Comment by thatfrenchguy | Hacker News Reader

Comment by thatfrenchguy | Hacker News Reader

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I think OP here is just keeping a completely dominated plan (and his health insurance company knows it). He has less than 50 employees, he is not required to offer health insurance to his employees and he should go on the ACA market.

Given he has 3 children, 400% of FPL in 2026 is $150,600 so he's easily eligible for ACA subsidies (which, by the way, in 2021-2026, were available to everyone) by tweaking his income (easy to do when you have a company).

He also says uninformed things like:

> My wife and I are healthy, but we’re building our family and I have yet to see a marketplace plan that supports child-birth. Maybe the subsidized ones do, but I earn too much money to see those.

The premiums have nothing to do with the plans. Every single plan on the marketplace has to cover child-birth, that's sort of the point of the ACA.

> HMOs or EPOs that have some issues with them: coinsurance

What matters at the end of the day when you have a child is your maximum out of pocket (which you will 100% hit the year you have a child!). Whether you have copays or coinsurance after a deductible does not matter here. The ACA caps your maximum out of pocket at $18,400 no matter what (which, yes, is too high), so what you need to optimize for is premium + OOP for the providers that you care about.

Like, I get it, it's America, for healthcare like many other things (student loans, credit card debt, ...) it's easy to end up in a bad situation, but at some point you have to spend time understanding the game.

> Given he has 3 children, 400% of FPL in 2026 is $150,600 so he's easily eligible for ACA subsidies

I am absolutely not eligible. I earn more than $150k. And "manipulating your income" is not really feasible with a pass-through entity.

> The premiums have nothing to do with the plans. Every single plan on the marketplace has to cover child-birth, that's sort of the point of the ACA.

As I mention in the piece, I check every year. I have no idea what subsidized plans include, but the other marketplace plans definitely do not include child birth.

I explicitly address this point:

> The Affordable Care Act (Obamacare) barred insurers from turning down applicants based on existing pre-conditions; the way insurers get around this for pregnancy and child-birth is not by rejecting pregnant applicants (illegal), but by simply refusing to cover the care those applicants need to survive pregnancy (legal and common.)

and

> My wife and I are healthy, but we’re building our family and I have yet to see a marketplace plan that supports child-birth. Maybe the subsidized ones do, but I earn too much money to see those. All of the ones I’ve found through eHealth Insurance or Healthcare.gov never cover it - and I check every year.

Love the over-confidence though. The best outcome for me in even writing this article would be to get some internet commenter pissed off enough to find me a cheaper version of my plan. That would solve my problem immediately!

> And "manipulating your income" is not really feasible with a pass-through entity.

I don't know if you have a CPA, but this is a sentence my CPA has never uttered.

> but by simply refusing to cover the care those applicants need to survive pregnancy (legal and common.)

Including...? I have never heard of this, and actually have delivered babies and worked with post-partum mothers.

The explanation of benefits simply doesn't cover child birth - this is extremely common for individual marketplace plans.

If by "individual marketplace" you mean the Healthcare.gov-style ACA individual marketplace, you now know this to be totally false.

ACA plans absolutely cover childbirth (https://www.healthcare.gov/what-if-im-pregnant-or-plan-to-ge...). But it might not matter because you aren't on a marketplace plan according to the screenshots in your post.

You are on this plan: https://www.trinetaetna.com/pdfs/Aetna_PPO_7150.pdf

Which does cover childbirth according to page 3. And has a 7150 deductible per person - the $14300 is the family out of pocket max, so the childbirth should top out at the 7150. Other expenses might put you at the same 40K cost for the year, but not the childbirth alone.

> the $14300 is the family out of pocket max

You know they charge you, separately, for both the mother's care AND the infant's during a delivery right? Those count as two people. I am, with 100% certainty, going to hit the out of pocket max - I have every time.

Like I've paid for three kids all on the same plan, including one born in January so my deductible got spread over two different billing years.

