Half of Americans fear a health-related bankruptcy | Hacker News Reader

Half of Americans fear a health-related bankruptcy

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240 pointssrameshc355 comments

Yeah this is 95% of what my fiance and I talked about when deciding whether we wanted to have a baby. It wasn't about paying for the kid's schooling or where we were going to live. It literally boiled down to whether we were willing to potentially wipe out our entire savings and go into debt to have a child.

And when she quit her job earlier this year it was mainly because we didn't want her to get sick and hospitalized because then I would get sick and hospitalized, and that would completely erase our savings.

Thank god her previous employer had good medical insurance so we could do COBRA. Now we just have to have a kid within 18 months of her separation date.

The insurance system in the US is completely broken because it doesn't actually insure you against catestrophic costs.

Yeah, health insurance in the US is kind of the opposite of insurance. It covers every-day expenses more-or-less but effectively will not cover unexpected large expenses (because the insurance companies will put the full force of their legal resources into not paying large claims).

That greatly depends on the type of insurance / plan (or at least it did...).

Cheaper plans absolutely apply to what you describe, or at least did a while ago, other plans do not. Even knowing can be hard.

But your description is way too general.

All 4 employer provided health insurance programs I've used worked that way, though only the last two were post ACA.

That’s not true at all. Other than ACA mandated well visits and vaccines, insurance forces you to pay for everyday expenses via deductibles and copays until you reach your out of pocket maximum. And then insurance will take over for large expenses.

And by and large, they do pay for the largest expenses, such as medications for anemia and cancer treatment and NICU situation.

That isn’t true at all. It used to be true because health care plans had lifetime limits to coverage, but the ACA removed those limits.

The ACA also ads out of pocket maximums. They might still be high enough to cause problems for some people, but it’s a lot better than it used to be.

As far as not paying, your chances of them just deciding not to pay are low. It’s definitely not high enough to support your claim that they effectively don’t cover large expenses. Here the ACA also helps because insurers are forced to spend at least 80% of premiums on healthcare costs and quality improvements for customers.

> your chances of them just deciding not to pay are low

What's your data on that? The US government says that private insurers deny 20% of claims.

Last year my insurer tried to say that it was medically unnecessary to get an MRI after I'd had a tumor removed from my brain. You see, I'd also had an MRI before the surgery and according to the quack on the insurance company payroll who "reviewed my case" more than 1 MRI in a year just can't be justified.

Your chances that an American health insurance firm will deny your claim, or at least attempt to, are very high. Virtually all of the staff at these firms are dedicated to not paying claims.

> The US government says that private insurers deny 20% of claims.

Most insurers deny every claim. Hospitals employ pretty large teams (of nurses, mostly) whose job it is to go through these denials and justify the medical care a patient received while in the hospital. If the insurance company doesn't think the treatment was necessary, they won't pay. If they can find a technicality, such as, a patient came in for a belly ache, but had a heart attack, they won't pay.

I'm willing to bet this 20% figure only represent denied claims not absorbed mostly, or entirely by the hospital.

I've been pushing the person whom I get this information from to write a book, because most Americans are completely ignorant about how fucked the health insurance scheme is in the US. That $6,000 asprin on your hospital bill is there to cover all the aspects of your treatment that the insurance company will successfully deny.

>The US government says that private insurers deny 20% of claims.

20% are denied at least once, not 20% are never paid. There's a lot of gray area in what is medically necessary, and there's a lot of outright fraud. Plus many claims are denied because someone didn't fill them out correctly, deductibles weren't met, premiums weren't paid etc... The back and forth is part of the process. It's not great but...

> more-or-less but effectively will not cover unexpected large expenses

This is completely unwarranted.

>Your chances that an American health insurance firm will deny your claim, or at least attempt to, are very high. Virtually all of the staff at these firms are dedicated to not paying claims.

Some amount of the 20% denied first time are fraudulent, so assuming you have a legitimate claim, you have a less than 20% of them denying something the first time it's submitted, and a much smaller chance of them refusing to pay eventually.

>Last year my insurer tried to say that it was medically unnecessary to get an MRI after I'd had a tumor removed from my brain. You see, I'd also had an MRI before the surgery and according to the quack on the insurance company payroll who "reviewed my case" more than 1 MRI in a year just can't be justified.

Did they eventually pay? Did your doctor think it was medically necessary, and did you refile?

I fail to see how a system where after a long and arduous battle with an illness spend several months sending letters and making phone calls with my insurance provider because they won't pay the bills for my treatment is better than a system where a single payer simply pays at a set rate for specific treatments. The whole point of the "insurance" system in the US seems to be to make everyone waste several hours a week on top of the time they spend being sick.

> is better than a system where a single payer simply pays at a set rate for specific treatments.

It's not.

>but effectively will not cover unexpected large expenses

That was the claim though, and it's wrong.

Does ACA have actual out-of-pocket maximums? My insurance has an advertised $0 out-of-pocket maximum, with an asterisk saying that this does not include co-pays or out-of-network care. It lists no out-of-pocket maximum for out-of-network care.

I've already experienced one case where I got stuck with a bill for an out-of-network physician at an in-network facility, so I have no confidence that there is any actual limit to what I could end up paying in a year.

Every claim I've ever submitted that was over $20k was denied the first time. One claim (smaller than $20k) ended up in collections while I was still negotiating with the insurance company!

Some of this is pre ACA, some of it post. I have no doubt that the ACA made things much better[1], but I've seen nothing to make me think there aren't still people at the insurance companies whose only job it is to make it as hard as possible for anyone to force the company to pay large claims.

1: a friend with a chronic health condition would be bankrupt if she were ever unemployed for longer than the COBRA limit prior ACA. Post ACA she was able to start her own business on private insurance.

Yes, the ACA has out of pocket maximums. $8,150 per individual or $16,300 for the family this year.

The maximum out of pocket for my company's PPO is $40k for out of network, with an asterisk listing all the things that doesn't include.

I've personally paid more than $16k out of pocket on the HMO. In fact, I did last year, and will this year as well.

Well, yeah, the HHS maximum out of pocket is for in-network covered services. How did you manage to spend so much out of network? Around here, no doctor will see you (outside the ER) without confirming they take your insurance first.

Where I live many of the good specialists will not even bill insurance for you; they just charge you up-front and give you documentation to submit to insurance.

> The ACA also ads out of pocket maximums. They might still be high enough to cause problems for some people, but it’s a lot better than it used to be.

That's pretty dismissive of reality. A more lifelike portrayal is that ACA co-pays/deductibles resulted in wholly unusable insurance for millions of economically vulnerable Americans.

Millions of economically vulnerable Americans already had wholly unusable insurance.

Before the ACA there were no out of pocket maximums, coverage was mostly limited to $100k per year per person, insurance companies could price you out or drop you as soon as you became expensive, and people with preexisting conditions were completely SOL.

Before the ACA if you didn't have employer provided insurance, there was basically no insurance option. All affordable individual insurance options were effectively prepaid minor to moderate medical care plans.

Yeah it sucks, particularity without the individual mandate, but it is significantly better than what existed before.

Except that it doesn't even really cover every-day expenses... Yes, if you have a catastrophic event it will kick in, but realistically if you are a healthy person, you are paying hundreds per person per month for coverage, plus will pay out of pocket for most of your care in a year before hitting that $5K+ deductible. It's simultaneously too expensive to not have insurance AND too expensive to go to the doctor.

I'll never quite understand why I have to pay out $XXX for a blood test that might give me preventative feedback about my health, yet once I finally get heart disease, cancer, diabetes, etc, magically the health system and health insurance system kick in. The whole system is perverse.

> It's simultaneously too expensive to not have insurance AND too expensive to go to the doctor.

Because healthcare is too expensive for Americans. Adding insurance doesn’t make the healthcare stop being expensive, it just helps distribute the costs more evenly across the population. Like universal taxpayer funded healthcare would.

In order to bring healthcare costs down, the supply of healthcare and number of sellers of healthcare in the market would need to increase.

If anything, it does insure you against catastrophic loss. ACA took away maximum benefit amounts.

The problem is most people don’t have enough cash to even pay for out of pocket maximums, which is around $25k to $30k for a family ($12k to $15k per year, but you need to have two year’s worth in case something happens to you at the end of the year and costs continue into the next year).

On paper it may seem to insure you against catastrophic loss, that is, if the insurance company can't find a way to deny your claim for one reason or another. You can surely bet they will be trying.

"You didn't check that the second doctor in your surgery, who came in while you were unconscious was in-networking? Well, too bad, you should have done your due diligence more carefully!"

When we had a kid, it was $10K out-of-pocket, and we had a bunch of "out-of-networking" bingo due to mostly lab tests or a doctor out of network at an in-network ER.

Since then kid themselves also had an ambulance ride (seizure), and that too was "out of networking" in spite of being the only ambulance provider available within 15+ minutes.

The involuntary treatment by out of network providers and them being able to charge you whatever they feel like definitely needs to be outlawed.

What you're describing is completely illegal now. Under the Affordable Care Act, which applies nationwide, insurers are required to cover out-of-network emergency care as if it was in-network care, which means your deductible and coinsurance can't be higher than the regular in-network amounts.

As far as I understand, the out of network provider can still come after you for whatever the insurance doesn’t pay them. In the US, you basically provide your healthcare provider with a blank check.

Everything I said happened under the ACA. It was "only" $10K because of the ACA's out-of-pocket maximums.

A quick google suggests this is common:

> It's important to understand, however, that the out-of-network emergency room does not have a contract with your insurer, and is not obligated to accept their payment as payment in full. If the insurer pays less than the out-of-network emergency room bills, the emergency room can send you a balance bill for the difference, over and above the deductible and coinsurance amounts you pay.

You said

>Since then kid themselves also had an ambulance ride (seizure), and that too was "out of networking" in spite of being the only ambulance provider available within 15+ minutes.

That's the illegal part.

If you say so.

The $1,500+ ambulance bill still existed, I still paid it, and my kid wasn't even born until five+ years after the ACA came into force. The insurance company was "nice" enough to let me count it towards my kid's deductible for that year, but I paid every cent.

People will gladly collect money they aren't legally owed. In this case, unless there is more to the story, you shouldn't have paid it.

In normal countries you don't have that kind of criminogenic environment. Also, do stop the victim blaming.

>In normal countries you don't have that kind of criminogenic environment. Also, do stop the victim blaming.

Stop using "victim blaming" as a way to shut down discourse.

In every country in the world people run scams. Universal healthcare would make these particular kinds of scams a lot harder, but I guarantee you, you could still find this kind of anecdotal evidence of criminal behavior relating to healthcare.

I’ve had that experience too. What makes you think it’s illegal?

For emergency treatments, insurance companies are required by the ACA to pay the out of network provider, but charge you as if you are using an in network provider.

It's possible for the out of network provider to then bill separately from your insurance if they charge more than what your insurance pays out of network providers, but there's no way that's what happened here because $1500 after the out of network fee from the insurance company is far too high for an ambulance trip.

I see. Any parts of the law I can cite if I complain? At least in my case and OPs it doesn’t seem that the law is being followed in practice.

Balance billing is (far too slowly) moving towards being illegal: https://www.commonwealthfund.org/blog/2019/state-efforts-pro...

sidebar: In 1991 we birthed a child at home and the absolute total was around $3500.

It was all out of pocket. At the time, insurance would not cover midwives, nevertheless a home birth.

My neighbor did that 3 times. Didn’t work out so hot for the third kid. I would never consider asking if they regret that choice, but I cannot imagine the grief from losing your child in a home birth scenario.

There's a lot of factors that go into the decision making. I don't want to speculate on their birth team - our midwives only accepted the lowest risk mothers.

For our first birth, a hospital would have been a terrible, terrible option. By the time of our 4th birth (10y later, twins), hospital birthing environments had vastly improved. Our OB/GYNs practice was 100% women w/ midwives on staff. The only thing we missed was having a doula.

They do not deny claims for reasons of just saving money. They employ teams of doctors and pharmacists who double check prescribing doctors’ and whether or not treatment plans are supported by evidence.

If people think multi billion dollar insurance companies are trying to nickel and dime them for medically supported treatments, then I don’t know what to tell them other than it’s simply not in their interest to risk so much for so little.

Explain to me what you mean by "supported by evidence?" Is it some kind of cost-benefit analysis? Because if so that's certainly denying a claim on the basis of saving money.

Supported by science experiments conducted by scientists showing efficacy or causation. It is doctors and pharmacists that deny and approve, and they don’t have information about how much the company is saving if they deny.

The most common denial reason is for doctors ordering brand name drugs that cost 10x more than a generic, but have no data to show they are any better. Or drugs that aren’t shown to have any effect, but doctors just want to appease the patient or experiment.

> The most common denial reason is for doctors ordering brand name drugs that cost 10x more than a generic, but have no data to show they are any better. Or drugs that aren’t shown to have any effect, but doctors just want to appease the patient or experiment.

My diabetic friend has documented bad reactions to the expensive name brand insulin and a couple of others, but not a specific cheap (relatively speaking) one.

His insurance mandates that he use the name brand exclusively and will categorically deny any other form of insulin.

Now, maybe this doctor is just prescribing insulin to a fucking diabetic to appease the patient, but for some reason I doubt that's the case.

> and they don’t have information about how much the company is saving if they deny.

Any denial, is prima facie, going to save money versus paying any claim.

Not if it causes them to spend more on costlier healthcare in the future.

>On paper it may seem to insure you against catastrophic loss, that is, if the insurance company can't find a way to deny your claim for one reason or another. You can surely bet they will be trying.

The most common method of denying claims was that it was a preexisting condition, something that ACA prevents them from doing. The vast majority of people who have health insurance will be covered in event of a catastrophic illness. It's definitely more than just "on paper".

