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Comment by nodesocket | Hacker News Reader

I’m self employed and literally have the cheapest (non healthcare.gov) plan I could find at $396 a month. The plan is absolute garbage with carve outs, high deductibles, limits, and caps. I fully expected if I ever really need to use it (knock on wood), they will screw me and deny claims. My premiums have nearly doubled in the last 5 years.

Seriously considering not having insurance and going cash. Any recommended plans for freelancers / solo self employed?

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A better option than going cash is a HSA through the government marketplace. It will give you tax deductions on your savings, you’ll end up paying almost everything out of pocket (same as cash), but you’ll be protected against total ruin if you need emergency care.

Don’t buy insurance outside of the marketplace. The ACA places limits on what insurers can deny, and those limits protect you from the rampant problems that existed before the ACA. I’m not sure if those protections apply to insurance purchased outside the marketplace.

I was going to say. This is probably one of those few things that Bush got somewhat right.

HSA limit is $4,300 annual, how does that protect against total ruin? That's a hospital trip in a Uber and a few tylenol.

They are probably using “HSA from the government marketplace” as shorthand for “a combination of an HSA with a HSA-eligible health plan from the state ACA marketplace”; the HSA doesn’t protect you from total ruin, thr linked high-deductible health plan should.

One emergency visit is like 10k here now. Best of luck.

As @dragonwriter said, the HSA doesn't protect you against ruin, the linked high-deductible insurance does. You use the HSA for your ordinary medical expenses and get a nice tax discount from it. The HSA is also acts as a retirement investment account.

So, if you're young with minimal healthcare needs, you can get multiple benefits:

1) High-deductible insurance that's (relatively) cheap but still protects you against financial ruin

2) After 10 years of maximum contributions, you'll have ~$10K in cash for emergencies and about $33K in retirement investment contributions.

Thanks for clarification, but I believe my private-market health insurance plan even though high deductible is not eligible for a HSA. I believe you have to use a healthcare.gov plan to be eligible for HSA which are significantly more expensive. So, not sure the benefits are there if your monthly premiums are 25-40% more expensive (HC.gov + HSA) than a private-market plan.

All health insurance plans in the US are private-market.* You may be confusing ACA-compliant plans (private insurance that's allowed to be listed on healthcare.gov and is eligible for subsidies) with non-ACA-compliant plans (not allowed to be listed on healthcare.gov, not eligible for subsidies).

Be careful about non-ACA-compliant plans. They're cheaper because they engage in sketchy behaviors that leave you without coverage when you need it.

*Well, except Medicaid, Medicare, etc.

You’re correct. I should be saying ACA compliant plans vs non-ACA instead of “private”. I have a non-ACA plan thus why I can’t have a HSA.

I've heard of co-op insurance, where self-employed people group together for better rates. No idea if it's good or not though. First google result was: https://opolis.co/insurance/

Also interesting ideas in this reddit thread https://www.reddit.com/r/HealthInsurance/comments/1hgg2q4/se..., probably skewed towards young/single people.

So the solution to healthcare for the self-employed is pansexual polygamy without the sex. Benefits without "benefits", if you will

Insurance has always been about groups of people banding together to soften emergencies. Prior to the ACA, the groups were people with the same employer, and getting insurance as an individual was prohibitively expensive and had ridiculous limits. The ACA added the ability to purchase through the marketplace and prevented the rampant denials that previously existed. I’m not sure how folks are grouped in the marketplace, but I believe it’s by zip code.

I paid for my own insurance for decades and the ACA absolutely made things better, and cheaper, for individuals seeking insurance. Not even counting the subsidies for lower incomes.

This is a structural death blow to small business and something needs to be done about it if we think it's a good thing not to live under corporate feudalism.

Would going with Direct Primary Care help? It is like concierge care in that you pay a monthly retainer to a doctor's office for unlimited access. You then supplement that with insurance with a very high deductible for major issues. DPC seems to be a growing trend among new primary care practices in the USA.

$396 (if un-subsidized) probably means you are on a bronze tier plan. And yes many of those are hot garbage. However, if you are paying that for a crap plan and getting a subsidy too, you're probably getting ripped off. Most people on healthcare.gov or a state exchange who sign up for bronze tier are getting a subsidy, so the premium is reduced to near zero in some cases. Still often a bad plan, but a cheap bad plan.

I pay ~$400 but the government kicks in ~$350 too due to my low income. Its a Silver PPO plan and not bad, though, I haven't used it for anything serious yet. The Silver plans have extra subsidies so are usually better quality than bronze.

It also can be helpful to switch insurers if the plan is bad. My insurer up until last year was once decent but has gone downhill. They are also the dominant insurer in my area. The one I switched to this year is trying to gain market share in my area, so they seem to be a better deal, the plan is more generous and has less red tape.

When I was on the marketplace, I couldn't tell much difference between the metals. I'd pick a network, all the tiers covered only the mandatory stuff as best as I could see; really same deal with all the networks, but different providers. Higher tiers had higher premiums and lower deductables... for me, I just went with bronze because premiums + out of pocket max was lowest; I'm sure there's portions of the curve where care would cost less with a higher tier, but I figured lower cost with minimal use and lower cost with maximal use is pretty good.

IMHO, health insurance makes it hard to do cost control of healthcare. Patients can't do it, because they won't know how much stuff costs until 6 months after service, so they can't really make decisions on cost. Providers can't do it either, they have even less idea of what things cost for patients, and they have an interest in providing more billable care. Insurance companies could do it, but denying care for economic reasons is hard, so they just go with denying care for beuracratic reasons; also, ACA insurers have revenue limits based on ratios to covered care, so covering more things allows them to get more revenue. Even government paid healthcare has trouble because everyone gets grumpy when they can't get all the care available.

The maximum you can make and receive any subsidy is absurdly low. I don't qualify for any government subsidies yet I'm the one actually paying real income tax.

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