they think they’ve signed up for a robust service and ultimately all they’ve got covered are cleanings. “You have to read the fine print of the plan,” said Michelle Rosenberg, director of the Government Accountability Office’s health care team.
States are required to cover dental for all children in Medicaid. Most states offer at least emergency dental services for adults, but many don’t offer much beyond that. The Affordable Care Act declared pediatric dental care an essential health benefit (though it’s a little complicated, depending on the state), but it didn’t do much for adults. Untreated dental issues can result in some scary negative consequences, including gum disease and undiagnosed oral cancers.
Because dentistry isn’t governed as an essential service, there are a bunch of patient protection regulations that don’t apply, Vujicic explained. “Under the Affordable Care Act, we protected consumers from health care costs, we said you can’t be denied care because of pre-existing conditions, there’s a limit to how much a family is going to pay out of pocket each year for their medical care, it doesn’t matter how sick you get,” he said. “All of those things don’t apply in the dental world, because it’s not regulated as a core service. So we have a little bit of a Wild West when it comes to what type of insurance is out there.”
Study after study shows Americans with and without insurance forgo dental visits and treatments because it’s so expensive. That decision can wind up being even more costly — hundreds of thousands of people land in the ER each year because of often preventable dental conditions, costing, by one estimate, $2 billion.
There’s not a lot of political energy around addressing dental benefits, and when there is, there’s plenty of resistance among those who prefer the status quo.
There’s plenty of evidence that moving away from the status quo on dentistry and dental benefits would be a positive development for patients. One study found that low-income people who gained access to dental coverage through Medicaid did start to go to the dentist more. Another found that embedding dental coverage in medical plans (in this specific case for children) reduced costs for beneficiaries.
So what’s stopping change? There’s not a lot of political energy around addressing dental benefits, and when there is, there’s plenty of resistance among those who prefer the status quo.
“Organized dentistry itself has actively and expensively campaigned to keep things the way they are,” said Lisa Simon, a dentist and physician at Brigham and Women’s Hospital and Harvard Medical School. “There have been plenty of opportunities for dental insurance to be, more recently, integrated into Medicare and Medicaid in various ways, and those who have been vociferously opposed by many dentists.” Simon noted that many dentists still work in private practice with their own offices and tend to accept public insurance at low rates, if at all. “[They] tend to be very reactionary in any attempts to update the insurance industry,” she added.
In 2021, the ADA fought against a proposal from Democrats to provide dental coverage for all Medicare recipients under President Joe Biden’s Build Back Better agenda, arguing the focus should be on low-income seniors, not everyone.
“As an association, we’re not against it, it’s a question of how it’s structured,” said Mark A. Vitale, dentist based in New Jersey and the former chair of the council of government affairs at the American Dental Association. He said introducing dental benefits for everyone over 65 could be “cost prohibitive” for the federal government and noted that there are structural differences between the Medicare system and dentistry. “We use different codes, different qualifiers, different types of fee schedules.”
“The [ADA] is a trade group that defends the interests of its members who are private practice dentists who have done very well under the current system and have perceptions that Medicare may increase their administrative burden or provide lower reimbursement that they’re not interested in participating in,” Simon said.
The White House eventually dropped the plan as part of a broader decision to pare back the package.
The dental insurance industry is lightly regulated and on many measures would like things to remain that way. One recent battle has been over medical loss ratios (MLR), which measures how much of the revenue insurers get from premiums goes toward medical claims and improving care quality compared to, for example, administrative fees. The ACA required health insurers to keep their MLR to 80/20, but it didn’t touch dental.
In 2022, voters in Massachusetts said yes on a ballot initiative that would make dental insurers spend at least 83 percent of premiums on caring for and improving care for patients. Dentists are keen on MLR rules. Dental insurers and the NADP, which represents them, not so much. They argue low-premium products like dental insurance naturally have a higher percentage of their operating costs eaten up by costs that are fixed. “My industry views the application of a medical-level medical loss ratio on any low-premium products, without considering the fundamental economic differences of medical and dental, as just kind of silly,” Adelberg said.
