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.
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.
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.
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.
I just took a look at our annual medical contributions and employer's part.
We pay just over 10k for health insurance through our (different) companies. Our different employers cover almost 28k. So around 38k for insurance. This doesn't even include dental or vision which is separate.
It just seems so crazy how much we pay and still have deductibles. I understand we have small copays and get items covered like age-related screenings but this just feels excessive.
Just talk to people in the healthcare industry about what kind of patients they have. We cover a tremendous amount of treatments in the U.S., at an arguably unsustainable level of service.
My aunt had a kidney infection in Canada and my cousin had to pull teeth to get her scheduled for an MRI. My five year old got a black eye from running into a table and they scheduled him for an X-ray and CAT scan (“just in case “) later that same morning. Had the results by lunch. My dad had a non-emergency scan scheduled the next day, and an outpatient procedure for a kidney stent (to treat high blood pressure) within two weeks. Once the surgeon was in there he realized my dad didn’t need a stent after all.
Here in the US, I see wait times for medical care comparable from what I hear from my Canadian friends. I don't think we our system can really tout that as an advantage over theirs.
Where are you located? E.g. the average wait times for CT scans and MRIs in Canada is weeks: https://canjhealthtechnol.ca/index.php/cjht/article/download.... UK NHS is 6-18 weeks. Here in suburban Maryland I’ve never had to wait more than a day or two for anything.
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.
What is a typical service that you only pay $25? This year I had two shoulder injuries. I paid for every single thing (doctor visits, X-Ray, MRI, Physical Therapy).
Not really... If you want more $s by inflating costs and keeping the margin constant, then you will need more capital for paying these higher costs. This additional capital will either come from equity or from debt. Currently both equity and debt are expensive....
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.
One requirement is to be willing to earn returns less than SP500.
Look up profit margins and annual returns for UNH, Elevance, CVS, Cigna, Humana, Centene, and Molina.
You have a billion laws to follow, you’re used as a punching bag by politicians and customers, have to get the price of your service approved by a government employee, and for all of that, you earn a 2% to 3% profit margin.
Health insurance premium revenue = medical loss ratio + operating costs + profit margin
Medical loss ratio is the money paid to healthcare providers. Operating costs end up being ~10%, across multiple publicly listed companies. This fact, plus 2% to 3% profit margins means any more cost reductions have to come from legislation, reduction in healthcare prices, or advances in automation.
Uh huh, and for them to have inserted themselves between me and my doctor, what exactly did they contribute to the transaction and how much should I want to pay for such a privilege since apparently $30k a year isn't enough? A measly 2-3% for adding no value and creating friction, egregious, we must get the profits higher!
First of all, some or much of your premium is a wealth transfer (from young and healthy to old and sick). So consider that portion a tax (it literally is, just not collected by the government directly):
>what exactly did they contribute to the transaction
Obviously this varies based on personal experience, but the biggest benefit is usually covering the big expenses beyond the out of pocket maximum, such as premature babies, bypass surgeries, cancer treatments, hemophilia treatments, etc stuff that costs hundreds of thousands and millions of dollars.
Second would be negotiated pricing with healthcare providers. If you think you can do a better job negotiating, you are welcome to not pay the health insurance company (better referred to as managed care organizations), and see what kind of deals you can get.
Third would be services as an agent that knows something about healthcare to be able to discern necessary and unnecessary care, since most buyers are unable to discern that information. This is, of course, highly subjective based on personal experience and the lack of government audits here leaves much to be desired.
>how much should I want to pay
When you have 7 publicly listed managed care organizations along with numerous non profits such as the various BCBS and Providence and Kaiser Permanente all selling insurance at roughly the same price, it's sufficient to conclude prices are about as low as they can get in this business environment.
>A measly 2-3% for adding no value and creating friction, egregious, we must get the profits higher!
This sentiment really doesn't make sense, unless the goal is to just be outraged for the sake of being outraged, because it has been clearly shown that there aren't much profits to be had in the first place. It's such a shitty business that one will end up with more money by investing in SP500.
