Hacker News Reader

>What was interesting is that it was our PRIVATE insurance that stalled and stalled over approving the surgery. When she switched to the MA plan, it was approved immediately.

At least one part of the scam seems to have worked here: you use "private" to describe your old plan, to contrast with MA. In reality, both your old and new plans are private.

Well, yes and no. The MA plan is privately operated, but funded in part by public dollars.

To the article's point, the problem arises when private insurers arbitrage the services those public dollars are supposed to be going toward.

I'm fully aware that both plans are private.

Is $85k annual premiums a typo? That's about an order of magnitude higher than my expectations would have been for near retirement age health care.

No, the Affordable Care Act restricts premiums for the most costly insureds (age 64) to 3x the least costly insureds (age ~21).

So the health insurance premiums you see for ACA compliant health plans are very subsidized by younger plan members, but this subsidy ends starting age 65.

In other words, expected healthcare costs for old people are massive.

Edit: also, annual premiums for age 64 are around $20k to $25k, and that is with the subsidy from younger plan members.

> this subsidy ends starting age 65

As I understand it, the subsidy ends at 65 because at that point the "affordable care" option is Medicare. Thus, there's less motivation to subsidize private insurance.

It is not a health care system, it's a sick and dying payment plan system. They definitely don't want you to die because then you stop paying into the system. But they don't care about quality of life, they want to pay out as little as possible.

> No, the Affordable Care Act restricts premiums for the most costly insureds (age 64) to 3x the least costly insureds (age ~21).

> Edit: also, annual premiums for age 64 are around $20k to $25k, and that is with the subsidy from younger plan members.

This implies premiums for the least costly group are $6500-8000/year, which is substantially more than the price I pay. I dont have employer-provided healthcare, nor a marketplace plan, I pay the cash price for individuals without any subsidy. And I haven't been 21 in decades.

I was assuming pricing for gold level plans (health plan covers 80% of costs).

https://www.nj.gov/dobi/division_insurance/ihcseh/ihcrates20...

See Omnia BCBS Gold at $731 per month for age 21 to 24. Omnia BCBS Silver HSA would be $423 per month.

Silver plans cover 70% of expected costs, but at age 64, I assume most would want the lower deductible and oop max of a gold plan. Even the insurance company is calculating it needs to charge $300 more per month for that extra 10% of expected healthcare costs they would have to pick up with a gold plan versus a silver.

As another datapoint, my family of four gold HSA BCBS plan is running around $33k per year in premiums for 2 adults in their 30s and 2 toddlers.

The whole point of insurance is that sick get paid from money of healthy.

The problem with health insurance is the healthy know who they are and the unhealthy know who they are, so you have massive adverse selection.

Hence, the ACA rule (now defunct per 2017 TCJA) to require everyone to buy health insurance.

> Hence, the ACA rule (now defunct per 2017 TCJA) to require everyone to buy health insurance.

Technically the rule still exists, but the penalty is now $0. (IANAL.)

That call is because Health Plans are rated by CMS on if you get certain types of services, or skip them. By skipping those checkups you are reducing your health insurance plans STARS rating, which means they lose significant monies from the government. Each .1 of a start equals around 1 million US in government funding to a health plan doing MA.

Wellness calls are also a starting point for shared savings and other value-based contracts

Do you have some sort of special private insurance? 85k /yr is unbelievable to me.

Sorry for the lack of an immediate response.

Yes, both of us are over 65.

The insurance was a high end PPO with no lifetime max and $20 copay. My wife is a cancer survivor, and I take drugs to minimize my cancer risk.

Additionally, the premium growth rate accelerated considerably after 65.

We did not actually pay $85k for a year but that was going to be the price. We were told what the new premiums would be, and instead of paying the $85k (paid monthly in installments), I switched immediately to the MA plan and told my wife, let's see how this works out. She held on for six months, then ran into the stalling, and then it took her another six months before she could get on the same MA plan.

The reason our MA plan works is that it's offered by the same medical center we happened to use 100% of the time on our previous insurance. So we didn't need to switch any physicians.

Regarding predatory MA's, my wife's surgeon, who was trying to get the approval for her surgery, told her, "This isn't going anywhere, you're past the time to switch to medicare, get an MA. However, be sure you avoid these companies."

Yes, we switched to medicare late, and we are reminded of that every month when we pay the penalty.

(I should mention our current MA plan is a HMO, not a PPO -- my typo.)

> Yes, we switched to medicare late, and we are reminded of that every month when we pay the penalty.

Doesn't the high-end PPO count as creditable coverage to avoid the penalty?

Hmm. It wasn't that we didn't have coverage -- that's a separate penalty instilled by the ACA.

