15 ms·

Is Health Insurance Even Worth It Anymore?

84 points by brandonb 1y ago

exabrial 1y ago
Repeal Obamacare, go back to HSAs. Nobody should be taxed on health expenses, which was the whole point of HSAs in the first place. We literally had a budding system that was working and affordable, and it was "fixed".
- John23832 1y ago
  The ACA didn't do away with HSAs.
  - vablings 1y ago
    I was about to chime in. I still have a HSA? Something interesting is that the ACA was probably making normal people's insurance cheaper because for people with the Medicaid plans were specifically targeted for aggressive coding knowing that the taxpayer was footing the bill It really does baffle me that the USA continues to subvert "socialism" by taking socialist programs and painting them with a capitalist brush^[1] and creating a worse result for everyone involved. It is the peak of government inefficiency 1: eg: fanny mae, The VA, Medicaid, The Federal Reserve....
    - ethin 1y ago
      Ah, but don't you know? Socialism is evil! Capitalism is GOD and is perfect! - Republicans pretty much everywhere in the US Seriously. This is pretty much why single-payer/universal healthcare systems aren't available in the US. It's also why UBI has never been tried. I'm sure someone is going to come in and say that I'm painting an overly-simplistic picture, but we seriously do have people still thinking that people willingly come to the US for healthcare because every other healthcare system is supposedly worse in every imaginable way (which somehow magically proves that what we have is better).
      - vablings 1y ago
        Honestly, I don't think the USA does a terrible job at managing these systems it's just funny to me how the song and dance pretend is such a thin facade. Something like UBI is too idealistic and out of reach for policymakers until the USA moves away from the concept that if you are poor, you are inherently evil. Really all the USA needs to do is make a fork of the VA healthcare and fix the rough-around-the-edges and start offering it as a well-controlled attractive option in the market that is taxpayer funded, maybe roll it out for union workers and blue collared folk first for maximum political appeal
  - exabrial 1y ago
    Correct, instead it made them unaffordable and disappeared them out of existence. Previously to ACA, I paid $280/month for a direct (non-employer sponsored) plan that had a $5k deductible. The plan was discontinued as the base fell out. There is so much wrong with ACA and the hardliners are not capable of self-reflection, and cannot admit that overregulation has done nothing but make things incredibly expensive.
    - sunshowers 1y ago
      do you have anything to say about the fact that before Obamacare, pre-existing conditions were generally not covered? to me that is the main purpose of Obamacare. I think not covering pre-existing conditions is a moral atrocity.
      - deleted 1y ago
        [deleted]
      - exabrial 1y ago
        Why does everyone thing that the "one thing" Obamacare did was pre-existing conditions? That is a footnote in the grand scheme of paperwork in unloaded on health insurers. It's one tiny straw in a hayfield of regulations.
    - John23832 1y ago
      Insurance middle-men have made healthcare expensive. That has nothing to do with the ACA.
  - WillPostForFood 1y ago
    ACA didn't do away with HSAs, but the way the Bronze and Catastrophic plans were designed made them incompatible with HSAs. Only this year was that changed. The plans covered certain non-preventive services before the deductible was met, which was not permitted under older HSA rules. It was really dumb, and took 15 years to fix.
  - anthomtb 1y ago
    Agreed. Upon passage of the ACA my company switched insurance coverage to a High Deductible plan with an HSA. So if anything, the ACA appeared to increase the prevalence of HSA's. But that is my narrow social circle and the grandparent poster seems to have a different experience.
- enraged_camel 1y ago
  It was “working” if you didn’t have a pre-existing condition, which could literally be anything the insurance company wanted it to be.
  - minton 1y ago
    Isn’t idea of insurance at odds with the idea of a pre-existing condition? Like car insurance is a hedge against a crash. We don’t let people buy it after totaling their car. We really need an alternative system to cover pre-existing and not force it into insurance.
  - lisbbb 1y ago
    Yes--the only thing ACA did right was force insurers to take on people with pre-existing conditions. All the other crap could be done away with and we would all be better off. I think we should do away with publicly traded healthcare companies like UNH, too. It's a huge conflict of interest to have billionaires involved.
- jakemcgraw 1y ago
  If we repeal ACA, we'll need to force insurers to take on patients with preexisting conditions. We can't ice out 38% of Americans[0] from coverage. [0]: https://www.commonwealthfund.org/publications/issue-briefs/2017/jun/access-coverage-and-care-people-preexisting-conditions-how-has#:~:text=Background,In%202016%2C%20the%20Henry%20J. https://www.commonwealthfund.org/publications/issue-briefs/2...
  - happytoexplain 1y ago
    Americans do not care about Americans, and there is no way to design a working system if Americans don't want it because it benefits Americans.
  - exabrial 1y ago
    As other commenters have said, pre-existing conditions could and should have been handled separately in a single issue bill, separate from existing insurance. Instead, the truckload of regulations that was brought in around Obamacare has buried health insurance in the US in depths of inefficiency. Its absurd to drive multi-ton flaming trash truck when all we originally needed was a scooter.
- wklauss 1y ago
  Define "budding system that was working". Before the ACA, the number of uninsured Americans was around 50 million and insurance companies routinely denied coverage or charge higher premiums based on pre-existing health conditions. ACA is not perfect (due in no small part to the concessions that had to be made in congress to get enough votes) but i'd say it's been a net win. Going back to a pre-ACA system won't lower premiums that much. Medical costs have risen in the last decade, same as any other goods or services, and the way US healthcare is structured, with hospital and doctors negotiating with a profit driven middleman (insurance companies) makes it almost impossible to change the rising premiums. US healthcare will continue to be a mess until there's a universal healthcare system or single payer system similar to any other developed country on earth.
amundskm 1y ago
I have been struggling to find the breakeven point for me and my family. On one side, it keeps getting more and more expensive even though we are young and healthy. On the other, if one of us needs an expensive operation or months of treatment, no amount of HSA savings will be enough. I don't know if there is a 3rd option that would be more reasonable.
- toast0 1y ago
  Third option is pay what you can reasonably pay and file for bankruptcy. Which sucks, but is an option. Try to get assets into bankruptcy protected holdings when possible (401k, house, etc, depending on state of residence), so you have more flexibility post bankruptcy.
  - JohnFen 1y ago
    There's a reason that medical debt is the #1 cause of bankruptcies in the US.
  - JKCalhoun 1y ago
    Another option for the U.S., fly to Mexico and take advantage of the "medical tourism" that is gaining in popularity.
  - deleted 1y ago
    [deleted]
  - hypeatei 1y ago
    Bankruptcy is not an easy path out of debt. I've seen others go through it and it's stressful: they pry into all your finances, you still have to pay it off (just at a lower amount), and it destroys your credit. There are weird restrictions also like not being able to pay it off early even if you're able to. EDIT: don't forget you have to pay the bankruptcy lawyer too.
- lostlogin 1y ago
  > I don't know if there is a 3rd option that would be more reasonable. There may be something less extreme, but leaving the US is one way out of that mess.
nonameiguess 1y ago
Reading the comments is hilarious. That "healthy 34 year-old male with minor sports injuries" was exactly me when I was 34. Then I hit my out-of-pocket max 7 out of the next 10 years and exceeded a million in insurance spend twice due to a whole lot of major surgeries. It also feels male-centric. Surely pregnancy and childbirth are all but guaranteed to put you over an out-of-pocket max, especially with how common c-sections are these days.
- gambiting 1y ago
  And then you have to wonder how many operations are done just to bill insurance companies money. I have injured my shoulder(here in the UK) and I saw a specialist shoulder surgeon who basically said that the state of the art research into these kinds of injuries is to just leave them alone and let them heal - but if you were in the US you would have had two operations on it already because they just love operating on things that don't need operating on for dubious medical benefit because they would charge 100k for each operation, easy.
- lotyrin 1y ago
  OP is a privileged take, yes. If you touch grass in poverty spaces, disability spaces, etc., there are a lot of preventable things that could be done or mitigations that could be made that would reduce future costs to society and individuals in incredible ways but are not done because people lack the resources to pursue them. The insurance model is flawed in practice for young, healthy, male IT workers yes, but that's just a testament to how broadly flawed it is that even those positions of privilege are being failed by it. Big picture: As a society we are failing to make investments in population health that would pay off and an industry exists in a position that it is directly antagonistic to social good. Medical bankruptcies when an under-insured person has a catastrophe is a failure. A person avoiding preventative or corrective care that will improve their future because in the present they need to pay rent instead is a failure. The market dynamic on private insurance creates pressures that produce these failures as a matter of course. Maybe single-state-payer isn't a perfect way to do this (I am pro-social but also a minarchist), but the private insurance model is obviously worse, and there's probably some solution to the holistic problem but we're incredibly bad at whole-system and whole-population thinking, accounting for "undesirables", and probability around unlikely catastrophe, (and propagandized into being even worse at these things than human psychology alone would allow) so any solution which is optimal is likely to be incredibly unpopular because at the individual optimistic case level it'll feel like it's "infantilizing" people or creating individual disincentives for "repsonsibility" or whatever, and that's before we get to the part where we have large populations of people who are so comfortable with hierarchical systems of exploitation that they are afraid improving things substantially means their currently-comfortable above-water status in the pile of drowning rats might be threatened.
notfried 1y ago
The article mentions early a "cancer diagnosis" but puts that aside and moves on, when this is pretty much the crux of the issue. Prostate and Breast cancers are a 1 in 8 chance. The risk of no insurance at 25 is very different than 50, and than 75. And everyone at all ages is paying for those expensive treatments. The system is broken, but going without insurance is you basically toying with the odds of life.
