I want to tell you a little story about how messed up healthcare is in the US.
I have medical and dental insurance. The medical insurance also covers basic dental, which makes it my “primary” dental insurance even though it doesn’t cover any dental treatment that isn’t basic preventive care. As a result, all dental claims—regardless of whether the medical insurance is actually going to pay them—need to be submitted to the medical insurance first. Then, any amount that isn’t paid by the medical insurance needs to be resubmitted to the dental insurance, with proof that it wasn’t paid by the medical insurance.
Furthermore, the medical insurance gives my wife “cash” “rewards” for doing healthy things, e.g., for getting an annual check-up or a colonoscopy. These are paid out on a debit card, and they can only be used for dental or vision-care expenses (which is why I put “cash” in quotes above).
My daughter is having her wisdom teeth removed today. I had to explain to the office staff about the primary and secondary insurance. They’ve encountered this before and were courteous and accommodating about it, though they did find it a bit weird and atypical that my primary dental insurance is my medical insurance.
But wait, there’s more. My medical insurance provider is a collaborative that doesn’t actually have its own provider network; instead, it contracts out the provider network and claims processing to other insurance companies. In 2023 the contractee was Aetna, but in 2024 they switched to United. So although the oral surgeon’s office needs to submit the claim for my daughter’s evaluation visit late last year to Aetna, they need to submit the claim for today’s surgery to United, even though the insurance company is ostensibly the same.
Once I straightened out the insurance with the office staff, I had to ask them to run a small charge on each of the “rewards” debit cards to use them up, more hassle for them, plus lost money from the fees on each of those charges. Again, they were courteous and accommodating about it, but this really shouldn’t be on them.
The rewards, the primary insurance, and the secondary insurance all together are only going to be pay for about 20% of the $5k surgery. The rest I have to pay for out-of-pocket. Well, not exactly out-of-pocket, because I have a Health Savings Account (HSA), so let’s talk about the additional complications that introduces.
I have a high-deductible health plan (HDHP), which essentially means that in exchange for a much lower monthly insurance premium, I have to pay a lot more out-of-pocket before the medical insurance starts to cover non-preventative things (it’s required to cover preventative treatment because of the Affordable Care Act which the GOP is trying to repeal; thanks Obama!). I’m essentially self-insuring for between $6k and $12k of healthcare costs (depends on whether it’s in-network or out-of-network) before the insurance will cover most remaining costs.
(Note: I switched to an HDHP so that I would be able to pay for therapy for the several members of my family who need it without needing to fight with insurance companies about the fact that all of their mental health provider networks are terrible, because they don’t pay market rates for therapy so the majority of therapists opt out of accepting insurance.)
Since I have an HDHP I’m also allowed to have an HSA which I can use to pay for medical, dental, and vision expenses. Some of the money in my HSA is comes from monthly deposits there by my insurance company, i.e., I get part of my premiums each month back in HSA money. That comes out to $2,400 per year. I can put in approximately $6k more from my own money. I can deduct that on my taxes, which effectively means that anything I get reimbursed for out of my HSA is pre-tax.
Theoretically, you’re supposed to be able to put more into your HSA than you need to spend in a year, and then you can invest it like you would in a 401k or IRA and then have money banked for healthcare expenses in later years. In practice, last year—my first with an HSA—I used up all the money I was allowed to deposit, and I expect to do the same this year.
I have a separate debit card that links directly to my HSA, so theoretically I should have been able to pay for the balance on the oral surgery directly from my HSA instead of putting it onto my personal credit card. Nope! The HSA debit card has a limit on it that is smaller than the oral surgery balance, so I couldn’t use it. That means I’ll have to submit a receipt from the payment to the HSA to get reimbursed for it after the fact. It’s a good thing that I’m financially secure enough to be able to outlay several thousand dollars like that!
(Speaking of which, when I told my son that dental insurance typically doesn’t cover most of the cost of a procedure like wisdom teeth removal, he reacted with astonishment: “Wisdom teeth removal is something many, many people need. It’s a standard procedure. Why doesn’t insurance cover it?” I replied, “Because even good dental insurance in the United States is terrible.”)
After my daughter’s surgery, I went to the pharmacy to pick up the two medications she needed. These are standard medications—an antiseptic oral rinse and an antibiotic—provided to every single person who has their wisdom teeth removed. In a country with civilized healthcare the oral surgeon would stock them and give them to the patient before discharge, but that’s not how things work in the US.
Our preferred pharmacy, less than a block from our house, was out of stock of the antibiotic. They couldn’t just transfer the prescription to another nearby pharmacy; I had to call the other pharmacy and have them initiate the transfer, then drive 20 minutes to pick it up. I was on hold with the other pharmacy for more than 10 minutes before somebody there finally picked up the phone, which isn’t surprising, because like most healthcare facilities nowadays, most pharmacies are overworked and understaffed right now.
I am a smart, financially secure person who has decades of experience navigating systems like this to maximize benefits and minimize out-of-pocket costs. Think about how this plays out for people who aren’t.
We’ve been conditioned to think all this is normal. It’s not. Here’s the alternative to all this that would happen in many other countries all over the world: I have no primary insurance. I have no secondary insurance. I have no insurance. I have no “rewards” cards. I have no HSA. My daughter and I walk into the oral surgeon’s office, and we walk out an hour or so later, without her wisdom teeth, with the medications she needs, and without her or me paying a cent. This is normal. What we’ve got is a healthcare dystopia.
