We need to strip insurers of the ability to deny care, period. The way the current system works, the insurance companies hire their own doctors. These doctors are employees of the insurance...
We need to strip insurers of the ability to deny care, period. The way the current system works, the insurance companies hire their own doctors. These doctors are employees of the insurance company and have a direct incentive to deny care. their own paid doctor, paid according to how many claims they deny, will then make a supposedly objective decision on whether a claim is medically necessary.
This needs to end. There's simply too much conflict of interest for an insurance company to ever objectively determine whether a given prescribed treatment is "medically necessary." This power needs to be stripped from insurance companies. In all but the most extreme circumstances, if a licensed medical doctor stating a treatment is medically necessary, the insurance company should be provided to pay for it (assuming its included in their list of covered treatments.)
Waste, fraud, and abuse are of course still concerns. However, they should be handled by a third party. Maybe an insurance company's only recourse should be to bring a doctor in front of their state's medical board. File a bunch of fraudulent or unnecessary insurance claims? You lose your medical license.
Or maybe we need special state-level courts devoted specifically to medical necessity. We've created many special courts over the years, built and staffed by experts in the court's particular purview. We have immigration courts, we have juvenile courts. We have drug rehabilitation courts. I see no reason we can't have an "insurance claim appeal" court. By default, insurers have to cover all claims by default. But if they truly disagree with a particular claim made by a doctor, they can appeal their required payout to a neutral third-party medical appeals court. To prevent them from abusing the process, the insurance company has to pay for both side's attorneys, and if their appeal is denied, they have to pay the cost of care plus pay a penalty equal to the cost of that care, a penalty split between the patient and the prescribing doctor.
You're going to run in circles and just come back to the realization that insurance for health care is a bad idea. Running healthcare in a capitalist way is just a bad idea. Just treat people....
Exemplary
You're going to run in circles and just come back to the realization that insurance for health care is a bad idea. Running healthcare in a capitalist way is just a bad idea. Just treat people. Even THEN, when you've basically said its all free, you'll still hit plenty of cases where you've got a child who might have a 1% chance of survival after a billion dollar treatment and we'll all scratch our heads and wonder what's the right thing to do. i.e. try that or feed a city full of the homeless, but... its still better than what we have now.
Just to pile on, this model is called "capitated" healthcare (flat rate per person per time period, regardless of utilization). I used to work for a county-level payor that paid for a lot of...
Just to pile on, this model is called "capitated" healthcare (flat rate per person per time period, regardless of utilization). I used to work for a county-level payor that paid for a lot of services this way, and it was extremely effective in terms of reducing administrative burden and aligning incentives.
There is the obvious issue of people abusing services simply because they have them available, but nominal copayments/coinsurance after a certain threshold is pretty effective at tamping that down in practice. E.g. first ten physical therapy appointments per year are free, and after that you start covering 25% of the cost out of pocket. >99.99% of people just want healthcare and aren't out to game the system.
There will also be cutting-edge treatments (biologics, orphan drugs), that simply can't be covered under these plans due to cost - but that's how things work outside of the US too. We have to focus on helping people as much as possible with the finite (but plentiful!) resources that are available, and that can mean denying risky $300k treatments that may cure a child with cancer if that money is better spent elsewhere. Right now, insurance companies just have to spend a fixed portion of the revenue they take in, with little incentive to disperse it across patients effectively. They don't mind dropping a million dollars on little Billy and using him as a poster child - all at the cost of denying basic, effective, necessary care like appendectomies to ten other patients.
Without going too off the rails too much, medical and pharmacy boards are basically failed institutions in their present state... I wouldn't trust them to be effective arbiters in the slightest. Not sure what the fix for that is though.
The downside of capitated models (and HMOs) is that it's nigh-impossible for insurers to have a decent web of specialty coverage at present. If there are only 1-2 specialists of a given variety in a 100 mile radius, and they're deadset on sticking to fee-for-service, the patients in that area are SOL. The necessary reform for this model to happen at scale has to be top-down or it won't work, and there's no current impetus for that to happen.
The system would be greatly improved if it were required that patients file the claim, not the provider. If the insurer pulls any shenanigans, the cost will be an unhappy customer who knows...