- mossTechnician 1y ago
  In a perfect world, a healthcare plan should pay for cancer treatments or crucial medical procedures. In the United States, I'm not sure this is a guarantee[0][1]. Going without healthcare seems to be the riskier gamble, but it's a gamble either way. [0]: https://www.startribune.com/unitedhealthcare-part-of-95m-settlement-over-denied-coverage-for-costly-cancer-treatment/601349639 https://www.startribune.com/unitedhealthcare-part-of-95m-set... [1]: https://www.propublica.org/article/unitedhealth-healthcare-insurance-denial-ulcerative-colitis https://www.propublica.org/article/unitedhealth-healthcare-i...
  - iso1631 1y ago
    It's amazing that Americans are so brow beaten that even in a "perfect world" they still require a "healthcare plan"
- fellowniusmonk 1y ago
  Pre-ACA my mother got cancer in a short window where the University my Dad was president of got wound down for financial reasons. Destroyed my entire trajectory in life. The prior system was mega fucked, our current system is still fucked. If you had a congenital condition prior to the ACA you were a wage slave once you hit 18, no private insurance and couldn't get public. Literally founded a successful startup the minute I got ACA. Over 40+ years I've seen nearly every profession go through a bubble and lean years, lawyers, mechanics, academics. But never doctors, in retrospect I should have joined that protectionist racket, but my family couldn't afford to let me at the time.
- JohnFen 1y ago
electric_mayhem 1y ago
Direct primary care was a completely game-changing improvement in healthcare for me. $95/mo to basically subscribe to a local doctor. Covers most things other than tests or surgery or limb setting. But tests are often very discounted relative to what insurance charges for them (with my previous dpc provider an entire battery of tests cost less through them than just the copay for two of them added up to). It’s remarkable how different it is when the healthcare provider is focused on you and your health rather than on gaming the metrics by which insurance companies judge them. Make other plans for catastrophic things (ie, a high deductible insurance plan). https://www.dpcfrontier.com/ https://www.dpcfrontier.com/
- jabroni_salad 1y ago
  I do this too and I love it, and it highlights what to me is the healthcare's system biggest constraint. It is amazing how little healthcare can cost when you do not need to staff seven paper pushers for every doctor.
- Taikonerd 1y ago
  My big question about DPC is: what about people who just don't think about primary care until they have something wrong? How long is the wait list at that point? Or can they go see a doctor for $X as a one-off, without a subscription?
  - electric_mayhem 1y ago
    If someone was hung up on only paying when they need care, the business model needs to support that would probably look a lot like an emergency room or urgent care facility. For me, I consider it an astonishingly good value paying $1200 a year even when probably nine months out of the year I don’t even talk to them. Being a healthy dude I get proactive tests done twice a year to keep tabs on a couple dozen different metrics ($150 each round, all in) and inform any needed course corrections over time (early insight- vitamin d was low (previous insurance-based provider refused to order test). Later insight- eating trash and five drinks a day for 7 days at a vacation resort made basically every metric go to absolute shit; subsequently did an early test after a month of clean diet and regular exercise showed tremendous improvement across the board). And then when something random comes up I know they’re there for me. If it sounds like the sort of thing, you might be into find a couple local providers and just have a conversation with them. I’ve yet to speak to a DPC provider that isn’t excited about the model and delighted to communicate its value to prospective customers. It’s as close to concierge healthcare as I’ll ever able to afford and I absolutely adore that it removes the parasitic insurance from my primary care loop.
righthand 1y ago
The truth is that Us health insurance industry has proven it is not about providing healthcare but instead capital extraction. The whole thing is seen as rotten by every participant. What has happened is that it’s now more affordable to get healthcare in foreign countries as an American. I can vacation and get whatever care I need by doctors in countries with healthcare systems. Doctors that are incentivized to provide healthcare. In economies where people are proud to have a job. There are some good doctors in the Usa but they are incentivized to charge as much as possible and put patients into studies or experimental drugs to get kickbacks. It costs me $50 to get my results from my doctor. They refuse to send an email and a phone call means it’s a “telehealth” appointment. Which is not a medical or technical health term but the name of the product category. Usa does __not__ have a healthcare system but instead a capital extraction health-insurance system that rarely helps with your health costs. I wish this topic was better understood and was in the spotlight during Biden’s term as Potus. But we made extra sure to snub Bernie when Biden ran the first time. No surprise for me if nothing changes. Seems to only be a major topic during the years when affordability is an issue. So when affordability isn’t an issue we’re just A-Ok as Americans with the grifting health-insurance industry.
- vablings 1y ago
  As a transplant to the states its absolutely astonishing to me how quickly doctors have pushed friends and family down the path of crazy expensive boutique treatments for issues that could simply resolved with more care and attention from clinicians. I'm not saying some these drugs don't work astonishingly well and for some people they are a miracle/lifesaving treatment but still. Drugs that are in excess of a thousand dollars a pill out of pocket blows my mind.
- Workaccount2 1y ago
  Health insurance companies are a not the problem, their stocks are trash because their business sucks for profitability. They're not the rich misers swimming in gold piles that they are made out to be. People just get that feeling because the insurers are the proxy for medical costs, but you don't have to dig deep to see that they are getting bent too.
infecto 1y ago
It is worth it imo but it could be better. This is my back of napkin mental model but I have convinced myself that most of our troubles are because health insurance morphed from truly emergencies to every day care. Routine care (both primary and specialist) have to hire deep staff to handle insurance claims with the different payers. It’s a constant game. For myself I always pick the high deductible plan. It’s the next best thing to an emergency only plan in my opinion. I am also lucky that I have an employer that picks this kind of plan as an option. Everyone should be on this type of plan imo. I think have a direct primary care (directs don’t take any insurance) for the family that costs $200 a month for 3 of us. The insurance cost is $100 with a max out of pocket I think around $8000. Now we are lucky in that these dollar figures don’t bother us, not true for everyone but I do think most of us would be better off if we have better forms of true emergency insurance. I want to pool the risk of a catastrophic illness or accident, not my doctors visit for a cough. I pay my dpc directly for all testing and it’s cheap. A lot cheaper than if it was billed via insurance.
- OptionOfT 1y ago
  I'm on the other side. A high deductible plan for me means I'm guaranteed to have to pay that amount, due to medication and visits. If I take the low deductible plan with the higher Max OOP I am actually spending less on a yearly basis because the insurance kicks in immediately. Of course, when something catastropic happens, like cancer, yea, the high-deductible plan would've been better, but that (knocks on wood) doesn't happen every year.
  - metadat 1y ago
    It's like a poker game, except it's your real life. Welcome to.. America? Not sure what to call it at this point. We're all meat for the grinder. Unless you're a billionaire.
- gtowey 1y ago
  Study after study finds that a health care model where you can visit a doctor frequently leads to much better overall heath for people. The system we have here forces people to wait until minor issues turn into life or death situations that require much more intensive and expensive care.
dtnewman 1y ago
I think what this misses is that insurers handle the hassle of dealing with negotiated rates. As an example, if you go to the ER and get a strep test, you might be billed $500, and insurance will pay $7 (as ridiculous as this sounds). If you go at this on your own, they'll probably bill you $100 and tell you they are giving you an 80% discount. With lots of phone calls, you can maybe get them down to $50. This is all obviously crazy. But it makes it such that you really do want insurance if you can afford it. More so, even if you are a billionaire and can afford to self insure, it still makes sense to have health insurance (whereas property or life insurance probably don't make sense for you). Also, don't forget that insurance premiums are often tax deductible for wealthy people, so the actual amount paid is less.
- lostapathy 1y ago
  Dental insurance is even worse. My dental insurance has ridiculously low limits, but it gets you access to the "real" negotiated rates rather than whatever silliness "retail price" is. I tried going without when I switched jobs to an employer that doesn't offer it, but one cleaning as a "cash payer" cost more than the annual premiums to buy insurance privately.
  - crazygringo 1y ago
    > but one cleaning as a "cash payer" cost more than the annual premiums to buy insurance privately. This is my situation too. It's baffling to me. It's not really "insurance" at all, it's more like a yearly Groupon. It's 0% about actual insurance, 100% about negotiated rates.
- Taikonerd 1y ago
  Executive order 14221 (passed in 2021, [0]) was supposed to provide transparency about what the actual negotiated rates were. The idea was that it would be a lot harder for hospitals to engage in price discrimination when they had to publish what everyone was paying. The actual effect has been... mixed. IIUC, the hospitals mostly haven't complied with the order, or they're maliciously complying while trying to keep their real rates secret. [0]: https://www.cms.gov/priorities/key-initiatives/hospital-price-transparency https://www.cms.gov/priorities/key-initiatives/hospital-pric...
Brendinooo 1y ago
I just looked at the local marketplace plans. The absolute dirt-cheapest I could do for my family is ~$1,225/month premium with a deductible of $13,400 and out-of-pocket max of $21,200. Most of the structure is some form of "zero help until the deductible, then I pay 20%-40% of everything up until the OOP max". In other words, I'm being asked to buy a product, and the cheapest form of it is to basically pay almost $15k in a year to hedge against someone getting cancer or whatever, and actively incentivizes me to not use it[0]. There is no meaningful shopping around, there is no incentive for me to do anything other than continue not smoking, there's no accounting for where I live or my health. I dunno what the solution is. I'm just glad that the ACA included health sharing co-ops as an exception. Been doing that for awhile now and have saved a lot of money. (And they'll give me a discount if I get my weight down a little more!) [0]: Because even if you get a free wellness visit or whatever, it's really easy for them to drop in some random test that ends up getting billed. Had this happen with my kids a few times if memory serves.
