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Comment by lotsofpulp | Hacker News Reader

It is for the six and seven figure heart surgery/NICU baby/cancer treatment.

Edit: My question is, is Sesame paying the doctors less, or are you actually paying $29 for a Nurse Practicioner/Physician's Assistant?

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And technically, that's what health insurance always should have been for.

Allowing insurers to step in the middle of smaller, everyday health transactions by empowering them to negotiate price fundamentally screwed up the system.

There's no reason insurance should be involved in non-catastrophic or routine pharmaceutical purchasing.

The US government does offer a massive carrot for people to choose high deductible health plans, in the form of the most tax advantaged account you can have, a Health Savings Account.

The root problem is most Americans are too poor to afford healthcare at the current prices of doctors/medicines/medical equipment/liability protection/etc, period.

Using an HSA can be a pain in the ass. On multiple occasions I’ve had to go back and forth with the provider and HSA to get an acceptable receipt. I ended up just giving up in one case because it was a small amount and not worth fighting phone reps and automated systems.

I thought the whole point of an HSA was to be used as a tax shelter. I didn't get one because it seemed way too complicated and also I don't make nearly enough money to set aside money in an HSA but that's what I remember when looking up on it a little.

I think you're not supposed to use it actually for healthcare, at least not in your young age.

I do not know why that would be difficult, I have never had an issue getting a receipt with patient name, charges, and the amount on it.

Also, the ideal way to use an HSA is to not use it. Every year, transfer the HSA funds to Fidelity, invest in VOO or whatever, and let it ride as long as you can. PDF all the receipts, and then pay yourself with tax free income when you finally need to.

> pay yourself with tax free income when you finally need to

My understanding's that direct withdraws are possible after 65, taxed as income. Does your "when you finally need to" mean only withdrawing for healthcare reasons or is there a way to transfer or withdraw without a tax hit, besides for health costs?

Yes, worst case scenario, it performs as an IRA/401k.

But pretty much everyone will incur healthcare costs as they get older, so you should be able to withdraw tax free for those. And all healthcare costs incurred by your family during your lifetime while you had an HSA are eligible for reimbursement.

Quite frankly, I do not know how auditable a 40 year old medical receipt is. Is the IRS' plan to just take everyone's word for it?

Probably yes, until they audit you. I don't think many people who want to defraud IRS do it by faking 40 year old medical receipts.

Medical expenses is a deduction category that can be itemized?

https://www.irs.gov/taxtopics/tc502

Never needed it, so don't know all the rules are, but I'd imagine the IRS gets a lot of fraud through it (since hospitals wouldn't report from their side).

But how would they audit it, if the healthcare provider has retired or deleted their records from 40+ years ago? Are healthcare providers keeping records that long?

I don't want to google the incorrect information. Can you provide a link that elaborates on this? I have an HSA (~20k right now), don't use it to invest at all, but it is investable within their system, using some preselected mutual funds. I've just been too much of a wimp to risk losing anything.

https://www.bogleheads.org/wiki/Health_savings_account

> Fidelity offers HSAs for employers and, as of November 2018, individuals.[36] Individual HSAs have no account opening or transaction fees.[37] In a favorable review of the Fidelity HSA's features, the The Finance Buff wrote: "No other HSA provider comes close to what Fidelity offers."[38]

I would go to Fidelity.com/toa and start a transfer of assets from your current HSA. If it is an employer sponsored HSA where your employer contributes to it, then leave $25 to avoid it getting closed. But every year, move the remainder to Fidelity and invest the remainder like any other IRA.

Mine has stopped even asking for a receipt. But more importantly it's a super-IRA that's the best tax reduction around.

Who's administering your HSA that you have to provide specially-formatted receipts?!

Every HSA I've had[0], I just reimbursed myself for eligible expenses[1] by transferring from the HSA to my regular bank account. That amount then gets reported on line 15 of form 8889[2] the following April. If it's not an eligible expense, that's between me and the IRS—not the bank at which my HSA is held.

