Hacker News Reader

Comment by mobilefriendly | Hacker News Reader

ACA is horrendous, unless you're receiving a government subsidy. I'm self-employed and we have one option of insurance provider, and the cheapest plan for my family last year was $18,000 a year with a huge deductible. That's after tax, out of pocket, for a healthy family with no pre-existing. Like all self-employed people I know (who aren't getting government subsidy), I moved my family to Christian Medishare, which is basically catastrophic coverage for about $3,000 year that was grandfathered in when Obamacare was passed. However it isn't truly insurance, it isn't regulated for soundness. I'm seriously considering returning to wage employment for health care benefits.

View on HN

The rate of increase for health insurance prices went down after the ACA was enacted. The motivation for enacting the ACA was, in large part, the untenable increase in insurance prices in the 10 years leading up to it.

People have a bad habit of blaming the ACA for insurance prices. The ACA failed at its goal of making individual health insurance affordable, that is true. But it didn't cause that problem, and it did something extremely important to mitigate it.

No it didn't, it reduced choice and drove up insurance costs by mandating that all private insurance cover everything + kitchen sink. My single brother's cheap catastrophic plan was OUTLAWED to force him onto the ACA exchange. The only thing ACA has done on prices is pass rising costs to taxpayers (more than 80% of ACA participates are subsidized) and the exchanges are in a death spiral because anyone who can escape them is doing so.

Another thing-- the data on prices are a flat out LIE, the government is also making massive payments to the insurance companies directly -- their prices don't reflect their actual costs.

I'm sorry you feel that way, but that's simply not what happened. I cofounded a company that provided insurance to ~40 full-time employees (and provided insurance before the ACA was passed), and the costs you're seeing today are in line with where costs were outside the ACA and prior to the ACA.

No matter what you think about prices, though, the most important thing the ACA did was create a nationwide requirement for guaranteed-issue insurance. However expensive you think insurance is, it's more expensive to be flatly and irrevocably restricted from buying your own insurance at all, which was the status quo ante of the ACA.

It isn't what I think about prices, it is the facts, ACA exchanges up 34% YoY. https://www.cnbc.com/2017/10/25/most-popular-obamacare-plans...

Nobody upthread of you is arguing that health insurance prices did not go up after the implementation of the ACA. The argument is that the rate of increase has decreased. I don't know if this is true, and don't have data to argue one way or another, but you and the other people in this thread are arguing about different numbers.

>ACA exchanges up 34% YoY

Stating "YoY" gives the false impression that this is the average increase over some number of years. However, this was simply the projection for 2018 and the article provides the reason:

"The price increases are fuelled by market uncertainty and the elimination of key federal payments to insurers."

> The price increases are fueled by market uncertainty and the elimination of key federal payments to insurers.

https://www.cnbc.com/2017/10/17/decision-to-kill-obamacare-p...

That price increase was engineered by the GOP by cutting the payments from the budget followed by the Trump Administration's "finding" that they had no authority to spend the money.

I genuinely hope your posts are just virtue signaling created by a desire to appear as one of the faithful.

A little data that agrees with your impression:

https://www.forbes.com/sites/theapothecary/2016/07/28/overwh...

That article, aided and abetted by the terrible writing in the Brookings article it's criticizing, is comparing apples (the rate of increase) and oranges (the actual increase). There's no controversy that health insurance rates are increasing; they've been increasing dramatically since the turn of the century.

So you are saying the acceleration of cost went down? It’s bad enough we have to compare health costs on the 2nd derivative. Maybe soon will need to use the 3rd.

Health insurance for my healthy young family of 4 spiraled out of control WITH ACA, so much so that I didn’t purchase proper health insurance in 2017, while also underfunding my income tax in hopes that ACA cannot legally “send me a bill” for 2.5% of my household income. (I mean shit, in a red blooded patriotic American, but that penalty made me absolutely furious) All this while paying cash for prenatal visits for our next child, still far cheaper than paying for a $15,000/yr policy + 15,000/yr deductible. In my decade of buying family insurance, I watched my family policy increase by nearly $1000/mo combined with a staggering decrease in value provided via super high deductible... oh, and no legal way out.

I know ACA is good for some, but goodness did it remove my interest in remaining insured. I’m sure you can cite data that tells a different story, but my experience, as well as that of my peers, says ACA has been very bad for those actually paying the bill unsubsidized. I fully blame ACA for this.

You have a young family of four, and can barely afford insurance premiums. Basically, without insurance, every single year you're hitting on a blackjack 17 against bankruptcy. You see the ACA penalty, and you see the insurance premium cost, but you're not factoring in the 5-digit cost of virtually any significant medical expense.

