7 ms·

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-

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
  I don't think it's fair to characterize unhealthy people as making bad choices. Many choices do affect health, but plenty of healthy people end up needing medical care every day through no fault of their own. Then there's the systemic issues of our healthcare system, low-cost low-quality food (HFCS and other garbage), and even if the consumer knows how to take better care of themselves, they may not have the resources to do much better depending on their life situation (think juggling jobs and taking care of kids, etc). So, I don't think it's strictly a choice to be healthy or to be a drain on the system.
- drivingmenuts 1y ago
  So it was my extremely poor choice to inherit kidney disease? Or maybe it's my extremely poor choice to undergo dialysis thrice weekly so I can survive? Or my extremely poor choice to even bother living it? There are a ton of reasons for ill health in this world before you should even suggest character flaws.
- ceejayoz 1y ago
  > Obamacare's modeling predicted that significantly more healthy people would sign up, driving costs down. It didn't happen. It was intentionally fucked with. The requirement to get insurance was nulled out for those young, healthy folks. The end result was obvious - eventual collapse of the system. https://en.wikipedia.org/wiki/Individual_shared_responsibility_provision https://en.wikipedia.org/wiki/Individual_shared_responsibili... https://en.wikipedia.org/wiki/Tax_Cuts_and_Jobs_Act https://en.wikipedia.org/wiki/Tax_Cuts_and_Jobs_Act
- insane_dreamer 1y ago
  > Obamacare's modeling predicted that significantly more healthy people would sign up, driving costs down. It didn't happen. That's because the GOP Congress gutted the provisions that heavily incentivized healthy people to sign up. We could also just do Medicare for All. Every other developed country seems to have figured that out but us :/
  - seanmcdirmid 1y ago
    Obamacare is basically based on the Swiss system, so not every other developed country has Medicare for all (even the German system is “it’s complicated”). The main difference between the Swiss system and Obamacare though is the Swiss outlaw health insurance being provided as a benefit at work (so basically no group plans, almost everyone is in the same risk pools). Foreigners living in Switzerland need to document their purchase of Swiss health insurance.
    - insane_dreamer 1y ago
      Switzerland does have mandated universal health care, so essentially the same result as "Medicare for All". It's just implemented in a different form: mandatory basic insurance + supplemental insurance, instead of a single-payer system. A number of other European countries have something similar.
      - seanmcdirmid 1y ago
        Yes, but that was what the ACA attempted, and there wasn’t just one simple model that America could have adopted to fix all its healthcare problems.
        insane_dreamer 1y ago
        Agreed. The ACA was a compromise solution meant to move the US closer to a single-payer system, but was later stripped of many of its clauses, making it of much less value (though not rescinded altogether -- thank you, McCain!)
whatever1 1y ago
So you have to pay like $30k out of pocket in a year before the insurance chips in a single dollar? And if you ever ask for a dollar, I can also reject your coverage. How can I start an insurance company?
- Brendinooo 1y ago
  Broadly speaking yes, though to be fair I should note that if your household size is a certain number and your income is a certain number, that can come down. They cap the amount you pay in premiums to a certain percent of your income. EDIT: https://www.healthreformbeyondthebasics.org/wp-content/uploads/2024/08/REFERENCE_YearlyGuidelines_CY2026-rev.pdf https://www.healthreformbeyondthebasics.org/wp-content/uploa...
- rayiner 1y ago
  You don't pay the deductible for many typical services if you're in-network. We have a mid-tier United Healthcare plan, and we only ever pay a $25 copay per doctor visit. United Healthcare's net profit margin is about half that of Chipotle in a good year: https://www.macrotrends.net/stocks/charts/UNH/unitedhealth-group/profit-margins https://www.macrotrends.net/stocks/charts/UNH/unitedhealth-g...; https://www.macrotrends.net/stocks/charts/CMG/chipotle-mexican-grill/profit-margins https://www.macrotrends.net/stocks/charts/CMG/chipotle-mexic...
  - garciasn 1y ago
    I pay around $1100 a month for me and my two children through my employer. Yes; I have a $25 copay for many services, but most are simply not covered under that $25 copay. They refused an age-appropriate colonoscopy last year. It's basically fucking useless and expensive. So; is it worth it anymore? No. Is it necessary? Yes; unfortunately.
    - Brendinooo 1y ago
      Yeah, I think that's a big part of the overall grievance. If we paid these high premiums and got great care, that'd be one thing. But I've almost never walked away from a sizeable medical expense in my family thinking I wasn't being ripped off somehow.
rayiner 1y ago
