Comment by trashface | Hacker News Reader

Comment by trashface | Hacker News Reader

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> FYI for anyone who isn't familiar with the wacky US insurance situation: Nobody in the US actually pays $800 for the drug. That's the "list price" for insurance companies to pay. Even insurance companies don't pay that price because they negotiate their own rates with the drug companies, which are lower.

This isn't really true on obamacare/ACA plans, even the high-end ones like gold PPOs. The formularies are much worse than employer-based plans. Insurers are required to cover one drug in each therapeutic category, but its usually an older generic. Most brand name drugs like this one have really bad coverage or not at all, which means the insurer won't even negotiate with the pharmacy to lower the drug.

Yes you can use coupons, sometimes, but the pharmacy can't always process them and the manufacture is always change the conditions and expiring them. I got one for my glaucoma drops directly from my eye doctor, and it was expired immediately when I tried to use it. I have paid $650 (for a 3 month supply, the full retail cost) for my drops when the coupon didn't work, and I couldn't get them any other way - I can't interrupt the med or else my eyes get damaged. So that falsifies your "nobody" assertion.

Anyone know what's going on with the ACA marketplace?

I like to take a peek at it every so often and it's just stupendously worse than employer healthcare. There is no plan in my market (Idaho) which doesn't have extreme out of network deductibles. The cost is also identical to what I and my employer pay for insurance.

Is it just that the ACA is mostly used by sick people or something?

It's because health insurance companies need to pad their profits. Because we have a backward system in the US where profits are extracted by everyone without any competition from a not-for-profit. That's why the idea of a public option is so popular (it was originally a Republican idea until it was decided insurance company profits are more desirable). Personally, I don't think any health insurance company should be for-profit. But the for-profit companies sure as hell should have a non-profit competition with the same bargaining power they do.

> Because we have a backward system in the US where profits are extracted by everyone without any competition from a not-for-profit.

California has an excellent non-profit option, and it depresses prices a bit, but not a huge amount

Yeah, some individual states do have not for profit, and it does help. These are the vast minority of states. That's why it should be available nationwide as a public option.

Pretty sure Kaiser Permanente is not-for-profit, many Blue Cross Blue Shield members are non-profit

Most (and the biggest) BCBS licensees are for-profit. Kaiser is not but is still eye wateringly expensive. For me, a silver plan will be about $700-800 next year. And then you take a look at what a bronze plan covers…

This is correct. BCBS is for profit and most others are. Kaiser Foundation Health Plan is one of the few not for profit insurances and only available in 8 states.

BCBS AL, AR, CA, KS, HI, LA, MA, MI, MN, NC, ND, RI, TN and VT are all not for profit, as far as I can tell.

Not an exhaustive list, just asked AI and quickly checked it's output with google.

Kaiser is the biggest HMO in the country (and available in DC).

Prices have jumped, see:

    * https://news.ycombinator.com/item?id=44604365
    * https://news.ycombinator.com/item?id=44989706

Many people that use the Marketplace plans don't have employer sponsored health plans available.

As a solo dev, I’ve been on ACA with my family for the past four years. In my market, a major insurance company is not returning for 2026 and the prices have gone bananas. Our premiums are increasing over 40%, all of our copays are more than doubling, and the deductible is astronomical. In many cases the cash pay price is probably cheaper than the insurance negotiated rate.

I’m the plus side, all bronze plans can contribute to HSAs next year.

We compared individual plans off market, but they’re mostly the same without HSA access or they’re targeting people with specific ailments (e.g. the diabetes plan).

On top of that, consolidation of hospital systems has made wait times for GPs months unless you’re lucky enough to find a cancelation. We have some older Canadian ex-pat friends and it seems like our health system has all of the downsides of socialized systems, plus we get to pay Cadillac prices.

I’m really hoping 2026 is so bad that something breaks enough to resolve some fundamental issues with private health costs, but I’m not naive enough to think it’s likely. ACA was such a monumental gift to someone, but it definitely not individuals who need family coverage.

For one thing, as I understand it, the ACA was pretty effectively sabotaged by removing the mandate, which destroys the math that makes insurance work.

Because pre-existing conditions have to be covered, you're free to wait until you have a serious (expensive) condition, then sign up for an ACA plan. And there's no mandate that spreads that risk around to healthy people, so the population is severely skewed.

I have no definitive data on this, but it seems self-evident that the system can't work well.

Even with the individual mandate, it seems self evident that incentives are for private insurance companies to happily take in the extra premiums from healthy people, and then drop or have prohibitively high premiums after people get sick. The medical loss ratio tries to mitigate this, but just kicks the can down the road where the incentive becomes to dump the money into administrative overhead and self-dealing with providers/pharmacies run by affiliated companies.

this is mostly right, but it's not true that you can just sign up at any time. there's an open enrollment period for the aca marketplace and if you miss it, you won't have the opportunity to buy health insurance until next year.

The individual mandate merely guaranteed a captive audience for health insurance companies. That doesn't do anything for cost. What drives cost is the ACA limiting profits based on the cost of care, thus more expensive care equals more profits. Can you see where this is going?

Five states plus DC still have an individual mandate (ugh), and yes health insurance premiums are spiking there too. A large part of that is due to the tax credits (generously labeled subsidies) expiring – even with an individual mandate health insurance is prohibitively expensive.

I’ve used ACA plans off and on for about a decade. They’ve mostly been as good (of not better) than the employer plans we had once or twice.

So my guess is this is heavily state dependent. Maryland as a state isn’t hostile to ACA so I think they have solid plans.

I can also only speak for BlueCross plans.

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