Rising insurance premiums aren't good for anyone. The ACA set out to fix the problem of rising insurance premiums and (I think) pretty much failed. But it didn't create that problem; 5-digit annual premiums for a family of four were a reality prior to the ACA --- or, at least, they were in Chicago on the small group market.

The subtext to these discussions though is whether we'd be better off without the ACA. No, we would not be. We would lose guaranteed-issue insurance, so a sizable fraction of families wouldn't be able to get insurance at all, and, from the available evidence, we would at least have the same rate problems we have now, and (according to some studies) have worse rates. Obviously, this subtext is about the GOP's health care rhetoric, and I'm not wild about opening up a political salient in this thread, but let's at least be clear: the idea that you can repeal the ACA, do nothing else, and get lower health insurance premiums for real coverage is sleight of hand.

For another example: my broken ankle: tib+fib fracture, 2 severed ligaments, partially torn syndesmotic ligament, gave myself plantar fasciitis during recovery. Two surgeries, a bunch of ortho visits, a bunch more PT, 10 months on crutches.

The net bill was over $110k if I hadn't had insurance and wanted to go to one of two ankle specialists in the city I live in. With insurance, $5k-ish.

If enough people didn't have access to insurance, then there would be pressure on hospitals to find ways to reduce prices (so that their volume could go up). As it stands the medical industry is allowed to hold the poor for ransom ("accept our increased costs or they won't get treated") against the US's deep but finite pockets.

Before, we had the (very poor) demand elasticity of people paying everything they had and then maxing out every credit source, and predictably prices rose to around that point. Now, we have no demand elasticity at all, and prices can be expected to rise well above the average person's net worth + credit access.

If you look at any microeconomic equilibrium chart, you'll see that the price is held in a balance between people buying and people holding off due to price. When the good is healthcare, the human cost of "holding off" is very high, and usually involves inability to pay. Unfortunately our economic system tends to fly off the rails if this balance is disrupted, no matter how noble or urgent the cause.

>pressure on hospitals to reduce prices

Elsewhere it has been said: choosing between bankruptcy for your family or cancer care for your child isn't an actual choice, it's two loaded guns pointed at your skull. One held by the hospital, the other by the insurance company.

The reason first world countries choose universal healthcare is that healthcare is a human right. Full stop. It is not an economic issue. If you want to get economic about it though you'll lose because as it turns out a healthy educated populace is more productive than one that loses productive families here and there to lances of bankruptcy from the unpredictable nest of human disease.

I also feel the moral imperative that you're describing. Nobody should have to tell their child that they're too expensive - to be honest, I can't imagine anything worse.

We were literally using lives as an economic mechanism, but now that we're not doing that we need to use something else in their place. The price of healthcare will continue to skyrocket unless we find something a little less horrifying than other people's lives to use as a balancing weight; although I won't claim to know whether it would be more possible to design a working market system or socialize it successfully.

Priority 1, stop making Soylent Green out of people. Priority 2, re-establish the food supply in a better way, because we need to eat.

I'm not sure its fair to argue that universal healthcare is a human right despite the fact it makes economic sense.

Humanity survived just fine without real healthcare and healthcare is not essential to a fair balance of power b/t the government and its citizenry.

Universal healthcare needs to be argued on the economics of the issue because that is the only practical way to make it sustainable. The "feel good" stuff about it being a human right will fail when stress is applied to America and stress is coming. The US, frankly, has peaked and it is all downhill from here.

You also have to watch out that asserting positive rights that are sometimes impossible to provide (like healthcare) will confuse people when governments attempt to claim that other, deeper rights are "impossible to give." (For example, they might try to argue that they can't afford to not torture, comparing it to how their impoverished country can't give everyone free internet.)

Why is that? If a country tries to claim it cannot afford not to torture, can't we simply point to all the countries that manage without it, as I do for the healthcare debate?

As anyone who lived through the more recent Bush Administration witnessed nearly daily, people claim “not torturing” is an impossible right to give while denying all positive rights—and acted on that argument—so I fail to see the relationship.

Denying every right is the last step of the manuver I'm describing, the first step is to re-define right to mean comfort. Bush-era politics just went straight to step 2 and it didn't work on us.

I suspect that the current UN rights council may be an example of this in action. See: the track record of the members on negative rights, the number of positive rights on their list of rights.

Healthcare is not hard. American healthcare is.

Frankly a single payer system is simpler and faster. But this is an area where American politics and market rhetoric just lead to terrible outcomes.

In law school we were always taught that there are no rights. Rights, in practice are nothing but duties, and should be looked at like that.

