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High-Deductible Health Policies Linked to Delayed Diagnosis and Treatment

158 points by Deinos 7y ago

PaulHoule 7y ago
These are going to be recognized as a policy disaster. There are many cases where a somewhat expensive treatment saves a very expensive hospitalization. For instance, a steroid inhaler for asthma costs about $200 a month, maybe you have two $200 specialist visits a year. So for $2800 a year (not covered by high-deductible insurance) you can probably be symptom free or you can take your chances and have an exacerbation and a $28,000 hospitalization (which insurance will pay some of after the deductible) Docs hate them too. With real insurance, you have maybe a $20 copay you pay at time of service and they know they are going to get paid by the insurance. With fake insurance, they don't know what you are going to pay until months later when the insurance gets around to telling them. Then you get a bill that says you owe $291.44 for some unspecified service you got 6 to 18 months ago. (They can't tell you what it was because that would violate your privacy) Needless to say they have a big accounts receivable this way, many people don't pay or they pay late (e.g. a few months after getting a bill they don't understand as well as something that says "THIS IS NOT A BILL" they don't understand). This is not good for their finances or their state of mind. In theory high-deductible plans might lead you to shop around between providers to get a better price but in practice nobody can or will tell you what things costs and it doesn't work. It's a perfect example of the neoliberal mind at work.
- sixQuarks 7y ago
  Policy disaster? On the contrary, insurance companies love this. They have a counterintuitive conflict of interest - that is, they make more money when health costs are more expensive, through higher premiums.
  - smt88 7y ago
    > they make more money when health costs are more expensive, through higher premiums Do you have a citation for this? If this were true, why would they aggressively negotiate lower costs and offer discount Rx cards? In the US, higher premiums mean fewer subscribers. I'm a co-founder of an auto-insurance company, and all we ever try to do is lower premiums in order to compete.
    - ceejayoz 7y ago
      https://www.healthcare.gov/health-care-law-protections/rate-review/ https://www.healthcare.gov/health-care-law-protections/rate-... > The 80/20 Rule generally requires insurance companies to spend at least 80% of the money they take in from premiums on health care costs and quality improvement activities. The other 20% can go to administrative, overhead, and marketing costs. Basically, if you want to make more profits, you have to increase the raw size of that 20%. There's really only one way to do that - raise premiums. You can't really lower costs, as you risk having to pay back your subscribers for having shrunk the costs side too much.
      - lotsofpulp 7y ago
        Assuming you have competing insurance companies, then you can’t just raise premiums if your costs are unnecessarily high. Unfortunately, a properly functioning insurance market would require dumping everyone on the market, not just those who aren’t lucky enough to have it from their employer, who tend to be in better health anyway.
        learc83 7y ago
        >Assuming you have competing insurance companies, then you can’t just raise premiums if your costs are unnecessarily high. That's true if it's just your costs that are unnecessarily high. But you can encourage policies and regulation that raise the total cost of healthcare for everyone.
        lotsofpulp 7y ago
        The main factors keeping cost high is low supply of doctors, hospitals, and medicines. I’m not aware of any insurance industry effort to keep those supplies down. If anything, seeing a doctor who charges $200 for a 5 minute visit to prescribe antibiotics for a fever or a hospital that charges $7.5k for a no complications birth is what keeps prices high. If people had doctors and hospitals competing to offer standard procedures like births, broken bones, fevers, etc at lower costs, then that’s what will bring prices down.
- Amezarak 7y ago
  I hate my HDHP but as far as I can tell it’s ultimately driven by the massive increases in medical care costs. My total premium cost (counting employer contribution) is a little more than 20k and I have a 7k deductible. How much higher would the premium be with a more reasonable deductible? You pay one way or another. I agree it’s a huge nightmare dealing with the bills and claims processes, but I’m not sure that goes away with high deductible plans. At the end of the day we have to get medical costs under control and I don’t think there are any great ideas for that right now. Public single payer will help, and it could at least end the billing nightmare, but I don’t see it actually solving the underlying problem of skyrocketing health care costs because the problem is too big and people are too politically invested in the way things are now. The insurance company is coming out ahead on me, even when I had a kid I still paid them more money than they paid out, but a coworker’s wife had a heart attack and had some extraordinary care that the insurance was ultimately paid more than a million dollars for. These major health events and chronic illnesses are completely through the roof in terms of costs.
  - PaulHoule 7y ago
    If HDCP and other plans exist on an open market, then the difference of the cost between them tends to be the amount of the deductible. This is what I have seen on the Obamacare exchange and also in prices for employer provided plans. The reason for that is adverse selection. If you don't expect to go to the hospital then you can save money with the HDHP. Only very sick people will choose the more reasonable deductible.
    - Amezarak 7y ago
      In my experience at three different employers the lower deductible plans are more expensive by more than the difference in the deductible. That is, in my experience, it has always been more rational to choose the higher deductible plans because even if I assumed I would always meet the deductible the cost of the deductible plus the premium was always less on the HDHP.
      - uberduber 7y ago
- apazzolini 7y ago
  While not applicable for everyone (such as your asthma inhaler example), HDHPs aren't bad for people who don't have regular health expenditures. I like my HDHP for two main reasons: - Regular annual checkups are still free - You get access to an HSA account, which is effectively the most tax-advantaged retirement account available. You can deposit income pre-tax, invest the balance (minus a few hundred), and withdraw tax-free as well for either health expenses (at any time) or for any purpose (after 65).
