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I just looked at the local marketplace plans. The absolute dirt-cheapest I could do for my family is ~$1,225/month premium with a deductible of $13,400 and out-of-pocket max of $21,200. Most of the structure is some form of "zero help until the deductible, then I pay 20%-40% of everything up until the OOP max".

In other words, I'm being asked to buy a product, and the cheapest form of it is to basically pay almost $15k in a year to hedge against someone getting cancer or whatever, and actively incentivizes me to not use it[0].

There is no meaningful shopping around, there is no incentive for me to do anything other than continue not smoking, there's no accounting for where I live or my health.

I dunno what the solution is. I'm just glad that the ACA included health sharing co-ops as an exception. Been doing that for awhile now and have saved a lot of money. (And they'll give me a discount if I get my weight down a little more!)

[0]: Because even if you get a free wellness visit or whatever, it's really easy for them to drop in some random test that ends up getting billed. Had this happen with my kids a few times if memory serves.

So you have to pay like $30k out of pocket in a year before the insurance chips in a single dollar? And if you ever ask for a dollar, I can also reject your coverage.

How can I start an insurance company?

The actual cost to treat "cancer or whatever" is extremely high in many cases. 15k a year to know you have that covered for a family isn't so bad given the true underlying cost.

A family member has a rare disease and I've gone through the details of the various treatments, how many people are involved in ongoing care and treatment etc. It's a lot of very well trained people spending a lot of time. A concrete treatment example - the process to create some blood plasma treatments is very complex, expensive etc. In the end, it will be millions of dollars of real underlying costs.

There is probably no cheap solution. Maybe GLP-1 type magic can put a real dent in the overall cost, but there will always be a desire to save people's lives even if the cost is very high.

It was never sustainable. Because the model relied on healthy people subsidizing the people who make extremely poor choices (obesity, smoking, drugs or a combination of that). Obamacare's modeling predicted that significantly more healthy people would sign up, driving costs down. It didn't happen.

Now it is a system that ONLY the unhealthy benefit from. Everyone else pays for extremely bad choices.

That seems... fine? That's $14,000 annually. For an income in the $75k-$100k range, Maryland health connection shows me a premium of $700/month for two parents/two kids. Judging by your premium and assuming 2 adults/2 kids, your income is probably over $200k. With that income in Canada, you'd be paying over $20,000 in taxes attributable to healthcare: https://www.fraserinstitute.org/sites/default/files/price-of....

Now you have to account for taxes you pay in the U.S. for medicare, and a risk-adjusted share of the deductible payments, but overall it doesn't seem that crazy.

> In other words, I'm being asked to buy a product, and the cheapest form of it is to basically pay almost $15k in a year to hedge against someone getting cancer or whatever, and actively incentivizes me to not use it[0]

You are not paying $15k to hedge against someone in your family getting cancer in a calendar year.

You are paying $15k to pay for old and sick people’s routine healthcare, due to the ACA’s requirement that the highest premium to be at most 3x the lowest premium, and the requirement that premiums be only a function of age and tobacco use (i.e. no underwriting for health risks by factoring in pre existing conditions).

So an ACA compliant health plan’s premiums are far more comparable to a tax than an insurance premium since they are explicitly a wealth transfer mechanism from young and healthy to old and sick.

New York state takes this wealth transfer even further and mandates that age not be used at all to price premiums. I think Massachusetts only allows an age rating factor of 2.

The article mentions early a "cancer diagnosis" but puts that aside and moves on, when this is pretty much the crux of the issue. Prostate and Breast cancers are a 1 in 8 chance. The risk of no insurance at 25 is very different than 50, and than 75. And everyone at all ages is paying for those expensive treatments.

The system is broken, but going without insurance is you basically toying with the odds of life.

If you get a very serious and expensive problem, insurance may not help nearly as much as you'd think. My mother had great insurance, but when she got cancer, the insurance didn't stop her from getting absolutely destroyed by the medical bills (not to mention having to constantly fight with the insurance company while being extremely ill).

