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Comment by smacktoward | Hacker News Reader

I bristle when I see health savings accounts presented as a solution to the health care crisis. The median household income in the U.S. is about $64,000 a year (see https://www.census.gov/library/publications/2019/demo/p60-26...). When a single major medical procedure can result in a six-figure bill, there's just no way that the average person could ever save enough. You end up with people who are lucky enough to never need to tap their HSAs, and people who are unlucky enough to get sick, whose HSAs just present a speed bump on their slide into bankruptcy.

There's only one thing HSAs are really good at, and that's creating a huge new tranche of money for Wall Street to suck fees out of.

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HSAs are part of high deductible insurance plans with out-of-pocket maximums. No one with such a plan would ever receive a six-figure bill. (With the possible exception of surprise billing from out-of-network providers, which we ought to ban.)

To the best of my understanding, you are 100% correct. Why are you being downvoted? Do other people know something you and I don't know?

Yes. Look at the in/out network for your high deductible plan. None of the providers I use on a traditional plan are considered as in network for the same employers high deductible/hsa plan. Our high deductible plan does not cover out of network. Not at all. Fun!!!

That's not the case with my plan at all. We can use all the exact same providers as the traditional plan on our high deductible/hsa plan. We just switched to the high deductible plan a few years ago (after doing the math and realizing how much better of a deal it is), but we've kept all of our same doctors and specialists as we used before.

Exactly. If you have insurance, you should never receive surprise bills that are higher than your out of pocket maximum. Bad insurance might mean a higher out of pocket maximum, but that should mean what is says...maximum.

Oh, people on such plans incur massive bills all the time.

Suppose you're in a bicycling accident, you're knocked unconscious, and an ambulance takes you to a hospital that isn't in your insurance network.

Boom. Out-of-network charges.

If your bicycling accident was so bad that you need surgery, a five figure bill is a certainty. A six figure one is rarer -- but absolutely possible.

What's really messed up is that, even if you end up at an in-network HOSPITAL, you might get care from an out-of-network provider.

In this bicycle surgery hypothetical, for instance, your hospital and your surgeon might be in your network - but the anesthesiologist isn't.

Boom. Another out-of-network charge.

(Thats called Surprise Billing, btw)

At median income levels, there's no amount of HSA savings money that can insulate you from costs like that.

The current US insurance system asks consumers to walk an insane tightrope of cost controls.

It's no wonder a lot of us fall.

> (Thats called Surprise Billing, btw)

Yes, and in some states, it's starting to be illegal.

https://www.nytimes.com/2019/09/26/upshot/california-surpris...

You're conflating in-network, out of network with HSA -- as these also apply for POS and HMO plans - only traditional plans don't get the plan cost savings, tax deduction, (or if they're lucky the employers savings into an HSA account)

Your bicycling example isn't far off though (as someone who had an HSA and was in a bicycling accident). I had a ~$3600 deductible, and that was spent between an ambulance ride, ER visit, blood test, and MRI.

So, at that point, all costs would be on my insurer and I would theoretically no longer care to price discriminate for follow up visits (to get stitches removed)

I still have an HSA, though I make sure I get the lower deductible now.

Wellll no one unless you somehow make it into an out of network situation. You know, like in an emergency. High deductible plans typically have much more constricted networks than the more traditional plans. Good luck figuring out what’s in and out of network while your appendix may be bursting!!!!

It's so odd that the claim of efficiency is based on HSA, when you look at Singapore, and say the UKs NHS have similar price performance at less than half per capita costs vs the US. As far as I understand, the NHS doesn't have any sort of HSA/deductible fees, nor price tag signals. What is in common between the low cost health systems of the UK and Singapore is significant government ownership of the service outlets as well as government negotiation of prices of input materials (drugs, etc..) for those services.

Can confirm we don't have any sort of HSA/deductible fees.

