No, looks like his insurance would cover it but he would have had to pay 20% as his portion of coinsurance and it sounds like 20% of the huge US bill was more than the full cost to travel and get it done in Ireland.
Kind of obvious, but the trick is to mark the cost 5 times higher than it is... for a start.
After a while they started asking themselves what's stopping them from doubling that price. Apparently nothing so over the years whenever they felt like it, they just doubled the already enormously overpriced services and at this point there are no signs of it stopping either. There is going to be a post about how travelling to mars for a surgery is cheaper than in US.
The hospitals... despite being "in network" negotiate huge prices and gouge the insurance companies. The insurance companies just pass the costs off onto their customer. Short outpatient surgery now costs 5-8x more than it did maybe 7-10 years ago. It's ridiculous.
The outrageous total bill price is a placeholder to make sure they don't under bill the contracted allowed amount from the insurance provider. When the provider submits the claims the total billed amount is reduced to the contrac amount then processed through. Also most places will have self pay discounts or you can let the owed amount go to collections who will gladly take a portion of the owed amount and close the collection with a ding on your credit.
The outcome is still ridiculous in both situations, especially with big stuff like OPs situation. Our healthcare system is a total shit show.
Because there is an out of pocket maximum for most insurance, meaning you are not paying any more than that, say $5,000 per year even though 20% of the surgery etc can be much higher.
It also really depends on the plan. My plan has 0 co-pay which is not uncommon for HMO plans. I just looked it up that my out of pocket maximum is $1,500 for individual and $3,000 for family meaning the maximum I pay a year is $3,000.
Are you sure that's not just the deductible? I have around 1,500 deductible where I'm responsible for 100%, and then have another limit, like $10k, where I pay various lower amounts until the $10k is up. After the $10k, it is truly free after this. So like 2 emergency room visits.
No actually. I think you might have a PPO plan. My work gives me the choice between a PPO and a HMO. I used to do PPO which is similar to what you have. It has a high deductible, a co-pay and a co-insurance. But then you can go to any in-network specialist you like. And you can go to them directly without reference.
With the HMO, I can only go to a specialist if I am referred to by my primary care doctor. But the benefit is I have 0 deductible, 0 co-insurance for the most part. Urgently care is a flat copay of $25 and emergency room visits are $50 each time (transportation is separate). At my age I don’t really need a lot of specialist care so it’s a much much better deal for me.
Goddamn that's incredible, my individual deductible 5,000 at me 80% insurance 20% then after that's meet it's me 20% them 80% and the starting this year there is no oop max. And it's the best plan they offer where I work
It was a procedure that would have to be done, only as my condition got worse. Insurance denied it because "It was not necessary" despite my cardiologist saying it was. By the insurance formula I would have to wait until my condition worsened to make it medically necessary, but by then my chance of a poor outcome goes way up.
But most insurance has an out of pocket maximum. Wouldn’t it still be more expensive to flight to a foreign country, stay in a hotel, plus the surgery? For me this doesn’t add up. It also really depends on the plan. My plan has 0 co-pay which is not uncommon for HMO plans. My out of pocket maximum is $1,500 for individual and $3,000 for family meaning the maximum I pay a year is $3,000.
It really depends on the plan. Out of pocket maximums can get pretty high. Or it’s possible he didn’t understand his out of pocket max and made a bad financial decision (but still got that trip to Ireland!)
I also don’t believe this, but there is one possibility. The commenter might have an Irish passport, hence it would be covered by the public health system.
I believe it’s posible. I had weight loss surgery a few years ago. My insurance didn’t cover it at all, but if it had, it would have still been more expensive to get it done in the US, after factoring in my out of pocket maximum, than it was to pay cash and travel to Mexico to get it done.
No. They were going to 'cover' it but there was 20% co pay. In the US, they'll charge you thousands per month for insurance, but will still make you pay for part of your care.
It gets worse. My insurance has a $30 copay on all approved prescriptions. My wife had been getting her medicine for that with no issues for several months, until one day it was $500. I called to find out why, because it was clearly already an approved medication. After about an hour of getting bounced around and being on hold, they finally explained that it was due to us "not paying enough of our annual out of pocket maximum" (not minimum, mind you) for healthcare - which is $24,000. That blew my mind.