It drove her to bankruptcy anyway. In hindsight, she commented that had she known that the insurance wouldn't be all that helpful, she would have just saved up all the money she poured into premiums over the decades.

Pre-ACA my mother got cancer in a short window where the University my Dad was president of got wound down for financial reasons.

Destroyed my entire trajectory in life.

The prior system was mega fucked, our current system is still fucked.

If you had a congenital condition prior to the ACA you were a wage slave once you hit 18, no private insurance and couldn't get public. Literally founded a successful startup the minute I got ACA.

Over 40+ years I've seen nearly every profession go through a bubble and lean years, lawyers, mechanics, academics.

But never doctors, in retrospect I should have joined that protectionist racket, but my family couldn't afford to let me at the time.

In a perfect world, a healthcare plan should pay for cancer treatments or crucial medical procedures. In the United States, I'm not sure this is a guarantee[0][1]. Going without healthcare seems to be the riskier gamble, but it's a gamble either way.

[0]: https://www.startribune.com/unitedhealthcare-part-of-95m-set...

[1]: https://www.propublica.org/article/unitedhealth-healthcare-i...

Author here. I'm definitely not advocating going without health insurance. Just running simple numbers to get some perspective.

I'd like to see health insurance act like insurance again though. Right now it covers absolutely everything, meaning it's more like pre-payment for routine care + insurance.

Insurance isn't for routine, predictable, or low-cost expenses. But we've mandated that our health insurance cover all of those things.

The comparison to car insurance is overused, but it's a good one. Catastrophic coverage + dedicated savings with lower premiums looks more attractive to a lot more people.

Good thing I became a Taoist before I could no longer afford insurance.
All I want is health insurance with low premiums, freedom to choose my providers, and a $50k deductible. Like, actual insurance for catastrophic risks. What we have now should not properly be called insurance. It's more like a mandatory membership in an extremely expensive and dysfunctional club.
Do you mean a life-time $50k? Otherwise an annual deductible of $50k sounds ludicrous. Maybe if they tied it to yearly income, it would make more sense.
$50k would probably still be outrageous, like your car insurance doesn't have that generally.
My parents use a shocking amount of healthcare services, considering that they are pretty normal 70-somethings. My dad has well managed diabetes and blood pressure, and my mom is pre-diabetic and has a bad knee, but that's about it. Their parents all made it to their 80s without modern medical care in Bangladesh. My kids don't use any healthcare services, but we're always been offered services. My younger one has low muscle tone, and we could get physical therapy for that. We had a (free) county evaluation for his speech delay. The evaluator said something along the lines of "we could give him a diagnosis so he could get services in public school, but since you send him to private school it's not worth it."

I'm not saying this is unnecessary, nor am I qualified to do so. My point is that we seem to be getting a lot more healthcare than was typical when I was a kid. So it's unsurprising premiums have skyrocketed.

It is worth it imo but it could be better. This is my back of napkin mental model but I have convinced myself that most of our troubles are because health insurance morphed from truly emergencies to every day care. Routine care (both primary and specialist) have to hire deep staff to handle insurance claims with the different payers. It’s a constant game.

For myself I always pick the high deductible plan. It’s the next best thing to an emergency only plan in my opinion. I am also lucky that I have an employer that picks this kind of plan as an option. Everyone should be on this type of plan imo. I think have a direct primary care (directs don’t take any insurance) for the family that costs $200 a month for 3 of us. The insurance cost is $100 with a max out of pocket I think around $8000. Now we are lucky in that these dollar figures don’t bother us, not true for everyone but I do think most of us would be better off if we have better forms of true emergency insurance. I want to pool the risk of a catastrophic illness or accident, not my doctors visit for a cough.

I pay my dpc directly for all testing and it’s cheap. A lot cheaper than if it was billed via insurance.

