I hope this is the correct sub, if not, please direct me somewhere.
Let me preface this – I do not live in USA.
I’m an interpreter from Poland, currently during training. Since we’re going to help Poles living in USA with, for example, health insurance, we’re being taught how it works.
But in theory it’s all nice and dandy, while in reality it seems horrible. I can’t find the middle ground and how it’s applied to real life situations. Trainer denied explanations, claiming interpreters are not allowed to have opinions (or at least express them), but I think this knowledge would allow me to better understand the context of the situation.
If there are deductibles and then copay and then out of pocket maximum (that apparently nobody ever reaches anyway), then why people have such high med bills even though they’re insured? If out of pocket maximum is for people with serious medical issues ending up with hospitalisation, why insurance companies suggest setting up gofunmes? If insurance or M4A work, then why people can’t afford their insulin, or don’t go to therapy? Why do I see people complaining about “insurance don’t cover my basic meds and I have to pay full price” if there are these… PPOs? I think that’s what they’re called. Insurance should direct them to where they can get a price at least partially covered by the insurance.
I don’t understand, but since I don’t live over there, I probably miss something that is obvious to people who do.
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Some necessary services might not be covered by insurance.
Sometimes a few thousand dollar out of pocket maximum would still be financially devastating for someone.
Or someone might not have insurance.
Also, many medications may not be covered by insurance, or one has an initial prescription deductible that is still unreasonable
I put this answer in another sub a few weeks back. It might not be exactly in point but it should have some answers.
The premium is the cost of the insurance. You have to pay it for the insurance to be active. If you are getting your insurance through your work place chances are they are actually paying most of the premium and only passing along part of the cost to you.
What is insurance? Essentially it is a bet. The insurance is there in case something big and bad happens to your health. As a 25 year old man the most likely medical expense you would have is a broken arm. If you knew the future and you knew in 2022 you would only ever need a standard check up, then you would not need insurance. But nobody knows exactly what medical expenses they will encounter, thus it is a bet.
I will get to the deductible in a minute.
What does your premium get you? Well if you go to an in network provider you get prenegotiated rates. For everything. Without insurance going to a general practitioner for a bad cough could cost you $600 for the office visit, $400 for the labs, $300 for the x-rays, and $200 for the medicine prescribed. Grand total, $1500. Still if that were your only medical need it could still be less than your yearly premium. But if you have insurance then the negotiated price for the office visit is $150, the labs are $100, the x-rays are $150, and the medicine is $25, for a total of $425.
Now in this example that $425 goes toward your deductible. As soon as you meet the deductible then insurance starts paying much more of the bill.
Let’s say your deductible is $2000, and you have already met that sum. Then you have that same office visit for a bad cough. Since your insurance is paying more instead of paying $425, you only pay $85.
Now back to the deductible, this is the amount of negotiated prices that you need to meet in order for the insurance to start paying your bills in earnest. Typically the less the deductible the higher the premium. As a young healthy man if you have the choice between a $2000 deductible and a $5000 deductible (with associated lower premiums) you would probably want the lower deductible plan.
Ok so where does insurance really start to work for you? Let’s say you have gall stones. The Emergency visit, follow up with your GP, the referral to a surgeon, the ultrasound to confirm, the surgery, and the cost of the surgery suite, and anesthetist might run you an insurance negotiated cost of $20000. Assuming you had a deductible of $5000 then you pay the first $5000, then insurance pays 80% and you pay 20% or $3000. The total cost to you is $8000 (assuming you have been paying your premiums). Without insurance the unnegotiated total cost to you might be $40000. Now if you were uninsured and you got that $40000 you could go to the hospital (and surgeon, and anesthetist, and your GP) and say “look I do not have $40000 could I pay the insurance negotiated prices instead if I payed all at once? And they would probably say yes. Then you go to your savings, or a credit union or a bank get a $20000 loan and pay the bill then pay off the loan. OR you say I cannot pay $40000 and see if they will put you on a payment plan (the hospital probably will the anesthetist probably not).
Many people cannot afford insurance, or only afford the most basic available which has very high deductibles (amount you much pay out of pocket before insurance starts covering). And even somebody with a decent job, company subsidized insurnace may still see themself with bills higher than they can afford.