The system would be greatly improved if it were required that patients file the claim, not the provider. If the insurer pulls any shenanigans, the cost will be an unhappy customer who knows exactly how they're being ripped off.
Re your proposal that patients must file the claims, you are assuming that all patients are literate in English or literate at all. What about people in comas or with brain disease such as...
Re your proposal that patients must file the claims, you are assuming that all patients are literate in English or literate at all. What about people in comas or with brain disease such as strokes?
I appreciate your thorough discussion and analysis but people should not be denied compensation for medical care because they are not capable of filling out forms in a timely accurate way.
I mean it wouldn't be too complicated to create exceptions for people who are literally unable to do it themselves. Competitive pressures on insurance companies would be stronger if by default...
I mean it wouldn't be too complicated to create exceptions for people who are literally unable to do it themselves. Competitive pressures on insurance companies would be stronger if by default patients filed their own claims.
People are wierd. People who can't read tend to work really hard to keep that information secret. Any formal program will miss some people it was meant to help.
People are wierd. People who can't read tend to work really hard to keep that information secret. Any formal program will miss some people it was meant to help.
A straightforward solution would be to have it automatically sent over the provider to file after a set amount of time for a small ~$5-10 fee (alternatively, it could be a rebate for doing it...
A straightforward solution would be to have it automatically sent over the provider to file after a set amount of time for a small ~$5-10 fee (alternatively, it could be a rebate for doing it yourself). I can't underscore how important it is to address the several market failures that arise from consumers not filing their own claims.
Time and money are in my experience not fungible when someone is caught up with disease, disability or full time caregiving. Both can be lacking, but beauracratic hassle can be an overwhelming...
Time and money are in my experience not fungible when someone is caught up with disease, disability or full time caregiving. Both can be lacking, but beauracratic hassle can be an overwhelming burden for someone taking care of a loved one and trying to maintain employment.
And disability is an inevitability for the majority of us. We don't know when or how and while being with someone who's injury maxed out someone else's insurance and then his own before being...
And disability is an inevitability for the majority of us. We don't know when or how and while being with someone who's injury maxed out someone else's insurance and then his own before being approved for disability gives me particular feelings about it, it could literally happen to any of us.
I appreciate this answer. Learning accurately and in a reasonable amount of time, just who is incapable of filing for themselves is an impossible task.
I appreciate this answer. Learning accurately and in a reasonable amount of time, just who is incapable of filing for themselves is an impossible task.
Unhappy customers who have one option of insurance via their job? And who are sick or injured and unable to think well much less call to speak to a manager? We're already unhappy customers and...
Unhappy customers who have one option of insurance via their job? And who are sick or injured and unable to think well much less call to speak to a manager?
We're already unhappy customers and they don't care.
You would be surprised what greater and more precise consumer awareness can do. People can start to demand to have their own insurance plans and be given higher compensation accordingly (as is the...
You would be surprised what greater and more precise consumer awareness can do. People can start to demand to have their own insurance plans and be given higher compensation accordingly (as is the case for all benefits (that don't themselves provide direct value for the employer such as tuition subsidies), the purpose and unavoidable effect of the health insurance benefit from employers is to reduce your pay more than the value of the actual health insurance. Doubly so for health insurance, since it imposes greater risk aversion in the labor market for quitting shitty jobs).
I fundamentally disagree with your belief that the free market will make a lick of a difference for multiple reasons. First, sick people and their families are exhausted. I'm a caretaker for my...
I fundamentally disagree with your belief that the free market will make a lick of a difference for multiple reasons.
First, sick people and their families are exhausted. I'm a caretaker for my disabled partner. I'm intimately familiar with insurance, prior authorization, and the like. I can't marry my partner because he'd lose his subsidization for healthcare costs, which we absolutely could not afford otherwise. I am exhausted from all the fights I'm having to win and from the hours per day spent being a caregiver. He's in near constant pain and has some brain fog from meds and TBI on top of being physically paraplegic. I also have my own physical and mental health needs. Why would we put more work on sick people?