I think my sentiment is that with single-payer we could go from arguing about how expensive health care is and how much money should middle-men be able to extract from the system, to mostly just arguing about how expensive health care is.
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.
> 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).
> 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).
It's a common misconception that the money we all pay into Medicare is going into a generational savings account, so we all need to "pull our weight" to make sure there's enough in there by the time we start withdrawing from it. Medicare is a pay-as-you-go system though – the money we pay into Medicare is being used by the people who are on Medicare right now, and when we're old enough to be using Medicare, it will be paid by the taxes of the young people who are working at that time.
Your parents shouldn't feel guilty for using more of the Medicare resources than they feel they paid in. That money was used up years ago by people who needed it back then.
Agree. As a society we probably need to accept that saving someones life when they are 80 maybe isn't worth $5 million or whatever. We have to map back to person hours and realize that it just doesn't add up in many cases.
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.)
I like universal healthcare in principle, but I don't think the funding mechanism is the problem. We see the same cost inflation in the U.S. in sectors that everyone agrees should be publicly funded, like community colleges or transit. U.S. public spending on tertiary education is about 0.95% of GDP, which is higher than the U.K. (0.5%), Ireland (0.57%), Italy (0.62%), Australia (0.68%), and not that much lower than Germany (1.1%): https://www.oecd.org/en/data/indicators/public-spending-on-e.... Most of those countries have what Americans would call "free college," but we spend just as much as a percentage of GDP--and more in absolute terms--without college being free.
Our colleges simply spend way more money than European colleges. I grew up in Virginia, where George Mason University (GMU) is the second tier public school (behind UVA, William & Mary, and JMU). It's got a budget of $1.4 billion for about 40,000 students.
Compare that to Heidelberg University, which I understand is a renowned university in Germany. Excluding the medical school (which GMU doesn't have), the budget is about 629 million euros, or about $725 million, for about 30,000 students. GMU, which is not a world-famous university, spends almost twice as much money for only 1/3 more students.
It's not the funding mechanism exactly, that matters I think. But that there's no single entity which looks at the whole pot of money and allocates according to best health for the population.
It's not like someone would forbid Warren Buffet from doing so. The government already set up a system that is all but in name compulsory. So, let's take a pile of the same size as the current system uses, but let it go through a single arbiter, with combined purchase power.
> 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.
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.
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.
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.
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.
> 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.
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....
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.
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?
They spend less because their nurses make poverty wages compared to the U.S. My sister in law is studying to be a nurse. Starting pay is around $70,000 here. In the UK it’s like $42,000. She could make that much being a nanny around here.
> OECD Health Statistics data show U.S. registered nurses (RNs) earn 1.5 times the OECD12 average salary. These data are adjusted for purchasing power parity. Using numbers of RNs in the U.S. from the Bureau of Labor Statistics,22 we computed total RN earnings using average U.S. pay and OECD12 average pay. The difference was $79 billion, or about 2 percent of 2021 NHE, representing approximately 5 percent of excess U.S. spending when rounded to the nearest multiple of five.
It's not nothing, but it's hardly the only reason, or even a particularly big one.
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.
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-thi...
Of course, that is why US employees should be able to have access to benefit costs in terms of dollars to be able to compare total compensation. Currently, that is usually only available after the end of a calendar year on form W-2 (box 12 code DD for health insurance premiums).
Technically, you have to get even more granular. If your employer subsidizes health insurance premiums, then you pay for health insurance with pre tax income. If your employer does not, then you have to buy with post tax income. The difference is thousands of dollars per year.
You even avoid FICA if you can max out your HSA via payroll withholdings, a decision solely made by your employer.
It’s actually amazing how many ways the US governments has come up with to screw young people and small businesses.
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.
If you get a very serious and expensive problem, insurance may not help nearly as much as you'd think. My mother had great insurance, but when she got cancer, the insurance didn't stop her from getting absolutely destroyed by the medical bills (not to mention having to constantly fight with the insurance company while being extremely ill).
It drove her to bankruptcy anyway. In hindsight, she commented that had she known that the insurance wouldn't be all that helpful, she would have just saved up all the money she poured into premiums over the decades.
