Comment by iamthepieman | Hacker News Reader

Comment by iamthepieman | Hacker News Reader

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my company pays 2000 dollars a month for our insurance premiums. This is a plan with a 2k individual/6k family deductible per year.

We are saving 1.37% next year by going to a plan with 3k individual 9k family deductible. If we didn't do that premiums were going to rise by 10.4% next year.

Our rates have gone up every year since I've been working here.

The total EOB (Explanation of Benefits) costs value for the medical care my family got last year was under 6k. This was unusually high because we had two minor surgeries. The two years prior were much closer to our baseline of about 3-4k of medical care. This includes shots for the young kids, regular checkups, the occasional prescription and one semi-emergent emergency. One year a kid broke her arm, the other my wife needed an MRI.

I know I represent a young family with relatively few health problems but so far, just since being on my current plan, we have paid 90,000 dollars (costs were slightly lower than our current premiums in prior years if you are doing the math) and received (at the high end) 18,000 dollars worth of medical care. I have paid 72,000 over just 4 years for insurance against catastrophic illness, disease or trauma.

As I sit here writing and calculating this I have this question in the back of my mind - Is it worth it?

I don't know. I think that question is ridiculous but I don't know what other question to ask.

we have paid 90,000 ... and received 18,000

But have you seen how they gouge the uninsured? I was in a minor bike accident last year and I had a 5k deductible. Just had an ambulance ride and got checked out at the emergency room. The bill was $6000 without insurance, which was reduced to $1500 with insurance.

Hospitals have such poor cost accounting.. they basically make something up if you're uninsured. It completely eliminates going without insurance. The charges would be outrageous.

Edit: The 4x multiple in my bill isn't anywhere near the worst. There are hospitals that charge up to 12x (so 1500 turns into 18000): https://www.washingtonpost.com/national/health-science/why-s... Add to that, hospitals won't tell you what something will cost up front... so you get to find out when they send you the bill.

It's also an issue for meds.

There are plenty of generic meds that cost less than $10 with the discount negotiated by the insurance company but cost upwards of $100 if you don't get the discount.

The calculation that "you get nothing with a high deductable plan" is not entirely accurate if you take these into account.

There are free pharmacy benefit managers that will get you similar negotiated discounts. There are also store programs like Walmart's $4 drugs https://www.walmart.com/cp/1078664 .

(that's what lots of drug discount cards are, you get a negotiated price instead of the cash price)

So having a PBM price is an included detail of insurance plans, I'm not sure how useful it is (I expect the formulary used by cheap insurance ends up similar to the free stuff).

I had a similar experience. Burned the sole of my foot. Twenty minutes talking to a nurse at the hospital - two pain pills and the assurance that it was below the threshold for a third degree burn - and I walked out with a $3000 bill. They eventually knocked it down to $2500 and gave me a no-interest payment plan.

I've had uninsured hospital visits and when I called to pay they were shocked and surprised. I think they jack up the price so they can write it down because they don't expect to get paid.

No. The price is jacked up because insurance companies negotiate down, so providers have to price anchor high in order to receive payment at a sustainable level. They can't offer you a cash rate without hell from insurance companies, so you encounter the uninsured negotiation dance.

They should just do the transparency shift and say everyone pays X and there is zero wiggle room.

https://en.wikipedia.org/wiki/Single-payer_healthcare

To me, the #1 benefit of health insurance is not the insurance (i.e., swapping the cost of the unlikely, major expenses for a regular constant payment). It is price negotiation with service providers.

I would love to be able to get, from my insurer, a low cost option just for this: patient pays 100% of their standard negotiated rates. I go to the same network, they pay the doctor and bill me for the payment. Premiums just need to cover their admin cost plus some insurance that kicks in if I do not pay.

Doctors should not care -- they still get the same $$ from the same source the same way. Catastrophic coverage can be arranged separately, but the above schema I think would provide much of the current insurance benefits at the much lower cost.

provide much of the current insurance benefits at the much lower cost.

The benefits of health insurance aren't those your alluding to here.

The benefits of health insurance are the flow of money from your bank account to the insurer.

Your premiums are going up 74% next year, what are you going to do about it? Complain on an internet forum. Go ahead.

For anyone interested, David Belck has some good lectures on how medical procedures get billed and how insurance (doesn't) work in the United States: https://www.youtube.com/user/davidbelk46/videos

This guy is excellent I wish this were higher up in the thread

The problem is insurance companies can negotiate bulk rates, but it's actually illegal for people to get together in a group and do the same thing without the insurance part.

What's also annoying is you can't determine ahead of time what something is going to cost, so even when it's not an emergency you can't shop around.

> As I sit here writing and calculating this I have this question in the back of my mind - Is it worth it?

Well, it's insurance. It's there so if you have twins in the NICU for two months because they were born in the second trimester (like I did) you don't wind up with a multi-million dollar bill to pay. Most people will incur more premiums than benefits. That's normal.