  - dkarl 7y ago
    I love my HSA as well, but perhaps there is another viable way to offer them besides linking them with HDHPs.
  - NotSammyHagar 7y ago
    Why I was 25 I hardly ever got sick. Now I'm double that age, and I'm in good shape but eventually something will happen. When I was 25, I could have had a hdhp then, but I was a super poor grad student and got whatever my university offered, a regular plan. Eventually I got a real job, there was no hdhp offered and I had regular insurance. The thing was, by being part of a larger pool, I was helping make insurance reasonable for everyone. That's as it should be. I do think ubiquitous health insurance that everyone has will save money in the end, and it's a humane necessity.
  - PaulHoule 7y ago
    You are right that the HSA is a nice complement for the HDHP. If your employer has an HDHP and puts a good chunk in your HSA for you that could be a better option than a conventional plan.
- LarryDarrell 7y ago
  My premiums and deductible are north of 10k. This is why I laugh when some one tries to scare me with the old "with Medicare for all, your taxes will go up!" I'd gladly and enthusiastically pay more in taxes to rid myself of the current system. I used to think employers would love to have to be able to stop offering insurance. But then I realized for the most part, employers love the current situation. Offering health insurance keeps employees chained to their desks. They'll moan every now and then about costs going up, but the current system ultimately serves them well.
  - 1123581321 7y ago
    What if someone suggests your taxes would rise by 10k? Are you concerned because that much money is an expenditure you can’t afford, or is it just behavioral and you’d rather prepay in the expense in your taxes than choose to spend it?
    - mgkimsal 7y ago
      If you get access to the same level of health care even during periods of unemployment - meaning, you might be paying no taxes at all - I wouldn't mind a bit.
      - moonka 7y ago
        Plus your family and friends who may not be as well off as you ALSO get health care. That's valuable.
      - conanbatt 7y ago
        For that service you need to pay more than the 10k, as you need the wones working paying for the ones that don't. You cant make a pizza larger by cutting it in different ways.
        QuotedForTruth 7y ago
        Healthcare is not pizza. The top level comment gave a perfect example why. Preventative care is cheaper than emergency care. When everyone (including the unemployed) can get preventative care, total costs go down. That unemployed person with no insurance still gets emergency care. The hospital doesn't turn them away to die in the street. They don't pay the bill. They go into bankruptcy instead. The hospital makes it up on all the paying customers (the insured). Your $10k is already paying for the ones who don't have insurance. Medicine is already socialized! Now, if we can acknowledge that, can we do the fiscally responsible thing and make sure everyone can get preventative medicine?
asdf333 7y ago
i hope this is a transitional cost. i am on the fairly liberal end of things but was hoping high deductible plans would force prices lower by getting consumers involved while still protecting against catastrophic events. and we are starting to see pressure on drug companies and medical care (epic pen issue for example) as consumers push for reform now that they are feeling it in their pocketbooks more directly.
- DubiousPusher 7y ago
  > but was hoping high deductible plans would force prices lower by getting consumers involved Part of the problem here is a lack of price transparency. That's what's stopping consumer choice driving any price reduction. It's very difficult to shop medical expenses. In the end it seems like the main choice they give you is really either to do it now or delay.
  - LarryDarrell 7y ago
    Not to mention the narrowing of In-Network providers. I can't shop around if my Network has already been reduced to the smallest size possible.
- lotsofpulp 7y ago
  It will push prices lower, but only after pay for doctors and drug makers and all the other well compensated medical professionals come down.
- snidane 7y ago
  It is more an issue of supply. The inflow of new doctors and new healthcare business is constrained by the incumbent system. Besides the cartel network that has established, the new potential disruptors are prevented to enter the market all in name of regulation and safety measures. Now it is a positive feedback loop when the current players are incentivized to lobby for a new safety regulations to prevent new market entrants rather than improving the service.
- mattkrause 7y ago
  > Getting consumers involved I have never understood how this is supposed to work. I can imagine shopping around for things that are a) have perfect substitutes and b) aren’t urgent. For example, maybe you’d pay a bit more for an MRI of your painful knee if it were at a convenient time or in a nicer facility, vs. 5am in a cold bore with no movie or other frills. Perhaps you opt for a cheaper generic or a twice-a-day pill instead of the more expensive extended-release version. Everything else comes with some fairly tricky cost-benefit analysis. How badly do I need to be screened for this or that? If something is missed now, how much worse will it be later—-and how much will it cost then? I’m skeptical that a half hour on WebMD will do much to improve on a trained doctor’s recommendation.
viburnum 7y ago
That’s the point, people are supposed to not get treatment. If you wanted people to get the treatment they need, then it would be free.
deleted 7y ago
[deleted]
olefoo 7y ago
The health care system in this country is a crime. It is structured to take advantage of people at their weakest and most helpless. We spend 3 times as much per capita as most other industrialized nations and get worse outcomes overall.
- xenospn 7y ago
  That is correct. I am originally from Israel and moved to California 7 years ago. I'm very healthy but on the rarest of occasions, when I do need to get SOMETHING done, it has proven to be an absolute nightmare, and I always walk away feeling like I've been scammed.
  - komali2 7y ago
    The one time you aren't being scammed is when you get something done and actually get to bill the insurance company. Paying monthly installments on your insurance plan, only to have to pay for your healthcare costs anyway (first the deductible, then this new maximum out of pocket they added to me this year), that's the scam.
    - beenBoutIT 7y ago