[0]: I highly recommend Fidelity, for anyone reading this and thinking they need a better option.

[1]: https://www.irs.gov/instructions/i8889#en_US_2022_publink379...

[2]: https://www.irs.gov/pub/irs-pdf/f8889.pdf (PDF)

Depending on the specifics of your financial situation, age, and healthcare utilization, it can actually be in your best interest to pay more out of pocket and save your HSA money for retirement.

For these kinds of relatively low-cost interactions, the HSA is even more of the same problem as health insurance: It's for people who find paperwork to be a fun hobby.

Just tell me how much money I owe you and let me pay. When I find myself at a clinic, I tell them I don't want to use health insurance to pay. They just give me a bill and I give them money.

The ultimate root of the problem is thinking healthcare works like a bakery: if the bread is too expensive i'll go shopping elsewhere or even choose something else besides bread. This last option is basically off the table in healthcare: you either get healthcare or die. Which in the usa seems to be the options indeed.

Would those procedures cost "six and seven figures" if it wasn't for health insurance? To put another way, would the costs be so high if it wasn't for the current health insurance system, where the "consumers" are actually the health insurance companies themselves and patients like you and I have basically no power to choose, well, anything.

The prices have got to be up there. It’s taking up dozens of hours from multiple highly skilled workers at the very least. That with the use of very expensive medication and some very complicated machines adds up.

I don't know if it is insurance or the administration on both the provider and insurer sides. I have a horrible respiratory infection in western Europe, here I'd have likely died or been so overcharged I'd wish I had died. There 17 days in ICU on a ventilator and a few weeks or normal hospital recovery the total bill in 2001 was under $20K, the Euro and Dollar were almost even then so the conversion isn't important. Now if a local had needed that bed more I might have not been as lucky. This is what a well organized society can do, keep everyone under some level of free care so there is less chaos in their ER departments and that they'd have time to treat a foreigner well. If we switched to single payer the estimates are that we'd save money as a nation the first year, even with all the backlog of needed care and any transition costs. The savings would compound as preventive care started preventing more serious outcomes and things like car insurance and liability insurance would come down in cost too.

Huyterds, they don’t cost that much in Belgium though, US medical prices are out of the roof.

But how much does the Belgium gov pay to subsidize healthcare? (Just because the upfront cost is low to you, it doesn’t mean that’s the actual cost.) Is it still sustainable given the trend of retirees starting to outnumber working adults? Also how bad are the wait times to get socialized medical care?

It's cheaper for Americans to travel to Belgium, and then pay out of pocket for surgical procedures, than it is to get them done in America. And that's including the airfare and hotels too.

> how much does the Belgium gov pay to subsidize healthcare?

Belgium spends 11% of GDP on healthcare (https://ec.europa.eu/eurostat/statistics-explained/index.php...)

The US spends 18% of its GDP on healthcare: https://www.cms.gov/data-research/statistics-trends-and-repo....

> Also how bad are the wait times to get socialized medical care?

How bad are the wait times for not getting healthcare at all because your insurance doesn't cover it? Or because the associated costs will bankrupt you?

Yes. They're expensive in the US because our healthcare providers are expensive.

Middlemen can't raise the price that much; you could just go around them if so, either by not using it or by going to another country.

You haven’t been paying attention to what pE is doing. Every day medical services aren’t an international market.

You wouldn't be able to corner the market if it wasn't supply constrained (because it was already cornered by the AMA). The US doesn't accept medical degrees from other countries, has an absurd residential training program designed by a stimulant abuser, there are price floors called "certificates of need" where you can't open a hospital unless your competitors say you can, etc.

NICU baby feels so weird. Why isn't that covered by Medicare or something else? Like why isn't basic health-care for children under whatever age 18 or 16 fully covered by government? At least to certain level.