I feel the constant fighting with insurance isn't spoken to enough. I don't want insurance because I don't want to be both a billing department and a sick person. We went through the same mess when both of my parents were sick. We were already taking in an enormous amount of new information about their illnesses and then we were also having to try and learn how their insurance worked, what was covered, what wasn't, trying to vet what would happen in every appointment, which doctors would show up (bc what if one of the doctors is out-of-network), duking it out with insuance over prior authorizations, trying to tie each bill that came in to something that happened months ago and then vetting if the bill was correctly billed, correctly covered by insurance etc, and on and on and on. I'd rather have 0 insurance and just negotiate each bill as it came in with one single entity, the hospital.
> I'd rather have 0 insurance and just negotiate each bill as it came in with one single entity, the hospital.
That's not how it works, insurance or not. You won't get just one bill from a single entity, you'll get many bills from many different entities and will have to negotiate with each separately.
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.
Author here. I'm definitely not advocating going without health insurance. Just running simple numbers to get some perspective.
I'd like to see health insurance act like insurance again though. Right now it covers absolutely everything, meaning it's more like pre-payment for routine care + insurance.
Insurance isn't for routine, predictable, or low-cost expenses. But we've mandated that our health insurance cover all of those things.
The comparison to car insurance is overused, but it's a good one. Catastrophic coverage + dedicated savings with lower premiums looks more attractive to a lot more people.
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.
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.
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.
@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.
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.
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.
Let's suppose that a doctor's visit costs $200 for someone without insurance. And let's say that the two options are 1) insurance premiums are $1000/month, but it's only a $20 copay to visit the doctor, and 2) major-only insurance at $100/month. I can visit the doctor pretty regularly on that difference of $900/month.
All this hypothetical tells us is that you're young, healthy, single, and have a good income. Which is exactly the issue with our health system -- it only works when you don't get sick.
The median household income in the US is $83k. That's for a whole family. I would challenge you to come up with a monthly budget for four people that can support anything like $1000 a month for insurance (which for a family is actually going to be more like $2000) OR handle multiple $200 doctor visits per month. And mind you there is no such things as a doctor visit that costs only $200 unless you're talking about a routine physical. Because the first thing that happens when you're sick is the doctor starts ordering tests and referring you to specialists. And let's hope nobody needs a prescription!
And then you find what life looks like for 150 million Americans -- you're constantly putting off healthcare until it becomes an emergency. You're gambling with your own life and the life of your children trying to not go bankrupt.
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.
I don’t believe this is really what I was talking about. I think there is a case for universal insurance but someone at the end of the day is still making a financial decision.
I tend to question that--I don't see how long wait times for serious conditions leads to better health outcomes. It would logically seem like it would lead to more and earlier deaths if truly spending less per patient. I suspect there are statistical shenanigans.
You seem to be more confident in universal healthcare having "long wait times for serious conditions" than in universal healthcare resulting in better health outcomes at a lower cost per citizen. What makes you trust the first premise more than the second one?
as we delve further into the mass media spectacle one thing has become clear as everything else has become very muddy: the truth isn't what the facts support, it's what you hear three times from people you consider your peers. the fact is that the data that show increased wait times are for elective surgery (https://www.comparethemarket.com.au/health-insurance/feature...) which (by nature of being elective) doesn't correspond to increased mortality or cost, but the wait times on emergency care are comparable for single payer and individual payer systems are comparable, with the US doing slightly better in waits for people who actually receive care but, again, no indication of how many people avoid care due to the cost.
The data are there. If there's a problem with the data, it's not enough for you to simply suspect it. You kinda have to determine what the problem is and show it to us. After all, no one waits longer for healthcare than someone who never gets it because they can't afford it.
Huh? Part of the problem in at least the us system is with insurance you have to run such a tight operational ship. I don’t believe inflation plays a large of a roll but you add significant headcount and leapt force practices to have scale to meet those headcount numbers.
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.
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.
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.
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.
That unfortunately is not an option for us. We talked about it when we were younger, but both sides of our family live within a two hour drive of us and it important to us to be present in their lives and have them be present in ours.
