Okay, so the American system is an employer based model, meaning that your health plan, if you have one, is determined by your employer. This means a few key things:

• Your plan may (and probably does) vary wildly in nearly every regard from someone else’s despite both of you being with the same insurer.

• You are not the customer, but the user. Your boss is the customer. As such, the insurance company doesn’t really care if they piss you off, because you can’t just fire them and go with some other plan. They only care about not pissing off your boss. Well, you can technically, but individual insurance is so expensive and bad (and there’s only a few big players in the market anyway) that it’s an obviously better choice to just get jerked around by your employer’s plan.

• The entire healthcare payment process is so arcane, unintuitive, and complex that no lay person outside the system can be really expected to navigate it if someone says “whoops, we’re not paying because the florp code was misapplied during Venus Wednesdays, and though you flipped your florp last month, some businesspeople made a deal just last week to agree that florps will only be covered by approved Todds (the closest is a convenient 600 miles from you). This judgment is final, may God have mercy on your soul.” As an example, I’ve had insurance pre-approve something and then turn around and deny it once it got billed, and because I didn’t think to get physical proof of pre-approval first, the insurance basically just ended it with “nuh uh, we never said that, do you have a receipt?” Lesson learned. And a lot of times, the people inside of it don’t have the full picture. There are people whose entire profession is either arguing with insurance companies all day to force them to pay what’s due, or helping patients navigate the system. It makes it really, really easy to rip off both patients and health providers.

• Government insurance like Medicare also sucks. Their reimbursement rates are terrible, among other factors, and it’s caused more and more providers (those who can choose, anyway) to stop seeing these patients, meaning that you start ending up with a few Medicaid clinics whose soonest appointment is months from now and spend about 20 seconds per patient. This is largely a result of our conservatives trying to prove that government doesn’t work by making the government not work. Just so we’re clear, private insurance holders also have long wait times and doctors that are pressed for time, it just tends to be a little less bad.

• Since insurers have figured out that there’s money to be gouged in medication, they’ve gotten into the mail order pharmacy and pharmacy Benefit manager (if you want to get a tummy ache, read up on PBMs, they’re the biggest bastards in a field full of absolute bastards) game. Since then, they’ve managed to kill off most small business pharmacies and turn just getting your medication into the same bureaucratic, clown energy pain in the ass as trying to arrange an MRI. (YMMV by insurer, plan, medication, etc)

On top of all that, about a decade or two back, private equity figured out that healthcare in the US is practically a license to print money, so they’ve come in, taken all kinds of stuff over, made everything worse for everyone involved but the businesspeople, all while jacking up prices and cutting services. Yaaaaaaaaay

Dr. Glaucomflecken on YouTube provides a pretty good (and funny / simultaneously infuriating) insight into the mess of healthcare in the US from a providers perspective.