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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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.
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