In health care typically your employer is the customer. The doctor and/or hospital also are customers. The insurance company is itself a customer.

Unlike - say - car repair you don't get a good estimate up front so it's hard to shop. Many times there aren't many good alternatives anyway. If you don't like a choice one of the actual customers made it doesn't matter because you have no real purchasing power anywhere in the system.

Its value is not to reimburse you for routine visits or minor procedures, it's to prevent you from going bankrupt if you get cancer or any similarly expensive condition to treat.

A useful way to look at it is the cost to treat each condition multiplied by your odds of getting that condition. That's also why pre-ACA, insurers would discriminate against patients with pre-existing conditions: the cost to them was nearly guaranteed to happen as the odds were close to 1.

If you were to start a health insurance company and only have a small pool of customers, you'd essentially be gambling as the variance is too unpredictable. (In reality, you'd be re-insured but that's a different story.) That is why a large pool of patients makes the most sense, and ideally, if the { pool of patients } = { country population } then you can rely on Public Health stats for risk modeling. And if you're not beholden to shareholders demanding a profit/dividends, there are some efficiencies that can be gained.

Notice the parenthetical where I said it's not only insurance.

Clearly the value of most health insurance plans isn't only to cover catastrophic illnesses. Look at the difference in cost between catastrophic illness plans or a very high deductible plan and the cost of a more traditional plan.

A huge chunk of your premium and therefore a huge chunk of the value is to pay for routine and less than catastrophic medical costs.

I would say that for any reasonable definition of "good", whether in skill or virtue, private insurers have shown they are definitely not good actors in our health system. Our health system might just be better off without them.

As for your question, I for one would like _doctors_ to double-check doctors' orders. Not an actuary.

To be fair, with private insurers, it's usually BOTH a doctor and an actuary reviewing care. Which isn't to imply I like insurance - I'd much prefer an NHS-style system where my taxes fund the majority of care and I can buy a private policy if I want a "Cadillac" plan.

To the surprise of no one the promised efficiencies never materialized.

...because the coverage of Medicare Part A + Part B is the legal minimum for Medicare Advantage, so they are necessarily on average greater coverage.

Like all Americans, they're free to buy private health insurance.

As a society, we trust the government to employ lawyers as circuit judges, appellate judges, and supreme court judges. It would be little difference for it to employ double-check nurses to review diagnoses and treatment plans against published standards and procedures, triple-check physicians to review contested or flagged cases, and quadruple-check physicians to ensure that the patients involved in difficult cases are receiving the best available standard of care, and to establish or modify standards for future cases that may be similar.

A lot of people don't even have enough money to visit a first doctor. And aside from that, families may have enough money to send one member to one doctor, and everyone else with perceived-to-be-lesser medical problems then has to forego treatment altogether. The diabetic gets improved insulin, while the asthmatic has to make do with too-frequent use of rescue inhalers, because the maintenance inhalers are too expensive, and the beesting-allergic person panics every time something flies nearby, because then there's no money left over for epinephrine autoinjectors.

The system does not currently consider whole-family finances as a medical consideration. It attempts to maximize profit on a per-patient basis, ignoring that at some point, that strategy may force a parent to choose which one of their children gets to survive. That's something that not only influences votes, but also creates activists.

The voters might not want the government to do it, specifically, but they are clearly not satisfied with the status quo.

Insurance companies, on the other hand, will break their own agreements left and right. One major health insurance company in the US has an internal policy of blanket denials of claims. Meaning, if you have them as an insurance provider, it's about as effective as having no insurance. Unfortunately I can't name names.

But perhaps some fellow HNers have anecdotes of an insurance company how's denied every claim they've made.

last i checked, insurance companies do not do this to any extent that is beneficial to the patient. in fact, my experience with this is that the insurance companies get in the way of the doctor doing their job and the patient getting the care they need close to 100% of the time. they only check to make sure the doctor isn't trying to use medical resources which are "too" expensive or similar.

i would be fine with getting the government to do it -- provided that the insurance companies were forced out of business in the process. at this point, i don't see a future where american life expectancy improves with insurance companies still existing in any form.

medical licensing boards perhaps?

Which voters? Do you have any numbers to back up the 'clearly' statement?