Let me ask the relatively cruel question though for the purposes of prompting further discussion:

At what point does subsidizing other people's outlier events become unacceptable? I will never have kids (biological issues). I will likely die from a one off critical heart failure (also genetic in my family) rather than anything that will cost me significant amounts of money. I do not drive, leave the house much, or do any risky activities, yet as the parent said, I pay _hilarious_ amounts of money each year for insurance.

And the real kicker for me, I've developed some conditions related to stress-side effects, sedentary behavior, and joint issues because of my work. So the insurance money would be BETTER SERVED being reinvested so I could stop working in such a way that damages my body.

Now, you can say this is selfish, but as I said, I'm taking an intentionally selfish point of view for this argument. At what point do we draw the line of "I need this money for me now" or "someone else needs the net effect of re-balancing costs across a society?"

I will openly admit that as I've gone through a decent chunk of my career without incurring any major events, but while incurring major costs, where I sit on being OK with the current arrangement has shifted.

That question is pretty close to home for me. Our family's highest yearly billing was about $3M, and we've hit $100k every year in the last 8. If you were writing a textbook about healthcare outliers, we'd be in it.

The closest thing I have to an answer for you is single-payer like the rest of the developed world, where they pay substantially lower medical costs for similar health outcomes.

I do hope to see our society mature a bit on end-of-life care. Dying is disproportionately expensive (http://time.com/money/2793643/cutting-the-high-cost-of-end-o...) and that money often results in little benefit to the patient (and at times, probably causes active harm).

> I do hope to see our society mature a bit on end-of-life care.

It looks like many countries are moving that way in the past 20 years: https://en.wikipedia.org/wiki/Legality_of_euthanasia

I don't think that really shows progress.

Patients who'd like to undertake euthanasia and can't would get a DNR order. Medicare isn't spending massive billions on folks with DNRs - it's the folks that won't accept a terminal cancer diagnosis and put grandma through intensive chemo instead of prioritizing quality of life that costs.

Let me ask an even crueler question. Let me preface by saying I am a parent of a child that needed some minor postpartum care in order to survive, so how horrible this sounds is not lost on me:

At what point do we stop holding up infant mortality as the gold standard of medical care? Spending untold resources on keeping alive infants who would otherwise die is inherently dysgenic, and allowing whatever conflagration of genetic anomalies that contribute to the necessity of postpartum care will inevitably lead to higher incidences of these cases in the future, as these genes are allowed to propagate into future generations.

Infant mortality is emotionally devastating, but preventing it will almost certainly increase our society's long-term medical costs.

But it also selects for empathy and parenting. Both will help build a better society. In fact we've been sacrificing physical skills for emotional ones, as long as human societies have existed. This is nothing new for sure.

On the other hand, something that is trivially treatable can be borne without issue, which, who knows, could enable later advancement.

Just look at the established tradeoff our species makes- our children are born helpless. Isn't caring for them dysgenic? But, being able to care for & protect them enables significant brain development to happen outside the womb.

Swaddling, clearing a wrapped umbilical cord, suctioning the nose & mouth... there are lots of things we do that improve mortality that are trivial.

Along this topic, if we are spending so much on these infants why is our rate higher than other first world countries?

Finland which is number one, "used the least resources and attained average results, making Finland the most efficient public sector health service producer according to the study's authors"

https://www.washingtonpost.com/news/wonk/wp/2014/09/29/our-i...

Granted it's way better than many other countries, but still we shouldn't be so off.

https://www.cia.gov/library/publications/the-world-factbook/...

Spending is unevenly distributed. Poverty and drugs have a negative effect. Basically, spending 100 million on one baby born without a heart doesn't save twenty other crack babies.

"fail early, fail often"

If you want to be a visionary, go out and have some accidents!

Wasn't this line of thinking discredited with the Nazis? Is eugenics back now? Do you also have a modest proposal for solving the problem of all those excess poor children?

Wright or wrong, this doesn't fit the definition of eugenics.

How does this not fit the definition of eugenics?

> Spending untold resources on keeping alive infants who would otherwise die is inherently dysgenic, and allowing whatever conflagration of genetic anomalies that contribute to the necessity of postpartum care will inevitably lead to higher incidences of these cases in the future, as these genes are allowed to propagate into future generations.

Well, cystic fibrosis patients are encouraged not to have children. Is that eugenics? In the extreme, with enough time and money we could even harvest eggs and sperm from CF patients to ensure they can procreate even if they don't live long enough to do so. Is it eugenics to not spend those resources?

It's a pretty big gap between "don't treat preemies who might be perfectly normal once stabilized" (case in point: my kids) and "you should think about not giving a kid a death sentence" that CF entails.

Eugenic/dysgenic thinking has never been discredited. Rather, it has fallen out of favor for ethical, not scientific reasons.