      In reality, if you're spending ANY money on healthcare in the US you're getting scammed. The healthcare you'll find in Israel and Europe is the modern standard of care and the US is on the opposite side of the spectrum with our corrupt for-profit "healthcare" industry. We pay more for generic crap (generic only has to be 80% as effective as brand) than modern countries pay for 'Made in USA' brand names.
      - m0zg 7y ago
        One thing people miss is, we're paying our doctors _several times_ as much. If that doesn't change (and nobody wants the doctors to earn as much as they do in Europe: there just won't be any doctors), there's really no way to achieve the same cost structure without replacing doctors with something like machine learning in a lot of capacities (radiology/imaging most immediately, other diagnostics in the longer term).
cosmosa 7y ago
no shit
CptFribble 7y ago
I think most people around here know that our healthcare payment structure is totally whack. However, we're not the people who need to know this. Try showing an NPR article about universal healthcare to Joe USA. I guarantee you'll get one or all of the following responses: 1: I don't want my taxes to go up 2: I don't want to pay for illegals to go to the doctor for free 3: My insurance will get worse 4: I like my doctor, I don't want to be forced to go to a worse one 5: I don't want the government deciding when I go to the doctor 6: I don't want to wait six months for a doctor appointment 7: NPR has a liberal agenda Many of my family and extended social circles are quite conservative (in the USA sense) because of how I was brought up. I have heard all of these and more every time the concept of universal healthcare is brought up. Most of the reasoning I hear is not based on facts, but on emotionally misleading arguments from the network of memes and punditry where they get their info. And when they vote, they vote for people who oppose universal healthcare on these fallacious bases. How do you convince someone like this that universal healthcare is better for all of us?
- dlo 7y ago
  > How do you convince someone like this that universal healthcare is better for all of us? Here is one approach. 1) Enumerate the different options. 2) For each option, enumerate the upsides versus the downsides, which includes cost of implementation and operations, along with their likelihoods. Every option has potential downsides -- are we willing to accept them for the potential upsides? 3) Rank the options by expected utility. Which one comes out on top? Ironically, you may find that universal healthcare is not the top-ranking option or that we have not yet come up with a high-expected-utility option.
  - arcticbull 7y ago
    The WHO and OECD did exactly that and disagree. [1] https://en.wikipedia.org/wiki/World_Health_Organization_ranking_of_health_systems_in_2000 https://en.wikipedia.org/wiki/World_Health_Organization_rank... [2] https://www.oecd.org/unitedstates/Health-at-a-Glance-2017-Key-Findings-UNITED-STATES.pdf https://www.oecd.org/unitedstates/Health-at-a-Glance-2017-Ke...
sologoub 7y ago
This is starting to feel like the mortgage crisis again - specialty tools that are not in themselves bad, are being misused to bolster affordability and in the process create very bad financial situation. The HDHP + HSA are great for those that can afford them AND are in good health overall. Good employers also add to your HSA each year to help with the initial costs. The HSA is a lot better than the FSA, which creates bad incentives on use it or lose it money. The problem becomes when HDHP is used without a well funded HSA and with insufficient income to handle the deductible, together with health problems.
- sokoloff 7y ago
  We took a HDHP just in order to qualify for the HSA. It probably doesn't save us money on the health-care side, but the HSA as stealth additional retirement account more than makes up for us. https://www.madfientist.com/ultimate-retirement-account/ https://www.madfientist.com/ultimate-retirement-account/
  - assblaster 7y ago
    I do as well. The best part of the HSA is that you can save your receipts and reimburse for those expenses 30 years later instead of right away so that you can pay with gains rather than principal.
- war1025 7y ago
  You phrase that as if the people choosing HDHP without a funded HSA could actually afford a traditional low deductible plan. My current insurance is something like $35k / year premiums for a 3k/6k family plan (which is actually a 6k/12k plan since 3k is when they start covering anything, and it isn't until 6k / 12k that they actually start picking up the whole bill) There is no way I could afford a "low deductible" plan.
  - sologoub 7y ago
    That’s not what I’m saying at all. I’m saying as a society/country/large group of people, we are choosing to pretend to offer affordable healthcare options, but in reality using specialty products designed for relatively wealthy and healthy people as a mainstream option. For financial/healthcare situation described, we need a true affordable option, not an exotic instrument. As a society we did the same thing with exotic mortgages and pretended they were affordable.
wsdfsayy 7y ago
This shouldn't be surprising. If you're on an employer-based healthcare plan, a HDHP only makes sense if you're young, healthy, have no dependents, don't take expensive medication, and your employer pays most of the annual cap into your linked HSA. I fit most of those checkboxes, but I take PrEP (preventative HIV med) that is something like $1500/month before deductible, and the math for HDHP vs traditional plan does not check out in that case at all.
- lotsofpulp 7y ago
  If the difference between the premiums for a non HDHP and the HDHP deductible is not too big, I can very well see it being worth it to go HDHP just to take advantage of the triple tax advantage of HSA. Pay for medical care/medicine with after tax, save the receipts, and let the HSA contribution with pre tax money grow tax free in a Fidelity HSA (since it’s free) and then withdraw it whenever you want, and just pay yourself whenever you need the money.
- uberduber 7y ago
  There's a whole thing with the $0 copay coupons on many expensive drugs like this, it usually just depends on which insurance you have. In many cases the drug companies have actually set up charities which will donate your entire max out of pocket on an HDHP regardless of income.
psim1 7y ago
I have found that by paying the same amount as the premium of the PPO into my HSA that I come out even, if I end up spending the whole deductible, or ahead (i.e. building savings), if I don't. In other words, I don't see any disadvantage to HDHP+HSA vs. PPO plan.
uberduber 7y ago
