Hacker News Reader

Comment by jonhohle | Hacker News Reader

As someone paying for a family on a marketplace bronze plan, that’s a bargain! I think our premiums will exceed $20K this year.

With all of the medical group consolidation, all of the wait time woes our Canadian friends always complained about are the reality here now as well. So I’m paying more than anywhere else on the world and have to wait 6 months for a PCP appointment. We have the worst of both worlds.

View on HN

I'm curious to compare this to other countries that have state owned/mandated insurance and are so far still mostly covering everything and which are always touted as "superior" to the US, who "have the most expensive health care system". Can't use Canada as OHIP et. al. don't cover much and the same employer tied insurance scheme as in the US exists and is necessary.

An example of a country with "good healthcare" and such a system would be Germany. Extra insurance does exist there as well nowadays from what I understand but health insurance isn't tied entirely to employment and the extras are things like a 20 EUR per month to cover the co-pay on large and expensive procedures. While private insurance exists there too, I want to compare to the often touted "free healthcare" i.e. public system. There are still different providers even under the one public system.

So from a quick search, Germany has insurance rates from ~14-16% of gross salary, half of which the employee pays from their gross salary. But most insurances have an extra percentage they charge on top. I found one as an example that charges 17.29% total, which if you're self-employed, you have to cover yourself (to be comparable to your marketplace bronze plan being entirely self-paid).

Now the question becomes: Are you paying more or less as a percentage of your salary and by how much?

(and side question for your parent I guess: how does that compare to the $10k the employer pays, which would be 8.645% in this example)

It is actually more complicated than this implies. For example hospitals are often held afloat by Medicare/Medicaid spending (25%/19%). Private health insurance is about 37%, so larger than either, but smaller than both. But then you have to remember that some of the private health insurance is being subsidized by taxpayer dollars (e.g.: the ACA subsidies), and that private health insurance is largely coming from tax exempt dollars (a form of subsidies). So where the costs are actually being paid is more difficult.

https://www.kff.org/health-costs/key-facts-about-hospitals/?...

I am not sure where your question about a percentage of your salary is valid on the face of it. Do you count the employer portion of your medical coverage as part of your salary? Do you count the tax exemption? How do you figure the taxes taken out to support Medicare/Medicaid/Veterans Health (all of which are required to support the system as it exists)? And how do you figure that for single payer systems?

So a much more direct way of comparing is to look at total costs per person, and then figure out how outcomes compare. When you do that the U.S. comes to about double the cost, and generally worse outcomes. Conservative politicians will scream about how long it takes to get procedures, but the research shows that elective procedures take about the same time (and no-one waits for emergency procedures in comparable systems).

https://www.pgpf.org/article/how-does-the-us-healthcare-syst...

That's a fair point overall but not why I asked.

I asked from an employee and cost perspective. So whether or not to count the employer portion depends on whether we're comparing one or the other. If you buy on the marketplace in the US, compare with the full cost in the example I gave for Germany. If you get insurance through your work the US/CA, compare with the employee only portion (as the employer pays part of the insurance there as well).

Theoretically it's even more complicated as at least in Germany private insurance also exists and is cheaper if you're a healthy single youth and more expensive if you're an older family ;)

But again, like you say, it is totally valid to also compare outcomes / wait times per dollar spent of course.

Canadian (OHIP recipient) here. As a long time employer, and former employee, I can tell you that no one takes a job here for the heath care. Some things like dental and vision are not covered (unless you are under 18, over 65, or low income), but everything else is. Over the course of a decade my father in law had 3 heart attacks, a stroke, and ultimately lost a year long battle with lung cancer. The total health care bill to him (or his employer) was $0.

Now the downside … because health care is free, everyone uses it and the wait times are longer. My grandfather recently required an MRI (non life threatening). The wait time in Ontario was 3 months. He drove to the USA, paid out of pocket, and had it done within in week …

> Now the downside … because health care is free, everyone uses it and the wait times are longer. My grandfather recently required an MRI (non life threatening). The wait time in Ontario was 3 months. He drove to the USA, paid out of pocket, and had it done within in week …

Imo, singapore solves this well, by ensuring that some cost is borne by the patient at point of use, but it's never anything excessive. No one goes bankrupt from emergency hospital visits.