Secondly, we all need healthcare at some point. We don't know how much we'll need, when. It isn't a supply and demand issue. It should just be provided for us. For everyone. People should not have to get in a battle directly with their insurance company for every service when they already don't understand the process. Yeah it should be uncoupled from employment but it should not be then tossed on the backs of individuals. Or else you basically condemn the unhealthy poor to go untreated. You don't solve one problem by making a worse one. The solution is universal healthcare.
Third, once again, we're already angry. Few people adore their health insurance company. It's not been effective. They don't care. Every day there's a news story about a GoFundMe raising enough for a lifesaving procedure for someone. Or a class of kids that raised money for their classmate's wheelchair. The ACA was gutted to protect the insurance companies. They simply don't care about our rage. It's not financially relevant because no matter how mad we are, we still will get sick sometimes.
Fourth, I'm not neurotypical. I rarely remember to scan a receipt for a reward app, return a product to Costco, or call back the person at work I needed to reach. I'm not going to meet filing deadlines for multiple services and providers. My mom had 4 kids, she might have been able to keep track of all that paperwork and file the claims herself. Maybe. But with what time?
I don't need better competition, I need effective regulation. I need respite services. I need to be able to afford to go to my own PT and medical services not just in regards to co-pays cut also in time and energy. I need universal healthcare.
This is all a bit like saying how great the current federal tax system is - we get to work with these tax prep companies directly! They can give us deals! Never mind that we could just get direct billed/refunded by the feds we're so lucky to get this opportunity.
I don't even live in the US anymore, but I listened to a lot of "Arm and a Leg" last year https://armandalegshow.com/ . Basically every week they just have somebody on who got denied a claim,...
I don't even live in the US anymore, but I listened to a lot of "Arm and a Leg" last year https://armandalegshow.com/ . Basically every week they just have somebody on who got denied a claim, spent months/years figuring out how to fight it and win (or lose sometimes), and then basically made their career helping other people fight theirs. Super interesting.
Requesting prior authorizations and appealing denials used to be a huge part of my job, for about four years. I'm happy to answer any questions about it. It was for a physical therapy department...
Requesting prior authorizations and appealing denials used to be a huge part of my job, for about four years. I'm happy to answer any questions about it.
It was for a physical therapy department in a multi-specialty practice of 15 doctors. We had a whole binder explaining how to handle each different insurance company and kind of denial, most of which I put together myself. The most egregious example of this byzantine nightmare was our (as far as I know) ongoing struggle with Oscar Healthcare.
In 2021, Oscar partnered with a third party called American Specialty Health or ASH to review their prior authorization requests, denials and appeals. ASH does not work with multi-specialty groups. Cigna was also partnered with this third party, but because ASH would not work with us, Cigna simply didn't require prior with from our practice or practices like us. Easy peasy. Oscar went a different route. First they tried to make us go through ASH. This lead to months of us submitting requests through ASH, being denied because they don't cover us, calling Oscar to explain and request that they directly review our request, and being successful maybe half of the time. None of this is down to medical necessity, only the attitude of the customer service rep we were speaking with at the time. This means postoperative patients were being capped at 5 visits (the among allowed before Auth is necessary) after a total hip replacement which typically require upwards of 30 seasons to retain mobility. We did warn Oscar patients when they began treating with us or the issue, but we had great therapists and worked directly with their doctors, and I don't think they truly understood how ridiculous the situation was. They thought if it was medically necessary, but there would be some delays or gaps, but certainly their insurance would eventually cover it. They were wrong. It had nothing to do with necessity.
Man, that hits so close to home. I've been trying to resolve a medical billing issue recently and it's just been mind-melting. Might be on the hook for thousands of dollars out of pocket if I...
Man, that hits so close to home. I've been trying to resolve a medical billing issue recently and it's just been mind-melting. Might be on the hook for thousands of dollars out of pocket if I can't figure it out soon.
I agree that it would be better to decouple health insurance and employment, and that the costs can be crazy if you don't have good insurance options (or if you have to buy insurance out of...
I agree that it would be better to decouple health insurance and employment, and that the costs can be crazy if you don't have good insurance options (or if you have to buy insurance out of pocket), but besides that this just doesn't align with my experience in the US at all. Perhaps what you've experienced is more related to the state(s) your were living in.