My insurance to cover me, my wife and son cost me $350 every 2 weeks through my employer. We then have a $4000 family deductible. I work in a corporate HQ of a large public company, in a marketing job, so this is GOOD insurance (PPO), not the garbage plans offered to people who work at Wal-Mart or fast food. So I’m paying about $9000 in premiums, and then another $4000 in deductibles — that’s $13,000! I had spine surgery a couple years ago, wife’s been having medical issues the past year or so, so we’ve been hitting that deductible cap. I make enough to absorb all those costs, but imagine somebody in a lower tier job, making $30-50k. That’s a HUGE chunk of their income, but their income is too high for programs like Medicaid.
And insurance often denies things… I couldn’t get the preferred surgery my surgeon wanted to do (artificial discs to replace ruptured ones) and had to settle for spine fusion. Wife has been fighting to get approval for a particular medication — she took it in the past, got off it to get pregnant and now needs to get back on but insurance wants her to try other cheaper ones first, despite fact she did all that 7-8 years ago when her issue first popped up. Without insurance, that drug would run $600/mo.
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The main explanation is that the US health care system is awful for a country as wealthy as ours and is at the mercy of the Health Insurance Industry
Insurance companies are profit driven. Their goal is to make money for investors, so the less they have to pay out the better. So things like deductions and out of pocket cost allow more of the burden to be put on the policy holder, thereby increasing profit margins.
Also, there are no standards for medical costs in the US, you can actually shop around to find varying costs for procedures. I am self employed and have negotiated fees for procedures by explaining to the accounting department of the hospital that my insurance would not pay. In addition, hospitals often charge very high amounts for standard procedures and medicines to help offset costs, this then drives up insurance policy premiums.
So short answer, our insurance system works very poorly in terms of providing health care at reasonable costs.
People get into trouble largely by not calling their insurance before a procedure. It is always the patients responsibility to verify coverage, even if the provider assures the patient that their insurance will cover something.
A provider might be out of network, the treatment might not be covered but a comparable treatment would have been. Each plan is different and if you check with your insurance you avoid lots of issues.
The short answer is that it’s so complicated that very few people (my self included) understand even what is covered by their own insurance, much less what other insurance plans might be better for them.
But you weren’t looking for the short answer. Here are some of the problems:
Resistance to the affordable care act:
The affordable care act was intended to cover most or all Americans either with private healthcare plans or under Medicaid. But for the increased Medicaid coverage to be implemented, it required the individual states to help out. Out of our 50 states, I think there are 12 that have refused to help. This often leaves low income people in these states without any health insurance.
Many different insurance plans:
There are many different insurance plans out there, and each one covers things differently. Even for someone in the medical field — and with the time to read pages and pages of fine print in the insurance policy — it can be difficult to determine what is covered and what is not covered by a policy. People might pick a policy based on what covers their current drugs the best, and not realize until it is too late that it doesn’t cover injuries from a car accident or a serious illness very well.
Insurance companies can make things difficult:
Since insurance companies are in the business to make money (that’s “The American Way”). Thus they try to avoid paying out claims. It’s impossible to write an insurance policy that covers every situation, and if someone tried to do this it would be ridiculously long. So when ever someone makes a claim in a gray area, the insurance company will likely refuse to cover the procedure. The only recourse the patient has is to sue the insurance company in court, but this may cost more than the bill in question. Also, the insurance policy may have wording that says they can’t be sued.
Pricing and coverage are extremely difficult or impossible to get ahead of time:
It can be difficult to get the price of a hospital procedure ahead of time. First, they may not want too tell you, and second the billing is often done separately by the doctors and the hospital. For example if you have a surgery, you will likely get at least three bills, one from the surgeon, one from the anesthesiologist, and one from the hospital. If you need to spend a few days in the hospital after the surgery, the cost here may depend on how well the surgery went and thus how much care you need afterwords.
Insurance companies won’t always tell you what is covered ahead of time either. A few years ago I needed to get a new CPAP machine (it helps me breath at night). I called the insurance company and I could not get an answer as to exactly what they would cover and what they wouldn’t.
These are just some of the issues. Even with a nurse and a medical doctor in the family, it can be hard sometimes for us to navigate the medical insurance system. People without as much inside knowledge of the medical system can have a really bad time with it.
Long story short, health care and insurance are for profit, so their interest is to charge as much as they can and cover as little as possible
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