> Can't use Canada as OHIP et. al. don't cover much and the same employer tied insurance scheme as in the US exists and is necessary

False. From what I know, only prescription drugs, dental, and vision are not covered. And since Americans frequently drive to Canada to buy prescription drugs, we can assume that's not as big a burden as in the US. But hospital stays, surgeries, lab testing, imaging, doctor visits, vaccines are all fully covered.

Fair enough, I guess I got carried away given the private insurance has to cover drugs, which would otherwise be covered by the provincial insurance (like OHIP), if you have it.

Private insurance also can cover a higher percentage, i.e. provincial plans do not always cover 100% of everything. Also, Health Care Spending accounts are in many cases part of private insurances and can be used to cover things that provincial plans do not cover at all (unapproved drugs et. al.)

And just for context … if medication is not covered and has to be paid out of pocket, the cost is generally under $100. Canadians don’t have $1000 medical costs

> provincial plans do not always cover 100% of everything

Like what?

Since we were using OHIP as an example: https://www.ontario.ca/page/get-coverage-prescription-drugs#... and following.

The first info about what's not covered for example is concerning diabetes. There's a limit to the number of test strips for example. I'm no diabetic, so I don't know if these numbers are "enough" or not but there is an actual limit. It also then states:

    Syringes, lancets, glucometers and other diabetic supplies are not covered by the ODB program.

If you're a senior with "too much income" you also have co-pays/deductibles, meaning the coverage is less than 100% of the cost of the drug:

    A single person aged 65 years or older with a yearly income above $25,000 after deductions pays:

    the first $100 of total prescription costs each program year (August 1 to July 31 the following year)
        this is called the deductible and is paid down when you fill your prescriptions
    after paying the deductible, up to $6.11 for each prescription, filled or refilled
        this amount is called the co-payment

This: https://www.vivahealthpharmacy.com/private-insurance-vs-ohip... too.

I'll stop here but I'm sure this is both similar in other provinces and/or other limits may apply in specific cases.

Just to be clear: I'm not saying the OHIP / other Canadian insurance programs aren't great overall in comparison to the US. But neither they nor I suppose Germany's "full coverage" actually are in all real world cases.

This is all prescription drugs.

Correct. Which doesn't invalidate either your or my previous points.

I'm pretty sure the original 10+k/yr/employee for good ppo coverage is a radical underestimate, for what it's worth, though I guess "way more than ten" is technically part of the "ten+" range, haha.

The last time I had reason to look at full market-rate price for a family of four for a good PPO (Seattle market, circa five years ago, large tech company), it was around 3300 USD per month, or over $39k/yr. That was for cobra coverage, so a combination of what I would have normally paid and what the employer would've (about one third us and two thirds them when I was employed by that corp). I can only imagine it's gotten more expensive since then; we left the country three years ago.

Just as an FYI, that is a massive outlier based on available data.

My employees are about $500 per month in a major metropolitan area, and a family of 4 can run up to $2000 a month for the most expensive plans (I cover individuals and their spouses in full for standard plans, and could cover one dependent for basic plans).

I looked at marketplace plans in WA because I was curious, and it looks like it's about the same as where I am but nowhere near what you were quoted 5 years ago.

I got the $10k a year employee from chatgpt with "Assume I have a company with 100 employees in New York, how much on average does it cost to provide health insurance" and it gave me poor, moderate and good ppo plan prices. I figure this seemed reasonable for ballpark figures from employer friends, so the numbers may be very well off.

The key part of your statement is that you're paying for a family.

Individuals do not cost $10k per year under any normal circumstances, and if you're paying almost $2k a month for a family bronze plan, you either have a lot of kids, you have some unusual needs, or you are getting ripped off. Even more so if you're waiting for a PCP appointment, because that is unusual as well.

So the ~$10k a year is just what the employer is paying in my example, taking some numbers from chatgpt for a medium sized company in new york. Not even counting the employee side of the premiums, which can be crazy high as well.

Reply on news.ycombinator.com