I've never had to wait more than a couple days to see my PCP if I needed to, sooner if it was urgent (but not urgent enough to go to urgent care). I can also just ping them a question via an app, with a picture of my concern if applicable, and they generally answer within a few hours if it's a business day - no appointment necessary. Specialist referrals are usually just a phone call as well, though thankfully my current plan doesn't require them.
My wife goes to the dermatologist annually and they have never had her schedule a follow up to remove a mole. It's always done then and there if they feel it's necessary to remove.
It can take time to find a PCP accepting new patients when you move or yours retire, but once you have one it's always been straightforward to get care here.
I don't think that's necessary. Really, we need medicaid expansion to cover the gap. Take, for example, the Japanese healthcare system, which in many metrics ranks amongst the best in the world,...
I agree that it would be better to decouple health insurance and employmen
I don't think that's necessary. Really, we need medicaid expansion to cover the gap.
Take, for example, the Japanese healthcare system, which in many metrics ranks amongst the best in the world, where 59% of households have insurance through their job (source). The difference is that there is a separate insurance run by the government for the unemployed, the elderly, and the self employed. We also have that in the US, it's medicaid - it's just far more limited.
Sure, that could be a workable solution. Providing some way for people to have more stablity and security regarding healthcare regardless of employment is the important part - there's more than...
Sure, that could be a workable solution. Providing some way for people to have more stablity and security regarding healthcare regardless of employment is the important part - there's more than one viable answer.
Here in the US, I get similar care from Kaiser Permanente group. But I live in California where they are strongest. I still have to keep current with premiums or I lose access to the system of...
Here in the US, I get similar care from Kaiser Permanente group. But I live in California where they are strongest.
I still have to keep current with premiums or I lose access to the system of doctors and specialists.
I haven't had health insurance for most of my adult life. Probably 10-13 years or so at least that I've gone without health insurance. I can't say for certain because the ACA was passed not long...
I haven't had health insurance for most of my adult life. Probably 10-13 years or so at least that I've gone without health insurance. I can't say for certain because the ACA was passed not long after I got kicked off my parents plan, and then I think I was able to get back on for a few years.
The last job I was at was offering to pay some towards an ACA plan (it was a business with fewer than 50 employees so they weren't required to offer insurance) and I looked at the plans and just decided not to deal with it. There didn't seem to be many options, it was seemingly just a few providers with several options but still only a few providers. One of them was some religious one where it was like faux charity or something in terms of how it covered things, I don't even remember it now. The rest just felt like a total scam, where there's myriads of rules and exceptions and limits etc. and no matter what you choose it feels like a scam because you aren't going to get what you pay for, it's literally their whole reason for existing is to extract as much money from you as they can and provide as few services as possible to get you to sign up. So even when my employer was offering to put some money towards this, I still had to put some of my own money towards it, and it seemed like it was no different than if I just threw a couple hundred in the trash every month.
Edit: Also I'm not sure that the religious option was even part of the ACA marketplace. My former employer had partnered with a company called Remodel Health
It does appear to be mostly ACA plans, but not sure if they all are. The way their reps described it to us when they went over things made it sound like it was just all ACA marketplace plans. When I looked up on healthcare.gov right now who is available, I don't see any faith-based healthsharing plans, so maybe they aren't on there this go around, or maybe they were never on there but they were being offered through this Remodel Health service but being placed next to marketplace plans to look cost-friendly and funnel people into those plans.
We need to strip insurers of the ability to deny care, period. The way the current system works, the insurance companies hire their own doctors. These doctors are employees of the insurance company and have a direct incentive to deny care. their own paid doctor, paid according to how many claims they deny, will then make a supposedly objective decision on whether a claim is medically necessary.
This needs to end. There's simply too much conflict of interest for an insurance company to ever objectively determine whether a given prescribed treatment is "medically necessary." This power needs to be stripped from insurance companies. In all but the most extreme circumstances, if a licensed medical doctor stating a treatment is medically necessary, the insurance company should be provided to pay for it (assuming its included in their list of covered treatments.)
Waste, fraud, and abuse are of course still concerns. However, they should be handled by a third party. Maybe an insurance company's only recourse should be to bring a doctor in front of their state's medical board. File a bunch of fraudulent or unnecessary insurance claims? You lose your medical license.
