Also I get the feeling that at the moment in the US you need to haggle with an insurance company for care, and that you can be left with huge debts on technicalities. Is this true or not?

Here in Australia we seem to have a partly government subsidized insurance setup, I think quite similar to what is being proposed over there, but I haven't had to put it to the test yet fortunately so don't have much to say on it

(In the interest of full disclosure: Please note the author worked for a major US Healthcare insurance company for 8 years and a P&C ins co for 3 years. He IS a supporter of the insurance industry.)

Kestas, its funny you mention haggling. I never really had problems with an insurance company, but also never really needed any expensive procedures. A few years back I needed hernia surgery. This is normally NOT considered an emergent procedure, so is scheduled in an outpatient clinic. My hernia was extremely uncomfortable - not painful, but walking gave me the extreme heebie jeebies. My surgery was scheduled for a week away, but the doctor said he could do it in the hospital tomorrow.

I spoke with 3 different people and couldn't get them to consider it emergent enough to do it in the hospital. Finally, I had to say to the 18 year old girl I was speaking on the phone with, and this IS a quote 'Listen, my intestines are in my scrotum...'

Finally it was approved. Turns out my doctor said it was one of the biggest hernias he had ever operated on.

There are good insurance companies and bad insurance companies here in the States. There are also good plans and bad plans. Depending on what you want/need si what makes a plan good or bad for you. For most of my coworkers, our plan is overkill (we have outstanding coverage with prescription, dental, vision, and the rest) as they are young and they complain about the cost coming from their check. What they don't have is experience anywhere else to realize that our costs are actually quite reasonable compared to other places I've worked and our coverage much better.

I've also worked at self-insured places where they use what's called a "third party benefits administrator" and that is where you health coverage starts to suffer. The TPBA is there to find excuses not to spend your employers money because they get a small percentage for every claim they can find a way to deny.

But the real problem is the small employers (under 20 people) who don't have any coverage for their employees at all, yet these same employees can't get on public subsidized healthcare because they have jobs and make money. THAT is what needs to be overhauled. If you run a small business, trying to get coverage for less than 20 people is outrageous because the insurance company looks at things like median age and over all health of your employees. You get one person like me with diabetes and they jack the rates up. Small businesses need a resource where they can get reasonable coverage for their people by going in with other small businesses so their bumps average out, and then (and only then) they need to be told to get it or else. But first it has to be made available to them.

I for one am looking forward to reform that includes a public option. I think it is long overdue. My health insurance has showed me the flaws of a for profit system. I m young so i dont use the health care much but when i do i expect it to work for me. when my chronic heartburn led my doc to perscribe nexium the insurance company wouldnt pay because they said my hearburn was "pre existing". when i was on a cruise and got strep throat, i went to the infirmary and got penicillin shot (visit exam and shot 471$) i got back filed my claim and again my insurance company refused to cover me cause i didnt go to an "in network " doctor. I WAS ON A GODDAMN CRUISE SHIP. after 2 months they did pay me 421 of the 471 $ but this took me 2 appeals over 3 months and a reclassification to "off shore emergency visit". I really laugh when i hear all of these people say govt will do this that or the other terrible thing, and the insurance companies are bending us over right now.

from what i have seen of the plan I like the exchange idea with a public option included. changing the pay basis from how many tests you do to how healthy your patients are should also help make it easier for doctors to concentrate on keeping people healthy

VexLord - when crusing on international cruiseships, it is generally considered your responsibility to pay the medical bills should you see the doctor. Most ICs won't cover it. You got lucky yours did at all.

@Dingle - I've done the insurance and TPBA thing both. All my insurance has been either commercial (Ohio Casualty Group) or personal property (Cincinnati Financial) as a consultant developing their online or remote office policy rating and issuance software. But I used to work for UMR - a huge TPBA. I left them because I didn't like what I was seeing with their efforts to avoid paying claims. I think that confuses a lot of people. They will say their insurance company wouldn't pay for it, but they worked for a GE or an HP who pays the claims and uses a TPBA to process them. There is no insurance company involved.

As someone who lives in the UK, I think our NHS is actually a very good system. I have needed hospital treatment several times over the last few years, and I have always been well looked-after.

I think private heathcare is morally very dubious - healthcare should be about looking after people's well-being, not maximising profits. If I was in charge, I would outlaw private hospitals here in the UK.

