> US health insurance coverage is very insurance-like, due to the out of pocket maximum.
Well, other than that whole "out of network" thing...
> Determining health insurance coverage can't be simple, because fixing bodies is not simple. It's unknown what will and will not fix issues, how to even measure if there is an issue, and what will cause more issues and the cost/benefit of that fix.
Don't disagree - but that doesn't make what we have more "insurance-like".
I mean for most auto and home insurers, the "negotiated price" is a pretty loose thing. My insurer might ask for a quote from someone in their "preferred network" but I can get a quote from anyone I want to do the work, and if it's within x% of the preferred quote, it's automatically approved, otherwise someone from the insurer calls them and asks about the different pricing, and I've generally got that approval within 24-48 hours. (Which has also worked in my favor - with an auto glass claim, their repairer was insistent that third party glass would work fine, despite the HUD, but the other was able to demonstrate to the insurer that OEM glass was required).
Mostly this all boils down to "the healthcare industry in the US needs to be comprehensively revamped in any one of several different ways or methodologies, but likely won't be".
> but I can get a quote from anyone I want to do the work, and if it's within x% of the preferred quote, it's automatically approved,
It would be the same in healthcare if quotes were for 4 and low 5 figures with no future costs.
Not only does healthcare easily reach into the 5, 6, and 7 figures, but the health insurance company is also on the hook for myriad known and unknown issues caused by the initial costs.
> It would be the same in healthcare if quotes were for 4 and low 5 figures with no future costs.
I mean, this is somewhat the same in auto, too. Is one of the reasons you're recommended to go through insurance even if involved in an accident and the other party offers to give you cash for the initial quote - it's quite common that they start repair work and find other issues because they hadn't removed components or panels to give you a quote. Got cash from someone? Now you have to go back and say "Well, I know the quote said $1,500, but they took off the back quarter panel and found other issues and now it's $3,800..."
That being said, ICD codes, one of the cornerstones of billing, are predicated around "encounters", and certainly not "future costs".
> is also on the hook for myriad known and unknown issues caused by the initial costs.
There's a pretty huge asterisk to all that. Health insurers are adept at neatly sidestepping any obligations. They've fought and won many many times over in court on similar issues, "Insurer is denying me care and I'm going to die/suffer serious issues as a result!" Insurer's response, which has been held in court many times over? "We're not denying you any care at all, we're just declining to accept financial responsibility for it. You're free to get that care and be directly billed."
>There's a pretty huge asterisk to all that. Health insurers are adept at neatly sidestepping any obligations
This might sidestep some obligations, rightly or wrongly. They clearly do not sidestep "any" obligations. The amount of money spent on healthcare claims (medical loss ratios) is public information, available in their SEC filings. It is required to be 80% or more by law.
Every state government has an insurance regulator that also has to approve insurance prices, which are based on the cost of claims. The regulator is not going to let an insurer increase premiums just for profit.
Also, the non profit and for profit insurers have similar premiums, with the for profit insurers having ~3% profit margins or less, indicating a highly competitive market where the revenue is barely covering costs.
Shareholders aren't making any money either (10 year returns lag SP500):
Finally, the fact that Buffett/Dimon/Bezos tapped out on creating a competitor should really drive home how little the profit potential is in health insurance, and any less "sidestepping" of obligations would lead to higher premiums.
I worked in EMS. United battled a bunch of civil suits years ago where they had denied HEMS transports (helicopter transport) from accident scenes due to "lacking pre-authorization". For a car accident.
What would that even look like?
"This is John, I'm a paramedic working on one of your patients who was hit by a truck. We would like to fly him to the trauma center due to extensive multisystem trauma but we need your authorization. His name? Hang on, let me find his wallet. No, that's Smythe, S-M-Y-T-H-E, sorry, I know, it's a bit loud with the jaws of life in the background... Uhh, sure, I guess I can hold for a nurse consult..."
Well, other than that whole "out of network" thing...
> Determining health insurance coverage can't be simple, because fixing bodies is not simple. It's unknown what will and will not fix issues, how to even measure if there is an issue, and what will cause more issues and the cost/benefit of that fix.
Don't disagree - but that doesn't make what we have more "insurance-like".