You have no right to "life, liberty and the pursuit of happiness", you have a duty to not interfere with other people's life, liberty or their pursuit of their happiness. But even that is a negative duty. Positive duties, like paying tax, are more like the right to healthcare.

So this should be looked on in similar fashion. Do you have a right to healthcare ? Well, answer the question : do you have the duty to take care of others' health problems, completely irrespective of how it affects you personally (for instance, what if it takes up 90% of your time, while still not doing much more than slightly prolonging a miserable short life for them ?).

These questions are not so simple and knee-jerk statements like "right to healthcare, period" are not helpful and will do nothing but get us into a lot of trouble.

No country has "right to healthcare, period". That does not exist. For the obvious reason that it simply isn't feasible. Providing a named (but finite) list of treatments and medicine free of charge if diagnosed by a licensed physician is the furthest any country goes. In some cases that list is pretty short.

http://jeffsachs.org/2017/06/jeffrey-sachs-america-can-save-...

I must say, I've read through his points on the CNN website, and I find 2 of them very wrong (capitation, and the shifting of money away from trained doctors into untrained "workers" "aided by computers"). Most others ... perhaps, but I can't see them making a large difference except the ones about medicine.

Capitation brings the insurance industry's incentives (ie. only work with healthy people) away from insurance companies and onto doctors. What is a diabetic to do when doctors just directly refuse to treat them directly (or delay, or ...). And before you say it won't happen because of hippocratic oath, we both know this rule will force doctors to do that for 90% of their time.

For such doctors and facilities getting people with longstanding illnesses that are just going to come in time after time after time and need expensive drugs and treatment, like MS patients (multiple sclerose), is going to be financially debilitating. That's not reasonable and absolutely not what we want.

As for replacing doctors with "workers" (presumably he means not even nurses), I feel like shouting at him. Doctor's salaries are high, but don't represent a decent fraction of expenses. You could give everyone in medicine a 100% raise and the cost would be in the low single digit percentages (2-3%). Let's face it, this is not what we need to save on. And if we are to save on it, let's PLEASE do it the right way: by subsidizing the training of more doctors, not by replacing doctors with idots.

What I keep hearing about US medicine is that 2 things are necessary:

1) legal changes limiting legal liability of doctors (doctors pay 5 digits per month in insurance in some places, money that is paid by patients but is definitely not going to better care). Something like the European system where a doctor can only be sued before a judge if he's found by the local ethics/hospital/national medical/... board (staffed with exclusively other doctors) to have gone overboard.

2) limit the cost of medicine and increase choices (e.g. mandatory licensing, importing of generic drugs, or just outright force the use of a generic alternative if available like a lot of European countries are doing)

This is the only point I agree with Mr. Sachs.

and for a bonus (just for bringing sanity into the system):

3) Outlaw any and all advertising for anything medicinal (something like if it requires a prescription, advertising it = jail time)

> I'm not sure its fair to argue that universal healthcare is a human right despite the fact it makes economic sense.

“Universal right” is simply that which people feel all people ought to have.

> Humanity survived just fine without real healthcare and healthcare

“Universal healthcare” as a right is simply the right to a certain minimal level which is dependent on technology and resources. The fact that their have in the course of human history been times when no real healthcare by the standards of the early 21st century isn't material to that one way or the other.

> healthcare is not essential to a fair balance of power b/t the government and its citizenry.

That's quite arguably not the case; “government” is an a abstraction than the ultimately boils down to the subset of the citizenry with the most power in allocating resources, and it's quite arguable that that floors for allocation of resources in several domains, including healthcare, are essential for fair balance of power between that subset and the rest of the body of the citizenry.

Further, your implicit argument that a “universal human right” must either be something that prehistoric humans could not survive without or relate to balance of power between people and government is simply a statement of your political values, not a boundary on the what “makes sense” as a universal right.

> Universal healthcare needs to be argued on the economics of the issue because that is the only practical way to make it sustainable.

The actual concrete floor at any given time must be, but then again since every OECD country which guarantees universal healthcare, regardlesa of the details of the system, does it for less total (measured by absolute expenditures, per capita, or per GDP) than the US does spends on healthcare (and some don it for less by all three measures than the US spends in the. smaller public portion of its system alone, let alone the private expenditures), the economics aren't really an issue when you are talking about the US system.

> The reason first world countries choose universal healthcare is that healthcare is a human right. Full stop.

I'm sure they said that in soviet Russia too. It's all good to say X,Y or Z is a right until you actually cash in on that right.

I mean you don't even have to look to the soviet union, what is goinig on with the VA? Obama was working to fix that smaller universal healthcare system from actually just waiting years for people to die but I haven't heard any good news comming out of there recently.

