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Comment by mancerayder | Hacker News Reader

The problem in the US is healthcare.

In my state the health insurance marketplace only has 'bronze' plans that are in-network only (with mediocre options) and high deductibles, it costs 6-800 for individual and close to 1500-2k for a family.

The United States has rigged the employment market to forever keep you dependent on a corporate employer until retirement. Now these same companies are taking away remote work, forcing people close to expensive and increasingly annoying cities like New York City, where the median one bedroom is one million to buy.

So, for giving your time to a company, your reward is never being able to be fully independent without huge risk. Healthcare is the Company Store Voucher of the modern era.

Has anyone else considered leaving the United States long before retirement age?

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In Canada you just die before you get a family doctor :)

Last time I went to the ER, the wait was 10h for kidney stones. Thankfully I passed out for 4h in the waiting room from the pain and the stones passed by the time I saw a doctor, so all they did was send me home.

My family doctor died 10 years ago and I'm still on a list.

If you're from Ontario, you might want to call the health care connect people... I was on a list for roughly a year and a half, then out of the blue I got 2 referrals in 2 months (the first one never called me)... while the one I got isn't a typical family doctor, just having someone to help me with my needs is a start...

Then you merely have unreasonably long waits for specialists and testing, and then more waiting for treatment!

It's super cool when you have to go through a chain of several specialists while dialing in on the problem. Especially when the default diagnosis is typically: "it's probably nothing, wait six weeks and make another appointment if it's still an issue...", lol.

In the US, 70-80% of the time they just send people with unpassed kidney stones home from the ER. With painkillers and a giant bill.

At least you get the painkillers. Not sure what else they'd really do for non-emergent kidney stones anyway. Painkillers is probably the best you can hope for, and getting them quickly and sent home sounds like a great outcome to me.

Well, it's not instant in the US either. All ERs triage and kidney stones are low priority. I'm not sure how long is standard, but even if admission took less than an hour, you're still low in the MD's priority.

A friend just had them and he was in the hospital a few hrs while they IV flushed him with some chemical magic that supposedly helped dissolve them. I think the bill with insurance was 250.

Happened to me in Canada too, minus the painkillers.

Can't find a primary care doctor in the US either, so we're even.

Have you tried calling doctors directly?

Sometimes there are information gaps between their capacity and the provincial bureaucracy.

Surprised you weren't offered MAID.

Do you really need a family doctor? I've never had one. Whenever I've had a non-emergency issue (in BC), I've just gone to a walk-in clinic where they've either helped me on the spot or referred me to a specialist. I can definitely see why having a family doctor might be a more pleasant overall experience, but as far as I understand in Canada it's practically a pipe dream.

There are no more walk/in clinics in Canada , you have to make an appointment and they will give you one based on the availability and your issue.. also when you see a specialist, they will now require a primary doctor source who will get CC’d on your test results , etc.

This is... incredible if true. How can this be? I looked up the old walk-in I used to go to (haven't needed it in a while) and it still shows up on maps but the most recent reviews says they "don't do walk-ins anymore". In which case I don't really understand what they do. Genuinely curious about the situation if anyone cares to chime in.

They're basically stand ins for family doctors. About 17% of Canadians no longer have access to primary care physicians and have to rely on either walk ins, urgent care, or the emergency room.

COVID was a big one; lot of doctors decided to just retire at once. But primary care physicians are facing issues of the workforce aging out. I think about 18,000 of the 48,000 primary care physicians are set to retire by 2030, but we only add in about 1600 new primary care physicians a year. So by we'll be down by 8400 primary care physicians by 2030 and then however many years it takes to back fill to 2024 levels.

Meanwhile Canada's increased it's population from 37 million in 2019 to 41 million in 2024, with projections of us hitting around 43 to 44 million by 2030.

Most of it stems from the fact that lot of doctors don't want to be primary care physicians. The hours aren't terrible but the pay is low good compared to their specialist care counterparts, and they have far more administrative overhead then any other specialty. And often the work is miserable and thankless. I can't remember who said it but IIRC family doctors have the highest burn out rate out of all physicians.

This is all third hand information so take it for what it's worth, and I'm assuming that I've got an overly simplified view of the issue. Someone in the medical field could probably answer better then me.

My brother (Australian) spent some time in Canada and was able to see a doctor straight away and really cheaply a bunch of times, and visited the hospital once with a nasty foot injury with no dramas. It seemed like a pretty good system.

I remember contrasting that with my US experience at the same time, where a 10 minute consult with a doctor cost 600USD. I had a really obvious ear infection, just needed some antibiotics, but he must have seen me as a cash-cow and ordered a ton of unrelated blood tests that were pointless since I was flying out the next day. I walked away feeling like I'd been scammed.

(In Australia a doctor's visit is under 30USD, blood tests don't cost much either)

Everything is a distribution. Most Canadians spend 6h+ waiting for a doctor in the ER, and 20% of Canadians don't have access to a family doctor.

Your brother was very lucky, or this is fake.

