Show HN: Healthcare Is Dumb | Hacker News Reader

Show HN: Healthcare Is Dumb

healthcareisdumb.com

441 pointsantcas283 comments

Before my father qualified for Medicare he figured out this hack.

He has a severe chronic condition.

Health insurance for him as a self employed person at the time was $4k/month

Tuition at the local public college at the time came with a senior discount for folks in his age group and insurance for $10k/year.

He loved the classes and saved a bundle on health insurance.

He needed a life flight and weeks of hospitalization related to his chronic illness. The insurance had him covered. I think it was a non-trivial payout for the insurance company.

The following year the insurance company changed the terms with the university to charge more if you didn’t live on campus.

My father went to a different school with a different insurer after that.

He’s finally on Medicare.

We shouldn’t tie healthcare coverage to employment in our country.

It’s stupidly expensive.

Tying health insurance to your employer is incredibly dumb. It means insurarers compete for your employers business, not yours, which influences their incentives. It means if you don't like your insurance company, your only option is to change jobs. It disincitives people from being self employed, because then health insurance is prohibitively expensive.

It's not dumb, it's smart for employers who want to trap employees.

So... it's dumb for 999/1000 people.

This was by design. Didn't the dems do this in '96?

All I see from '96 is HIPPA. What are you referring to?

How does it trap employees? If I’m considering switching jobs, wouldn’t my new employer offer the benefit also?

Not all providers and plans are the same, so some treatment for some health condition you have that is 75% paid for by insurance might go down to 25% or even 0% (not covered) with your new employer's health insurance plan. You also might just not have another job to go to immediately, like what happened at the beginning of Covid-19, in which you'd either need to pay for your previous insurance in full or cancel treatment.

This happened recently to someone I know. They were offered a significant pay bump and a leadership position in a well-respected organization that lines up with their personal goals, but the new employer doesn’t offer insurance.

They eventually decided to take the job, but having to even consider healthcare access in that calculus is ridiculous.

Suppose your employer is less than ideal but you’re not particularly confident in your ability to get another job should you be laid off. A lot of people feel trapped in this situation every day.

Not everyone has the skills and experience to be in demand. A lot of people feel their current job is the only thing standing between them and the food stamp line. These people should not have to worry about getting sick and losing everything after losing their job.

If you have a health condition then you can be trapped, because a new insurer won’t cover existing conditions.

This has not been true since Jan 1, 2014:

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

Before 2014 plans were required to cover pre-existing conditions as long as you had “prior credible coverage” and didn’t have a lapse in coverage for more than a short period of time.

If you let coverage lapse, plans were allowed to impose a waiting period before coverage for the existing condition would start.

Since 2014, the “fix” is that now it’s just required to always have insurance, or else you pay a penalty.

Then for the last couple years the penalty was repealed but the coverage for pre-existing conditions is still guaranteed, which does open up a hazard that people will only buy insurance after they get sick... but really the risk of a sudden health issue is still high enough that most healthy people will still want coverage.

No. They offer what they offer. Even when plans seem similar, are you willing to pay out of pocket for a $4k/month medicine that you've been taking for years and only paying $250/month now for, all because the new insurance doesn't cover it?

This is even more pronounced with lower-wage employees. I didn't switch jobs for years because of benefits: At best, I'd have to pay for COBRA for 60-90 days, which would basically take all of my money and then some. But mine was also fairly cheap and I had good coverage, something that similar jobs usually didn't match.

Deductibles and max out of pockets have to be met again.

I do not leave my current employer specifically because of health insurance. No other employer in the area provides comparable coverage. It would take about a $30,000.00 per year premium to get me to even consider leaving. Healthcare is my number one consideration on all employment decisions.

Exactly. I don't understand why people don't understand this.

It's a huge chilling effect on employee turnover. Until ACA pre-existing conditions was a huge aspect of that. Even now IIRC when I changed jobs once I recall any existing conditions would not be covered for 1 month.

And it's the biggest cost increase over the past 2 decades and has soaked up almost all the profits that could have gone to employee salaries.

https://www.pewresearch.org/fact-tank/2018/08/07/for-most-us...

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

If a company has to trap employee with health insurance to keep them from leaving, that suggests they aren't treating their employees very well.

> It means if you don't like your insurance company, your only option is to change jobs.

Well, a bit less effective, but sometimes works, you can also complain to HR about the insurance.

Let's say HR really does care about employees interests. It could be that they chose an insurance program that is best for 90% of employees, but is a terrible choice for you. HR is unlikely to change anything because of a few outliers.

Think about the state of the software rolled out for HR. i.e. speed, UX, cross platform support.

I think from that alone you can safely conclude that HR departments don’t or can’t deliver things that employees need.

Employees are not the customers of HR departments and they won’t or can’t fix your health insurance.

No, it works exactly as it was designed. Health insurance keep s costing more, cover less and not care about helping people in the time of need. That is not an accident. It is a result of concentrated effort of lawyers, lobbyists, salesmen, etc... - a whole system that maximizes profits and market share at all costs, and not the quality, breadth and affordability of healthcare. It is like that by design. So the results are logical - we pay more and get less. And will continue paying more and getting even less. There will be a point in future when this approach will "meet its maker", the hope is that will happen sooner rather than later.

It's an efficient market. It's efficient at collecting money from customers who little or no choice, and at not providing those customers with a service - because providing a service costs money, which takes a cut out of profits.

This is what markets do. They amplify political and financial inequality.

Anyone who thinks that competition will somehow magically fix this isn't paying attention to how markets actually work.

> Anyone who thinks that competition will somehow magically fix this isn't paying attention to how markets actually work.

If you allowed foreign doctors to come and practice in USA the problem would get fixed extremely quickly. Competition is the solution. The problem isn't the free market here, but that the incumbents gets to control legalization and hence stifle competition. I'm not sure why private money has so much more influence in USA than other western countries, but it is the main source of this problem.

Aren't drugs very expensive in the US, too?

Isn't it illegal to move drugs across the border? Importing other goods seems much simpler. I mean, according to this you can only import drugs into USA if you are the manufacturer, meaning USA doesn't permit global market forces.

https://www.kff.org/medicare/issue-brief/10-faqs-on-prescrip...

drugs are very expensive everywhere it's possible, and implicitly expensive drugs are not available where they're unaffordable (and hence no market at the high price). This leads to bigger group buying programs and a focus on generics, but has the unfortunate effect of shifting the focus of drug companies to very high price, small-market specialty drugs and lifestyle & vanity drugs that a broad, public healthcare system would never cover.

Say you have a drug that you need to charge $100 to make it worth your time. Other countries say they will only pay $20 for it. Since the US doesn't have price controls, they will charge $180 here to make up for missing revenue in other countries. So in effect, the US subsidizes countries with universal healthcare.

we can both complain about the final outcome and disagree on how we got here. I think it's a stretch to call healthcare an efficient market. There are huge upfront and switching costs for almost every component making it rife with opportunities (intentional) and mistakes (mistakes) that erode efficiency. I also feel you conflate what markets can do with what their intent is. You seem to imply that markets have no role in a huge swath of our economy and lives, yet I look at my medical experiences in Canada (almost 100% public) and wonder if many people actually know how it works and what the outcomes look like. In a nutshell it's both harder to die and harder to get better under our system, and I think markets could help with the later without hurting the former.

You are conflating markets with meta-markets. The market for healthcare has been corrupted by activities outside of the market.

The market has been intentionally manipulated to set up little choice for individuals and even worse, little transparency on cost and benefits.

Markets DO work, but you have to set them up to succeed. Customers need to be able to choose between providers, customers need to know what the full cost of healthcare is prior to committing, and customers need to be able to walk away or find an alternative if a price is unattractive.

So markets work in theory, kind of like communism.

ha ha that's exactly how i play it to my friends.

Employer driven health insurance was pushed for by unions back in the 70s IIRC. That is how we ended up with this setup becoming normal.

It was older of a trend than that I believe back to post-WW2 when private sector was hobbled. To keep people incentivized to stay longer with employers they offered more benefits that were employer tied such as pensions and health insurance programs not available to job hoppers or self employed.

But more complex is that when people argued for a nationalized health plan a lot of people agreed with it until opponents argued that white people would be paying for minorities’ health insurance with their tax increases. These days it’s difficult to outwardly tell whom opposes public welfare policies requiring some solidarity based upon fiscal principles or social ones first.

Right, the initial were benefits offered by employers to sweeten their compensation and improve retention. Later unions demanded these everywhere and that’s what led to employer sponsored health insurance being normalized.