One common theme here is that all parties involved would like more money in their pockets.
Some dentists also note that insurance maximums haven’t gone up in recent decades, even though the price of dentistry has. “Forty years ago, $1,500 bought you a lot of dentistry,” said Vitale. “Today, $1,500 doesn’t buy you a lot of dentistry. My question to the insurance carrier is why haven’t you increased the benefit level?”
When people are picking out dental insurance plans, what they need to understand, really, is that it’s not insurance. Richard Manski, chair of dental public health at the University of Maryland’s School of Dentistry, said to think of it more like Amazon Prime — you hand the company money, and in return they go out into the marketplace, find sellers (in this case, providers), and try to get you deals that are better than what you would get in your own. “When you buy dental insurance, and you buy the kind of dental insurance where the dentist is part of a network, that means the dentist has agreed to a set pricing for all these procedures,” he said. “So even if the insurance company didn’t pay a dime for anything, you’re already getting back a really valuable service, which means you don’t have to negotiate with the dentist.”
Indeed, if you’ve got a painful tooth infection or something, you’re probably not in the position to talk discounts with the doc.
There are ways to strategize around dental care and insurance. If a patient hits their annual max, they can consider moving certain procedures to the following year. People can also try to decipher ahead of time whether dental insurance is even worth having. Say someone’s never had a cavity, just goes twice a year for a cleaning and checkup — the cost of that might be less than the insurance premium. Or maybe the insurance they’re offered doesn’t pay much or anything on more complex issues, anyway.
It’s not realistic to expect people to try to do their own health care math.
“I give talks on why you don’t need dental insurance to go to the dentist,” Vitale said. “Offices today will have office loyalty plans, they’ll have various financing modalities available.” He also noted people can try to negotiate discounts with their dentists, which, as mentioned, your mileage may vary on that one.
This scenario where people are supposed to try to anticipate what sort of care they’ll need and essentially hope it isn’t too much is far from ideal. It’s not realistic to expect people to try to do their own health care math, said Simon, “because it requires a level of such sophistication in terms of understanding health care pricing, health care access, and all these other things, which makes it super inequitable.” If English is someone’s second language, or they’re working multiple jobs, or the bus ride to the dentist is really long, deciphering the basics of insurance and whether it’s worth the financial burden is even harder to do. “That’s why one of the things that is so bad about the way our dental ‘insurance system’ works is that it’s really unjust for most people,” Simon said. “For anyone, but it works the worst for the people who need the most help.”
It’s worth noting that patients can also have a hard time deciphering what procedures they really even need at the dentist — some offices recommend the basics, it can feel like others suggest doing everything under the sun. (The Invisalign push at some dentists is real.) “The consumer has an obligation to press their provider and say to them, ‘Is this necessary?’” Manski said. “Patients should be much more involved in their caretaking decisions.”
Of course, all of this is easier said than done. Most people don’t have the time or energy to be gaming out their dental care or dental insurance, nor should they. From a patient perspective, it’s not hard to look at this and wonder whether there isn’t a better way to approach oral health in America than the way we do now. The thing is, a lot of that would require legislation and a different regulatory framework.
That might mean congressional action to expand dental coverage in Medicare and Medicaid. It’s something the dental community would likely resist, though Manski said he believes there’s some sort of deal both sides can probably “live with.” One could also envision ACA-like requirements that, for example, get rid of maximums on dental insurance and protect consumers from high costs. Dental, perhaps one day, could be covered as part of everyday medical insurance — once the country stops treating people’s teeth like some separate bodily entity.
Update, November 1, 10 am ET: This story was originally published in 2023 and has been updated with more current figures for coverage among US adults.