I got an individual HDHP as soon as I turned 18 in 2004. Shopping around on these plans is not easy, I'm really the only one to do it. I thought it would get easier as more people got HDHPs, it got a little bit better over the years and then drastically went downhill after the ACA. Two main reasons: reduced competition, and our bizarro culture where no one blinks at an $800 surprise bill. I used to have a couple imaging facilities that I went to because their rates were low. In the past few years they have all been bought up by some sort of conglomerate and prices have gone up. It’s not advertised, so I literally have to call the place, talk to the back office and find out if they’ve been bought. So last year I go to the one place that hasn’t been bought, rates were good, I go this year and the bill was a surprise. Even my blood test rates have gone up this year, I’ve asked several doctors and they’re like “Yeah, it’s pretty much Quest or Labcorp now.” So my rule now is, if the back office has no clue what they're doing, they will likely be cheap, and they will likely either get bought up or go out of business. Many years ago when I’d go to the doctor I think I was literally the only one with an HDHP, and the allowable amount would come out to $200, and they’d go “Oh, that’s not right. How about $60?” And just take $60 from me and call it a day. Now when I ask “Will this test cost me more than $200?” No one has an answer or seems to care like we are in some crazy bureaucracy.
- winter_blue 7y ago
  I was on high-deductible plan a couple of years ago, and went in for an allergy test. After the test, I got a bill for $750 ish. Insane. This was in November as well, so two months later the deductible would reset in 2 months. In the same year I had a whole array of expensive dental work done, and I almost exhausted my HSA. I swore off high-deductible plans ever since then. Even though I'd selected a HDHP at the beginning of open enrollment (in Nov) that year, I was able to call HR in December and switch me to a normal PPO plan (which just had copays).
jhawk28 7y ago
People don't like HDHP, but they are the only type of insurance that puts downward pressure on prices. the only alternative is to regulate.
- maxxxxx 7y ago
  In what way are they putting downward price pressure? every tried to get prices for a treatment so you can pick a cheaper provider? It's close to impossible to get any numbers.
tomohawk 7y ago
When selecting from health insurance options, I only ever consider HSA plans, which typically have large deductables. Why? The US has the best health CARE in the world, but with a crappy health insurance system. The health insurance has been regulated to a hot mess by cronies and politicians that is slowly destroying the care system. An HSA gives you more control of your care. Rationing care is not the answer to solve the insurance problems. I'm not interested in waiting for long periods of time for rationed care, such as what is seen in Canada. https://www.fraserinstitute.org/studies/waiting-your-turn-wait-times-for-health-care-in-canada-2017 https://www.fraserinstitute.org/studies/waiting-your-turn-wa... For all its faults, at least I can get an MRI within a day or two, and can see a specialist within a day or two. That's way better than waiting on rationed care.
- deleted 7y ago
  [deleted]
snr 7y ago
A little off track rant but the tax and health policies of USA are super freaking unbelievable. Why on Earth can one not be eligible for a HSA when they don't have a HDHP? The healthcare is screwed up. The least you could let people do is use their pre tax monies for the health treatments. And don't even get me started on FSA and forfeiture. That's MY money. What the hell do you mean the amount is forfitted? Apologies for my language. The policies are making me go crazy.
40acres 7y ago
I'm exhibit A. I signed up for an HDHP because I didn't want to pay a monthly premium and thought and HSA sounded like a great way to save for health expenses. I had a bout of rhabdomyolysis after pushing myself while at the gym, after doing some research and learning that it probably wasn't life threatening I decided to wait it out and self treat instead of going to the ER.
javagram 7y ago
I’ve had a HSA+HDHP for years. I’ve always contributed the annual maximum into the HSA so there was never a question for me of running out of money to pay for care, and it hasn’t held me back from seeking medical care or treatment. However, it’s perfectly possible for someone to elect the HDHP and not contribute to their HSA, in which case you could be facing a $3000 or higher bill without the money to pay for it. It seems like this is the case described in the article. With a fully funded HSA I almost feel like I have the opposite problem, which is I don’t feel a need to attempt to shop around and compare prices. In general it feels like the HSA/HDCP experiment has failed although I’ll keep using it for as long as it’s offered, as I like the ability to build up my savings every year in the HSA and eventually use it as a second retirement account unless I have a huge medical problem in the future.
- conanbatt 7y ago
  HDHP are growing a lot, so its succeeded. PPO plans are garbage. Way too expensive and has terrible utilization incentives.
bryan11 7y ago
Switching from a co-pay based insurance to an HDHP + HSA was a big change. My deductible is quite high, so all normal, non-catastrophic medical costs are paid for without insurance. A doctor visit starts at $139 and may be from $300 to $500 depending on the diagnosis. One cannot determine the cost in advance. Any lab work is extra. Is it worth $1000 every year to have a doctor do standard blood tests? Like anything that suddenly becomes very expensive, it makes one look at things differently and question whether they are necessary. Some people put off doctor visits longer until things seem unbearable. Some research online and try to self medicate with over the counter things.
nicodjimenez 7y ago
Obamacare is unfortunately a band aid solution and does nothing to address the fundamental issues: 1) complete lack of price transparency, which means virtually no price competition between clinics / doctors 2) artificially low supply of doctors to jack up prices 3) corrupt regulation to prevent consumer health startups from existing Fixing these issues is going to take a lot more than just taxing people for not buying high deductible health insurance. There's no fundamental reason why most doctors should get paid more than airplane mechanics for example. Either way if they mess up, people die.
ykevinator 7y ago
The gullible have become emboldened so despite the headline, they confidently believe there is no problem.

