The ACA also ads out of pocket maximums. They might still be high enough to cause problems for some people, but it’s a lot better than it used to be.
As far as not paying, your chances of them just deciding not to pay are low. It’s definitely not high enough to support your claim that they effectively don’t cover large expenses. Here the ACA also helps because insurers are forced to spend at least 80% of premiums on healthcare costs and quality improvements for customers.
What's your data on that? The US government says that private insurers deny 20% of claims.
Last year my insurer tried to say that it was medically unnecessary to get an MRI after I'd had a tumor removed from my brain. You see, I'd also had an MRI before the surgery and according to the quack on the insurance company payroll who "reviewed my case" more than 1 MRI in a year just can't be justified.
Your chances that an American health insurance firm will deny your claim, or at least attempt to, are very high. Virtually all of the staff at these firms are dedicated to not paying claims.
Most insurers deny every claim. Hospitals employ pretty large teams (of nurses, mostly) whose job it is to go through these denials and justify the medical care a patient received while in the hospital. If the insurance company doesn't think the treatment was necessary, they won't pay. If they can find a technicality, such as, a patient came in for a belly ache, but had a heart attack, they won't pay.
I'm willing to bet this 20% figure only represent denied claims not absorbed mostly, or entirely by the hospital.
I've been pushing the person whom I get this information from to write a book, because most Americans are completely ignorant about how fucked the health insurance scheme is in the US. That $6,000 asprin on your hospital bill is there to cover all the aspects of your treatment that the insurance company will successfully deny.
20% are denied at least once, not 20% are never paid. There's a lot of gray area in what is medically necessary, and there's a lot of outright fraud. Plus many claims are denied because someone didn't fill them out correctly, deductibles weren't met, premiums weren't paid etc... The back and forth is part of the process. It's not great but...
> more-or-less but effectively will not cover unexpected large expenses
This is completely unwarranted.
>Your chances that an American health insurance firm will deny your claim, or at least attempt to, are very high. Virtually all of the staff at these firms are dedicated to not paying claims.
Some amount of the 20% denied first time are fraudulent, so assuming you have a legitimate claim, you have a less than 20% of them denying something the first time it's submitted, and a much smaller chance of them refusing to pay eventually.
>Last year my insurer tried to say that it was medically unnecessary to get an MRI after I'd had a tumor removed from my brain. You see, I'd also had an MRI before the surgery and according to the quack on the insurance company payroll who "reviewed my case" more than 1 MRI in a year just can't be justified.
Did they eventually pay? Did your doctor think it was medically necessary, and did you refile?
It's not.
>but effectively will not cover unexpected large expenses
That was the claim though, and it's wrong.
I've already experienced one case where I got stuck with a bill for an out-of-network physician at an in-network facility, so I have no confidence that there is any actual limit to what I could end up paying in a year.
Every claim I've ever submitted that was over $20k was denied the first time. One claim (smaller than $20k) ended up in collections while I was still negotiating with the insurance company!
Some of this is pre ACA, some of it post. I have no doubt that the ACA made things much better[1], but I've seen nothing to make me think there aren't still people at the insurance companies whose only job it is to make it as hard as possible for anyone to force the company to pay large claims.
1: a friend with a chronic health condition would be bankrupt if she were ever unemployed for longer than the COBRA limit prior ACA. Post ACA she was able to start her own business on private insurance.
I've personally paid more than $16k out of pocket on the HMO. In fact, I did last year, and will this year as well.
That's pretty dismissive of reality. A more lifelike portrayal is that ACA co-pays/deductibles resulted in wholly unusable insurance for millions of economically vulnerable Americans.
Before the ACA there were no out of pocket maximums, coverage was mostly limited to $100k per year per person, insurance companies could price you out or drop you as soon as you became expensive, and people with preexisting conditions were completely SOL.
Before the ACA if you didn't have employer provided insurance, there was basically no insurance option. All affordable individual insurance options were effectively prepaid minor to moderate medical care plans.
Yeah it sucks, particularity without the individual mandate, but it is significantly better than what existed before.
I'll never quite understand why I have to pay out $XXX for a blood test that might give me preventative feedback about my health, yet once I finally get heart disease, cancer, diabetes, etc, magically the health system and health insurance system kick in. The whole system is perverse.
Because healthcare is too expensive for Americans. Adding insurance doesn’t make the healthcare stop being expensive, it just helps distribute the costs more evenly across the population. Like universal taxpayer funded healthcare would.
In order to bring healthcare costs down, the supply of healthcare and number of sellers of healthcare in the market would need to increase.
Cheaper plans absolutely apply to what you describe, or at least did a while ago, other plans do not. Even knowing can be hard.
But your description is way too general.
And by and large, they do pay for the largest expenses, such as medications for anemia and cancer treatment and NICU situation.