Separating the consumer of a insurance (the employee) from the decision of which insurance to use (the employer) is where this all went sideways.

Otherwise, in a competitive market, people would be free to jump to any provider with a better offer, forcing other providers to respond and preventing the disaster that we have now.

But now it’s a national mess to unravel and we have union demands to thank for it.

Yep, the more producers and consumers of products and services are separated the more markets are improperly incentivized even without any government involved. B2B has a place in commerce obviously but much of the problems of enterprise software is because it’s designed for a lengthy sales process to meet decision-makers’ needs rather than for those that work under the decision-makers.

Yes, the unions are 100% to blame for the current state of affairs.

Providers, trial lawyers, drug/device companies, and insurance companies are absolved of blame!

I used to tell people that when the subject of "why is healthcare so expensive" comes up, these four pigs feasting at the trough point to whomever is to their right.

Now they have someone to point to that's not even eating, and arguably died a long time ago.

The root cause is root cause.

No, it was during he Second World War. There was a labor shortage as many men were drafted or even signed up, but the federal government had instituted wage and price controls. As wages could not be raised, benefits like health care were offered to try to lure workers.

Some big companies, like the car companies, ran (and I believe may still run) their own medical systems. Most of course outsourced.

Nowadays a company would be insane to drop this because it’s a very sticky incentive. We’d probably have more innovative startups if we had ACA which is a reason the big companies lobbied against it and why having a company to simply pay your ACA premium was made more expensive than the company running a health plan the old way.

As is not allowing interstate competition, and not requiring pricing to be published, and not paying rebates for seeking out less expensive treatments.

I'm my own employer, and the exchange choices are shitty beyond belief. I pay $15K/yr for a family of 3 (that's excluding the considerable deductibles), and I'm not even sure to what extent I will be covered if I e.g. break a leg. The premiums go up every year like clockwork, and will likely go _way_ up this year, due to C19.

I'm thinking of just finding a clinic somewhere abroad if shit really hits the fan, and going without insurance in the US at all, covering my yearly physical out of pocket. It boggles the mind that politicians are proposing to sink trillions more into the bottomless money pit that is the US "healthcare" system.

I was paying about $1.5k / mo for a terrible plan for just a family of two in NC under ACA. The public risk pool is completely terrible and large corporate employers’ risk pools are separated from the general public and self employed.

More and more employers are now self insured. Making your employer your negotiate with healthcare providers directly for care. They might also us a TPA (third party administrator).

Thing is, your boss may know way more about your health than you’d expect.

The entire system is broken.

In my experience, when I was unemployed, an ACA plan doesn't cost $4K or even $800. I'm not sure even COBRA was that expensive.

Perhaps your anecdote is from before the ACA, but is it really productive to still be complaining about the way things were? Maybe spend more time making sure we vote for people who will keep it going.

It varies based on pre-existing conditions.

COBRA is just regular health insurance.

I have had an ACA plan during two separate periods of time over the last decade and it was on the order of $400/month, with no consideration of pre-existing conditions. I've also had the opportunity for COBRA, which was too expensive, but still under $800.

Where do you get your "information"?

I think you need to consider your age and zip code as well. I have a family member who is an insurance broker and she had to factor in age and zip code to give me quotes on insurance.

Maybe the original anecdote was about a family plan. I interpreted it as not, but then reconsidered.

Currently, in an urban area of NY state where I am, a basic family plan is ~$1600 and an individual plan is ~$550.

You may say "what about the deductible", but it looks to me like the deductible is effectively only a payment plan. Even if you have a chronic condition, and you know you will go through the deductible for sure, you don't gain anything by paying for a lower deductible. The deductible is nowhere near the difference between $1600 and $4000 anyway.

Yes, with ACA the government basically made it so health insurance premiums are a tax, and young people subsidize old people by capping old people’s premiums as a multiple of young people.

Of course, pricing will vary by zip code because healthcare providers cost different amounts in different places, so a rural area might be more expensive where there are fewer doctors who have more negotiating power versus in urban areas where there are more doctors competing.

Pre existing conditions don’t affect premiums or eligibility for coverage since Jan 1, 2014:

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

Depends on the state and plan. For me COBRA was $2000/mo. When employed I paid like $20/mo and my employer paid $1980/mo. When I left I paid the entire amount.

For an individual or family?

Actually in your case it depends on the employer.

The plan you had was $2,000 (wow, that's really a lot though) and your employer was willing to pay $1,980 (again, that's a lot compared to employers I worked for) in addition to your salary.

Has the ACA caused prices to go down? I'm getting mixed messages about who has actually benefited, with "only insurers and people who were covered by the Medicare expansion actually benefited" being the impression that I get.

Whether prices have gone down may be of importance to society, but on a personal level, being able to pay is more germane. Before the ACA, when I was unemployed and not in school, I just wasn't insured. At this point though, that's kind of a long time ago.

Also, I think you may be confusing Medicare and Medicaid. I've never been covered under either.

Yes, I am mixing them up.

It did (especially for older people), but in the states that were willing to expand medicaid (the red states refused so there's an income gap where you make too much to qualify for subsidy, but too little to afford the regular prices)

It dramatically decreased prices for people with pre existing conditions. Which slightly raised prices for everyone else. Considering that expensive medical conditions are the point of medical insurance this is likely a good thing on average. Aka, cheap insurance that’s not actually covering you is kind of pointless.

All Marketplace plans must cover treatment for pre-existing medical conditions. No insurance plan can reject you, charge you more, or refuse to pay for essential health benefits for any condition you had before your coverage started. Once you're enrolled, the plan can't deny you coverage or raise your rates based only on your health.

COBRA is essentially the employer's plan without employer's subsidy. The employer's plan seems cheaper because of that subsidy.

> The employer's plan seems cheaper because of that subsidy.

And it is cheaper, because that part of it is tax-free.

That's a good point, forgot about that.

I don’t think there is anywhere a single-person ACA plan costs anywhere near $4K. Even a “platinum” family plan in most places is $2K or less (not that that is cheap, but it isn’t $4K either) But these are also the “retail” unsubsidized prices. If you just lost your job and are without income, its extremely likely that you would qualify for a subsidy, making even a $1600 family plan likely much, much cheaper (and much cheaper than keeping your employer’s plan via COBRA as well).

Of course, as evidenced by people on this discussion thread, a lot of people are not aware of how ACA plans and subsidies work. Anyone who would even consider sticking with a COBRA plan after losing a job probably doesn’t realize they would come out much better with an ACA plan. When filling out the form you have to estimate what you’re whole year income will be... assume that you’ll be unemployed for the rest of the year when entering your yearly income. Even if you do end up getting a job in a month or two, you’ll just have to pay back some of that subsidy at tax time (the following April), but in the mean time you had cheap health insurance when you really needed it (while unemployed).

I find it sad, yet interesting, how many things/institutions/processes have built up in a way that you would never actively choose as an option.

As in, if given the choice between building the current system and some alternative, there is no way you'd say, "for sure, build again what we have now, it's great".

Yet that's what we kind of do every year implicitly by continuing through inertia. Healthcare, financial/banking, transportation, rocket launches, etc.

I guess that's how a country gets old and slow -- too many legacy things that have to be supported or can't be changed without disruption to people's established habits or ways that they've come to rely on. (or make a profit from)

And it's not until some outside actor shows you it's possible that you're shocked into knowing that it can be done differently. Or forced to do it differently out of necessity now.

I am currently in government. I would say that most processes are not really designed at all. They are the sum of a lot of other decisions kludged together.

We are currently putting together a software system for managing parking contracts and in doing so are excruciatingly copying how those contracts are currently handled (often to an absurd level). Nobody thinks the current process makes sense, but here we are baking it into a mega project.

It is sad indeed, but I guess no manager wants to change things not be responsible for changes that fail.

Eh, one of the larger challenges is figuring out who is responsible for certain things. We genuinely are not sure who is responsible for various elements of projects.

Here’s a whole article about that! “Kludgeocracy in America” (2013)

https://www.nationalaffairs.com/publications/detail/kludgeoc...

Posted in its own thread:

Kludgeocracy in America (2013) https://news.ycombinator.com/item?id=24310523

Private industry really isn’t much different. The commonality is: humans.

No. Just in the private industry, there is at least hope of change.