I'm "self-employed", ie employed by the company that I own, and so I have to shoulder the entirety of health insurance cost for my family of 4. Because I'm the only FT employee, we aren't eligible for "business/small group" health plans; which means we either have to buy private health insurance (often not meeting ACA Essential Coverage requirements) and/or purchase health insurance from the 'health exchange' marketplace administered by our state.

The first year, we could actually purchase decent coverage and while it was expensive, it was a solid PPO plan. The past two years however, there isn't even a single PPO plan offered on the exchange in my state -- not one -- I don't even think there were any "Platinum" coverages offered. The end result is that we pay essentially a mortgage-size payment each month and in exchange we get relatively abysmal coverage.

Worse yet? It seems they categorically deny ~75% of claims, which generally means we have to appeal & fight them on it (our success rate is high but it's time-consuming); if it's testing/labs that need done, we also have to front the cash out of pocket to avoid delaying diagnosis & any potentially needed treatment. Often that means $800+ out of pocket PLUS a 4-8 hour time investment over a 3-4 month span in order to try to recoup that money -- all the while, we're of course paying the absurd premiums each month.

Insurance & the financial aspect of healthcare is so completely broken in the US that it's sickening. I believe the problem is so severe that it's really hurting our country's economy and is incredibly stifling for individuals & small businesses. I wish I knew how to fix it. :(

Unfortunately not so much an option for a bit, but medical tourism is the best answer. You can take a vacation and get treatment for less than you're paying just for insurance.

Finding a good doctor is tough to do even domestically, how do you vet foreign doctors? Referrals from doctors you already trust?

I abandoned my business of 15 years last year because of worry about availability of health insurance. It looks like I was in a similar situation to you.

My business was going well. I was making equivalent income of a bit more than a high-end salary for my skill set in my area. I was fine (grudgingly) paying the premiums.

The problem was that there was absolutely no assurance insurance that would actually cover anything would be available in the future. We had "marketplace" plans for a number of years. Eventually there were no "silver" marketplace plans available in my locale (and "bronze", with 20% "co-insurance", means I'm going bankrupt if I have any significant events anyway, so I might as well just have no coverage).

I gave up and took a job. I couldn't expose my family to the risk of not having any insurance available. It was crushing.

I took the route of not having employees and was unable to qualify for "business" plans. I guess I wasn't "successful" after all, since I didn't aspire to grow the business beyond what would support my family.

Stories like these are reflective of the fact that there are higher rates of entrepreneurship in countries with universal healthcare.

it's insane to me that the democrats haven't latched onto this as a talking point... it's a pro-small business move that would spark entrepreneurship that both sides love to talk about. the big businesses know that it will kneecap their ability to retain employees with the threat of losing their subsidized insurance.

Does the "bronze" plan have "out of pocket maximum"? It supposed to be 20% up to the OOM and total coverage after, right?

That is an excellent synopsis of the ACA.

I feel like this is one of the shortfalls of the HSA, if individuals are going to be exposed to this, there should be tax benefits until you can get up to the max out of pocket for your family, not a <4k limit a year.

Check out non-ACA-qualified insurance.

Mine is cheap, low-deductible, and covers catastrophic events. For working numbers, its $415 per month, $2500 deductible and per person/year maximum out of pocket, $5000 for the family. I pay a bit more to get a larger provider network. I had a plan a couple years ago that was < $200/month, $1500/$3000 maximum OOP, but we had to drive across town for an in-network provider.

These kinds of plans were common (and cheaper) prior to the ACA. The biggest change is that the post-ACA plans have smaller provider networks, where before, they were similar to employer-provided benefits.

The biggest "downside" is it is absolutely, no exceptions, cash payments until you hit the yearly deductible. Even then, the negotiated rates for procedures are sometimes cheaper with insurance, sometimes not. So, I had to get a head MRI late last year. Doc wrote a script for a local hospital that would take my insurance, which was a $3K procedure. I called up a local imaging company, it was $615 cash. A little bit of price shopping saved me $1800 ($2500 OOP - $615 or so).

US citizens forgot that a lot of private insurance was really quite good compared to post-ACA plans, and as long as you get "illegal" insurance, it still can be.

>These kinds of plans were common (and cheaper) prior to the ACA.

They weren't comparable because before the ACA these plans almost exclusively had lifetime and yearly coverage limits, and they could raise your premiums to affordable levels the next year if you actually developed a long term serious illness. If you ended up with cancer, a plan like you're talking about would have dropped you like a hot potato after they blew through your $100k a year coverage limit.

But because no preexisting condition clause in aca you just need to bridge the gap to the open enrollment period

And back then folks who, say, had type ii diabetes were entirely literally uninsurable in many states. Generally those states were the same ones where it was also nearly impossible to get medicaid. The outcome of this is a lot of folks committed their fortunes to the local hospital, pre aca was not some halcyon era of good benefits for everyone.

Quite good... if you could get it and stay healthy.

Have a pre-existing condition? Sorry, not available. Get diagnosed with some ongoing or chronic condition? Buh-bye.

> US citizens forgot that a lot of private insurance was really quite good compared to post-ACA plans, and as long as you get "illegal" insurance, it still can be.

This is ridiculous, of course insurance is cheap if you don’t have to help pay for pregnancies and cancer and diabetes and other chronic condition.

I believe I'm correct when I say that there are not protections from incurring excessive out of network fees that insurance won't pay even if you're covered.

As in, you go to the hospital but the doctors that work your case aren't part of your insurance network, so you're given a bill that you're responsible for and your insurance won't pay.

Given that heart attacks can cost up to nearly $1 million to treat[1], and you can't always choose which hospital you're sent to or which doctors treat you, that's a concern.

[1] https://www.cbsnews.com/news/how-much-would-a-heart-attack-c...

Under the Affordable Care Act, which applies nationwide, insurers are required to cover out-of-network emergency care as if it was in-network care, which means your deductible and coinsurance can't be higher than the regular in-network amounts.

Thanks for the clarification.

ACA is just a super expensive catastrophic insurance plan.

I have to budget $2k/month for premiums and about $10k a year for unexpected visits to urgent care or the ER. So about $24k+$10k = $34k a year in after tax income. This doesn't include dental. That is another $4k to $8k/yearly depending on orthodontic treatment.

For example this year, an ER visit is going to cost $7k after insurance. Last year a couple of urgent care visits cost $1k each after insurance.

Even worse, in my market the number of insurers has dropped every year. A competitive "market" doesn't really exist.

The ACA needed a parallel side to the legislation that aggressively attacked medical price inflation: taking on medical liability insurance reform, forcing price transparency across the entire medical system, fixing in-network vs out-network blackholes, etc.

The ACA did nothing to fix the cost of medical care.

> ACA is just a super expensive catastrophic insurance plan.

Because healthcare is super expensive.

> The ACA did nothing to fix the cost of medical care.

ACA did not fix the root cause of the high cost of healthcare, which is low supply of healthcare. But insurance companies have been able to slow the rise in healthcare costs:

https://www.healthsystemtracker.org/chart-collection/u-s-spe...

In Canada, we pay around 7k$ CAD on healthcare, or 5300 USD, with better outcomes. It is expensive, but not 34k$ a year expensive. Actually, about a seventh!

Healthcare providers have far lower incomes in Canada than the US.

Not 3-7 times as much on aggregate , and if that's the case then the US has a problem.

Where are you getting the $7K CAD number from? There's a similar number floating around from the Canadian Institute for Health Information[1] but that same source also lists USA per capita expenditure at $14K[2], and not $34K USD.

It seems that much of the funding for the Canadian healthcare system(s) is funded by provincial tax revenue supplemented with federal transfer payments. There's a reason why our tax system generally works out to be a higher tax burden compared to most American locales.

[1] https://www.cihi.ca/en/national-health-expenditure-trends-19...

[2] https://www.cihi.ca/en/how-does-canadas-health-spending-comp...

Yes, if you have employer given Healthcare and so on you can get it down to around 14k, which is still almost three times more. But if you're buying it on the open market, alone, it'll run you around 30K for equivalent coverage.

Our taxes are generally higher, but not significantly so for the median person, and healthcare spending is, everything considered, cheaper and as good. So the system is more efficient.

>But if you're buying it on the open market, alone, it'll run you around 30K for equivalent coverage.

Way, way off. Median annual cost without an employer contribution for a 27 y/o single person is ~$4700. Median cost for a family of four is ~$18000.

www.nytimes.com/2019/10/22/us/politics/obamacare-trump.amp.html

The 27 y/o single person is not the average case, and that is only the cost of insurance, not including deductibles and other costs, electives, or drugs, which are included in the above mentioned numbers.

Finally, many people are simply not eligible for Obamacare.

Your numbers assume that the average case is spending 10k+ per year our of pocket? That's nonsense. My average year is a couple of hundred dollars. The year my child was born was under 5k.

Those prices are for the Obamacare exchange, pre-subsidy. Who isn't eligible?

Gee, am I just lucky or careless or both? I'm 35 and have not needed a doctor visit for 10+ years. I've gone for perhaps one regular check-up once in the past 5 years and have only seen my dentist in a pub during that time frame.

Stay healthy.

I have a family of four that is thankfully healthy. Things still happen. E.g. kidney stones, an unexpected mass somewhere that needs to be biopsied and turns out benign, falls and scrapes, etc. All need engagement with the medical care system and all are fraught with unexpected expenses. The $7k (out-of-pocket for me) ER visit was billed at $27k to the insurance.

What is "unexpected mass"?

Where I'm from, "falls and scrapes" are generally self-medicated with water and peroxide and don't need engagement with the medical care system unless something's broken. When I was in school, most of the minor accidents were handled just fine by the teachers.

What is "unexpected mass"?

Tumor/growth/lump/etc.

I see, thanks. I've had these two hard lumps in my right leg for like 10 years, perhaps I should tell a doctor or something.

At my healthiest at 31, tons of marathoning and cycling going back a decade I got appendicitis out of the blue, it was $35k and about 15 minutes in the OR.

Back to healthy now but wow that literally came out of nowhere and I learned a lot of humility about the parts of my body I'm not bruising/breaking.

Yes, I'm not surprised at one-time unexpected expenses. I'm surprised people casually mention several urgent-care visits a year as if it was normal.

Appendicitis can be prevented through dietary choices and the total out of pocket max for a catastrophic health plan is 15k usd at the worst

I was about 10% bodyfat and literally in the best shape of my life when it happened. If you can expound on the dietary thing I'd like to hear it. I've heard ideas that its a bile duct blockage but I've never seen any correlation between what blocks that duct and what you eat in any studies.

Believe me, I was curious after having my organ ripped out after crawling into the ER after driving myself to the hospital and experiencing my first surgery ever in my life that charged my insurance company $35k.

I heard eating certain things can trigger appendicitis. I haven't heard about any diet that would reliably prevent it.

Seeds and other hard to digest foods cause appendicitis. It is a dietary choice to avoid nuts and seeds. These bits can get caught in the location of where the appendix is and eventually cause an infection there.

Oh, if they only charged your insurance company 35k, that's actually a bit cheap for that surgery. Usually they charge closer to 50 or 75.

> that charged my insurance company $35k.

WHAT THE FUCK.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2966171/

> PATIENTS AND METHODS

> Data were collected prospectively on patients undergoing laparoscopic appendicectomy within Leeds Teaching Hospitals Trust. Theatre and bed costs were obtained. Cost analysis was performed, and costs were compared to the re-imbursement due.

> RESULTS

> Fifty laparoscopic appendicectomies were performed. Median operative time was 60 min. The median total operative cost of laparoscopic appendicectomy was £906. Median equipment cost for laparoscopically completed cases was £254. Median total in-patient cost was £1617 (range, £880–£3360). This compared with a mean re-imbursement of £1981 representing a cost benefit of £233 per case (P = 0.0009).

Wild huh? I think insurance paid $500 for one 500mg Ibuprofen. Even drove myself to the ER, no ambulance, that'd be another $10k I'm sure.

https://khn.org/news/appendicitis-is-painful-add-a-41212-sur...

> Appendicitis can be prevented through dietary choices

This is untrue. Appendicitis caused by plant seeds are a minimal number of total cases.

Then what causes it? Appendicitis does not have a random global distribution. Neither do dietary choices.

Not knowing the answer isn't carte blanche to throw your pet theory out as fact, either.

Shit can happen to any of us. One day you’re healthy, a few days later and you’re recovering from surgery for a “bad luck” cancer.

Get your checkups so you have a chance to catch the freak issues early.

> Get your checkups so you have a chance to catch the freak issues early.

Or pay rent. Either one is good.

> The ACA needed a parallel side to the legislation that aggressively attacked medical price inflation: taking on medical liability insurance reform, forcing price transparency across the entire medical system, fixing in-network vs out-network blackholes, etc.

Most of the text of the ACA attempted to do exactly that. The problem is that there are no simple answers, the rhetoric notwithstanding. The ACA created rules and processes built around consensus advice for controlling costs, but predictably the results were more meager than the rhetoric and studies claimed. But it was always understood that would likely happen. Much of the ACA also included data acquisition and feedback mechanisms that would feed into both regulatory committees and into subsequent reform legislation. But the GOP stonewalled both mechanisms. Remember, their sole desire was repeal. Replace or even supplement was never on the table for most of the past 12 years, and offered proposals were never made in good faith because they were always patently deficient.[1]

To the extent the ACA has failed (and that's debatable because people have very rose-colored glasses about the previous state of affairs), it's because it was deliberately sabotaged.

[1] For example, prohibiting denial for preexisting conditions but removing the universal mandate is patently not fiscally viable! Certainly not without a hefty tax increase to reimburse insurers, a process (temporary under ACA) which the GOP also subverted. That's not even Econ 101, but Kindergarten Econ.

> If anything, it does insure you against catastrophic loss. ACA took away maximum benefit amounts.

This statement is nominally true, but it doesn’t stop insurers from trying.