The health system in the US needs to be reformed, but I don't agree with maknig a public system. Here are some examples of my experience why it should be reformed:

1. I have a 'good' health insurance plan... yet when my youngest son was born, I was billed $6k from the hospital. This lead to an incredible time sink to get the hospital and the insurance company to come to terms and pay it.

2. When my oldest son was born, we went to a hospital and used a doctor that I knew was 'in network'. Afterwards, i received a bill for $600 bucks. It turns out the hospital (that was in network), contracted out the Anesthesiologist, which turns out was not in network. I was stuck with the bill even after I did the homework.

3. My copays are $30 for every hospital visit. Between my wife, and 2 young sons, I'm paying probably 60-90 USD per month. Not including prescriptions, which is another 50 - 100 per month. This is insane.

4. Both of my sons were born with a digestive condition requiring them to be on an expensive special formula. The insurance company said they will cover it, but it was classified as MEDICAL SUPPLIES... which meant I had to pay the $600 per year deductible first. Of course, they were both born near the end of the year, so i would get to 550 and have the year reset. Get to 550 again and they didn't need the formula anymore.

5. Emergency Room visits cost a premium, so there is a constant debate on what is really an emergency, or if it can wait until the morning or next day.

6. My oldest son accidently rammed a stick in my eye and put a small hole in my cornea. I went to the doctor, paid $30 copay. The doctor said i need to go to an eye specialist. I went to the specialist, paid a $60 specialist copay. They fixed me up and gave me some meds (another $20 bucks)

** It's just so expensive. I've found myself cutting back for going to the dentist and to the doctor myself, just to save a buck. My medical bills, just to maintain a young family, is like a car payment..

!!! And I pay insurance directly via my pay check each week. !!!

The worst part of the entire fiasco is having to deal with the insurance company. It literally is a full time job if you get in a situation where they won't cover things because a "t" is not crossed right. It's sickening, and many times the consumer will just let it slide because it's not worth dealing with.

That's exactly the sort of thing I mean. The insurance company is constantly trying to screw you, because they are only interested in their profits, not your health.

"That's exactly the sort of thing I mean. The insurance company is constantly trying to screw you, because they are only interested in their profits, not your health."

I don't believe this is true. Regardless of the bigwigs, who are concerned with company profits, the people playing your claims are low paid $10/hour workers. They really don't care. Do you think your average Walmart employee pays attention to stock prices or cares when quarterly earnings are released? They don't get paid by commission and they aren't rewards x for every claim they deny.

It's a bit different from a worker at Wal-Mart. I'm sure a lot of insurance company workers are actually under pressure to refuse as many claims as possible.

I think the doctors are to blame also. If you look at the actual cost of the health care that is submitted to the insurance company, it's outrageous. And many times (like I have done with a Chiropractor), the doctor will forgo the copay and just be happy billing the insurance company just to keep your business.

Based on my experience with 3 different insurance company, there was never any pressure to refuse claims. Not even a hint of it. I don't work for that profession any longer, so I have nothing to gain or lose by saying that.

What do you base that on Jamie?

"VexLord - when crusing on international cruiseships, it is generally considered your responsibility to pay the medical bills should you see the doctor. Most ICs won't cover it. You got lucky yours did at all."

Draugnar - this is kind of my point. i pay my premiums ontime everytime, and I expect that this means I have help when i get sick. I do not expect that everytime i get sick the company who takes my money has an automatic first response of how can we not help this sick person. I still have the chronic heartburn by the way, it sucks but milk is your friend.

@ ag7433: "I think the doctors are to blame also. If you look at the actual cost of the health care that is submitted to the insurance company, it's outrageous"

Yes. And again, that's because they are interested in making a profit, first and foremost.

@DingleberryJones: "What do you base that on Jamie?"

Firstly, I would assume that there would be some pressure to refuse claims, because the fewer claims paid out, the more money the firm makes. So it's in their interests to do so, as long as the majority of their competitors behave similarly.

Secondly, a friend of mine used to work for a major insurance company - albeit in his case dealing with household insurance claims rather than medical insurance - and he has told me that he was regularly encouraged to reject legitimate claims in the hope that the policyholder wouldn't argue.

