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Comment by magicalhippo | Hacker News Reader

Relative recently had their baby come several months early. The baby needed intensive care for a couple of months, and breathing support (CPAP) for another two. Mom lived at the hospital hotel for the duration.

Baby got regular inspections of the heart, lungs and eyes (too much oxygen in the blood can lead to problems with the cornea or something), including after checkout.

They got billed exactly zero.

Both parents even got full pay during the hospital stay, so didn't have to worry about the economy.

Ok, so I pay a fair bit of taxes here in Norway, and some of it is used on stupid stuff. But overall I like knowing my life won't be ruined because of some random event forced me into insolvency.

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A lot of folks are looking at the higher US comp but aren't correctly pricing in the long-term risk.

You can be fine for years, but a single, major medical event can zero out those salary gains and lead directly to bankruptcy. It's a systemic flaw that isn't obvious until it's your turn to deal with it.

If one lives in a state like CA, the taxes (income, sales, etc) basically are equal to that of Norway/etc. The downside, we don't get any real benefit from those taxes paid out.

I know of Indian immigrants who suffered for decades/years on H1B, endless anxiety and tensions, eventually make it to GC, then a passport.

Then all of a sudden fall ill, lose everything and return back to India.

People keep forgetting the US society is a giant stack/pyramid ranking system, the structure keeps getting narrow as you move upwards. You get pushed off the sides, in the ever narrowing funnel, and you need increasing levels of luck at every level to survive.

BTW, this is not just with regards to health care. You could lose your job, suffer from ageism. Lose your home, run out of money. A million different things can happen, that can cause the above said phenomenon.

You can use the difference in comp to buy a Cadillac level plan with zero deductible, zero out of pocket max. You won’t be going bankrupt.

This helps with the denials how exactly?

You can pay a lot of money in premiums, have a $0 deductible, and now OoP maximum, and still end up having claims denied.

Do you think countries with even the most coveted universal healthcare just approve everything blindly?

Should everyone (anyone?) receive monoclonal antibodies, gene therapies, biologic medications? What criteria should be used to make these determinations?

Everything? No. But routine stuff will NEVER be denied. If your doctor thinks you need a scan, you're getting the scan. I have quite literally NEVER heard of someone in my country (Australia) going bankrupt from medical bills. It can happen but the rate is so low it's not something anyone ever worries about happening to them.

Routine stuff is never denied in the US either. I've never had one thing denied ever and I even have a weird condition that requires expensive testing to diagnose and even more expensive treatment (narcolepsy). The insurance companies will throw up annoying bureaucracy like prior authorizations, and made me switch medication to generic when it came out (reasonable) and then back from the generic to another brand name when it came out (WTF??), but never actually a denial.

Never denied eh? Interesting.

I had an MRI denied for a partial pectoral rupture. Which was a routine diagnostic as a precursor to open shoulder surgery to determine the extent and location of the rupture to figure out if surgery was absolutely necessary and to prep a viable surgical plan.

I had to fight the insurance company with the assistance of both my surgical and non-surgical sports medicine doctors.

The good news though appears to be that I imagined the entire thing, because denials for routine things never happen.

Gemini states that an ultrasound is just as good for diagnosis as an MRI and is much cheaper. Could it be that the denial was correct and the mistake was from your doctor ordering a less cost effective diagnostic test, not from the insurance company?

And from my personal experience with narcolepsy, AI is a much better doctor than most human doctors.

Odd that your experience would be so different from mine. I routinely experience denials.

To give an example, about 60 to 80% of the time, when I visit the dentist for a regular cleaning the charge is denied and I have to submit additional paperwork to convince them to pay it. I can't think of any more simple and basic procedure than that.

I have no idea why your experience with healthcare in the US is so much better, but I can assure you that there are many people whose experience is more like mine.

Dental is an entirely different system: dental insurance isn't actually insurance.

I am in 100% agreement with you about dental insurance, but that's a completely separate system.

> Do you think countries with even the most coveted universal healthcare just approve everything blindly?

Yes. Everything that they are trained and able to do here, is covered by the national insurance, at least where I live.