158 points by Deinos 7y ago

These are going to be recognized as a policy disaster. There are many cases where a somewhat expensive treatment saves a very expensive hospitalization. For instance, a steroid inhaler for asthma costs about $200 a month, maybe you have two $200 specialist visits a year. So for $2800 a year (not covered by high-deductible insurance) you can probably be symptom free or you can take your chances and have an exacerbation and a $28,000 hospitalization (which insurance will pay some of after the deductible) Docs hate them too. With real insurance, you have maybe a $20 copay you pay at time of service and they know they are going to get paid by the insurance. With fake insurance, they don't know what you are going to pay until months later when the insurance gets around to telling them. Then you get a bill that says you owe $291.44 for some unspecified service you got 6 to 18 months ago. (They can't tell you what it was because that would violate your privacy) Needless to say they have a big accounts receivable this way, many people don't pay or they pay late (e.g. a few months after getting a bill they don't understand as well as something that says "THIS IS NOT A BILL" they don't understand). This is not good for their finances or their state of mind. In theory high-deductible plans might lead you to shop around between providers to get a better price but in practice nobody can or will tell you what things costs and it doesn't work. It's a perfect example of the neoliberal mind at work.

sixQuarks 7y ago
Policy disaster? On the contrary, insurance companies love this. They have a counterintuitive conflict of interest - that is, they make more money when health costs are more expensive, through higher premiums.
- smt88 7y ago
  > they make more money when health costs are more expensive, through higher premiums Do you have a citation for this? If this were true, why would they aggressively negotiate lower costs and offer discount Rx cards? In the US, higher premiums mean fewer subscribers. I'm a co-founder of an auto-insurance company, and all we ever try to do is lower premiums in order to compete.
  - ceejayoz 7y ago
    https://www.healthcare.gov/health-care-law-protections/rate-review/ https://www.healthcare.gov/health-care-law-protections/rate-... > The 80/20 Rule generally requires insurance companies to spend at least 80% of the money they take in from premiums on health care costs and quality improvement activities. The other 20% can go to administrative, overhead, and marketing costs. Basically, if you want to make more profits, you have to increase the raw size of that 20%. There's really only one way to do that - raise premiums. You can't really lower costs, as you risk having to pay back your subscribers for having shrunk the costs side too much.
    - lotsofpulp 7y ago
      Assuming you have competing insurance companies, then you can’t just raise premiums if your costs are unnecessarily high. Unfortunately, a properly functioning insurance market would require dumping everyone on the market, not just those who aren’t lucky enough to have it from their employer, who tend to be in better health anyway.
      - learc83 7y ago
        >Assuming you have competing insurance companies, then you can’t just raise premiums if your costs are unnecessarily high. That's true if it's just your costs that are unnecessarily high. But you can encourage policies and regulation that raise the total cost of healthcare for everyone.
        lotsofpulp 7y ago
        The main factors keeping cost high is low supply of doctors, hospitals, and medicines. I’m not aware of any insurance industry effort to keep those supplies down. If anything, seeing a doctor who charges $200 for a 5 minute visit to prescribe antibiotics for a fever or a hospital that charges $7.5k for a no complications birth is what keeps prices high. If people had doctors and hospitals competing to offer standard procedures like births, broken bones, fevers, etc at lower costs, then that’s what will bring prices down.
Amezarak 7y ago
I hate my HDHP but as far as I can tell it’s ultimately driven by the massive increases in medical care costs. My total premium cost (counting employer contribution) is a little more than 20k and I have a 7k deductible. How much higher would the premium be with a more reasonable deductible? You pay one way or another. I agree it’s a huge nightmare dealing with the bills and claims processes, but I’m not sure that goes away with high deductible plans. At the end of the day we have to get medical costs under control and I don’t think there are any great ideas for that right now. Public single payer will help, and it could at least end the billing nightmare, but I don’t see it actually solving the underlying problem of skyrocketing health care costs because the problem is too big and people are too politically invested in the way things are now. The insurance company is coming out ahead on me, even when I had a kid I still paid them more money than they paid out, but a coworker’s wife had a heart attack and had some extraordinary care that the insurance was ultimately paid more than a million dollars for. These major health events and chronic illnesses are completely through the roof in terms of costs.
- PaulHoule 7y ago
  If HDCP and other plans exist on an open market, then the difference of the cost between them tends to be the amount of the deductible. This is what I have seen on the Obamacare exchange and also in prices for employer provided plans. The reason for that is adverse selection. If you don't expect to go to the hospital then you can save money with the HDHP. Only very sick people will choose the more reasonable deductible.
  - Amezarak 7y ago
    In my experience at three different employers the lower deductible plans are more expensive by more than the difference in the deductible. That is, in my experience, it has always been more rational to choose the higher deductible plans because even if I assumed I would always meet the deductible the cost of the deductible plus the premium was always less on the HDHP.
    - uberduber 7y ago
apazzolini 7y ago
While not applicable for everyone (such as your asthma inhaler example), HDHPs aren't bad for people who don't have regular health expenditures. I like my HDHP for two main reasons: - Regular annual checkups are still free - You get access to an HSA account, which is effectively the most tax-advantaged retirement account available. You can deposit income pre-tax, invest the balance (minus a few hundred), and withdraw tax-free as well for either health expenses (at any time) or for any purpose (after 65).
- dkarl 7y ago
  I love my HSA as well, but perhaps there is another viable way to offer them besides linking them with HDHPs.
- NotSammyHagar 7y ago
  Why I was 25 I hardly ever got sick. Now I'm double that age, and I'm in good shape but eventually something will happen. When I was 25, I could have had a hdhp then, but I was a super poor grad student and got whatever my university offered, a regular plan. Eventually I got a real job, there was no hdhp offered and I had regular insurance. The thing was, by being part of a larger pool, I was helping make insurance reasonable for everyone. That's as it should be. I do think ubiquitous health insurance that everyone has will save money in the end, and it's a humane necessity.
- PaulHoule 7y ago
  You are right that the HSA is a nice complement for the HDHP. If your employer has an HDHP and puts a good chunk in your HSA for you that could be a better option than a conventional plan.
LarryDarrell 7y ago
My premiums and deductible are north of 10k. This is why I laugh when some one tries to scare me with the old "with Medicare for all, your taxes will go up!" I'd gladly and enthusiastically pay more in taxes to rid myself of the current system. I used to think employers would love to have to be able to stop offering insurance. But then I realized for the most part, employers love the current situation. Offering health insurance keeps employees chained to their desks. They'll moan every now and then about costs going up, but the current system ultimately serves them well.
- 1123581321 7y ago
  What if someone suggests your taxes would rise by 10k? Are you concerned because that much money is an expenditure you can’t afford, or is it just behavioral and you’d rather prepay in the expense in your taxes than choose to spend it?
  - mgkimsal 7y ago
    If you get access to the same level of health care even during periods of unemployment - meaning, you might be paying no taxes at all - I wouldn't mind a bit.
    - moonka 7y ago
      Plus your family and friends who may not be as well off as you ALSO get health care. That's valuable.
    - conanbatt 7y ago
      For that service you need to pay more than the 10k, as you need the wones working paying for the ones that don't. You cant make a pizza larger by cutting it in different ways.
      - QuotedForTruth 7y ago
        Healthcare is not pizza. The top level comment gave a perfect example why. Preventative care is cheaper than emergency care. When everyone (including the unemployed) can get preventative care, total costs go down. That unemployed person with no insurance still gets emergency care. The hospital doesn't turn them away to die in the street. They don't pay the bill. They go into bankruptcy instead. The hospital makes it up on all the paying customers (the insured). Your $10k is already paying for the ones who don't have insurance. Medicine is already socialized! Now, if we can acknowledge that, can we do the fiscally responsible thing and make sure everyone can get preventative medicine?