If I had no personal ties, I would very much like to live abroad.
The third option that becomes more tantalizing every year in the US is to not have insurance, pay OOP for routine matters, and when something catastrophic happens let the medical debt go to collections and settle for pennies on the dollar. It doesn't feel right, but it's the direction the medical-pharmaceutical-insurance cartel is pushing us.
> 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.
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.
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.
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.
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.
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.
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.
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.
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?
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.
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.
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.
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.
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.
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!".
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).
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.
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?
I still have a HDHP for intensive visits and if I go to local out of network Urgent Care for the narrow range of things Urgent Care is good for, it's like $50 tops.
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.
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.
Indeed, healthy or not, once you hit 40s .. the number of friends/family/self dealing with accidents/injuries/serious illness/death grows exponentially.
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.
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.
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.
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.
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?
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.
> 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.
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.
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.
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
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?
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.
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.
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.
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.
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.
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.
Right what reality is this where the insurers are innocent? Did Luigi Mangione allegedly shoot an insurance CEO in the back for life-taking business practices or not?
If insurers aren’t the rich misers and are getting screwed too, then why do they lobby Congress to destroy the ACA and destroy any chance at a real healthcare system? If it’s so terrible for them why wouldn’t they help build a better system and fix the issues with them getting screwed?
I didn't say they were innocent, I said they were/are awful capital extractors. Like, they do a really bad job at making money.
If you are following the money, it absolutely does not lead to health insurers. It passes right through them. But people need to do more than watch tiktoks to learn that. So it's lost.
Can you be a bit more clear as to something someone could reference to start following the money? Perhaps the awareness of the issue would spread faster if the advice wasn’t so inactionable.
Follow what money? My insurance payment? How? Are you alluding to political payments? Lead me to water or we’re all doomed. Being coy helps nothing only misunderstanding. As demonstrated by my previous response to your comment. It’s lost because I have no clue what you’re talking about.
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".
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.
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.
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.
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.
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.
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.
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.
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....
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).
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
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.
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.
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?
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-g... https://www.macrotrends.net/stocks/charts/CMG/chipotle-mexic...
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.
I just took a look at our annual medical contributions and employer's part.
We pay just over 10k for health insurance through our (different) companies. Our different employers cover almost 28k. So around 38k for insurance. This doesn't even include dental or vision which is separate.
It just seems so crazy how much we pay and still have deductibles. I understand we have small copays and get items covered like age-related screenings but this just feels excessive.
Just talk to people in the healthcare industry about what kind of patients they have. We cover a tremendous amount of treatments in the U.S., at an arguably unsustainable level of service.
My aunt had a kidney infection in Canada and my cousin had to pull teeth to get her scheduled for an MRI. My five year old got a black eye from running into a table and they scheduled him for an X-ray and CAT scan (“just in case “) later that same morning. Had the results by lunch. My dad had a non-emergency scan scheduled the next day, and an outpatient procedure for a kidney stent (to treat high blood pressure) within two weeks. Once the surgeon was in there he realized my dad didn’t need a stent after all.
Here in the US, I see wait times for medical care comparable from what I hear from my Canadian friends. I don't think we our system can really tout that as an advantage over theirs.
Where are you located? E.g. the average wait times for CT scans and MRIs in Canada is weeks: https://canjhealthtechnol.ca/index.php/cjht/article/download.... UK NHS is 6-18 weeks. Here in suburban Maryland I’ve never had to wait more than a day or two for anything.
I’ve never had anything that available (outside of urgent care which imo is not very good). None of this had an immediate need.
MRI a few years ago had a month and a half wait (not urgent but recommended).
Pediatrician? At least 3 months and thats IF they take new patients.
Allergist, 6 month waiting list.
My last PCP I had to book out 2 months in advance (the practice I wanted to go to was booked 6 months out).
We are also suburbs of a big city.
It's not about wait times, it's about excessive scanning and endless, marginal-benefit end of life care
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.
What is a typical service that you only pay $25? This year I had two shoulder injuries. I paid for every single thing (doctor visits, X-Ray, MRI, Physical Therapy).
