How would you improve the ACA?

[hobbsyoyo]

You, as an individual, have so little bargaining power over the company that your answer might as well be the insurance company alone.

Who can then retroactively change the terms and conditions of your coverage when they don't feel like paying for your cancerous ass. Remember how fun pre-existing conditions used to be? When they could say you sprung your ankle when you were 5 and use that as a pre-text to drop you when you actually needed your insurance?

But hey, free markets know best. If you want healthcare you should just boostrap a medical school.

 

[GoodSarmatian]

Public option.
If the market can't it's just proof that it's better to let the government run health insurance.
If it can compete than there's no harm.
Except for lover profits for private insurance, but that's irrelevant in the great scheme of things.

 

[Tahuti]

While for some reason I sense that I have the reputation of being one of the most Pro-Market types around here, insurance definitely should be significantly more tightly regulated than industry. Unlike industry, economic barriers to entry are very high, so you can't just start your own insurance. Insurances can easily blow up. Insurances put a lot of undue faith in auctorarians and econometricians (the bane of any Austrian economist - I'm talking to you amadeus!) who then make dangerous decisions that do not seem to be justified. And of course, failure to pay up when you actually need it.

 

[MagisterCultuum]

I'd really rather just repeal the law and pass something very different.

We should aim at making healthcare cheaper, not so much at making more people get insurance.

I would remove the power of either the states or federal government to prevent individual customers from buying insurance that does not cover what the government considers minimum standards. The governments could still set standards of what is considered reasonable coverage and could require that insurers warn their customers when these standards are not met, but could not prevent actual insurance sales between companies and individual customers with full informed consent. State governments would obviously be unable to ban its residents from buying insurance from companies in other states, or even in other countries.

I would allow states to mandate a sort of medical liability insurance for employers who place their employees in situations likely to lead to medical issues. Those whose jobs require them to handle hazardous waste should get their employers to pay for the costs of medical problems caused by exposure to such waste. Most jobs don't really warrant such things though. In general, it is better for individuals to buy their own insurance than to rely on their current employer. As such, I would try to eliminate all governmental incentives for insurance to be provided by employers rather than purchased by individuals. I'd allow the minimum coverage mandates to be legally binding in cases where the employer chose the healthcare plan for the employee instead of simply agreeing to pay for a plan that the employee selected for himself.


I would radically reform the patent system. I would rather abolish it completely than leave it as is, but am open to some more moderate compromises. I'd consider taxing patent holders based on the royalties which are charged for licensing the information to other manufacturers. I'd consider making patents automatically expire once they have recouped some predetermined multiple of the cost of development. I'd consider forbidding patent holders from restricting who can make use of their patent, so long as an predetermined royalty is paid.

I would obviously repeal the laws banning the (re-)importation of prescriptions.

I would re-instate the laws that once banned direct to consumer advertisements of prescription drugs. It is a travesty that drug companies now spend more on those stupid TV ads than they do on research and development. I guess I could still permit them to make public service announcements to raise awareness of the diseases their drugs treat, but they would not be permitted to include the phrase "ask your doctor about [insert drug name here]" in any such advertisements. Advertisements in medical journals would still be permitted so long as sufficient data is provided about its effectiveness and potential side effects.

I would reform the way that pharmaceuticals are tested, so that its makers are not permitted to keep secret those studies that make the product look bad and publish only those which present it as effective. I would require all drugs be tested against placebos, not merely against other drugs which may have been approved due to such corrupt testing practices.

I would overturn all the laws that prohibit competition between medical facilities. Currently there is a bureaucratic nightmare that requires those wishing to open new hospitals to prove that the nearest competitor is not sufficient to handle the community's demand. We do not currently allow the market forces of competition to drive prices down.

I would mandate that medical facilities openly publish their pricing information. Currently it is not uncommon for two hospitals only a couple miles away from each other to offer the same services at prices that differ by hundreds of thousands of dollars. These include many non-emergency procedures with plenty of time for shopping around, but the customer is not able to know ahead of time where to go for the lower price.

I'd seriously consider forbidding medical facilities from charging the uninsured higher rates than they charge insurance companies.

I would implement tort reform that is not based on capping liability, but rather on the loser pays principle. I'd extend the system of public defenders so that it does not only work in criminal cases where the defendants are too poor to afford representation, but also includes litigators to sue on behalf of the poor who have suffered from medical malpractice from doctors or fraud from medical insurance companies.