asdf333 7y ago

i hope this is a transitional cost. i am on the fairly liberal end of things but was hoping high deductible plans would force prices lower by getting consumers involved while still protecting against catastrophic events. and we are starting to see pressure on drug companies and medical care (epic pen issue for example) as consumers push for reform now that they are feeling it in their pocketbooks more directly.

DubiousPusher 7y ago
> but was hoping high deductible plans would force prices lower by getting consumers involved Part of the problem here is a lack of price transparency. That's what's stopping consumer choice driving any price reduction. It's very difficult to shop medical expenses. In the end it seems like the main choice they give you is really either to do it now or delay.
- LarryDarrell 7y ago
  Not to mention the narrowing of In-Network providers. I can't shop around if my Network has already been reduced to the smallest size possible.
lotsofpulp 7y ago
It will push prices lower, but only after pay for doctors and drug makers and all the other well compensated medical professionals come down.
snidane 7y ago
It is more an issue of supply. The inflow of new doctors and new healthcare business is constrained by the incumbent system. Besides the cartel network that has established, the new potential disruptors are prevented to enter the market all in name of regulation and safety measures. Now it is a positive feedback loop when the current players are incentivized to lobby for a new safety regulations to prevent new market entrants rather than improving the service.
mattkrause 7y ago
> Getting consumers involved I have never understood how this is supposed to work. I can imagine shopping around for things that are a) have perfect substitutes and b) aren’t urgent. For example, maybe you’d pay a bit more for an MRI of your painful knee if it were at a convenient time or in a nicer facility, vs. 5am in a cold bore with no movie or other frills. Perhaps you opt for a cheaper generic or a twice-a-day pill instead of the more expensive extended-release version. Everything else comes with some fairly tricky cost-benefit analysis. How badly do I need to be screened for this or that? If something is missed now, how much worse will it be later—-and how much will it cost then? I’m skeptical that a half hour on WebMD will do much to improve on a trained doctor’s recommendation.

viburnum 7y ago

That’s the point, people are supposed to not get treatment. If you wanted people to get the treatment they need, then it would be free.

deleted 7y ago

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olefoo 7y ago

The health care system in this country is a crime. It is structured to take advantage of people at their weakest and most helpless. We spend 3 times as much per capita as most other industrialized nations and get worse outcomes overall.

xenospn 7y ago
That is correct. I am originally from Israel and moved to California 7 years ago. I'm very healthy but on the rarest of occasions, when I do need to get SOMETHING done, it has proven to be an absolute nightmare, and I always walk away feeling like I've been scammed.
- komali2 7y ago
  The one time you aren't being scammed is when you get something done and actually get to bill the insurance company. Paying monthly installments on your insurance plan, only to have to pay for your healthcare costs anyway (first the deductible, then this new maximum out of pocket they added to me this year), that's the scam.
  - beenBoutIT 7y ago
    In reality, if you're spending ANY money on healthcare in the US you're getting scammed. The healthcare you'll find in Israel and Europe is the modern standard of care and the US is on the opposite side of the spectrum with our corrupt for-profit "healthcare" industry. We pay more for generic crap (generic only has to be 80% as effective as brand) than modern countries pay for 'Made in USA' brand names.
    - m0zg 7y ago
      One thing people miss is, we're paying our doctors _several times_ as much. If that doesn't change (and nobody wants the doctors to earn as much as they do in Europe: there just won't be any doctors), there's really no way to achieve the same cost structure without replacing doctors with something like machine learning in a lot of capacities (radiology/imaging most immediately, other diagnostics in the longer term).