For "emergency"-type catastrophic loss, it's not always clear when your "emergency" ends. Once stabilized, if you’re in an out-of-network hospital, you may begin to accrue costs that are not going to be covered. And of course, sitting there in your out of network hospital room, with out of network tubes in your body keeping you alive, talking to out of network nurses and doctors, your first thought should not have to be “how do I get to an in-network facility?” And when you do finally get home, and get balanced billed, and every conversation with your insurer starts with you re-explaining your heart attack, or stroke, or pregnancy complication, and you are on month three of $75k bills from your out-of-network hospital (in month five it goes to collections!), it is small comfort to know that your insurer is technically in violation of the ACA, and that with the help of a lawyer and your state’s insurance commissioner to sort things out, you might get them to reimburse your $75k payment to your out-of-network hospital.

For medium- or longer-term illness, this is more true, but the onus is still on the patient to stay on top of shifting networks and shifting plans, shifting adjusters, all typically while sick.

The ACA plugged a bunch of holes in the previous disastrous patchwork, including absurdities like annual and lifetime limits, pre-existing condition exclusions, plan nonrenewal on illness, etc. Those were necessary bandaids, but there are still holes.

Ask me how I know.

It does if you don't have an EPO (like say, most grad students) and you end up with an emergency at a out-of-network hospital. How plans like EPOs are legal baffle me every day.

The insurance system is completely broken, but the bankruptcy protection system isn't!

I used to vaguely know this illegal alien sushi chef who had two kids. Nice enough guy, made good sushi, liked life in California; probably still works in the same place in Mountain View. I was always confused as to how he afforded two kids living in Mountain View. Well, it turns out, in California, the state apparently pays for it. I mean, he was a nice guy, and family formation should be a priority for any sane government, but the idea that you get subsidized if you break the rules and penalized if you don't kind of rankles.

> Well, it turns out, in California, the state apparently pays for it.

Pays for what? His sushi chef salary? His kids' medical bills? Housing?

California paid for all the hospital bills for childbirth, all the subsequent doctors bills for the kids. I have no idea how he paid his rent; probably by making sushi. Only reason I knew about the kids thing was by asking. He was kind of surprised that wasn't available for everyone, like, you know, citizens and people like above who was worried making a baby would bankrupt him and his fiancee.

I assume it was ordinary Calmed and his job was off the books; didn't pry into details.

>you know, citizens

It has nothing to do with immigration status. Medicaid is available in California for people making below a certain income.

I kind of said that. Meanwhile, legally employed OP above fears bankruptcy for putting a baby in his fiancee. Good job America.

>He was kind of surprised that wasn't available for everyone, like, you know, citizens...

It is available for citizens. Citizens who make below a certain amount. If the OP's fiancee lost her job and didn't have medical coverage, she would qualify for the same insurance your sushi chef did.

Although I think it should be available to everyone regardless of income. The sushi chef should have access to the same level of care that I do regardless of their income. The solution to this specific problem can't be to eliminate health care for the sushi chef.

> California paid for all the hospital bills for childbirth, all the subsequent doctors bills for the kids.

> that wasn't available for everyone, like, you know, citizens

The kids are citizens though...

And as learc pointed out, it's available to anyone below a certain income. In other words, the California taxpayer is subsidizing that sushi restaurant and paid for part of your meal.

Yeah people making poverty wages qualify for subsidized insurance in some (all?) states. It's cheaper for the state than having them use the ER for everything.

> Thank god her previous employer had good medical insurance so we could do COBRA. Now we just have to have a kid within 18 months of her separation date.

We're lucky to be in positions to be able to afford COBRA. I used it about a decade ago, and the premiums were over $2k a month. I don't think that most people can afford anything like that while they aren't working.

How much were you expecting it to be?

I don't know about OP, but where I am the cost of the average vaginal delivery is ~$8k and the average c-section is ~$12k on top of that, so ~$20k. C-sections account for ~30% of the births where I am. Complications with the birth will add to the cost.

The devil is in the details though. I don't know if Medicaid is factored into these averages and I don't know what the median cost is. Individual insurance will vary wildly, and the specifics of every delivery also vary wildly.

You could be paying $0 or $100,000, it's a total crap-shoot.

Brutal. I've seen a lot of people advertise giving birth in bathtubs (or small pools) with just a midwife. Now I'm starting to wonder if that's a response to the high costs of hospital delivery.

That's exactly what it is. We did a lot of research on this to try to keep the costs low, but the risk of complications with delivery requiring us to then go to the hospital is high enough that this doesn't save us any money. It just makes it more likely she or the baby will die from complications before they get to the hospital.

We birthed at home (& later at birthing centers) so my wife could be appropriately in control.

She's a chemical sensitive. Staying out of a hospital was the only way to keep some rando hospital staffer caked in perfume (or Tide) from walking in & triggering an 8 hour migraine.

We used a birthing center, twice. In conjunction with medical insurance from a large local employer, the births and associated pre/post-natal visits each cost us $500 out-of-pocket roughly a decade ago.

The insurer, not surprisingly, was happy to have us pursue that route. Hence including pre/post-natal care in the bundle.

Now, the birthing center screened for low-risk mothers and we were indeed lucky. Still, a considerable fraction of the population should be able to to access, at low cost, "technology" that we have exercised as a species since time immemorial.

Adding to this, another reason I hate private insurance is the concept of networks and claims. It doesn't really matter what insurance you have.

I have an upper-middle tier PPO, and still two doctors offices have turned me away because they don't accept it... completely boggling.

Not to mention the herculean efforts you have to put forth to synchronize your personal health records / documents between offices and systems because everyone is using different nightmarishly siloed systems (although in theory will start improving eventually thanks to the FHIR standard, but still change in healthcare is SLOW).

If it was like that between US states, I would understand. But between offices up the road from each other? Give me a break.

In my opinion, the only thing we have that works well is Planned Parenthood, which I've used a couple of times and attest that they are just phenomenal. Unsurprisingly they also happen to be a non-profit. For-profit does not work for everything, and thinking it does (or should be a requirement of capitalism) is completely lacking in imagination and empathy.

Why not just use on HMO?

HMOs are poorer quality insurance. PPOs you don't need referrals - you don't have to make two appointments if you need to see a specialist or convince your primary care doctor it's necessary.

Why wouldnt you get an opinon from your doc first before getting a specialist you might not even need?

> it doesn't actually insure you against catestrophic costs.

Unless you're old enough to get medicare.

Works for the people who vote :\

It's drastic, but are you in a position to emigrate? Canada still has Jus soli citizenship and if you can pull it off you might be doing your child a big favour for just the reasons you state.

I’m so sorry you have to live with that system. I’m in Australia and had my first child not that long ago. After multiple hospital visits due to ongoing complications during pregnancy, an induced labour and an emergency c-section followed by a week in hospital for my wife to recover...the only thing we had to pay for was parking at the hospital and a few meals for myself at the cafeteria.

The whole ordeal was stressful enough but the financial aspect was never in our minds. I can’t even imagine having to add financial stress on top of that.

What is community for? What is society for?

Community is for mutual care, support, and education. A society of communities is for betterment and civilisation. These are not hard things to do but they require ethics and sharing and must be protected. They are vulnerable to barbarians.

It is barbaric to create a predatory environment where the powerful manipulate the poor for profit and then cast the poor away when they are sick.

How do people on the Maury Povich show manage to have five children? Or what about other Darwinian success stories such as this gentleman? <https://www.google.com/amp/s/www.dailymail.co.uk/news/articl...

I think the problem is that you want both children and an upper middle class (read: upper class) lifestyle. But that's not how this works. You are going to consume a lot of your resources in creating and raising children, but you will gain the wisdom to rebuild those same resources and in the end finish with more than you started (timescale: 20-40 years)

EDIT: Povitch -> Povich

I don’t. Already had one! I had full coverage and got sent to a hospital that wasn’t contracted with my insurance company. 4 days in the hospital for a bike accident with 6 broken bones and surgery cost hit me back with $100k in out of network hospital bills.

I don’t know if this is still the case, but in 2006, San Francisco General Hospital (now the Zuckerberg themed hospital) was the only level 1 head trauma hospital in the city. I had head trauma and was forced to go there. I asked them if they took my insurance. They said yes. What they meant is they’d bill my insurance and hit me with anything insurance wouldn’t cover. That ended up putting me into a spiral of depression that took years to recover from, on top of the physical recovery. What a shit show.

Yea, one lesson I also learned the hard way is to stop asking doctors if they "take my insurance". They all will gladly take your insurance, meaning they take the insurance card and laugh at you while knowing that none of what they bill will actually be covered.

Don't ask the doctor anything. Ask your insurance company whether the doctor in question is in-network. This of course assumes you are conscious, and can do such due diligence.

Yup. 100% correct.

This is extraordinarily dystopian.

This reads like something straight out of a William Gibson novel. How much longer can Americans tolerate this ever-worsening shitshow of a system before something gives? What will that look like?

so insurance didn't cover anything?

You had a $100k bill that you ultimately had to pay for?

that sucks man

Insurance coverer half, and they went after me for the rest.

That sounds dreadful, sorry to hear. Out of curiosity, has that changed the way you'd vote? As in, you'd pick a candidate based on their health care program?

Anyone who thinks we don't need health insurance for everyone doesn't understand how insurance works and/or has never been in a compromising health situation. The more people have health insurance, the cheaper it gets. Taking away the incentive to profit for healthcare sounds good to me, too. I truly don't understand arguments against healthcare for all, because there's no financial argument against it that makes sense, unless you one of those that profits from people been somehow unhealthy. But politics isn't about being rational, it's about power & influence & control, and that makes me sad.

Your story is incredible. I hope you continue to share it as frequently as possible. It's the only way people will start to wrap their heads around why things need to be changed.

If you have severe head trauma can you even consent to anything? As in, if you were completely unconscious when they found you, and they took you to that hospital, would you be on the hook for the bill even though you never agreed to be taken there?

The healthcare system in the USA is set up to milk you like a the cash cow that you are, and it does not require your consent to start doing that. Most of the time I think you can opt out of receiving treatment, but I'm not 100% sure about that, and to your point, you may not be in a position to opt out.

I had cracked my skull & scraped off half my face on the asphalt. I was in shock. The took me to the hospital the moment I couldn't answer some of the basic question that first responders ask. If I recall correctly, they asked me what day it was, and I said knew the answer, but that I needed to think about it. I was most definitely not in my right state of mind, but I was not in a position to deny treatment, let alone navigate the finer points of in & out of network care.

SF General is an absolute cluster. It’s mostly for indigent care, so the SF Board of Supervisors tells insurers to f-off when it comes to contracts. Or at least that’s what I’ve read in the local media.

And this is a hospital run by the local government.

Ouch, I also went to a level 1 trauma hospital after I got hit on my bike (no head injuries, but broken pelvis, femur, vertebrae, ribs), but Kaiser covered almost all of that (to the tune of $250K). I ended up with maybe $40K of out-of-pocket, and recovered that in the insurance settlement (Kaiser even agreed to only take $125K of the settlement, which was friendly of them). Not the best lottery to play, no matter what, but I'm sorry to hear your experience was so terrible.

No price transparency, no ability to choose between doctors, your job decides your insurance.

There is no room for a market to function in our health system. With no ability for consumers to move around or even see the differences between different providers, prices will naturally go up, and there will be no pressure to improve care.

I haven’t done a ton of research - do you know of any big healthcare bills have been proposed that resolve these issues?

Medicare for all

I do not want my health insurance provided by the people that gave us the VA. Look at how "the best of us" are treated by the government when they're no longer needed.

How will they treat me who never served them?

> I do not want my health insurance provided by the people that gave us the VA.

I mean, those same folks give us Medicare, which is both quite popular with the public and gets better marks on results, cost, and efficiency than private healthcare.

I see no evidence my insurance company cares about me any more than the VA cares about its patients. Does the VA have problems? Absolutely. Is "give up and give it to for-profit corporations" likely to fix that? Nope.

I’m not sure being private is the issue. Medicare Part D (pharmacy) is entirely run by private insurers, Medicare just funds it.

And Medicare Part C is a private insurer option, where again, Medicare just funds premiums.

It’s how the system is set up that’s the issue, not whether it’s managed by the government or a private insurer.

Private insurers have a profit motive which is hard to align with public interest.

Do you know if Medicare Part D insurers are able to get drugs at a lower cost than the Canadian system does?

Private insurers do have a profit motive, but with the right regulations, that can help, rather than the US system where it encourages more spending. There are plenty of countries with universal coverage that rely on private insurers - the difference is the system is set up to control costs while providing a pretty standard set of benefits and cost-sharing.

So one reason why Medicare Part D works pretty well is because the private insurers do the negotiating on drug prices. I've read reports that they actually get better prices than for their private plans (there is a ton of competition for Medicare prescriptions).

Are the prices lower than Canada? No, not generally. But they are some of the lowest prices in the US (excluding Medicaid which has a mandatory discount).

Would you settle for a public option? So then you could choose either private insurance or Medicare.

That's the beauty of medicare for all, you can still buy insurance on the private market if you want to. For what it's worth, Medicare itself already does a pretty good job being the single largest insurance provider in the United States.

Comparison to the VA is not apt. It's not the same people, it's not even the same concept as M4A.

The VA isn't a great thing to compare medicare-for-all to. The VA's entire customer base has afflictions you just don't see in the general public.

I'd compare M4A to Medicare/Medicaid, if you look at patient surveys they are much happier in general than people who have to deal with insurance companies.

We really should fix the VA though too.

Yes. I do not know why Democrats block bills to fix the VA.

Tried to find what you are talking about. Turned up a lot of political meme's basically saying vote for Trump, because democrats tried blocking the VA Mission Act. Looked up the actual vote counts and it passed successfully with strong bipartisan support in both the house and senate [1]. Are you referring to something else?

[1]: https://www.congress.gov/bill/115th-congress/senate-bill/237...

