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That isn’t true at all. It used to be true because health care plans had lifetime limits to coverage, but the ACA removed those limits. The ACA also ads out of

That isn’t true at all. It used to be true because health care plans had lifetime limits to coverage, but the ACA removed those limits. 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.

jeffbee 6y ago
> your chances of them just deciding not to pay are low 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.
- mywittyname 6y ago
  > The US government says that private insurers deny 20% of 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.
- learc83 6y ago
  >The US government says that private insurers deny 20% of claims. 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?
  - jschwartzi 6y ago
    I fail to see how a system where after a long and arduous battle with an illness spend several months sending letters and making phone calls with my insurance provider because they won't pay the bills for my treatment is better than a system where a single payer simply pays at a set rate for specific treatments. The whole point of the "insurance" system in the US seems to be to make everyone waste several hours a week on top of the time they spend being sick.
    - learc83 6y ago
      > is better than a system where a single payer simply pays at a set rate for specific treatments. It's not. >but effectively will not cover unexpected large expenses That was the claim though, and it's wrong.
aidenn0 6y ago
Does ACA have actual out-of-pocket maximums? My insurance has an advertised $0 out-of-pocket maximum, with an asterisk saying that this does not include co-pays or out-of-network care. It lists no out-of-pocket maximum for out-of-network care. 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.
- lostapathy 6y ago
  Yes, the ACA has out of pocket maximums. $8,150 per individual or $16,300 for the family this year.
  - aidenn0 6y ago
    The maximum out of pocket for my company's PPO is $40k for out of network, with an asterisk listing all the things that doesn't include. 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.
    - lostapathy 6y ago
      Well, yeah, the HHS maximum out of pocket is for in-network covered services. How did you manage to spend so much out of network? Around here, no doctor will see you (outside the ER) without confirming they take your insurance first.
      - 6y ago
WarOnPrivacy 6y ago
> 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. 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.
- learc83 6y ago
  Millions of economically vulnerable Americans already had wholly unusable insurance. 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.

jeffbee 6y ago

> your chances of them just deciding not to pay are low 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.

mywittyname 6y ago
> The US government says that private insurers deny 20% of 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.
learc83 6y ago
>The US government says that private insurers deny 20% of claims. 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?
- jschwartzi 6y ago
  I fail to see how a system where after a long and arduous battle with an illness spend several months sending letters and making phone calls with my insurance provider because they won't pay the bills for my treatment is better than a system where a single payer simply pays at a set rate for specific treatments. The whole point of the "insurance" system in the US seems to be to make everyone waste several hours a week on top of the time they spend being sick.
  - learc83 6y ago
    > is better than a system where a single payer simply pays at a set rate for specific treatments. It's not. >but effectively will not cover unexpected large expenses That was the claim though, and it's wrong.

aidenn0 6y ago

Does ACA have actual out-of-pocket maximums? My insurance has an advertised $0 out-of-pocket maximum, with an asterisk saying that this does not include co-pays or out-of-network care. It lists no out-of-pocket maximum for out-of-network care. 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.

lostapathy 6y ago
Yes, the ACA has out of pocket maximums. $8,150 per individual or $16,300 for the family this year.
- aidenn0 6y ago
  The maximum out of pocket for my company's PPO is $40k for out of network, with an asterisk listing all the things that doesn't include. 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.
  - lostapathy 6y ago
    Well, yeah, the HHS maximum out of pocket is for in-network covered services. How did you manage to spend so much out of network? Around here, no doctor will see you (outside the ER) without confirming they take your insurance first.
    - 6y ago

WarOnPrivacy 6y ago

> 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. 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.

learc83 6y ago
Millions of economically vulnerable Americans already had wholly unusable insurance. 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.