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Throw-away because I like to keep my financial details personal.

I'm self employed and have been for about 15 years. We purchase health insurance from the state exchange. Prior to this, I'd purchased it as an individual directly from the insurers, or used the plan my wife had through her employer. Those options are no longer available to us, so we use the state exchange.

My family's health insurance rates increased 17% last year. This year, my state has approved an increase of 27% for the provider I use and a 31% increase for one of the other providers in the state.

To insure our family of four, we'll pay around $25,000 for insurance before a dollar is spent on deductibles, co-pays or other associated costs. We're generally all healthy. Have no pre-existing conditions to speak-of. We earn more than the level where you qualify for any subsidy.

This is unsustainable.

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> This is unsustainable.

It's not just unsustainable, it's absurd! $25,000 USD is most of, if not the entirety, of the TOTAL income taxes many people pay in other OECD nations. How are these other nations providing all of the functions of government, including universal health care, for what Americans are paying just for insurance? This shouldn't be a partisan issue - even the most conservative of Americans should be outraged that we are being ripped off.

https://data.oecd.org/healthres/health-spending.htm - the US spends $9,800/year per capita, clearly an outlier, and yet we still can't cover everyone in a reasonable way?!

I took my child in for a regular 15 minute doctors appointment recently and the cost of seeing the provider (no tests) was $350. Does it really cost $1,400/hour to operate a medical clinic? Google tells me that the average GP salary in the US is $189,000 ($90/hour), average salary for a nurse is $67,000 ($32/hour), and average for a receptionist is $27,000 ($12/hour). Add another nurse for administering shots/drawing blood and the total payroll per hour is about $166/hour. Where is the other $1,234/hour going?

I'm sure there are reasonable explanations for some of it (cost of the building, cost of medical equipment in the clinic, professional insurance, and maintenance on the fish tank) but the ridiculous cost of everything is the elephant in the room that no amount of "cracking down on fraud" or "incentivizing healthy behaviors" will solve.

As an immigrant to the US, it's maddening. It just doesn't have to be this way, there is half a century of evidence showing that alternative systems are cheaper and more effective. I also look at that $9,800/year per capita and wonder what our economy looks like if everyone had an extra $2-4,000/year in their pocket. Or if we eliminated the burden of health care from businesses and individuals trying to start a business.

Not to take away from any of your points, but just a minor correction that in many OECD nations (Europe specifically), it's payroll taxes that pay for the healthcare, not income taxes. The former can be double what the latter are.

To some degree, hospitals perform a kind of internal socialism: a poor, homeless person can't be turned away from the emergency room, but they also can't pay for its actual cost. To balance their books, hospitals then have to overcharge people with good insurance.

This is similar to private universities charging rich students the full sticker price, while giving poorer students scholarships and financial aid.

Hospitals put the costs of uncompensated care at 5-6% of total expenses:

http://www.aha.org/content/16/uncompensatedcarefactsheet.pdf

(that's charity care and non payments but not any unfunded expenses due to Medicaid and Medicare)

"*The above uncompensated care figures represent the estimated cost of bad debt and charity care to the hospital."

Cost is the key word there and is bolded in the link. The billed amount they would have lost would be much higher. Most hospitals collect about only 25% of patient payments owed to them. When they write it down, they use the cost to the hospital not the amount billed.

I don't see what is important about that.

What is interesting about the amount they attempt to bill?

For example, if we're talking about a $5 bandaid (in terms of cost), the hospital will list the price at $20 on the chargemaster. They'll charge an in-network payer $15 and an out of network payer $20. An uninsured patient would probably get charged $10.

In any case, if the patient gets charged $10 and doesn't pay, the hospital only writes off $5 as uncompensated care because that's the requirement for government reimbursement. But really they lost $10 on gross patient revenue. It scales up much higher as you can imagine. The point is that the financial cost of uncompensated care is much higher than the dollar amount and why so many hospitals are in financial danger today.

Why are "cost" and "financial cost" different things?

The stated "cost" of say, taking an x-ray, should be the fully loaded cost, the facility space, the equipment depreciation, any consumables, the time, etc.

Because the margin is so huge in healthcare products and services, especially at hospitals. Hospitals rely on astronomical margins on certain payer classes to subsidize uncompensated care costs.