If you're referring to Veteran's Choice, while Trump repeatedly and falsely claims to have created it, it was passed into law and signed by Obama in 2014.

https://www.cnn.com/2020/08/08/politics/trump-veterans-choic...

Why do you think Canada and Japan and England and Australia can do so much better? We (Americans) debate universal care like it's some radical idea. We pretend that there aren't successful implementations with different configurations all over the world.

They're also the same people that brought us Medicare, and people eligible absolutely love Medicare.

The VA's problems are in no small part because of the way it is structured (i.e. duplicate facilities, staff, low salaries, etc) and funded (combined with other military appropriations). If VA benefits were provided via Medicare it would have a structurally better system.

My father received good treatment from the VA, from bypass surgery to treatments for various complications from diabetes to a long recovery period from a stroke. So the whole system isn't broken.

I'd be happy with that level of care compared to what's currently available for everyone, which is none.

It doesn't have to be administered by the federal government. Every state can set up and administer its own system, like Canada does.

For those unfamiliar, this was the last bill introduced.

https://www.congress.gov/bill/116th-congress/senate-bill/112...

https://www.congress.gov/bill/116th-congress/senate-bill/112... is a pretty good one.

Latest Action: Senate - 04/10/2019 Read twice and referred to the Committee on Finance

I wonder what that means. I really hope something like this passes at some point.

Thanks. The comment I replied to seemed to be lamenting issues with an open market insurance system, which to my knowledge, Medicare for All is not. Am I missing something?

It is my opinion that the simplest way to fix the ills caused by an open market insurance system is to abolish it and replace it with single-payer healthcare.

I can't think of any other business that can get away with not even giving you a ball-park estimate on costs. If my car breaks down, my mechanic will at least give me an estimate within a hundred bucks or so. But a hospital has no idea what it will cost (and neither does insurance) until they finally negotiate that specific case.

Another issue is that insurance does not have to compete across state lines. They've divvied up the country and are sticking to their corners (much like ISPs).

Insurance should be required to accept customers from anywhere in the country. Hospitals should be required to publish prices. These seem like no-brainers to me. But hospitals and insurance make too much money, and give too much of it to congress for any real change.

Why should a hospital have a price list? Does the fire department? The police?

Both public services which don’t directly bill you. Maybe something like a public health system is a good idea...

Hospitals are not particularly equivalent to fire departments or the police, since the latter two are paid for by taxes. Some hospitals definitely do get some money from taxes, but as far as I know that isn't the norm.

This is my point... it should be a public service paid for by tax.

They do have a price list. I receive it every year as my property taxes.

Does the fire department

Apparently there are unincorporated areas that do not have fire service from the county but you can buy fire service from the nearest city's fire department. If you do not have fire service the firemen come and watch that the fire does not spread from your property to the neighbours who have service.

This ends up just as you would expect. The poorest and most indigent go without, and then there's death threats, newspaper coverage, the works. You wonder why people are permitted to make themselves wards of the state because if your house burns down your biggest savings vehicle is gone and you are homeless and a burden on the public pocket.

Similarities with medical coverage are incidental.

The police sure do for tickets they give. Those penalty fees are all set. Hospitals should have listed fees for procedures.

Well, they have a publicly accessible price list in most hospitals out of USA.

Actually, hospitals do publish prices. Well they do and they don't. As in, good luck finding that price list. The Feds require them to do that so hospitalizations can be indexed for medicare.

I would go further to say that what we have in the US doesn't even meet the minimum definition to be called a market. In addition to what you cited there is also massive regulation which can't be removed due to the nature of medicine, there is massive information asymmetry between patients and everyone else, and, oh yeah, the fact that a sick or injured person can't "shop around". It's insane.

When my wife was in the hospital for days after a C-section, we were entirely at their mercy. They could add anything they wanted to our bill and we had no idea if it was justified or not.

At the base of this pile of bullshit are simple, incontrovertible facts:

Health providers make money when their customers are unwell.

Insurance providers make money when they don't deal with the most vulnerable people.

Employers only care as far as keeping their employees able to return value.

Maybe all of that says that healthcare can't be a market. Due to its very nature it's not suited to fit in a market model.

I don't understand why the USA is so adamant to see that forcing market solutions to every societal demand or problem might not be good a thing. To see that this ideology has had time enough to prove itself in the real world and has been found lacking. We need something different. Accepting that there are no absolutes and that perhaps some things shouldn't be market-based doesn't sound too revolutionary for a start...

There are markets that can work in healthcare, but my point is that individual patients CANNOT partake, they don't have the information, power, or even agency (ie. currently bleeding to death). There could be a market of providers to payers, but again, care must be taken to ensure the interests of the payers aligns with the interests of the patients.

Is there a country where market based health insurance works? Specifically where it works without there also being a strong public health insurance option. For instance in Germany you are required to be insured and as a young healthy person you can save money by choosing a private option. But eventually as you get older your insurance costs will go up. So most people choose and are extremely happy with the public option TK.

A private health insurance marketplace seems like the type of industry ripe to take advantage of consumers. And what if the health insurers in the market conspire to fix prices? The government or a class action suit could fight against it but that's the type of corrupt business practice at large that could take over a decade to correct.

Switzerland I think, but only from stories I’ve heard.

I'm not sure you can consider the US "market based" anymore, given that the government is paying for most of it: https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2015...

I don't know what to even call it. A bizarrely paid for fragmented national health system with a goofy market component?

Yep. I've been thinking about retiring, and almost certainly would have already if not for the twin spectres of private health-insurance cost vs. unreimbursed medical expense risk. And I'm one of the lucky ones, with healthy savings and no significant medical issues. If it feels like Scylla and Charybdis for me, how terrifying must it be for those less fortunate?

Have you considered retiring in a different country?

Absolutely.

Australia is very easy to emigrate to as a technology professional and has a relatively good universal healthcare system.

EDIT: @robotbeat: Yes, but I have lost my confidence in the US Congress and the electorate. Until that confidence is restored (Medicare For All is passed), I have to make plans to live in a functioning nation, as a single healthcare event can wipe you out entirely. I would rather pay more taxes (yes! I like taxes, with them I buy civilization) and take my wealth to where sanity prevails (and like minded citizens vote for representatives who vote in their electorate's interest, instead of against them).

@wintermutestwin: https://techwireasia.com/2019/08/australia-decides-to-keep-t...

https://immi.homeaffairs.gov.au/visas/working-in-australia/v...

Won’t you be eligible for Medicare once reaching retirement age anyway?

To me, M4A is about everyone BUT retirees. Just lower the eligibility age to zero.

I'm 55 now. Medicare will definitely be a big help a decade from now, but I'll still be carrying the full cost until then and some kind of supplementation after that. It's OK, I'm not complaining about my own lot, but if it's a concern for me in the 1% then it's a true burden to others.

100%. Medicare is available for a good chunk of voters, they have a "fuck you got mine" attitude so nothing better for the rest.

Until that confidence is restored (Medicare For All is passed), I have to make plans to live in a functioning nation

Where you will then be a target of U. S. foreign policy. I'm still on the fence about which I'd rather face.

I am very curious to know how "tech pro" changes the AU immigration process. My spouse is actually an AU citizen and it looks like a very complex/expensive/variable process for me to emigrate there. Any info you could pass me would me much appreciated.

And yeah, my retirement plans are based on going somewhere with a sane health care system too...

Are you a US citizen?

Where are you getting the information that Australia is "very easy" to immigrate to as a tech person? That is not my experience from multiple data points, and that was before covid.

One guy I know was denied a renewal to continue working at his company, which should be a steady state formality. He was making a great wage, not eligible for Medicare and the tax bracket is punishing until you have PR. He was a cash cow win/win deal that my country saw fit to pass on.

It may be easier than moving to the US, but compared to NZ or Germany, the other countries I have first hand experience with, it's practically Fort Knox.

In fact it's widely seen as easier to immigrate to NZ first then use that to get to Australia, though that differs with policy changes and your occupation.

I'd recommend NZ anyway, at least if you're semi retiring. The wages aren't great but everything else is better.

Apparently they're making it easier for people in tech post covid - https://ia.acs.org.au/content/ia/article/2020/skilled-tech-m...

This doesn't seem to be making it easier than before, just making an exemption to our current blanket closing of the borders.

> how terrifying must it be for those less fortunate?

The people I know who are less well-off than me simply don't think about it. If the topic does come up, "well, guess I'll die" is the joke-but-not-really answer.

I know someone who was involved in a rather severe traffic incident where a driver disregarded the "no left turns" signal and cut across the bike lane where the person I know was riding a bike. The driver hit her square on and broke her right leg and caused her to fall to the ground and hit her head on a curb, and the driver subsequently left the scene. She (the person on the bicycle) is uninsured and now has several thousand dollars in medical debt that she is largely unable to pay and additional medical needs that are going unmet.

Situations like these, where I can be doing everything right yet still fail, are why I do not leave my job at a FAANG. I am largely healthy, though my spouse and kid have a couple of (minor) medical conditions, yet I am absolutely never going to be without the A-One-Top-Tier-Super-Golden medical insurance my employer provides.

I have wanted to start my own business or simply move to another job at another employer where the benefits are not as glittering but I cannot justify the risk.

Before the pandemic I was a "digital nomad" and I had private health insurance that covered me literally anywhere in the world... except the United States. And here's the kicker: one year's worth of coverage was less than one month's worth of health insurance in the US.

United States prices are so out of whack with the rest of the world, they can’t even be included in worldwide insurance without drastically increasing premiums

It's impressive how bad the US employer-provided healthcare system is for the privileged.

Back when Obamacare was being debated, people had to be reassured they'd be able to see the same doctor... I guess that's how they get away with it?

More between the lines: Half of Americans know they're under-insured and haven't done/can't do anything about it.

A deeper cut is that some Americans are just rolling the dice, they could afford better insurance but choose not to, even though after they got hit with a huge bill they would probably say something like, "in hindsight I probably should have paid the higher premiums for better coverage and could have taken a vacation to Missouri instead of Europe."

But there are also a lot of Americans that may not be able to afford higher premiums, even if they were better at budgeting.

And then politicians pick and choose which group of people they use as examples when talking about the healthcare system, depending on their goals/party. The truth is that both of the previously mentioned groups exist and get screwed if they have an emergency. It's a easier to say "tough luck" to the first group that was rolling the dice, but I would love to see actual change in the healthcare system.

I did my dissertation research using insurance claims data, so I've seen the actual amount of money that's changing hands and it's ridiculous. Even if normal people were able to get the negotiated rates that the insurance companies get, most families could not afford a surgery and week long hospital stay. I don't know exactly what the solution is, but I think one of the main roadblocks is that there are some people making a bunch of money and they are quite happy with the way everything works right now.

Related to this is the cost of care in the United States versus the outcomes is completely out of band of the rest of the world. So not only are you trying to budget for expensive healthcare, that expensive healthcare doesn't get you better outcomes on average anyway.

> I did my dissertation research using insurance claims data

Is your research published publicly anywhere?

It is currently embargoed and the raw data will never be released because of HIPAA. I didn't focus on the costs, so even when my dissertation is published next year the costs won't be discussed. It's just one of those things that I couldn't help but write a quick query because the information was present.

There were a few extreme cases where a person had over 10,000 claim lines in a single year at a cost of millions of dollars. And insurance actually paid, because I only saw adjudicated claims. But a more typical person has a dozen or so claims costing maybe a thousand dollars in a year. There are also people that go years without a single medical encounter, but as soon as they need treatment for something it tends to be an expensive year. The issue I see is that most people probably don't have good enough savings habits to be able to afford basic healthcare if they don't have their premiums on autopay or pulled out of their paycheck before they have a chance to spend it. So although most people could save $1k in a year, insurance is like a savings account that you have to make deposits to and can bail you out if you really need more.

This is ridiculous. I'm what most here would consider pretty conservative, but even I have trouble understanding the arguments against universal healthcare. Do that many people exist that really vote against it? Please don't point at ACA, that was nothing close to it.

Disinformation campaigns.

ACA has one important aspect of it, which is the universal coverage mandate. Plenty of people have voted against that. You can't have your cake and eat it too.

It polls favorably but the GOP won’t vote for it, likely because of ideological (Govt is bad!) and financial (insurance industry lobby) reasons.

It seems to me that the former is a convenient excuse for the latter.

I still remember when Trump was campaigning in 2016, someone asked him about health care (I don't care to look up the specifics). He replied pretty vague that he wasn't going to let people just die. The audience boo'd. I still can't believe it. Most Republicans I know aren't even steadfast against it. It really feels like the lobbyist/business people/politicians are trying to paint a different picture than reality.

Edit for clarity - This wasn't a rally, but a small event of 'suits' in the audience. Perhaps a debate?

What is Biden wins the election? Democrat Senate + House + POTUS would make UHC actually within reach, no?

Possibly, assuming Democrats get rid of the Senate filibuster.

I haven’t checked what Biden’s plan is currently, but I assume it will be something that strengthens Obamacare. But ... you never know, Harris would be VP...

Biden is against UHC I believe. He said he would veto Medicare-For-All in a debate.

Biden has repeatedly said he would veto Medicare for all, and the program was pointedly left out of the party platform despite 87% support among democratic voters.

AFAIK universal health care is a fairly popular idea in the US, including by self-identified republicans.

If an idea isn't triggering action, does it really matter how popular it is?

"Universal health care" is actually a broad term. The problem is that people agree on the broad principle, but disagree on the details and can;t come to a compromise. Thus, nothing gets done.

Not for lack of trying. It's only ONE person who is blocking action, which is Mitch McConnell refusing to even consider bills in the senate.

It is still in the power of the people to replace him as majority leader of the Senate, if they want to unblock that logjam.

He's elected by his peers in the Senate. They're all responsible for blocking action.

True.

The problem in the US is that a large chunk of the population have been trained to be anti-tax regardless of goal.