I do R&D for government. A significant portion of what my group develops is required to conform to or to mimic business processes that emerged, practically accidentally, 50+ years ago. Nobody dares innovate, perhaps for two reasons: professional risk, and institutional preservation (departments, unions, etc.). :-/

Sounds like every large code base I have worked on.

https://en.wikipedia.org/wiki/Recurrent_laryngeal_nerve

For those wondering:

>The extreme detour of the recurrent laryngeal nerves, about 4.6 metres (15 ft) in the case of giraffes,[26]:74–75 is cited as evidence of evolution, as opposed to Intelligent Design. The nerve's route would have been direct in the fish-like ancestors of modern tetrapods, traveling from the brain, past the heart, to the gills (as it does in modern fish). Over the course of evolution, as the neck extended and the heart became lower in the body, the laryngeal nerve was caught on the wrong side of the heart. Natural selection gradually lengthened the nerve by tiny increments to accommodate, resulting in the circuitous route now observed

While everything you say is true, my experience in software with the Big Rewrite suggests that continuing through inertia, while by no means always the right choice, is also not always the worst choice. Big projects can end up going very badly, and the devil you know is sometimes the lesser evil.

Although, in the case of healthcare pricing in the U.S., maybe not.

> given the choice between building the current system and some alternative, there is no way you'd say, "for sure, build again what we have now, it's great".

> Yet that's what we kind of do every year implicitly by continuing through inertia. Healthcare, financial/banking, transportation, rocket launches, etc.

Also on this absurd list: academic publishing

What's wrong with rocket launches?

This is how all life evolves. The bigger and grander the plans, in general, the harder and worse they fail. Communism and Brazilia spring to mind as examples. "Seeing Like A State" takes a look at the causes of failure patterns endemic to bureaucracy/government/planning. (Not saying we should give up on planning, but that we might learn to love and live with the idiosyncrasies introduced by iterative development in all domains.)

I'm going to tag the news media industry as the major problem. If a politician (of any stripe) says (the mature and reasonable thing...): "I'm going to compromise with the opposition, we're going to give them X, try Y, gather evidence and if it doesn't work out we'll reverse the decision" then:

1) All the media is going to report is "[Politician] is caving in to the opposition".

2) The media will report misleading stats and not bother trying to actually understand the evidence gathered.

3) Nobody will point out or honour the part of the deal that involved an unroll if it didn't work.

Can't negotiate, can't compromise, can't improve. Fools errand to try with the press waiting in the wings. They might even be purposefully hiring ignorant people because they are more entertaining.

> I'm going to tag the news media industry as the major problem.

I'd argue your critique would apply not so much to the industry, but to those in positions of power/influence who control and manage how the industry behaves - i.e. the decision-makers of the companies which own the media companies.

> Fools errand to try with the press waiting in the wings. They might even be purposefully hiring ignorant people because they are more entertaining.

This is how voting to hire politicians is going too..

Actually, I can't think of any news media (save Fox) that would report compromises in such a way. Instead, that negative reporting is more likely to come via outrage-generating feedback mechanisms like the commentary that accompanies sharing of news articles instead of the actual news pieces themselves.

The news media are owned by the same people who own healthcare, and they target anyone who threatens the value of healthcare companies, not the "mature and reasonable."

Compromise between the two specific parties that run the US government is not obviously reasonable. Completely ineffective compromises between a party who explicitly wants to preserve industry profits and another party who wants to appear like they do not while still maintaining their healthcare industry donor base - that they do often manage to come to an agreement is why our healthcare is not only the most expensive in the world, but also the most complicated.

Our large press is captive, not this force for extremism and disruption that you see it as.

https://www.amazon.com/Inadequate-Equilibria-Where-Civilizat...

We do this in software engineering too. People need to find something that works, and then insert themselves in there to extract some value and get money. Service A talks to Service B? Put a message queue in there! You can monitor it, you can buffer it. Oh, it doesn't work? Just pay us and we'll fix it. Now some of the value your software creates is going to some middleman.

Healthcare is just like that. Patient pays doctor? That's fine, but what if we got some finance dudes in there? Maybe they could smooth out the costs for everyone -- fall out of the sky in your airplane, break every bone in your body, costs you $0. Just keep paying your monthly fee and you're covered. Sounds good, right? (Nobody really pays for healthcare, though; so they sold it to employers to use as a perk. "As long as you work for us, we'll cover the costs of any catastrophic health problem!" Kind of nice peace of mind.)

Ultimately, this is how people make money in capitalism. Find money, and insert themselves in the middle. When it gets to be too much, people push back. Amazon doesn't want to pay for UPS employees to have nice uniforms, a consistent route, and health insurance... so they found some randos on the Internet that will deliver packages out of the back of their sedan. The money saved is sucked out of giving people a decent life and into the coffers of one of the richest people in the world. No doubt, healthcare is going in this direction too. People are noticing the inefficiency, and stand to make a lot of money by eliminating it. (We'll all probably suffer, of course, because that's how it always goes.)

I built a spreadsheet showing how many credits you have to take at a school to qualify for their health insurance plan. In many states, the cost of taking the class + health insurance costs is actually lower than monthly premiums for a plan within the state.

What would this do to the university or state’s finances if a ton of people did it? Would it make budget shortfalls? Or do insurance companies just make less from those plans?

Both the school and the insurer would make a bunch more money in the short-term.

Might bite the insurer's in the long term if a bunch of sick people sign up, but very sick people don't tend to stay in school.

Perhaps college plans are inexpensive in part because those insured are generally younger and healthier than the overall population? If a representative sample of the general population did this, presumably the prices would adjust upward.

This is part of it, however there's positive price pressure from "anti-selection".

Basically healthy young students are more likely to already be insured or be on their parents plans so they opt-out more frequently.

Wrote a thread with more deets the other day: https://twitter.com/AnthonyCastrio/status/129870277198685798...

Perhaps, but I think it's more likely just price differentiation the same as any other student discount.

Plus universities have better negotiating power than individuals.

I suspect more schools would adopt schemes like Rutgers. They charge part-time students over twice as much as full-time: https://riskmanagement.rutgers.edu/student-information/rates...

So I've had some limited involvement university fee structures and their health clinics. I actually had a conversation with the director of one about these plans. He explained:

* The university already has the clinic that is funded by student fees and a bit from the university general fund

* Uninsured students are seen for free and just pay for supplies used ($10 for a lab test, $5 for an xray, etc)

* They wave all copays for students with outside insurance

* For students on the student insurance plan, they are expected to use the clinic for general/minor needs. In these cases, the university agrees to eat the cost and not bill the insurer.

So all the insurance company is paying is major medical expenses for services not rendered by the school. Its just like large companies that have an on site clinic to save on their premiums.

So technically, it does end up costing the school a bit more if students buy the insurance through them because the school pays for all the supplies that they would normally be reimbursed for. If more student use the clinic, the university will end up having to expend their budget. But in comparison to how much money the university already bleeds, the clinic is a pretty minor cost. I think the whole clinic costs less to run than they pay their athletic director.

One interesting side note was regarding students that have outside insurance. Many times, they don't even bother billing the insurance if its just an office visit. Because medical billing is such a mess, they realized that it was actually costing them money to pay someone to deal with it when the insurance will only pay them ~$40 anyway. So they'll only bother if there are additional procedures and they expect a reimbursement >$100.

Thank you!

I would be interested in seeing your spreadsheet if you're willing to share it.

https://healthcareisdumb.com

It's wild that less than $500/month for health insurance is a win in the United States

It really depends. If you're single and under 40 it's not so bad.

But if you have a partner, kids, and are a bit older then suddenly it can be quite expensive.

I mean, even if your young its ridiculous. I'm mid thirties now with a wife and kid, healthcare costs are double my mortgage. For the highest deductible I can get. None of us have any illnesses or do anything other than see the physician on the usual prescribed basis. It's insane.

You've got much cheaper housing or much more expensive insurance than the average person.

His numbers seem correct if you assume national-average housing costs, not Bay Area figures. Which is fair because the insurance cost does not vary much between locales.

It’s because you’re not paying for your healthcare when you’re young.

Health insurance is just a tax, with the premiums going towards paying for healthcare for the sick and elderly (in the US, people 55+).

ACA specifically capped health insurance premiums for the elderly as a multiple of a 21 year old’s premiums.

Otherwise health insurance premiums for 20 year olds would be $30 a month and $3000 a month for 60 year olds.

Also FYI to anyone reading this, these plans are all individual-rate plans but many also offer family or spouse plans for not that much more.

It's pretty dumb tbh

And then think about how it shakes out for a family plan.

Health insurance in the US is an untenable situation and I really just hope it explodes sooner rather than later.