That seems... fine? That's $14,000 annually. For an income in the $75k-$100k range, Maryland health connection shows me a premium of $700/month for two parents/two kids. Judging by your premium and assuming 2 adults/2 kids, your income is probably over $200k. With that income in Canada, you'd be paying over $20,000 in taxes attributable to healthcare: https://www.fraserinstitute.org/sites/default/files/price-of-public-health-care-insurance-2024.pdf https://www.fraserinstitute.org/sites/default/files/price-of.... Now you have to account for taxes you pay in the U.S. for medicare, and a risk-adjusted share of the deductible payments, but overall it doesn't seem that crazy.
- steveBK123 1y ago
  Right I think a lot of upper income Americans don't understand how it compares globally. Seeing what my UK colleagues deal with, a $200K income would land you solidly in the 40% marginal tax bracket over there, vs (if married) .. 22% here. US federal effective tax rate (before getting into deductions) would be like 17% on that 200k, for a $166k take home.. versus equivalent UK take-home would be as low as $123k (again not getting into deductions). So UK similar income has $43k more in taxes.. to get you NHS? Doesn't seem like a great trade if in the US you have options starting from $14k?
  - lotsofpulp 1y ago
    Effective tax rates are not that easy to compare. In fact, the portion of a US health insurance premiums IS a tax, based on your age! Not to mention the myriad ways tax policy (including the age rating factors that cause young people to pay a tax via their health insurance premium) vary among not only the 50 states, but the smaller jurisdictions within the states. https://news.ycombinator.com/item?id=45800973 https://news.ycombinator.com/item?id=45800973 https://www.healthcare.gov/how-plans-set-your-premiums/ https://www.healthcare.gov/how-plans-set-your-premiums/
    - rayiner 1y ago
      Sure. But if you make the calculation that granular, you also need to include employer-paid health insurance on the compensation side of the ledger. More than half of Americans have employer-paid health insurance, and employers contribute on average $17,000 per employee: https://www.business.com/articles/health-insurance-costs-this-year/ https://www.business.com/articles/health-insurance-costs-thi...
lotsofpulp 1y ago
> 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] You are not paying $15k to hedge against someone in your family getting cancer in a calendar year. You are paying $15k to pay for old and sick people’s routine healthcare, due to the ACA’s requirement that the highest premium to be at most 3x the lowest premium, and the requirement that premiums be only a function of age and tobacco use (i.e. no underwriting for health risks by factoring in pre existing conditions). So an ACA compliant health plan’s premiums are far more comparable to a tax than an insurance premium since they are explicitly a wealth transfer mechanism from young and healthy to old and sick. New York state takes this wealth transfer even further and mandates that age not be used at all to price premiums. I think Massachusetts only allows an age rating factor of 2.
danielmarkbruce 1y ago
The actual cost to treat "cancer or whatever" is extremely high in many cases. 15k a year to know you have that covered for a family isn't so bad given the true underlying cost. A family member has a rare disease and I've gone through the details of the various treatments, how many people are involved in ongoing care and treatment etc. It's a lot of very well trained people spending a lot of time. A concrete treatment example - the process to create some blood plasma treatments is very complex, expensive etc. In the end, it will be millions of dollars of real underlying costs. There is probably no cheap solution. Maybe GLP-1 type magic can put a real dent in the overall cost, but there will always be a desire to save people's lives even if the cost is very high.
- rayiner 1y ago
  > but there will always be a desire to save people's lives even if the cost is very high. Also, Americans place extraordinarily high value on life. My wife's grandmother had cancer in her 60s and had a quarter of her lung removed. She then had a stroke in her late 80s. She was in rural Oregon, and they evacuated her via helicopter to Portland. They wanted to give her an aggressive treatment, but she refused, and passed away a couple of days later, having lived a full and complete life. She didn't have special health insurance or money saved up--she was a waitress before retiring, and had Medicare. I took my dad (who is also on Medicare) to the ER three times in the last couple of months. There was nothing serious--his blood pressure was rather high and he got scared. Here in exurban Maryland, the hospitals aren't that busy. He got a non-emergency CT scan/MRI (I forget which) scheduled within a day, and an outpatient procedure to insert a stent in a kidney artery within two weeks. When the surgeon got in there with some pre-surgery diagnostics, he realized the kidney artery was fine and didn't insert the stent. My parents were upper middle class, but there's no way they paid enough into Medicare to cover the amount of medical care they've used just since retiring (last 5 years or so).
  - actionfromafar 1y ago
    +1 The whole system is setup to maximise the "care" whenever possible. IMHO it would be better with a universal healthcare that asked itself some tough questions. Start from a pile of money and calculate maximum impact backwards from there. But maybe that's impossible for the US. (It's satanic and/or communist or something.)