Because babies and kids do not vote. Why is Medicaid a separate thing than Medicare? Because poorer people are less likely to vote than older people.

The US is composed of very fractured tribes, that people move in and out of throughout their lives. And US politicians are tasked with keeping taxes extremely low, and services very high, and the various tribes do all they can to give disproportionately little relative to how much they benefit.

I imagine your appts/per hour go WAY up when it's a 5 minute voice chat versus occuyping a room in a physical building for an hour, having a nurse take vitals, all that ancillary stuff.

Probably the latter, buf this would frequently be the case now in other providers too. Unless you want to wait for 2 months.

The solution is to have universal catastrophic insurance for all citizens automatically, say $100k or some number. Combine that with tax-deductible health savings accounts and a competitive retail healthcare market, you find a sweet spot between universal and for-profit.

Anyone who thinks the universal model standard in Canada and the UK is actually working has a hole in their head. The solution is a combo.

It is not as easy as that because supply is heavily constrained. You need a lot more people able and willing to become doctors, nurses, people who change bedpans and clean hospital rooms, so on and so forth. Add in aging populations with fewer proportionate working age people, and the equation does not balance.

That is not something any policy change can fix until far in the future. In the short term, all that is possible is deciding who gets allocated the available healthcare.

Nurse practitioners have been allowed by states to handle more and more services. Telehealth primary care has enabled more scaling - I know because I use such a service for my whole family. I’m much, much more confident in the US to handle an influx of immigrants and aging retirees than Canada or the UK with their rigid services.

Yes, one of the ways that the limited resource of doctor time will be allocated is to simply have increasing portions of the population see people less qualified than doctors (perhaps not bad from a systems point of view if it is diagnosing conjunctivitis, but from an individual point of view, you can see where this is going.). You pay more, you get people who have met a higher standard of education/experience, e.g. concierge care and direct primary care practices.

Yes the reality is harsh. But much better than waiting 12 months to get in cancer care and then dying while you wait.

> The solution is to have universal catastrophic insurance for all citizens automatically

> It is not as easy as that because supply is heavily constrained

I don't think this argument works when the data shows 90%+ of the population has health insurance.

My assumption is that the many people, if not the majority, still avoid seeking healthcare due to a doctor visit costing a minimum of $250+. You can give everyone the $100k deductible insurance, which is great, but the issue in this thread is that a regular consultation with a doctor costs so much, that a $29 telehealth option (probably with someone less qualified than a doctor) is better.

Completely agree. I am fairly conservative in my thinking, and this is a strategy I could get behind.

You mean above $100K they pay? Per year or what? Because a $99K/year bill for ongoing treatment is still going to bankrupt people.

Considering the average family cost for insurance is $22.5k

https://www.kff.org/report-section/ehbs-2022-section-1-cost-....

It is quite feasible that redirecting all of that to a tax-free savings account could pay for itself in no time.

That much? Makes the $2600/yr that I pay sound good. I have a high deductible though ($3K). I don't know if putting $23K aside each year and not having any insurance would work for everyone... I think we should just give that money to the gov't and they should cover pretty much everything. With a pool that big I think the economics would work.

> a competitive retail healthcare market

What's a "competitive healthcare market" for diabetes? Or cancer? Or childbirth?

> Anyone who thinks the universal model standard in Canada and the UK is actually working has a hole in their head.

The UK has a population of 67 million. There are half a billion patient contacts in any given year. I've yet to hear stories like "I can't afford my insulin" or "we had a child, the bill was 200k and we were also charged for holding the baby"

One thing I've noticed about the UK is that I've had to stop reading every British author I've read in my life because they've all died young.

Some of them did manage to release statements about how much they support the NHS before dying. I'd be more impressed if they lived though.

Tolkien lived to 81. Agatha Christie 86. John La Carre 91. Jackie Collins 77. Ken Follet is 74 and still very active. Anthony Burgess 76. PD James 94.