I would require that the medical licensing boards review all cases where licensed medical professionals are sued for malpractice. Good doctors should not have their liability insurance rates driven up by the actions of bad doctors who should have given up the practice once their first major mistakes were caught.

I would eliminate agricultural subsidies that distort the market, making grain and meat so much cheaper than fresh produce.

I would eliminate all sales taxes, tariffs, income taxes, and payroll taxes. These would be replaced by Land Value Taxes, Mineral Royalties, and Pollution Charges. Pigouvian taxes on recreational drugs might also be included. We should not tax productive economic activity, but rather the monopolization or destruction of the commons. I would provide everyone a Citizen's Dividend, an unconditional basic income guarantee funded by those taxes.

Providing the poor with money is more important than providing them with health insurance. With a guaranteed income they could better afford insurance, better afford to pay expected health costs out of pocket, and better afford the kind of diet and lifestyle that would reduce the need for medical care in the first case.

 

[Azale]

Providing the poor with money is more important than providing them with health insurance. With a guaranteed income they could better afford insurance, better afford to pay expected health costs out of pocket, and better afford the kind of diet and lifestyle that would reduce the need for medical care in the first case.

I can mostly dig this. I didn't see this in your post, but how much would your preferred guaranteed income be?

 

[KmDubya]

I'd really rather just repeal the law and pass something very different.

We should aim at making healthcare cheaper, not so much at making more people get insurance.

I would remove the power of either the states or federal government to prevent individual customers from buying insurance that does not cover what the government considers minimum standards. The governments could still set standards of what is considered reasonable coverage and could require that insurers warn their customers when these standards are not met, but could not prevent actual insurance sales between companies and individual customers with full informed consent. State governments would obviously be unable to ban its residents from buying insurance from companies in other states, or even in other countries.

I would allow states to mandate a sort of medical liability insurance for employers who place their employees in situations likely to lead to medical issues. Those whose jobs require them to handle hazardous waste should get their employers to pay for the costs of medical problems caused by exposure to such waste. Most jobs don't really warrant such things though. In general, it is better for individuals to buy their own insurance than to rely on their current employer. As such, I would try to eliminate all governmental incentives for insurance to be provided by employers rather than purchased by individuals. I'd allow the minimum coverage mandates to be legally binding in cases where the employer chose the healthcare plan for the employee instead of simply agreeing to pay for a plan that the employee selected for himself.


I would radically reform the patent system. I would rather abolish it completely than leave it as is, but am open to some more moderate compromises. I'd consider taxing patent holders based on the royalties which are charged for licensing the information to other manufacturers. I'd consider making patents automatically expire once they have recouped some predetermined multiple of the cost of development. I'd consider forbidding patent holders from restricting who can make use of their patent, so long as an predetermined royalty is paid.

I would obviously repeal the laws banning the (re-)importation of prescriptions.

I would re-instate the laws that once banned direct to consumer advertisements of prescription drugs. It is a travesty that drug companies now spend more on those stupid TV ads than they do on research and development. I guess I could still permit them to make public service announcements to raise awareness of the diseases their drugs treat, but they would not be permitted to include the phrase "ask your doctor about [insert drug name here]" in any such advertisements. Advertisements in medical journals would still be permitted so long as sufficient data is provided about its effectiveness and potential side effects.

I would reform the way that pharmaceuticals are tested, so that its makers are not permitted to keep secret those studies that make the product look bad and publish only those which present it as effective. I would require all drugs be tested against placebos, not merely against other drugs which may have been approved due to such corrupt testing practices.

I would overturn all the laws that prohibit competition between medical facilities. Currently there is a bureaucratic nightmare that requires those wishing to open new hospitals to prove that the nearest competitor is not sufficient to handle the community's demand. We do not currently allow the market forces of competition to drive prices down.

I would mandate that medical facilities openly publish their pricing information. Currently it is not uncommon for two hospitals only a couple miles away from each other to offer the same services at prices that differ by hundreds of thousands of dollars. These include many non-emergency procedures with plenty of time for shopping around, but the customer is not able to know ahead of time where to go for the lower price.

I'd seriously consider forbidding medical facilities from charging the uninsured higher rates than they charge insurance companies.