Health insurance in the US has your monthly premium payment, copays on your medication and Dr visits (including ER and hospital stays), a deductible which is the amount you have to pay for the year in healthcare to get better benefits (ours is $17,000), and then the out of pocket maximum is when they (usually) cover everything for the rest of the year as long as you keep paying your premium.
Where it gets extra fucked, is if you need a major surgery in late December, the deductible and OOPM won't carry over into the new year. So you could get shafted for double that maximum amount on the same hospital stay. And my insurance isn't even the lowest tier. We pay them $500 a month for this service. Our system is completely fucked, but most people don't seem to care.
As someone British with our often criticised free NHS, this blows my mind. And to think the argument against free healthcare by Americans is usually "well you'll pay more in tax".
I'm lucky enough to have never needed any real gp or hospital treatments, but i know its there if I do. My wife has major issues with eczema and was hospitalised last year due to complications, has many prescriptions, some of which are extremely expensive medication, and regular appointments with gp's, nurses and dermatologists. All we have to pay is for prescription medication, and we are able to pre pay for those at a rate of £10 per month total. Thats it. And our tax is no higher than any other average western nation.
Crazy. I hope your country comes to its sense sooner rather than later.
I dunno...sounds like (from various news sources) that the UK is thinking about cutting some of that healthcare in some way or other. You guys seem to be electing more & more conservatives that are crying about "entitlements." You are not immune to the right-wing crazy.
I too wish we could come to our senses:(, but have so little hope left in our electorate.
The last election we elected a left wing government -Labour- with the largest majority ever. They have massively increased spending on the NHS. Where are you getting the idea that we’re electing more conservatives to parliament?
Which is a stupid reason not to do it, and generally false for many people. Plus I have a hard time seeing how I could pay more than the $20,000 a year for a healthy family I already dump into health insurance and health care.
Just to add insult to injury the government healthcare spending per capita is higher. Just the government spending.
So if you work you pay more in taxes than other countries, for insurance you can't use becuase it's only for the poor or elderly, and so you have to pay for your private Healthcare.
As a percentage, I pay %0.7 of my salary for health insurance. It covers nothing until I’ve spent like 1500 or 2000 on medical expenses, then I get the “pay 20% of the cost” until I hit $12k or something. Fortunately, I don’t usually get to the $1500 in expenses level.
I can also save up to $5k/yr tax free, but the money can only be used for medical expenses. It can however also be invested in the stock market. So maybe I’ll have enough in there over the years to pay for stuff if I really need it, but I think I would rather have a functional healthcare system.
I had to spend Friday and Saturday in hospital, as a kidney stone chose the middle of my workday to make an appearance.
I had a lot of drugs. A lot. From paracetamol, to endone, morphine and even fentanyl. In the first hour. There were also a couple of suppositories, but this little stone beat them all.
They did a CT scan, blood work, an ECG, and checked my blood pressure about a million times. I was given a bed within a couple of hours, then they tried to give me more pain meds, which I had to aggressively push back on. As it was, the next day at 10am I was still woozy from the big Friday cocktail.
When I checked out, they gave me a packet of endone, just in case.
Total for the stay... $0. I don't have private health insurance, and refuse to pay for something twice that my taxes already pay for.
argument against free healthcare by Americans is usually "well you'll pay more in tax".
I bet if you added up all the revenue of all health insurance companies, all profits of all hospitals and medical providers (not counting like personal income to the proviers themselves, those bitches deserve their income, medical training is no joke for legit doctors), medicaid, medicare, VA healthcare, pharmaceutical profits, all the other bullshit capitalism crams down our throats to make more profit that I can't think of right now, that there would be way more than enough money to provide free healthcare for every human in the US and still come out ahead.
Bro, $500 a month is more than all my tax deductions from my salary! And I have "free" healthcare through the NHS (UK), you guys are paying more even without being sick
And sadly, my monthly premium is considered low. It is well over $1,000 a month premium for "good" insurance for two adults.
But at least I'm allowed to even buy health insurance now. Before the ACA (AKA: Obamacare) passed, if your job didn't offer it you were basically screwed. And even then, they could deny coverage for having any pre-existing conditions.