The point is that providers are far more invested in maintaining the huge margins rather than minimizing the cost.

Problem is the payer mix has been shifting from insurance companies to patients via high deductible health plans over the past decade so it's starting to wreck their margins, even though the cost doesn't change.

This is nonsense. Public health systems in Australia and Europe also has to take care of everybody.

> I took my child in for a regular 15 minute doctors appointment recently and the cost of seeing the provider (no tests) was $350.

A 30 minute visit with my primary care doctor is ~$160.

I now realize my local hospital is fairly reasonably priced.

Also don't forget to factor in the small army in the billing department that has to deal with the insurance company. And the third party payment provider that runs the online web portal that you pay through.

Interestingly enough, in Washington State all hospital finances are a matter of public record[1]. I am somewhat amused that health insurance for employees make up ~5.7% of the hospital's total expenses.

Charity care was only .87% of overall expenses.

[1]http://www.doh.wa.gov/DataandStatisticalReports/Healthcarein...

> It's not just unsustainable, it's absurd! $25,000 USD is most of, if not the entirety, of the TOTAL income taxes many people pay in other OECD nations.

In most European countries (probably in all of them, but I do have motivation to check) the cost of the health care is paid based on the solidarity principle. This means that the amount that goes for the state level insurer is proportional to the income amount (private insurances for the extra coverage usually work on the fixed amount basis).

Around 500 per person in month is probably not on the very high side considering decent salary levels. The difference is that the health care of the minors is free. This splits the amount in half.

In Germany, this is less. Suppose you are insured through the public system (Krankenkasse) and you have a salary high enough to pay the maximum rate, you pay 365.40€/month (your employer pay about the same amount). If you are self employed, you pay 656.85€ (employer and employee part).

This covers you, your kids and your partner if he/she is not working. If your partner is working, he/she pays like you.

So, imagine you are a family of four, both self employed, the maximum you pay is 656.85€ x 12 x 2 = 15764€/year. This covers 100% of the kids medications, 70 to 100% of the adult medications, 100% of the visit to the doctor and stay in a hospital. You do not have to pay and get reimbursed, you just provide your insurance card and the doctor/hospital will automatically charge your insurance (Krankenkasse).

The system is working a bit differently if you opt-in for a private insurance.

Edit: I cannot reply to the question about the maximum, so, answering as an edit. Yes you have a maximum and the values I gave are at this maximum.

Slight offtopic. Did I understand right that there is a limit for 'Krankenkasse' monthly payment?

Where I live - there is no limit.

If your _payroll_ is ~1315eur, that means your _income_ is 1000eur, because you've paid (or employer did that for you):

- 15% income tax (~197eur),

- public health insurance 6% (~79eur),

- public retirement fund 3% (~40eur).

- employer pays 31.18% of the _payroll_ to public health insurance (~410eur).

Making the __whole employment price__ - 1726eur, of which 489eur goes to public health insurance. If your __income__ is 10 000eur - everything is tenfold.

I do not know nuances of self employment, but you pay less for the public health insurance. From 1726eur, you'd pay ~234eur for public health insurance and ~181eur income tax - leaving you with ~1311eur.

https://slatestarcodex.com/2017/02/09/considerations-on-cost...

well, you probably also make a lot more than in your home country ;) So that seems to be the game we're all in...

> How are these other nations providing all of the functions of government, including universal health care, for what Americans are paying just for insurance?

by america subsidizing their defense spending

You're not wrong. I'm sure there are points to debate, but the US does provide a free military to the EU.

https://www.cato.org/blog/us-taxpayer-subsidies-european-wel...

Very sorry to hear about the burden you and your family are bearing.

I hope we can devise an alternative to the current system, as $25,000 is more costly than just buying everything up front!

I did some research and found that an apendectomy is one of the most important things insurance can pay for, as it is sudden, life threatening, and generally not easily controlled by lifestyle choices.

The quoted cost of an apendectomy from a variety of different countries and hospitals?

"Between $3,000 and $150,000 USD"

It might as well be "blank check", if this price gouging is allowed in the US.

A single person can easily incur more than $30,000 of medical expenses, even at a hospital with reasonable prices.