I would implement tort reform that is not based on capping liability, but rather on the loser pays principle. I'd extend the system of public defenders so that it does not only work in criminal cases where the defendants are too poor to afford representation, but also includes litigators to sue on behalf of the poor who have suffered from medical malpractice from doctors or fraud from medical insurance companies.

I would require that the medical licensing boards review all cases where licensed medical professionals are sued for malpractice. Good doctors should not have their liability insurance rates driven up by the actions of bad doctors who should have given up the practice once their first major mistakes were caught.

I would eliminate agricultural subsidies that distort the market, making grain and meat so much cheaper than fresh produce.

I would eliminate all sales taxes, tariffs, income taxes, and payroll taxes. These would be replaced by Land Value Taxes, Mineral Royalties, and Pollution Charges. Pigouvian taxes on recreational drugs might also be included. We should not tax productive economic activity, but rather the monopolization or destruction of the commons. I would provide everyone a Citizen's Dividend, an unconditional basic income guarantee funded by those taxes.

Providing the poor with money is more important than providing them with health insurance. With a guaranteed income they could better afford insurance, better afford to pay expected health costs out of pocket, and better afford the kind of diet and lifestyle that would reduce the need for medical care in the first case.

I could agree with most of this. The free money for the poor I'd have issue with as I think people should work but the rest sounds like a well thought out common sense approach to reducing the cost of healthcare.

 

[MagisterCultuum]

Most of the sources I've read say that it is a fairly conservative estimate to say that the citizen's dividend in most places should be something close to $1000 per capita per month. (Incidentally, that is very close to the average per capita cost of housing plus medical insurance.)

It could be higher or lower though, and in the richest countries would tend to be significantly higher. With a Basic Income Guarantee you could set a fixed benefit, but the level would probably have to be frequently adjusted by the legislature else indexed to inflation. A Basic Income without a Land Value Tax would tend to cause high rates of inflation, particularly when it comes to land rent and thus also the cost of housing. The amount paid in a Citizen's Dividend could vary greatly depending on circumstances. It is not as predictable, but would tend to adjust automatically to the changing costs of living. (That is particularly the case if it and the LVT that funds it are administered at local levels rather than nationally.) Having more people go to a region for the dividend instead of work would certainly drive the dividend down, while economic development would drive it up. The shift in tax structure would spur economic development. The LVT has zero deadweight loss, so shifting from less efficient taxes greatly boosts the economy. Tax increases of this type actually tend to stimulate the economy rather than slowing growth, as the LVT discourages idle speculation and encourages more efficient use of scarce resources. The LVT drive rents down relative to wages, making it highly progressive as well as efficient.


A citizen's dividend would ideally be an equal share of all surplus government revenue (which would be gathered entirely from taxes on natural resources, not on anyone's wages or profits) after the bare minimum costs of administering most essential government services are paid. It could replace almost all forms of government spending, and would actually provide the poor an incentive to support a smaller government: the voters would all see that any special benefits given to a specific group are costing themselves. Voters who support wasteful spending would directly suffer from it. Some sorts of spending, mostly on basic infrastructure in areas where it is most useful, could however boost land values enough that it brings in more revenue from the land value taxes and so actually increase the dividends. Voters would have an incentive to examine the estimated return on investment before approving spending. It is very unlikely that we would continue to run deficits under a Geo-Libertarian system, but given the size of the current debt and the shocks to the system causes by rapid changes, we might have to start with something closer to a basic income guarantee before gradually transitioning to the sort of system I would really prefer.


A key part of a citizen's dividend or basic income is that it is not means tested. It is not just for the poor, but for everyone who wishes to claim it. Means testing itself requires the sort of bureaucracy that tends to waste a lot of money, so much that in many cases it is actually cheaper just to give out money indiscriminately. More importantly though, means testing is the main cause of perverse incentives. If you know that you will get welfare so long as you earn less than a given amount, then you are far less likely to accept jobs that pay just slightly more than that threshold. If your basic income is given regardless of how much you earn on your own, there is more incentive to work to try to better yourself. Basic income guarantees provide the sort of safety net that makes it easier to take the risks needed in order to succeed. Trials in Namibia have shown they cause greatly decrease unemployment and increase hours worked, largely by helping the poor to start their own businesses. Trials in Manitoba did show very slight degrease in hours worked, but it was only statistically significant among two demographics: teenagers who no longer had to help support their families and so started studying more and doing better in school, and working mothers who ended up spending more time caring for their young children rather than leaving them home alone or sending them to low quality day care centers. Those can both be considered wise investments towards the next generation.