It was that, after 65, you're supposed to be on Medicare. Period. And they way they enforce it is they charge you extra when you do finally get on it (presumably after your private insurance becomes just too expensive...)

I'd be delighted to be proven wrong, but we were told repeatedly, including by Medicare itself, we Shall Be Penalized.

> It was that, after 65, you're supposed to be on Medicare. Period. And they way they enforce it is they charge you extra when you do finally get on it (presumably after your private insurance becomes just too expensive...)

https://www.medicare.gov/basics/costs/medicare-costs/avoid-p...

"It’s important to sign up for Medicare coverage during your Initial Enrollment Period, unless you have other coverage that’s similar in value to Medicare (like from an employer). If you don’t, you may have to pay an extra amount, called a late enrollment penalty."

The penalty is intended to stop people from saving money by forgoing insurance entirely, then hopping on when they get sick. Ask your insurer if they can provide a certificate of creditable coverage for the period. I wonder if a quick consult with a lawyer with relevant experience would be of use.

There is a late enrollment penalty, and it can be substantial (ie paid for the remainder of your lifetime).

https://www.medicare.gov/basics/costs/medicare-costs/avoid-p...

> I take drugs to minimize my cancer risk.

What is this about?

I take laetrile via raw bitter apricot seeds, and generally avoid sugar and avoid many carbohydrates.

Look up Barrett's Esophagus and the recommended treatment for it.

I wonder if 65+ health insurance plans are allowed to price insurance based on the insured’s health, since the Affordable Care Act pricing rules only applies up to age 64.

If so, I can see someone with chronic ailments with high probability of things like heart attack, stroke, and other high cost events cause a premium that high.

You don't stay on private insurance after 65 in the US. You go on Medicare.

85K per year is unbelievable and the OP isn't responding.

See above.

Thanks. Yeah, big penalty of you don’t switch to Medicare.

Being old is one of those preexisting conditions insurance probably doesn't like.

It’s utterly incredible.

A gold plated plan where I live for a 65 year old couple who smoke and have a child is about US$10k for a year.

https://join.southerncross.co.nz/quote/step2

I was paying $2700/month 13 years ago for a higher-end family plan when I owned my own business. I'm not surprised then, if I paid $32k/year 13 years ago, that some plan today might be $85k. US health insurance is indeed crazy expensive. You will see some people paying less, but that's because large businesses subsidize costs, some of them only use the big insurance companies for administration, and pool their own funds to pay from. What individual people pay varies wildly.

Socialised healthcare is not a utopian dream and is riddled with problems. However I can’t see how costs of even a fraction of those cited here don’t motivate people to demand change. A heart bypass graft, cancer treatment or a joint replacement every year could be paid for and there would be cash left over (but not in the US obviously).

That's more than the median income in the US

49 years old, married (same age), six kids, and my ACA plan in my area is $3k/mo for bronze, and $4 to $5k/mo for gold, with $10k deductibles. We have paid cash for five of our six kids.

Thankfully, my spouse and I and kids are healthy, but that's so much money that if I'd carried insurance when building my startup, we wouldn't have a startup today.

The ACA kills the American Dream. One possible fix is that I should be able to buy any insurance I want from anywhere in the country I want; this would mean real competition; currently, I can only buy from a few providers that operate in my local part of my (large) state.

Anyway, I find $85k shocking, but not that shocking given that I'm looking at $60k/year (not including deductibles) at a much younger age. (When I first started in my career, that was more than I made in a year!)

Once I had commercial insurance from out of state. A doctor visit was covered as in-network and all was well. But they did a lab. The lab was in a hospital 100 miles away. The insurance said "ok you have to pay the deductible for this lab", which is like fine, how much can a single lab cost? Single urine sample, easy.

Well didn't you know, the hospital did NOT have a negotiated in-network rate with the insurance company. The hospital insisted that we owed them $650, because that was our deductible.

Other in-state insurance companies cut those stupid bills down by 95-97% with 'allowed amounts', but the out of state insurance didn't have that negotiated rate with them.

In the end I called the hospital and told them I knew from other insurance bills how much it should have cost, and that we can just not pay, and ignoring collectors is easy. I offered them $50 (for a $20-30 lab) and they send me a new bill "writing off" the other $600.

So, you want out of state insurance, well, be careful what you wish for, it just might come true, and you may not like it at all.

Why isn't stuff like this covered by price gouging laws?

Because as a whole, this industry can't actually determine what fair pricing is. There are too many perverse incentives concurrently in play for anyone to realistically make sense of things.

Auctions are an excellent price discovery mechanism.

We can easily look north to Canada or east to Japan for context on what services and procedures should cost.

Japan has the health insurers and medical providers engage in structured fee negotiations and standardize prices in systems.