cosmosa 7y ago

no shit

CptFribble 7y ago

I think most people around here know that our healthcare payment structure is totally whack. However, we're not the people who need to know this. Try showing an NPR article about universal healthcare to Joe USA. I guarantee you'll get one or all of the following responses: 1: I don't want my taxes to go up 2: I don't want to pay for illegals to go to the doctor for free 3: My insurance will get worse 4: I like my doctor, I don't want to be forced to go to a worse one 5: I don't want the government deciding when I go to the doctor 6: I don't want to wait six months for a doctor appointment 7: NPR has a liberal agenda Many of my family and extended social circles are quite conservative (in the USA sense) because of how I was brought up. I have heard all of these and more every time the concept of universal healthcare is brought up. Most of the reasoning I hear is not based on facts, but on emotionally misleading arguments from the network of memes and punditry where they get their info. And when they vote, they vote for people who oppose universal healthcare on these fallacious bases. How do you convince someone like this that universal healthcare is better for all of us?

dlo 7y ago
> How do you convince someone like this that universal healthcare is better for all of us? Here is one approach. 1) Enumerate the different options. 2) For each option, enumerate the upsides versus the downsides, which includes cost of implementation and operations, along with their likelihoods. Every option has potential downsides -- are we willing to accept them for the potential upsides? 3) Rank the options by expected utility. Which one comes out on top? Ironically, you may find that universal healthcare is not the top-ranking option or that we have not yet come up with a high-expected-utility option.
- arcticbull 7y ago
  The WHO and OECD did exactly that and disagree. [1] https://en.wikipedia.org/wiki/World_Health_Organization_ranking_of_health_systems_in_2000 https://en.wikipedia.org/wiki/World_Health_Organization_rank... [2] https://www.oecd.org/unitedstates/Health-at-a-Glance-2017-Key-Findings-UNITED-STATES.pdf https://www.oecd.org/unitedstates/Health-at-a-Glance-2017-Ke...

sologoub 7y ago

This is starting to feel like the mortgage crisis again - specialty tools that are not in themselves bad, are being misused to bolster affordability and in the process create very bad financial situation. The HDHP + HSA are great for those that can afford them AND are in good health overall. Good employers also add to your HSA each year to help with the initial costs. The HSA is a lot better than the FSA, which creates bad incentives on use it or lose it money. The problem becomes when HDHP is used without a well funded HSA and with insufficient income to handle the deductible, together with health problems.

sokoloff 7y ago
We took a HDHP just in order to qualify for the HSA. It probably doesn't save us money on the health-care side, but the HSA as stealth additional retirement account more than makes up for us. https://www.madfientist.com/ultimate-retirement-account/ https://www.madfientist.com/ultimate-retirement-account/
- assblaster 7y ago
  I do as well. The best part of the HSA is that you can save your receipts and reimburse for those expenses 30 years later instead of right away so that you can pay with gains rather than principal.
war1025 7y ago
You phrase that as if the people choosing HDHP without a funded HSA could actually afford a traditional low deductible plan. My current insurance is something like $35k / year premiums for a 3k/6k family plan (which is actually a 6k/12k plan since 3k is when they start covering anything, and it isn't until 6k / 12k that they actually start picking up the whole bill) There is no way I could afford a "low deductible" plan.
- sologoub 7y ago
  That’s not what I’m saying at all. I’m saying as a society/country/large group of people, we are choosing to pretend to offer affordable healthcare options, but in reality using specialty products designed for relatively wealthy and healthy people as a mainstream option. For financial/healthcare situation described, we need a true affordable option, not an exotic instrument. As a society we did the same thing with exotic mortgages and pretended they were affordable.

wsdfsayy 7y ago

This shouldn't be surprising. If you're on an employer-based healthcare plan, a HDHP only makes sense if you're young, healthy, have no dependents, don't take expensive medication, and your employer pays most of the annual cap into your linked HSA. I fit most of those checkboxes, but I take PrEP (preventative HIV med) that is something like $1500/month before deductible, and the math for HDHP vs traditional plan does not check out in that case at all.

lotsofpulp 7y ago
If the difference between the premiums for a non HDHP and the HDHP deductible is not too big, I can very well see it being worth it to go HDHP just to take advantage of the triple tax advantage of HSA. Pay for medical care/medicine with after tax, save the receipts, and let the HSA contribution with pre tax money grow tax free in a Fidelity HSA (since it’s free) and then withdraw it whenever you want, and just pay yourself whenever you need the money.
uberduber 7y ago
There's a whole thing with the $0 copay coupons on many expensive drugs like this, it usually just depends on which insurance you have. In many cases the drug companies have actually set up charities which will donate your entire max out of pocket on an HDHP regardless of income.

psim1 7y ago

I have found that by paying the same amount as the premium of the PPO into my HSA that I come out even, if I end up spending the whole deductible, or ahead (i.e. building savings), if I don't. In other words, I don't see any disadvantage to HDHP+HSA vs. PPO plan.