- 0xy 1y ago
  It was never sustainable. Because the model relied on healthy people subsidizing the people who make extremely poor choices (obesity, smoking, drugs or a combination of that). Obamacare's modeling predicted that significantly more healthy people would sign up, driving costs down. It didn't happen. Now it is a system that ONLY the unhealthy benefit from. Everyone else pays for extremely bad choices.
  - aDyslecticCrow 1y ago
    Why is that only an major issue in the US? we have to step back look at the purpose and functionality of an insurance to realise something is fundamentally off in the calculation (Like this post does the napkin maths for). Corruption greed and blooming price gouging in a market devoid of regulation is to me the only thing that can make the situation this bad. We already know insurance companies pay less than the out of pocket price, so why is the premium so high that paying out of pocket can even come close to beating insurance.
  - accrual 1y ago
philipwhiuk 1y ago
I mean clearly the excess in the system is the profit margin of the companies involved.
modeless 1y ago
All I want is health insurance with low premiums, freedom to choose my providers, and a $50k deductible. Like, actual insurance for catastrophic risks. What we have now should not properly be called insurance. It's more like a mandatory membership in an extremely expensive and dysfunctional club.
- roflyear 1y ago
  $50k would probably still be outrageous, like your car insurance doesn't have that generally.
- y-c-o-m-b 1y ago
  Do you mean a life-time $50k? Otherwise an annual deductible of $50k sounds ludicrous. Maybe if they tied it to yearly income, it would make more sense.
  - FeloniousHam 1y ago
    @modeless is essentially arguing for self-insurance, which is perfectly sensible. You don't need insurance for things you can plan for, or have savings for (make sure you're analyzing your total financial tail risk). Dental "insurance" is basically a savings plan with a negative return, considering the low lifetime maximums, and the fact that biannual cleanings aren't that expensive out of pocket. I have a $20k deductible (with lower premiums), and I'm coming out ahead. There's societal side benefit that paying with your own money makes you a more discriminating consumer. The $50K is not outrageous, assuming you have the savings to cover it. You need insurance for the big things, which is basically anything more than a two-day stay in a hospital. The costs blow up from there.
deleted 1y ago
[deleted]
rayiner 1y ago
My parents use a shocking amount of healthcare services, considering that they are pretty normal 70-somethings. My dad has well managed diabetes and blood pressure, and my mom is pre-diabetic and has a bad knee, but that's about it. Their parents all made it to their 80s without modern medical care in Bangladesh. My kids don't use any healthcare services, but we're always been offered services. My younger one has low muscle tone, and we could get physical therapy for that. We had a (free) county evaluation for his speech delay. The evaluator said something along the lines of "we could give him a diagnosis so he could get services in public school, but since you send him to private school it's not worth it." I'm not saying this is unnecessary, nor am I qualified to do so. My point is that we seem to be getting a lot more healthcare than was typical when I was a kid. So it's unsurprising premiums have skyrocketed.
lenerdenator 1y ago
You can always make the argument that insurance, no matter what it covers, isn't worth it. You're paying for coverage in the case something goes wrong. If it doesn't go wrong, you don't get your money back. The one exception to this is Old-Age, Survivors, and Disability Insurance, better known as Social Security. For some reason, we feel the need to mail checks to, statistically speaking, the wealthiest age demographic in the country whether they need it or not. But is health insurance worth it? If you're a very lucky and healthy 25-year-old with no dependents and six figures in the bank, maybe not. Everyone else? I don't know. That would depend on things like your state's bankruptcy laws. What's not to love about the bankruptcy process? The major problems with health insurance in the US are that 1) there is no basic public option that everyone could use if they absolutely had to, and 2) the largest providers are for-profit, meaning that they have to satisfy the free riders known as shareholders.
- seanmcdirmid 1y ago
  Risk pooling is also broken. People with jobs good enough to get health insurance are generally cheaper risks than people who have to buy health insurance on the market. So your corporate policies wind up cheaper than if you joined the rabble risk pool of people who have to purchase their own insurance.
  - lenerdenator 1y ago
    I could absolutely see that becoming more of an issue for more people if the next step in profiteering is to have more contractors who do work for companies while having to get their own health insurance for themselves. Also, the other problem with risk pools for healthcare in the US is that the most expensive risks - chronic illnesses like heart disease and cancer - are arguably the ones that no one wants to manage the risk of financially. Could you reduce those risks over time by making it more expensive to be obese, like we do with tobacco consumption? Probably, but it'd be incredibly unpopular with the insured.
freetime2 1y ago
Is medical tourism a potential option for uninsured people to decrease costs in the event of major illness like cancer? How about for a chronic condition?
- sssilver 1y ago
  It is and many immigrant families frequent their origin countries for this purpose (my own as well as many others I know), but it’s hard for someone born and raised in the United States to conceptualize what this looks like in a country like Portugal, Armenia, Russia, Turkey, Korea, etc. There’s issues of trust, risk, learning new and unusual systems, travel discomfort, and the incumbent American system benefits from this. It’s a massive thing for someone in Nebraska to say “let me check treatment options for my chronic back pain in Seoul and run the numbers”. There’s nothing, absolutely nothing that as an immigrant I loathe more in the United States than the healthcare system. It is disgusting. The mediocrity of the average doctor combined with how much they charge for that mediocrity blows my mind every time life forces me into their wretched cabinets.
fabiofzero 1y ago
Looking from outside your system is scary. I don't get how anyone could defend it in earnest.
- lenerdenator 1y ago
  Honestly, I don't think anyone would defend the healthcare system itself in the US. What they would defend is the premise of returning value to shareholders. And of course, that's what most for-profit healthcare and insurance companies are set up to do. The largest shareholders are typically retirement and pension funds. That can be applied to almost anything, of course, but if you look at the "enshittification" of most markets in the United States, you'll notice that the process began in earnest around the time that the Baby Boomers began to retire. The Boomers, mathematically speaking, did not have enough children to sustain increasing returns on investments through market expansion. When you have fewer people to extract wealth from, you have to extract more from the average person in order to keep up the numbers, and that's ultimately what we see here and across many sectors of the US economy. You have a generation that was told they would have as good of a retirement as their parents' generation, while also being told that they didn't need to produce the human capital in order for that retirement to happen with the same margins as before. The effect is a generation that gets their basic healthcare met by the taxpayer through Medicare, while getting their retirement checks paid for by their children being squeezed on everything from real estate to healthcare to transportation costs. It's the tyranny of the gerontocracy.
- gambiting 1y ago
  Easy - they will say providing it for everyone is communism and by default bad. Despite spending more on healthcare than every other developed nation and having a robust and well funded by the taxpayer healthcare system for the selected few. But suddenly it's not communism if you're treating veterans and old people not just all of your citizens.
- xboxnolifes 1y ago
  What I think you will find is usually defended is not the healthcare system itself, but the idea of not "paying for the bad decisions of others".
ChrisMarshallNY 1y ago
I'm not (yet) willing to do this for general health insurance, but I made this decision for dental, a couple of years ago. It has not been an issue. I've had a couple of crowns, and paid a fraction of what insurance would have covered, minus the ridiculously high deductible, and the monthly premiums. Of course, now it's time to re-up for next year, and the message seems to be "Squeal, boy!".
aeturnum 1y ago
I think this is worth considering for younger folks, but I wanna point out how low the numbers in the "medical expense" column are. They're similar (if low) for routine care but if you have an actual emergency you'd have much higher bills. IIRC when my mom had breast cancer she was getting a weekly shot to inhibit the HER2/neu mechanism of her cancer that had a list of $10,000 a shot. As an uninsured person you won't pay list but you are rolling the dice pretty hard. Insurance costs are highway robbery - and also the part of their prices that aren't driven by greed are driven by absurd underlying costs.
suninsight 1y ago
[dead]
neilv 1y ago
> 1. What would happen if instead of buying health insurance, you set aside annual premiums plus your deductible every year and paid out of pocket? What would happen if healthcare was a shared pool for the often-unpredictable risk for everyone, so that everyone was taken care of? This is obviously a government function in the interests of everyone, so there's no need for profit-taking insurance companies with perverse incentives.
standardUser 1y ago
Any good explanations as to why insurance companies haven't merged? Each provide roughly the same service. Instead of one staff (and one highly paid exec team and management hierarchy), our healthcare spending has to support a dozen or so, and for what gain to the consumer?
readthenotes1 1y ago
I think to address the problem we should first address the language. It is not largely health insurance, it is medical treatment payment insurance, so I usually just call it medical insurance. We are not paying so much money for promotion of or preservation of health, or even early detection of disease. We are paying so much for late medical treatment of disease
opwieurposiu 1y ago