There is no reason in the USA that injecting a Covid vaccine should cost $42.70, while injecting a Mpox vaccine should cost a different price of $67 when self paying at Kaiser. Meanwhile, insurers pay significantly less than this for the same service.

https://wagner.nyu.edu/files/faculty/publications/hlthaff.20...

The current version of the ACA (i.e. as subsequently amended) limits your premiums to 8.2% of your household AGI were you to sign up for the 2nd most costly Silver plan in your state.

So no, you're not paying $60k a year unless you have a shockingly high AGI.

You need to look into federal subsidies. You can get them either through the relevant (federal|state) marketplace or as refunds on your federal tax bill.

The subsidies reduced my wife & I (late 50's, New Mexico) premiums by more than 50%.

This type of experience heavily depends on which state one is in!

Not really. The subsidies are provided by the federal, not the state government. If your state isn't making it easy to access them, then just claim them on your federal tax return.

The subsidies are provided by the other taxpayers.

> You need to look into federal subsidies. You can get them either through the relevant (federal|state) marketplace or as refunds on your federal tax bill.

Wondering why I'm just now hearing of this -- can you recall any focused search terms, or web links?

They should automatically get applied on the healthcare.gov site or your states local version. They only apply to the silver level plans, which is why the GGP post talking only about bronze and gold plans quoted such high numbers. Those plans completely skip the subsidies.

That's why the websites ask you your income levels.

It also affects your max out of pocket expenses for the year (total limit of deductibles and copays before insurance has to cover it all)

>They only apply to the silver level plans,

This is false.

They are computed from a given state's 2nd-most expensive silver plan, but they apply to all plans. I am on a gold plan and receive them; last year I was on bronze and received them.

The subsidies have no impact on deductibles or OOP - that is determined by the insurance plan itself.

I looked it up, and we are both correct. There is a premium subsidy based on the silver plan but that applies to any plan and a deductibles/OOP pocket subsidy that only applies to the silver plan. They have different qualification levels. It seems the deductibles level has a pretty low income cutoff, and the premium subsidy has changed a lot over COVID (to the point where the income limit was removed, at least temporarily).

IRS Form 8962 Premium tax credit

The Republicans are generally opposed to these, and they are not permanent.

I would note that I am also opposed to them in principle - I do not like a system that allows insurance companies to continue to overcharge and under-provide by limiting what consumers actually pay (the rest being paid by the government). However, in 2023, this seems to be the best the USA can come up with.

The ACA is what allows small business and individuals to buy insurance in the first place. Without ACA, you would be subject to benefit maximums, pre existing coverage denials, and no requirement that insurance cover proven treatments for your ailment.

> One possible fix is that I should be able to buy any insurance I want from anywhere in the country I want; this would mean real competition; currently, I can only buy from a few providers that operate in my local part of my (large) state.

If anything I think we'd see more consolidation and fewer choices if people could buy across state lines. If enough people in state A buy from a provider in state B, state A's providers could very well close up shop.

Why would you want out of state insurance? You want to drive 500 miles to get to an in network doctor?

So American insurance is bad but there is no way you are paying well above the median income of America per year on just premiums.

Want to see my bills? I don't shred paperwork until 3 years go by, so they're around somewhere. We were able to afford it, though it did take a good chunk of our retirement income away. And it was less in previous years.

The goal was to protect against really bad things happening that would result in hospital bills of a million or more -- and screw up our retirement completely.

(We had private insurance because both of us retired early, and the early premiums were reasonable. Also, my wife had heard that Medicare was a bad insurance to have, and didn't want to take the risk she couldn't get the care she might need.)

>Want to see my bills?

I wouldn’t have asked, but since you are offering, yes.

(With your personal information redacted, of course.)

https://imgbox.com/OwGh0xwd . That's my wife's. Mine is buried in a box in the garage and it's staying there. I am ~four years older than her so my premiums were noticeably higher.

Please let me know if I failed to anonymize the image.

Are they immediately approving the surgery so you stay on for a year and then are hooked? How long from approval until the procedure takes place? Will they deny future, follow up or other, procedures down the road?

As I mentioned elsewhere, the MA covers the same health center we've used for 40+ years as a HMO. I've had no issues with getting stuff approved. Her surgery was approved in less than a month and it's scheduled in a month. She'll need another later this year, but approval of that must wait until we see how this one turns out.

There's always the possibility the MA will stall. If it's egregious, we'll need to look into legal alternatives.

She's probably already high risk, so the visit would be an additional cost to the insurance company.

> (That stalling finally motivated my wife to make the switch out of the private insurance.)

They would have known that you had the option of going elsewhere. The stalling looks strategic and, unfortunately, successful.

Indeed. Got to play the hand dealt.