The biggest issue, in my opinion, is how much of the cost is shielded by employer contributions that no one ever thinks about.

This makes it too easy for people with good employer-sponsored health insurance to scoff at and dismiss all the people who aren't in that situation.

When your employer is shouldering $20k in health insurance premiums without really telling you, it's easy to feel like the costs aren't a problem.

It’s a double whammy because the employer gets to deduct 100% of their contribution but the little guy buying it on the open market has to use post tax dollars.

Which is _bullshit_. Everyone should be able to deduct their out of pocket premium costs.

Or better yet, nobody.

Yeah either way. The playing field should be level.

This is probably a better idea. No hidden costs to any one. Employers would either lower salaries in America, or stop covering insurance.

When the cost of healthcare is visible, maybe then the majority who have employer provided insurance would then fight with the minority of us who use the marketplace, and shoulder the entire burden of the price.

last I saw, roughly 80% of people in the US have employer provided healthcare. In a democracy a 20% minority has to be VERY vocal

edit: I was incorrect, this is 80% of people get healthcare from their employer OR the government. Only 20% of people are responsible for paying for their healthcare separate from their employer (if they have one)

Is that number out of the total of insured people? Because I guarantee you there are a LOT of people that faced with that choice don’t get insurance.

That sounds fishy given the huge numbers of people covered by Medicare, Medicaid, and the VA.

That must be 80% of people who have insurance and work full time. Something like 30-40% of Americans are on medicare, medicaid, or both.

I think that's where the scam sits. The cost is not being driven by the cost of actual healthcare anymore. It's being driven by how much companies are willing to pay for each employee. So instead of companies just paying the employees more per year, they're paying an insurance company about 10% to 20% of their salary.

Well, I think the actual problem is that there is no downward pressure at all for healthcare costs. And in fact all pressure is all upward, starting with the provider and the small network of sub-providers they represent. The complexity of billing allows the provider to "not know" what their own services cost! So anyone who complains is considered a cheapskate trying to skimp on their own health, or worse, on someone else's.

Its horrible. I had one billing department lady in the US literally tell me when I complained about the exorbitant cost of a simple ER visit (in the thousands), "Well, how much is your life worth?" After the steam stopped coming out of my ears, I was able to come back with: if that's your position, then why stop at 5k? Why not charge 50k? Or 500k? Why not take everything I have or will ever have? She didn't respond, and just looked at me thoughtfully, as if I'd just given her a really good idea.

That lady is in the wrong line of work.

The scam is that employers get to purchase the insurance with pretax money, whereas a person whose employer doesn’t offer health insurance gets to purchase it with post tax money.

In my outsider opinion, aside from very complicated legislation, it seems that your main problem is that you don't have a public, universal and suficiently competent competitor.

In Spain private healthcare is somewhat affordable, even full coverage plans, because everyone can walk away any moment.

AFAIK the situation is very similar in many other countries.

> When your employer is shouldering $20k in health insurance premiums without really telling you, it's easy to feel like the costs aren't a problem.

Yes and this makes it really suck if you happen to be a sole proprietor or self employed.

It's over $500 a month here to get insurance for a single adult for the absolute most basic insurance possible with the worst possible service you can expect.

I don't understand how society puts up with this. It's not that just the service is horrible and massively over priced but it's a torturous experience just to interact with anything related to medical insurance. Like having to wait 30 minutes on hold or spending weeks trying to resolve things, or spending a month trying to find a doctor who even takes your insurance, etc..

Suddenly instead of getting the best treatment plan for your issue, it becomes a game of trying to extort you for doing the minimum amount of work while making sure you pay as much as possible out of pocket while already paying for insurance.

And then on top of that, it's like btw, $500 / month please or you run the risk of being bankrupt if you step foot inside of a hospital for anything that's non-trivial.

It is only a "win" in a very general sense if you just need catastrophic coverage.

You cannot really judge a win w/o seeing what is/isnt covered, co-pays, deductibles, co-insurance, networks, and a variety of other factors.

All of that just points out how bad it is, even with 'insurance'.

Exactly. One of the really bad things about US health insurance is that you dont know how bad it is until you have a John-Q type event (https://en.wikipedia.org/wiki/John_Q.) or a difficult pregnancy or a surgery.

Healthy people go in for annual visits and think "wow, this is great" not knowing what exception scenarios are like. Then people vote for politicians who uphold the status quo thinking everything is fine.

Not sure where I read it, but a theory was that since there is some sort of extreme self-reliance doctrine at the base of many sociological and political concepts in the USA it's frowned upon to ask for help, or help each other, or create a system where everybody agrees that helping each other by default is a good thing.

Keeps most things as-is, keeps people fighting over who gets to proxy-kill sick people and what the best way to screw each other for perceived personal gain is.

Edit: here on HN there was a comment from someone along the lines of "from the outside looking in, the USA looks like people fighting over who gets to punch babies and you're not allowed to not want to be on either side because that's taking a side as well".

For comparison, in the UK we spent £197.4 billion in 2017, or approximately £2,989 spent per person [0]. Which works out as:

~£250/per person/per month. Which is $330. Or $350 adjusted for inflation since 2017.

That covers everything: emergency room, ambulances, giving birth, cancer treatment. Everything: no copays (except very small ones (<£10) for prescription medicines). And it covers the entire population.

* Except dentistry. For some reason that is separate.

[0]: https://www.ons.gov.uk/peoplepopulationandcommunity/healthan....

To compare apples to apples, note that the American number is just the premium. In my case for example, I need to spend an additional $6800 before the insurance kicks in and starts paying out.

It's more complex than that. Certain services are built into the premiums.

An annual primary care visit, cancer screening, vaccinations, and so on. So for example if you have medical need for a colonoscopy, it will be covered before the deductible has been met.

Yes, but in a system with national health case, the preventative care would be covered as well.

Preventative care is covered in the US as well, at no cost

Precisely, so why does this matter to the point at hand?

“I need to spend an additional $6800 before the insurance kicks in and starts paying out.” This line isn’t accurate, insurance in the U.S. is required to pay for some things at 100% before the deductible is met.

"To compare apples to apples..."

You think that's cheap? Singapore's total per capita health expenditure in 2017 was $2,619[1] per person per year, or $219 per month.

It's just about the lowest per capita health expenditure in the developed world.

[1] https://knoema.com/atlas/Singapore/Health-expenditure-per-ca...

Its also fascinating to note that US public spending on healthcare is greater than the UK, both in terms of absolute numbers and as share of GDP [0].

[0]. https://www.bbc.com/news/uk-42950587

Just the tax subsidy for employer-sponsored health insurance costs the Federal government $273 billion per year: https://www.taxpolicycenter.org/briefing-book/how-does-tax-e...

The US healthcare system is a Rube Goldberg machine.

Tax deductions are not costs. They are shifts in weighting between taxpayers.

What? Tax deductions absolutely are costs. They are represented as expenditures on the Federal budget. The deduction isn’t a default, it’s an affirmative benefit by the Federal government, and one that causes a heavy market distortion.

The not-so-secret reason the business community is fighting single payer in the US is because 18-20% of our economy depends on the healthcare industry. A good portion of that is paper shuffling, marketing, accounting, and related middle/upper management -- they would serve no purpose in a system where you show up with identification, prove you're a citizen, and then get healthcare. So single payer means maybe 8-10% of the country is out of a job.

That's why Medicare/Medicaid is cheaper per person even though they serve the poor and elderly.

Sometimes I wonder if the way to make changes in these sorts of industries (with a powerful rent seeker that prevents change... e.g. health insurance, tax prep, etc) is to bite the bullet and just agree to bribe them... say, "we are winding down private insurance... we will pay you guys what your profit has been each year, diminishing each year, for the next 10 years. You can take that money and try another industry."

It might seem expensive and wasteful, but it might be better than the status quo.

Not trying to draw too much of a comparison here, but Britain did this when they formally abolished slavery. It's still very controversial today, but it did thwart the opposition to abolition among Parliament's pro-slavery lobby and plantation owners, particularly in the Caribbean. Paying off health insurers for years' worth of profits would be very expensive, but on the flip side I doubt it would be as unpopular as the slavery payments.

https://en.wikipedia.org/wiki/Slave_Compensation_Act_1837

I believe that's called a transition period and we saw how it worked with Obama care.

We could also drag the obstructionist leeches into the capital and roast them like Jim gaffigan just roasted Karen.

When someone's abusing an entire country you don't pay them to stop, you throw them in jail. People are dying are dying by the truckload and we care about

Or just roast them considering the number of people that are dying every year due to their greed.