They'll support Universal Medicine hypothetically but as soon as you talk about the required payroll tax they'll oppose it, even if it is lower than they're paying now in premiums. Then the conversation will immediately turn into a "government cannot be trusted"/"stealing my money" etc.

People will love it once it is online, just like the ACA/Medicare/Social Security, but getting it online is politically radioactive and will sink both the politician and party until people realize they love it.

Yes. It means that you can make the action happen if you can fix the broken reward model.

(What is the political equivalent of dopamine signalling?)

From a third-world immigrant traumatized by dysfunctional govt. institutions back home, and seeing some spectacular cockups by state-run institutions here, what is the guarantee that UHC won’t be worse?

There is no guarantee - but the more immediate problem is that talking heads spectacularly amplify such doubt for shallow political reasons. Similar to how "free college" gets turned into "communist mass starvation".

A significant percentage of the US is descended from those who abandoned the life they knew to move across an ocean because they were so afraid of a neighborhood or government conspiracy to murder them.

For example: My wife's father's family.

The relatives that didn't flee Europe were murdered in the early 1940s by a German government conspiracy.

There are plenty of ways to phase a transition to mitigate concerns. It makes senses to take an approach like that. It doesn't make sense to continue the status quo.

For any other change, there would generally be a preference from people to phase the changes, why not healthcare too?

I assume you believe there are some things the American government does better than your home country, otherwise you wouldn't be here. Why are you so worried it'll turn out poorly?

The real arguments are too dark to say aloud. E.g. without the perks over civilian life, the military would be unable to recruit a volunteer force large enough for empire.

Is this actually a thing, joining the military to get healthcare?

It is definitely a perk. That and cheap housing, paid-for education and years of experience in whatever field you get put in. The army and marines sent recruiters to my high school in a poor area and I got to hear about all these things twice a year. The military is a way out of poverty for a lot of people.

This is not the first time I'm hearing that US recruiters use health insurance or college education as a lure for poor teenagers.

Kinda, same with college tuition.

If you made university free for everyone the Reserves would take a hit on enlistment, same with active duty but to a lesser extent. I'm a vet and those things were huge in making my choice to join, lots of family and friends, fellow service members have echoed the same.

The military is largely downsizing though in warm body count so it might not matter much anymore.

Also a thing: intentionally committing a crime for the sole purpose of getting healthcare in prison.

These are really inefficient incentives. With UHC it would be possible to lower health costs, freeing up budget for the military to increase wages for recruits, for example. In HN language, this is tight coupling that in the end would work far better in a loosely coupled manner for both UHC and the military.

ACA was nothing close to it because our voters don't allow us to get closer than that, as far as I can tell. I don't think people actually oppose universal healthcare, they just oppose the worst case scenario of its implementation, or some bastardized version of it, that is constantly emphasized by the politically/socially/economically powerful people on their side of politics. Some people even oppose it simply because it is associated with the other side of politics - that's frankly all it takes sometimes for an issue to be a non-starter.

It's hard to get closer to it as a voter when we don't have anyone to vote for who isn't bought and paid for by Super PACs funded by insurance companies. It's tantamount to bribery and the only reason we aren't prosecuting people like former Senator Joe Lieberman for killing the public option is because people like the former Senator were the ones that wrote the laws that make such bribery legal.

I dont think many Americans are aware of the underlying issues with the system. The arguments against it are also rooted in valid concerns even if they're exaggerated beyond belief. So yeah, plenty of people will vote against it.

ACA was as close as “conservatives” let the US people get to universal taxpayer funded healthcare.

> Do that many people exist that really vote against it? Please don't point at ACA, that was nothing close to it.

During the debate surrounding ACA, single-payer healthcare was not deliberated in congress. Nobody really got the chance to vote for or against it, or express much in the way of pleasure or displeasure with representatives in support or opposition.

Here, let me explain.

The average wait time at a Starbucks in my town is about 18 minutes because of the number of people who are in line. Starbucks is seen as a great independent business whose lines are just a byproduct how successful they are and representative of capitalism.

The average wait time at the USPS is about 10 minutes in the same town, which largely includes people having to fill out forms for packages. This is seen as an inadequate and inefficient endeavor by a government that spends way too much money.

Because the wait time for the USPS negatively impacts their livelihood, they would prefer to go bankrupt or watch people kill themselves via untreated illnesses (because they can't afford to get them treated) than submit to a single-payer system, even if they had the option to supplement the public plan with private insurance.

Until they turn 65. Then suddenly they're for it, as long as the younger people still suffer.

Americans tend to judge capitalism by its successes and socialism by its failures, even though any modern functioning society is going to have a mix of both.

I'm aware that nearly all nuance in discussing economic systems has been absolutely obliterated, but I must say that I can't think of any modern functioning societies that actually mix (the socialist bedrock of) public ownership of the means of production with (the capitalist bedrock of) private property on a macro level.

Lobbying.

Many of the industry actors make bank based on spread, which incentivizes lack of downward pressure on prices in order to get allocated bigger chunks of money to manage as float. This increases earning in the event your risk pool is on the lighter side, and ensures that all actors material to price point fixation converge on price increases.

Medicare/Medicaid don't factor into the price point equation, because they aren't allowed to negotiate as a private market actor, and are considered by most who got into the U.S. medical industrial complex as a price of doing business to cash in on the fundamentally dysfunctional market.

Until you can get a straight answer out of insurers/hospitals/medical practices how much something will cost ahead of time,you won't get sane downward price pressure.

There's also the F'd Medical Education Complex issue and cartel as well, but that's another issue.

Full disclosure: Working somewhere that's trying to remedy at least a part of this dysfunction.

I'm assuming by "universal healthcare" you mean single-payer. I think the biggest problem is that changing who pays for it doesn't actually fix the problem. You've still got the most expensive, least effective healthcare system in the world -- now it's just financed with your tax dollars.

Not necessarily. Right now, hospitals/doctors/etc can tell insurance companies to pound sand if they aren't willing to pay much. If there is only one insurance company, they are beholden to it and have to negotiate from a position of little-to-no power.

Free-at-point-of-care does reduce costs because it reduces complexity. Once hospitals don't have to haggle with insurance companies, they can fire a bunch of administrators and thereby reduce costs.

the uncertainty around the cost of healthcare makes universal healthcare a hard sell for a rational, mostly self-interested voter with a decent job. to get to "yes", you need to convince this voter that their additional tax burden would be less than their current healthcare costs. comparing US insurance premiums with european per-capita costs doesn't do much unless you can explain why this would be different than all the other public services that are way less efficient here than overseas.

take me for example. I have no idea how much my employer contributes to my premiums. the only way I can think of to estimate the cost is to look up typical pricing for comparable ACA plans. if we switched to universal healthcare, I have no way of knowing what fraction of those premiums would be tacked back onto my salary versus simply pocketed by my employer. all I know is that things are currently okay for me, and as long as I do the in/out-of-network dance correctly, my exposure is limited to my out-of-pocket max. outside of ideological/moral concerns, there's really no incentive for me to rock the boat.

That gives me an interesting idea. What if employer provided health insurance was outlawed? Once people see the real costs of their coverage, I feel they'll all be all in on reform of some kind.

interesting idea, but probably even less viable than full universal healthcare politically. individual rates are not really the true cost of insurance. they're just the rates you get when you can't negotiate as a group. you would lower the standard of living for pretty much everyone with a full-time job and give them nothing in exchange.

Employers don’t get lower health insurance premiums because they are big enough to negotiate. They might get them if they happen to employ healthier people than average and if the employees are on the younger side, hence experience lower healthcare costs.

Employer provided insurance should be outlawed, and everyone should be forced to go to healthcare.gov. Then there would be enough lived on the marketplace for competing insurance to stay in business and the more competing insurers there are, the more pressure there will be to keep premiums lower.

> I have no idea how much my employer contributes to my premiums. the only way I can think of to estimate the cost is to look up typical pricing for comparable ACA plans.

Code DD in box 12 of your W2 shows the cost of the health benefits from your employer.

it does not on my W2. for whatever reason, my employer is not required to provide this information.

They are only a few unlikely scenarios where they don’t have to:

https://www.irs.gov/affordable-care-act/form-w-2-reporting-o...

> The Affordable Care Act requires employers to report the cost of coverage under an employer-sponsored group health plan. Reporting the cost of health care coverage on the Form W-2 does not mean that the coverage is taxable. The value of the employer’s excludable contribution to health coverage continues to be excludable from an employee's income, and it is not taxable. This reporting is for informational purposes only and will provide employees useful and comparable consumer information on the cost of their health care coverage.

there's something about it being optional for:

> Employers required to file fewer than 250 Forms W-2 for the preceding calendar year (determined without application of any entity aggregation rules for related employers)

I'm guessing it's that; pretty sure we have less than 250 employees in the US.

Doesn’t the US government already spend more per capita on healthcare than any other developed nation? Surely it would just be cheaper by cutting out the parasites.

It seems some people have forgotten the rhetoric of the time. The opposition had a wide variety of arguments against universal health care, such as government death panels[0], increased wait times for essential care[1], government control over 1/6 of the economy, free medical care for illegals, etc. I particularly remember a claim coming out that Stephen Hawking would have died under a universal system like the NHS[2].

As such, Obama proposed the ACA as some kind of middle road[3], with the goal of having something that both sides would be in favor of, and to hold the moderates that were against single payer[4]. After the better part of a year of negotiation and multiple efforts to reach out to the opposition, the ACA was passed without any Republican votes, who then spent the following eight years running for office on the idea of repealing it (with at least 50 attempts in a four year span).

Unfortunately, the Republicans don't have any plan for healthcare themselves, resulting in a failed repeal attempt three years ago even after taking control of the house, senate and presidency.

It should be fairly obvious at this point that logical arguments for or against policies are irrelevant, even more so than they were ten years ago - and yes, a great many people would vote against it. They spent the last decade doing just that.

[0] https://www.politico.com/story/2009/08/palin-doubles-down-on...

[1] https://www.usnews.com/opinion/blogs/peter-roff/2009/07/28/s...

[2] https://theincidentaleconomist.com/wordpress/passing-the-bat...

[3] https://www.nytimes.com/2009/09/10/us/politics/10obama.text....

[4] https://www.newsday.com/business/single-payer-health-care-pl...

I too am a fiscal conservative and see the merits behind a comprehensive single-payer health care system. Realize the American people are being told that 'socialized' medicine will eliminate choices such as choice of doctor and/or hospital. That was the main reason given by the 'moderate' Democratic Presidential candidates as to why not have universal healthcare. Look more closely and you see why. One of candidate Biden's largest contributors is big health insurance (the other being credit card banks). You saw the same thing with Amy Klobachar for much the same reason. Incidentally, I was oringally against the ObamaCare legislation, but having imagined a country without that option, I now believe it's essential. And it's certainly far from sufficient.

I like how you conveniently ignore the mountains of horseshit conservatives have been spouting about the negative of universal healthcare for a decade.

M4A is very popular, with 69% support in the US. The reason it hasn’t been instituted is that the US is an oligarchy. As such, policy is formed according to the desires of the oligarchic class rather than broad public opinion, and they oppose M4A.

Regarding voters, an aside I find pretty rich is that among those 65 years and older, i.e., voters who currently enjoy Medicare coverage, and overwhelmingly regard the program positively, support for M4A is only 46%.

>Do that many people exist that really vote against it?

I have never even seen it on a ballot.

America is a failed state. Every single other industrialized country has universal healthcare, free universities, paid vacation, paid maternity leave. I could go on.

And these things are not on the table. They are not, nor have they ever been, really considered -- at least not for the last 50 years. The recent candidate who ran on this platform, Bernie Sanders, was widely loved by the public and absolutely slated by the media.

The wealthiest in America are fine but the poor are more miserable than some third-world countries. The country is falling apart and there's really no opposing force, trying to stop it.

Every health event is literally a blank check to multiple unknown providers. There's nothing to stop them from charging whatever they want.

This is absolutely correct. In fact, most of their master price list is artificially inflated as a negotiating point with insurance companies. If you are unable to negotiate before your care, you get the hospital's mater price list price.

The worst part is most medical care is inelastic, meaning you don't really get to pick and choose, like in an emergency.

Not sure how much factual basis I have to back this up, but from my observations, the insurance system the US has was created by accident, but is absolutely maintained on purpose. Keeping health insurance tied to employment was a nice benefit for when insurance wasn't universal in many other countries, and healthcare wasn't nearly as expensive (as it wasn't as good as it is now). Now, keeping it tied to employment keeps people working, in service to large corporations that can afford insurance and less likely to take risks like working at upstart companies that could challenge established market players, or protest and try to make change in a broken political system. It's all pretty nefarious.

I was laid off, I've got a $500/mo prescription that keeps me out of a dark pit and gives me the ability to even work, I either pay that or pay $850/mo for COBRA to extend my healthcare. Or, what, medicaid? I'll probably be employed by the time that goes through. Six week wait to see a $250/hr cash-only psych.

Telehealth "loosened" red tape for everyone BUT people with mood disorders. I still need to go in person for an appointment to get the medication I need.

This is bad. I'm super privileged even being unemployed right now. I have savings. I feel for the people who can't afford any of this right now who are going through serious things.

If I come down with COVID I'll be bankrupted forever I'd imagine.

For those not in USA, can someone summarize? I know (from reading online) that if you go a hospital, the bill can be scary. But what happens when companies offer health insurace with a position? That means it covers everything? Just a %? It depends on the topic (for example, hearth related sickes are covered, not more cosmetics ones)?

Who are the people who is becoming profitable with this? Doctors? Companies? Are doctors allowed to open their own offices and have high prices? From the outisde everything seem so confusing!

In theory you can predict the total cost for things covered by insurance, but there are many layers of complex bureaucracy involved and the insurance company is actively trying to get you to fall through a crack and end up on the hook for a real bill. The insurance company also is practically the arbiter of whether or not you did it correctly.

