# Is there any way to avoid falling through the cracks of the US health insurance industry
**URL:** https://boards.straightdope.com/t/is-there-any-way-to-avoid-falling-through-the-cracks-of-the-us-health-insurance-industry/723513
**Category:** In My Humble Opinion
**Created:** [June 26, 2015, 4:01am UTC](https://boards.straightdope.com/t/is-there-any-way-to-avoid-falling-through-the-cracks-of-the-us-health-insurance-industry/723513 "2015-06-26T04:01:32Z")
**Posts on this page:** 9
**Page:** 2
### Author:  [@septimus](https://boards.straightdope.com/u/septimus)
#### Post date: [June 26, 2015, 11:53pm UTC](https://boards.straightdope.com/t/is-there-any-way-to-avoid-falling-through-the-cracks-of-the-us-health-insurance-industry/723513/21 "2015-06-26T23:53:32Z")
> [@Wesley\_Clark](#):
>
> The entire system in the US is unsustainable, the question is when/how will it collapse and be reformed?
Before 2009 there were a variety of complex reasons why American health care was fraught with high costs and insurance problems.
Now we live in a simpler time. 45% of Americans are certain that any health insurance problem they have can be 100% attributed to a certain black man from Kenya.
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### Author:  [@Wesley\_Clark](https://boards.straightdope.com/u/Wesley_Clark)
#### Post date: [June 27, 2015, 12:16am UTC](https://boards.straightdope.com/t/is-there-any-way-to-avoid-falling-through-the-cracks-of-the-us-health-insurance-industry/723513/22 "2015-06-27T00:16:02Z")
> [@septimus](#):
>
> Before 2009 there were a variety of complex reasons why American health care was fraught with high costs and insurance problems.
>
> Now we live in a simpler time. 45% of Americans are certain that any health insurance problem they have can be 100% attributed to a certain black man from Kenya.
To be fair, the US had the best health care system on earth before 2010. Its a scientific fact.
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### Author:  [@Senegoid](https://boards.straightdope.com/u/Senegoid)
#### Post date: [June 27, 2015, 1:19am UTC](https://boards.straightdope.com/t/is-there-any-way-to-avoid-falling-through-the-cracks-of-the-us-health-insurance-industry/723513/23 "2015-06-27T01:19:19Z")
To be sure, the American way of medical insurance is a rotten-to-the-core hodge-podge, and PPACA did little to fix that except maybe around the edges.
The Republican mantra “repeal and replace”, if taken to an extreme, might mean we should tear down our entire health care financing system and start over from scratch. Probably, nothing less will be much of a fix. The single-payer system would probably have been the best way to go.
Of course, the Republicans don’t actually seem to have any thought-out replacement plan, and anything they might come up with would probably be even worse.
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### Author:  [@GreenElf](https://boards.straightdope.com/u/GreenElf)
#### Post date: [June 27, 2015, 1:51am UTC](https://boards.straightdope.com/t/is-there-any-way-to-avoid-falling-through-the-cracks-of-the-us-health-insurance-industry/723513/24 "2015-06-27T01:51:15Z")
For over a decade, I had no health insurance coverage and paid $400 for a simple vitamin screening. Then I started going to a local community health center ([http://www.nachc.com/nachc-pca-listing.cfm](http://www.nachc.com/nachc-pca-listing.cfm)), and signed up for state-sponsored medicare in 2013 during the Obamacare rollout. I just filled out some paperwork at the community health center. My health insurance is free and covers my medical care, but I’m healthy enough that I haven’t required surgery or the like.
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### Author:  [@Wesley\_Clark](https://boards.straightdope.com/u/Wesley_Clark)
#### Post date: [June 27, 2015, 2:48am UTC](https://boards.straightdope.com/t/is-there-any-way-to-avoid-falling-through-the-cracks-of-the-us-health-insurance-industry/723513/25 "2015-06-27T02:48:44Z")
> [@Senegoid](#):
>
> To be sure, the American way of medical insurance is a rotten-to-the-core hodge-podge, and PPACA did little to fix that except maybe around the edges.
>
> The Republican mantra “repeal and replace”, if taken to an extreme, might mean we should tear down our entire health care financing system and start over from scratch. Probably, nothing less will be much of a fix. The single-payer system would probably have been the best way to go.
>
> Of course, the Republicans don’t actually seem to have any thought-out replacement plan, and anything they might come up with would probably be even worse.
The republican solution is to cut regulation and taxes. They will eliminate federal regulations on health insurance, and insurers will all locate in states with the fewest consumer protections. It’ll speed up the transition to ‘why bother even buying health insurance’. People who spend several thousand a year already realize there is no reason to have it, it isn’t really going to cover you if you get sick or need help.
Either way, the GOP has no real solution and could care less about the health care issue unless they can use it as an excuse to push their ideological and philosophical agenda.
Truly fixing health care in the US will require strong government regulations and restructuring the health system to give much more power to both the public and private sector to drive down prices. That involves statism and taking on wealthy, powerful interests like hospitals, doctor groups, pharma, medical supply. Nobody wants to do it.