We never even have to explicitly ask them to approve anything, it's all automatic. You don't see the bill.

You might have to pay the difference for "nonessential upgrades", like a plastic cast instead of a normal one when you break your arm. Had to pay 5.00 EUR for that and it was the only time I had to pay out of pocket in my entire life.

Which country do you live in that pays for gene therapies or other biologics?

I love that you're thinking this is what USA insurance companies are denying, not simple diagnostics / medications that save lives.

The point is that there's a value judgment being made somewhere - who should be the arbiter and why?

Diagnostics aren't free, either: many (most?) countries do not have anything remotely resembling the private offerings that Quest Diagnostics and Labcorp provide (breadth of tests, 3+ different methodologies for some tests, etc.)

> You might have to pay the difference for "nonessential upgrades"

This is exactly what happens in the US. It's just that in your case the nonessential upgrade is a $5 cast. Sometimes the nonessential upgrade is an expensive surgery. My grandfather had heart surgery at 86 shortly before he died. My relatives went to 3 surgeons who all refused to perform surgery on the grounds that he was too old and frail for the procedure. Then they went to a fourth who agreed to perform it. The first three doctors were right, and he died a few months later. The insurance company quite correctly denied the claim and my family ended up fighting them over a bill for open heart surgery north of $50,000.

Your government wouldn't (and shouldn't) have paid for that surgery either. I think the real difference is that since you have a government system, that in your country that unnecessary surgery just never would have happened in the first place. I will admit this is a more efficient system, but it is no different in that there is a cost benefit analysis being done over what gets paid for and what doesn't whether you see it happening or not.

> Should everyone (anyone?) receive monoclonal antibodies, gene therapies, biologic medications? What criteria should be used to make these determinations?

Yes, if that's an indicated and effective treatment.

Do you think people should just be left to die if they can't pony up the dough in the hospital? Oh, your card's declined, no oncology ward for you?

Where is the limit to how much money is expended on one person?

What if they have a 99% likelihood of death, are unlimited funds expended in this case?

What if there's a shortage on drugs - who should get the limited supply available?

Which country with public health options pays for biologic medications or similar patient-tailored solutions?

> Where is the limit to how much money is expended on one person?

It depends on what would be an effective and indicated treatment.

> What if they have a 99% likelihood of death, are unlimited funds expended in this case?

Then treatment would neither be effective nor indicated. But if it was your parent, your child, your granny, wouldn't you rather they at least try?

> What if there's a shortage on drugs - who should get the limited supply available?

The people for whom treatment is most likely to be effective

> Which country with public health options pays for biologic medications or similar patient-tailored solutions?

The UK, for a start.

Avoid UHC and that is mitigated significantly. I’ve never had a claim denied by BCBS.

I realize some people are stuck with UHC. I’d turn down a job unless it was perfect in every other way and paid extremely well if they only had UHC plans.

Does such a thing exist these days? If so I can't find it.

More importantly, it doesn't solve the real problem. You're still subject to the same system. Fighting for prior authorizations, staying in-network, and navigating all the other administrative friction.

More than likely they'd find a way to make you go bankrupt rather than pay up. That or deny till you die.

My company offers us a range of plans, and one of them is always the zero deductible zero out of pocket max policy. More popular with those that have chronic conditions, the premiums are fairly steep.

I’m on the cheapest plan my company negotiated and my premiums are basically zero, because I’m young enough that most years I don’t spend more than a thousand bucks on health care (for me and my kids). Couple years ago I did hit the out of pocket max, though, and they did indeed cover everything from that point at 100%. I would never have gone bankrupt.

In my experience (lately), the cost difference between a zero deductible plan and the high deductible plan is about the out-of-pocket max of the latter. Pretty much a wash.

So high deductible it is! Only met the out of pocket max once and it was glorious.

Before Obama, the zero deductible plans were only slightly more expensive than the high deductible plans. (Just an observation)

Seems crazy I was able to make an appointment directly with a specialist and only pay the copay back then…

I'd much rather not have every part of my society for sale to someone with infinitely deeper pockets.