Or maybe we need special state-level courts devoted specifically to medical necessity. We've created many special courts over the years, built and staffed by experts in the court's particular purview. We have immigration courts, we have juvenile courts. We have drug rehabilitation courts. I see no reason we can't have an "insurance claim appeal" court. By default, insurers have to cover all claims by default. But if they truly disagree with a particular claim made by a doctor, they can appeal their required payout to a neutral third-party medical appeals court. To prevent them from abusing the process, the insurance company has to pay for both side's attorneys, and if their appeal is denied, they have to pay the cost of care plus pay a penalty equal to the cost of that care, a penalty split between the patient and the prescribing doctor.
You're going to run in circles and just come back to the realization that insurance for health care is a bad idea. Running healthcare in a capitalist way is just a bad idea. Just treat people. Even THEN, when you've basically said its all free, you'll still hit plenty of cases where you've got a child who might have a 1% chance of survival after a billion dollar treatment and we'll all scratch our heads and wonder what's the right thing to do. i.e. try that or feed a city full of the homeless, but... its still better than what we have now.
Just to pile on, this model is called "capitated" healthcare (flat rate per person per time period, regardless of utilization). I used to work for a county-level payor that paid for a lot of services this way, and it was extremely effective in terms of reducing administrative burden and aligning incentives.
There is the obvious issue of people abusing services simply because they have them available, but nominal copayments/coinsurance after a certain threshold is pretty effective at tamping that down in practice. E.g. first ten physical therapy appointments per year are free, and after that you start covering 25% of the cost out of pocket. >99.99% of people just want healthcare and aren't out to game the system.
There will also be cutting-edge treatments (biologics, orphan drugs), that simply can't be covered under these plans due to cost - but that's how things work outside of the US too. We have to focus on helping people as much as possible with the finite (but plentiful!) resources that are available, and that can mean denying risky $300k treatments that may cure a child with cancer if that money is better spent elsewhere. Right now, insurance companies just have to spend a fixed portion of the revenue they take in, with little incentive to disperse it across patients effectively. They don't mind dropping a million dollars on little Billy and using him as a poster child - all at the cost of denying basic, effective, necessary care like appendectomies to ten other patients.
Without going too off the rails too much, medical and pharmacy boards are basically failed institutions in their present state... I wouldn't trust them to be effective arbiters in the slightest. Not sure what the fix for that is though.
The downside of capitated models (and HMOs) is that it's nigh-impossible for insurers to have a decent web of specialty coverage at present. If there are only 1-2 specialists of a given variety in a 100 mile radius, and they're deadset on sticking to fee-for-service, the patients in that area are SOL. The necessary reform for this model to happen at scale has to be top-down or it won't work, and there's no current impetus for that to happen.
Its crazy how bad people will always find ways to rise to the top, in basically every profession.
Remember Palin’s “death panels”?
We need to disable the option for health care providers from using two different prices between insured and uninsured people.
The End.
The system would be greatly improved if it were required that patients file the claim, not the provider. If the insurer pulls any shenanigans, the cost will be an unhappy customer who knows exactly how they're being ripped off.
Re your proposal that patients must file the claims, you are assuming that all patients are literate in English or literate at all. What about people in comas or with brain disease such as strokes?
I appreciate your thorough discussion and analysis but people should not be denied compensation for medical care because they are not capable of filling out forms in a timely accurate way.
I mean it wouldn't be too complicated to create exceptions for people who are literally unable to do it themselves. Competitive pressures on insurance companies would be stronger if by default patients filed their own claims.
People are wierd. People who can't read tend to work really hard to keep that information secret. Any formal program will miss some people it was meant to help.
A straightforward solution would be to have it automatically sent over the provider to file after a set amount of time for a small ~$5-10 fee (alternatively, it could be a rebate for doing it yourself). I can't underscore how important it is to address the several market failures that arise from consumers not filing their own claims.
Now you're just charging people more for what's already happening.
Which is also not surprising. That's actually the least surprising suggestion.
Time and money are in my experience not fungible when someone is caught up with disease, disability or full time caregiving. Both can be lacking, but beauracratic hassle can be an overwhelming burden for someone taking care of a loved one and trying to maintain employment.