When I was child, our dog got hit by a car. The dog had two broken legs and was bleeding from the nose. My dad said, "Come with me son, I will show you what to do." So we went into the woods behind the house and dug a hole. I put the dog in the hole and my dad shot the dog in the head. After we filled in the hole my dad said. "Now you know what to do with me when I get old." So my health insurance is healthy living, CrossFit, rapamycin etc. When that fails, I have a 9mm pistol I keep in the safe. I do worry about if I am somehow too incapacitated to use the pistol but not enough to die naturally. Infirmity scares me a lot more then death does.
- lisbbb 1y ago
  I have buried many pets, but last year my wife got cancer and while insurance was a huge headache, it came through in terms of protecting our wealth. She's currently in remission a year later after a very, very difficult fight that she nearly lost multiple times. It was extraordinarily stressful. I learned not to worry about the insurance crap, it all eventually worked itself out despite how frustrating it all was. So I'm not sure 9mm, 45, 357, or any other caliber for the "Hunter S. Thomson" solution, would have been a smart move for us. I totally understand the sentiment, because there are fates worse than death for sure. What didn't hold up was not our insurance but my employer, who found a sneaky way to get rid of me and not have to deal with an employee who needed to dip out for his wife's numerous medical appointments.
- impure-aqua 1y ago
  There are all manner of health conditions that can occur that have little to do with your own healthy living, and don't incapacitate you or make life not worth living, but will cripple you financially. You might end up with Crohn's or all manner of autoimmune conditions where patented biologics easily costs north of $100k US a year just in medication, but your quality of life if you find a medication that works is not particularly degraded from the average person. CrossFit will not prevent you from getting into that situation, and I think it would be a vast overreaction to commit suicide in response to such a diagnosis.
baggachipz 1y ago
The only reason we have this broken system in the US is because of "lobbying" in an environment where unlimited money is "free speech". As long as these "insurance" companies continue to own the politicians, there will never be any meaningful progress. A 6% tax hike each year would induce riots in the streets, but somehow this same scenario in premiums is accepted by the population with anger and a shrug.
efunnekol 1y ago
In the last two years, my mother had a tumour (successfully) removed from her brain and my sister had day-long heart surgery. Two extensive processes with lots of consults before and after, both requiring significant hospital stays. At the time I was a bit grumpy that I had to pay $15 a day for parking at the hospital, which was really the only out of pocket cost to the family here in Canada. We do have a major shortage of GPs and wait times can be longer than you want, so I would not say that we necessarily have the best health care system in the world. But you really need to go to the cafeteria in a hospital to find cash registers. And when I picked up my mother from the hospital, we said goodbye to the nurses and just walked right out.
vasilzhigilei 1y ago
I wonder how many incredible founders and companies we're missing out on because the potential founders never left their jobs due to health insurance costs. Same for rising housing costs. High rent and mortgages reduce risk taking, and that's bad for the economy.
- jandrewrogers 1y ago
  > I wonder how many incredible founders and companies we're missing out on The many countries that don't have this healthcare issue do not seem to be producing a notable excess of incredible founders or companies.
jsbisviewtiful 1y ago
Anecdotal - A friend of mine decided to go without health insurance this year and then tore her ACL. So guess who is walking around with a torn ACL until next year because she simply can't afford the surgery... The US healthcare system is rotten to the core but the populous refuses to educate themselves and keeps voting for losers that won't do anything to fix the system - so we all suffer. Republicans have been promising an alternative to the ACA (for some reason) for over 10 years now and have yet to produce anything - They are just interested in tearing down any progress and not offering fixes to current problems... but thanks to voter education and gerrymandering Republicans are able to keep their vulture capitalism ideals afloat. That's not even mentioning establishment Democrats that don't do much when they have the chance.
- ceejayoz 1y ago
  > So guess who is walking around with a torn ACL until next year because she simply can't afford the surgery… And if the pre-ACA preexisting condition thing comes back, she might be waiting much, much longer.
oliwarner 1y ago
A question to everyone unhappy paying for their insurance: would you be happier paying 50% income tax, 20% sales tax and not having to ever worry about paying for healthcare?
- csa 1y ago
  > A question to everyone unhappy paying for their insurance: would you be happier paying 50% income tax, 20% sales tax and not having to ever worry about paying for healthcare? I hope it’s obvious that this is a false dichotomy. There are many ways to have affordable health care that don’t involve “50% income tax, 20% sales tax”. There is very good healthcare in places that don’t have those conditions. It’s not hard to find. In the US, in most cases, incentives for the insurance companies and the insured are not aligned. Ditto for hospitals and patients. These are two very obvious systemic flaws in the US system that, if addressed in a constructive way, could have a significant impact on healthcare affordability.
  - oliwarner 1y ago
    It's not a dichotomy. I never said those were the only two choices available, but that's how it is in the UK where I am, so I wondered how US insurance payers would feel about our system. Higher earners' tax feels painful until you see the mental load, gouging, denied claims from US insurance companies.
- toast0 1y ago
  California residents with high income are already paying 50% income tax; if you include social security and medicare tax, it's even more. 20% sales tax is high, but if you're buying imported things that are being tariffed at high rates and then paying sales tax on that it's about there. IMHO, if you look at European tax rates vs benefits, and US tax rates vs benefits; US taxes simply aren't efficient, our rates are a little lower and our benefits are a lot lower. Healthcare costs could be significantly reduced if the whole thing were managed as a whole. Do we really need every medical office to have an insurance billing expert whose only job is to interface between the chart and the various insurance rules? OTOH, if you cut out 10% of the cost, healthcare is still expensive, and insurance billing coders and the people who work the other side of that would all be out of work. Managing healthcare as a whole, you'd be able to do systemwide interventions like increasing residency spots to increase supply of Doctors, and set standards for what care can be delivered by Nurse Practitioners to balance demand against supply. OTOH, you'd have people complaining that life clocks are a lie, and carousel is a lie and that there is no renewal.
UltraSane 1y ago
Basic healthcare and life saving treatments should NOT be for profit.
mikewarot 1y ago
I got yeeted out of the work force by Long Covid back in 2020. Thanks to this change, I'm feeling quite fortunate that my "early" Security starts in December (otherwise who knows what would happen, medical bankruptcies are going to go astronomical next year). This might allow us to continue health insurance if all of it (plus some) goes into premiums. I've been avoiding looking at the new options, for my own mental health.
insane_dreamer 1y ago
> I know I’d rather pay for a Direct Primary Care membership, have catastrophic insurance that covers medical spending above a certain dollar value, and contribute to an HSA every year in the meantime while I’m healthy. "Bronze" level insurance is essentially catastrophic insurance. The deductible is so high that you're paying out of pocket for regular care. So the author's desirable scenario already exists. The problem is that even these catastrophic plans cost a significant amount. So much so that it's not really worth it. If you do go to the doctor often you're better off with a higher level of insurance where your premium at least also covers some of your routine care. So it's not that the structure doesn't exist, it's that it's too expensive.
sharts 1y ago
The problem with insurance is that we don't use it as insurance and just as an account to charge everything to when really we should just be paying for health care. You wouldn't charge your car insurance for gas. Yet that is the majority of what we do for healthcare.
OutOfHere 1y ago
Healthcare in the US is a complete protectionist racket in all of its aspects. The costs and bureaucracy are 100x to 1000x what they should be in a highly competitive system. No wonder it's unaffordable. Until this is fixed, shuffling around who pays can't sustainably fix it. Regulations in favor of the racket need to be systematically identified at all levels of government and loosened or struck down.
prewett 1y ago
Part of the problem is that ACA made catastrophic insurance illegal, because all insurance had to have lots of minimum coverage. I don't want insurance to provide one free checkup per year, I want to pay for normal stuff normally, and not have to pay the insurance company's expenses + profit margin on normal stuff just to have the unlikely stuff covered.
insane_dreamer 1y ago
I don't like the US healthcare/insurance system, but my objection to the article is that it fundamentally misunderstands the point of insurance. Insurance is fundamentally a transfer of wealth from those who do not experience misfortune (in this case, poor health) to those who do experience misfortune (so they can pay for it). In the case of healthcare, old people are much more likely to experience misfortune than the young, which means that health insurance -- no matter how you structure it -- is essentially a transfer of wealth from the young and healthy to the old and sick. The only way insurance works is if enough people pay into it, ideally everyone. European countries work with mandated insurance (either through taxes, or a legal requirement) to fund the system sufficiently. Catastrophic-only insurance is a nice idea and is truer to the idea of insurance as a protective measure, but healthcare costs are so high in the US compared with other countries, and the frequency at which non-routine care is necessary is also very high -- partly because Americans lead such unhealthy lives, particularly in terms of diet (and here we have a separate food industry problem) -- that the costs for the "catastrophic-only" insurance have to be quite high. We see this in the "Bronze" level plans. And if people are paying that much per month, it starts to make sense to pay a bit more and get some of the more routine care covered rather than pay so much for nothing really (unless there's a catastrophe). Bear in mind that "catastrophe" is not just cancer. It's almost any non-routine care. I had surgery this year for a hernia -- the bill was $30,000. I was insured so that's not what I paid. But my point is, an unexpected $30K can easily put a household in a serious financial bind given that Americans don't have much in the way of savings.
atlasmd 1y ago
[dead]