For my family, annual screenings are around a $40 copay (no other bills after). I think I paid that for some age related screenings.
I only go to the doctor for the kids. So checkups, vaccines, ear infections, minor injuries, etc.
Profit margins are irrelevant if you inflate your costs to reduce them.
Not really... If you want more $s by inflating costs and keeping the margin constant, then you will need more capital for paying these higher costs. This additional capital will either come from equity or from debt. Currently both equity and debt are expensive....
Profit margin is quite relevant...
The capital comes from raising premiums.
Mine went from $3k/month to $3.6k/month this year.
Bonus points if you can steer the increased costs to providers you own. https://www.statnews.com/2024/11/25/unitedhealth-higher-paym...
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/uploa...
>How can I start an insurance company?
One requirement is to be willing to earn returns less than SP500.
Look up profit margins and annual returns for UNH, Elevance, CVS, Cigna, Humana, Centene, and Molina.
You have a billion laws to follow, you’re used as a punching bag by politicians and customers, have to get the price of your service approved by a government employee, and for all of that, you earn a 2% to 3% profit margin.
No it will be a zero profit company. All of the revenues will go to my compensation and bonuses.
> for all of that, you earn a 2% to 3% profit margin.
Yeah -- it seems like a paradox that the insurance companies charge so many people so much money, yet struggle to make a profit.
I've heard that they spend a lot of money handling their "internal friction" -- reviewing claims, handling appeals, etc.
Health insurance premium revenue = medical loss ratio + operating costs + profit margin
Medical loss ratio is the money paid to healthcare providers. Operating costs end up being ~10%, across multiple publicly listed companies. This fact, plus 2% to 3% profit margins means any more cost reductions have to come from legislation, reduction in healthcare prices, or advances in automation.
https://www.oliverwyman.com/our-expertise/insights/2023/mar/...
https://www.kff.org/private-insurance/medical-loss-ratio-reb...
Uh huh, and for them to have inserted themselves between me and my doctor, what exactly did they contribute to the transaction and how much should I want to pay for such a privilege since apparently $30k a year isn't enough? A measly 2-3% for adding no value and creating friction, egregious, we must get the profits higher!
First of all, some or much of your premium is a wealth transfer (from young and healthy to old and sick). So consider that portion a tax (it literally is, just not collected by the government directly):
https://news.ycombinator.com/item?id=45800973
https://www.cms.gov/marketplace/private-health-insurance/mar...
https://www.healthcare.gov/how-plans-set-your-premiums/
>what exactly did they contribute to the transaction
Obviously this varies based on personal experience, but the biggest benefit is usually covering the big expenses beyond the out of pocket maximum, such as premature babies, bypass surgeries, cancer treatments, hemophilia treatments, etc stuff that costs hundreds of thousands and millions of dollars.
Second would be negotiated pricing with healthcare providers. If you think you can do a better job negotiating, you are welcome to not pay the health insurance company (better referred to as managed care organizations), and see what kind of deals you can get.
Third would be services as an agent that knows something about healthcare to be able to discern necessary and unnecessary care, since most buyers are unable to discern that information. This is, of course, highly subjective based on personal experience and the lack of government audits here leaves much to be desired.
>how much should I want to pay
When you have 7 publicly listed managed care organizations along with numerous non profits such as the various BCBS and Providence and Kaiser Permanente all selling insurance at roughly the same price, it's sufficient to conclude prices are about as low as they can get in this business environment.
>A measly 2-3% for adding no value and creating friction, egregious, we must get the profits higher!
This sentiment really doesn't make sense, unless the goal is to just be outraged for the sake of being outraged, because it has been clearly shown that there aren't much profits to be had in the first place. It's such a shitty business that one will end up with more money by investing in SP500.
I think my sentiment is that with single-payer we could go from arguing about how expensive health care is and how much money should middle-men be able to extract from the system, to mostly just arguing about how expensive health care is.
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.
> 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).
> 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).
It's a common misconception that the money we all pay into Medicare is going into a generational savings account, so we all need to "pull our weight" to make sure there's enough in there by the time we start withdrawing from it. Medicare is a pay-as-you-go system though – the money we pay into Medicare is being used by the people who are on Medicare right now, and when we're old enough to be using Medicare, it will be paid by the taxes of the young people who are working at that time.