uberduber 7y ago

I got an individual HDHP as soon as I turned 18 in 2004. Shopping around on these plans is not easy, I'm really the only one to do it. I thought it would get easier as more people got HDHPs, it got a little bit better over the years and then drastically went downhill after the ACA. Two main reasons: reduced competition, and our bizarro culture where no one blinks at an $800 surprise bill. I used to have a couple imaging facilities that I went to because their rates were low. In the past few years they have all been bought up by some sort of conglomerate and prices have gone up. It’s not advertised, so I literally have to call the place, talk to the back office and find out if they’ve been bought. So last year I go to the one place that hasn’t been bought, rates were good, I go this year and the bill was a surprise. Even my blood test rates have gone up this year, I’ve asked several doctors and they’re like “Yeah, it’s pretty much Quest or Labcorp now.” So my rule now is, if the back office has no clue what they're doing, they will likely be cheap, and they will likely either get bought up or go out of business. Many years ago when I’d go to the doctor I think I was literally the only one with an HDHP, and the allowable amount would come out to $200, and they’d go “Oh, that’s not right. How about $60?” And just take $60 from me and call it a day. Now when I ask “Will this test cost me more than $200?” No one has an answer or seems to care like we are in some crazy bureaucracy.

winter_blue 7y ago
I was on high-deductible plan a couple of years ago, and went in for an allergy test. After the test, I got a bill for $750 ish. Insane. This was in November as well, so two months later the deductible would reset in 2 months. In the same year I had a whole array of expensive dental work done, and I almost exhausted my HSA. I swore off high-deductible plans ever since then. Even though I'd selected a HDHP at the beginning of open enrollment (in Nov) that year, I was able to call HR in December and switch me to a normal PPO plan (which just had copays).

jhawk28 7y ago

People don't like HDHP, but they are the only type of insurance that puts downward pressure on prices. the only alternative is to regulate.

maxxxxx 7y ago
In what way are they putting downward price pressure? every tried to get prices for a treatment so you can pick a cheaper provider? It's close to impossible to get any numbers.

tomohawk 7y ago

When selecting from health insurance options, I only ever consider HSA plans, which typically have large deductables. Why? The US has the best health CARE in the world, but with a crappy health insurance system. The health insurance has been regulated to a hot mess by cronies and politicians that is slowly destroying the care system. An HSA gives you more control of your care. Rationing care is not the answer to solve the insurance problems. I'm not interested in waiting for long periods of time for rationed care, such as what is seen in Canada. https://www.fraserinstitute.org/studies/waiting-your-turn-wait-times-for-health-care-in-canada-2017 https://www.fraserinstitute.org/studies/waiting-your-turn-wa... For all its faults, at least I can get an MRI within a day or two, and can see a specialist within a day or two. That's way better than waiting on rationed care.

deleted 7y ago
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snr 7y ago

A little off track rant but the tax and health policies of USA are super freaking unbelievable. Why on Earth can one not be eligible for a HSA when they don't have a HDHP? The healthcare is screwed up. The least you could let people do is use their pre tax monies for the health treatments. And don't even get me started on FSA and forfeiture. That's MY money. What the hell do you mean the amount is forfitted? Apologies for my language. The policies are making me go crazy.

40acres 7y ago

I'm exhibit A. I signed up for an HDHP because I didn't want to pay a monthly premium and thought and HSA sounded like a great way to save for health expenses. I had a bout of rhabdomyolysis after pushing myself while at the gym, after doing some research and learning that it probably wasn't life threatening I decided to wait it out and self treat instead of going to the ER.

javagram 7y ago

I’ve had a HSA+HDHP for years. I’ve always contributed the annual maximum into the HSA so there was never a question for me of running out of money to pay for care, and it hasn’t held me back from seeking medical care or treatment. However, it’s perfectly possible for someone to elect the HDHP and not contribute to their HSA, in which case you could be facing a $3000 or higher bill without the money to pay for it. It seems like this is the case described in the article. With a fully funded HSA I almost feel like I have the opposite problem, which is I don’t feel a need to attempt to shop around and compare prices. In general it feels like the HSA/HDCP experiment has failed although I’ll keep using it for as long as it’s offered, as I like the ability to build up my savings every year in the HSA and eventually use it as a second retirement account unless I have a huge medical problem in the future.

conanbatt 7y ago
HDHP are growing a lot, so its succeeded. PPO plans are garbage. Way too expensive and has terrible utilization incentives.

bryan11 7y ago

Switching from a co-pay based insurance to an HDHP + HSA was a big change. My deductible is quite high, so all normal, non-catastrophic medical costs are paid for without insurance. A doctor visit starts at $139 and may be from $300 to $500 depending on the diagnosis. One cannot determine the cost in advance. Any lab work is extra. Is it worth $1000 every year to have a doctor do standard blood tests? Like anything that suddenly becomes very expensive, it makes one look at things differently and question whether they are necessary. Some people put off doctor visits longer until things seem unbearable. Some research online and try to self medicate with over the counter things.

nicodjimenez 7y ago

Obamacare is unfortunately a band aid solution and does nothing to address the fundamental issues: 1) complete lack of price transparency, which means virtually no price competition between clinics / doctors 2) artificially low supply of doctors to jack up prices 3) corrupt regulation to prevent consumer health startups from existing Fixing these issues is going to take a lot more than just taxing people for not buying high deductible health insurance. There's no fundamental reason why most doctors should get paid more than airplane mechanics for example. Either way if they mess up, people die.

ykevinator 7y ago

The gullible have become emboldened so despite the headline, they confidently believe there is no problem.