2025-11-03 22:30:00
在开放参保期间，许多人选择加入的“医保优势计划”（Medicare Advantage）并非传统意义上的政府主导医保项目，而是由私人公司管理的替代方案。目前，超过一半的6300万医保受益人（约3400万美国人）选择了该计划，其份额在十年内几乎翻倍。尽管该计划提供了更简便的流程和额外福利（如牙科、视力等），但研究和媒体报道指出，它存在一些问题，例如医生和医疗资源较少、患者报销问题更多，以及保险公司可能滥用权力，如使用人工智能决定何时停止覆盖服务。
医保优势计划的兴起源于1997年《平衡预算法案》，旨在通过降低费用和简化流程吸引参保者。然而，数据显示，该计划的成本比传统医保更高，且加剧了医保的财政危机。联邦政府为这些计划支付固定费用，而保险公司则通过控制支出获得利润，导致医保资金紧张。2020年，医保优势计划的过度报销金额估计在120亿至250亿美元之间，而传统医保的费用则相对较低。
尽管政府试图通过调整支付规则来遏制过度报销，但保险公司和共和党强烈反对，认为这会损害医保优势计划的盈利能力。例如，拜登政府试图削减医保优势计划的支付，但最终调整后的方案反而更有利于保险公司。这表明医保优势计划在政治上具有强大影响力，任何改革尝试都将面临阻力。
目前，医保优势计划已成为美国医保体系的核心，但其增长也引发了对财政可持续性和患者权益的担忧。医保信托基金预计将在2033年耗尽，而医保优势计划的扩张进一步加剧了这一问题。未来，政策制定者需要在控制成本和规范保险公司行为之间找到平衡，但改革之路将充满挑战。
If you’re signing up for Medicare benefits this open enrollment, odds are you aren’t actually enrolling in the traditional government program that people may envision. More than half of Medicare beneficiaries are now choosing an alternative version of the program administered by private companies.
Medicare, the paragon of America’s welfare state, is undergoing a subtle but fundamental transformation from government program to public benefit provided by private companies, a shift with major implications for both patients and taxpayers. This alternative version of Medicare, known as Medicare Advantage, now covers more than half of the program’s 63 million enrollees, or about 34 million Americans — nearly double its share 10 years ago.
Fears over Medicare’s solvency have renewed the debate about how much the plans cost the federal government. New data shows Medicare Advantage enrollees have access to only half as many doctors and health care providers as patients on traditional Medicare. And media investigations have added to concerns about how private companies oversee the public benefits they are supposed to provide.
If you’re choosing between traditional Medicare and an Advantage plan, here’s what you should know about the two versions of the program — how we got here, the potential drawbacks, and what could be in store for the program going forward.
Medicare has traditionally been a government-run insurance program for people over 65 and those with long-term disabilities. Medicare Advantage allows private insurers to offer their own plans that provide Medicare benefits, as well as some additional perks not available in the original program. The secret to the program’s success is simplicity. Traditional Medicare is a fragmented program: Part A covers hospital care, and Part B covers outpatient services. Patients must enroll in a separate Part D plan for prescription drug coverage that is administered by private insurers. Most people also purchase supplemental coverage, extra insurance that helps reduce their out-of-pocket costs.
Medicare Advantage, also known as Part C, combines those benefits into one insurance plan that also includes an annual limit on out-of-pocket costs, something that does not technically exist in regular Medicare.
Open enrollment, the set time period for picking health benefits for the coming year, is a moment when millions of people come face-to-face with the complexity of American health insurance.
Our goal is to help you make choices about your own health — and understand how the health system got this way. Here are the questions you should ask yourself while picking a health plan, and here’s why health care in America is tied to your job in the first place. Here’s how dental insurance and flexible spending accounts came to be, and why even most Medicare beneficiaries get insurance through private companies.
Is there a better way to do this? Judge for yourself: In 2020, Vox explored the upsides and downsides of health insurance systems in Taiwan, Australia, the Netherlands, and the United Kingdom.
But the benefits to patients seem to come at a cost to taxpayers. Though the health insurance industry disputes these findings, MedPAC, the independent committee tasked with overseeing Medicare on Congress’s behalf, found Medicare Advantage plans cost the federal government more money per patient than the original program would have if those same people had stuck with the traditional benefits.