We're not the customers of healthcare, insurance, mortgages, etc. The planet's wealthiest pensioners are. No difference in comp is going to make that work out best for you.

Also, the existence of Cadillac plans implies that someone in our government doesn't believe the population at large should be receiving world-class care. It's like when Senator Biden had two cranial aneurysms, had top surgeons flown in on taxpayer dime, then fought against universal healthcare.

We're all already paying for the best healthcare in the world, just not for us.

Horrible system.

You can be a small business owner, employer and (low) multimillionaire, and still have it go down the drain via an accident, illness or disability that affects you and/or your family. Over time, disabilities can cost millions of dollars. Surviving a heart attack can cost hundreds of thousands to a million dollars. Long-term care insurance can still deny coverage based on pre-existing conditions, and long-term care is very expensive.

This is why insurance plans have out of pocket maximums. To prevent this exact issue.

We can say whether those maximums are still too high (some really are), but the mechanism is there.

The real issue is that most people don't have a rainy day fund to deal with such emergencies. And that they are too expensive anyway.

There are 2 concepts you should always keep in mind.

1. Always avoid the hospital unless you are literally dying. Surgery centers are owned by doctors who will negotiate a fixed fee, because there's someone to negotiate with (unlike Hospitals which run on the CYA principle). Also, most doctors can do procedures in office, if they have the right one.

2. Medical debt will never lead to collections. Hospitals may sue you, depending on the state, but that carriers reputational risk. A good PR push and a decent lawyer to threaten discovery will be enough to fend off even the most aggressive hospitals - this allow you to setle at a very reasonable price vs what insurance would normally pay.

That analysis is flawed because it misses the systemic nature of the risk. The Out-of-Pocket Max is an annual liability, not a one-time fix. A single serious illness, like cancer, spans multiple plan years. A $9,200 OOPM hitting three years in a row, on top of $15k-$18k in annual premiums, is the bankruptcy. This also assumes 100% in-network care, which is a fantasy in a real emergency when you don't get to pick the ambulance or the anesthesiologist. This isn't a "rainy day fund" problem. This is a system that requires a $50k-$100k emergency fund just to handle a single medical event, all while assuming you're still healthy enough to keep the job that provides the plan.

"Always avoid the hospital" isn't a choice either. You don't "negotiate" with a surgery center for a heart attack, a stroke, or a major car accident, which are some of the common events that cause this. And the claim that "medical debt will never lead to collections" is factually incorrect.

It is the number one cause of collections in the United States. The idea that every citizen can just "hire a decent lawyer" or "run a good PR push" to settle debt isn't a functional or scalable mechanism, nor is it reality.

> Hospitals may sue you, depending on the state, but that carriers reputational risk

I'm sorry but if I need a hospital, my first thought isnt, "well how is their reputation".

I don't understand why people defend the insurance system in the US when you're already paying taxes. If it's not the responsibility of the government who you pay to take care of their people in an emergency then what are taxes for. It's like people just accept it because that's how it's always been.

What we have is not insurance.

What we have is all-you-can-eat ferrari care

Insurance is what i have when i drive my car , or get water damage insurance for my house.

The monster we have today is not insurance. Instead, it is the frankenstein born out of the womb of bureaucrats and politicians influenced by money. Decades of tinkering politicians without a clue, messing around with the relationship between the doctor and patient, responding to voting patterns of the electorate, led us to today.

Unless you blow it up, (and it will blow up, just like it happened in sweden) there's no solution, except paying more for ferrari all-you-can eat.

Your country is twisted dude

That's the 'societal' part of living in society, sharing the risks and yes sharing the gains a bit too. I know some right wing folks see it as unnecessary burden, either they are above the financial cut or (dumbly) believe their health is and will remain stellar for rest of their lives. That tiny minority shouldn't ever decide such societal policies and shouldn't be let to do so.

Its shortsighted and plain stupid and properly selfish move. It works rather well short term if one simply doesn't give a fuck about suffering of others, but even thats shortsighted and stupid long term - we live in hyper-interconnected society and not some prepper wet dream, what goes around always comes around.