I wonder if meaningful health reform can be done via public referendum. I know that is a tactic California is looking at, just make a ballot initiative and if it gets 50.1% of the vote then the health system changes. Politicians on both sides are totally unwilling to do what needs to be done to fix our system and legislation is mostly a dead end, even in one party blue states.
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### Author:  [@Wesley\_Clark](https://boards.straightdope.com/u/Wesley_Clark)
#### Post date: [June 27, 2015, 2:53am UTC](https://boards.straightdope.com/t/is-there-any-way-to-avoid-falling-through-the-cracks-of-the-us-health-insurance-industry/723513/26 "2015-06-27T02:53:13Z")
> [@GreenElf](#):
>
> For over a decade, I had no health insurance coverage and paid $400 for a simple vitamin screening. Then I started going to a local community health center ([http://www.nachc.com/nachc-pca-listing.cfm](http://www.nachc.com/nachc-pca-listing.cfm)), and signed up for state-sponsored medicare in 2013 during the Obamacare rollout. I just filled out some paperwork at the community health center. My health insurance is free and covers my medical care, but I’m healthy enough that I haven’t required surgery or the like.
Do you mean medicaid, or medicare?
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### Author:  [@GreenElf](https://boards.straightdope.com/u/GreenElf)
#### Post date: [June 27, 2015, 1:32pm UTC](https://boards.straightdope.com/t/is-there-any-way-to-avoid-falling-through-the-cracks-of-the-us-health-insurance-industry/723513/27 "2015-06-27T13:32:15Z")
> [@Wesley\_Clark](#):
>
> Do you mean medicaid, or medicare?
I think it’s medicare though it doesn’t say on my insurance card. I’m one of the “10 million uninsured” that Obama referred to in his 2009 presidential campaign. I’m not on SSI, but am low income. I don’t pay an insurance premium for the coverage, and I don’t pay any deductible for doctor visits. I do have to go through my primary care physician and get a referral from him for any medical treatment by specialists.
I’m not sure about any “out of network coverage” though, since I’m required to route everything through my physician.
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### Author:  [@kayaker](https://boards.straightdope.com/u/kayaker)
#### Post date: [June 27, 2015, 1:46pm UTC](https://boards.straightdope.com/t/is-there-any-way-to-avoid-falling-through-the-cracks-of-the-us-health-insurance-industry/723513/28 "2015-06-27T13:46:14Z")
Before ACA I had affordable healthcare insurance that covered pretty much everything.
After ACA that plan was no longer available. The nearest plan that was offered cost much more, has huge copays, and covers next to nothing.
So, I’ve given up on any kind of proactive healthcare. I’m using my insurance as a catastrophe plan. I kind of think in the long run I’ll cost the insurance industry more.
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### Author:  [@Mdcastle](https://boards.straightdope.com/u/Mdcastle)
#### Post date: [June 27, 2015, 2:18pm UTC](https://boards.straightdope.com/t/is-there-any-way-to-avoid-falling-through-the-cracks-of-the-us-health-insurance-industry/723513/29 "2015-06-27T14:18:10Z")
> [@Wesley\_Clark](#):
>
> Even if you get insurance, and even if you can meet the deductibles and copays you can still not get covered. Off the top of my head you have situations like
>
> The hospital is out of network
Most contracts I’ve seen will pay out-of-network charges up to charge at in-network benefits if the admission was through the ER. If you go to an OON ER and need an impatient admission you need to notify your insurance as soon as possible and they may elect to transfer you if you can be at that point.
> [@](#):
>
> The hospital is in network, but provider is out of network
This can be appealed as “non-patient-driven-care” but requires at least a phone call and possible appeal to the insurance company.
> [@](#):
>
> The insurance decides that your treatment wasn’t medically necessary
If it is an in-network provider they are responsible for the charges, and if they’re billing you call your insurance company who will tell them to cut it out.
> [@](#):
>
> I’ve heard you can get charged if you leave against medical advice. But I’ve also heard that isn’t true.
That’s a myth. In 10 years at an insurance company I’ve never rejected a claim for this. I’ve never even been instructed to check to see if this is the case.
> [@](#):
>
> I was told today by someone who works in healthcare that if you are deemed an ‘out patient’ admission to a hospital you end up with the bill, insurance will only pay for in patient admissions. How the fuck does a person have any role in determining that?
I’ve not heard of this, but if this is the case if the provider was in-network the liability would be assigned to them and not you.
> [@](#):
>
> Is there anything a person can do? Not everyone has access to an insurance plan with out of network coverage. I’ve looked, I don’t see high deductible supplemental insurance that covers out of network charges to cover what primary insurance doesn’t cover.
I’m assuming a person that would buy "OON insurance’ would be someone that expected to use it, say because they liked they’re wive’s hairdressers surgeon or wanted the most prestigous care at the Mayo or something. So the risk pool would be too skewed to offer it as a product.
1. Choose in-network providers. 2) If you’re taken to an out-of-network provider tell your insurance company ASAP.
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