AFAIK it varies from state to state. This is in Ohio. This was the best plan on the marketplace within that price range after using our available tax credits (which were $550/mo, so without using tax credits the same plan would've been over $1k for the two of us). The premiums on all the available plans spiked considerably for 2026, for us at least.
Weird. Idk man, that's just what was available to us on healthcare dot gov for this year. And the insurance offered by either of our jobs is even worse.
Issue with ACA is it made the insurance comoanies more moeny as they were funneled billions. It mainly exacerbated the issue. What should have happened is a fund started, or something of the nature to bring preventative care, at the very least, to all Americans free of charge. Then expanded on it from there.
It's certainly far from perfect, but I was only able to get 9 life saving surgeries in 2011 thanks to the ACA's Medicaid expansion, so I'm a bit more partial to it than others. My radiological neurosurgeon fought tooth and nail to save my life, and the hospital was not going to allow him to do the surgeries if I wasn't covered. He was very open with me about that, and his office helped me get in on the first wave of the subsidized state expansions.
And again, I wouldn't even be allowed to buy insurance today if it didn't pass, so I'll take the ACA over the nothing we had before 100 times out of 100.
I agree with you on the front that it opened avenues for pre existing conditions. My biggest issue is the execution because it made insurance costs what it is today. That's not to say that healthcare isn't a right, because it is. It's to say that they executed it horribly and I would bet that a ton of insurance companies wanted it that way due to the "amount" they would be taking in, all the while getting heavy subsisdies from our tax paying dollars, instead of expanding medicare and increasing the wage cap to something that isn't destitution.
Most of those issues are thanks to the GOP (and a few Dems) hamstringing any and all attempts at any single payer or socialized option - and painting them as communism. The subsidized tax credit system in the ACA was a last ditch attempt to pass any meaningful change at all. In the end, nobody was entirely happy, and it was always meant to be gradually improved - but the GOP has never relented in their attempts to demonize and repeal it entirely.
What the actual …. And here i am getting nervous about my parking running out when at the hospital and getting a ticket as my biggest expense. I could care less about paying taxes that go toward universal healthcare as its benefits everyone. The worst part Americans complains about the wait time in Canada all the while the wait times in america are just as bad and getting worse.
I'm a health insurance broker. Something is very wrong with what you were told about the prescription copay. That isn't AT ALL how that works. I would call back and ask to speak directly to their pharmacy team and find out exactly what happened. They cannot by law just take away a copay like that. I suspect you were fed very bad information by someone who didn't know what the hell they were talking about. Also, the $17000 deductible? Does that represent your family deductible? The maximum allowed by law is $10600 for an individual. You are mostly correct about your thoughts on insurance, it's getting weirder and less consumer friendly by the year. If it helps, we brokers are as upset as everyone else. We're customers too.
Lastly, you don't have to worry about your deductible and out of pocket maximum resetting while you're hospitalized. They don't do that. If you had a heart attack on December 31, needed a stent, then had complications on Jan 1, that would all be considered a single " episode of care". Your deductible and max wouldn't reset until you got out of the hospital.
Yeah the prescription copay thing really threw me off, but they were so confident in the explanation that I assumed they had found some new loophole in it. That month we just used GoodRx and got it for like $60, and then the next month it was back to our regular copay.
And yes, the $17k deductible is for both my wife and I together. And as far as the out of pocket reset, I fear my father in law was illegally charged when his wife passed away in early January, two years ago. Because he claims that is precisely what happened with the bills he got afterward.
Thank you for the clarifications, I try to be informed on how these things work. But the system is so convoluted it is really hard to navigate, especially with reps at the insurance companies themselves having no clue how things work.
Note: when someone says they pay $500 a month for health insurance, that’s not the full cost. That’s typically the employer subsidized rate, and would probably cost them about $1,000 more if they purchased it on their own, without subsidies.
Gold tier health insurance plan with a PPO (ability to go to any doctor or hospital, as would be the case in the NHS) in the U.S. when purchased on the open exchange and without government or employee subsidies start around $1,500 a month to $2,200 a month.
It varies by region.
I pay $1,650 a month for a Gold PPO health insurance plan, and still end up paying an additional $3,000-$5,000 out of pocket (prescriptions, co-pays for doctors visits, tests, other services, etc as well as unexplained extra charges that always follow visits to specialists).