I do tend to think that the data on who collects their dividends should be public. That would make it easier for the public to help make sure that an individual was not claiming funds under multiple names in multiple places. It would also open the possibility of social shaming of those who take funds they don't need. Billionaires might be just as entitled to collect citizen's dividends as are paupers, but actually doing so would be bad publicity.


Although it has implications for healthcare, this is not strictly on topic. Perhaps we should get back to the subject of the OP.

 

[Cutlass]

I could agree with most of this. The free money for the poor I'd have issue with as I think people should work but the rest sounds like a well thought out common sense approach to reducing the cost of healthcare.

Many of the poor cannot work. Others of the poor there simply are no jobs for. So making them work is actually not an option.

 

[Kaitzilla]

So, how would you improve the Affordable Care Act, also known as Obamacare?

I suppose half are going to say "UHC BABY" and the other half "DITCH IT", but I'd like to focus on potential fixes for the law that are legislatively possible.


A couple of things about the law irk the crap out of me:

1)Subsidies come back to you after you file your taxes. This is just stupid to be blunt. If you have low-enough income to qualify for subsidies, why should you have to pay everything upfront only to get it back at the end of the year? I understand that the plans are already subsidized so, for example, I would only pay $300/mo for a plan that would have cost $800/mo before the ACA and then get a chunk of that money I pay back so that it winds up costing around $250/mo all told. However, it just doesn't make sense to me to have people pay the full price up-front. I can see no good reason for this at all other than maybe it's easier for the tax authorities to handle the subsidies/penalties this way. It's definitely a hardship for a lot of folks and is inconvenient and confusing.

2)Costs need to come down across the board; coverage should go up or both. I know that with the subsidies, insurance for individuals is now actually somewhat affordable. As with my earlier example, I really would have to pay $800/mo for coverage before the ACA. Now the government takes on the role that employers have traditionally played by paying for the bulk of the coverage and having individuals pay a smaller portion of it. However, the rates are still too high to be popular in my opinion.

Yes, what is popular isn't necessarily good public policy. But in this case, people like me are having to decide if the almost-unreasonable rates are worth it or if they'll just eat the penalty. When it is the case that a lot of young, healthy people like myself are faced with this choice, it's really going to hurt the effectiveness of the law and drive up costs when we opt-out en masse. I am really struggling justifying paying for coverage that is a big chunk of our income for less-than-stellar coverage.

I don't go to the doctor and don't usually have need to. The one thing the coverage would be great for someone like me is if I got hit by a bus or something. However, the crappy coverage means a massive deductible that is big enough that if I were hit by a bus I would still go bankrupt which defeats the purpose of the law.

I understand that it's very difficult to have good coverage with low deductibles that are cheap. It's really not possible to be cost-effective that way. But on the other hand, if something isn't done to either make the law cheaper or increase coverage/lower deductibles, a lot of people are going to be skipping on healthcare coverage. At the end of the day it will be cheaper to just eat the penalty than it is to pay for the coverage that I don't really need and won't really help me when I need it most such as getting hit by a bus.

In any case, while I think cost-effectiveness/cost-controls are great, the primary purpose of this law should be to provide affordable coverage to anyone who needs it. On that point it's failing I think.

I'd mention the website as well but that issue speaks for itself.

What say you all?

--Oh crap, one other thing:

They need to make the damn law easier to understand. I'm an informed consumer and I go out of my way to figure out stuff with regards to implementation of the ACA and even I am confused a lot.

Ah, I've found some good news now that more details are coming out!

It turns out that you can get the subsidy upfront towards your monthly premium payment
I was wrong earlier thinking it was at year-end only evidently.

Just if you make more than 400% or less than 100% of poverty level for some reason in 2014, you have to pay all or some of the subsidy money back at the end of the year.
https://ttlc.intuit.com/health-care...macare-now-or-later-when-2014-taxes-are-filed

Hi muddler: First of all, you probably already know that only insurance plans purchased through the ACA Marketplace (or state exchanges, like the one in your state) are eligible for Advanced Premium Tax Credit. You also probably already know that your eligibility is determined by your estimated household income for 2014.

