I think most of what you said is on the mark, but the core problem is still what the providers are charging. I wouldn't worry so much about in/out-of-network or claim denials, and might not even worry about having insurance coverage at all, if: a 90-minute ER visit (even for a false alarm) didn't cost $10k; or if one night in the hospital (just for observation and a couple blood tests) didn't cost $50k; or if anything actually serious didn't cost hundreds of thousands or millions of dollars.