(08-13-2023 09:33 AM)Hambone10 Wrote:  The mere existence of Medicare Advantage plans (plus the profitability of insurers) is proof positive that Insurers are better at managing overhead than government. The whole 'denial' farce sells well to people, but treatment and diagnosis codes are universal. D it right, you get paid... do it wrong and you don't.... and the coverages (what codes must be covered) are mandated by CMS.... so it s an exceptionally rare exception where something is denied by an insurer that wouldn't also be denied by CMS.
For commercial insurance, you can be a bit more flexible... and that is reflected in the cost of the plan.
For Exchange plans, there is no company subsidy. It costs what it costs and although there can be some flexibility, there are still innumerable numbers of commonalities of coverage, wth the biggest difference being how copays and deductibles are allocated.... or perhaps the networks (how expansive they are) and not in the coverages.
but if you want an employer to subsidize your plan, you either have to make it a tax on all industry... whether that industry is profitable or not... which will kill lots of businesses... OR you have to make it worth a companies while to do so by letting it be a form of employee retention.
The idea that you can separate a voluntary subsidy from the benefit of offering that subsidy is just a non-starter.

And your background and experience clearly make you the expert on this subject. All that you say dovetails very nicely with the Bismarck approach.

(08-11-2023 04:39 PM)greyowl72 Wrote:  After reading all of the above detailed arguments and descriptions of our health care system, I continue to be amazed that anybody… Medicare, private insurance, disability etc can navigate through it. It’s difficult on a day to day basis. It becomes almost impossible for elderly patients, most patients with no previous experience regarding co- pays, deductibles, OOPs etc. ..just about everyone. Especially, when facing a major hospitalization.

This is very true... and entire industries are built around this lack of knowledge/education... but there is a third option... we could invest the time (especially in say high school health classes) to educate people.

It's really not that difficult... with the difficulty coming in based on the fact that there are literally tens of thousands of diagnosis and treatment codes

Said simply....
Some (mostly purely preventative) services are covered completely under the plans.

Other services (you're sick or injured) are covered as part of a cost-sharing practice. Common things like a general doctor visit for minor ailments have a set copay... You pay usually $5-50 and your insurer pays the rest (to a negotiated limit)

More serious injuries, you pay a percentage of the cost up to a negotiated maximum.... Insurance again pays the balance, to a negotiated limit.

Whether your bill is paid 'in full' or not depends on whether you see a doctor in your network and/or what kind of program you have.

If you have no, out of network benefits then you MUST see a network doctor... period... and your costs are limited by the maximums in your policy. If you go out of network, they pay nothing. Other plans have mixes of in and out of network benefits.

If you want to know how this works in some light detail, Network doctors are paid to treat you whether you need coverage or not. Guaranteed income for doctors, but no upside. Same with insurers. This controls lots of costs, but also leads to doctors/systems cutting a few corners. This can extend from your PCP to an entire hospital network for all coverage you might possibly need. Other doctors are essentially Fee for Service, which is more expensive to deliver that service, but also provides 'upside' for both insurers (if you don't need care) and doctors (if you do)

(08-11-2023 04:39 PM)greyowl72 Wrote:  After reading all of the above detailed arguments and descriptions of our health care system, I continue to be amazed that anybody… Medicare, private insurance, disability etc can navigate through it. It’s difficult on a day to day basis. It becomes almost impossible for elderly patients, most patients with no previous experience regarding co- pays, deductibles, OOPs etc. ..just about everyone. Especially, when facing a major hospitalization.

The legal system is similarly opaque -- but that's mostly by design.