The best example, is that you can go in for a surgery or something at a covered hospital for a covered procedure, but you can be surprised because some doctor assigned to you isn't in your network. Sometimes this happens after you're already under knocked out for the surgery, so you can't practically consult your complex policy at the time.

That has created an entire industry called "medical billing" where the job is to submit claims properly so as not to be rejected.

To be fair, fraud is probably a thing from every angle so having some process to prevent that makes some sense. But for patients with serious problems or families of those that just died, battling bureaucracy over large sums of money can be brutal.

How can your example even be legal?

The lawmakers have good insurance and are wealthy enough to pay for the rest of it.

The positive spin on this is that it allows for more "consumer" choices. With 300 million people, it's easy to find a few individuals pushed into a worse situation. People consistently underrate how bad the status quo is.

It's equally confusing from the inside.

So the way it works is that the insurance covers X% of something up to some pre-set limit which doubles or triples if you have a family. This is called co-insurance. So if you have a 50% co-insurance then you are responsible for 50% of the cost of treatment up to the yearly limit for your insurance. If your yearly limit is $9,000 then that means you rack up a $9,000 bill from $18,000 of medical treatment. Where it gets complicated is that if you add another person to your insurance then your yearly limit goes from EG $9,000 to $16,000 which can bankrupt most people. And this is for a "high-quality" plan.

And what's worse, because it's a yearly limit it resets in December. This means that if you get sick in December, you can rack up $9,000 of bills from December, then roll over into January and rack up another $9,000 worth of bills. Or $32,000 as a family.

This is strangely still sold as insurance.

You can buy platinum level health insurance that covers 90% of your expected healthcare costs and has out of pocket maximums of a couple thousand dollars.

Most people just can’t afford the monthly premiums for it. It’s just a simple result of the actual healthcare itself costing a ton more in the US than in other countries, since all up and down the healthcare business a lot more people make a lot more money than in other countries.

We helped a friend through this last year. Where she lived there was only two insurance providers providing ACA plans. And both were HMO only. And both only offered Silver and Bronze plans. I also checked this out in a couple of other counties and it was the same situation. (I didn’t find a single gold plan in my search.) So for a lot of people they can’t buy better plans even if they could afford it.

That’s a result of the political compromises that had to be made in order to pass ACA, which is people didn’t want to give up their silo’d white collar employer based health insurance, and insurers can’t compete across state lines.

If there was a single marketplace for health insurance where everyone had to go, there would be sufficient lives for health insurance companies to be able to offer more options.

I’m 100% for single payor as IMO it’s the best compromise in the US system to achieving universal healthcare, but I do agree with you. The employer provided healthcare plans are a huge distortion and abolishing that and making people buy their own plans would be preferable to the status quo for a multiple reasons.

PS. I don’t have it handy but there was a great chart breaking down changes in how people were covered over the years I saw a few months back and what was most startling was just how little coverage is from ACA plans. It’s puny. Like 10% or something. Better for those 10% than before they didn’t have it, and some things like not disqualifying for preexisting conditions were important changes, but the ACA really wasn’t this revolutionary thing many people hold it up to be. It’s more of a blip.

I disagree that pre existing conditions was revolutionary. It enabled people to get healthcare that they simply couldn’t before, because payers had the ability to decline them.

Also revolutionary was capping insurance premiums for old people as a multiple of young people, thereby instituting a wealth transfer from the young to the old.

This is necessary because there is no incentive for a young person to purchase insurance, and without universal taxpayer funded healthcare, this mechanism serves as a tax.

It’s all one and the same, except universal taxpayer funded healthcare is unpalatable to sufficient voters, so the best we could do is this system where instead of taxes paying for other people’s healthcare, you have insurance premiums paying for other people’s healthcare.

Oops, in the above comment, I meant “I disagree that removing pre existing conditions was NOT revolutionary”.

I would be suspicious of that still; usually the "maximum out of pocket" has a lot of footnotes.

The footnote is that it has to be in network providers and it has the treatment has to be justified (e.g. have supporting data of efficacy).

$9000 /year is not 'high-quality', that sounds more like a high deductible plan that would have relatively low premiums. Higher premiums would lower the deductible.

Lol it's been about what I got at all the jobs I've had. It's pretty comparable to the Silver plan I was on as a contractor.

Most health insurance comes with a % copayment. Paying 10-20% of the bill is not uncommon, and generally considered pretty good health insurance.

Add to that a high deductible -- some families have to pay thousands of dollars out of pocket before health insurance will even start to cover you.

If you have a major medical event, you might be on the hook for tens of thousands of dollars.

This summer my gallbladder started acting up and after going to the emergency room twice I finally got it removed last month.

I have insurance but there is a deductable and a copay and the insurance company will decide not to cover things. I have gotten bills from the hospital, the radiologist, the surgeon, and the anesthesiologist even though they were all in the hospital. One of them has been sending me notices saying that - again even though they were in the hospital - the insurance company won't accept their billing so the insurance company will apparently at some point send me a check then I am supposed to send it to them and they will tell me how much I owe. My insurance company says so far I have been charged over $200,000 even though I have only had to pay around $4000 so far. But most of that $200,000 is fake because hospitals have a price they charge the insurance and then the insurance says "no, we're only paying this much" and the hospitals will say "Ok."

I got a bill for $1600 three weeks ago and there were no details on what it was for except for the date of when this started back in May. My insurance company didn't have anything that corresponded to that date so I called the hospital billing department. They were like, "Ok. we will refile it." and I haven't heard anything since.

I've also gotten bills in the mail for like $36. I go to the bill pay website and they say I don't own anything.

The actual surgery was 5 weeks ago tomorrow and I haven't had any bills about that at all.

What you ask would take many paragraphs to explain in full. The short is that is varies a lot depending on your employers plan. A small percentage of working age individuals get coverage outside on “Obamacare” and those plans vary a lot too. Initially there were decent plans but over the years now in most areas you can only get “silver HMO” plans that limit who you can see, carry very large (several thousand dollar) deductibles that have to be met before insurance pays, then have high coinsurance amounts (up to 30% that you have to pay even after meeting the deductible) and have max put of pocket limits of several tens of thousands before you finally don’t pay anything. As a result it’s generally not financially advisable to get insurance unless your employer provides it because you won’t be able to use it.

Medicare kicks in for over 65s or those who have been disabled for over 2 years. Medicare requires a 20% copay for everything which can be taken down to zero by using a supplement plan which generally costs between 100-300 per month depending on your age and region. You also then need separate prescription insurance which costs $20-50 per month and has really insane complex rules that mean you may still end up paying tens of thousands a year if you have specialty drugs.

Medicaid is for “poor” people but varies depending on states. The cut off for eligibility is very low and in some states it still doesn’t cover adult age people unless they have a child or are on social security insurance.

Those profiting are a mixture of medical professionals, administrative staff due to the bloated administration required, of course all the private hospital and clinic systems around the country. And the insurance companies who take their increasingly large cut.

In defense of the medical professionals many want to move to single payer for a variety of reasons (eg American college of physicians group and others have come out in support). Although they may make more revenue in the current system it also causes an insane amount of extra overhead and distracts from their ability to do their job.

By 2027 the US health spending is projected to become 20% of GDP. This is not a healthy economic situation to be in.

Our current system is both morally indefensible (65,000 die every year due to lack of coverage) and also fiscally indefensible ($500 billion would be saved every year moving to single payer). Yet it persists. That is the power of bested interests, lobbyists, and legalized political corruption.

Edit: That wasn’t very short in the end. I’m on mobile or I’d provide more detail and references.

The topic resists summary.

Yes, bill will be scary if paying out of pocket.

Health care is often tied to employment (you or spouse). There are different insurance options, even when employed. A good plan will cover everything but a relatively small fixed amount of even large bills (e.g., emergency delivery of child). A bad plan will have a lot of excluded procedures or very large "co-pays" where insurance pays some, you pay some. Other plans have mixes of the above approaches.

If you have a professional job, your plan will typically be pretty good; if not, there can be problems.

To pay for the co-pays, a system of tax-free health care saving accounts (HCSA) was set up. You pay into the HCSA, and the co-pays come out of that, and it's tax-free up to a point.

So you notice there is this piecemeal and patch-atop-patch theme to the whole thing.

When you get older, typically 65, there is a government health pool called Medicare that you can enroll in, that takes over most of the role of employer-provided insurance. Most older people do this. Then, you can get further insurance on top of that to plug holes it may have. Also, there is a very lucrative prescription drug plan that's now built in to Medicare, thanks to big pharma.

A lot of doctors really don't like the insurance companies controlling whether procedures are considered acceptable. But, historically, the American Medical Association, the US physician's professional organization, has lobbied hard against public health plans.

Finally, this is just one citizen's description of some of the major features of this so-called "system". There are a lot of other parts to the puzzle -- for instance, it varies by state, and there are 50 states -- and there are special cases, like veterans. It's wacko.

"If you have a professional job, your plan will typically be pretty good".

Define good. I'd say 80% insurance, 20% co-pay is good in the US.

It's complicated. Here's the basic rundown:

There are two types of plans offered a PPO and an HMO. PPOs usually have larger deductibles, larger premiums or both, so if your employer offers a PPO, it will usually come with a larger out-of-pocket cost for you.

Here's how each works in theory for non-emergency care:

HMO: You have a physician that is your "primary care provider." This physician must have a contract with the insurance company. Any non-emergency care must be mediated by this physician. e.g. you go to the physician and they will refer you to a dermatologist if you have skin problems. The insurance company will pay for any care that the primary care provider recommends, possibly with a nominal co-pay (e.g. $20 per visit) and possibly with a per-year deductible. If you go to any doctor without a referral for non-emergency care you must pay everything out-of-pocket.

PPO: You can go to any doctor for any reason. If you go to a doctor that has a contract ("in-network") with the insurance company, insurance pays some fraction of the cost (usually around 80% for non-routine things). There is a maximum per-year out-of-pocket cost for in-network care. If you go to a doctor without a contract with the insurance company ("out of network") they pay either a smaller fraction of the cost, or the fraction of what the in-network would have cost (so if it's $4000 out-of-network and $2000 with an in-network doctor, the insurance would pay say 60% of the $4000 or 80% of the $2000 leaving you with a $1600 or $2400 bill respectively)

All of the above is for routine care. There are two levels of "emergency" above that: "urgent care" and "emergency room". Urgent care is "it can wait hours, but not a week" emergency room is "it needs help immediately"

For urgent care, it's more-or-less like routine care, except that you don't need a referral with the HMO. Just like routine care, if the urgent-care facility you go to lacks a contract with the insurance company, you will have to pay for everything out-of-pocket.

For emergency-room (ER), usually in-network doesn't matter, but usually you must pay at least $100 out-of-pocket to visit as a "co-pay" (compared to $10-$20 for other visits). However, if a doctor sees you in the ER that is not employed by the ER, and they do not have a contract with your insurance, you pay the out-of-network rate for just their services (i.e. you are stuck with the entire bill for an HMO, and you pay a larger percentage of the cost with a PPO). That's how we got stuck with a $4k bill after taking my son to the ER with an HMO.

That's all the "in theory" cost.

In actuality there is a lot of fine-print in the contracts giving ways for insurance companies to deny claims for various reasons, and they will almost always refuse a large claim for some bogus reason (e.g. I got a $90k bill when my daughter cut her hand on some broken glass and needed 60 stitches because the insurance company coded it as an "elective surgery") there is usually something like a 6 month limit for challenging claims, so if you don't spend about 20 hours on the phone over the next few months, you can end up stuck with a bogus bill just because you didn't challenge it soon enough.

> Who are the people who is becoming profitable with this? Doctors? Companies? Are doctors allowed to open their own offices and have high prices? From the outisde everything seem so confusing!

It's confusing from the inside too. Doctors do open their own offices and usually have very high prices. However, the insurance companies negotiate a lower price, and if you do get stuck with a bill, you can usually negotiate a lower price yourself (Insurance companies usually pay 1/3 to 1/2 of the original billed price).

The insurance companies make money, but the cost they impose is far larger than the profits they make, because of all the inefficiencies and administrative staff. A medium sized doctors office will often have at least 1 full-time employee whose only responsibility is to work with the insurance company. People often delay or forgo care because they plain just don't know if the insurance company will pay for it.

I've recently been going through this process learning how terrible our medical billing system is in America

Here's some examples...

1. You might go for a surgery. You'll get a bill from the anesthetist, doctor, and the facility. The anethestist might not be in your network, so insurance doesn't cover it. Not only that, all three places can bill whatever they want, multiple times even.

2. You go to the specialist doctor for a visit. I recently went to two different ENTs just for a nasal checkup. One billed a claim for $1000 just to inspect my nose on a first time visit and billed it as a "surgery" procedure code. To be fair I signed a waiver stating I would pay things outside of insurance, that's just because I don't know any better and scheduling doctors appointments take forever. Insurance covered a small portion of it, hospital reduced it a bit, but now I have to pay $250 on top of a $60 normal pay for visiting (copay)

So basically, I have to pay $300 for visiting a doctor, for a basic checkup. I expected to pay $60 with my insurance.

AFAIK, in other countries, there's just a catalog of prices of how much everything costs. The doctor tells you how much things cost up front, you agree and pay for it. That's how things should work

Here in America, we artifically mark up everything by a huge amount, and insurance pays a portion of it, depending on your setup. You pay the rest of that inflated amount past a certain amount in your insurance coverage.

You can negotiate rates after the fact, but the hospital networks can just say no. You have to pay it anyways.

Basically you're always in financial jeopardy when you go to the hospital. The people profiting are all in the medical industry. The end user (you) is always screwed over.

If you want to fight a bill, you call the insurance company, they'll tell you to call the doctor. The doctor will tell you to call the insurance company. Either that they'll say they will try and renegotiate terms in 10 days, which at this point you'll probably get tired of fighting it and pay up anyways. Its pretty much a waste of time.