That's how Japan abolished the samurai. The Meiji emperor promised very generous pensions to all samurai if they turned in their swords and retired.

A few years later, there was a budget crisis and the government cut the pension to a fraction of what was agreed on. But the ex-samurai were too demobilized to overthrow it by then.

Insurance companies are already making money from Medicare, and not just on Medicare Select. The Feds pay the bills, but there are 5 regional contracts under which private insurance companies actually administer Medicare.

If you work for a large company it’s pretty much the same thing. Your employer brings a risk pool and then a private insurance company like Cigna quotes for how much it takes to “fill” it while taking their vig.

I would expect the same under M4A: 5 really big insurance companies would continue to cost-plus bill the Feds, and then maybe there would still be a few re-insurance companies to cover stuff M4A doesn’t cover.

Probably applies to other cases as well. I think many people would be ok with "ok Disney, you have Mickey mouse exclusivity for 200 years if you stop messing with copyright extensions".

> maybe 8-10% of the country is out of a job

what do all these people do in the UK, Scandinavia and other countries with single-payer health care?

Hopefully something more useful but the point is that nobody wants to be the administration that created 10%+ unemployment overnight and the ensuing ripples.

Instead of employing them to shuffle paper, we could just directly pay them to burn money?

They work in small businesses or for themselves[1] because they don't have to worry about health insurance. Or they become a teacher[2]. Or they don't have to work at all because they are raising kids or getting a better education - again, because they don't have to worry about health insurance.

Eventually, they would join other parts of the economy in the US, but in the short term, the unemployment rate would spike and the economy in general would suffer.

[1] https://www.cepr.net/documents/publications/small-business-2... [2] https://www.nationmaster.com/country-info/stats/Education/Se...

> Eventually, they would join other parts of the economy in the US, but in the short term, the unemployment rate would spike and the economy in general would suffer.

And if an administration managed to get this through in the beginning of their first term, they'd never get re-elected, and most of the Congresspeople who supported it would be out as well. The next group voted in would dismantle it and put things back the way they were.

Any plan to dismantle the US private insurance industry will need to ensure a very soft, cushy landing for the people employed in that industry, or it'll never work.

My mom worked very hard and well for a company that administered benefits for union employees. The way that things worked would be that if you worked at least a certain number of hours in January you would have medical insurance coverage in March. But not February. If you worked the required number of hours in February, you'd be covered for April. And so on.

In going through her things after she died, I found letters to her bosses about how well she'd treated the plumbers, electricians, etc. I know she would take work home and do it off the clock.

What was really unfortunate, for me, is believing that her job shouldn't exist. To me it's crazy the expenses we have a universal healthcare system.

Of course, that also applies to avoiding taxes, etc. There was an attorney interviewed on a recent podcast about tariffs - he specialized in finding things like shipping bikes from China without tires and the tires from Vietnam would be much less in tariffs than just shipping from China.

Medicare/Medicaid is cheap because it is legally required to be the lowest price, so providers make up the cost by raising prices for other users.

Medicare for all wouldn't put 10% of the population out of a job. Not even close. Also, Medicare/Medicaid are cheaper primarily because they pay providers a lot less than private insurers for the same service.

> Also, Medicare/Medicaid are cheaper primarily because they pay providers a lot less than private insurers for the same service.

Do you have numbers to back this up? I'm not saying you're wrong, but my mom worked for a GP for ~20 years (recently retired) and listening to her talk about it this was not true for her employer at all. She said that in many cases the private insurer paid less, and on top of that required more back and forth to get claims addressed.

That is the the exact opposite of my parents, who are both doctors.

https://www.google.com/search?q=medicare+vs+private+insuranc...

I'm not trying to be an ass, just trying to point out that many, many sources all say the same thing.

Well we were 15% unemployed not too long ago...

The median salary in the UK is £24,400 (ONS, 2018)

    +£2,033 paid per month
    -£  149 national insurance (healthcare, welfare, etc.)
    -£  198 income tax
    =£1,686 take home pay (=$2,224)

The median salary in the US is $49,764 (BLS, 2020)

    +$4,148 paid per month
    -$  317 social security 
    -$  357 federal tax
    =$3,474 take home pay

=$1250 per month in favour of the US median earner.

$1250 per month should go a fair way to covering health insurance premium, deductible, co-pays & drugs (these are all £0 in scotland)

For comparison purposes, it's useful to think of things like retirement contributions and healthcare premiums as taxes, even if they're not formally taxes. There is an article comparing this across countries that argues that if you take this view, US taxes are actually pretty high, because our health insurance is so expensive. https://www.peoplespolicyproject.org/2019/04/08/us-workers-a...

For national financial comparisons - sure.

The real difference, of course, is that taxes will ensure you're covered even if you're low income.

In the US, you're already covered if you're low income, through Medicaid and ACA subsidies, that's part of where the current taxes go. It's certainly debatable if the existing programs are optimally structured.

Do you get the same level of cover when you’re low income?

Ironically, you get some of the best coverage when you're low income, since Medicaid is so generous.

> In the US, you're already covered if you're low income, through Medicaid and ACA subsidies, that's part of where the current taxes go

Talking to low income folks, it's not the same as in other countries. They still have financial stress because of medical concerns.

Medicaid experience differs greatly depending on the state you're in. And how it compares with people who have the means to buy insurance also varies quite a bit.

In general, Medicaid is one of the more generous health insurance plans available in the US. The maximum nominal deductible is $3, and the maximum nominal copay for managed care is $4. For drugs, it’s around the same: $4 for preferred drugs and $8 for non-preferred drugs.

There’s certainly variation in who can qualify, per State; some States are more generous than others. It’s debatable whether it makes sense to even consider the US as a whole, since it’s really a heterogenous collection of 50 self-governing sub-cultures. The Canadian healthcare system for eg is also provincial, with the Federal government providing minority financial support. It’s actually more Province-driven than Medicaid is State-driven, today.

You can also make the taxes progressive, so wealthier pay more. I'm also not sure if this looks at total costs or only premiums. People don't go bankrupt or have surprise bills [1] for medical reasons in other countries the way they do here.

[1]: https://www.marketwatch.com/story/1-in-5-americans-get-hit-w...

While that may be true, its also true that people from all over the world come and pay airfare, stay, and tens of thousands of dollars to get procedures done here.

For example, Canadians going to https://surgerycenterok.com/

Here is another fact. The above has had transparency in prices since it was founded in 1990

Guess what also has not changed: the price that they charge for every single procedure since they were founded. In fact they technically charge less now because some procedures include additional services that were originally not part of the package.

So why is it that 1 clinic does not need to change pricing in 30 years, while everything else is increasing at 5-10% per year?

Hint: you dont have to throw away the baby with the bathwater. Its possible to have a system that is not going to bankrupt you and also at the same time not make you wait for 3 years for something you need today

While it's true that the UK has recently made itself a lot poorer, these kind of direct comparisons don't really capture the differences in living costs between countries since most expenses also scale with median earnings (rent, services, domestically produced goods.)

Consumer goods made abroad are incredibly cheap in the US in comparison to the UK, but as a Brit living in the US I definitely relate to this observation I recently saw go by:

> As a friend of mine from abroad who lives here put you “you don’t really get that there’s a really high standard of living and nothing works“

- https://twitter.com/__seab/status/1298342388537139200

If you make too much below the median salary in the US, you probably still can't afford health insurance.

Also consider that everything isn't covered when your employer pays for your health insurance. Americans still have a lot of out-of-pocket costs.

And remember that there are a lot of people who are unemployed or underemployed, or work under arrangements that don't provide them health insurance at all. They also probably make a bit less than the median salary. So sure, maybe 50+% of the US could afford their own health insurance, but is it ok there's some percentage, regardless of how small, that can't afford it and has to do without? I say no.

> Also consider that everything isn't covered when your employer pays for your health insurance. Americans still have a lot of out-of-pocket costs.

I have a doctor I see every 4 months. I mentioned to her that I thought my copay probably was about what she was actually making off my visit and she said, 'if that'.

She also said insurance companies are now doing things like not approving full scripts for insulin. And demanding that she prove a 50 year Type I diabetes patient still needs insulin.

If you make too much below the median salary in the US, you either qualify for Medicaid (at best) or direct ACA subsidies (at worst).

Sure, but there are several bands of income levels where you're basically screwed. The ACA subsidies have some phasing in/out based on income levels, but they're far from perfect, and depend on often-unreliable definitions of the "poverty line".