84 points by brandonb 1y ago

Repeal Obamacare, go back to HSAs. Nobody should be taxed on health expenses, which was the whole point of HSAs in the first place. We literally had a budding system that was working and affordable, and it was "fixed".

John23832 1y ago
The ACA didn't do away with HSAs.
- vablings 1y ago
  I was about to chime in. I still have a HSA? Something interesting is that the ACA was probably making normal people's insurance cheaper because for people with the Medicaid plans were specifically targeted for aggressive coding knowing that the taxpayer was footing the bill It really does baffle me that the USA continues to subvert "socialism" by taking socialist programs and painting them with a capitalist brush^[1] and creating a worse result for everyone involved. It is the peak of government inefficiency 1: eg: fanny mae, The VA, Medicaid, The Federal Reserve....
  - ethin 1y ago
    Ah, but don't you know? Socialism is evil! Capitalism is GOD and is perfect! - Republicans pretty much everywhere in the US Seriously. This is pretty much why single-payer/universal healthcare systems aren't available in the US. It's also why UBI has never been tried. I'm sure someone is going to come in and say that I'm painting an overly-simplistic picture, but we seriously do have people still thinking that people willingly come to the US for healthcare because every other healthcare system is supposedly worse in every imaginable way (which somehow magically proves that what we have is better).
    - vablings 1y ago
      Honestly, I don't think the USA does a terrible job at managing these systems it's just funny to me how the song and dance pretend is such a thin facade. Something like UBI is too idealistic and out of reach for policymakers until the USA moves away from the concept that if you are poor, you are inherently evil. Really all the USA needs to do is make a fork of the VA healthcare and fix the rough-around-the-edges and start offering it as a well-controlled attractive option in the market that is taxpayer funded, maybe roll it out for union workers and blue collared folk first for maximum political appeal
- exabrial 1y ago
  Correct, instead it made them unaffordable and disappeared them out of existence. Previously to ACA, I paid $280/month for a direct (non-employer sponsored) plan that had a $5k deductible. The plan was discontinued as the base fell out. There is so much wrong with ACA and the hardliners are not capable of self-reflection, and cannot admit that overregulation has done nothing but make things incredibly expensive.
  - sunshowers 1y ago
    do you have anything to say about the fact that before Obamacare, pre-existing conditions were generally not covered? to me that is the main purpose of Obamacare. I think not covering pre-existing conditions is a moral atrocity.
    - deleted 1y ago
      [deleted]
    - exabrial 1y ago
      Why does everyone thing that the "one thing" Obamacare did was pre-existing conditions? That is a footnote in the grand scheme of paperwork in unloaded on health insurers. It's one tiny straw in a hayfield of regulations.
  - John23832 1y ago
    Insurance middle-men have made healthcare expensive. That has nothing to do with the ACA.
- WillPostForFood 1y ago
  ACA didn't do away with HSAs, but the way the Bronze and Catastrophic plans were designed made them incompatible with HSAs. Only this year was that changed. The plans covered certain non-preventive services before the deductible was met, which was not permitted under older HSA rules. It was really dumb, and took 15 years to fix.
- anthomtb 1y ago
  Agreed. Upon passage of the ACA my company switched insurance coverage to a High Deductible plan with an HSA. So if anything, the ACA appeared to increase the prevalence of HSA's. But that is my narrow social circle and the grandparent poster seems to have a different experience.
enraged_camel 1y ago
It was “working” if you didn’t have a pre-existing condition, which could literally be anything the insurance company wanted it to be.
- minton 1y ago
  Isn’t idea of insurance at odds with the idea of a pre-existing condition? Like car insurance is a hedge against a crash. We don’t let people buy it after totaling their car. We really need an alternative system to cover pre-existing and not force it into insurance.
- lisbbb 1y ago
  Yes--the only thing ACA did right was force insurers to take on people with pre-existing conditions. All the other crap could be done away with and we would all be better off. I think we should do away with publicly traded healthcare companies like UNH, too. It's a huge conflict of interest to have billionaires involved.
jakemcgraw 1y ago
If we repeal ACA, we'll need to force insurers to take on patients with preexisting conditions. We can't ice out 38% of Americans[0] from coverage. [0]: https://www.commonwealthfund.org/publications/issue-briefs/2017/jun/access-coverage-and-care-people-preexisting-conditions-how-has#:~:text=Background,In%202016%2C%20the%20Henry%20J. https://www.commonwealthfund.org/publications/issue-briefs/2...
- happytoexplain 1y ago
  Americans do not care about Americans, and there is no way to design a working system if Americans don't want it because it benefits Americans.
- exabrial 1y ago
  As other commenters have said, pre-existing conditions could and should have been handled separately in a single issue bill, separate from existing insurance. Instead, the truckload of regulations that was brought in around Obamacare has buried health insurance in the US in depths of inefficiency. Its absurd to drive multi-ton flaming trash truck when all we originally needed was a scooter.
wklauss 1y ago
Define "budding system that was working". Before the ACA, the number of uninsured Americans was around 50 million and insurance companies routinely denied coverage or charge higher premiums based on pre-existing health conditions. ACA is not perfect (due in no small part to the concessions that had to be made in congress to get enough votes) but i'd say it's been a net win. Going back to a pre-ACA system won't lower premiums that much. Medical costs have risen in the last decade, same as any other goods or services, and the way US healthcare is structured, with hospital and doctors negotiating with a profit driven middleman (insurance companies) makes it almost impossible to change the rising premiums. US healthcare will continue to be a mess until there's a universal healthcare system or single payer system similar to any other developed country on earth.

amundskm 1y ago

I have been struggling to find the breakeven point for me and my family. On one side, it keeps getting more and more expensive even though we are young and healthy. On the other, if one of us needs an expensive operation or months of treatment, no amount of HSA savings will be enough. I don't know if there is a 3rd option that would be more reasonable.

toast0 1y ago
Third option is pay what you can reasonably pay and file for bankruptcy. Which sucks, but is an option. Try to get assets into bankruptcy protected holdings when possible (401k, house, etc, depending on state of residence), so you have more flexibility post bankruptcy.
- JohnFen 1y ago
  There's a reason that medical debt is the #1 cause of bankruptcies in the US.
- JKCalhoun 1y ago
  Another option for the U.S., fly to Mexico and take advantage of the "medical tourism" that is gaining in popularity.
- deleted 1y ago
  [deleted]
- hypeatei 1y ago
  Bankruptcy is not an easy path out of debt. I've seen others go through it and it's stressful: they pry into all your finances, you still have to pay it off (just at a lower amount), and it destroys your credit. There are weird restrictions also like not being able to pay it off early even if you're able to. EDIT: don't forget you have to pay the bankruptcy lawyer too.
lostlogin 1y ago
> I don't know if there is a 3rd option that would be more reasonable. There may be something less extreme, but leaving the US is one way out of that mess.

nonameiguess 1y ago

Reading the comments is hilarious. That "healthy 34 year-old male with minor sports injuries" was exactly me when I was 34. Then I hit my out-of-pocket max 7 out of the next 10 years and exceeded a million in insurance spend twice due to a whole lot of major surgeries. It also feels male-centric. Surely pregnancy and childbirth are all but guaranteed to put you over an out-of-pocket max, especially with how common c-sections are these days.

gambiting 1y ago
And then you have to wonder how many operations are done just to bill insurance companies money. I have injured my shoulder(here in the UK) and I saw a specialist shoulder surgeon who basically said that the state of the art research into these kinds of injuries is to just leave them alone and let them heal - but if you were in the US you would have had two operations on it already because they just love operating on things that don't need operating on for dubious medical benefit because they would charge 100k for each operation, easy.
lotyrin 1y ago
OP is a privileged take, yes. If you touch grass in poverty spaces, disability spaces, etc., there are a lot of preventable things that could be done or mitigations that could be made that would reduce future costs to society and individuals in incredible ways but are not done because people lack the resources to pursue them. The insurance model is flawed in practice for young, healthy, male IT workers yes, but that's just a testament to how broadly flawed it is that even those positions of privilege are being failed by it. Big picture: As a society we are failing to make investments in population health that would pay off and an industry exists in a position that it is directly antagonistic to social good. Medical bankruptcies when an under-insured person has a catastrophe is a failure. A person avoiding preventative or corrective care that will improve their future because in the present they need to pay rent instead is a failure. The market dynamic on private insurance creates pressures that produce these failures as a matter of course. Maybe single-state-payer isn't a perfect way to do this (I am pro-social but also a minarchist), but the private insurance model is obviously worse, and there's probably some solution to the holistic problem but we're incredibly bad at whole-system and whole-population thinking, accounting for "undesirables", and probability around unlikely catastrophe, (and propagandized into being even worse at these things than human psychology alone would allow) so any solution which is optimal is likely to be incredibly unpopular because at the individual optimistic case level it'll feel like it's "infantilizing" people or creating individual disincentives for "repsonsibility" or whatever, and that's before we get to the part where we have large populations of people who are so comfortable with hierarchical systems of exploitation that they are afraid improving things substantially means their currently-comfortable above-water status in the pile of drowning rats might be threatened.