And disability is an inevitability for the majority of us. We don't know when or how and while being with someone who's injury maxed out someone else's insurance and then his own before being approved for disability gives me particular feelings about it, it could literally happen to any of us.
Being unsurprised is not hostility. I am not assuming anything about you, I'd appreciate you doing the same.
Edit: your edit is further unsurprising.
I appreciate this answer. Learning accurately and in a reasonable amount of time, just who is incapable of filing for themselves is an impossible task.
Unhappy customers who have one option of insurance via their job? And who are sick or injured and unable to think well much less call to speak to a manager?
We're already unhappy customers and they don't care.
You would be surprised what greater and more precise consumer awareness can do. People can start to demand to have their own insurance plans and be given higher compensation accordingly (as is the case for all benefits (that don't themselves provide direct value for the employer such as tuition subsidies), the purpose and unavoidable effect of the health insurance benefit from employers is to reduce your pay more than the value of the actual health insurance. Doubly so for health insurance, since it imposes greater risk aversion in the labor market for quitting shitty jobs).
I fundamentally disagree with your belief that the free market will make a lick of a difference for multiple reasons.
First, sick people and their families are exhausted. I'm a caretaker for my disabled partner. I'm intimately familiar with insurance, prior authorization, and the like. I can't marry my partner because he'd lose his subsidization for healthcare costs, which we absolutely could not afford otherwise. I am exhausted from all the fights I'm having to win and from the hours per day spent being a caregiver. He's in near constant pain and has some brain fog from meds and TBI on top of being physically paraplegic. I also have my own physical and mental health needs. Why would we put more work on sick people?
Secondly, we all need healthcare at some point. We don't know how much we'll need, when. It isn't a supply and demand issue. It should just be provided for us. For everyone. People should not have to get in a battle directly with their insurance company for every service when they already don't understand the process. Yeah it should be uncoupled from employment but it should not be then tossed on the backs of individuals. Or else you basically condemn the unhealthy poor to go untreated. You don't solve one problem by making a worse one. The solution is universal healthcare.
Third, once again, we're already angry. Few people adore their health insurance company. It's not been effective. They don't care. Every day there's a news story about a GoFundMe raising enough for a lifesaving procedure for someone. Or a class of kids that raised money for their classmate's wheelchair. The ACA was gutted to protect the insurance companies. They simply don't care about our rage. It's not financially relevant because no matter how mad we are, we still will get sick sometimes.
Fourth, I'm not neurotypical. I rarely remember to scan a receipt for a reward app, return a product to Costco, or call back the person at work I needed to reach. I'm not going to meet filing deadlines for multiple services and providers. My mom had 4 kids, she might have been able to keep track of all that paperwork and file the claims herself. Maybe. But with what time?
I don't need better competition, I need effective regulation. I need respite services. I need to be able to afford to go to my own PT and medical services not just in regards to co-pays cut also in time and energy. I need universal healthcare.
This is all a bit like saying how great the current federal tax system is - we get to work with these tax prep companies directly! They can give us deals! Never mind that we could just get direct billed/refunded by the feds we're so lucky to get this opportunity.
No thanks. I would not be surprised.
I Set Out to Create a Simple Map for How to Appeal Your Insurance Denial. Instead, I Found a Mind-Boggling Labyrinth
I don't even live in the US anymore, but I listened to a lot of "Arm and a Leg" last year https://armandalegshow.com/ . Basically every week they just have somebody on who got denied a claim, spent months/years figuring out how to fight it and win (or lose sometimes), and then basically made their career helping other people fight theirs. Super interesting.
Requesting prior authorizations and appealing denials used to be a huge part of my job, for about four years. I'm happy to answer any questions about it.
It was for a physical therapy department in a multi-specialty practice of 15 doctors. We had a whole binder explaining how to handle each different insurance company and kind of denial, most of which I put together myself. The most egregious example of this byzantine nightmare was our (as far as I know) ongoing struggle with Oscar Healthcare.