The rest of your claims are just nonsensical in this context since your just assuming universal healthcare works because the government decrees it to be universal.

On Reddit, to responses like this ("America is incapable of universal healthcare because... Reasons") I like to link to the Wikipedia pages of the multitude of other countries with far lower GDPs solving the problem.

I can probably predict the response but on the chance I'll be surprised - why can't America solve the problem when Taiwan, Switzerland, Sweden, France, Germany, the UK, Canada, Finland, Norway, etc etc etc have or nearly have?

(I have received healthcare in several of these countries and an readily prepared with counterpoints to the inaccurate "healthcare isn't good / lines are long in those countries" arguments, fair warning)

Americans pay double in health care costs per capital than any industrialized nation. And we don't have better outcomes. All of those countries have universal healthcare. Citation, OECD.

How can you knowingly discuss demand elasticity and then apply to healthcare?

Healthcare is a non typical market and the cost of a persons health is irrationally high to that person.

Think about this:

Everyone on a boat has twenty dollars and absolutely needs an EpiPen to live. You have a supply of EpiPens and want to get as much of their money as possible. There's zero elasticity between 0 and 20 dollars, but you better not charge $21!

Now, imagine that there was only one person who needed an EpiPen, but everyone else was willing to pitch in as much as it took to help them out. If the supplier of the medicine was perfectly evil, the price would be $20 times the number of people.

Perfect self-interest is a pretty good model of any industry, including pharma, so I think this is a good picture of the situation. The ACA was careful to keep something like a market system in place, which is why we're faced with a problem that can be understood with microeconomics.

Insurance markets are really really old concepts.

Healthcare is known to be a market which has non standard policy imperatives

The cheapest, simplest and most effective system is single payer with everyone in a single pool.

Every major first world power achieves better outcomes for lower costs than America.

Your theoretical premise would have merit if this was only theoretical, and we had no real world evidence that this was a bad idea.

I'm describing market actors with phrases like "perfectly evil," so I hope my comments aren't coming across as policy proposals. All I was arguing is that uninsured people running out of money was a pressure that used to be restraining the price increases but now isn't.

I really feel like this discussion is suffering from false-dichotomy-itis: I've actually been very careful to avoid saying anything beyond my point, about (say) whether or not single payer is a good idea for the US.

> pressure on hospitals to find ways to reduce prices

This might be the case if hospitals had to actually show their prices rather than sending bills after the fact for a price you aren't allowed to know when you consent to treatment. It might also help if competition were allowed, but for hospitals it is pretty much not in a lot of states. To open a new hospital in many states, you need a "certificate of need", which is basically a document demonstrating that you won't be competing with the existing hospitals. So much for "free market health care".

Medicaid and medicare are what keep hospitals open. Most of the volume comes from those patient populations.

"the idea that you can repeal the ACA, do nothing else, and get lower health insurance premiums for real coverage is sleight of hand." --> it's a lie actually.

You are taking a huge, basically unlimited risk with your now healthy family. And note that you will probably save at least as much by the discounts you get through the insurance company's networks as by how much insurance pays vs. patient. Example, had a covered but elective heart procedure. Insurance was billed around $220,000. But they got the hospital and doctors to accept less than $20,000. Yes, I paid some of that - but you see it's all in the under 10% part of the bill. Good luck negotiating your bill down 90% on your own.

I do have a catestrophic policy, I wasn’t clear above. Agree it is a risk, but it’s not unlimited. However, The list prices are sham values. Why do you think the doctors would be willing to accept $20k from one payor but not another? Medical billing ultimately becomes a game of persistence, and you can wear down the billing office and reach a settlement that ultimately. Been there, Done that!

The ACA is not at fault there, that problem was there before.

Absolutely false to say ACA is not at fault. It’s not solely ACA’s fault, but it is complicit. dramatic annual increases occurred every year after ACA. I’m not looking at statistics but my family insurance premiums over time.

Years ago I purchased private insurance for my family in CA. As I recall I was able to get a plan for my wife with no maternity benefits since we were done having children at that point which was significantly cheaper than the alternative. We were paying something like $400/mo total for a family of 4 with an HSA and $4k deductibles.

Later, after some health issues <cough> first child diagnosed with T1D <cough> we were grandfathered into the private plans and the premiums did not change but the deductible was pretty high and the network was not great.

Later, and this was still pre-ACA - California had guarantee issue health insurance with little or no rating factor adjustment (surcharge) for companies with 2-50 employees. So I hired my wife and we switched to one of those plans. Premiums around $800/mo and $2k deductibles. That was about the time when our 2nd child was diagnosed with T1D.

