Hacker News Reader

Comment by returningfory2 | Hacker News Reader

> Yes, healthcare and the cost of living are more expensive in the US

I feel Europeans looking in on the US from the outside consistently have a misleading view on healthcare. I'm saying this as a European in the US working in big tech.

My plan's maximum out-of-pocket in a year is ~$3k, which I can pay pre-tax thanks to an HSA. It is less than 2% of my total comp in the worst case (in 2020 I spent less than $300 on healthcare). In return I get coverage that is generally better than the free public healthcare back in Europe.

I think CoL is similar, but not as clear cut. One thing CoL discussions often miss is that many expenses are independent of the local CoL; for example, a Macbook Pro costs the same in every US city. If your salary adjusts exactly for CoL, you're actually doing better because of this.

View on HN

My worries about US healthcare don't revolve around the cost or the quality, but more about the instability. If I know roughly how much I'll need to pay I can plan for it, even if it's quite a bit. But if I get into a crash in another state and taken to an out-of-network hospital without even being conscious, that can fuck up your finances straight away.

What I'd like to know is how much NHS-level healthcare would cost me in the US. Given a monthly payment, I want 100% of everything covered all the time. No out-of-pocket, no out-of-network, everything with no exceptions. I'm happy with generics, a bit of a wait and a non-private room, but I want 0 unexpected bills.

Maybe companies like Kaiser do things like that?

> What I'd like to know is how much NHS-level healthcare would cost me in the US.

If you're employed by a tech company, the out-of-pocket costs to you will be $0, and your standard of care will probably go up.

Yes, you will occasionally have a $10 or $20 co-pay, but on a tech salary costs are negligible unless you're on a ton of meds.

The problem with care in the US is how it's impacting the lower-middle class and the poor. The professional class generally have great care and don't pay much for it.

Not sure why parent is downvoted, as a European that has lived in Zurich, London and Oslo + NYC and SF healthcare cost is a non-issue for those of us lucky enough to work at a company that provides healthcare. This applied from what I understand to even the smallest startups.

US healthcare sucks in general, but for the wealthy (and most of the people reading this site falls into this category) it is actually pretty good.

Health care cost, or the predictability of it, is not an issue to not move to the US IMHO.

> for the wealthy [...] it is actually pretty good.

Yeah, I mean no shit. It's like that all over the world.

What is really important is how healthcare is for the 99% rest of population, who needs help more than you who are wealthy. That's the problem.

I really agree with you, and I am all in on M4A. But for the thread the important part is that if you are a software engineer moving to the US is safe.

Sounds like a pair of golden handcuffs. Is your family at least covered as well?

What if your partner gets in that car crash, or your kid has an expensive birth defect? Expensive care is a matter of time, not a matter of luck. It really makes me uncomfortable as well that timing or location (or employment) seem to matter.

Your full family is covered yes.

My wife was covered before we were married as well, being in a stable relationship was enough.

And yes agree I would like healthcare to be not tied to employment.

And for the handcuffs if you get any other job it almost certainly has similar insurance.

The main issue is if you have no job, when you live you are offered what is called I think Cobra that will keep you on a similar plan. I’ve heard from coworkers that left, sometimes not voluntarily, that it is not cheap at all. California also has decent options for private insurance.

> The professional class generally have great care and don't pay much for it.

Wealthy people in the US are over-tested, which leads to over-diagnosis and over-treatment, and these things cause harm.

Zero out of pocket seems like a silly line in the sand. Why wouldn't you care about out-of-pocket max? The only reason I can see about a well-paid professional caring about $20 co-pays is because of a psychological aversion to being paid for healthcare.

(Not saying this feeling is necessarily wrong. Humans may have evolved a feeling that their community should take care of the sick and injured. Demanding more for this act, I think makes a lot of people feel tawdry and icky, in a similar way to paying for sex. Still this is a psychological, not an economic argument.)

Imagine, that you insisted on car insurance that covered every oil change and car wash starting at dollar zero. It'd probably be astronomically expensive.

Ah, sorry for not being clear; if I moved to the US, I wouldn't look for a plan like this. I'm convinced a US developer salary/benefits would be more than enough for me. I'm more curious what an NHS level of healthcare would cost, so set the parameters based on my experience.

Hes thinking not of 20$ out of pocket but more like the $20k horror stories we sometimes hear about.

My beef w/ the US healthcare system is that doesn't even need to be an accident. My wife went to see a specialist for a checkup. At the front desk, they said she had to pay around $200. She's the type to decide whether to do things based on cost, so she asked: "That's all?" Them: "Yes."

