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Comment by tamyinfo | Hacker News Reader

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!)

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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.

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...

Auctions are an excellent price discovery mechanism.

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?

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