I think you're mixing up full time salaries and all salaries. For full time in the UK in 2019 it was just over £30k meaning a take-home of £2018 per month, $2662 at your exchange rate.

Still lower, we're a poorer country, but it is quite a difference.

> Except dentistry. For some reason that is separate.

Would the reason be that British teeth are maintained like American waistlines?

It might be part of the explanation, but I think it's also cultural. People just don't care about good teeth here the same way that they seem to in the US. Or rather: they have a different idea of what good teeth are. If your teeth are actually black or rotting or missing, then that's seen as bad. But a little crooked or yellow is mostly seen as normal.

Teeth seem in the USA to be a class marker, where in the UK class markers are different (used to be accent when I lived there aeons ago).

This seems a little cliche. Personally I find the brilliant white beacons people have in their mouth in the states a little unsettling. Teeth aren’t naturally a beaming snow white - they’re bone coloured.

The Brits have better average tooth health than Americans. They don't go for orthodontia as frequently, but in terms of cavities and missing teeth, they do better.

This is largely explained by economic differences in the US. The poor have awful tooth health; the wealthy have very good tooth health. In the UK, the poor and wealthy are closer to the median.

https://www.cnn.com/2015/12/17/health/british-american-bad-t...

It appears that the obesity rate in the UK is about 30%, whereas in the US it's around 40%. For historical context, it seems that the US was at about 30% roughly around 2000.

So I guess that the US is fatter, but the UK is still one of the fattest countries in the world. The BBC claims the UK is getting fatter faster than the US too.

https://www.bbc.com/news/uk-41953530

http://www.oecd.org/unitedkingdom/Health-at-a-Glance-2017-Ke...

Teeth are probably a myth. People see Americans on TV, of course they do extreme things to make them blindingly white.

Another Brit here - wow, I had no idea the NHS was so cheap! The NHS is far from perfect, but £250/m per person seems like a bargain for what it provides. When you put that beside the US system, the US system seems even more insane.

I pay $1200 a month for my family and don't even really get to use it for anything but routine checkups (which I still pay $30/ea for) until I hit my $5k deductible (and to another extent, the $8k out-of-pocket max).

A few times a year I spend an hour on the phone arguing about coverage or an incorrect billing code.

This is all for peace of mind that if I get hit by a car or fall off my roof that I won't instantly be ruined by debt.

In the event of one of those accidents I fully expect to have to fight the company I pay over $10k a year to actually provide that "I'm broke but at least I'm not bankrupt" coverage.

Oh also, we need a separate plan to insure our teeth for some reason and most plans only cover $1500 a year. I needed to get my wisdom teeth out and ended up splitting it over two years so I didn't have to pay the full uninsured price.

Our "liberal" presidential candidate is painted as "radical" by the current president, and said "radical liberal" has said on multiple occasions that "people love their insurance"

I've considered trying to move to another country simply because of healthcare. I am immediately skeptical of anyone who thinks this is a reasonable system.

I don’t think there are many people who think as a whole our system is “reasonable.” Just those that recognize the “be careful what you wish for” possibility. For example, for people who always point out how efficient European single payer health care is and how much money we’d all save if we switched to it: the U.S. government is already spending more per-capita on healthcare (Medicaid, Medicare, VA, etc.) than most European countries pay for single-payer healthcare systems that covers everyone [0]. So switching everyone on private plans (or uncovered) to a single-payer system is mathematically impossible to be even close to as cheap as other countries have it. (When I say per-capita, that means dividing the costs by all residents of a country, not just those enrolled in the plan).

That doesn’t mean it wouldn’t be better than what we have now, but it’s disingenuous when people imply that all it takes is to change the “payer” and we’d magically fall in line with costs seen in Europe. The real issue is many-fold and in order to truly bring costs down its going to take a lot of sacrifices from the provider side as well. Most doctors, nurses, and others in the health care industry in Europe (and other places with single-payer systems) do not earn nearly as much as their counterparts in the U.S.

[0] https://www.commonwealthfund.org/publications/issue-briefs/2...

That's just for insurance. You still going to be paying 20% of the actual medical bill. You can easily run up a $100k bill in a week.

Under the ACA, out of pocket maximums are ~$8000 or $16,000 (individual/family).

That leaves care that doesn't get covered by insurance of course, but people aren't on the hook for 20% of the bill that insurance covers.

Don't out of pocket maximums only apply to in-network care most of the time?

I think you're still on the hook for the full coinsurance amount if you're at a hospital and a doctor from out of your network happens to step in the room without telling you they're out of network.

Yeah. I'm certainly not trying to defend the US system, just trying to paint a clearer picture of how it works.

Totally fair to always discuss the huge caveat of out of network providers getting involved without any opportunity to refuse their care alongside the out of pocket maximums for in-network services.

What's even wilder is that in the recent primaries (both 2020 and 2016) of the "left" party a major argument was that this system is so awesome that it must be protected at all costs, even if moving to something like single-payer would be cheaper while covering more people [1].

[1]: https://www.peoplespolicyproject.org/2018/07/30/mercatus-stu...

Yes! Another indicator of how bad it is.

Relatedly, I like to joke that you can get a huge discount on delivering a pregnancy if you make sure you're on a European vacation when the baby comes due.

They'll come to you and super-apologetically explain that, well, you're not a citizen or permanent resident, so you haven't paid into the system and have to pay the full price of the medical services, which is sadly ... something like 500 USD. And then you laugh at how that's less than you'd pay with insurance in the US.

While I think this project and the data are interesting, one thing that becomes problematic is that you actually DO have to invest time in whatever courses you register for at most colleges and universities (or at least the ones that I've seen).

Generally, if you aren't making adequate progress in a course, you can be dropped by the instructor mid-semester/quarter or placed on academic probation, both of which can cause you to fall below the minimum number of credits needed to be eligible for healthcare coverage.

So while you may save some money on health insurance, you lose a potentially large amount of time due to having to keep up with coursework to maintain eligibility.

That being said, this may not be a problem if they are courses you are actually interested in and can dedicate time to completing.

100%

This works out best if you're taking classes that are relevant to you so that you're getting value from the time spent as well.

Otherwise your goal should be to find the easiest most phone-in-able class possible.

> Otherwise your goal should be to find the easiest most phone-in-able class possible.

Thanks, COVID!

Take big engineering classes at a state school, nobody will pay any attention to you.

Funny, I was thinking that the opportunity to spend time in classes sounds like a win. I’d love to brush up on discrete math and take a bowling credit for the next five months.

True that, but in many cases, if you just need to stay enrolled and don't have the stress of needing a good grade or to juggle a full load, it could be just eating into your TV couch potato time, be way more interesting and rewarding, and be a win as well. Depends on how much you have to take to get the insurance, though.

Back in undergrad there were 1 credit hour online classes that you could bust out entirely in probably 2 hours total of focused work. Small price to pay imo.

$500/MONTH is considered cheap? gosh damn, I'm sorry USA but you really, deeply fucked yourself over on this one..

yea, it's pretty dumb

While I am not one to subscribe to the "Europe does everything better"-style thinking of U.S. progressives, the reality is, in this particular field, there is absolutely no way to defend the U.S. system.

How much do you pay per month for health insurance where you live? (Or if you don't know, how much does your country spend per capita on healthcare?)

My wife and I pay way less than $500/month, but her employer pays some of it so I'm not sure what the total cost is. When I was looking for it on my state's healthcare exchange it was also considerably cheaper than $500/month, but then since I was unemployed at the time, it ended up being free.

Healthcare in the US is a real problem that needs to be resolved, but it's not a simple situation.

> How much do you pay per month for health insurance where you live? (Or if you don't know, how much does your country spend per capita on healthcare?)

The cost per capita in the US is apparently 85% than in Sweden [0] while the gdp per capita in the US is only around 27% more than in Sweden [1]. I'm not sure how current/accurate those numbers are, but they do fit in with everything I've read over the years.

> Healthcare in the US is a real problem that needs to be resolved, but it's not a simple situation.

I don't really understand this sentiment. There are so many other systems to look to for comparison. If you mean that powerful entrenched interests that would stand to make less money and they are hard to fight, then sure that's hard, but it's not like we don't know better systems. They are everywhere if we choose to look. I think the main problem is that too many Americans seem incapable of recognizing that the system there really is worse than many high-tax socialist countries. They don't really have any reason to believe this, but they know this deeply in their heart. It only hurts the US and plays into the hands of the aforementioned entrenched interests (which to be fair certainly work hard to propagate the lies that Americans later believe).