Your parents shouldn't feel guilty for using more of the Medicare resources than they feel they paid in. That money was used up years ago by people who needed it back then.
I don't think the post was about guilt. It was about math.
Agree. As a society we probably need to accept that saving someones life when they are 80 maybe isn't worth $5 million or whatever. We have to map back to person hours and realize that it just doesn't add up in many cases.
+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.)
I like universal healthcare in principle, but I don't think the funding mechanism is the problem. We see the same cost inflation in the U.S. in sectors that everyone agrees should be publicly funded, like community colleges or transit. U.S. public spending on tertiary education is about 0.95% of GDP, which is higher than the U.K. (0.5%), Ireland (0.57%), Italy (0.62%), Australia (0.68%), and not that much lower than Germany (1.1%): https://www.oecd.org/en/data/indicators/public-spending-on-e.... Most of those countries have what Americans would call "free college," but we spend just as much as a percentage of GDP--and more in absolute terms--without college being free.
Our colleges simply spend way more money than European colleges. I grew up in Virginia, where George Mason University (GMU) is the second tier public school (behind UVA, William & Mary, and JMU). It's got a budget of $1.4 billion for about 40,000 students.
Compare that to Heidelberg University, which I understand is a renowned university in Germany. Excluding the medical school (which GMU doesn't have), the budget is about 629 million euros, or about $725 million, for about 30,000 students. GMU, which is not a world-famous university, spends almost twice as much money for only 1/3 more students.
It's not the funding mechanism exactly, that matters I think. But that there's no single entity which looks at the whole pot of money and allocates according to best health for the population.
The idea that some entity will make a good decision is almost certainly wrong.
It's communist is the problem. Whose pile of money? If old Warren Buffett wants to spend a billion to extend his life by a year, who am I to stop him?
It's not like someone would forbid Warren Buffet from doing so. The government already set up a system that is all but in name compulsory. So, let's take a pile of the same size as the current system uses, but let it go through a single arbiter, with combined purchase power.
In some sense we have that - what is covered by medicare and the insurance companies is covered for the relevant people in those schemes.
> 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.
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.
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.
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.
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.
> 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_responsibili...
https://en.wikipedia.org/wiki/Tax_Cuts_and_Jobs_Act
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....
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.
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?
> So UK similar income has $43k more in taxes.. to get you NHS?
Well, and all the other services those taxes provide.
They wind up spending a lot less on healthcare. https://commons.wikimedia.org/wiki/File:OECD_health_expendit...
They spend less because their nurses make poverty wages compared to the U.S. My sister in law is studying to be a nurse. Starting pay is around $70,000 here. In the UK it’s like $42,000. She could make that much being a nanny around here.
https://www.commonwealthfund.org/publications/issue-briefs/2...
> OECD Health Statistics data show U.S. registered nurses (RNs) earn 1.5 times the OECD12 average salary. These data are adjusted for purchasing power parity. Using numbers of RNs in the U.S. from the Bureau of Labor Statistics,22 we computed total RN earnings using average U.S. pay and OECD12 average pay. The difference was $79 billion, or about 2 percent of 2021 NHE, representing approximately 5 percent of excess U.S. spending when rounded to the nearest multiple of five.
It's not nothing, but it's hardly the only reason, or even a particularly big one.
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://www.healthcare.gov/how-plans-set-your-premiums/
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-thi...
Of course, that is why US employees should be able to have access to benefit costs in terms of dollars to be able to compare total compensation. Currently, that is usually only available after the end of a calendar year on form W-2 (box 12 code DD for health insurance premiums).
Technically, you have to get even more granular. If your employer subsidizes health insurance premiums, then you pay for health insurance with pre tax income. If your employer does not, then you have to buy with post tax income. The difference is thousands of dollars per year.
You even avoid FICA if you can max out your HSA via payroll withholdings, a decision solely made by your employer.
It’s actually amazing how many ways the US governments has come up with to screw young people and small businesses.
