> You can easily add tens of thousands of out of network costs with some medical issues

It doesn't matter, because that's still capped.

I know people who have run up medical bills in the hundreds of thousands due to a long term illness despite having insurance. I don't know how this could happen, but it did.

> I know people who have run up medical bills in the hundreds of thousands due to a long term illness despite having insurance. I don't know how this could happen, but it did.

The bills themselves aren't capped. The amount they are obligated to pay is. Insurers make up some of the difference, and the rest is forgotten about. (It's not written down in the accounting sense, because the hospital doesn't necessarily actually treat the entire billed amount as receivable.)

I explained in a top-level comment how this works and why it works this way.

I hear what you are saying but I know people who have 6 figure medical debt despite being insured. This happens.

Indeed it doesn't take much imagination: chronic illness + prescriptions + high deductibles. Worse if multiple family members are sick (so many problems are inheritable and so on).

Also worth mentioning, it's been broken for a while (e.g.: ACA is not even broken in yet).