Private companies are also making healthy margins on their Medicare business. A Kaiser Family Foundation analysis found that insurers were making more money per patient in Medicare Advantage than with their individual or employer-sponsored plans. Humana, which covers 5 million beneficiaries, or roughly one in five people who have elected to go with the Medicare alternative, announced in 2023 it was dropping the rest of its portfolio to focus exclusively on the Medicare Advantage market and Medicaid managed care, a version of that government program that is similarly run by private insurers with state supervision.
Patients have clearly found something to like in what Medicare Advantage offers. The program was established in 1997 to give people a streamlined alternative, a private option less overt than more recent GOP voucher proposals.
But scholarly research and media investigations have revealed notable downsides in turning over a program that covers America’s seniors, the people who need and use the most health care, to private companies. Medicare Advantage enrollees are more likely to report trouble affording health care than people on traditional Medicare. Some of the behavior by Medicare Advantage plans, such as using AI to decide when to stop covering services for their enrollees, may be becoming more common in the private sector but is still unheard of for public programs.
The trade-off the United States seems to be making is accepting more administrative bloat and more stringent provision of benefits in exchange for a more navigable Medicare plan. The trade-off is one other countries have made as they designed universal health care programs. (A similar trend is underway in Medicaid.)
But as concern grows about Medicare facing a potential financial cliff, and evidence mounts about the costs of Medicare Advantage, the risks of the trade-off are becoming clearer. Medicare is no longer what it used to be: Once the epitome of government-run health insurance, its benefits are on the verge of being primarily funneled through private companies. Any attempts to change the program will have to wrestle with that reality.
Pilot programs for private insurers’ administration of Medicare date to the 1970s, but the Medicare Advantage program was created by the Balanced Budget Act of 1997, at a time when concerns about Medicare’s solvency ran high. Originally known as Medicare Choice or Part C, it was renamed Medicare Advantage in 2003, when Medicare was expanded to cover prescription drugs.
The idea was to provide patients with a simpler Medicare plan. If you have traditional Medicare, you are combining Part A, for which most people don’t pay a premium, and B, for which most people do, with a separate Part D drug plan, and potentially supplemental coverage, too. With Medicare Advantage, people can enroll in a single insurance plan that provided the full menu of benefits.
Some Medicare Advantage plans also include dental, hearing, and vision benefits, services that are not covered by the traditional program but can be critical for seniors. Medicare Advantage plans also set annual caps on out-of-pocket costs, which don’t apply in traditional Medicare. (Supplemental coverage or Medicaid instead lowers costs for most — but not all — Americans who opt for the original version of the program.)
Beneficiaries pay monthly premiums to purchase a Medicare Advantage plan; people with lower incomes qualify for subsidies. There are notable limitations in coverage. In traditional Medicare, for example, patients can go to any doctor or hospital that accepts Medicare; Medicare Advantage has more limited provider networks, and patients can be on the hook for higher costs if they are treated at an out-of-network doctor or hospital. A KFF analysis published in October 2025 found that Medicare Advantage patients could use their plan with less than half as many physicians — 48 percent — as those on traditional Medicare. Some patients on the most stringent could receive care from only one-third of all providers who accept the historical program.
The federal government pays Medicare Advantage plans a flat rate for the expected cost of covering their particular customers and the insurers are required to adhere to certain rules about benefits and costs. But companies still have flexibility about how to run their plans and have a financial incentive to limit expenses. The less money they spend, the more they get to keep for themselves.
Still, customers will vote with their feet and, after slower-than-expected initial uptake, Medicare Advantage is now growing so quickly that it has become the dominant form of Medicare.
Why the movement? In a 2021 analysis published in Health Affairs, Ken Terry and David Muhlestein observed that “we’re witnessing the rapid privatization of Medicare” and offered an explanation: Medicare Advantage plans “offer beneficiaries a better deal than traditional Medicare.”