I have to ask - why are you defending this?

I'm not defending it. I'm correcting your misinformation. You are claiming that ACA plans do not cover childbirth. They do. You are claiming that this event alone costs 40K, which is not accurate. It hits your out of pocket max, exactly as designed.

It sounds like you have never looked at an ACA silver plan, which is the lower deductible/out of pocket max option. I also have a family of 5, and have a $1800 per year out of pocket max from an ACA plan. You would still have the same level of premiums as you do now for silver plans, but you would save 13K a year. You are picking bad plans, dude.

Our system has problems, but when you make enough to not be subsidized, yet still pick a crappy 40K per year plan, that is beyond the systemic problems. It is a bad choice. There are insurance consultants who work with people, especially high income people, to find good plans for their family. You should be calling them.

Dude, you don't even have your own facts straight and you are embarrassing yourself. It's clear you have no experience, don't understand your own sources you provided, or any clue how child birth actually works from a medical billing standpoint.

Edit: what do I have to gain from spreading "misinformation?" I just want better / more options?

I don't know what you have to gain from it, but you're wrong. 42 U.S. Code § 18022, (b)(1)(D). ACA plans are required to cover childbirth.

That's not what the link the OP included said and not what I said either, but I concede your point - that's my fault for checking individual health care marketplaces (like eHealthInsurance and Aetna direct) or not looking closely enough on healthcare.gov.

Looking through some plans now, but TBH these are genuinely not much of an improvement in the cost department and a massive downgrade in the provider selection department. Hence my whole section on trade-offs.

The logic you're using about out-of-pocket costs versus your deductible appear also not to be valid, and are causing you to misstate your out-of-pocket liability by a factor of roughly 4x.

I can assure you they are, if anything, understated - as I am not including the expenses my health insurance will not cover. So no, you are fully in the wrong there. What do I have to do to prove it? Show you itemized receipts?

Moreover, what are you even trying to accomplish by asking for this? Please provide me with a forthright defense of the modern U.S. health insurance markets and why it makes sense for me to have to pay this much to keep our population above replacement level.

Do you have non-ACA insurance? One explanation for why your costs are so much higher than the national average is that you're on a non-complying plan (you can also still buy plans that will exclude preexisting conditions --- they just can't be sold on the ACA marketplace). I'm pretty confident KFF isn't making these numbers up.

As for your second question, one easy response is that prospective parents in other health care systems aren't paying less (with everything factored in) but rather differently: that people making your $119k "true" poverty rate in Europe tend to be taxed at their top marginal rate, which is substantially higher than ours (in fact, in a lot of places in Europe, a Chicago Public School teacher would also be paying the top marginal rate).

A thing worth pointing out is that while the system we have is especially punishing on the uninsured, it's actually not that bad a deal for the insured, demographically/actuarially speaking. That's because being insured definitionally puts you in the cohort that excludes Medicaid-eligible poor/working class people and fixed-income seniors. If you move the typical household from that cohort to the UK, they're likely to be worse off. In surveys, insured families tend to be satisfied with their insurance, which is why taking existing health insurance off the table is such a third rail in American health policy.

Anyways, unless you personally are responsible for keeping our population above replacement level (which sounds exhausting), your numbers just aren't probative for the cost of bringing new citizens online. Other numbers might be!

> Do you have non-ACA insurance? One explanation for why your costs are so much higher than the national average is that you're on a non-complying plan (you can also still buy plans that will exclude preexisting conditions --- they just can't be sold on the ACA marketplace). I'm pretty confident KFF isn't making these numbers up.

Asked and answered in the piece dude - I wish I had the confidence of a Hacker News commenter who didn't read the article.

I read the article. It's extremely unclear to me whether you have ACA-compliant health insurance or not. I've been a startup principal since 2005 and have had PEO coverage at various points since the ACA passed, and it was always ACA-compliant. Could you just answer the question? It shouldn't be a riddle!