When ACA passed all CA guaranteed issue small business plans disappeared and everything switched over to marketplace. Silver plans for $2,000/mo for the family and $2,000 deductibles with $12,500 our of pocket max. Basically every spare penny went to healthcare, and then some, and we were slowly drowning in debt because of it.

Finally, I stepped off the treadmill, stopped taking a salary, and we switch to Medicaid. And went from spending $35,000/yr out-of-pocket after tax on healthcare to spending $0.

ACA unquestionably increased premiums and total cost for my family substantially, until I stopped taking a salary and went on Medicaid at which point ACA was a god-send due to Medicaid expansion / cost-sharing reductions.

For a healthy family of 4 ACA is horrifically expensive and acts as an extraordinary tax on middle class families who start earning too much for the subsidies. The marginal effective tax rates are so high, the CBO doesn’t have the guts to publish them with the ACA subsidy phase-out included in the calculations.

Yes, ACA is bad if you don’t care about your others in your country getting healthcare. If you do, then you need to figure out how to spread the costs, and ACA is the best we could get with the legislature we had.

The ACA is bad for people that even do care and even initially supported the ACA, like myself. It has plenty of good parts, but I have to be honest, my choices of insurance options went to almost nothing, and the prices skyrocketed. Part of this may have to do with certain parties in Congress purposely underfunding the ACA to make it fail, so I don't know how much blame goes to the ACA and how much goes to those trying to sabotage it.

However, the fact remains that my health insurance options have generally been worse and more expensive since ACA passed. This year, thankfully, I am on employer healthcare plan instead. Because in my area, with the ACA, there is one provider only, and none of the plans are good, and they're all more expensive than before, and at least 2x what I was paying pre-ACA and with MUCH MUCH higher deductables.

ACA allowed more people to get access to healthcare. This means increased demand. ACA did not increase supply of healthcare. This means higher prices, implying higher premiums and deductibles.

Your options are fewer now because you have to be bigger to able to absorb the costs of the extremely high cost individuals such as those with anemia and premature babies and cancer patients.

Everything you’re experiencing is because more people are getting access to healthcare, and instead of everyone paying for it via higher taxes, we’re paying for it via higher premiums and deductibles.

Only way to bring relief is through more supply of healthcare, which means more doctors (they lobby against that) and more medicine (they lobby against that too).

One solution is to marry a doctor so you can take advantage of the situation.

Simplistic supply and demand analysis does not reflect the complexities of the US healthcare market. There are numerous public analysis of where the costs from our market come from - and they are strongly correlated with the fact that it's a "market" at all.

e.g. the US as more doctors per capita than the UK and Canada - both of which have much lower healthcare costs than the US.

Businesses were screaming about double-digit percentage, year over year premium increases for their employees.

As I see it, the ACA was a very middle-of-the-road policy initiative. Building upon a Republican governor's program, namely Romney's in Massachusetts. It was meant to appeal to and help business as much as uninsured individuals. It was conservative in that it didn't throw out the existing system of insurance; rather, it brought new customers to the existing insurers. Insurers became enthusiastic about increased marketshare.

Law consists of two parts: 1) The law itself, and 2) Paying for it.

Republicans made very clear statements about their primary, number one goal (really, the primary goal of their party and their Federal legislative presence) being making Obama's presidency a one term presidency.

The ACA was passed, in spite of their opposition. But they used their subsequent control in Congress to not pay for an essential component. The law provided two years of compensation to insurance companies for excessive expenses resulting from ACA Marketplace plans. The idea was to provide a buffer -- government security -- while insurers caught up on the population's deferred medical expenses and built an actuarial understanding of the population.

When the insurers sought that compensation, I've been told by a professional working in the industry, they received about 15 cents on the dollar.

Premiums shot up. Companies dropped out. Republicans cited the "failure" that they helped create in the first place.

This isn't the only aspect of the situation, but it's a very significant one.

The ACA wasn't perfect. Work could have been done to improve it. Instead, a lot of political effort went into killing it.

Oh, and as tptacek mentioned, it did bring many costs under more control. Something that benefited group plans such as those provide by employers.

You don't hear so much about that, eh? Or the enormous profits that insurers are reaping, in spite of complaints about the ACA Marketplace plans.

P.S. As I've mentioned before, I'm someone who was denied coverage, at all, outright, prior to the ACA coming into full effect. I had a minor condition that a very well respected surgeon would not operate on, while I was still on a corporate group plan. Risk/benefit favored simply monitoring.

That didn't matter. No insurance for me!

(Fortunately, a professional and personal contact in the industry pulled some strings. Something NOT available to most people.)

