[Bubbadoo]

Health insurance in the United States' for-profit healthcare complex is a nightmare. Besides the fact the premiums are onerous, it is the health insurance carriers that evaluate if and how much insurance will cover an expenditure, usually after a copay and possibly coinsurance has been paid. To say nothing of ever-growing deductible limits. On top of that, the Trump Administration is working overtime to purge what little insurance benefits are provided via Obamacare (in it's quest to eliminate any legacy of the Obama Administration). Unfortunately, the GOP is woefully short on replacement ideas. One does get the idea--in the true spirit of the Republican Party--the replacement will consist of costly, high-deductible health insurance that will include many exclusions from its coverage.

All this begs the question: quality of life in the US, especially for the middle class, is crashing compared to our friends in other industrialized nations. Why middle class especially? Because the middle class is most likely to have an employer-sponsored plan that has deductibles and exclusions. In fact, most of those carrying employer sponsored health insurance never really know how much of the bill insurance will cover. Poor and indigent people, in many states, can still obtain health care without insurance and many states have funds just for this so the bill is paid by the tax payers in one form or another.

And since the healthcare complex is an aggressive lobby in Washington, this situation is not likely to change. Not under Biden, certainly not under Trump. And to those Democrats who say millions of people who have employer-sponsored health insurance love their coverage and don't want to give it up, I say poppycock! I don't know anyone, outside of public union members, who really like their coverage, employer-furnished or not. Year-to-year premium increases with less coverage over time effects this group more than any other.

[lotsofpulp]

> Besides the fact the premiums are onerous, it is the health insurance carriers that evaluate if and how much insurance will cover an expenditure, usually after a copay and possibly coinsurance has been paid.

This is not true. ACA requires health insurance companies to pay for all healthcare expenses after reaching one’s out of pocket maximum.

And they have some discretion to call out fraud, but insurance companies have to by and large follow medical procedure guidelines. They don’t have to cover experimental treatments, but if they are denying appropriate healthcare, they would get nailed by various government agencies.

[Bubbadoo]

The 'ACA' is not one plan and it certainly does not require health insurance carriers to pay for 'ALL' healthcare expenses after you reach your deductible. Coverage varies by state and by level (ie., gold or platinum). Many plans do not cover out-of-network doctor visits for example. On top of this, you need to get prior approval for every medical procedure because not ALL are covered. In some cases, the insurance company will recommend a different treatment, instead of the prescribed treatment. I speak from experience.

AHCA coverage is superior to what we had before, but it isn't enough. It was drafted with the Health Insurance lobby in the room, so do the arithmetic.

[lotsofpulp]

ACA requires insurers to pay for all healthcare expenses at in network providers for coveted procedures, unlike pre ACA where the insurer could simply stop paying at a certain dollar amount.

And health insurance does recommend different treatment depending on what the insurance’s doctors think. That’s the entity with the knowledge to be able to challenge a doctor, since the patient rarely has sufficient knowledge to do so.

The alternative system of a check and balance is if the government pays for healthcare and a government employed doctor approves or suggests alternative treatment. That’s what the UK does.

Either way, you have to have a second opinion to avoid mistreatment or overcharging by the healthcare provider. This isn’t an issue specific to healthcare, it’s present in any sufficiently complicated field.