This entire thread makes me think you guys over there in the north-American continent are living in literal hell. And I'm not even saying this from a "first world" European country. I'm saying this from a so-called "shithole" country at the bottom of Africa, South Africa to be precise. The last thing I had to worry about wrt my medical was whether or not I was using all my "benefits". The deductible (or excess) is basically peanuts (or zero) for most things, and I have so far in my entire adult life never had to pay a deductible. I get a doctor's appointment at a moments notice, ER rooms are practically empty and really just 24-hour doctor's rooms with access to hospital equipment, pay for nothing out of my pocket, they cover all my meds, they cover my entire hospital stay, I wait for at-most weeks for certain specialists (that are all leaving the country btw, due to government), and never worry that medical bills will bankrupt me.

Of course, as with most things, government in South Africa is basically jealous of private medical insurance here and is trying to destroy it because public healthcare is a failure here. We really need to add a third item to this list: Nothing in life is certain, except for death, taxes and the government fucking up everything it touches.

Does Canada just have a lack of doctors? What’s up with that?

Brain drain to the US like other professions.

Being your own employer is the only way to take charge of this.

Platforms like Gusto, etc. make it so even small businesses can offer benefits and insurance like bigger companies do.

I went though various big and small employers plans, several states' exchanges, and none were nearly as good as doing the legwork to get benefits setup for my own company. Now I choose.

How do the costs pencil out on that, if you are signing up with Gusto etc. only for access to the health care plans? Presumably you need some minimum payroll or something?

Yes, even of you are a one person company you need to pay yourself through some sort of payroll service so that you stay compliant with all the regulations and pay things like disability, various taxes, etc. So you already need them, or similar, to handle that stuff.

The minimum payroll is defined by the minimum wage in your local area, keep in mind you can also choose how many hours you work.

This sounds like one hell of a hack! Can you go into a bit more detail about how you have it set up?

Someday I'll write a blog post about it. Feel free to reach out to me, contact info is in my bio. I'll be happy to share anything you'd be interested in.

This seems like an incredibly useful piece of information to anyone who doesn't have trad employment in the US. I found on Gusto's site info about how you can write off your insurance costs if you meet certain criteria. Is the benefit this, or something else?

Yes, theyre deductable for any employer, this is no different. Lots of benefits including this. It gives you the same power and security a employer plan does, because it is. In my experience the marketplaces and insurance from them can be a minefield needing navigation.

In some states the insurance group policy won't be available for a one person LLC, and there's no option direct from the health insurance companies, so all that remains is the state marketplace. I tried. I ended up signing up with an agency that basically put me as a W2 employee and took a fee, so I could use their so-so but better networked group insurance.

Is Gusto for stuff like that? Single member LLCs?

Yes, that's exactly what's it's for, also bigger companies. For smaller ones they sort of bundle you in with other small companies for the insurance, is my understanding. You may not have as many options, but they're better in the same ways an employer plan is, because they are one.

This may vary by state, but in Washington my broker tells me that a one-person LLC can work, if it elects to be taxed as a corporation so it can issue that person a W-2. Which accountants hate because of the potential extra taxes, but as she says, "my job is to get you health insurance, not reduce your taxes".

That's for a C Corp, check out S Corps.

I disagree, I think it's there job to help you reduce your taxes, if they're able to do so legally. I'd look for accountants who think so too.

>Being your own employer is the only way to take charge of this.

One step further, being your own doctor when ever possible is even better. Bring out the rusty knife for surgery, a club for anesthesia etc. most surgeries are not rocket science.

I'm trying to figure this comment out. What point are you trying to make?

Even if you had all the money in the world, the medical system is very inadequate, for a variety of reasons. If you find a doctor that is competent AND conscientious, good for you, else you have to fend for yourself. Philosophically I'm an anarchist of sorts, and I believe that doctors should not have monopoly on practicing medicine. So if you can get away with doing safe medicine, be it pills or surgery, go for it.

I've been designing medical devices , complicated ones like surgical robots and artificial hearts.

Trust me, you want modern medicine, the kind that comes from factories and hospitals. Not what you can cook up in your backyard.

Modern medicine is truly magical, don't let anyone tell you otherwise. We just need to make sure it doesn't bankrupt us to get it.

>Modern medicine is truly magical,

Assuming that you have done your homework and that you are right. ( a lot of especially young people think that things are magical now, while IMO some things have regressed) .

>We just need to make sure it doesn't bankrupt us to get it.

Why shouldn't a motivated/intelligent layman try and get hold of those devices and learn them? Yes things can go wrong, but what _real_ suggestions you have for people to get procedures done, safely AND reasonably priced?

Things have not regressed. Have you driven in a modern car? Flown in a modern plane?

"Why shouldn't a motivated/intelligent layman try and get hold of those devices and learn them?"

Why don you buy a typewriter and write Shakespeare?

You really just assume that you, untrained and unexperienced would be better than a trained professional? You would really cut open your partner or child, cut out a section of their bowels, sew them back together, and know all the right drugs to give and have the half million dollar anesthesia machine? Do you have the MRI machine you need to diagnose this?