Health insurance does provide a financial net, but only to a degree. My out of pocket max I might have to put out in a year is $10k. The average out-of-cost payment after insurance might be $2k, so I might expect to pay $2k out of pocket. But the hospital can bill whatever I want, so I might be out $10k in cash now. I have no control over how much I will be billed for, even though I know how much things generally get billed for.

The analogy is like going to a restaurant. You order a burger. You don't get to see the menu prices, but the waiter tells you its $10. You get a check for $50. You don't understand why but you have to pay it anyways. That's the medical system here in the states.

> 2. You go to the specialist doctor for a visit. I recently went to two different ENTs just for a nasal checkup. One billed a claim for $1000 just to inspect my nose on a first time visit and billed it as a "surgery" procedure code. To be fair I signed a waiver stating I would pay things outside of insurance

In some states, that waiver is illegal (about 20 of them).

> billed it as a "surgery" procedure code

That's provider fraud. Much as insurers are horrible, they hate fraud, be it claims or provider.

Call your insurer - tell them what happened in the checkup and why it was not surgical.

So I actually had a health-related bankruptcy.

1: Your insurance is tied to your employer but you can also get insurance on the private market. Generally Employer insurance is much much cheaper as the employer can negotiate with a large number of seats over costs and has a vested interest in employee health.

2: Health insurance generally works like car insurance with a deductible that you pay out of pocket to a point and then everything past that point is covered by insurance. Some services (such as a doctors visit or ER visit may be covered at a set price [such as $40 a visit]) whereas an Xray or such would be billed to you until you hit deductible. The deductible on a PPO plan may be something like $2,000.

Now..let me tell you the insane ball game here.

You may think: Well if health insurance is like $400 a month, if I'm healthy, why even have it?

For one, there was a Tax fine for not having health insurance of ~$600.

For another...Hospitals bill non-insurance patients full amount but insurance companies (who when you have health insurance act as middlemen) an agreed upon amount.

These amounts are massively different.

I had just lost my company insurance when I became a contractor for another company, I did not have insurance yet.

I ended up in the ICU for 6 days due to a really crazy blood pressure related inter-cerebral hemorrhage.

I found myself two weeks later being asked to pay over $100,000 over the phone by their billing department.

Talking to someone, I was told to ask for an itemized bill. It was over 50 pages long.

It noted an MRI as a $6,500 procedure.

Later I got insurance and went back for a follow up MRI. The insurance company sent me a bill for the co-pay and on it I saw the same $6,500.00 bill...but with a line item below it:

`Insurance Group Discount -$6,120.00` America.

The fact of the matter is that healthcare costs are really not that high, but insurance companies are hedged into the position that they are made necessary by the system and everyone is required to hold it. In a country with universal healthcare none of this exists as all prices are set and approved by the country making it all public.

> Your insurance is tied to your employer but you can also get insurance on the private market. Generally Employer insurance is much much cheaper as the employer can negotiate with a large number of seats over costs and has a vested interest in employee health.

Another reason might also be that an employers group consists mostly of healthy working age adults. Once they’re not healthy they often are no longer able to work for the employer and aren’t in the group.

If you have health insurance, and you keep your health insurance through whatever your medical emergency is, you won't have a financial problem with regards to medical bills. I'm splitting this up into two parts: how it works, and why that's the wrong question to ask.

Here's the nitty gritty. Health insurance will cover each expense minus a deductible. Once all your individual deductibles have reached a set value called an "out of pocket maximum", health insurance covers 100% of it. So if your deductible is $200 and your out of pocket maximum is $2,000, and you have a serious medical problem that requires multiple hospitalizations, you'll pay $200 up to a maximum of ten times, at which point every hospital trip is free for you. If your out of pocket maximum is $2,000, you don't have to pay more than $2,000 for healthcare in a year.

Here's why that doesn't matter. It's too easy to lose your insurance. If you buy health insurance directly, and you miss a payment, and you are an expensive client to your health insurer, your insurer will drop you. If you get your health insurance from your employer, (which is a majority of insured people in the US) chances are pretty good that an expensive medical emergency will coincide with losing your job- which means your health insurance changes. There are systems in place to deal with this, but these systems suck. There are a lot of cracks you might slip through while transitioning from your employer provided insurance to whatever you transition to.

Literally everybody loses with this system. Insurance companies have it the least bad, but health insurance companies aren't actually that profitable. Doctors can open their own practices and "set" their own prices, but insurance companies can and do ignore those prices. There's this weird nonsense where providers (hospitals and independent doctors) set prices, and insurers pay a percentage of those prices, so providers raise the prices quoted to insurers... so insurers lower the percentage. This is why you hear stories about people receiving ridiculously expensive bills for short/trivial hospital stays. The cost to the hospital might be $2,000, so the hospital quotes the health insurance company $50,000 with the expectation that the insurance company is going to write a check for 2.5% of that or $2,500. But the patient is uninsured and gets the $50,000 bill instead. If you're familiar with the system, you can haggle with the hospital and they'll be happy to accept $2,500 from you, but that's only if you're familiar with the bullshit system- most people obviously aren't. When you hear complaints about the 'lack of price transparency' this is one of the many ways that is presented.

It is the worst of all possible systems. If the government literally repealed every law and regulation with regards to healthcare, that would be a less awful system. Significant change, whether that means going full socialism or full lassez faire free market, would require a filibuster proof majority. (60 votes in the Senate) Many politicians who want to improve the system would not be keen on voting in a half measure; for instance, breaking the link between employment and health insurance would be a huge benefit to all Americans, but it's a political loser for Democrats. So there's insufficient support for dramatic measures, (because people are either strongly opposed to socializing everything or they're strongly opposed to deregulating) and there's insufficient support for small improvements. (because if the system were less intolerable they wouldn't be able to run on a platform of significant change) It's bigger than just a problem with healthcare; it's a problem with the two party system.

https://www.healthcare.gov/glossary/out-of-pocket-maximum-li...

https://www.healthcare.gov/glossary/deductible/

> Once all your individual deductibles have reached a set value called an "out of pocket maximum", health insurance covers 100% of it.

Keep in mind "out of pocket maximum" doesn't mean what any normal person would consider it to mean. You can (and I have) easily end up having to pay way more out of pocket than the supposed maximum.

That's because the insurance company can unilaterally and arbitrarily decide how much of what you end up paying out of pocket they actually credit towards their tally of "out of pocket".

Even the best health insurance in the US generally leaves you paying a lot compared to any other developed nation.

I had FAANG engineer health insurance, cracked my elbow. For the exam+x-ray+soft wrap the clinic billed the insurance like $15k, insurance actually paid like $5k and I paid $1k. I received 4 separate very unclear bills from 2 or 3 different sources. That's in-network with insurance considered so good I paid a "cadillac tax" for having it.

I cracked a rib and had identical treatment in Sydney with no coverage as a non-resident (travel insurance reimbursed me later). They told me the costs upfront, made sure I agreed and understood. I paid maybe $400 for the same treatment.

I think people incorrectly attribute it to lack of single-payer though: Switzerland doesn't have single-payer and one part of your insurance is provided by your employer; my partner paid full price for an x-ray there and it was much less than the post-insurance price I paid.

Not to sound conspiratorial, but the politicians that put these mechanisms in place know exactly what they're doing and this is a tool to keep the masses compliant and afraid of taking collective action against the overlord ruling class. Decoupling healthcare from employers, and making health care affordable are a direct threat to the entrenched status quo.

Free markets do a really good job of allocating resources most of the time. People are generally very good about making decisions about what clothes to buy, what food to eat, what house to live in, etc. There are some exceptions there, but its easy to design market incentives to guide them to better choices.

Heath care really doesn’t work with free markets though. People just aren’t able to make good decisions when it comes to health care, and profit focused business are able to exploit that, which results in horrible outcomes. It’s not hard for a lay person to assess the advantages and disadvantages of different cell phones sold from different retailers and from different providers, but how can people assess the pros and cons of different cancer treatments from different doctors at different hospitals? The complexity of biology and medical treatment is much much greater than anything people have to deal with in their normal lives. Decisions are almost impossible to make.

Also consider that allocated resources based on a price/demand relationship doesn’t really work. Right now, health care companies focus on developing treatments for conditions that mostly afflict the rich, rather than treatments that could help the most people. It would not be hard for a medical board to make decisions about where research and treatment priorities are. We have lots of good data on how people are getting sick and how they get better.

Lastly, if you get sick for no fault of your own, whose burden should that be? That burden should be spread across society as a whole.

It's not a free market if the prices are hidden. Consumers can't make educated decisions without prices.

As any negotiator knows, you only have leverage if you are willing to walk away.

Health care will never be like this because if you need it to not die, you need it.

As a US->UK immigrant, I really appreciate the degree to which free-at-point-of-care encapsulates complexity.

Unencapsulated complexity imposes real stress on:

- Hospital administrators, who then hire more colleagues and pay their salaries[1]

- Government agencies trying to implement a new law...or even determine which agency is responsible for pieces of that law[2]

- Patients trying to access medications[3], who then might go without care or go to the ER.

There is inherent complexity in healthcare because bodies are complex. It is stressful enough dealing with a medical condition itself. Dealing with the incidental complexity of insurance on top of that is... bad.

When there is new attempt to reform US healthcare, can we also get Prof John K. Osterhout in the room where it happens?

[1] https://time.com/5759972/health-care-administrative-costs/

[2] https://digital.hbs.edu/platform-rctom/submission/the-failed...

[3] https://www.youtube.com/watch?v=aKUdadCsuRE

Perhaps "give me your tired, your poor, your huddled masses yearning to breathe free" doesn't carry the same meaning when no better life awaits. The exodus will happen slowly, then suddenly.

COVID-19 made this much worse, but the current system is too complicated. It took me years to learn how to navigate it and it's probably going to change dramatically again very soon.

Most ACA plans are a ripoff if you're not getting a subsidy. Who can save $9,000 in a year for a deductible while paying $1,000 a month in premiums? Nobody I know.

It's well-known that hospitals jack up their prices. It's a crooked system. Good luck fixing that with a magic wand from Washington.

But- it seems to me that the underlying problem is the epidemic of chronic illness. Chronic illness is crippling this country. We're spending so much because we're actually all sick.

I'd like to know, what's making us sick?

https://www.cdc.gov/obesity/data/adult.html

>The prevalence of obesity was 42.4% in 2017~2018

This is one chronic illness (mostly unique to America in the developed world) that makes socialized health care very expensive.

Obesity sadly is only one of many...

    Attention-Deficit Disorder (ADHD)
    Arthritis
    Asthma
    Autism Spectrum Disorder (ASD)
    Auto-immune disorders
    Developmental/Learning Disorders
    Cancer
    Cardiovascular problems
    Cerebral Palsy
    Cystic fibrosis
    Diabetes
    Epilepsy
    Food allergies
    Respiratory allergies
    Sickle cell anemia
    Spina bifida

According to that link the medical cost of obesity is $147 billion. Healthcare spending in the US is around 3.3 trillion. Obesity is a problem, but it is not the main driver of medical costs. Also, we are already paying for the healthcare of obese people through insurance premiums and taxes. Proper socialized health care would incentivize and allow for more preventative treatment for obesity-related problems.

This is not good for any demand-driven economy.

It's honestly a little weird, America health insurance can't be driven by demand. If it where, it would be cheaper.

Why is it that the providers and insurance companies isn't trying to undercut each other on price? I know very little about US health insurance, but I can only assume that it's not truly a capitalist system, something else most be at play, driving the prices up.

There’s absolutely no transparency, which makes it hard for an informed consumer to make decisions based on price. And frankly picking a health care provider based on price feels scary: do you really want the cheapest LASIK procedure around, e.g.

There isn’t just one cause but here are two I know of:

Health insurance companies leave markets where there is competition.

When an emergency happens, suddenly you don’t care which hospital you go to, you just want to live/make the pain stop. (Or your family makes that decision)

One reason is that the supply of doctors is artificially limited by the AMA to keep their income up.

Let's just hope that all these people get out and vote this November. This is a fixable problem.

Neither of the candidates are going to fix this problem

There is more than the presidency on the ballot.

What could you possibly vote for on the ballot to fix this.

You could vote for reps that believe in universal healthcare or at least support ACA. Those reps will overwhelmingly be democrats. So vote D down the ballet.

I live in Brooklyn. What now.

You can still volunteer to help drive the vote in swing states! https://votesaveamerica.com/adopt-a-state/

There are very few people in the political system even in the Democratic Party that want to fix this. Healthcare companies and insurance providers are big donors to many people on that side of the aisle. Bernie was the best chance of that this year, but instead we arrived at an openly corporatist candidate who is vehemently against any real reform of the medical system. Admire your optimism though.

Passing any change in the US healthcare system requires consensus across the House, the Senate, and the Executive Branch, so it is by no means a one-person job.

Bernie favoured the radical overhaul it frankly needs. But if you can't get that, any progress is still progress.

California has a Democratic governor and Democratic super-majorities in both the state assembly and senate. Even with total control in the state, they won't go after something as uniformly reviled as balance billing:

https://stateofreform.com/news/california/2019/07/california...

Why expect more progress at the federal level?

Healthcare for the Democrats is like guns for Republicans. It's too useful as a wedge issue they can use to scare voters to the polls. They're more interested in yelling about what the other side will than passing the legislation they promise.

I couldn't agree with this more. Healthcare costs have increased unabated since the passage of the ACA. Make all the noise you want about Republicans attacking the bill at lower levels of government, it's ultimately the Democrats who didn't pass a public option, and more damningly, it's the Democrats who wouldn't pass Medicare for All. There's no interest in actually solving the issue when they make so much money off the system as it exists.

For fixing this specific issue, the balance of the Senate is by far the most important thing, even above the Presidency.

As I said in the other comment, I live in Brooklyn. Even most Democrats are not all that invested in universal healthcare. The Presidential candidate does not believe in Medicare for All.