The premiums people pay for a Medicare Advantage plan can be significantly lower than the combined cost of supplemental coverage and a Part D plan — less than $50 compared to more than $200 on average, per Terry and Muhlestein — with the added benefit of having only a single insurance card. According to a 2022 Commonwealth Fund survey, the additional benefits offered by Medicare Advantage plans (such as dental or vision) and the limits on out-of-pocket costs were the most common reasons seniors gave for choosing the alternative over the original program.
In general, patients with traditional Medicare and people with Medicare Advantage say they have similar satisfaction with their benefits. On some metrics, the latter group excels; people with a Medicare Advantage plan are more likely to have a regular doctor and to say they have received preventive health care services. With a few exceptions for particular medicines, Medicare Advantage customers report fewer problems accessing their prescription drugs, too.
But people enrolled in Medicare Advantage also experience a unique set of problems compared to people who choose the original program.
Those problems, based on the available research, start with cost. A higher percentage of Medicare Advantage enrollees report having problems affording care (about 19 percent, per a 2021 KFF analysis) than those on traditional Medicare (15 percent), though people on the original program without supplemental coverage had the most problems with affordability (30 percent). (Most people on Medicare do purchase this coverage.) Black Americans and people with lower incomes were more likely to report having trouble paying for health care while enrolled in Medicare Advantage.
Other findings appear worrisome, too. Medicare Advantage patients are less likely to receive medical care at the highest-rated facilities for their particular needs, compared to people with traditional Medicare, a reflection of more restrictive provider networks. Families also reported more satisfaction with end-of-life care when using traditional Medicare.
Specific business practices by Medicare Advantage plans, and their consequences for patients, have also been called into question by investigative reporting and government inquiries over the past few years, practices that seem to run counter to Medicare’s function as an entitlement program for Americans over 65 and those with long-term disabilities.
In 2023, STAT reported on the increasing use of AI algorithms by these plans to determine when to cut off benefits for a customer. The lead example of their reporting was an 85-year-old woman with a broken left shoulder, whose insurer followed an algorithm that said she should be ready to leave a nursing facility and return home within 17 days.
On the 17th day of her stay, the insurer said it would no longer cover the bills for her stay, even though her doctors and nurses observed that the woman was still in extreme pain and incapable of doing basic activities, such as dressing herself or going to the bathroom. It took more than a year, and a federal judge’s order, for the patient to receive payments for the three additional weeks she needed to stay in the nursing facility. Doctors shared other stories of patients who saw benefits withdrawn at the end of their life, leaving their families to fight over the leftover bills for years after their loved one had died.
A report from federal investigators published in April 2022 found that tens of thousands of Medicare Advantage customers were denied coverage for services they should have been entitled to. A significant number of prior authorization denials (13 percent) and payment denials (19 percent) reviewed by the investigators were for services that should have been covered by the program but were not.
“Denied requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers,” they wrote. “Even when denials are reversed, avoidable delays and extra steps create friction in the program.”
In addition, as the New York Times reported in October 2022, most of the largest Medicare Advantage insurers have been the subject of federal audits that found they improperly billed the program and of litigation that accused them of fraud. Taken together, the plans overbilled Medicare by between $12 billion and $25 billion in 2020, depending on the estimate.
Though Medicare Advantage was first established as a tool for reining in spending, these private plans instead seem to be perpetuating the program’s solvency crisis.
According to MedPac, since 2004, Medicare has always paid more to Medicare Advantage insurers for the cost of covering their customers than the program would have spent if the same beneficiaries had instead been enrolled in traditional Medicare. Some years, the private plans were receiving a nearly 20 percent markup compared to the original benefit structure.
Those high payments are drawing more attention with an insolvency crisis for Medicare Part A, which covers hospital bills, on the horizon. Part A is funded almost entirely through the program’s dedicated payroll taxes. If those benefits cost more than the government receives in Medicare payroll taxes in a given year, as can happen in an economic downturn, the difference comes out of a trust fund earmarked specifically for Part A. The Medicare trustees, who issue annual reports on the program’s finances, project that Medicare spending will begin outpacing revenue again in 2024, requiring the program to dip into the trust fund. The trust fund is projected to be fully depleted by 2033 without further policy changes.