By the way, I'm both an American and Swedish citizen. I was born in Sweden, lived most of my life in the US, and am now back in Sweden. I definitely identify more as American than a Swede. In my experiences of the US and Swedish systems I'd take the Swedish one (i.e. the cheapest setup without any of the possible extra insurance which can be purchased extra here) over the US system any day of the week. I think the Americans who have knee-jerk reactions against "socialized medicine" are either totally ignorant or deluded. It's sad. Such self-defeating attitudes weaken American as a nation.

[0] https://www.businessinsider.com/personal-finance/cost-of-hea... [1] https://en.wikipedia.org/wiki/List_of_countries_by_GDP_%28no...

The US government spends around as much or more on healthcare per capita as any country with socialized healthcare. Every penny that you pay and your employer pays on your behalf is due to graft/rentseeking.

The data here may not be totally accurate, but the sentiment is right. For my local school it's showing the marginal cost of the first credit hour, but the average cost per credit hour is substantially lower once you get to the minimum number of credit hours to qualify for insurance. After correcting for that mistake it cut the monthly cost for tuition+insurance for my local school in half. In addition, some schools offer insurance for spouses and children as well, which usually drives the cost per person down even further. For our situation, the total cost of tuition (9 credit hours per semester) plus insurance (2 people) is about $870 per month. A comparable ACA-compliant insurance plan would be about $1,000 per month.

Even with a "gold level" insurance plan we ended up spending around $4,000 for an accident that occurred on campus that required an ambulance to the University hospital (1 mile away) and about 4 hours in the emergency room to get stitches and confirm that a head injury was not a concussion. It's hard to visualize how much money has been legally stolen from the American people over the last few decades due to the giant scam that is the health insurance industry. The combined salaries of every single doctor in America could be paid for with 8% of what we spend on healthcare every year. If you add in the salaries of nurses, pharmacists, drug researchers, etc. it's probably under 25% of what we pay. Unfortunately there are literally millions of middlemen and unnecessary administrators who soak up a very large percentage of healthcare spending without really doing anything.

Canada and Australia spend less than half as much per capita as we do on healthcare despite having similar levels of GDP per capita and better average life expectancies. If the US could save 50% on healthcare we could probably solve climate change single-handedly. This is not even an exaggeration, it's an illustration of just how much we spend on healthcare.

Eastern/Western Washington State University is listed...

https://cougarhealth.wsu.edu/studentinsurance/insurance-cove...

https://inside.ewu.edu/bewell/optional-medical-insurance/

This spreadsheet is inaccurate, at best. Also, what kind of insurance matters. I can get you 50$ a month insurance that wont cover anything. Without context, this spreadsheet is a big list of rumours for you go look up and be disappointed.

I'm curious how one would actually sign up for $50/mo insurance that doesn't cover anything. How is it marketed? Where is this sort of thing found?

(The argument being that there's got to be some kind of fraudulence-meets-loophole sort of thing going on for this to work at all.)

Getting foreign car insurance is pretty common, which gets you nothing when you try to make a claim in the US. For healthcare it goes down to 30$ (that I've found, I assume it's more like 50 per employee with their business healthplan), again with the vast majority of claims being rejected - eg Apria Healthcare. You might need to learn to speak some Tagalog.

I wonder how many of those schools would kick you out for never showing up and failing all your courses every quarter.

Maybe you could filter this list for those schools.

Or perhaps you could subcontract our your schooling online and just pay people to do the minimum required to get a passing grade. :-)

If you don't show up to class then technically you won't qualify for a lot of these plans.

In the policy they require in-person classes.

How that's going to work this year with online-only classes is an open question.

Looking at the first plan on the list, Auburn: https://www.uhcsr.com/uhcsrbrochures/Public/BenefitSummaryFl...

On first blush, this looks like phenomenally good coverage for the cost. $1970 for the year. $7150 out of pocket maximum. 80% coinsurance after a $250(!) deductible.

The ACA limited how much cost discrimination insurance companies can do by age, and I am wondering if college plans are a workaround - it's not age descrimination, per-say. But the risk associated with students is much, much lower than on the marketplaces.

College plans are considered "special-risk" plans and therefore aren't obliged to follow ACA guidelines at all.

So they can do tricky stuff ACA banned like have low lifetime maximums, exclusions, and kick you off the plan when you drop out of school because you're too sick.

It is age discrimination. People who were silo’d in employer plans and other lower risk pools than the general public were incensed they would have to help pay for everyone’s healthcare, so they lobbied to be exempt from ACA.

It’s a major hindrance to proper insurance mechanisms when your healthiest lives aren’t on healthcare.gov. Ideally everyone would be forced into the same marketplace subject to the same sick and healthy lives proportions so the costs are spread out evenly.

OP actually confirms my long term suspicion. Thanks!

For the longest time, one of my early retirement plan is to simply go back to school, learn everything that excites me and enjoy the health insurance offered by the school.

I think this math is off, as it assumes a single semester lasts a full year. For a full year you would need to pay for multiple semesters of tuition, probably 3 at most universities to cover the summer.

Let me double check, should be multiplying semester by 2 when necessary.

Annual insurance fee is already calculated annually.

Portland State is actually on a quarter system, so you'd need to multiple those values by 3 or 4 (depending on if you include the Summer quarter or not).

Source: I'm a Portland State alumnus.

Thanks for this note!

I'll include this when I build out v2.

I thought about summer as well. I checked my alma mater's web site. Seems you can get year-round health insurance without registering for summer classes.

The exception is when summer is the first time you attend and you want to start insurance before fall. Then you need to meet minimum hour requirements.

I'd guess most schools are similar because otherwise they'd practically force every student to take summer classes. But it's good to verify.

Thanks. I didn't realize most schools allow only 2 semesters for insurance coverage but that makes sense.

I did the math with Auburn University and it's definitely off. Unless that school allows an entire semester to last a year? (1 credit hours * $430 per credit) + $2028 insurance cost / 12 = $204. I think it would be 2 credit hours, so: (2 credit hours * $430 per credit) + $2028 insurance cost / 12 = $240

Okay you were right, should be fixed now, thanks!

Now the tuition is doubled.

The insurance premium stays the same though because that's already the annual rate.

I just checked, and I paid 189,60 € for my health insurance last month, in Germany.

Germany doesn't let us Americans in anymore unfortunately.

Even before COVID-19, you'd have to get a work visa, which probably isn't too tough for most software people, but can be a hassle.

Does that include the healthcare-related taxes you paid? Not being snarky, genuinely wondering.

There are no extra healthcare taxes.

https://www.krankenkassen-direkt.de/themen/thema.pl?id=47494...

The public insurance which covers 88% of the population gets 15 billion tax EUR annually, with total revenue of public insurances being 250 billion.

https://de.statista.com/statistik/daten/studie/192409/umfrag...

So most money comes from the insured people. The maximum you pay for the public insurance is 703€ per month, and it covers your children and non working spouse.

Note that the cost is split with your employer. So the maximum you will have to pay is €365/month I think. Less if you income is not high.

About 139 here in The Netherlands.

Does this mean The Netherlands and Germany are not single-payer?

Nope (this is a common misconception)! Thankfully, the price of premiums and deductibles is capped.

I once paid 350€/month when I made 200€/month

The minimal self-employment fee

It's been reduced since 2019, now it's 156€.

To most of us Americans that looks like 189k euros, so go figure.

So many things in healthcare are screwed up. I was in IT for 20+ years and ready to move into law when a healthcare IT management job fell in my lap. 5 years later I still love healthcare IT because there is SO MUCH OPPORTUNITY to improve things, save money, make things better for users and patients. The entire system needs an overhaul, but the really odd thing is that as a nation (USA) we actually CAN do all the things we need to fix it. It's all payment and administrative stuff we need to fix.

It's unrolling the entire system of economic incentives that needs to be fixed. This is going to be monstrously difficult... there is lots of potential to improve healthcare but actually trying to achieve it is a bit Quixotic.

Nah, we can fix it chunk by chunk. It's actually doable. People IN healthcare WANT it, so that helps a lot.

You can do something similar in Germany to get access to cheap public transport.

Just enroll in an University which cost around 280€ for half a year. This will get you a ticket which you can use in busses and trains for quite some distance. Usually a whole Bundesland (County or whatever the US equivalent is).

This is a fraction of the cost of a regular ticket and nobody checks if you pick an unpopular field like physics.

I know people doing this for many years.

And yes the US should totally get a proper public Healthcare system...