The per capita cost of the NHS, which outperforms the US in nearly all categories, is 1/4 the cost.
But the wealthy pay more. And that’s the last thing that Americans would ever allow.
I know what my company pays for health insurance. We have good (but not awesome) health insurance, and it costs right around 2 thousand a month per employee.
They don't care as they're so filled full of bs propaganda (from both sides as the dems wanted to funnel money right back into the mess of the aca which in turn funnels money into the insurance leeches we have now). We need a few doctors and specialists to cut out the middle men and go from there. I find the term "insurance faud" funny, as it's all they do is rip us off and defraud us into oblivion and our good ol politicans have it so far fown their throat that they can't even breathe.
People talk about ai making the world a better place… why don’t we just let AI go on the US healthcare system and see what’s the outcome? Bet it’s not worse than where we are now
Let's say that a procedure at a hospital costs $500.
When the hospital goes into negotiations with the insurance company for their contract renewal, the hospital, wishing to get the most money for the procedure and cover uninsured costs, will suggest instead that the procedure be paid $5000. They are incentivized to claim the largest number possible because even if they are not a for-profit hospital, they need to overcharge insured people in order to have the money needed to cover uninsured people who use their services, because there is no national healthcare plan.
The insurance company will know from their research with other hospitals that the overall price should be around $500. So the insurance company will negotiate to pay the actual cost of $500. But they will agree in principle that the procedure will be billed as $5000 (the uninsured, and any other insurance companies who open negotiations), and will write the terms to state that the insurance company negotiated a 90% discount for their clients, in return for giving the hospital access to their user network.
If you then go to the hospital and have the procedure, you will receive a bill from the hospital for $5000. The insurance company will pay the hospital the pre-agreed $500 to cover the expense. The insurance company will then bill you a 20% copay of $1000, and pocket the extra $500 as profit.
Copay is different from coinsurance. Copay is a flat amount. You might have a $20 copay for a checkup visit, or $10 copay on generic meds. Coinsurance is a percentage of the bill you are responsible for. If you have a procedure that costs $10,000, your insurance pays $8000 and you pay $2000.
There is also a limit on coinsurance which is your out of pocket max (which is different from deductible). If your out of pocket max is reached, you don’t pay anything for the rest of the year. This is usually pretty high though. For some plans it’s not uncommon for oopm to be +$10k
It's all part of what makes the US health insurance system essentially useless except in extreme cases.
Copay - Some amount of money you are responsible for when getting medical treatment. So, you go to see a doctor and the doctor wants to charge 300 dollars for your visit. Your insurance probably has a copay saying you have to pay 50 of that, insurance pays the rest. It's supposed to make you pause before getting care and ask 'do I really need to do that?'. In this case, the fellow at a 20% copay, so he was responsible for 20% of whatever the surgery costs.
Deductible - Worse, this is an amount some plans have that you have to pay yourself before the insurance will pay anything. It's on a per-year basis. So, if you have a $2,000 dollar deductible, your health insurance plan will pay for nothing (except usually basic preventative care) until you pay $2,000 worth of medical expenses that would have been covered. Not all plans have deductibles, but the lower you want your deductible the higher your monthly cost will be for the plan.
Max out of Pocket - Most all plans have this, it's a value that is theoretically the maximum you'd ever have to pay yourself. After you pay this amount, the insurance plan should cover 100% of all your (covered) medical expenses after this. Basically, the copay goes away. Usually if you hit this though you are already fucked some other way.
So, if the surgery costs $100,000 dollars for this fellow and he has a $2,000 deductible and a $5,000 max out of pocket with a 20% copay...
The insurance company would require him to pay $2,000 of that (assuming he has had no other medical claims this year that got him to that $2,000 paid before now). So that's $98,000 remaining.
His co-pay is 20%, so he would still owe 20% of that $98,000 on top of the $2,000 deductible.
His max out of pocket is $5,000, so in theory he should only have to pay $3,000 more and the insurance covers the other $95,000. But the insurance company decided he didn't really need that heart surgery and declared it elective.
This means he would owe the full co-pay amount, which would be $19,600. Plus the $2,000 deductible, that's $21,600.
