OT insurance

The insurance companies have a list (varies from company to company) that i ndicates what they consider "reasonable and customary" pricing for all medi cal items. If you get your care from a participating provider they are obl igated to accept that as full payment. In fact, no small part of the benef its of insurance are just doing that negotiation for you even if they never pay a dime in your behalf.

What is a bigger problem for drugs is when they don't consider a new drug t o be a proven treatment yet. Then they pay nothing. But that happens with all insurance, if they don't think it is a valid treatment, they won't pay .

Rick C.

On a lot of things: the insurance company, the details of your policy's coverage and deductible and limits, how much you've already spent out-of-pocket that year, and on the medication.

Cheap policies might pay you back nothing - no prescription drug coverage at all (such policies may only pay for hospitalization or doctor's service and not for prescriptions).

A more complete policy (perhaps the commonest type): you might get nothing back for the first month or two, as such policies often have a deductible (you pay the first $xxx per year yourself, before coverage kicks in). After that, 80-90% coverage for prescriptions is common, with you "co-paying" the rest. There may be co-pay limit for the year, after which you get 100% coverage... but there may also be a total coverage limit (per year, or lifetime) after which point you get nothing back.

If the drug in question is a standard for treating your condition, good coverage is more likely... "off-label" or "experimental" drugs are less likely to be covered especially if expensive. The insurance company may rule them "not medically justified" for the condition, and refuse coverage. Getting coverage for experimental drugs (those not yet FDA-approved) is pretty much impossible, even if the results are good.

Some insurance companies have "standard formularies" - lists of drugs they consider appropriate (and thus covered) for certain conditions... these are often the less-expensive drugs. If you come down with one of those conditions, they may refuse to pay for non-formulary drugs entirely... or require that you first try the formulary drugs first, and have them fail to help, before they'll pay for more expensive alternatives.

If you have to ask you can't afford it...

I feel like it should be possible to derive or intuit some rule of thumb or heuristic e.g. find the most expensive drug you believe you're 50% likely to need in a given time frame, pay 50% of that and if you get sick the copays will only consume 50% of the average American income. Only thing left to do is figure out the exact values...

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The simpler rule of thumb is that if you get sick with something expensive in the USA you should emigrate rapidly to some country that has proper univ ersal health care. Australia doesn't - it isn't as bad as the US, particula rly when you get seriously sick, but you can get stuck with the gap between what the health insurance will pay for and what the doctors charge.

In the UK and the Netherlands you pay your health insurance, and that's it.

It's already happened to me once, lost just about everything and the only saving grace was that I was still fairly young and able to work hard and pull myself back out again. lookie me! the model of a self-made man. pulling myself up by my bootstraps and all that. I expect my certificate of appreciation from the GOP will arrive any day now. LOL

Insurance is for expenses you don't expect to incur, but might if you are unlucky. A major part of insurance is that you are paying for peace of mind.

If you expect to have to incur an expense then insurance must be more expensive, since you have to pay insurance company overheads.

It appears that US medical insurance is both much more expensive (by a factor of 2-3), and it doesn't give peace of mind.

A cynic would call it large-scale salami slicing.

Or you could say the health insurance industry is a mechanism for converting racism into money.

ck and

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e in the USA you should emigrate rapidly to some country that has proper un iversal health care. Australia doesn't - it isn't as bad as the US, particu larly when you get seriously sick, but you can get stuck with the gap betwe en what the health insurance will pay for and what the doctors charge.

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And what do the people do who can't afford the premium?

Rick C.

It's a tax rather than a premium, and if you don't pay tax either because you can't afford to or you can afford not to, you still get the benefit, like most state provision.

Cheers

In the Netherlands there is a system where people below a certain before-tax income get a benefit to allow them to pay for their health insurance. (effectively a reduction on the tax they are paying)

Health insurance is mandatory. When you don't get an insurance by yourself, you get one assigned by the authorities. When you don't pay the premium, you get in serious trouble including seizure of whatever income and/or posessions you have to pay the premium.

The authorities/government live in the bubble where "not paying premium" (or tax, or a fine) only exists because of unwillingness to pay, so in cases like this there are hefty increases, in effect fines, when people are not paying. This can result in a downward spiral of debt that can only be solved by personal bankrupcy.

It isn't an insurance premium, the money comes out of general taxation; hypothecation is not practiced since it is regarded as the thin end of a very big wedge.

Hence the poor pay nothing, other than via "consumption" taxes such as VAT and fuel duty.

Some people also have their own private insurance, which entitles them to more obsequious medical staff and better decor/food. Plus the option of treatment in a hospital that is poorly equipped for medical emergencies (when problems arise the patients are usually shunted off to the nearest NHS hospital!)

It might appear as such to a blind man.

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The blindness is all krw's.

The medical expenditure per head in the UK is about $4200, and in the US ab out $9900. The UK has universal health care, and the US has roughly 10% uni nsured (15% before Obamacare kicked in) so the medical expenditure per head in the US is actually mostly spent on only 90% of the population, which pu shes it up to closer to $11,000 per head of those actually cared for.

It is absurdly expensive, particularly when you keep in mind that the US is n't a particularly healthy place, as advanced industrial countries go.

Is the tax proportional to your income or other indicator of your ability to pay? If not, how can you not pay the tax? Here people go to jail for not paying taxes. It's the only debtor's prison we have.

Rick C.

Over here there are tax bands, so you pay a percentage of income above a fixed allowance depending on which band you fall into. Those who earn below that allowance pay no income tax.

And of course if you're very wealthy you can afford accountants and avoid/evade a lot of tax.

For most employees the tax is deducted (PAYE - pay as you earn) before you get paid.

Cheers

Where is "over here"?

Rick C.

UK