(Note that "non-ACA insurance" doesn't mean "insurance you didn't buy on the ACA public marketplace". I've got Anthem Blue Cross through our benefits provider. It is very definitely ACA-compliant.)

While I might not have been happier income-wise when I was on Medicaid vs now, I was much happier with my medicaid insurance than I have ever been with any private insurance. I could see basically any provider and didn’t have to deal with any of the typical insurance bullshit.

Also when you’re beyond the Medicaid threshold but not that much beyond it absolutely sucks. One year I was paying for dramatically worse insurance with a deductible that would have just made it better for me to just not make more money because if I hit that deductible I would be net negative on my income vs the threshold for Medicaid.

Also I think this is such a false premise. You can still have private plans if you want in the UK or elsewhere with a public health system. Nobody is forcing you to use the public system if you don’t want to. To wit, I don’t have children but I still pay for schools with my taxes. You might not want to use the public health system and instead go private, but yes, you should still be paying for a freely accessible healthcare system.

Here’s the rub on that too: The prices we pay here are so much higher than in Europe even if you go private in those countries. Our system is terrible. Point blank.

I would agree that the NHS in the UK has gotten pretty bad. A large part of that is the result of the Tory government actively working against it though for a very long time. The waitlists for a lot of things are quite long and my fiancé who is from the UK and still lives there has to do some things there are crazy to me. On the other hand she still is able to get care freely. She’s paid private for some dental work but that also cost her pennies on the dollar compared to what I’d be paying if I did the same thing here.

If you’re happy with your insurance I am truly thrilled for you because I don’t think of that as being a common experience.

I too am nearly universally irritated with my health insurance (due to reasons I’ve had 4 employer sponsored plans in the last year).

But I recognize I’m in the minority. And it’s not close. Most people with private health insurance like it.

tps://www.kff.org/affordable-care-act/kff-survey-of-consumer-experiences-with-health-insurance/

> Most people with private health insurance like it.

Most people don't use it all that much, and in the common case of employer-paid premiums, the actual cost is significantly masked. As your link notes, the more care you need, the less likely you are to enjoy the experience. They dig their heels in more; sometimes egregiously so. https://www.propublica.org/article/unitedhealth-healthcare-i...

Seems like a just-so story given the numbers. Why would heavy users of health services be concentrated in the minority cohort that is dissatisfied with their insurance?

> Why would heavy users of health services be concentrated in the minority cohort that is dissatisfied with their insurance?

"Why would people who drive a lot care the most about gas prices?"

The more you use health insurance, the more chances you have to run into the kafkaesque bits. Someone who sees a GP once a year and thinks their premium is $50/month because that's the bit they have to chip in while their employer covers the rest is largely gonna go "this is fine!"

Right but there's no such selection effect for whether or not people have employer-provided coverage, and the cohort of households that do strongly approve of their current insurance coverage. I don't see how the argument you're making could hold up statistically. There are a lot of chronically ill people with employer-provided coverage; in fact, most non-senior chronically ill pts fall into that bucket.

> Right but there's no such selection effect for whether or not people have employer-provided coverage…

False. Someone with significant medical issues may well need a higher acuity plan than the employer offers. I, for example, was on the exchanges until last year, for this very reason; my employer's coverage would not have made financial sense.

> There are a lot of chronically ill people with employer-provided coverage…

The chronically ill are less likely to be employed.

> ACA plans absolutely cover childbirth (https://www.healthcare.gov/what-if-im-pregnant-or-plan-to-ge...)

that link doesn't even say what you says it does - it said you can apply for coverage, not that there are plans that cover child birth. Have you never done this before?

Welcome to healthcare plans in Texas.

This same price gets you a platinum plan with Sharp or Kaiser in San Diego and wouldn't have those gigantic deductibles.

He moved his business from California to Texas and is now complaining about pricing problems in markets caused specifically by the lack of regulatory environment in Texas.

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