notfried 1y ago

The article mentions early a "cancer diagnosis" but puts that aside and moves on, when this is pretty much the crux of the issue. Prostate and Breast cancers are a 1 in 8 chance. The risk of no insurance at 25 is very different than 50, and than 75. And everyone at all ages is paying for those expensive treatments. The system is broken, but going without insurance is you basically toying with the odds of life.

mossTechnician 1y ago
In a perfect world, a healthcare plan should pay for cancer treatments or crucial medical procedures. In the United States, I'm not sure this is a guarantee[0][1]. Going without healthcare seems to be the riskier gamble, but it's a gamble either way. [0]: https://www.startribune.com/unitedhealthcare-part-of-95m-settlement-over-denied-coverage-for-costly-cancer-treatment/601349639 https://www.startribune.com/unitedhealthcare-part-of-95m-set... [1]: https://www.propublica.org/article/unitedhealth-healthcare-insurance-denial-ulcerative-colitis https://www.propublica.org/article/unitedhealth-healthcare-i...
- iso1631 1y ago
  It's amazing that Americans are so brow beaten that even in a "perfect world" they still require a "healthcare plan"
fellowniusmonk 1y ago
Pre-ACA my mother got cancer in a short window where the University my Dad was president of got wound down for financial reasons. Destroyed my entire trajectory in life. The prior system was mega fucked, our current system is still fucked. If you had a congenital condition prior to the ACA you were a wage slave once you hit 18, no private insurance and couldn't get public. Literally founded a successful startup the minute I got ACA. Over 40+ years I've seen nearly every profession go through a bubble and lean years, lawyers, mechanics, academics. But never doctors, in retrospect I should have joined that protectionist racket, but my family couldn't afford to let me at the time.
JohnFen 1y ago

electric_mayhem 1y ago

Direct primary care was a completely game-changing improvement in healthcare for me. $95/mo to basically subscribe to a local doctor. Covers most things other than tests or surgery or limb setting. But tests are often very discounted relative to what insurance charges for them (with my previous dpc provider an entire battery of tests cost less through them than just the copay for two of them added up to). It’s remarkable how different it is when the healthcare provider is focused on you and your health rather than on gaming the metrics by which insurance companies judge them. Make other plans for catastrophic things (ie, a high deductible insurance plan). https://www.dpcfrontier.com/ https://www.dpcfrontier.com/

jabroni_salad 1y ago
I do this too and I love it, and it highlights what to me is the healthcare's system biggest constraint. It is amazing how little healthcare can cost when you do not need to staff seven paper pushers for every doctor.
Taikonerd 1y ago
My big question about DPC is: what about people who just don't think about primary care until they have something wrong? How long is the wait list at that point? Or can they go see a doctor for $X as a one-off, without a subscription?
- electric_mayhem 1y ago
  If someone was hung up on only paying when they need care, the business model needs to support that would probably look a lot like an emergency room or urgent care facility. For me, I consider it an astonishingly good value paying $1200 a year even when probably nine months out of the year I don’t even talk to them. Being a healthy dude I get proactive tests done twice a year to keep tabs on a couple dozen different metrics ($150 each round, all in) and inform any needed course corrections over time (early insight- vitamin d was low (previous insurance-based provider refused to order test). Later insight- eating trash and five drinks a day for 7 days at a vacation resort made basically every metric go to absolute shit; subsequently did an early test after a month of clean diet and regular exercise showed tremendous improvement across the board). And then when something random comes up I know they’re there for me. If it sounds like the sort of thing, you might be into find a couple local providers and just have a conversation with them. I’ve yet to speak to a DPC provider that isn’t excited about the model and delighted to communicate its value to prospective customers. It’s as close to concierge healthcare as I’ll ever able to afford and I absolutely adore that it removes the parasitic insurance from my primary care loop.

righthand 1y ago

The truth is that Us health insurance industry has proven it is not about providing healthcare but instead capital extraction. The whole thing is seen as rotten by every participant. What has happened is that it’s now more affordable to get healthcare in foreign countries as an American. I can vacation and get whatever care I need by doctors in countries with healthcare systems. Doctors that are incentivized to provide healthcare. In economies where people are proud to have a job. There are some good doctors in the Usa but they are incentivized to charge as much as possible and put patients into studies or experimental drugs to get kickbacks. It costs me $50 to get my results from my doctor. They refuse to send an email and a phone call means it’s a “telehealth” appointment. Which is not a medical or technical health term but the name of the product category. Usa does __not__ have a healthcare system but instead a capital extraction health-insurance system that rarely helps with your health costs. I wish this topic was better understood and was in the spotlight during Biden’s term as Potus. But we made extra sure to snub Bernie when Biden ran the first time. No surprise for me if nothing changes. Seems to only be a major topic during the years when affordability is an issue. So when affordability isn’t an issue we’re just A-Ok as Americans with the grifting health-insurance industry.

vablings 1y ago
As a transplant to the states its absolutely astonishing to me how quickly doctors have pushed friends and family down the path of crazy expensive boutique treatments for issues that could simply resolved with more care and attention from clinicians. I'm not saying some these drugs don't work astonishingly well and for some people they are a miracle/lifesaving treatment but still. Drugs that are in excess of a thousand dollars a pill out of pocket blows my mind.
Workaccount2 1y ago
Health insurance companies are a not the problem, their stocks are trash because their business sucks for profitability. They're not the rich misers swimming in gold piles that they are made out to be. People just get that feeling because the insurers are the proxy for medical costs, but you don't have to dig deep to see that they are getting bent too.

infecto 1y ago

It is worth it imo but it could be better. This is my back of napkin mental model but I have convinced myself that most of our troubles are because health insurance morphed from truly emergencies to every day care. Routine care (both primary and specialist) have to hire deep staff to handle insurance claims with the different payers. It’s a constant game. For myself I always pick the high deductible plan. It’s the next best thing to an emergency only plan in my opinion. I am also lucky that I have an employer that picks this kind of plan as an option. Everyone should be on this type of plan imo. I think have a direct primary care (directs don’t take any insurance) for the family that costs $200 a month for 3 of us. The insurance cost is $100 with a max out of pocket I think around $8000. Now we are lucky in that these dollar figures don’t bother us, not true for everyone but I do think most of us would be better off if we have better forms of true emergency insurance. I want to pool the risk of a catastrophic illness or accident, not my doctors visit for a cough. I pay my dpc directly for all testing and it’s cheap. A lot cheaper than if it was billed via insurance.

OptionOfT 1y ago
I'm on the other side. A high deductible plan for me means I'm guaranteed to have to pay that amount, due to medication and visits. If I take the low deductible plan with the higher Max OOP I am actually spending less on a yearly basis because the insurance kicks in immediately. Of course, when something catastropic happens, like cancer, yea, the high-deductible plan would've been better, but that (knocks on wood) doesn't happen every year.
- metadat 1y ago
  It's like a poker game, except it's your real life. Welcome to.. America? Not sure what to call it at this point. We're all meat for the grinder. Unless you're a billionaire.
gtowey 1y ago
Study after study finds that a health care model where you can visit a doctor frequently leads to much better overall heath for people. The system we have here forces people to wait until minor issues turn into life or death situations that require much more intensive and expensive care.

dtnewman 1y ago

I think what this misses is that insurers handle the hassle of dealing with negotiated rates. As an example, if you go to the ER and get a strep test, you might be billed $500, and insurance will pay $7 (as ridiculous as this sounds). If you go at this on your own, they'll probably bill you $100 and tell you they are giving you an 80% discount. With lots of phone calls, you can maybe get them down to $50. This is all obviously crazy. But it makes it such that you really do want insurance if you can afford it. More so, even if you are a billionaire and can afford to self insure, it still makes sense to have health insurance (whereas property or life insurance probably don't make sense for you). Also, don't forget that insurance premiums are often tax deductible for wealthy people, so the actual amount paid is less.

lostapathy 1y ago
Dental insurance is even worse. My dental insurance has ridiculously low limits, but it gets you access to the "real" negotiated rates rather than whatever silliness "retail price" is. I tried going without when I switched jobs to an employer that doesn't offer it, but one cleaning as a "cash payer" cost more than the annual premiums to buy insurance privately.
- crazygringo 1y ago
  > but one cleaning as a "cash payer" cost more than the annual premiums to buy insurance privately. This is my situation too. It's baffling to me. It's not really "insurance" at all, it's more like a yearly Groupon. It's 0% about actual insurance, 100% about negotiated rates.
Taikonerd 1y ago
Executive order 14221 (passed in 2021, [0]) was supposed to provide transparency about what the actual negotiated rates were. The idea was that it would be a lot harder for hospitals to engage in price discrimination when they had to publish what everyone was paying. The actual effect has been... mixed. IIUC, the hospitals mostly haven't complied with the order, or they're maliciously complying while trying to keep their real rates secret. [0]: https://www.cms.gov/priorities/key-initiatives/hospital-price-transparency https://www.cms.gov/priorities/key-initiatives/hospital-pric...