In 2021, Oscar partnered with a third party called American Specialty Health or ASH to review their prior authorization requests, denials and appeals. ASH does not work with multi-specialty groups. Cigna was also partnered with this third party, but because ASH would not work with us, Cigna simply didn't require prior with from our practice or practices like us. Easy peasy. Oscar went a different route. First they tried to make us go through ASH. This lead to months of us submitting requests through ASH, being denied because they don't cover us, calling Oscar to explain and request that they directly review our request, and being successful maybe half of the time. None of this is down to medical necessity, only the attitude of the customer service rep we were speaking with at the time. This means postoperative patients were being capped at 5 visits (the among allowed before Auth is necessary) after a total hip replacement which typically require upwards of 30 seasons to retain mobility. We did warn Oscar patients when they began treating with us or the issue, but we had great therapists and worked directly with their doctors, and I don't think they truly understood how ridiculous the situation was. They thought if it was medically necessary, but there would be some delays or gaps, but certainly their insurance would eventually cover it. They were wrong. It had nothing to do with necessity.
Man, that hits so close to home. I've been trying to resolve a medical billing issue recently and it's just been mind-melting. Might be on the hook for thousands of dollars out of pocket if I can't figure it out soon.
I agree that it would be better to decouple health insurance and employment, and that the costs can be crazy if you don't have good insurance options (or if you have to buy insurance out of pocket), but besides that this just doesn't align with my experience in the US at all. Perhaps what you've experienced is more related to the state(s) your were living in.
I've never had to wait more than a couple days to see my PCP if I needed to, sooner if it was urgent (but not urgent enough to go to urgent care). I can also just ping them a question via an app, with a picture of my concern if applicable, and they generally answer within a few hours if it's a business day - no appointment necessary. Specialist referrals are usually just a phone call as well, though thankfully my current plan doesn't require them.
My wife goes to the dermatologist annually and they have never had her schedule a follow up to remove a mole. It's always done then and there if they feel it's necessary to remove.
It can take time to find a PCP accepting new patients when you move or yours retire, but once you have one it's always been straightforward to get care here.
I don't think that's necessary. Really, we need medicaid expansion to cover the gap.
Take, for example, the Japanese healthcare system, which in many metrics ranks amongst the best in the world, where 59% of households have insurance through their job (source). The difference is that there is a separate insurance run by the government for the unemployed, the elderly, and the self employed. We also have that in the US, it's medicaid - it's just far more limited.
Sure, that could be a workable solution. Providing some way for people to have more stablity and security regarding healthcare regardless of employment is the important part - there's more than one viable answer.
Here in the US, I get similar care from Kaiser Permanente group. But I live in California where they are strongest.
I still have to keep current with premiums or I lose access to the system of doctors and specialists.
I haven't had health insurance for most of my adult life. Probably 10-13 years or so at least that I've gone without health insurance. I can't say for certain because the ACA was passed not long after I got kicked off my parents plan, and then I think I was able to get back on for a few years.
The last job I was at was offering to pay some towards an ACA plan (it was a business with fewer than 50 employees so they weren't required to offer insurance) and I looked at the plans and just decided not to deal with it. There didn't seem to be many options, it was seemingly just a few providers with several options but still only a few providers. One of them was some religious one where it was like faux charity or something in terms of how it covered things, I don't even remember it now. The rest just felt like a total scam, where there's myriads of rules and exceptions and limits etc. and no matter what you choose it feels like a scam because you aren't going to get what you pay for, it's literally their whole reason for existing is to extract as much money from you as they can and provide as few services as possible to get you to sign up. So even when my employer was offering to put some money towards this, I still had to put some of my own money towards it, and it seemed like it was no different than if I just threw a couple hundred in the trash every month.
Edit: Also I'm not sure that the religious option was even part of the ACA marketplace. My former employer had partnered with a company called Remodel Health
https://www.remodelhealth.com/ichra-plus/
It does appear to be mostly ACA plans, but not sure if they all are. The way their reps described it to us when they went over things made it sound like it was just all ACA marketplace plans. When I looked up on healthcare.gov right now who is available, I don't see any faith-based healthsharing plans, so maybe they aren't on there this go around, or maybe they were never on there but they were being offered through this Remodel Health service but being placed next to marketplace plans to look cost-friendly and funnel people into those plans.