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
I don't think it's fair to characterize unhealthy people as making bad choices. Many choices do affect health, but plenty of healthy people end up needing medical care every day through no fault of their own. Then there's the systemic issues of our healthcare system, low-cost low-quality food (HFCS and other garbage), and even if the consumer knows how to take better care of themselves, they may not have the resources to do much better depending on their life situation (think juggling jobs and taking care of kids, etc). So, I don't think it's strictly a choice to be healthy or to be a drain on the system.
drivingmenuts 1y ago
So it was my extremely poor choice to inherit kidney disease? Or maybe it's my extremely poor choice to undergo dialysis thrice weekly so I can survive? Or my extremely poor choice to even bother living it? There are a ton of reasons for ill health in this world before you should even suggest character flaws.
ceejayoz 1y ago
> Obamacare's modeling predicted that significantly more healthy people would sign up, driving costs down. It didn't happen. It was intentionally fucked with. The requirement to get insurance was nulled out for those young, healthy folks. The end result was obvious - eventual collapse of the system. https://en.wikipedia.org/wiki/Individual_shared_responsibility_provision https://en.wikipedia.org/wiki/Individual_shared_responsibili... https://en.wikipedia.org/wiki/Tax_Cuts_and_Jobs_Act https://en.wikipedia.org/wiki/Tax_Cuts_and_Jobs_Act
insane_dreamer 1y ago
> Obamacare's modeling predicted that significantly more healthy people would sign up, driving costs down. It didn't happen. That's because the GOP Congress gutted the provisions that heavily incentivized healthy people to sign up. We could also just do Medicare for All. Every other developed country seems to have figured that out but us :/
- seanmcdirmid 1y ago
  Obamacare is basically based on the Swiss system, so not every other developed country has Medicare for all (even the German system is “it’s complicated”). The main difference between the Swiss system and Obamacare though is the Swiss outlaw health insurance being provided as a benefit at work (so basically no group plans, almost everyone is in the same risk pools). Foreigners living in Switzerland need to document their purchase of Swiss health insurance.
  - insane_dreamer 1y ago
    Switzerland does have mandated universal health care, so essentially the same result as "Medicare for All". It's just implemented in a different form: mandatory basic insurance + supplemental insurance, instead of a single-payer system. A number of other European countries have something similar.
    - seanmcdirmid 1y ago
      Yes, but that was what the ACA attempted, and there wasn’t just one simple model that America could have adopted to fix all its healthcare problems.
      - insane_dreamer 1y ago
        Agreed. The ACA was a compromise solution meant to move the US closer to a single-payer system, but was later stripped of many of its clauses, making it of much less value (though not rescinded altogether -- thank you, McCain!)

whatever1 1y ago

So you have to pay like $30k out of pocket in a year before the insurance chips in a single dollar? And if you ever ask for a dollar, I can also reject your coverage. How can I start an insurance company?

Brendinooo 1y ago
Broadly speaking yes, though to be fair I should note that if your household size is a certain number and your income is a certain number, that can come down. They cap the amount you pay in premiums to a certain percent of your income. EDIT: https://www.healthreformbeyondthebasics.org/wp-content/uploads/2024/08/REFERENCE_YearlyGuidelines_CY2026-rev.pdf https://www.healthreformbeyondthebasics.org/wp-content/uploa...
rayiner 1y ago
You don't pay the deductible for many typical services if you're in-network. We have a mid-tier United Healthcare plan, and we only ever pay a $25 copay per doctor visit. United Healthcare's net profit margin is about half that of Chipotle in a good year: https://www.macrotrends.net/stocks/charts/UNH/unitedhealth-group/profit-margins https://www.macrotrends.net/stocks/charts/UNH/unitedhealth-g...; https://www.macrotrends.net/stocks/charts/CMG/chipotle-mexican-grill/profit-margins https://www.macrotrends.net/stocks/charts/CMG/chipotle-mexic...
- garciasn 1y ago
  I pay around $1100 a month for me and my two children through my employer. Yes; I have a $25 copay for many services, but most are simply not covered under that $25 copay. They refused an age-appropriate colonoscopy last year. It's basically fucking useless and expensive. So; is it worth it anymore? No. Is it necessary? Yes; unfortunately.
  - Brendinooo 1y ago
    Yeah, I think that's a big part of the overall grievance. If we paid these high premiums and got great care, that'd be one thing. But I've almost never walked away from a sizeable medical expense in my family thinking I wasn't being ripped off somehow.