You just phone the doctor and make an appointment. Stuff happens. Pay for nothing. Ambulance turns up to help you? No payment. 5 days in hospital? No payment. Major surgery? No payment.

15 years ago, I went to the doctor with a back pain, turned out it was an pilonidal abscess, got told not to eat anything, sent directly to hospital, surgery next morning, next 2 days in hospital, then nurse came round to my house once a week for the next 8 weeks to change the dressings. I paid? Nothing. No-one even mentioned cost. I filled in no forms. It just happened.

Only thing we have to pay for is prescriptions, a fixed fee regardless of the drug of £9 ($12). And only people who can afford it, people like pensioners and people on benefit get prescriptions free. Oh, and a fairly small charge for dental checkups (£40 every 6/12 months) and if you want non-standard dental work (you used to have to pay for white fillings, otherwise you got the cheaper amalgam ones, but now you can get either I believe).

They'll usually tell you if it's a lot cheaper to buy for prescriptions yourself, i.e. if they reckon simple painkillers is the best thing, the doctor will tell you to go buy £0.40 paracetamol from the supermarket, instead of giving a prescription for the same drug at £9.

Doctors in the UK don’t regularly make $300k+ per year.

https://www.medscape.com/slideshow/uk-doctors-salary-report-...

https://www.medscape.com/slideshow/2019-compensation-overvie...

Nor do most US doctors, what's your point? And programmers in the UK don't regularly make $250k+ a year either.

Different countries, different pays.

TBH, if you feel doctor pay is somehow too expensive in the US, you're probably thinking about the wrong thing.

I would confidently expect the profits all your health insurance companies dwarf the difference in doctor salaries (an activity which is economically and socially worthless rent-seeking), let alone the salaries of all the utterly pointless health insurance company employees.

The median is over $300k for most of the fields in my link, and from my doctor friends, most easily clear it. The point is that healthcare costs less in other countries. Doctors’ labor costs less, medicines cost less, lawsuits cost less.

There’s no way to attack this problem than to lower the costs. And that means lower pay. Insurance companies have 20% margins at most, by law. Their activity is not socially worthless. The NHS performs the same activity as insurance companies, but US voters don’t want the government to do that.

What is it about Americans that cause them to be so belligerent in the face of basic, clear, undeniable evidence?

A lot of countries have universal healthcare and, shock, horror, it is cheaper per capita.

A lot of countries have strict gun laws and, shock, horror, they don't have mass killings.

But no, you're American, of course you're way is right because, um? You say so! You've have some compelling "arguments", despite all the evidence.

It would be funny if it wasn't causing so many preventable deaths, both from a lack of affordable healthcare, and mass murder sprees.

I don’t know what you thought I was arguing, but my intent is to point out that things with NHS are cheaper because everyone in the healthcare chain earns less in the UK.

I never mentioned the US way is the right way, I actually think taxpayer funded healthcare is the way to go if we are going to force hospitals to provide care to anyone that shows up at their doors.

There is a lot of overhead from insurance companies that isn’t needed IF the US had taxpayer funded healthcare, but there isn’t, so they do serve a purpose of vetting a provider’s care and negotiating pricing.

Americans are being pumped full of divisive rhetoric from every angle and their politicians have been swinging to the right for something like forty years. The right wing realized the population elects R or D with something like a coin toss rate independent of what platform the party runs upon decades ago. As a party, the Rs decided to just always push their party platform to the right at every election, regardless of win or lose. It worked, and we’re four decades into the practice. All the while, the Ds also moved right in response to the center moving and not knowing the same premise. This is for national elections.

Health insurance companies in the US absolutely ARE socially worthless. They’re the singular reason we have this crazy price inflation. Doctors raise prices as a direct way to impact what they actually get paid from insurers. Insurers have “market power” (read that as-unilateral power to tell their customers and providers which way they can shove it) over providers incomes. In order to get price X from insurance providers charge X+e where e is an inflation factor to noisily correct for the kick in the pants from the insurance company. But by law providers then have to charge that price from everybody. This is a failed market.

