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> Health insurers are required to accept all insureds without pricing the insured’s risks. It would increase premiums a lot if people could bounce around, as it

> Health insurers are required to accept all insureds without pricing the insured’s risks. It would increase premiums a lot if people could bounce around, as it would make already difficult to forecast medical loss ratios even more volatile. It's almost as if there is nothing insurance-like about US health "insurance" but the name. Picture health insurance models laid on top of your car. Imagine your car gets totaled: Your insurer says, "Hey, we're going to pay out $25,000 for your vehicle. So you have a $1,000 deductible, so that's $24,000, and then your copay for a total loss is $2,000, so that brings us down to $22,000. For total losses, your coinsurance as your contribution for your vehicle coverage is 20%, which is $5,000, so here's a check for $17,000. Buttttt... that's only if you're buying a Hyundai, otherwise the vehicle is out of network and you'll get a check for $8,500 instead."

lotsofpulp 9mo ago
US health insurance premiums are not insurance-like, as they are mostly a tax due to the forced wealth redistribution. US health insurance coverage is very insurance-like, due to the out of pocket maximum. Determining auto insurance coverage is very simple, because fixing/replacing cars is simple. Determining health insurance coverage can't be simple, because fixing bodies is not simple. It's unknown what will and will not fix issues, how to even measure if there is an issue, and what will cause more issues and the cost/benefit of that fix. The people who can fix the issue are a lot more rare and in demand than the people who can fix automobiles. Also, the medicine is patented, and the seller of the medicine wants to be able to charge different prices to different buyers, hence all the games.
- FireBeyond 9mo ago
  > US health insurance coverage is very insurance-like, due to the out of pocket maximum. Well, other than that whole "out of network" thing... > Determining health insurance coverage can't be simple, because fixing bodies is not simple. It's unknown what will and will not fix issues, how to even measure if there is an issue, and what will cause more issues and the cost/benefit of that fix. Don't disagree - but that doesn't make what we have more "insurance-like".
  - lotsofpulp 9mo ago
    What is the alternative to a network? Auto insurers, home insurers, all kinds of insurance relies on negotiating prices with sellers. Insurance cannot work if any seller can send a bill for any amount to the insurer and be owed that amount.
    - FireBeyond 9mo ago
      I mean for most auto and home insurers, the "negotiated price" is a pretty loose thing. My insurer might ask for a quote from someone in their "preferred network" but I can get a quote from anyone I want to do the work, and if it's within x% of the preferred quote, it's automatically approved, otherwise someone from the insurer calls them and asks about the different pricing, and I've generally got that approval within 24-48 hours. (Which has also worked in my favor - with an auto glass claim, their repairer was insistent that third party glass would work fine, despite the HUD, but the other was able to demonstrate to the insurer that OEM glass was required). Mostly this all boils down to "the healthcare industry in the US needs to be comprehensively revamped in any one of several different ways or methodologies, but likely won't be".
      - lotsofpulp 9mo ago
        > but I can get a quote from anyone I want to do the work, and if it's within x% of the preferred quote, it's automatically approved, It would be the same in healthcare if quotes were for 4 and low 5 figures with no future costs. Not only does healthcare easily reach into the 5, 6, and 7 figures, but the health insurance company is also on the hook for myriad known and unknown issues caused by the initial costs.
        FireBeyond 9mo ago
        > It would be the same in healthcare if quotes were for 4 and low 5 figures with no future costs. I mean, this is somewhat the same in auto, too. Is one of the reasons you're recommended to go through insurance even if involved in an accident and the other party offers to give you cash for the initial quote - it's quite common that they start repair work and find other issues because they hadn't removed components or panels to give you a quote. Got cash from someone? Now you have to go back and say "Well, I know the quote said $1,500, but they took off the back quarter panel and found other issues and now it's $3,800..." That being said, ICD codes, one of the cornerstones of billing, are predicated around "encounters", and certainly not "future costs". > is also on the hook for myriad known and unknown issues caused by the initial costs. There's a pretty huge asterisk to all that. Health insurers are adept at neatly sidestepping any obligations. They've fought and won many many times over in court on similar issues, "Insurer is denying me care and I'm going to die/suffer serious issues as a result!" Insurer's response, which has been held in court many times over? "We're not denying you any care at all, we're just declining to accept financial responsibility for it. You're free to get that care and be directly billed."