Study after study finds that a health care model where you can visit a doctor frequently leads to much better overall heath for people.

The system we have here forces people to wait until minor issues turn into life or death situations that require much more intensive and expensive care.

I have been struggling to find the breakeven point for me and my family. On one side, it keeps getting more and more expensive even though we are young and healthy. On the other, if one of us needs an expensive operation or months of treatment, no amount of HSA savings will be enough. I don't know if there is a 3rd option that would be more reasonable.
The only reason we have this broken system in the US is because of "lobbying" in an environment where unlimited money is "free speech". As long as these "insurance" companies continue to own the politicians, there will never be any meaningful progress. A 6% tax hike each year would induce riots in the streets, but somehow this same scenario in premiums is accepted by the population with anger and a shrug.
In the last two years, my mother had a tumour (successfully) removed from her brain and my sister had day-long heart surgery. Two extensive processes with lots of consults before and after, both requiring significant hospital stays. At the time I was a bit grumpy that I had to pay $15 a day for parking at the hospital, which was really the only out of pocket cost to the family here in Canada.

We do have a major shortage of GPs and wait times can be longer than you want, so I would not say that we necessarily have the best health care system in the world. But you really need to go to the cafeteria in a hospital to find cash registers. And when I picked up my mother from the hospital, we said goodbye to the nurses and just walked right out.

Direct primary care was a completely game-changing improvement in healthcare for me.

$95/mo to basically subscribe to a local doctor. Covers most things other than tests or surgery or limb setting. But tests are often very discounted relative to what insurance charges for them (with my previous dpc provider an entire battery of tests cost less through them than just the copay for two of them added up to).

It’s remarkable how different it is when the healthcare provider is focused on you and your health rather than on gaming the metrics by which insurance companies judge them.

Make other plans for catastrophic things (ie, a high deductible insurance plan).

https://www.dpcfrontier.com/

> 1. What would happen if instead of buying health insurance, you set aside annual premiums plus your deductible every year and paid out of pocket?

What would happen if healthcare was a shared pool for the often-unpredictable risk for everyone, so that everyone was taken care of?

This is obviously a government function in the interests of everyone, so there's no need for profit-taking insurance companies with perverse incentives.

I wonder how many incredible founders and companies we're missing out on because the potential founders never left their jobs due to health insurance costs.

Same for rising housing costs. High rent and mortgages reduce risk taking, and that's bad for the economy.

Reading the comments is hilarious. That "healthy 34 year-old male with minor sports injuries" was exactly me when I was 34. Then I hit my out-of-pocket max 7 out of the next 10 years and exceeded a million in insurance spend twice due to a whole lot of major surgeries. It also feels male-centric. Surely pregnancy and childbirth are all but guaranteed to put you over an out-of-pocket max, especially with how common c-sections are these days.
When I was child, our dog got hit by a car. The dog had two broken legs and was bleeding from the nose. My dad said, "Come with me son, I will show you what to do." So we went into the woods behind the house and dug a hole. I put the dog in the hole and my dad shot the dog in the head. After we filled in the hole my dad said. "Now you know what to do with me when I get old."

So my health insurance is healthy living, CrossFit, rapamycin etc. When that fails, I have a 9mm pistol I keep in the safe. I do worry about if I am somehow too incapacitated to use the pistol but not enough to die naturally. Infirmity scares me a lot more then death does.

You can always make the argument that insurance, no matter what it covers, isn't worth it. You're paying for coverage in the case something goes wrong. If it doesn't go wrong, you don't get your money back. The one exception to this is Old-Age, Survivors, and Disability Insurance, better known as Social Security. For some reason, we feel the need to mail checks to, statistically speaking, the wealthiest age demographic in the country whether they need it or not.

But is health insurance worth it?

If you're a very lucky and healthy 25-year-old with no dependents and six figures in the bank, maybe not.