P.P.S. I should add that some people think that some insurers may have underpriced their ACA plans a bit, initially, eager to maximize their portion of the increase in market size and relying on the temporary government security for protection. I don't know whether this is true. Even if it is, no law/program is perfect, and the two year timeframe placed an inherent limit on this behavior.

When the repayments came up so short (15 cents on the dollar), this might have magnified the corresponding premium increases somewhat.

But all this was accounted for by the ACA law, including limiting its effect. It just wasn't, subsequently, paid for by the Federal budget process.

And if it is true, it reveals insurer's enthusiasm about the ACA. They wanted the increased marketshare.

Instead of working with this momentum, it was thrown under the bus for political reasons. As I see it.

And it worked for the Republicans, they used it as a wedge issue to regain control and ultimately the Presidency. That in turn allowed them to pick our pockets and hand out tax breaks to the wealthy. The media failed in its duty to protect the public by exposing these dirty tricks.

>ACA is horrendous, unless you're receiving a government subsidy.

I'm curious as to why you say "the ACA is horrendous" rather than "The income cutoffs for the ACA subsidies are way too low" - I mean, it seems obvious to me that if you make a median salary and have a family of four that you need some sort of health insurance subsidy, but I don't know where the ACA subsidy lines are, or even if they vary per state or not.

I personally am in favor of just expanding medicare or medicade so that everyone can use them to get minimal health care if they need it. I mean, sure, if you have money, you probably still want private insurance on top of that, just like retirees today, but we've got a reasonable system for giving everyone over 65 a minimal level of care, and healthcare for younger people is a lot cheaper than healthcare for old people, so it seems like a big rich country like ours should be able to cover that bill.

but I don't think that is politically possible. I think this last election was in some ways a referendum on the ACA, and I would interpret the results as saying that many, if not most Americans think that you should only get healthcare if you can pay for it. Which seems weird to me, because as you point out, if you make anything like average money, healthcare for a family for three or four is impossible to pay for without a subsidy.

>I'm seriously considering returning to wage employment for health care benefits.

In the days before the ACA, I'd just get a full time job every time COBRA and CAL-COBRA ran out, because I couldn't get a plan at all without. I mean, I was happy paying $6K/year just for me, and that's what I'd pay under COBRA or CAL-COBRA but, once that ran out, nobody would sell to me. Maybe I wasn't asking the right people, but it wasn't like they came back with high numbers, they just said they couldn't cover me. It was weird, because while I did have a chronic condition or two, none of them were particularly dangerous or unusual.

My own personal "why I hate the ACA"...

In 2016, I decided to take off from work and travel outside the US. I did what I thought was the responsible thing and purchased a travel insurance plan. In total, I was gone for a year...I had an amazing trip.

When I got home, I wanted to sign up for insurance again. But since it wasn't a life event, I wasn't eligible to enroll until the open enrollment period. And when that time rolled around, I wasn't eligible for the subsidized plans because I hadn't gotten a job yet and my monthly salary was $0/mo. Nevermind that I'd done enough contracting work during my trip such that if you divided my annual earnings by 12 to arrive at a monthly earning, it would've easily qualified me for a subsidy to stay on a plan that let me see my previous doctor. But I did eventually get signed up for Medicaid for the month between open enrollment and when I found a job, so...yay?

Then tax time rolls around and, it turns out, you need to be out of the country for 11 out of 12 calendar months to qualify as a non-resident. Since my trip didn't start on Jan 1st, despite being out of the country for an entire year, I didn't qualify as a non-resident for either 2016 or 2017 and had to pay the ACA penalty for the entire time I was gone because I didn't buy health coverage that would've only been useful in a country I wasn't present in. And adding insult to "please don't let me get injured", I had to pay a penalty for the time I was uninsured between when I got home and open enrollment.

In short, I feel like the ACA was rushed and they never seriously considered what was right for people not working a 9-5 job getting regular pay checks. By deciding to opt out of the workforce and do my own thing for a while, even doing it responsibly, the ACA cost me thousands because I somehow managed to find corner cases that were simply not considered or poorly handled by those writing the bill.

So there's a lower bound on how much you can make and still get the subsidized plan? that seems broken in a very American sort of way.

I think a lot of the bureaucratic issues might be the nature of insurance companies? My (pre-aca) experience was that any lapse in coverage and they don't let you back on. All this 'life event' stuff, I think, was part of how group plans worked back in the day, the rules about when you could change things and when they could kick you off.

I guess what I'm saying is that (aside from charging you the extra tax) I don't think it's worse than it used to be.

There is a lower bound on income to qualify for ACA subsidies because the ACA also expanded medicaid to cover people below that threshold.