If you're talking about Douglas Adams, he died of a massive heart attack...in California, where he'd lived for years.

So, in summary, uh wot mate?

Iain Banks (59), Pratchett (66), and I'm not letting them off for Douglas Adams yet.

Though everyone in my family in Glasgow seems to live well into their 90s.

Both Banks and Pratchett died from untreatable illnesses. Feels a bit unfair to blame the NHS.

    The United Nations World Population Prospects suggests current life expectancy in Australia in 2022 to be 83.79.

    In fact, Australia enjoys one of the highest life expectancies in the world, ranking 8th out of 60 developed countries. That’s higher than the UK (81.65) and the US (79.05).

[ quote source ] https://www.hcf.com.au/health-agenda/health-care/research-an...

[ raw data source ] https://population.un.org/wpp/

So it appears that both Australia and the UK with National Health services (named differently in AU) have greater life expectancies than the US.

Perhaps it's the authors you read?

Bertrand Russell was 97 when he died.

Medicare isn't the same type of system as the NHS. My understanding is the NHS is actually fairly rare among healthcare systems, but aside from that it has the bad luck to be run by UK politicians.

US's lifespan is not caused by lack of access to healthcare though, that is fentanyl.

> Medicare isn't the same type of system as the NHS.

True, however Australia has a tiered health care system with a very low gap to ensure that practically the entire population has access to healthcare that they can afford in addition to national bulk pharmacy deals to cap generics for the bulk of ailments that require prescription.

For all it's warts the Australian system delivers a kind of healthcare that the US system does not .. widely available affordable treatment for the bulk of medical issues.

US (general mean both sexes) life expectancy sharply dropped as COVID spread, the most that fentanyl can be accused of is the flattening of the general slow increase between 2012 and 2018 .. even that ended and was on the increase until the USofA foot gunned its handling of COVID.

[ Historic USofA ] https://population.un.org/wpp/Graphs/Probabilistic/EX/BothSe...

[ Historic Australia ] https://population.un.org/wpp/Graphs/Probabilistic/EX/BothSe...

> US's lifespan is not caused by lack of access to healthcare though, that is fentanyl.

How do people with substance use disorders stop using substances? They use healthcare, unless they're in the US where they'll using some quasi-religious abstinence-only residential programme.

The horror stories from the UK type system are more like "I had to wait 8 months for treatment" or "my medication wasn't available".

"I had to wait X times for treatment" is a very common complaint in the US on top of "I can't get treatment because my insurance doesn't cover it".

Same for "medication wasn't available": "my insurance doesn't cover the medication required".

The US literally has a video genre of "rationing of insulin to survive".

in uk, good thing is, if you do get to see the doctor, you don't have to pay anything but the tricky thing is "getting some one to see you".

on average, system is good for bottom half but system is pathetic in terms of services after paying such high taxes.

You can definitely have a competitive market for any procedure that can be scheduled. Amazon will often negotiate on behalf of their employees in order to shop around procedures (see Oklahoma Surgery Center).

The difficulty is for sudden situations like heart attacks. For these you need savings accounts and a baseline catastrophic plan.

> You can definitely have a competitive market for any procedure that can be scheduled.

You don't have unlimited fully equipped hospitals and operating rooms. You don't have unlimited heart surgeons. You don't have unlimited MRT scanners or labs doing blood tests.

In healthcare both the supply and the demand are inelastic. Market forces here work only for the most common and the most simple cases like nasal sprays and eye drops.

Hard disagree. The market exists for healthcare. The government may artificially restrict certain aspects of it but the market does respond to signals by building more facilities.

Furthermore a lot of innovation goes to increasing bandwidth of the existing doctors. See tele health.

I think you have a very limited view of what is possible.

I think you have a very rosy view of the market. And you also overestimate the supply and demand in healthcare.

This is a pretty hot take. The NHS has been run into the ground. That doesn't mean socialised healthcare is not possible. I don't look at broken old car and say "no cars work".

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