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this post was submitted on 11 Dec 2023
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So I'm trying to follow the misery in this thread, but I don't know what "in network" means. Is there some sort of intranet that hospitals and insurance companies use to bill each other? I don't get it.
Kind of. Insurance companies make deals with healthcare providers to give better rates on procedures than the book price. The book price is the price that the care provider "officially" charges. Usually it is some bullshit number they pull straight out of their ass. If you do not have insurance, they will charge you that made up book price. But you can call them up and negotiate with them because they want some payment and they realize most people cannot pull $50k out of their rectum.
So back to insurance...they negotiate with certain care providers in the region they operate. Those are in network and get better rates. Ones outside of that network get worse rates and insurance generally does not cover most of the cost...unless you have hit your out of pocket maximum for the year. The out of pocket maximum is when you have spent so much out of pocket on things like co-pays and out of network costs that insurance will now start covering 100% of the medical bills.
Not confusing or fucked up at all, right? It gets more complicated because there are also deductibles. That one is similar to out of pocket maximum but insurance does not pay 100%, generally closer to 80%. Your deductible goes toward the out of pocket maximum.
Before Obama, insurance companies also had maximum lifetime benefits. Basically if you were costing them too much for shit like a heart transplant, they'd tell you to fuck off after they already paid out $500k or whatever number they chose.
They could also deny coverage for a pre-existing condition. Generally you would be fine for that one if you had continual coverage but not necessarily. So if that heart transplant person wanted to switch insurance because he had a new job, they could see that he had a transplant previously and decide to not cover them. That one is a bit personal to me because my wife and her mother had a similar issue. My wife had a liver transplant when she was young. My mother-in-law did not ever try to switch jobs because she was afraid that a new insurance would not cover my wife. Dialing in the proper dosage for a growing kid so their liver does not get rejected takes a lot of doctor visits and would have been very costly.
That is nuts. And so complicated! Healthcare here is far from perfect (and getting worse all the time!) but at least it's not that. How hard of a concept is it that if you're unwell, you just go to any hospital and get treatment? Good to know that I'd just straight up die in the states though.
Larger companies have teams dedicated to negotiating with the insurance companies and answering insurance questions for employees. All that additional complexity means about 19% of the US GDP goes towards healthcare costs compared with most developed countries spending 10-12%. Even libertarian groups have shown that socialized insurance through extending Medicare to everyone would be cheaper than what we currently do and it would cover everyone (including dental) and there would be no out of network garbage. Several Democratic presidential candidates initially pushed for that at the start of their campaign only to back down from it later on in the race leaving only Sanders pushing for it.
As for straight up dying? Thousands each year die because of lack of insurance. I'm guessing several thousand more die even with insurance because they can't afford the out of pocket maximum or their insurance declines covering a necessary procedure. I recall one woman who was attacked by a bear and her first thought while being attacked was how she would afford the medical bill if she made it through. And she was right to be worried. Her insurance denied most of her coverage and only paid 20% of her $300k worth of bills.