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Your health care open enrollment questions, answered

From the politics of US health care to assistance for selecting a Medicare Advantage plan.

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Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Health care open enrollment is here and we’re here to help guide you through it.

During this baffling annual ritual, Americans encounter our health care system’s most confounding questions. Why am I stuck with my employer’s health plan? Who thought flexible spending accounts were a good idea? Why do I have to make so many choices when enrolling in Medicare? Is my dental insurance a scam?

Those were the questions we had here at Vox going into this open enrollment season. But we were curious to know what questions our audience had too. Last week, Vox supporters had an opportunity to ask and have answered their questions about open enrollment. If I were to identify a common theme, it was less about specific benefits and more big picture: Why is it so hard to make things simpler? Why is our health care discourse so contentious?

In the spirit of Vox’s commitment to keeping our journalism free to all, we wanted to share some of those questions and answers with all of our readers. So here they are, lightly edited for clarity and length.

Why does Medicare For All or some universal health care for everybody seem like such a monumental task to accomplish in the USA as opposed to other countries around the world? Is it simply that we as Americans are focused on ourselves instead of helping others around us or is it more complicated than that?

I think the problem boils down to two distinct but related issues.

  1. The health care industry is very influential in Congress and willing to spend a lot of money to preserve the status quo.
  2. The American public may have reservations about our current health care system, but they are apprehensive about change.

The first issue speaks for itself: Going back to the Truman era, the industry has marshaled immense resources to oppose proposals that would lead to more government involvement in health care. The Clinton health plan, opposed by the insurance industry’s Harry & Louise ads, is the best example of the effectiveness of its tactics. The Obama administration cut deals with the industry to get the Affordable Care Act (ACA) passed but, as a result, the law largely worked under the infrastructure that was already in place. There are some signs of the industry’s influence waning, such as Congress’s success in authorizing Medicare drug negotiations, but its ability to sway Republicans and moderate Democrats will always be the most important vote-counting hurdle to any major restructuring getting passed.

The political headwinds are also strengthened by the second issue: the voters. I have sat in on focus groups about Medicare-for-all with middle-of-the-road-ish voters who are in theory open to change. They may not love what they have now, but many of them like the idea of having choices and they are worried that they will somehow end up worse off if there is a big overhaul. I do think people find some of the theoretical benefits of Medicare-for-all appealing, but they can be swayed by arguments pointing out the potential downsides. And the truth is, for all its problems, there is a critical mass of people who are just satisfied enough with the status quo. Polling consistently finds Americans think poorly of the system as a whole but they are more positive about their own health coverage. That’s the paradox Medicare-for-all supporters have to solve.

So I think as long as those two factors hold true, it’s hard to imagine big changes happening. It’s certainly possible that things will deteriorate enough that the political environment will change. But who knows if we’ll ever reach that point.

Why is health care so political in the US?

I don’t think the US is unique in having health care be a contentious issue. I traveled to other countries for our Everybody Covered series a few years ago and each of the places I visited had been through spirited health care debates. Protesters marched through the halls of the Taiwanese capital when Taiwan was considering its single-payer plan. Australia has seen its health care system swing wildly between the public and private sectors depending on which party was in power, before settling into a hybrid model. Doctors in the Netherlands protested over working conditions in the early 2000s, leading to reforms to their sector.

But I think the US health care discourse is distinct for one big reason. While those countries have difficult debates about health care and have seen big changes, they have reached a social consensus that universal health care is the goal. It’s just a question of how to achieve it. The US has never reached that kind of consensus. Even today, the two parties have very different views on that question. I think that’s why our health care debate can seem so divisive: because it’s over fundamental questions about what the government should be doing and its obligations to its citizens.

On top of that, you have a lot of money behind any health care debate. Health care is one of our economy’s biggest sectors and the various companies involved with it are willing to spend a lot of money whenever their interests are at stake.

Something I’ve been wondering about is how much more accessible care for mental health has gotten, even though there’s a long way to go. When did mental health become more recognized/a more important part of health insurance?

You’re right: We do still have a long way to go. A recent survey found that 40 percent of patients who sought in-network mental health care had to make four or more calls to find a provider who would see them — compared to just 14 percent for physical health care. More than half of patients said they had had an insurance claim for mental health care denied three or more times, compared to about one-third who said they had the same experience with physical services.

But, to your point, that doesn’t mean we haven’t made progress. Insurers used to have no obligation to cover mental health care at all. The first mental health parity law was passed in the late 1990s as a kind of bipartisan consolation prize after Bill Clinton’s health care reform plan fizzled out. It was largely symbolic because the health insurance market was mostly unregulated at the time. Sometimes health insurers didn’t cover mental health care at all. On the individual market, health insurers would disqualify people from coverage if they had mental health needs.

In 2008, Congress took another pass at improving coverage for mental health services, attaching a bill to the must-pass financial bailout and establishing the rules that exist today. (The ACA then extended these requirements to insurance sold on the law’s insurance marketplaces.) The 2008 law said insurers couldn’t place unfair limits on mental health care. You couldn’t be limited to two mental health visits but permitted six doctor visits, for example. Patients couldn’t face higher out-of-pocket costs for mental health services.

In practice, though, it has been hard to enforce. Mental health providers may be in an insurance network, but that doesn’t mean they have availability to see new patients, to name one common problem. The Biden administration is taking new steps, 15 years after the law first passed, to try to force more compliance.

On behalf of my mother, I’d like to ask how best to determine if a Medicare Advantage plan serves her better than traditional Medicare. I know that the Advantage plans generally cover medical, prescription and some dental and that traditional Medicare does not cover prescriptions or dental and that she’d have to enroll in a Part D plan for prescriptions. Other seniors I know have told us to steer clear of Advantage plans due to losing benefits under medical.

It’s funny you should ask. After our series published, I was sent a new online tool for Medicare plan shopping, by a Berkeley professor who sits on the company’s board. I can’t formally endorse it, of course, but I did mess around with it a bit as a hypothetical shopper and it seemed designed to help people compare different options. Healthpilot might be worth checking out:

The AARP has other resources that might be useful to people in this situation. As Allie Volpe wrote for our series, in a guide to picking your health plan, there’s a lot of free assistance available to help people make open enrollment decisions.