Options for how/when you apply your APTC (if eligible) is dependent on your choice. You can choose to have the entire subsidy sent directly to the insurance company each month, or to have only a portion of it sent each month, or to have none at all sent each month. In the last scenario, you would be paying the entire premium yourself and essentially "settling up" with the government when you file your tax return for 2014. And yes, you do need to update your estimated income during the year if you see that your income will be significantly different than what you estimated.

But you DO have to go ahead and apply through the Marketplace (I know it's not working well) now in order to have your policy in place on when you need it. So unfortunately, you have to go through the arduous process of estimating your household income and applying (probably by telephone right now) in order to qualify for the subsidy.

And more reliable info here:
http://www.ctmirror.org/story/2013/11/08/teetering-obamacare-subsidy-cliff

For people close to the limit for getting a subsidy, there are other issues to consider too, particularly if they have variable income.

Eligibility for subsidies will be based on a person’s projected 2014 income, and verified using 2012 tax returns.

The subsidies will ultimately be reconciled when people file their 2014 taxes. People who received more in financial assistance than their income ultimately justified will have to pay back some or all of the difference, and people who earned less than expected and qualify for more assistance will get a tax credit.

The repayment amount is capped for people earning below 400 percent of the poverty level. But those who get a subsidy but ultimately don’t qualify for one because of their actual 2014 income will have to repay the full amount.

Calkins, the insurance agent, said he’s been warning clients close to the subsidy line with variable income to be conservative in how they handle potential subsidies. People can elect to take all or a portion of the tax credit up front -- it would be paid to the insurance company -- or pay the full premium themselves and get the tax credit when they file their 2014 taxes. Calkins said he advises clients on the edge of qualifying to be careful about how much they take up-front.

“Those people on the line are saying, ‘I can’t afford [the premiums] now,’” Calkins said. “But I’m saying to them, ‘Can you afford to have to pay this all back?’”

So if you are making decent money the last 2 years, and are pretty sure you won't get fired in 2014 (better stop smoking mary jane ), getting the subsidy upfront looks like quite a good deal.

 

[Labtec600]

ACA just passes off the cost. It's not addressing the cost.

People can't afford to pay for Medical bills. Solution? Force insurance.

Insurance companies are not going to be able to take on the burden of increased expenses. Solution? Come up with the Reinsurance fee on all employers that offer health insurance.

Employers (who already provide health insurance to their employees - one of the good guys I thought....) now face increased costs. Solution? Increase price on products, increase employee contribution to employer plans, layoffs, extra costs for having a dependent or spouse on the plan....

Only thing to do is sit back and watch what happens.

 

[Angst]

Individual States have unique coverage requirements and mandates. All states do not let all companies in. Companies that are in a state already lobby politicians to pass regulations and laws to keep competition out. It is cheaper to pay off a politician then to offer a better product.

More regulation = less competition + more cost

Tort reform is needed for any meaningful attempt to reduce costs in the US. Winning millions for burning oneself with coffee while driving should never happen in a sane and just world.

It is the younger people who should be more upset with this. Higher costs, employers rewarded for using workers 29 hours per week. Combine this with the larger student loans, higher housing costs, high unemployment rate and the outstanding 17 trillion in debt and your generation is going to be economic slaves.

There are people who work for a living and people who vote for a living. When there are not enough people pulling the sled (workers) the whole system will crash.

Why are you Americans going through so many loops in order to cope with lobbyism when lobbyism is, according to your argument, your most fundamental problem when shaping up this policy?

 

[KmDubya]

Why are you Americans going through so many loops in order to cope with lobbyism when lobbyism is, according to your argument, your most fundamental problem when shaping up this policy?

There is too much money involved in lobbying. It permeates through all levels of government and both parties.

As Alexis de Tocqueville said “The American Republic will endure until the day Congress discovers that it can bribe the public with the public's money.”
― Alexis de Tocqueville

 

[ZeletDude]

I'd like to see the employer mandate and the individual mandate dropped out of Obama Care. The employer mandate is only going to cause employers to reduce part timer's hours to be under the threshold for compliance. Killing off part time hours. As for the individual mandate, I don't want to pay a penalty tax just because I don't have health insurance. Worst of all, the penalty goes up each tax year.

If you want to keep the legislation as is that's impossible. The fact that we are making it so insurance companies don't bias people with pre existing conditions is the reason we need the mandate because we don't want people getting insurance the second they get sick, that only causes a strain to the system, and further problems

 

[hobbsyoyo]

Ah, I've found some good news now that more details are coming out!