So no, $25,000 isn't more expensive than buying everything up front for 4 people.

It's expensive, but the US spends something like $10,000 a year per capita on health care, so it isn't an outsized chunk.

Over 10 years ago, I had my gallbladder taken out. I spent two nights in the hospital (one in the ER, where they diagnosed it, and one more after they took it out).

I was uninsured at the time, and at the end was given a bill for $18,000.

Gallbladder removal is the simplest major surgery that can be done on a person; it's a simple organ to remove, and rarely presents any challenges.

I could easily see surpassing that dollar amount for anything more complicated.

For comparison, the total cost to do the surgery in a developing nation (where I spent several years in my early 20s) would have been $300-400, according to friends there.

In 2004, I had gallbladder removed. Total bill for surgery and overnight stay was around $11k. The insurance I had at the time covered things, and I got a bill for around ~$40. That was it. I had employer-provided insurance, but I'd been there less than a month(!).

With different insurance, different state, a few years later, my wife had to go to ER with pneumonia. 5 hours in total to draw some blood, xray, and a drip. Bill later - with blue cross insurance - was ~$3000.

Health "care" here is insanely priced and managed.

had mine out last year. 3 nights in hospital. the bill for just the room and what little food i was allowed to have after surgery was 40K billed to insurance. that didn't include all of the smaller charges submitted by the pharmacy, radiology, anesthesia, the surgeon, the GI doc who visited once...

Did a quick look-up of appendectomy pricing based on published CMS data from 2015. Results listed here:

https://docs.google.com/spreadsheets/d/1vPg1jtV8CK3pAs5EXC48...

Source:

https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...

Sometimes I think other nations should be a bit more pragmatic in generating revenue from the huge costs of healthcare in the US.

In the UK we can charge foreigners for use of our NHS. I believe that using this private service, is significantly cheaper than the equivalent in the states. Flight costs are trivial when looking at US healthcare costs. Of course this can only deal with non-urgent and (relatively) well off people.

My family has employer provided healthcare. But at this point if the premiums go up faster than we can afford I'm switching to an HSA. I can easily afford to fly my family to Cent/South America to have a checkup or surgery compared to the money I'm throwing into the wind with our HMO.

We're young, healthy, with no chronic issues. Just the type of people insurance companies would want to insure.

That's why a lot of people at the border go to a private dr in Mexico instead.

Sucks but I'm pretty sure they'll take every penny. People said college costs were out of control in 2000, stuff kept going up for a decade.

Again for comparison, Germany has free tuition even at university level. And it doesn’t cost the country a great deal. These sudden rises in tuition in the US Zaire a relatively recent phenomenon too.

To be fair, you do give up some things for that free tuition in Germany. You basically attend lecture and take the test at the end. It scales well, and some people do really well, but it might not be for everyone.

Free tuition for foreigners as well.

Pretty sure they are still going up

I graduated in 2009. Tuition has passed double what I paid, and today is approaching 3 times what I paid.

Would it be more cost effective to buy a catastrophic insurance policy and self-insure (pay cash) for routine services?

Under ACA medical plans deductibles are capped at "For 2017, your out-of-pocket maximum can be no more than $7,150 for an individual plan and $14,300 for a family plan before marketplace subsidies."[1]

[1] https://obamacarefacts.com/health-insurance/out-of-pocket-ma...

Not sure if only plans in the ACA system must meet this requirement or that private companies cannot even offer say a $50,000 deductible plan with a $3 mil cap.

Probably the option we'll explore when reviewing plans. Or go back to work for a company which provides coverage as part of the employment package.

It's worse than that. With the biologics on their way to market today, and with guidelines changing, we could be treating relatively common diseases with absurdly expensive drugs, and insurance companies will have no choice but to cover these therapies. That will in turn cause premiums to skyrocket.

At that cost would you not be better off saving it?

It might be.

But then you either get hit with a penalty for not buying insurance, or you get hit with a penalty and also a bill for $500,000 when you find out you've got some illness you didn't know about and hospital bills bankrupt you.

Just noticed your throwaway user ID. Clever. I'm guessing that you support single payer?

Seems to work reasonably well in other countries.

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