The growth of Medicare Advantage is contributing to the financial crunch. Those plans receive funding based on the type of service provided to their customer, which means money for hospital care comes from Part A. Annual Part A payments to Medicare Advantage plans are expected to increase from about $176 billion in 2022 to $336 billion by 2030.
With revived concerns over Medicare’s solvency and evidence of excess spending in Medicare Advantage, policymakers are starting to look at making changes to the program. But that won’t be easy.
Health insurers are going to fiercely defend their Medicare Advantage business against any proposed cuts, as the flap over the Biden administration’s proposed payment changes reveals. That’s because Medicare Advantage is now the industry’s most profitable line of business. United Healthcare, the nation’s largest health insurer and the largest seller of Medicare Advantage plans, has been aggressively expanding its offerings for people in the program.
That has made insurers very protective of their Medicare Advantage business. Insurers are not quite the lobbying force they were before the Affordable Care Act, but they remain highly influential and they have found allies among Republicans who have always preferred to see Medicare become more of a private operation.
The Biden administration’s failed attempt to cut payments for Medicare Advantage plans revealed the industry’s clout. As KFF analysts explained, the Biden White House wanted to crack down on overpayments in 2023 with adjustments to the complicated formula that determines when Medicare Advantage plans need to pay back the federal government for improper billing. The insurance industry painted that proposal as a cut, even though the Biden administration estimated that, when the entirety of their proposed payment plan is taken into consideration, Medicare Advantage plans would still see a 1 percent increase in payments from the federal government in 2024.
Health insurers warned of premium increases and benefit cuts, “though there is no clear evidence to suggest that,” according to the KFF analysts. They were joined by Republicans, who sought to turn the tables on Biden by accusing him of proposing Medicare cuts after the president had criticized Republican plans to cut spending for the program.
“Joe Biden is trying to gut Medicare benefits. Seniors can’t trust Democrats to protect Medicare,” one Republican campaign spokesperson told Roll Call in February. The Better Medicare Alliance, a lobbying group for Medicare Advantage plans, has started running TV ads asking seniors to petition the White House to reverse the proposed payment changes.
Though independent fact-checkers concluded that calling the Biden proposal a cut is inaccurate, the private insurers still won. The payment rates that the administration finalized in April after the brouhaha ended up being more favorable to the Medicare Advantage plans. The entire episode demonstrated Medicare Advantage’s growing political clout and previewed the fight that would likely meet any efforts to seriously alter the program. It remains to be seen whether the Trump administration will make major changes to Medicare Advantage, though some patient advocates worry the administration will take a lax approach to enforcing the program’s rules, potentially leaving beneficiaries at risk.
The policy structure of Medicare Advantage is not without precedent. States have outsourced much of the administration of Medicaid to managed care plans. Countries like the Netherlands have set up health systems that use private insurers, operating under strict government oversight, to provide insurance benefits to their citizens. Giving people more choice and a more streamlined experience can have its benefits, as evidenced by the popularity of Medicare Advantage in the US.
But asking private actors, with profit motivations, to administer government benefits to which people are supposed to be entitled brings risks. People are more likely to have trouble affording health care, and their claims are more likely to be denied; that is true in places like the Netherlands, compared to other countries with more direct government administration, and that is true of Medicare Advantage when compared to the traditional Medicare program.
To date, policymakers have seemed content to let Medicare Advantage grow without much moderation. Medicare beneficiaries have been attracted to its comparative simplicity. But the costs of funding the program, amid the political environment’s shift toward more fiscal restraint, and the problems experienced by patients have put the program under the microscope.
It is difficult, at this point, to imagine the Medicare program without Medicare Advantage. The question is whether policymakers can make it more cost-effective and crack down on insurer behavior that runs counter to the program’s objectives. Recent events suggest that if they try, they will have a fight on their hands.
Update, November 3, 9:30 am ET: This story was originally published in 2023 and has been updated to include new reporting and moves from the second Trump administration.