Prices clear when supply curves meet demand curves. A plumber can’t charge $1,000 per hour because another equivalently plumber is willing to work for $200 per hour.

Doctors can charge high prices because they have low supply and high demand for their services.

No one is stopping a doctor from offering their services at $25 or even $50 per 30 min consultations. If doctor A was offering their services for X + e to insurance just to get X, and doctor B was offering their service for Y, and Y is less than X, then insurance would still go with doctor B even though there was no “e”.

Insurance companies solve the issue of a buyer having no knowledge about what they are buying since they also employ doctors to check others’ work, and to negotiate pricing as a group. Some countries don’t need this since the buyer is the government, but the government is still performing the same functions of negotiating prices and verifying doctors’ work.

Usually I see HSA’s combined with a high deductible plan so that the six figure medical bill is protected. We were on one when my daughter needed surgery (~$50k). We also had another child the same year ($20k), and all we paid was the $6k deductible which also came out of pre-tax money AND my employer contributed $3k to cover the premium. There were no bank fees involved. i am now self employed. Unfortunately I can not buy a high deductible or a HSA plan in my state post Obama care and my premiums in 2018 where $38k and this year have dropped to $32k. To be honest I kind of miss that $6k deductible.

Which state? I’m very surprised an entire state would not have an HSA eligible option on healthcare.gov.

I bought marketplace insurance from 2013 to 2018 in Ohio. The number of HSA-eligible plans dropped in that time period. For 2019 there were no HSA-eligible plans available in my county.

There is one but the premium is the same as the gold plan.

Gold means a “typical” population is expected to pay 20% while insurance company pays 80%. A plan can be gold and HSA eligible at the same time, it will just have lower out of pocket maximum and coinsurances.

If you have enough cash to afford the deductible, you should always go for HSA as you can earn the tax free investment returns on the HSA funds.

A gold non HSA and gold HSA both are designed for the insured to pay 20% and insurance company to pay 80%, but the HSA will let you invest $3,550/$7,100 single/family, and that can add up over the years.

If you started it around 10 years ago, you could realistically have over $100k in the HSA for family plans.

HSAs have limits, granted at $13,500 for a family when studies show most families have to take a loan for a $500 expenditure doesn't help that much.

The minimum deductible for an individual is $1,350.

So, yeah, one problem is that an ambulance + ER visit will blow through any person's deductible quite easily.

The $500 loan statistic is false.

https://mobile.twitter.com/p_millerd/status/1118071142311288...

That thread also misinterprets the study. The question asked is multiple-choice, so you can't just add up the numbers the way he does (what's weird is that he acknowledges this, and then adds up the numbers anyway…) Depending on how you imagine the percentages to overlap, you can kind of have it say whatever you want.

No, he adds the numbers up to accurately provide a maximum value that's low enough that his point is proved regardless of how far below it the real value is.

The survey design, reduced to a trivial example:

Select all that apply

- A: 100% select - B: 50% select - C: 12% select

Suppose there were 100 people. There is no way to imagine overlap that leads to more than 12 people selecting C, as you claim.

> There's only one thing HSAs are really good at, and that's creating a huge new tranche of money for Wall Street to suck fees out of.

You can move HSA funds to an HSA at Fidelity and put it in FSKAX or FZROX at no fee.

> When a single major medical procedure can result in a six-figure bill, there's just no way that the average person could ever save enough. You end up with people who are lucky enough to never need to tap their HSAs, and people who are unlucky enough to get sick, whose HSAs just present a speed bump on their slide into bankruptcy.

While I agree the HSA is an ineffective solution, what you're describing isn't accurate.

The HSA savings segment is not for major medical expenses. The savings portion is for minor medical expenses. The HSA savings account is paired with a high-deductible insurance policy that covers major medical expenses.

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