Childhood mortality has to have imposed a tremendous selective pressure, on both the immune system and general congenital defects. I've been reflecting on what lifting this selective pressure means. Also on the fact that this lifting is nonuniform across cultures -- infants in less-developed nations are still subject to most of these effects.

That said: most of the improvement is through public health measures (clean drinking water, sewerage systems, municipal waste collection) and nutrition. Heroic measures are very much the outlier. That may be an even stronger argument against them -- other than as a learning experience, the resources they consume relative to providing much more basic, and effective, outcomes interventions is difficult to defend.

From the CDC: Infant mortality in the US <1 year was "up to" 30% in 1900. Maternal mortality was around 0.8% in 1900.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4838a2.htm

To me, that's what health insurance is. Insurance should be for rare (or at least uncommon) events. Flood, fire, car accident, etc.

But health "insurance" has crept into regular health maintenance. But that's not really insurance; that's more like an extended warranty for your life.

That's true for various reasons such as benefits expectations (some of it the result of union negotiations historically) and tax effects. [1] There's also the theory, which may not be especially true as I understand it, that preventative medicine like regular physicals can cut healthcare costs down the road. In any case though, I'm pretty sure that annual physicals and the occasional stitches or urgent care visit aren't huge contributors to overall healthcare costs.

[1] And certainly things like dental insurance are pretty much just "extended warranties" rather than insurance against catastrophic expenses.

Yes, many people are asking that question now.

Those who work for a company and receive a W-2 form can look at Box 12 on the W-2 to see how much their employers paid for their side of their health insurance policy (coded with "dd").

You might think "who cares" but that's money that could have gone towards your salary.

To which they would then have to spend on their own, more expensive health insurance plans?

One should also question why an individual healthcare purchase should be charged more than a work based group plan. Shouldn't the operative "group" of patients basically be everybody who is a customer of the insurance company (or at least everybody at some tier of the insurance plan).

The historical (and continuing--hence the controversial Obamacare mandate) problem is adverse selection. If you know you'll be using a lot of expensive insurance coverage you'll buy insurance--probably the most comprehensive you can get. If you're a 20-something who doesn't think he will ever get sick or injured (or just doesn't think about future events a lot), you may pass on insurance entirely.

Outside of health care specifically, this is also why disability plans tend to be relatively inexpensive for large companies to offer but are pretty pricey--when you can even get them--for individuals.

I'm not sure I follow. Healthcare is mandated, or you'd be paying some penalty on your taxes. So charge a startup fee for some entrance check of taxes, but otherwise why would an individual getting insurance be any riskier than a group? (It does make me start to think of farfetched scenarios like people joining a front-company to get group insurance rates...)

Same with disability, examine the individual coming in to make sure they don't already have a disability that's being covered, but after that why would the individual odds be any different than accepting a whole group? If you do an actual exam, they might actually be better.

The mandate is weak enough that there are still healthy individuals who aren't covered by company plans who are choosing not to buy insurance. [ADDED: And there's a fair bit of concern that the number of these individuals will rise as rates go up, driving further rate increases, in what's often called a "death spiral.]

There are non-employer group plans for certain types of insurance e.g. through something like the IEEE but generally not for healthcare AFAIK.

With respect to disability--leaving aside that an exam won't find all pre-existing conditions such as joint problems--there's still adverse selection. The people who would even apply for disability insurance are a higher risk pool (probably older for one thing) than the working population as a whole or all employees working at a large company.

oh I know. That's why I said "we have paid 90,000 dollars" Even though the insurance premiums are all covered by my employer I still count it as coming out of my salary.

My understanding is that beginning this year, obamacare premiums paid by your employer are now considered income and are subject to taxes.

I assume you're talking about the "Cadillac tax" on more generous insurance plans. Its implementation has already been pushed back to 2020 and there's a pretty decent chance that it will never see the light of day.

The problem there is that the subsidy money has to come from somewhere, and the longer that tax gets pushed back, the more we have to do other shenanigans to come up with the money: borrow more, raise taxes elsewhere, etc. As it is, the subsidies don't really help folks as much as was planned, and even with the subsidies, the costs are rising quickly. It's a runaway train at this point: costs rise, making the subsidies insufficient, so the politically expedient thing to do is to expand the subsidies, which means that taxes must rise to pay for them.

>As it is, the subsidies don't really help folks as much as was planned, and even with the subsidies, the costs are rising quickly.

I don't think this is in spite of subsidies but beacuse of them. Just like the epipen mess, the less of a bill the customer sees the more you can raise it.

Twelve years $158,000.

Orthopedic replacement $23,000 one year. Other years combined $2600

Not worth it. But plan your surgeries and up the coverage for that year. That strategy can work (not dental)

Even with a high out of pocket it is smart.

Unfortunately the interests of the industry trumps the interest of affordable healthcare. We need someone to come in and dismantle all the middlemen in healthcare. The Healthcare Industrial Complex is just a machine to move money around.

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