Where I lived (Kraków, Poland; but arguably, similar schemes apply across the country), you'd get half-priced tickets if you're a student under 26. After finishing their 5 years at the uni, many people then sign up with whatever private school offers the cheapest nonsense course in underwater basket weaving or whatnot, and continue to use the public transport for half the price (as well as using many other discounts for things like trains, cinemas, etc., for which a student card makes you eligible).

My friend did something similar - he started studying something at the University of Warsaw's Faculty of Education - really easy to get in and since this is UW, academic progress is judged on an annual basis.

He even showed up there a few times.

At my University (Ohio State) we get unlimited bus passes in the metro area for quite cheap. Sadly, we don't have any real public transport lines. Columbus is one of the largest US cities without light rail/subway.

A Bundesland is technically a federal state, which is quite a large area in the US, though also large for some states in Germany too. I am mostly familiar with Bavaria, a big state where you can get a "Bayernticket", that lets you travel on any public transit in the entire state for a day, and even gets you to Salzburg in Austria. Seems the pricing has changed and is not quite as good anymore, though still a good deal. It used to be you could get one ticket that would cover up to 5 people for about 25 euro. Unbelievable value.

Where can I find more stories like this where someone who has a familiarity with a system finds some form of leverage that is often overlooked? stuff like this excites me

For healthcare specifically I'd check out https://twitter.com/nikillinit

More generally HN is a good place ;)

http://reddit.com/r/lifeprotips

In the UK there is moneysavingexpert.co.uk that sometimes goes to ludicrous lengths to save a quid (a British pound)!

Think sign up for a credit card using a cash back site to buy an easy jet plane ticket using a promo code to fly for free kind of thing!

I guess you have to actually try to pass the class as well, right? Otherwise you trash your academic record and/or jeopardize your ability to do this again next year.

That not only requires your time, it might also require you to spend money on textbooks, etc.

Although maybe not if there are schools that let you drop all your classes but stay eligible for health insurance for the rest of the term.

You don't have to pass the class you just can't get kicked out of the school.

One BIG caveat with these plans is that coverage ends if you leave school.

That's how the insurers cover their asses. They're able to provide cheaper plans because many of the sickest will drop out.

It's dumb.

Read this article by Charles Gaba for deeper insights than I can muster: http://acasignups.net/20/08/26/updated-how-much-can-risk-poo...

That's not dumb, that's evil.

Why not both?

Because it isn't dumb.

Or neither dumb or evil, but just an expected result of the way group insurance works.

1. University: Has group of people they want to insure

2. Insurer: Measures risk of that group

You're either in the group or your not. Sick people drop out of school not because insurance is making them drop out, but because academics is hard to do when your health issue prevents you from doing so.

The people at fault are your representatives, who forgot about university group plans when drafting COBRA.

As long as it exists, private health insurance will incentivize providers to cherry-pick, lemon-drop, and sell insurance that they have every intention of not making good on. Those are the core "innovations" they are in a position to deliver, and they are the core innovations that get delivered. The concept is evil, the act of carrying it out is evil, and regulators are to blame precisely to the extent that they allow private health insurance to exist in the first place. They are complicit, to be sure, but "simply following incentives" does not absolve the private side of this equation from moral responsibility. Legal responsibility, yes, moral responsibility, no. Hence: evil.

What would a moral insurance company do to fulfill their moral obligation in the above example?

Are they a company that maximizes their profit or are they moral? In this case, the profit motive points in the wrong direction, so they can't be both.

The implied “all for-profit companies are evil” argument is radically oversimplified, IMO. It is possible to maximize profit by efficiently providing value.

Most of the downward pressure to cut corners in any industry is not from profiteers but from customers themselves.

This apply to a lot of jobs too? You get fired when you are too sick to work and consequently lose your insurance?

That...is actually kind of clever.

Wonder how long before these loopholes get shut down.

In the ideal world this loophole would be made irrelevant by universal healthcare.

Realistically the minimum credit hour requirements might be increased at some schools, but otherwise if you take advantage of this system you're pretty much using the system as designed.

Insurers already account for the fact that healthy and insured students are less likely to opt-in for their student health plans.

That was the ideal with ACA (since taxpayer funded healthcare is such a bad word for many US voters), but the voters got up in arms about having to pay for others’ healthcare so they got to keep their silo’d school/church/employer health insurance pools.

It probably was insurance companies that got up in arms about it rather than voters since insurance companies are incentivized to silo their clients as much as they can. Also insurance companies are the ones who have actual say in the matter of writing the law compared to the voters.

I remember people being pissed off their premiums went up because people with pre existing conditions and pregnancy and whatnot had to be covered now.

People are still pissed off about having to pay increased premiums so more people can get more healthcare.

Insurance companies, by statute, can earn up to 15% to 20% of healthcare expenses they pay for, so increasing the population they cover is in their interest.

Sadly it shouldn't be considered a "loophole" as society gets an individual looking to educate themselves (since realistically you'd have to try hard enough to not get kicked out so you're bound to learn useful things) that is also health-insured. Right? That's what I think, anyway.

One of these is a medical school. Can you imagine?

You apply, you get admitted, you go to your first class. You meet young bright-eyed students.

"I want to be an oncologist! My aunt's battle with cancer really inspired me."

"I want to be a neurologist. The brain is just so fascinating!"

"I wanted health coverage."

A Soviet Russia joke goes:

A toy factory worker wanted to get his son a nice toy for Christmas, but couldn't afford it. So he sneaks out a single component from the factory every day. When he assembled it, it turned out to be a machine gun.

The topical American joke would be:

At a medical school graduation party, the whole class started discussing their future career prospects. It turns out that none of them would become doctors; all of them joined for the healthcare coverage.

Any idea what level of coverage you get for these rates? It's hard to compare these options to exchange plans, some of which are significantly cheaper. I tried doing it for Rutgers, but the site they use won't let me see plans without a student ID number.

Most of the plans you can find on the school website's with some digging.

Some common gotcha's are low lifetime maximums and exceptions. Also, the the sickest students are most likely to drop out of school and lose their coverage.

Are you eligible for health insurance with these universities if you live out of state?

The monthly cost for health insurance through using Cal Maritime ($627) is more than what I spent for health insurance for a single person via COBRA ($494.36) in California from 2018 - Spring 2019.

If you qualify for COBRA or Medicaid that might be a better option.

California is also an odd bird in general and a lot of their public schools didn't offer a student health plan for part time students that I could find.

I’m sorry USA that this site needs to exist for you guys. Hope you get affordable healthcare soon :-(

It should be $0 and no hack required, for all, ideally at point of care (so no invoice).

When I quit my job a couple of years ago, I bought my own insurance for about $400 a month. This was not done via COBRA.

I don't fully understand the need for this. Can someone explain?

Won’t this drive up the costs for students in the long run?

Mentioned in another reply, but insurers already take into consideration the fact that sicker students are more likely to need their insurance. This is mitigated by lower maximums than normal and the fact that the sickest students will tend to drop out.

I might be misunderstanding this chart, but it appears the author is saying that by enrolling for the minimum number of credits, you will receive the associated insurance for free. For at least one university listed -- Penn State -- that is not true. You must also purchase the insurance plan.

No, you also have to opt-in and pay the annual premium.

This is included in the cost calculation (see notes section at the bottom for details).

OK, I did misunderstand. The numbers make more sense now. I believe step 3 "enroll, get that cheap insurance" should make this a little more clear. (It's not just the act of enrollment that gets you the insurance.)

This is a good point, and also kind of an unintentional pun since enroll could refer to either enrolling in school or enrolling in the healthplan.

Some (many?) schools you are enrolled automatically to the healthcare plan unless you opt-out.

> US Healthcare Is Dumb FTFY

this is kinda brilliant.

> Health insurance in the United States is expensive (duh). Healthcare through a university is less expensive. Using this website you can find insurance for less than

...

> $500 per month.

jaw drops to the floor

The fact that "just" paying $500 per month (in premiums, I assume?) is considered an improvement...

Its this a big issue for most on HN? If even junior engineers are making $200k these days they should have pretty nice health plans.

Well, the key word here is "most". Not everyone on HN is in a tech job.

I imagine it could be helpful for people who are self employed or semi-retired and make too much for maximum Obamacare subsidies while not being old enough for Medicare

You can go take a ballroom dancing class with a bunch of 20 year olds while getting slightly cheaper insurance

I'm a mid-level engineer making half that. Please point me towards these entry-level jobs that are offering $200k.

My comment was mostly a poke at the claim on HN and elsewhere that starting engineers make a vast amount of money.

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