Brendinooo 1y ago

I just looked at the local marketplace plans. The absolute dirt-cheapest I could do for my family is ~$1,225/month premium with a deductible of $13,400 and out-of-pocket max of $21,200. Most of the structure is some form of "zero help until the deductible, then I pay 20%-40% of everything up until the OOP max". In other words, I'm being asked to buy a product, and the cheapest form of it is to basically pay almost $15k in a year to hedge against someone getting cancer or whatever, and actively incentivizes me to not use it[0]. There is no meaningful shopping around, there is no incentive for me to do anything other than continue not smoking, there's no accounting for where I live or my health. I dunno what the solution is. I'm just glad that the ACA included health sharing co-ops as an exception. Been doing that for awhile now and have saved a lot of money. (And they'll give me a discount if I get my weight down a little more!) [0]: Because even if you get a free wellness visit or whatever, it's really easy for them to drop in some random test that ends up getting billed. Had this happen with my kids a few times if memory serves.

0xy 1y ago
It was never sustainable. Because the model relied on healthy people subsidizing the people who make extremely poor choices (obesity, smoking, drugs or a combination of that). Obamacare's modeling predicted that significantly more healthy people would sign up, driving costs down. It didn't happen. Now it is a system that ONLY the unhealthy benefit from. Everyone else pays for extremely bad choices.
- aDyslecticCrow 1y ago
  Why is that only an major issue in the US? we have to step back look at the purpose and functionality of an insurance to realise something is fundamentally off in the calculation (Like this post does the napkin maths for). Corruption greed and blooming price gouging in a market devoid of regulation is to me the only thing that can make the situation this bad. We already know insurance companies pay less than the out of pocket price, so why is the premium so high that paying out of pocket can even come close to beating insurance.
- accrual 1y ago

philipwhiuk 1y ago

I mean clearly the excess in the system is the profit margin of the companies involved.

modeless 1y ago

All I want is health insurance with low premiums, freedom to choose my providers, and a $50k deductible. Like, actual insurance for catastrophic risks. What we have now should not properly be called insurance. It's more like a mandatory membership in an extremely expensive and dysfunctional club.

roflyear 1y ago
$50k would probably still be outrageous, like your car insurance doesn't have that generally.
y-c-o-m-b 1y ago
Do you mean a life-time $50k? Otherwise an annual deductible of $50k sounds ludicrous. Maybe if they tied it to yearly income, it would make more sense.
- FeloniousHam 1y ago
  @modeless is essentially arguing for self-insurance, which is perfectly sensible. You don't need insurance for things you can plan for, or have savings for (make sure you're analyzing your total financial tail risk). Dental "insurance" is basically a savings plan with a negative return, considering the low lifetime maximums, and the fact that biannual cleanings aren't that expensive out of pocket. I have a $20k deductible (with lower premiums), and I'm coming out ahead. There's societal side benefit that paying with your own money makes you a more discriminating consumer. The $50K is not outrageous, assuming you have the savings to cover it. You need insurance for the big things, which is basically anything more than a two-day stay in a hospital. The costs blow up from there.

deleted 1y ago

[deleted]

rayiner 1y ago

My parents use a shocking amount of healthcare services, considering that they are pretty normal 70-somethings. My dad has well managed diabetes and blood pressure, and my mom is pre-diabetic and has a bad knee, but that's about it. Their parents all made it to their 80s without modern medical care in Bangladesh. My kids don't use any healthcare services, but we're always been offered services. My younger one has low muscle tone, and we could get physical therapy for that. We had a (free) county evaluation for his speech delay. The evaluator said something along the lines of "we could give him a diagnosis so he could get services in public school, but since you send him to private school it's not worth it." I'm not saying this is unnecessary, nor am I qualified to do so. My point is that we seem to be getting a lot more healthcare than was typical when I was a kid. So it's unsurprising premiums have skyrocketed.

lenerdenator 1y ago

You can always make the argument that insurance, no matter what it covers, isn't worth it. You're paying for coverage in the case something goes wrong. If it doesn't go wrong, you don't get your money back. The one exception to this is Old-Age, Survivors, and Disability Insurance, better known as Social Security. For some reason, we feel the need to mail checks to, statistically speaking, the wealthiest age demographic in the country whether they need it or not. But is health insurance worth it? If you're a very lucky and healthy 25-year-old with no dependents and six figures in the bank, maybe not. Everyone else? I don't know. That would depend on things like your state's bankruptcy laws. What's not to love about the bankruptcy process? The major problems with health insurance in the US are that 1) there is no basic public option that everyone could use if they absolutely had to, and 2) the largest providers are for-profit, meaning that they have to satisfy the free riders known as shareholders.

seanmcdirmid 1y ago
Risk pooling is also broken. People with jobs good enough to get health insurance are generally cheaper risks than people who have to buy health insurance on the market. So your corporate policies wind up cheaper than if you joined the rabble risk pool of people who have to purchase their own insurance.
- lenerdenator 1y ago
  I could absolutely see that becoming more of an issue for more people if the next step in profiteering is to have more contractors who do work for companies while having to get their own health insurance for themselves. Also, the other problem with risk pools for healthcare in the US is that the most expensive risks - chronic illnesses like heart disease and cancer - are arguably the ones that no one wants to manage the risk of financially. Could you reduce those risks over time by making it more expensive to be obese, like we do with tobacco consumption? Probably, but it'd be incredibly unpopular with the insured.

freetime2 1y ago

Is medical tourism a potential option for uninsured people to decrease costs in the event of major illness like cancer? How about for a chronic condition?

sssilver 1y ago
It is and many immigrant families frequent their origin countries for this purpose (my own as well as many others I know), but it’s hard for someone born and raised in the United States to conceptualize what this looks like in a country like Portugal, Armenia, Russia, Turkey, Korea, etc. There’s issues of trust, risk, learning new and unusual systems, travel discomfort, and the incumbent American system benefits from this. It’s a massive thing for someone in Nebraska to say “let me check treatment options for my chronic back pain in Seoul and run the numbers”. There’s nothing, absolutely nothing that as an immigrant I loathe more in the United States than the healthcare system. It is disgusting. The mediocrity of the average doctor combined with how much they charge for that mediocrity blows my mind every time life forces me into their wretched cabinets.

fabiofzero 1y ago

Looking from outside your system is scary. I don't get how anyone could defend it in earnest.

lenerdenator 1y ago
Honestly, I don't think anyone would defend the healthcare system itself in the US. What they would defend is the premise of returning value to shareholders. And of course, that's what most for-profit healthcare and insurance companies are set up to do. The largest shareholders are typically retirement and pension funds. That can be applied to almost anything, of course, but if you look at the "enshittification" of most markets in the United States, you'll notice that the process began in earnest around the time that the Baby Boomers began to retire. The Boomers, mathematically speaking, did not have enough children to sustain increasing returns on investments through market expansion. When you have fewer people to extract wealth from, you have to extract more from the average person in order to keep up the numbers, and that's ultimately what we see here and across many sectors of the US economy. You have a generation that was told they would have as good of a retirement as their parents' generation, while also being told that they didn't need to produce the human capital in order for that retirement to happen with the same margins as before. The effect is a generation that gets their basic healthcare met by the taxpayer through Medicare, while getting their retirement checks paid for by their children being squeezed on everything from real estate to healthcare to transportation costs. It's the tyranny of the gerontocracy.
gambiting 1y ago
Easy - they will say providing it for everyone is communism and by default bad. Despite spending more on healthcare than every other developed nation and having a robust and well funded by the taxpayer healthcare system for the selected few. But suddenly it's not communism if you're treating veterans and old people not just all of your citizens.
xboxnolifes 1y ago
What I think you will find is usually defended is not the healthcare system itself, but the idea of not "paying for the bad decisions of others".

ChrisMarshallNY 1y ago

I'm not (yet) willing to do this for general health insurance, but I made this decision for dental, a couple of years ago. It has not been an issue. I've had a couple of crowns, and paid a fraction of what insurance would have covered, minus the ridiculously high deductible, and the monthly premiums. Of course, now it's time to re-up for next year, and the message seems to be "Squeal, boy!".

aeturnum 1y ago

I think this is worth considering for younger folks, but I wanna point out how low the numbers in the "medical expense" column are. They're similar (if low) for routine care but if you have an actual emergency you'd have much higher bills. IIRC when my mom had breast cancer she was getting a weekly shot to inhibit the HER2/neu mechanism of her cancer that had a list of $10,000 a shot. As an uninsured person you won't pay list but you are rolling the dice pretty hard. Insurance costs are highway robbery - and also the part of their prices that aren't driven by greed are driven by absurd underlying costs.

suninsight 1y ago

[dead]

neilv 1y ago

> 1. What would happen if instead of buying health insurance, you set aside annual premiums plus your deductible every year and paid out of pocket? What would happen if healthcare was a shared pool for the often-unpredictable risk for everyone, so that everyone was taken care of? This is obviously a government function in the interests of everyone, so there's no need for profit-taking insurance companies with perverse incentives.

standardUser 1y ago

Any good explanations as to why insurance companies haven't merged? Each provide roughly the same service. Instead of one staff (and one highly paid exec team and management hierarchy), our healthcare spending has to support a dozen or so, and for what gain to the consumer?