Another similar is public education, literally defining future of society. How dumb is to not have it in stellar shape, shitting on one's own kids and mankind future.

But hell will freeze sooner than majority of americans will realize and accept that. Till then, if its important enough for you, you can vote with your feet, its easier than ever.

The whole time I was reading this, as someone from the U.S., I was wondering what country the writer was from, because it sure as #$@! wasn't written by someone in the U.S. When I got to that part, I was, "Oh. Okay. That makes sense."

In the US, you'll be billed the maximum out of pocket for your health insurance whether your little one is in the ICU for months or whether it was a easy delivery though, so at least birth is a predictable medical expense.

If you have health insurance... Which is not automatically a thing for many Americans, and it seems even more with current political trends.

If someone doesn’t have health insurance in my state, they get sent to financial counselling/assistance and signed up for Medicaid, CHIP, or HCAP.

I asked one of their counsellors once if they ever have any ultra wealthy people who don’t have insurance and also don’t qualify for any assistance. (This was at a children’s hospital with a Level IV NICU.) She said she was unaware of that ever happening, other than very wealthy foreigners who would prepare in advance, arrange payment in advance, fly in, and have a special procedure done.

Overall, in many states, it is logistically impossible to have an unaffordable bill and also not qualify for assistance. The worst situation actually is the person who has insurance but has high deductibles and copays.

Ah you don’t seem to understand the depravity of the modern American medical system. It’s not as bad in the way you think, and significantly fucked up in a different way.

If you do not have insurance, you tell them you don’t. They’ll give you a bill lower than what you’d pay as deductible if you had insurance. Or you just don’t pay…

This raises insurance premiums and reduces the quality of healthcare in a dystopian AF feedback loop.

Yeah in my case, for two years in a row now we've maxed out my kid's out of pocket expense within ~30 days of the year starting...that's not fun.

Realistically it's much more likely that someone in the US would be telling this story vs someone from Norway.

Norway has only 50k births a year. The US has 3.6 Million, and >40% of those are 100% free to Medicaid recipients. So 1.4 million each year, meaning a story like this is about 28 times more likely to be told from someone in the US than Norway.

Medicaid isn't paying parents to not work. New parents will still have to worry about paying bills and the economy.

When those parents die, any potential generational wealth for their children will be taken by the state to pay back the benefits they received from Medicaid.

Well of course it will because medicaid is healthcare for poor people, not people with generational wealth. If you are rich and use medicaid that's fraud, and medicaid should take double for that.

>Medicaid isn't paying parents to not work. New parents will still have to worry about paying bills and the economy.

That would be up to their job if they had one of course, but Medicaid does have some cash benefits and if you have a baby on Medicaid you typically get auto-qualified for TANF so that covers a lot of bills.

>When those parents die, any potential generational wealth for their children will be taken by the state to pay back the benefits they received from Medicaid.

This would only be true if the parents received long-term care or something. And this happens to TONS of people who have otherwise been financially well off, they have to exhaust their assets before Medicaid starts paying for a nursing home. It's got nothing to do with pregnancy benefits.

I just looked it up and I'm wrong, estate recovery is for anyone at any age who is institutionalized and/or anyone over 55 receiving care. States can additionally choose care and populations from which they do estate recovery for their Medicaid programs.

All I know is a family member would get the Medicaid warnings about their estate each month in the mail.

That is misuse of statistics if I ever saw it. You could count the people that are screwed in the US and also get a much larger number than in Norway. The US has a relative problem.

> too much oxygen in the blood can lead to problems with the cornea or something

You are likely thinking of ROP (retinopathy of prematurity, where retina starts detaching due to prolonged stay in the incubator).

The norwegian healthcare is really bad at specific sectors if they deem you as a 2nd class citizen (for example trans healthcare, where there is a lot of malicious gatekeeping and multi-year long waitlists)

that sounds like 0.0001% of sectors

Where did you pull this number from? And even if so, what is your point? Seeing how a nation treats its minorities helps judge whether they have any humanity left.

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