Six months later, I get a letter from a collections agency saying I owed $700. Confused, I call Kaiser to find out that not only was the $200 not the entire amount, they also apparently had no way of quoting accurately ahead of time (even though they knew exactly what she was coming in for), and as the icing on the cake, they forgot to mail us the bill, which is how it ended up going to collections.

I had to then press them to get an actual bill with itemized numbers, but it doesn't matter because the numbers make no sense anyways: none of the numbers match up to the amounts we paid, the insurance quoted price or the collections amounts. When pressed they all basically shrugged and said they don't understand how any of it works, and that's just how it is.

And the reason for this whole ordeal? We changed health insurance plans and Kaiser said they couldn't renew a prescription because it was a 2-in-1 and insurance only covered the two drugs if they came in separate vials.

That wasn’t the reason. I went to the ER with no insurance. While I was lying in a bed between visits from the doctor a woman came in and wanted payment for the ER. I asked in no uncertain language if it covered my ER visit and explained I knew the doctor would charge me separately. She said yes, so I paid.

I went home. The doctor billed me. I paid. The X-ray tech billed me (a surprisingly small amount). I paid. The hospital never billed me. Then the collections calls started.

Was it the X-ray tech or a radiologist that billed you? Radiologist is often $30 or whatever.

(I would expect the cost of the tech to be included in the hospital billing)

> I feel Europeans looking in on the US from the outside consistently have a misleading view on healthcare

Maybe. All I know is that if I get sick or any other health emergency, I go to the hospital, they patch me up and I go home or stay there until I'm better. I literally have to do nothing else.

Even knowing what HSA or anything else is, is too much for 90% of the people, including me. Some of us view healthcare as something that should be there for everyone and with as little complications as possible, even if it is more expensive overall. When you're dealing with healthcare, you're most likely in a situation where you want to deal with as little as possible, so free public healthcare really help then.

So you are right on the general principle (at least I think so), that healthcare should just be available for everyone etc. That is not the case in the US.

But as a software engineer in the US it is not a worry. Like not at all.

How about if you’re a seed stage startup?

It's a cost you probably need to have or you're going to have trouble hiring people.

I thought I answered this, but you are right. All the startups I have talked to, even seed startups, have decent medical.

There is a fundamental difference though. The startups actually use insurance so you have to deal with the insurance company, while Google/Amazon/others self insure and just use the network etc. So if you have Google insurance you call a specific Google number and they will help you. At least that have been my experience.

Many companies that self-insure still contract with an outside administrator that is usually a department/subsidiary of an insurance company. In my experience, there's no material difference. You still have covered procedures, tiers of insurance, etc. I've admittedly never worked for one of the big West Coast companies so perhaps their insurance is more gold-plated than the norm, e.g. I still pay out for my insurance even though my employer does as well.

You are probably right, I just know the administrator for the google and Amazon insurance were always super helpful and even though I have had some massive claims I never had to fight with the insurance company. Like I said many times I believe in any decent paying job in the U.S. healthcare is taken care of.

I still pay a portion of my paycheck for insurance too, and the amount varies depending on which insurance you want. I think the highest I have seen is still less than $500/month for whole family coverage.

A few messages below in this thread, someone writes:

"San Francisco’s only level 1 trauma center does not take private insurance, so if you are taken there, expect an absolutely massive bill despite how good your employer-provided health insurance is."

Sounds like this would be a worry for anyone in the city, software engineer or not.

Nah, my insurance (like all Google and Amazon insurances) have an out of pocket maximum/year. It is like less than 10k.

> But as a software engineer in the US it is not a worry. Like not at all.

Cool. What about the rest of you, the majority of people who are not in tech? I get the feeling that many Americans don't worry about services as long as they themselves are covered, while many go without.

If you ignore national boundaries and just look at human beings in general, basically the entirety of the global west does precisely this.

~half of the humans don't even have internet access.

The list of countries without "universal government-funded health system" is smaller than the list of countries with it. US (together with Uganda, Yemen, Jordan and some other countries) is pretty lonely with its healthcare system.

In general, the West does not work like the US when it comes to healthcare. And when you compare globally, the US still has the highest "Health Expenditure per capita", far higher than any other country really.

There is no way to spin it, healthcare is absolutely terrible in the US and gets worse every year.

I wasn't trying to spin the healthcare situation, just to point out that "fuck you, got mine" isn't really unique to the USA, but is echoed in the entirety of the global west.

One just needs look at the vaccine distribution situation to see this writ large.

If they would let me I would vote for M4A, and give every American decent healthcare even if it would raise my taxes a bit.

But that is beside the issue in this thread. All software engineers can safely move to the US and not worry about healthcare.