It's the same reason we don't just let anyone work on airliners.

Someone who thinks they can do this is dangerous, and borderline psychopath. I'd encourage them to watch one live surgury first. Saying you can fo something like this without even seeing it once is why this shows too much unfounded confidence. Yikes.

>Someone who thinks they can do this is dangerous, and borderline psychopath.

Can tell right away that you aren't too bright. It's attitude like that that gives rise to guilds.

"...gives rise to guilds"

Are you a barbarian from the middle ages?

I'm in Illinois, my bronze marketplace plan was $247/mo this year, and the coverage was good (for what I used at least). 2025 plans look to be going up $50/mo or so which is annoying. Still a good chunk to have to pay, but nowhere near as bad as your situation.

Makes me curious how much marketplace costs vary per state?

In any case, as another person pointed out, the ACA plans also provide very high premium credits for low income households, covering up to ~80% of the costs (from what I've seen). But this also varies by state, I think.

> Has anyone else considered leaving the United States long before retirement age?

Yes. I'm American but was born in a small country in Eastern Europe. I was planning on moving back during the pandemic, however I was presented with some job prospects I couldn't reject and my move was delayed. But I do plan on retiring in my hometown within two years. There is universal healthcare which sucks for the most part, but private insurance is extremely cheap (compared to the US) and I could retire more than comfortably with my current nw. And by 'retire' I don't mean stop working, I mean I'm going to work on whatever I want.

And to your original point about healthcare, it is the absolute single reason for why I did not take any sabbaticals or long term leave even while burned out, for my insomnia during layoff seasons and generally for my job related stress.

The bronze plans are basically catastrophic insurance, not preventative care. If you want that you have to take it into your own hands in the USA; eat right, exercise, do the annual checkup Mine paid out when I had an appendix close to exploding and several days in the hospital. Of course I paid the deductible which was $6500, however the remaining portion would have put a large dent in my retirement fund, but thanks to the “bronze” plan, I was fine. So what is the risk for me?

ACA plans would be free / fully subsidized in that circumstance.

I did. Healthcare was a big part of that decision. My older siblings have been through hell both medically and financially because of the US healthcare system.

I decided to learn from their experiences and GTFO while I could. I miss my family and friends dearly, but it’s a massive relief (and privilege) to be able to get the care I need and not worry about whether the cost is going to bankrupt me.

Where did you end up going? I have some savings and would like to retire early, and getting health insurance is an impediment to that. Need somewhere that doesn’t require a work visa and is a good place to raise a family. I have enough to do it in the US but would be happy to consider alternatives.

To Portugal. If you have enough assets to retire in the US then you probably qualify for the passive income visa.

It’s not all smooth sailing, though. The immigration agency here (AIMA) currently has 300,000 cases in the queue. It’s so difficult to get an appointment that people are making hundreds of calls per day, standing in queues for hours only to not be seen, and filing lawsuits.

Most people here make about €1200/mo and there’s a severe housing crisis that I have contributed to with my presence. The influx of people like me with vastly higher purchasing power is creating resentment: the far-right party quadrupled (5% -> 20%) their seats in parliament by running against immigration.

Having said that, I do love it here. I’ve been considering blogging about my experience since there’s a dearth of clear-eyed information from real people who moved to Portugal and aren’t selling something.

Anyhow, I’m happy to share more info and resources with anyone who wants to learn more. Please feel free to reach out - my contact info is in my profile.

Thanks for sharing your experience. And thanks for acknowledging your part in "the problem" -- truly, a lot of people in your position e.g. immigrate, and then try to pull the ladder up after them.

How's the healthcare?

I have Portuguese friends who relocated to the US (for the salary, rest assured they own homes there to go back to). They're saying there are waits and quality issues.

I can’t speak to the public system. My visa requires me to carry private insurance, so I have only used the private system.

It’s a breath of fresh air. I’ve had to wait a week or two here and there for exams and tests, sure. My preferred hospital system has a great app where I can book doctor appointments (€15) and see results as soon as they’re available. The system knows what my copay is and I pay it on my way home. That’s the end of it; there are no inscrutable bills in the mail months later for hundreds or thousands.

Here’s an example: due to family history, my doctor recommended an MRI. When she saw my horrified face she told me not to worry. I booked it, got a text from my insurance company a few days later with the approval, and had the exam a week after that. The results were available in the app soon after, including the raw images (not that I have the training to interpret them).

My copay for the MRI was €50. I pay €80/mo for the best insurance available. I’ve never had a claim denial and have never interacted with my insurance company.

My friends have successfully relied on Medicaid during financial hardships + unemployment. At least in NYC, the Medicaid plans are quite decent.

Also, for those who require plans similar to the one previously provided, COBRA (18 months) is decent -- expensive but presumably less expensive than "equivalent" in the marketplace if we're talking about a good corporate plan.

18 months + 18 months in NY State for a total of 36

Just that COBRA costs quite a lot.

in CA if you make less income than the minimum (like $18.5k as a single person) you are put onto the free Medi-Cal plan. so thats nice. :)

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