lotsofpulp 9mo ago

US health insurance premiums are not insurance-like, as they are mostly a tax due to the forced wealth redistribution. US health insurance coverage is very insurance-like, due to the out of pocket maximum. Determining auto insurance coverage is very simple, because fixing/replacing cars is simple. Determining health insurance coverage can't be simple, because fixing bodies is not simple. It's unknown what will and will not fix issues, how to even measure if there is an issue, and what will cause more issues and the cost/benefit of that fix. The people who can fix the issue are a lot more rare and in demand than the people who can fix automobiles. Also, the medicine is patented, and the seller of the medicine wants to be able to charge different prices to different buyers, hence all the games.

FireBeyond 9mo ago
> US health insurance coverage is very insurance-like, due to the out of pocket maximum. Well, other than that whole "out of network" thing... > Determining health insurance coverage can't be simple, because fixing bodies is not simple. It's unknown what will and will not fix issues, how to even measure if there is an issue, and what will cause more issues and the cost/benefit of that fix. Don't disagree - but that doesn't make what we have more "insurance-like".
- lotsofpulp 9mo ago
  What is the alternative to a network? Auto insurers, home insurers, all kinds of insurance relies on negotiating prices with sellers. Insurance cannot work if any seller can send a bill for any amount to the insurer and be owed that amount.
  - FireBeyond 9mo ago
    I mean for most auto and home insurers, the "negotiated price" is a pretty loose thing. My insurer might ask for a quote from someone in their "preferred network" but I can get a quote from anyone I want to do the work, and if it's within x% of the preferred quote, it's automatically approved, otherwise someone from the insurer calls them and asks about the different pricing, and I've generally got that approval within 24-48 hours. (Which has also worked in my favor - with an auto glass claim, their repairer was insistent that third party glass would work fine, despite the HUD, but the other was able to demonstrate to the insurer that OEM glass was required). Mostly this all boils down to "the healthcare industry in the US needs to be comprehensively revamped in any one of several different ways or methodologies, but likely won't be".
    - lotsofpulp 9mo ago
      > but I can get a quote from anyone I want to do the work, and if it's within x% of the preferred quote, it's automatically approved, It would be the same in healthcare if quotes were for 4 and low 5 figures with no future costs. Not only does healthcare easily reach into the 5, 6, and 7 figures, but the health insurance company is also on the hook for myriad known and unknown issues caused by the initial costs.
      - FireBeyond 9mo ago
        > It would be the same in healthcare if quotes were for 4 and low 5 figures with no future costs. I mean, this is somewhat the same in auto, too. Is one of the reasons you're recommended to go through insurance even if involved in an accident and the other party offers to give you cash for the initial quote - it's quite common that they start repair work and find other issues because they hadn't removed components or panels to give you a quote. Got cash from someone? Now you have to go back and say "Well, I know the quote said $1,500, but they took off the back quarter panel and found other issues and now it's $3,800..." That being said, ICD codes, one of the cornerstones of billing, are predicated around "encounters", and certainly not "future costs". > is also on the hook for myriad known and unknown issues caused by the initial costs. There's a pretty huge asterisk to all that. Health insurers are adept at neatly sidestepping any obligations. They've fought and won many many times over in court on similar issues, "Insurer is denying me care and I'm going to die/suffer serious issues as a result!" Insurer's response, which has been held in court many times over? "We're not denying you any care at all, we're just declining to accept financial responsibility for it. You're free to get that care and be directly billed."