My thoughts are these: No matter whether or not the plan in and of it self will increase healthcare costs, we can not afford it.

Jamie,
If what your friend is true, I have never heard anything like that. I would recommend he report it to the authorities and seek protection under the whistleblowers protection act.

@AG - I would say "I have a 'good' health insurance plan" must be sarcastic. I'm on a plan with no deductible (you have $600 per person per year sounds like, probably $1200 total family, hardly a good health plan by industry standards) and $10, $25, and $40 copays for prescriptions depending on generic, formulary, or non-formulary. Also, my provider doesn't deny "preexisting conditions." The only issue I've had so far is when a hospital or doctor submits lab work or something to an out of network provider. But my doctor knows better now and the hospital I go to is good about eating the costs if they screw up, so it hasn't cost me any extra (knocks on wood).

@Jamie - I'm with Dingle in that the big ins cos don't pressure their claims adjusters to deny claims. I really think the TPBAs are to blaim for this confusion because of how they make their money.

Of course, I have been out of the insurance companies and TPBAs for about 7 years now, so things may have changed. But I doubt they've changed that much.

"Firstly, I would assume that there would be some pressure to refuse claims, because the fewer claims paid out, the more money the firm makes. So it's in their interests to do so, as long as the majority of their competitors behave similarly."

By that same logic, it would also make sense in the drive thru at McDonalds for employees to be encouraged accidentally short them a hamburger, to accidentally give them the wrong change at the supermarket, etc.

@ Draugnar: What is a TBPA?

@Vexlord - the problem is that the insurance companies are US based and the cruise ships are international, usually based out of Scandanavia somewhere. The ins cos can't negotiate or even confirm that the onboard doctor isn't trying to take them to the cleaners. I don't blaim them on that one. If you want to be certain you'll be taken care of on a cruise, use a US based carrier like Disney's Big Red Boat, not Norwegian or Royal Caribbean or one of the other non-US lines.

@Jamie - TPBA stands for Third Party Benefits Administrator. It's a company that handles claims for other LERGE companies (like GE, HP, Microsoft, etc) who may chose to pay their own employees claims rather than have a real insurance company. A TPBA receives all the claims and does the reviews, approvals, denials, and adjustments. They are usually paid a fee plus a bonus for keeping claims under $X per year or an average $X per employee.

grrrrr LARGE

@ Draugnar: "They are usually paid a fee plus a bonus for keeping claims under $X per year"

Well that gives them a direct incentive to reject as many claims as possible.

Again, that is a TPBA. Read, Jamie, read. TPBAs aren't insurance companies.

@Vexlord,
That is similar to you driving your vehicle in Egypt and expecting your American car insurance company to pay for it. Your US based auto policy will cover you in the US and Canada (but not Mexico, go figure).

"TPBAs aren't insurance companies."

No, but they are still part of a system in which healthcare is provided privately, rather than through the state, and in which profit therefore comes before health. If the US had a system like our NHS, TPBAs would not be a factor.

Health Care in America is great if you're healthy and rarely if ever sick and don't mind pissing money away. Once you get sick though you get completely fucked. I am employed by a small business that doesn't provide Health Insurance. I checked around and in Florida the best deal I could get for 'good' insurance (even good insurance has caps on yearly coverage - so if you have two tragedies the second one fucks you anyway) was ridiculous.

Example: $225 a month as a 24 year old male who never drinks, smokes and is in perfect health with a $2,500 deductible and even then the insurance company only covers up to 80% of the costs. How many times do you go to the doctor and need to spend over $5,000? Oh, and you need to go to a primary care physician and have him refer you to specialists that are participating in the network. Get fucked in another state that doesn't have someone in the network and you're stuck with the full costs.

The 'good' plan: $444.68 a month for the freedom to go to any doctor you need to in an emergency,with $500 deductible but they still only cover 80% so you have to pay 20% of whatever the costs are over the deductible - congrats on paying almost a mortgage payment for a pittance of care.

And Insurance companies almost always deny first because most people will not want to fight it. Every time they deny a claim it directly increases their profits. Insurance companies shouldn't be privately run the same way that the military or police should not be privately run.

It's a conflict of interest.

Hibiskiss +10

@Hisbiskiss "And Insurance companies almost always deny first because most people will not want to fight it. "

As I did with Jamie, I'll ask again. What do you base that on?