Everyone else? I don't know. That would depend on things like your state's bankruptcy laws. What's not to love about the bankruptcy process?

The major problems with health insurance in the US are that 1) there is no basic public option that everyone could use if they absolutely had to, and 2) the largest providers are for-profit, meaning that they have to satisfy the free riders known as shareholders.

I don't like the US healthcare/insurance system, but my objection to the article is that it fundamentally misunderstands the point of insurance. Insurance is fundamentally a transfer of wealth from those who do not experience misfortune (in this case, poor health) to those who do experience misfortune (so they can pay for it). In the case of healthcare, old people are much more likely to experience misfortune than the young, which means that health insurance -- no matter how you structure it -- is essentially a transfer of wealth from the young and healthy to the old and sick.

The only way insurance works is if enough people pay into it, ideally everyone. European countries work with mandated insurance (either through taxes, or a legal requirement) to fund the system sufficiently.

Catastrophic-only insurance is a nice idea and is truer to the idea of insurance as a protective measure, but healthcare costs are so high in the US compared with other countries, and the frequency at which non-routine care is necessary is also very high -- partly because Americans lead such unhealthy lives, particularly in terms of diet (and here we have a separate food industry problem) -- that the costs for the "catastrophic-only" insurance have to be quite high. We see this in the "Bronze" level plans. And if people are paying that much per month, it starts to make sense to pay a bit more and get some of the more routine care covered rather than pay so much for nothing really (unless there's a catastrophe).

Bear in mind that "catastrophe" is not just cancer. It's almost any non-routine care. I had surgery this year for a hernia -- the bill was $30,000. I was insured so that's not what I paid. But my point is, an unexpected $30K can easily put a household in a serious financial bind given that Americans don't have much in the way of savings.

Is medical tourism a potential option for uninsured people to decrease costs in the event of major illness like cancer? How about for a chronic condition?
> I know I’d rather pay for a Direct Primary Care membership, have catastrophic insurance that covers medical spending above a certain dollar value, and contribute to an HSA every year in the meantime while I’m healthy.

"Bronze" level insurance is essentially catastrophic insurance. The deductible is so high that you're paying out of pocket for regular care. So the author's desirable scenario already exists. The problem is that even these catastrophic plans cost a significant amount. So much so that it's not really worth it. If you do go to the doctor often you're better off with a higher level of insurance where your premium at least also covers some of your routine care.

So it's not that the structure doesn't exist, it's that it's too expensive.

Looking from outside your system is scary. I don't get how anyone could defend it in earnest.
I think this is worth considering for younger folks, but I wanna point out how low the numbers in the "medical expense" column are. They're similar (if low) for routine care but if you have an actual emergency you'd have much higher bills. IIRC when my mom had breast cancer she was getting a weekly shot to inhibit the HER2/neu mechanism of her cancer that had a list of $10,000 a shot. As an uninsured person you won't pay list but you are rolling the dice pretty hard. Insurance costs are highway robbery - and also the part of their prices that aren't driven by greed are driven by absurd underlying costs.
Basic healthcare and life saving treatments should NOT be for profit.
Healthcare in the US is a complete protectionist racket in all of its aspects. The costs and bureaucracy are 100x to 1000x what they should be in a highly competitive system. No wonder it's unaffordable. Until this is fixed, shuffling around who pays can't sustainably fix it. Regulations in favor of the racket need to be systematically identified at all levels of government and loosened or struck down.
I got yeeted out of the work force by Long Covid back in 2020. Thanks to this change, I'm feeling quite fortunate that my "early" Security starts in December (otherwise who knows what would happen, medical bankruptcies are going to go astronomical next year). This might allow us to continue health insurance if all of it (plus some) goes into premiums.

I've been avoiding looking at the new options, for my own mental health.