It turns out that you can get the subsidy upfront towards your monthly premium payment
I was wrong earlier thinking it was at year-end only evidently.

Just if you make more than 400% or less than 100% of poverty level for some reason in 2014, you have to pay all or some of the subsidy money back at the end of the year.
https://ttlc.intuit.com/health-care...macare-now-or-later-when-2014-taxes-are-filed



And more reliable info here:
http://www.ctmirror.org/story/2013/11/08/teetering-obamacare-subsidy-cliff



So if you are making decent money the last 2 years, and are pretty sure you won't get fired in 2014 (better stop smoking mary jane ), getting the subsidy upfront looks like quite a good deal.

Thanks for the info Kaitzilla.

Now I'm super confused because this is not how I understood the system worked. I thought you would have a subsidized cost upfront and then also got a rebate at the end of the year. What I mean is that the sticker price for everyone on the private market is waaaay below the market rate. Using an earlier example, before the ACA, the cost per month for insurance for me is $800 - whereas under the ACA, it's closer to $300. That's also roughly the price anyone would pay at any income level, that's the upfront subsidy.

Then there is also the tax rebate subsidy. So if you are poor, at the end of the year, you get a chunk of money back that effectively brings the monthly cost down (in my case, down to around $250/mo).


If I read you correctly, we have options on how we receive the tax rebate subsidy which is definitely good because only getting it at the end of the year is pretty dumb.



All of this goes to my last point in the OP - The law needs to be easier to understand!

 

[Cutlass]

There is too much money involved in lobbying. It permeates through all levels of government and both parties.

As Alexis de Tocqueville said “The American Republic will endure until the day Congress discovers that it can bribe the public with the public's money.”
― Alexis de Tocqueville

The public being bribed with the public's money is not a problem the US is experiencing. The government being bribed with private money is.

 

[classical_hero]

I fail to see why can't you a public health system and a private health system at the same time. We have this here and it works fine.

 

[hobbsyoyo]

We do, it's called Medicare/Medicaid but it isn't open for everyone.

 

[Cutlass]

I fail to see why can't you a public health system and a private health system at the same time. We have this here and it works fine.

The difference is that in the rest of the developed world, the public health system is dominant enough to discipline the private system. That is, there is a limit to how bad the private system can get, before they either run up against regulations, or people simply won't pay for the private, and stick to the public.

In the US that is not an option. Medicare/Medicaid pay for a sizable part of the healthcare in the US, but exercise very little control over the provision of the healthcare services themselves. Essentially, the doctor says 'patient needs this, here's the bill' and M/M pays it. Efforts to control what M/M pays have generally not been effective. Efforts to limit what the doctor can charge for have generally not even been tried. Probably half to 2/3 of what Medicare pays for the elderly's medical treatments is testing, drugs, and treatments that do not extend life or improve quality of life, but do rack up the costs.

But the healthcare for those who are not elderly or poor is even worse, because now the government is hardly involved at all. That is private sector payer and private sector providers. And no one is offering an alternative which would control costs or let the patients opt out and still have healthcare.

 

[Labtec600]

In the US that is not an option. Medicare/Medicaid pay for a sizable part of the healthcare in the US, but exercise very little control over the provision of the healthcare services themselves. Essentially, the doctor says 'patient needs this, here's the bill' and M/M pays it. Efforts to control what M/M pays have generally not been effective. Efforts to limit what the doctor can charge for have generally not even been tried. Probably half to 2/3 of what Medicare pays for the elderly's medical treatments is testing, drugs, and treatments that do not extend life or improve quality of life, but do rack up the costs..

So there should be a system that controls how much will be paid? That's what private healthcare does.

 

[Bamspeedy]

So there should be a system that controls how much will be paid? That's what private healthcare does.

And we all know how well that works. Hospital charges $1000 for something, insurance thinks it should only be worth $500 and just pays the $500. The patient is then responsible for the other $500. But, I do wonder if government doing the job won't result in the same thing.

The patient can't go to a different hospital because the insurance says they will only pay for 'in network' hospitals.

It's often believed hospitals will charge MORE if you have insurance. An ultrasound cost us $1050 at a hospital with insurance. We could have gone here:

http://www.storkvision.com/ultrasound/Eau-Claire-wi-ultrasound-pricing.html

And it would cost us about $100. But not covered by insurance so won't apply towards our deductible.