This is very true. It probably wouldn't be passed tomorrow if given a chance. However, sentiment on this is swinging very rapidly. It was a fringe idea in 2016, and in 2020 it was a central pillar of many (if not a majority) of the Democratic candidates in 2020. Because people campaigned for it, made the case for it, and built coalitions on their side.

Politics is a marathon not a sprint. It may not happen in 2020, but it's certainly closer to reality than it has ever been.

The Senate isn't gonna do shit either.

Haha, as if the Senate going blue would change this headline. The Democrats had 60/59 Senators 10 years ago and passed a disgusting reform that's ultimately not done anything about healthcare costs, and allowed those who benefit from the system to reap in even more money.

You don't think that banning denying coverage for preexisting conditions is a huge step into solving this problem?

That has been law since Jan 1, 2014. It is part of the ACA[0].

It is not surprising that some people do not know this, as the president has recently said he would sign an EO mandating this, even though it is already law[1]. It’s unclear if he is unaware that the ACA already includes this mandate or if it is a deliberate misinformation campaign.

[0] https://www.hhs.gov/healthcare/about-the-aca/pre-existing-co...

[1] https://www.usatoday.com/story/news/politics/2020/08/08/trum...

Yet the ACA has been under constant attack since it passed by one party and the sitting president, so there’s reason to believe that protection will go away.

His words on this are meaningless as his actions are the polar opposite, they are in court arguing that the entire ACA needs to be voided, and with it the pre-existing condition protections.

Ridiculous claim. There are much better odds of fixing health care with Biden and democrats in power. The progressive dems are pro universal healthcare and the moderates will expand or at least maintain ACA.

Remember that the vote that matters here is not the presidential one, but the congress one. So specifically, the hope is to elect the correct representatives.

Even insurance doesn’t protect against this. Case in point: family member battling cancer had over $50K in costs not covered by insurance. Not to mention costs that they had to pay initially until the insurance company accepted the claim. (They usually had a few back and forth a where the insurance co would initially refuse to pay)

As someone with good insurance through my employer I've seen first hand the incredible hassle the US system is.

It really stood out when I was traveling with my kid they needed a hospital stay. This was in SE Asia and at a private, international hospital.

My kid stayed in a private room, all meals included (including for family) for 3 days. I was a little nervous about the cost, but knew it wasn't going to be more than a few thousand dollars and my insurance would cover some.

The final bill? $600. A one-page, itemized bill with things like "antibiotic tablet - $0.50; 72 hr hospital room stay w/ nurse - $350".

Of course the cost is going to be much lower in a developing country, but damn, it was refreshing to see such a smooth process and clear price transparency.

Ignoring the insurance side for a moment - just knowing what things cost would be a massive step up for the US system.

I have the cheapest ACA / Obamacare bronze-level plan available to me in my area.

It costs $500 monthly (no subsidies if you make more than 45k a year) and has a $7000 deductible. It provides zero coverage (except life/limb emergency) outside of my metro area.

This isn’t working for me but I have no other options.

I really wish apologists for the current US healthcare system could actually agree that it's nothing like their vaunted "free market apples" example of capitalism. If anything, actual competition, within some limitations to avoid monopolies capturing key markets (insulin anyone?) could do wonders:

If I want an apple, I see a price, think "yep sounds good" and pay it. If the apple is rotten and I return it only to have the vendor say "sorry sucker!", I take my money elsewhere.

If I get in a bad accident, I am in no decision to make decisions about where to get care; I may not even be conscious. Moreover, I am orders of magnitude more knowledgeable about what apples I like and what they ought to cost than I am about what medical procedures I need. Delegating those decisions ought to be a sacred act enshrined in law, the Hippocratic oath, and relatively high pay for medical professionals (that job is hard).

So long as the US has the right to emergency care for anyone, taxpayers will continue shouldering that bill when folks can't pay. I get being for "personal liberty and freedom", but paying for Unemployed Uncle Fred's blood pressure medication is a far cheaper prospect than his massive heart attack.

I'm so glad I moved out of there to a sane country that, although it doesn't have single-payer, has a heavily regulated free market and no crazy medical bankruptcies.

This country is the land of contradictions (and I'm saying this as a resident). More than half of the Americans are not happy with the state of the healthcare, but more than half of the Americans are not happy to contribute to a better healthcare system. Go figure!

If you are privileged with a good job and good coverage, it’s far better to be in the system we have now. Your chances of incurring huge costs are relatively low and you’re saving tens of thousands of dollars by not paying to benefit others. Also if you need to get a specific treatment you don’t need to go through a government bureaucracy, you just pay for the treatment or insurance might cover part of it.

Of course there are significant downsides if you aren’t privileged or if you care about other people. If you have a kid that is born with diabetes for example it can be a huge unnecessary cost, but that’s probably due to drug pricing in America which is a whole other topic.

My point is it isn’t fair to say that the current system is universally bad for everyone. But I personally think we would all be better off as a society if everyone had access to good medical care without the risk of financial ruin.

Your chances of incurring huge costs are relatively low and you’re saving tens of thousands of dollars by not paying to benefit others.

Is this actually true though? It seems that the chance of encountering huge expenses are non-negligible, and that you wouldn’t actually save any appreciable amount of money.

Also if you need to get a specific treatment you don’t need to go through a government bureaucracy, you just pay for the treatment or insurance might cover part of it.

Using the UK as an example, obtaining necessary treatment involves no “government bureaucracy”. It just involves that treatment being deemed medically necessary and then provided. No messing around with insurance and hospital billing departments. Of course, you are still free to pay private providers for services, or indeed to take out private medical insurance.

It's so sad.

When I changed jobs doing so / not had a lot of considerations to do with keeping / getting health insurance.

I feel like people would feel so much more flexible not having that tied to employment.

> I feel like people would feel so much more flexible not having that tied to employment.

This should be a bi-partisan issue since both sides claim to love "small business."

Health insurance is unaffordable for any small business and prevents many from striking out on their own.

It's also a hidden expense that many never realize they have.

If you looked at my "out of my bank account" spending, I could spend probably 5-10 years unemployed and be fine.

Add in the extra $20-30k/yr for health insurance premiums and that drops down to maybe two years if I was lucky.

And you'd hope businesses would be happy to be out of that game too....

For those who are concerned about this problem and can afford to help, this is a charity that buys up medical debt for pennies and forgives it: https://ripmedicaldebt.org/

It's obviously a band-aid for a deeply broken system, but it can un-ruin real people's lives in the immediate-term.

Having my health insurance tied to my employer terrifies me. Fortunately i have good insurance through my employer but what if i lose my job? I still can't fathom how having a universal healthcare is a political issue. It should be a basic human right. Even poorer developing nations have started recognizing it and making healthcare free.

The other half who reported not fearing health-related bankruptcy work in government and now have better health benefits than those in the private sector. They don't see anything wrong with the healthcare system because it hasn't affected them.

Yeah but that’s barely the tip of the iceberg.

People are afraid of having a major, expensive surgery or treatment and that’s a valid fear but what about the years you spend hitting (or almost hitting) your deductible just trying to find out what’s wrong with you?

Seeing that the potential presidential candidate whose platform was mostly centred around healthcare did not advance to a full candidature implies that either the survey was not representative or the fear is outweighed by other political worries.

Bill Moyers has a good segment on this subject:

Profits Before Patients

http://www.pbs.org/moyers/journal/07102009/profile.html

I wish we could cut as many of the PBMs, claims, and overall middlemen out of this damn system.

Health insurance costs would be significantly lower if it was as direct as possible, as transparent as possible, and the end user had a say.

The other 48-49% are just cluelessly oblivious to what reality is. One person getting sick in the family is all it takes.

Another poll said that 67% of Americans could not scrape $2,000 together to cover an emergency expense.

A "socialist" public healthcare system could never work!

Well... Unless you're in Austria, Belarus, Bulgaria, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Isle of Man, Italy, Luxembourg, Malta, Moldova, Norway, Poland, Portugal, Romania, Russia, Serbia, Spain, Sweden, Switzerland, Turkey, Ukraine, United Kingdom or many other countries...

Health insurance in the United States' for-profit healthcare complex is a nightmare. Besides the fact the premiums are onerous, it is the health insurance carriers that evaluate if and how much insurance will cover an expenditure, usually after a copay and possibly coinsurance has been paid. To say nothing of ever-growing deductible limits. On top of that, the Trump Administration is working overtime to purge what little insurance benefits are provided via Obamacare (in it's quest to eliminate any legacy of the Obama Administration). Unfortunately, the GOP is woefully short on replacement ideas. One does get the idea--in the true spirit of the Republican Party--the replacement will consist of costly, high-deductible health insurance that will include many exclusions from its coverage.

All this begs the question: quality of life in the US, especially for the middle class, is crashing compared to our friends in other industrialized nations. Why middle class especially? Because the middle class is most likely to have an employer-sponsored plan that has deductibles and exclusions. In fact, most of those carrying employer sponsored health insurance never really know how much of the bill insurance will cover. Poor and indigent people, in many states, can still obtain health care without insurance and many states have funds just for this so the bill is paid by the tax payers in one form or another.

And since the healthcare complex is an aggressive lobby in Washington, this situation is not likely to change. Not under Biden, certainly not under Trump. And to those Democrats who say millions of people who have employer-sponsored health insurance love their coverage and don't want to give it up, I say poppycock! I don't know anyone, outside of public union members, who really like their coverage, employer-furnished or not. Year-to-year premium increases with less coverage over time effects this group more than any other.

> Besides the fact the premiums are onerous, it is the health insurance carriers that evaluate if and how much insurance will cover an expenditure, usually after a copay and possibly coinsurance has been paid.

This is not true. ACA requires health insurance companies to pay for all healthcare expenses after reaching one’s out of pocket maximum.

And they have some discretion to call out fraud, but insurance companies have to by and large follow medical procedure guidelines. They don’t have to cover experimental treatments, but if they are denying appropriate healthcare, they would get nailed by various government agencies.

The 'ACA' is not one plan and it certainly does not require health insurance carriers to pay for 'ALL' healthcare expenses after you reach your deductible. Coverage varies by state and by level (ie., gold or platinum). Many plans do not cover out-of-network doctor visits for example. On top of this, you need to get prior approval for every medical procedure because not ALL are covered. In some cases, the insurance company will recommend a different treatment, instead of the prescribed treatment. I speak from experience.

AHCA coverage is superior to what we had before, but it isn't enough. It was drafted with the Health Insurance lobby in the room, so do the arithmetic.

ACA requires insurers to pay for all healthcare expenses at in network providers for coveted procedures, unlike pre ACA where the insurer could simply stop paying at a certain dollar amount.

And health insurance does recommend different treatment depending on what the insurance’s doctors think. That’s the entity with the knowledge to be able to challenge a doctor, since the patient rarely has sufficient knowledge to do so.

The alternative system of a check and balance is if the government pays for healthcare and a government employed doctor approves or suggests alternative treatment. That’s what the UK does.

Either way, you have to have a second opinion to avoid mistreatment or overcharging by the healthcare provider. This isn’t an issue specific to healthcare, it’s present in any sufficiently complicated field.

Was going to post this in response to a comment stating that COBRA is affordable and when you can't you qualify for medicaid, but it was deleted. Here's some uncomfortable facts:

In truth, most can't afford COBRA and many of the most COVID hard-hit industries don't even have that option because they were never offered employer-based healthcare to begin with

A lot of Conservative|Libertarian folks will tell you: "The current system works and when it fails there are social protections to help people." This is simply a nice fantasy perpetuated by those that have never had to rely on the American social safety net. In truth, our social safety net has never been that strong and has been weakened by ~60 years of conservative-led entitlement cuts while we have expanded military spending and corporate welfare.

Most workers who've lost their job cannot afford an additional $20k/year for COBRA while not being employed (see quote from EPI below). In fact, it's much worse than that: 50% of Americans struggle to confront an unexpected $400 expense. (https://www.federalreserve.gov/publications/files/2018-repor...)

Check these statements from the director of the Economic Policy Institute: (https://www.marketplace.org/2020/05/13/cobra-health-insuranc...)

"""

EPI (Economic Policy Institute) research director Josh Bivens said that fewer than half of all workers receive health insurance from their employer, and COVID-19 has hit the hardest among workers with low pay and meager benefits. “Job losses so far in this crisis have been pretty concentrated in sectors like accommodations and restaurants that don’t tend to offer employer-provided health insurance,” he said.

Workers who get their health insurance through their employers can keep it. Under a provision of federal benefits law called COBRA, most employees who lose or leave a job can remain on their employer’s health plan for at least 18 months.

But it isn’t cheap.

“Very few people sign up for COBRA,” said Matthew Rae, associate director of the Health Care Marketplace project at the Kaiser Family Foundation. “And the reason is, it’s unbelievably expensive. The worker’s got to pay the full cost, so you end up paying — for a family of four — somewhere north, on average, of $20,000 a year.”

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The gap from "affording cobra" to "no assets and no income" which is the basic requirement for medicaid is pretty far. States use the federal poverty guideline which has been kept too low for years due to politics to determine eligibility. For a single person that's $12,490 and for a family of four that's $25,750. Where in the US are either of those a livable wage? Do any of those places have reasonable access to work and social services?

In fact, I'm actually surprised that only half of American's fear this. I'd surmise that those who don't are either unaware of the potential for the looming crisis or otherwise fatalistic.

And only Americans.

Every other developed, even developing, nation has a superior, if not perfect, solution.

As a European, this is just one of many reasons why I would never fathom moving to America. Your quality of life would be just way below what you can get almost anywhere else in the industrialised world.

This is a big reason why I rejected my green card offer and moved to France.

In another thread, I was told that $19k was enough for an American, and that someone making $60k was just interested in making money. That if the median income wasn't enough, then we "have bigger problems as a country".

And yet here we are.

You should go ask that person in the other thread.

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