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.
If you get a very serious and expensive problem, insurance may not help nearly as much as you'd think. My mother had great insurance, but when she got cancer, the insurance didn't stop her from getting absolutely destroyed by the medical bills (not to mention having to constantly fight with the insurance company while being extremely ill).
It drove her to bankruptcy anyway. In hindsight, she commented that had she known that the insurance wouldn't be all that helpful, she would have just saved up all the money she poured into premiums over the decades.
I feel the constant fighting with insurance isn't spoken to enough. I don't want insurance because I don't want to be both a billing department and a sick person. We went through the same mess when both of my parents were sick. We were already taking in an enormous amount of new information about their illnesses and then we were also having to try and learn how their insurance worked, what was covered, what wasn't, trying to vet what would happen in every appointment, which doctors would show up (bc what if one of the doctors is out-of-network), duking it out with insuance over prior authorizations, trying to tie each bill that came in to something that happened months ago and then vetting if the bill was correctly billed, correctly covered by insurance etc, and on and on and on. I'd rather have 0 insurance and just negotiate each bill as it came in with one single entity, the hospital.
Absolutely.
A comment about this, though:
> I'd rather have 0 insurance and just negotiate each bill as it came in with one single entity, the hospital.
That's not how it works, insurance or not. You won't get just one bill from a single entity, you'll get many bills from many different entities and will have to negotiate with each separately.
And getting bills 6 to 18 months after the date of services!
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-set...
[1]: https://www.propublica.org/article/unitedhealth-healthcare-i...
It's amazing that Americans are so brow beaten that even in a "perfect world" they still require a "healthcare plan"
Author here. I'm definitely not advocating going without health insurance. Just running simple numbers to get some perspective.
I'd like to see health insurance act like insurance again though. Right now it covers absolutely everything, meaning it's more like pre-payment for routine care + insurance.
Insurance isn't for routine, predictable, or low-cost expenses. But we've mandated that our health insurance cover all of those things.
The comparison to car insurance is overused, but it's a good one. Catastrophic coverage + dedicated savings with lower premiums looks more attractive to a lot more people.
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.
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.
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.
@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.
$50k would probably still be outrageous, like your car insurance doesn't have that generally.
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.
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.
OK, but...
Let's suppose that a doctor's visit costs $200 for someone without insurance. And let's say that the two options are 1) insurance premiums are $1000/month, but it's only a $20 copay to visit the doctor, and 2) major-only insurance at $100/month. I can visit the doctor pretty regularly on that difference of $900/month.
All this hypothetical tells us is that you're young, healthy, single, and have a good income. Which is exactly the issue with our health system -- it only works when you don't get sick.
The median household income in the US is $83k. That's for a whole family. I would challenge you to come up with a monthly budget for four people that can support anything like $1000 a month for insurance (which for a family is actually going to be more like $2000) OR handle multiple $200 doctor visits per month. And mind you there is no such things as a doctor visit that costs only $200 unless you're talking about a routine physical. Because the first thing that happens when you're sick is the doctor starts ordering tests and referring you to specialists. And let's hope nobody needs a prescription!
And then you find what life looks like for 150 million Americans -- you're constantly putting off healthcare until it becomes an emergency. You're gambling with your own life and the life of your children trying to not go bankrupt.
Author here.
DPC is terrific if you have an option near you! Paired with catastrophic insurance, it's a great bet for relatively healthy people.
The DPC Alliance map is well worth a visit: https://mapper.dpcfrontier.com/
And I wrote about DPC a while back: https://church.substack.com/p/direct-primary-care
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.
if this were true why is it that countries w universal healthcare spend less per patient and get better health outcomes with a longer life expectancy?
I don’t believe this is really what I was talking about. I think there is a case for universal insurance but someone at the end of the day is still making a financial decision.
I tend to question that--I don't see how long wait times for serious conditions leads to better health outcomes. It would logically seem like it would lead to more and earlier deaths if truly spending less per patient. I suspect there are statistical shenanigans.