rayiner 1y ago

That seems... fine? That's $14,000 annually. For an income in the $75k-$100k range, Maryland health connection shows me a premium of $700/month for two parents/two kids. Judging by your premium and assuming 2 adults/2 kids, your income is probably over $200k. With that income in Canada, you'd be paying over $20,000 in taxes attributable to healthcare: https://www.fraserinstitute.org/sites/default/files/price-of-public-health-care-insurance-2024.pdf https://www.fraserinstitute.org/sites/default/files/price-of.... Now you have to account for taxes you pay in the U.S. for medicare, and a risk-adjusted share of the deductible payments, but overall it doesn't seem that crazy.

steveBK123 1y ago
Right I think a lot of upper income Americans don't understand how it compares globally. Seeing what my UK colleagues deal with, a $200K income would land you solidly in the 40% marginal tax bracket over there, vs (if married) .. 22% here. US federal effective tax rate (before getting into deductions) would be like 17% on that 200k, for a $166k take home.. versus equivalent UK take-home would be as low as $123k (again not getting into deductions). So UK similar income has $43k more in taxes.. to get you NHS? Doesn't seem like a great trade if in the US you have options starting from $14k?
- lotsofpulp 1y ago
  Effective tax rates are not that easy to compare. In fact, the portion of a US health insurance premiums IS a tax, based on your age! Not to mention the myriad ways tax policy (including the age rating factors that cause young people to pay a tax via their health insurance premium) vary among not only the 50 states, but the smaller jurisdictions within the states. https://news.ycombinator.com/item?id=45800973 https://news.ycombinator.com/item?id=45800973 https://www.healthcare.gov/how-plans-set-your-premiums/ https://www.healthcare.gov/how-plans-set-your-premiums/
  - rayiner 1y ago
    Sure. But if you make the calculation that granular, you also need to include employer-paid health insurance on the compensation side of the ledger. More than half of Americans have employer-paid health insurance, and employers contribute on average $17,000 per employee: https://www.business.com/articles/health-insurance-costs-this-year/ https://www.business.com/articles/health-insurance-costs-thi...

lotsofpulp 1y ago

> 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] You are not paying $15k to hedge against someone in your family getting cancer in a calendar year. You are paying $15k to pay for old and sick people’s routine healthcare, due to the ACA’s requirement that the highest premium to be at most 3x the lowest premium, and the requirement that premiums be only a function of age and tobacco use (i.e. no underwriting for health risks by factoring in pre existing conditions). So an ACA compliant health plan’s premiums are far more comparable to a tax than an insurance premium since they are explicitly a wealth transfer mechanism from young and healthy to old and sick. New York state takes this wealth transfer even further and mandates that age not be used at all to price premiums. I think Massachusetts only allows an age rating factor of 2.

danielmarkbruce 1y ago

The actual cost to treat "cancer or whatever" is extremely high in many cases. 15k a year to know you have that covered for a family isn't so bad given the true underlying cost. A family member has a rare disease and I've gone through the details of the various treatments, how many people are involved in ongoing care and treatment etc. It's a lot of very well trained people spending a lot of time. A concrete treatment example - the process to create some blood plasma treatments is very complex, expensive etc. In the end, it will be millions of dollars of real underlying costs. There is probably no cheap solution. Maybe GLP-1 type magic can put a real dent in the overall cost, but there will always be a desire to save people's lives even if the cost is very high.

rayiner 1y ago
> but there will always be a desire to save people's lives even if the cost is very high. Also, Americans place extraordinarily high value on life. My wife's grandmother had cancer in her 60s and had a quarter of her lung removed. She then had a stroke in her late 80s. She was in rural Oregon, and they evacuated her via helicopter to Portland. They wanted to give her an aggressive treatment, but she refused, and passed away a couple of days later, having lived a full and complete life. She didn't have special health insurance or money saved up--she was a waitress before retiring, and had Medicare. I took my dad (who is also on Medicare) to the ER three times in the last couple of months. There was nothing serious--his blood pressure was rather high and he got scared. Here in exurban Maryland, the hospitals aren't that busy. He got a non-emergency CT scan/MRI (I forget which) scheduled within a day, and an outpatient procedure to insert a stent in a kidney artery within two weeks. When the surgeon got in there with some pre-surgery diagnostics, he realized the kidney artery was fine and didn't insert the stent. My parents were upper middle class, but there's no way they paid enough into Medicare to cover the amount of medical care they've used just since retiring (last 5 years or so).
- actionfromafar 1y ago
  +1 The whole system is setup to maximise the "care" whenever possible. IMHO it would be better with a universal healthcare that asked itself some tough questions. Start from a pile of money and calculate maximum impact backwards from there. But maybe that's impossible for the US. (It's satanic and/or communist or something.)