readthenotes1 1y ago

I think to address the problem we should first address the language. It is not largely health insurance, it is medical treatment payment insurance, so I usually just call it medical insurance. We are not paying so much money for promotion of or preservation of health, or even early detection of disease. We are paying so much for late medical treatment of disease

opwieurposiu 1y ago

When I was child, our dog got hit by a car. The dog had two broken legs and was bleeding from the nose. My dad said, "Come with me son, I will show you what to do." So we went into the woods behind the house and dug a hole. I put the dog in the hole and my dad shot the dog in the head. After we filled in the hole my dad said. "Now you know what to do with me when I get old." So my health insurance is healthy living, CrossFit, rapamycin etc. When that fails, I have a 9mm pistol I keep in the safe. I do worry about if I am somehow too incapacitated to use the pistol but not enough to die naturally. Infirmity scares me a lot more then death does.

lisbbb 1y ago
I have buried many pets, but last year my wife got cancer and while insurance was a huge headache, it came through in terms of protecting our wealth. She's currently in remission a year later after a very, very difficult fight that she nearly lost multiple times. It was extraordinarily stressful. I learned not to worry about the insurance crap, it all eventually worked itself out despite how frustrating it all was. So I'm not sure 9mm, 45, 357, or any other caliber for the "Hunter S. Thomson" solution, would have been a smart move for us. I totally understand the sentiment, because there are fates worse than death for sure. What didn't hold up was not our insurance but my employer, who found a sneaky way to get rid of me and not have to deal with an employee who needed to dip out for his wife's numerous medical appointments.
impure-aqua 1y ago
There are all manner of health conditions that can occur that have little to do with your own healthy living, and don't incapacitate you or make life not worth living, but will cripple you financially. You might end up with Crohn's or all manner of autoimmune conditions where patented biologics easily costs north of $100k US a year just in medication, but your quality of life if you find a medication that works is not particularly degraded from the average person. CrossFit will not prevent you from getting into that situation, and I think it would be a vast overreaction to commit suicide in response to such a diagnosis.

baggachipz 1y ago

The only reason we have this broken system in the US is because of "lobbying" in an environment where unlimited money is "free speech". As long as these "insurance" companies continue to own the politicians, there will never be any meaningful progress. A 6% tax hike each year would induce riots in the streets, but somehow this same scenario in premiums is accepted by the population with anger and a shrug.

efunnekol 1y ago

In the last two years, my mother had a tumour (successfully) removed from her brain and my sister had day-long heart surgery. Two extensive processes with lots of consults before and after, both requiring significant hospital stays. At the time I was a bit grumpy that I had to pay $15 a day for parking at the hospital, which was really the only out of pocket cost to the family here in Canada. We do have a major shortage of GPs and wait times can be longer than you want, so I would not say that we necessarily have the best health care system in the world. But you really need to go to the cafeteria in a hospital to find cash registers. And when I picked up my mother from the hospital, we said goodbye to the nurses and just walked right out.

vasilzhigilei 1y ago

I wonder how many incredible founders and companies we're missing out on because the potential founders never left their jobs due to health insurance costs. Same for rising housing costs. High rent and mortgages reduce risk taking, and that's bad for the economy.

jandrewrogers 1y ago
> I wonder how many incredible founders and companies we're missing out on The many countries that don't have this healthcare issue do not seem to be producing a notable excess of incredible founders or companies.

jsbisviewtiful 1y ago

Anecdotal - A friend of mine decided to go without health insurance this year and then tore her ACL. So guess who is walking around with a torn ACL until next year because she simply can't afford the surgery... The US healthcare system is rotten to the core but the populous refuses to educate themselves and keeps voting for losers that won't do anything to fix the system - so we all suffer. Republicans have been promising an alternative to the ACA (for some reason) for over 10 years now and have yet to produce anything - They are just interested in tearing down any progress and not offering fixes to current problems... but thanks to voter education and gerrymandering Republicans are able to keep their vulture capitalism ideals afloat. That's not even mentioning establishment Democrats that don't do much when they have the chance.

ceejayoz 1y ago
> So guess who is walking around with a torn ACL until next year because she simply can't afford the surgery… And if the pre-ACA preexisting condition thing comes back, she might be waiting much, much longer.

oliwarner 1y ago

A question to everyone unhappy paying for their insurance: would you be happier paying 50% income tax, 20% sales tax and not having to ever worry about paying for healthcare?

csa 1y ago
> A question to everyone unhappy paying for their insurance: would you be happier paying 50% income tax, 20% sales tax and not having to ever worry about paying for healthcare? I hope it’s obvious that this is a false dichotomy. There are many ways to have affordable health care that don’t involve “50% income tax, 20% sales tax”. There is very good healthcare in places that don’t have those conditions. It’s not hard to find. In the US, in most cases, incentives for the insurance companies and the insured are not aligned. Ditto for hospitals and patients. These are two very obvious systemic flaws in the US system that, if addressed in a constructive way, could have a significant impact on healthcare affordability.
- oliwarner 1y ago
  It's not a dichotomy. I never said those were the only two choices available, but that's how it is in the UK where I am, so I wondered how US insurance payers would feel about our system. Higher earners' tax feels painful until you see the mental load, gouging, denied claims from US insurance companies.
toast0 1y ago
California residents with high income are already paying 50% income tax; if you include social security and medicare tax, it's even more. 20% sales tax is high, but if you're buying imported things that are being tariffed at high rates and then paying sales tax on that it's about there. IMHO, if you look at European tax rates vs benefits, and US tax rates vs benefits; US taxes simply aren't efficient, our rates are a little lower and our benefits are a lot lower. Healthcare costs could be significantly reduced if the whole thing were managed as a whole. Do we really need every medical office to have an insurance billing expert whose only job is to interface between the chart and the various insurance rules? OTOH, if you cut out 10% of the cost, healthcare is still expensive, and insurance billing coders and the people who work the other side of that would all be out of work. Managing healthcare as a whole, you'd be able to do systemwide interventions like increasing residency spots to increase supply of Doctors, and set standards for what care can be delivered by Nurse Practitioners to balance demand against supply. OTOH, you'd have people complaining that life clocks are a lie, and carousel is a lie and that there is no renewal.

UltraSane 1y ago

Basic healthcare and life saving treatments should NOT be for profit.

mikewarot 1y ago

I got yeeted out of the work force by Long Covid back in 2020. Thanks to this change, I'm feeling quite fortunate that my "early" Security starts in December (otherwise who knows what would happen, medical bankruptcies are going to go astronomical next year). This might allow us to continue health insurance if all of it (plus some) goes into premiums. I've been avoiding looking at the new options, for my own mental health.

insane_dreamer 1y ago

> I know I’d rather pay for a Direct Primary Care membership, have catastrophic insurance that covers medical spending above a certain dollar value, and contribute to an HSA every year in the meantime while I’m healthy. "Bronze" level insurance is essentially catastrophic insurance. The deductible is so high that you're paying out of pocket for regular care. So the author's desirable scenario already exists. The problem is that even these catastrophic plans cost a significant amount. So much so that it's not really worth it. If you do go to the doctor often you're better off with a higher level of insurance where your premium at least also covers some of your routine care. So it's not that the structure doesn't exist, it's that it's too expensive.

sharts 1y ago

The problem with insurance is that we don't use it as insurance and just as an account to charge everything to when really we should just be paying for health care. You wouldn't charge your car insurance for gas. Yet that is the majority of what we do for healthcare.

OutOfHere 1y ago

Healthcare in the US is a complete protectionist racket in all of its aspects. The costs and bureaucracy are 100x to 1000x what they should be in a highly competitive system. No wonder it's unaffordable. Until this is fixed, shuffling around who pays can't sustainably fix it. Regulations in favor of the racket need to be systematically identified at all levels of government and loosened or struck down.

prewett 1y ago

Part of the problem is that ACA made catastrophic insurance illegal, because all insurance had to have lots of minimum coverage. I don't want insurance to provide one free checkup per year, I want to pay for normal stuff normally, and not have to pay the insurance company's expenses + profit margin on normal stuff just to have the unlikely stuff covered.

insane_dreamer 1y ago

I don't like the US healthcare/insurance system, but my objection to the article is that it fundamentally misunderstands the point of insurance. Insurance is fundamentally a transfer of wealth from those who do not experience misfortune (in this case, poor health) to those who do experience misfortune (so they can pay for it). In the case of healthcare, old people are much more likely to experience misfortune than the young, which means that health insurance -- no matter how you structure it -- is essentially a transfer of wealth from the young and healthy to the old and sick. The only way insurance works is if enough people pay into it, ideally everyone. European countries work with mandated insurance (either through taxes, or a legal requirement) to fund the system sufficiently. Catastrophic-only insurance is a nice idea and is truer to the idea of insurance as a protective measure, but healthcare costs are so high in the US compared with other countries, and the frequency at which non-routine care is necessary is also very high -- partly because Americans lead such unhealthy lives, particularly in terms of diet (and here we have a separate food industry problem) -- that the costs for the "catastrophic-only" insurance have to be quite high. We see this in the "Bronze" level plans. And if people are paying that much per month, it starts to make sense to pay a bit more and get some of the more routine care covered rather than pay so much for nothing really (unless there's a catastrophe). Bear in mind that "catastrophe" is not just cancer. It's almost any non-routine care. I had surgery this year for a hernia -- the bill was $30,000. I was insured so that's not what I paid. But my point is, an unexpected $30K can easily put a household in a serious financial bind given that Americans don't have much in the way of savings.

atlasmd 1y ago

[dead]