Unfortunately, the portion of the ACA requiring states to expand medicaid was ruled unconstitutional. As a result, 19 states have choosen not to expand medicaid, leaving a portion of the population to poor to qualify for ACA subsidies, but too rich to qualify for medicaid.

I should also point out, that the medicade expansion is 90% funded by the federal government starting from 2020 into perpetuity. Prior to then is a ramp up period where the federal government pays an even larger share.

Am I right in thinking this is uniquely American? The states that need welfare the most seem to be most strongly against said welfare, even when the more wealthy states are footing most of the bill.

There was a similar thing here in the UK with the Brexit vote - the regions that got the least money from the EU voted most strongly to remain and the regions that got the most money voted to leave:

https://www.prospectmagazine.co.uk/politics/which-uk-regions...

If your income was zero, couldn't you have gone on Medicaid?

Once open enrollment rolled around, yes. But the point was I didn't want Medicaid, I wanted a plan that let me keep my previous doctor. And I was willing and able to pay (savings), but the ACA didn't allow me to take the subsidy in lieu of Medicare. And also, there was the matter of the nearly 4 months between when I returned to the US and when I was allowed to enroll during open enrollment. For a law that's designed to help people get healthcare, mandating that someone wait to get healthcare seems like an odd choice.

Not necessarily, depends on the state. Texas for instance has no adult medicaid.

Should've not stopped travelling outside the US and settled in a civilized country.

How do you make sure you're actually getting catastrophic coverage for $3k? The information asymmetry between insurance providers and customers heavily incentivizes the creation of "value" plans that achieve their "value" by appearing to cover more than they actually do. Since only a tiny fraction of customers ever make catastrophic claims, most people will be unaware that they are buying garbage even if a policy were to never pay out (100% lemon-drop rate). Is your due diligence sensitive enough to pick up even a severe 50% lemon-drop rate (affecting, say, 0.5% of customers)?

Last year I didn't care because I couldn't afford the ACA, and Christian Medishare met the Obamacare requirement to carry insurance or face a tax penalty. The "health care sharing ministry" operates differently than insurance, my concern isn't denial of coverage but that the entire enterprise will collapse. https://en.wikipedia.org/wiki/Health_care_sharing_ministry

I'm not totally clear on the different situations here. I thought the tax penalty was only about $3k for even fairly wealthy families (family of 4, $150k/yr salary). It sounds like you felt you couldn't afford ACA insurance ($17k) and couldn't afford to pay the penalty either, so you went out and purchased $3k of "insurance" you don't actually have any faith in and didn't really want. Am I confused about the penalty amounts? Or you just felt that if you were going to pay $3k, you might as well give it to Christian Medishare?

If the price of the fine and the price of MediShare are comparable, then any benefits obtained through MediShare are effectively free.

We moved to Samaritan Ministries and have been really happy with it. Our “premium” is $500/mo and our total out of pocket costs have just been checkups and misc small prescriptions. Our two major medical incidents have been 100% covered by members and we got some nice cards in the mail, too. I estimate we have saved about $20,000 without increasing risk (possibly reducing it since the uncertainty of the claims process is gone.)

It’s been nice to see that a well designed system can help people take care of people so humanely.

$18,000 doesn't sound large, relative to the high prices we all pay. I have a good solid job, and my family plan is $24k per year. That's the most basic family plan my employer offers, but it isn't a high-deductible plan. Of course, most of that is paid by my employer, so I only pay about $4k directly out of my salary. If you are self employed, then you obviously have to pay the employer part too.

For a little perspective, I supported a family of 3 on less than $18k last year and we only had partial coverage. Even though we were homeless for most of the year, the ACA penalty is pretty painful. I am in the midst of filling out my taxes.

For a great many Americans, the figure you brush off as not particularly large is an unimaginable amount to come up with for insurance alone.

Sorry, I didn't express myself clearly

I agree, $18k for insurance, or $24k, is an enormous burden for most Americans. I was just trying to point out that that the ACA price the parent was calling an outrageous seemed completely inline with every other insurance policy I have ever had, ACA or not. Insurance in the US is just plain expensive, no doubt about it.

For 3 people, the federal poverty level is $20,160. $18k is less than that, and in California, you would have been on Medical. Even if you are on Obamacare, not Medical (in California: 138% of fpl and up), under 200% fpl the silver plans are close to free.

see eg https://www.healthforcalifornia.com/covered-california/incom...

I don't really understand your point. I will note that since I could not afford housing for most of the year and struggled to get enough to eat, close to free is not cheap enough.

Were you eligible for Medicaid or CHIP?

If you want a lower payment per year go pick a really large company (the larger the pool the less you will pay).

