Hacker News Reader

Comment by jamestimmins | Hacker News Reader

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

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.

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.

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.

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 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".

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.

It's pretty dumb tbh

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...

Reply on news.ycombinator.com