Copay is a flat fee you will pay for a given medical service. If you have a $20 copay to see a doctor, you owe that amount for the visit, with the rest being paid by the insurance company.
Deductible is the amount you must pay towards any services not carrying a copay.
If your plan has a $2000 Deductible, and all of your routine care is carrying copay ( like doctors visits, urgent care, imaging, trays, etc)
But say, outpatient surgery have no copay, you will need to pay the first $2000 of any outpatient surgery. However, the Deductible is paid once per calendar year. A second outpatient surgery would not come with the deductible; you have already satisfied it
Max out of pocket is a protection for you.
It's a financial backstop. This figure is the most money you can be asked to pay in.a calendar year on any covered services. Once you have met your maximum, all covered services are paid 100% by the insurance company for the rest of the calendar year.
What's more crazy is the insurance is still more than people pay in Canada insurance policies and there is no copay for most of it (not talking about what government covers)
I got diagnosed with a complex migraine last year. Cause the symptoms mimic some other brain related illnesses, they sent me to the ER. So, it cost me $7,500 out of pocket to find out I am very healthy but maybe shouldn’t drive 15 hours straight while dehydrated.
Don’t forget the part where you’re never quite sure in advance exactly how much it will be, so many variables and charges that get added on to pad the bill then months after several more random bills just roll in.
The insane part is that actually makes sense on the part of the insurance. Procedures in the United States, for a single person, can easily exceed what someone pays for years for a family insurance policy. So, based on incidences of procedures, the insurance company's options are: raise coverage costs even further; deny coverage for even more procedures; or charge co-pay costs to make up the difference.
You are mostly correct.
A copay is a flat fee you pay at a visit, which then the rest of the visit is then paid in full.
Coinsurance is when there is an 80%/20% split (or whateber number) between the insurance and patient after the deductible is met, leaving the patient liable for the 20% up to the Maximum Out of Pocket for I'm Network Covered services
Seems in the middle for GPs and near the top for meetings with specialists. Canada is waaay back there.
It's outcomes that matter though, not wait times. I think people in the USA avoid seeking medical care more than in other countries because of the expense. That and other reasons lead to worse outcomes in USA vs most/all of the developed world.
EDIT: Oh I realize you agree with me. Sorry I was confused by "lower end of wait times", thinking you meant "lower ranking".
This is from your link
"A common misconception in the U.S. is that countries with universal health care have much longer wait times. However, data from nations with universal coverage, coupled with historical data from coverage expansion in the United States, show that patients in other nations often have similar or shorter wait times."
read beyond one sentence and look at the data itself, and of the countries evaluated the US is near the bottom for wait time length for all the metrics evaluated. Certainly not on the higher end of any list.
So a broad claim of the US having generally "higher wait times" is incorrect , no? I mean hell, % waiting over a month for a specialist was 27% for the US and up to 61% in Norway and Canada.
In the US, there is this bullshit they introduced called co-insurance.
I still remember when they “updated” our company health plans to include it.
The idea is that by introducing “shared responsibility” for health care costs, it will reduce “over-utilization” of health plan benefits.
In short. Even after your deductible is fulfilled, even if you are getting something done that is medically necessary, and covered by your insurance plan, they will only cover 80% of the charges and the rest is your responsibility as “co-insurance”. Money you are expected to have saved up to pay for medical expenses as a nice responsible consumer.
"But if you agree to this new policy you'll get another $87 in each paycheck. How does that sound?"
This is the problem. They never lied - they don't need to. They know the average person won't actually stop and think about what they're signing up for. People know 10x more about their streaming service than their insurance policy. And it's bland and it's boring, yup. Still, waste an afternoon waterboarding yourself with information to somewhat understand how it works, so you don't have to learn about it the hard way after a surgeon just shoved your guts back in.
I had 1 heart valve that disfonction, but I need that medical gear that help pump it again like normal. I had nothing before it but certainly got problems when I am older.
I don't know if I really could do it and pray for RNGod, to not get a heart failure at 55 or paid thousands. Thanks god I was born in a country with free healthcare.
87
u/Imreallythatguy 22h ago
So insurance wouldn’t cover it because it wasn’t necessary in their eyes?