My mom pays half of what I pay and she gets family insurance while I get a single person insurance. Her pool is a large grocery store company.

$18,000 for a family is high but within the range of what insurance costs today. Family coverage on the small group market (<50 employees, which is where Matasano was at), which approximates the individual market in price, was ~$1100/mo a few years ago.

(I just looked it up and, weirdly, average premiums on the large group market in 2017 were higher than those in the small group market; on the small market, they're around $17,000, and in the large market, $19,000).

That’s still roughly the case, I work for a medical billing company owned by a physician group, we have a pretty large group and are essentially self-insured.

I pay ~$220-ish a month for my family of three, the company pays $800+/mo. Boy am I glad to work for a company that pays such a large chunk of my benefits, many other places cover maybe 50% of your dependent costs.

The injustice of the system is that self-employed have to pay with after-tax dollars while your employer can deduct the cost of providing those benefits.

As I understand it (I hope I understand this, because I rely on it), LLC principals are allowed to deduct the cost of health insurance.

Unfortunately neither Christian Medishare nor our out-of-pocket health care payments are deductible.

https://www.medishare.com/blog/is-healthcare-sharing-tax-ded...

Any HN conversation that starts out as a debate about Obamacare and ends up saving someone a few thousand dollars a year is a good conversation, so you are very welcome.

Health insurance prices are a nightmare. Please don't let me come off as sounding like I don't think they are. The goal of the ACA was fix that problem, and though it fixed some very important problems, it surely didn't fix that one.

I think personally that the ACA is a great step toward affordable health care. We really need ACA++ that would address these small issues but unfortunately we probably aren't going to get it passed within the near term.

Repealing really isn't an option (due to the near impossibility of repealing an entitlement) and the public doesn't want that either. I don't know how you would fix the issue that the loss ratios will be more skewed negative since the fact that sick people pay more attention than healthy people for insurance (even when you introduce tax penalties).

Interesting! Are there no other options available? This is clearly an inferior option for the self-employed. I'd go with another provider with a higher premium and without this curious shares thing. How is that legally not health insurance? Baffling. What state are you in?

my accountant never allowed me to do this in PA

As I understand it, and your accountant is an expert while I am not, you have to be actually self-employed --- not moonlighting or doing side-work, with your money all coming in through the LLC --- and your spouse can't be eligible for group coverage through their job.

i was sole proprietor of my own pass through llc with no other income and single through oct 2017

You should maybe ask your accountant why you couldn't deduct, then? I know there are conditions, but this is one of the better-known self-employment deductions.

I have the entirely opposite experience in NY. It's a Federal guideline though.

Tangent: people tend to fixate on "LLC" as if it were the only reasonable corp structure for small outfits. S-Corp is often a better choice.

It's just the cheapest one to set up. I was assuming that if someone's self-employed and not deducting insurance, they're probably a sole proprietorship, and are probably sensitive to accounting costs.

You can typically deduct 100% of your health insurance costs if you have a sole proprietorship. It doesn't matter how you're self-employed, as long as you have no other coverage and your business income funds the insurance, then you can deduct 100%.

https://www.irs.gov/publications/p535#en_US_2017_publink1000...

No, that's one of the wrong assumptions / myths I'm pushing back against: LLC is _not_ necessarily the cheapest to set up. I'm the sole employee of my Massachusetts S-Corp, and it was both less expensive and better tax-advantaged.

False, as a self-employed person you can consider this a business expense. I have for two years with no issues. One-person LLC.

You're still the one paying the $800, the only benefit is you get to do it with pre-tax money. It's not like that money comes out of the aether, it's part of your compensation.

Yes, but taken in context it’s still a huge benefit. You have to keep in mind we have a lot of employees making much more median salaries, a medical biller or coder making in the mid 10’s to low 20’s an hour gets the same benefit I do as a $89K/yr DevOps engineer.

18k for a small business is typical. My mom pays much less than that because she doesn’t even make anything near 18k. For a small business it limits who you can hire because their take home pay would be 0.

Basically what I’m saying is the loss ratio for a bigger pool will be much lower than a smaller one. For insurance companies who charge premiums if you are in say a Bigcorp sized pool compared to a small business size pool the bigcorp pool will be larger and can have smaller premiums .

> That's after tax, out of pocket, for a healthy family with no pre-existing.

And once you get a condition, you will get NO insurance without the ACA.

And we will all get a condition--it's called age.

That $18k was what I was quoted too. Of course no one would believe me.

I believe it completely, since it's just a small figure off what companies were paying for group coverage several years ago. The problem isn't that the figure is unbelievable; the problem is that the causal link being suggested isn't real.

Reply on news.ycombinator.com