Part of the problem is that ACA made catastrophic insurance illegal, because all insurance had to have lots of minimum coverage. I don't want insurance to provide one free checkup per year, I want to pay for normal stuff normally, and not have to pay the insurance company's expenses + profit margin on normal stuff just to have the unlikely stuff covered.
I'm not (yet) willing to do this for general health insurance, but I made this decision for dental, a couple of years ago. It has not been an issue. I've had a couple of crowns, and paid a fraction of what insurance would have covered, minus the ridiculously high deductible, and the monthly premiums.

Of course, now it's time to re-up for next year, and the message seems to be "Squeal, boy!".

I think to address the problem we should first address the language.

It is not largely health insurance, it is medical treatment payment insurance, so I usually just call it medical insurance.

We are not paying so much money for promotion of or preservation of health, or even early detection of disease. We are paying so much for late medical treatment of disease

Any good explanations as to why insurance companies haven't merged? Each provide roughly the same service. Instead of one staff (and one highly paid exec team and management hierarchy), our healthcare spending has to support a dozen or so, and for what gain to the consumer?
The problem with insurance is that we don't use it as insurance and just as an account to charge everything to when really we should just be paying for health care.

You wouldn't charge your car insurance for gas. Yet that is the majority of what we do for healthcare.

I think what this misses is that insurers handle the hassle of dealing with negotiated rates.

As an example, if you go to the ER and get a strep test, you might be billed $500, and insurance will pay $7 (as ridiculous as this sounds). If you go at this on your own, they'll probably bill you $100 and tell you they are giving you an 80% discount. With lots of phone calls, you can maybe get them down to $50.

This is all obviously crazy. But it makes it such that you really do want insurance if you can afford it. More so, even if you are a billionaire and can afford to self insure, it still makes sense to have health insurance (whereas property or life insurance probably don't make sense for you).

Also, don't forget that insurance premiums are often tax deductible for wealthy people, so the actual amount paid is less.

A question to everyone unhappy paying for their insurance: would you be happier paying 50% income tax, 20% sales tax and not having to ever worry about paying for healthcare?
Anecdotal - A friend of mine decided to go without health insurance this year and then tore her ACL. So guess who is walking around with a torn ACL until next year because she simply can't afford the surgery...

The US healthcare system is rotten to the core but the populous refuses to educate themselves and keeps voting for losers that won't do anything to fix the system - so we all suffer. Republicans have been promising an alternative to the ACA (for some reason) for over 10 years now and have yet to produce anything - They are just interested in tearing down any progress and not offering fixes to current problems... but thanks to voter education and gerrymandering Republicans are able to keep their vulture capitalism ideals afloat. That's not even mentioning establishment Democrats that don't do much when they have the chance.

I mean clearly the excess in the system is the profit margin of the companies involved.
The truth is that Us health insurance industry has proven it is not about providing healthcare but instead capital extraction. The whole thing is seen as rotten by every participant.

What has happened is that it’s now more affordable to get healthcare in foreign countries as an American. I can vacation and get whatever care I need by doctors in countries with healthcare systems. Doctors that are incentivized to provide healthcare. In economies where people are proud to have a job.

There are some good doctors in the Usa but they are incentivized to charge as much as possible and put patients into studies or experimental drugs to get kickbacks. It costs me $50 to get my results from my doctor. They refuse to send an email and a phone call means it’s a “telehealth” appointment. Which is not a medical or technical health term but the name of the product category.

Usa does __not__ have a healthcare system but instead a capital extraction health-insurance system that rarely helps with your health costs.

I wish this topic was better understood and was in the spotlight during Biden’s term as Potus. But we made extra sure to snub Bernie when Biden ran the first time. No surprise for me if nothing changes. Seems to only be a major topic during the years when affordability is an issue. So when affordability isn’t an issue we’re just A-Ok as Americans with the grifting health-insurance industry.

Repeal Obamacare, go back to HSAs. Nobody should be taxed on health expenses, which was the whole point of HSAs in the first place. We literally had a budding system that was working and affordable, and it was "fixed".