A Freelancer's Forty-Three Years in the American Health-Care System

Yes, and there is no doubt healthcare is expensive. I won't rehash the reasons it's particularly expensive in the USA; they're well-known, though there isn't strong consensus. But:

> I feel the only way to survive long-term is to have a career that enables access to jobs (or unions) that offer health care as a benefit. Without it, paying for family-level premiums is similar to a mortgage.

"Obamacare" tried to remedy this by capping healthcare costs at 8.5% of income. Yes, there are holes (in particular, before 2021 this only applied to those earning under 400% of the federal poverty line FPL) and healthcare is even more egregiously expensive in those special cities where 400% of the FPL is below the local poverty line.

But whether you get subsidized by the state, a union, or your employer, the thing to keep in mind is that the costs of healthcare are ultimately still borne by "you": really, we, collectively, employees, union-members, taxpayers -- yes some of us are privileged enough to work for companies that are not financially constrained, but for most employers an extra $1000-3000/mo going to healthcare (you did say "family-level premiums") just feeds in to their total cost of employing you. Offering that benefit to employees means the pay they can offer you as an employee is constrained by its cost as well.

If having employer-based care is the only way to survive, then what that really means -- since money is fungible, really -- is that having the privilege of being well-compensated is the only way to have effective healthcare.

I think that's worse, honestly.

This sucks, and I’m genuinely really sorry that you and your sister are having to go through this. I hope she gets the care she needs soon and that the delays don’t cause any irreparable harm.

Unfortunately, the current issues with access probably have more to do with the way the pandemic has crushed the health care system than with whatever insurance your sister is using. My experience has been that getting access to services right now is much harder than it was in 2019. I’ve had referrals take 3 weeks just to get a scheduler on the phone (plus 1–4 month wait times), physicians wasting their time chasing people up and doing their own scheduling because their support staff no longer exist or aren’t doing their jobs, labs that don’t return phone messages. I even had a clinic outright ghost me last year. It’s an absolute shitshow out there right now.

(Also, pedantically: Medicare and Medicaid are two confusingly similarly named but distinct things. Medicare is federally managed for old and disabled people; Medicaid is state managed federally assisted for low income people. You can be on both Medicare and Medicaid at the same time because Medicaid will pay costs that Medicare doesn’t, but they aren’t the same thing.)

> I feel the only way to survive long-term is to have a career that enables access to jobs (or unions) that offer health care as a benefit. Without it, paying for family-level premiums is similar to a mortgage.

I’m not sure even this is a long-term solution. A friend of mine who works for a very large financial institution as a software architect has had their premiums increase by 200%, OOP by 300%, and deductible by 400% over the past three or four years. They had to figure out how to absorb almost $10000 in new health care costs this year after the company eliminated everything except for some high-premium high-deductible plans.

Honestly I don't even need to tell you which country that is as that's what I would expect in any western or northern European country (except maybe Switzerland, which is its own capitalist hellscape).

The US is still the richest country in the world. That you are suffering is not needed. It is not a necessary feature of the system. It's a policy choice.

NHS budget in 2021 was about £135B or ~$180B in USD, which is offered to the entire UK population ~67M.

Medicaid budget was $458B in 2020, offered to part of the US population (~84M).

So we have UK: $180B for 67M people US: $458B for 84M people

The only difference is that $458B is provided solely by the 270M Americans who, in exchange for their medicaid funding, are banned from using it.

So basically, we have an NHS in America but it's only for the people who don't pay for it. Then we have an entire secondary subsidization going on with health insurance which some comments above have pointed out is often tens of thousands per year.

One of the most crooked things I've ever seen.

A while ago I went to an endoscopy clinic, and there was a woman crying and pleading with the secretary because her husband has cancer and couldn’t get treated on the day of his appointment because some medicaid paperwork didn’t go through regarding his diagnosis and thus medicaid wouldn’t approve the procedure yet.

https://techcrunch.com/2016/07/27/how-president-obama-shaped...

You get Medicare B (hospital or physician administered drugs like chemotherapy) if you pay the premium.

Everyone should get Medigap, as Medicare A + B only pay 80% (or 90%?) of costs, so Medigap covers most of your obligation under A+B. Those with very low incomes can get a LLS (low income supplement where the government covers the gap).

Medicare C is Medicare Advantage is HMO Advantage. It's basically the government paying premiums to an HMO Medicare plan instead of providing the benefit directly themselves. It covers Medicare A+B+Medigap.

Medicare D is prescription drugs (drug you take home and give yourself). Your premiums are paid by the government but offered by private insurers. The choice here (and there are calculators) are more complex as there are multiples plans to choose from and they are updated each year and it depends on what drugs you're on or think you'll be on.