Personally I would not move now as I think democracy is dying, but that is a different concern I guess.

I think the key difference here is that you are ultimately at the behest of your insurance company. I don’t like the idea of insurers making decisions over my health. I’d take the British NHS over US system any day as I know ultimately if I’m sick I can rely on it. You don’t have a plan B in US - or am I mistaken?

You are mistaken, in the good plans all they do is serve as a middleman that pays most of the bills, and all the bills after a certain number.

Having lived in London, NYC and SF and broken bones in all locations I can say if I could choose to have a big issue I would probably do it in SF but they all gave good treatment and I am thankful and think the healthcare is good enough in all places that I would not even take that into account when choosing where to live of those places.

I’m genuinely surprised you trust the intentions of an insurance company over a nationalised health system. Insurance companies are famous for weasling their way out of claims.

Maybe you can elaborate a bit more on this.

There is a yearly out of pocket maximum in the best insurances. It doesn't matter what happens, I will pay max something like $10k for me and family no matter what happens.

This is true for all of Google and Amazon (note that this is all Amazon workers including those that work in delivery centers).

On a country wide look we are super privileged, and of course if I could choose I would pay a bit more tax and cover everyone. But that is not an option. I am just saying if you are software engineer, you will most likely be fine.

Edit: Also these big companies don't really have insurance, but insure themselves and just use the network and negotiating capabilities from the insurance companies.

> I will pay max something like $10k for me and family no matter what happens.

Does that usually apply for out-of-network treatment? Or long-term medication/care?

Yes, there is a different amount for out of network yearly max, but it’s still less than $10k. It applies to anything.

I’ve had several surgeries, one was over $100k just for the surgery (a broken arm that was healing wrong and had to be reset, all the tendons were turn off from the bone) and insurance paid without any questions.

A stated many times it is not my preferred system, but as a software engineer you and your family will be taken care of and healthcare is not a worry.

San Francisco’s only level 1 trauma center does not take private insurance, so if you are taken there, expect an absolutely massive bill despite how good your employer-provided health insurance is.

It really doesn't work that way. My insurance covers out of network as well with a yearly maximum. My wife has gone to ER by ambulance a few times (she gets really strong periods and sometimes faints in strange places). It has always been covered.

This is fine while you're employed, but what if you lose your position or decide to take a couple years off? Then it becomes a different equation.

Spread out over time, in the places I lived outside of the US that was not really a concern. Same with most other "social care" situations. In the US, it all felt a lot more tenuous which was a source of constant low-key anxiety.

COBRA coverage is very affordable for tech company ex-employees because their workforces skew young, male, and healthy. So that’s another 18 months.

It’s certainly not perfect, and in my citizen hat I think it’s quite flawed, by as experienced by most software engineers it is not a huge concern.

That is true as long as you are employed. Once you lose employer-provided healthcare or fall on hard times and your expenses mount with no income, things get a lot more tenuous. The folks perched at the top of the heap are not the ones who are the determinant factor in the quality of healthcare provisions in a country.

You make it sound as if your healthcare cost is limited to 2% of your total comp. My credit cards/atm records show that I spent nothing on healthcare in 2020, as I am "young and healthy" and skipped my annual checkup because Covid. But my W2 box 12 dd entry says that $19246 was paid on my behalf.

Also when I go to coveredca.org I find that the maximum cost for healthcare this year if I were unemployed and 64 years old would be 76k.

Sadly, each of these figures is substantially more than 2% of my total comp. Sure, my wages as a Bay Area FANG engineer are high compared to European counterparts at less prestigious employers, but the elevated costs of healthcare are still material to me and in fact it is by far the largest expense in my retirement budget (savings for retirement being by far the largest sink for my present income).

> less prestigious employers

You make it sound like Bay Area FANG is more prestigious while in reality they just pay more. There is a difference between admiration and salaries.

Unfortunately not everyone thinks like you. Though I would agree.

For anyone that will listen I will tell them not to answer to the lure of prestige and 'benefits' of FAANGs but a lot won't. It's just too prestigious for them. Who doesn't want to work for Google?

Who wouldn't have wanted to work for IBM back in the day?

(a friend of mine worked for IBM precisely because it would look good on a CV even today and is now at Google ;))

Keep in mind that the plan is tied to your employment, paid by your employer, and better than what many Americans do have as a healthcare plan.

It's a good place to be if you're in the upper middle class and above, but people working in the service industry have worse healthcare outcomes in the US than in Europe.

[but not that much more expensive, you can just make a fuckton of money its as simple as that]

Reply on news.ycombinator.com