“Insured” Doesn’t Mean “Covered” – Health Insurance in Maine.

“Insured” Doesn’t Mean “Covered” … And Definitely Doesn’t Mean “Cared For”

~Dr. Lou Jacobs

Why so many Americans feel like they bought a health plan but got an unusable coupon book instead.

Most Americans shop for health insurance the way they shop for a winter coat:
“Does it look decent? Is it “technically”functional? Will it keep me alive in February?”

Unfortunately, the health-insurance version of this coat often shows up thin, overpriced, and full of strategic holes that the wind – your medical bills – blow right through.

Let’s clarify something that I believe the industry doesn’t care that  you ever understand:

1. Being Insured ≠ Having Coverage

You can absolutely be insured and still effectively uninsured.

If your deductible is the size of a used 2014 Mini Cooper, around $8,000…
If your copay makes you sweat before you even step into an office…
If you are absolutely compelled to ask about prices before you make an appointment…
If your policy excludes everything short of emergency limb reattachment…

Congratulations! You’re “insured.”
Just not covered.

Insurance companies excel at this trick: they sell protection while designing contracts that make it remarkably difficult for that protection to ever activate. My health insurance for four people costs $2800/month. Our individual deductibles are $8,000. When we reach $8,000 in bills, then we “only” have to pay 50% of the bill until we pay out $9,200, and then it’s finally covered.  This is the most common type of plan. Most of our patients have this type of plan.

This leads to the next sleight of hand:

2. Coverage ≠ Care

Let’s say you do meet your deductible, dodge the exclusions, and your claim survives the denial lottery. Even then, you may not receive the care you actually need – just the care that fits the insurer’s spreadsheet.

Coverage is implied on paper.
Access and care is what you need in real life.

Insurers know how to control the difference with surgical precision. As you may have heard when you call to check on your benefits, any information they tell you, even the benefit information they pull from their computer and give you over the phone or on the computer is “not a guarantee of coverage”.

How insurers avoid paying for your care

• High deductibles that delay their responsibility as long as possible. We all expect this and there are reasons why deductibles may be high. As Americans continue to grow less healthy at all ages, the insurance companies have to pay more for these people. It’s just the way it is, and we create this. Yes, CEO’s are still making tens of millions of dollars a year, but the sicker the population, the more it’s going to cost for coverage. Again…there are many reasons for this, but it’s making life hard.

• Prior authorizations that force you to prove you deserve care you’re already paying for. Health insurance claim that they are emptying the swamp and preventing wasteful spending. Prior authorizations delay care, are often denied, and they affect your ability to get the care you need.

• Strategic claim denials (“insufficient documentation,” “not medically necessary,” “processed incorrectly,” “submitted on a Tuesday”). This is happening more and more. Research has shown that many medical facilities accept the denial and don’t get paid, or charge the patient directly when legal (not “balance billing”).

• Tiny coverage windows so narrow that even medically conservative doctors nationwide raise an eyebrow.

These aren’t accidents. They’re business strategies.

3. Why Cash-Based Healthcare Isn’t a Rebellion – It’s a Relief

More Mainers are quietly discovering something the insurance companies don’t want printed:

Cash-based, affordable practices often cost far LESS than using insurance.

And they give you something the big carriers can’t:

• Less pressured time with the doctor

• Transparency

• Predictable pricing

• Zero denial letters

• No middleman deciding whether your spine, your leg, your shoulder, or your nervous system deserve attention.

People with insurance often choose to pay cash for chiropractic care, for example, because the insurer’s alternative is so restrictive it borders on comedic. Historically coverage has been good, but in recent years, this year in particular, with a population that is more sick than ever and people about to not be able to afford monthly premiums, the insurance companies have to make money somewhere. They’ll charge you more and pay for less.  Patients are tired of paying premiums only to be told:
“Actually… no.” But we’d better get used to it, or take our health into our own hands.

In a healthcare system where “insured” doesn’t guarantee “helped,” cash-based care isn’t a workaround.
It’s a way back to sanity, predictability, and getting ahead of problems. Remember, “Health insurance” is for sick people. They don’t generally cover health, they cover sick – if at all.

4. Bottom Line: Don’t Confuse the Paperwork With Care.

When Americans shop for insurance, they think they’re buying peace of mind. We all do it, and to some degree we are. Most of us have catastrophic insurance plans to protect against bankruptcy if we get seriously ill and bills are very high. Some argue that this forces people to take care of themselves better, which in some cases it does, but the U.S. is statistically becoming less healthy.

What most of us are often buying is a very expensive gamble. If we don’t use it, the plan resets each year and we continue to pay whether we use it or not. If the insurance company decides not to pay, you pay…Surprise!

Real care requires access, consistency, and a provider who listens and works with you—not your insurance code—as the priority. Great care means true prevention that is affordable and helps people stay healthy and “high functioning”.

If you’re choosing a plan this year, remember:

Insurance is a financial product.
Healthcare is a human service.
They are not the same thing – Ideally, they work together, but the current status of Coverage vs. Care in the United States resembles a clogged toilet more than anything, and it’s overflowing in all the wrong ways.

Truth in Advertising

And if your insurer is doing everything in its power to keep its dollars, Maine’s affordable cash-based practices are doing everything in their power to keep you moving, functioning, and performing at your best. Don’t be afraid of the out of pocket cost, just ask first. To give you an idea, “office visits” at our clinic – out of pocket (not including exams)- including decompression, soft tissue work and an adjustment will be only $70 in the new year (2026). Adjustment only maintenance care once a patient has reached maintenance status, only costs $40 in the new year (2026). There are offices with doctors who care more about people getting care than getting “rich”, but you have to get a feel for them when you walk through the front door and meet them, or check their google reviews.