You seem to be more confident in universal healthcare having "long wait times for serious conditions" than in universal healthcare resulting in better health outcomes at a lower cost per citizen. What makes you trust the first premise more than the second one?
as we delve further into the mass media spectacle one thing has become clear as everything else has become very muddy: the truth isn't what the facts support, it's what you hear three times from people you consider your peers. the fact is that the data that show increased wait times are for elective surgery (https://www.comparethemarket.com.au/health-insurance/feature...) which (by nature of being elective) doesn't correspond to increased mortality or cost, but the wait times on emergency care are comparable for single payer and individual payer systems are comparable, with the US doing slightly better in waits for people who actually receive care but, again, no indication of how many people avoid care due to the cost.
https://ourworldindata.org/grapher/life-expectancy-vs-health...
The data are there. If there's a problem with the data, it's not enough for you to simply suspect it. You kinda have to determine what the problem is and show it to us. After all, no one waits longer for healthcare than someone who never gets it because they can't afford it.
This happened because of inflation. Costs rose so much that people had to make claims.
Huh? Part of the problem in at least the us system is with insurance you have to run such a tight operational ship. I don’t believe inflation plays a large of a roll but you add significant headcount and leapt force practices to have scale to meet those headcount numbers.
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.
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.
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.
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.
There's a reason that medical debt is the #1 cause of bankruptcies in the US.
Another option for the U.S., fly to Mexico and take advantage of the "medical tourism" that is gaining in popularity.
> 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.
That unfortunately is not an option for us. We talked about it when we were younger, but both sides of our family live within a two hour drive of us and it important to us to be present in their lives and have them be present in ours.
If I had no personal ties, I would very much like to live abroad.
The third option that becomes more tantalizing every year in the US is to not have insurance, pay OOP for routine matters, and when something catastrophic happens let the medical debt go to collections and settle for pennies on the dollar. It doesn't feel right, but it's the direction the medical-pharmaceutical-insurance cartel is pushing us.
> 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.
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.
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.
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.
> 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.
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.
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.
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.
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.
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?
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.
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.
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.
> 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.
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-pric...
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.
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!".
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/
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.
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?
I still have a HDHP for intensive visits and if I go to local out of network Urgent Care for the narrow range of things Urgent Care is good for, it's like $50 tops.
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.
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.
Indeed, healthy or not, once you hit 40s .. the number of friends/family/self dealing with accidents/injuries/serious illness/death grows exponentially.
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.
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.
Basic healthcare and life saving treatments should NOT be for profit.
Looking from outside your system is scary. I don't get how anyone could defend it in earnest.
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".
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.
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.
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?
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.
> 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.
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.
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.
> 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.
I mean clearly the excess in the system is the profit margin of the companies involved.
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
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?
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.
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.
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.
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.
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.
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.
Right what reality is this where the insurers are innocent? Did Luigi Mangione allegedly shoot an insurance CEO in the back for life-taking business practices or not?
If insurers aren’t the rich misers and are getting screwed too, then why do they lobby Congress to destroy the ACA and destroy any chance at a real healthcare system? If it’s so terrible for them why wouldn’t they help build a better system and fix the issues with them getting screwed?
I didn't say they were innocent, I said they were/are awful capital extractors. Like, they do a really bad job at making money.
If you are following the money, it absolutely does not lead to health insurers. It passes right through them. But people need to do more than watch tiktoks to learn that. So it's lost.
Can you be a bit more clear as to something someone could reference to start following the money? Perhaps the awareness of the issue would spread faster if the advice wasn’t so inactionable.
Follow what money? My insurance payment? How? Are you alluding to political payments? Lead me to water or we’re all doomed. Being coy helps nothing only misunderstanding. As demonstrated by my previous response to your comment. It’s lost because I have no clue what you’re talking about.
These are public companies, their financials are open and readily available.
You can see for yourself how bad they are at making money.
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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".
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/2...
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.
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.
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.
The ACA didn't do away with HSAs.
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.
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.
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.
Insurance middle-men have made healthcare expensive. That has nothing to do with the ACA.
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.
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.
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....
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).
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
It was “working” if you didn’t have a pre-existing condition, which could literally be anything the insurance company wanted it to be.
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.