If you're a tech entrepreneur, it's the first story in here that should alarm you the most. It's about denying coverage altogether, not about denying individual claims. Outside of the "guaranteed issue" ACA market, there is virtually no due process for coverage denial. You can be denied on a whim, with little recourse.
The list of conditions for which insurance outside the ACA will be denied is long and opaque. The story makes it sound as if they're looking for reliably diagnosed conditions like diabetes. No. They're looking for indicators of a long list of potential conditions. If you or your spouse has a functioning female reproductive system, the chance of your family being denied is high, even without a diagnosed or treated condition. We were denied for something like that, and also because my daughter had an unexplained seizure when she was 4 (she's now 16 and just fine). To get insurance for the first couple years of Matasano, my wife had to take a crappy full-time job with group coverage.
Without insurance, a typical working family is one major medical incident away from zeroing themselves out. My daughter has never met a pickleball net that didn't break her ankle (she has met one pickleball net). Even with insurance, the cost of that injury was high single-digit thousands of dollars. Without it? The cost of a pretty decent car. Find a friend who's had an appendectomy some time and try to find out how much the insurance company was (nominally) billed for it. A down payment on a house.
If you work in this industry, intend ever to start your own business and potentially have a family at the same time, you should be extremely alarmed at the prospect of guaranteed issue regulated health insurance (the ACA) being replaced.
ACA is horrendous, unless you're receiving a government subsidy. I'm self-employed and we have one option of insurance provider, and the cheapest plan for my family last year was $18,000 a year with a huge deductible. That's after tax, out of pocket, for a healthy family with no pre-existing. Like all self-employed people I know (who aren't getting government subsidy), I moved my family to Christian Medishare, which is basically catastrophic coverage for about $3,000 year that was grandfathered in when Obamacare was passed. However it isn't truly insurance, it isn't regulated for soundness. I'm seriously considering returning to wage employment for health care benefits.
The rate of increase for health insurance prices went down after the ACA was enacted. The motivation for enacting the ACA was, in large part, the untenable increase in insurance prices in the 10 years leading up to it.
People have a bad habit of blaming the ACA for insurance prices. The ACA failed at its goal of making individual health insurance affordable, that is true. But it didn't cause that problem, and it did something extremely important to mitigate it.
Health insurance for my healthy young family of 4 spiraled out of control WITH ACA, so much so that I didn’t purchase proper health insurance in 2017, while also underfunding my income tax in hopes that ACA cannot legally “send me a bill” for 2.5% of my household income. (I mean shit, in a red blooded patriotic American, but that penalty made me absolutely furious) All this while paying cash for prenatal visits for our next child, still far cheaper than paying for a $15,000/yr policy + 15,000/yr deductible. In my decade of buying family insurance, I watched my family policy increase by nearly $1000/mo combined with a staggering decrease in value provided via super high deductible... oh, and no legal way out.
I know ACA is good for some, but goodness did it remove my interest in remaining insured. I’m sure you can cite data that tells a different story, but my experience, as well as that of my peers, says ACA has been very bad for those actually paying the bill unsubsidized. I fully blame ACA for this.
You have a young family of four, and can barely afford insurance premiums. Basically, without insurance, every single year you're hitting on a blackjack 17 against bankruptcy. You see the ACA penalty, and you see the insurance premium cost, but you're not factoring in the 5-digit cost of virtually any significant medical expense.
Rising insurance premiums aren't good for anyone. The ACA set out to fix the problem of rising insurance premiums and (I think) pretty much failed. But it didn't create that problem; 5-digit annual premiums for a family of four were a reality prior to the ACA --- or, at least, they were in Chicago on the small group market.
The subtext to these discussions though is whether we'd be better off without the ACA. No, we would not be. We would lose guaranteed-issue insurance, so a sizable fraction of families wouldn't be able to get insurance at all, and, from the available evidence, we would at least have the same rate problems we have now, and (according to some studies) have worse rates. Obviously, this subtext is about the GOP's health care rhetoric, and I'm not wild about opening up a political salient in this thread, but let's at least be clear: the idea that you can repeal the ACA, do nothing else, and get lower health insurance premiums for real coverage is sleight of hand.
For another example: my broken ankle: tib+fib fracture, 2 severed ligaments, partially torn syndesmotic ligament, gave myself plantar fasciitis during recovery. Two surgeries, a bunch of ortho visits, a bunch more PT, 10 months on crutches.
The net bill was over $110k if I hadn't had insurance and wanted to go to one of two ankle specialists in the city I live in. With insurance, $5k-ish.
"the idea that you can repeal the ACA, do nothing else, and get lower health insurance premiums for real coverage is sleight of hand." --> it's a lie actually.
If enough people didn't have access to insurance, then there would be pressure on hospitals to find ways to reduce prices (so that their volume could go up). As it stands the medical industry is allowed to hold the poor for ransom ("accept our increased costs or they won't get treated") against the US's deep but finite pockets.
Before, we had the (very poor) demand elasticity of people paying everything they had and then maxing out every credit source, and predictably prices rose to around that point. Now, we have no demand elasticity at all, and prices can be expected to rise well above the average person's net worth + credit access.
If you look at any microeconomic equilibrium chart, you'll see that the price is held in a balance between people buying and people holding off due to price. When the good is healthcare, the human cost of "holding off" is very high, and usually involves inability to pay. Unfortunately our economic system tends to fly off the rails if this balance is disrupted, no matter how noble or urgent the cause.
Elsewhere it has been said: choosing between bankruptcy for your family or cancer care for your child isn't an actual choice, it's two loaded guns pointed at your skull. One held by the hospital, the other by the insurance company.
The reason first world countries choose universal healthcare is that healthcare is a human right. Full stop. It is not an economic issue. If you want to get economic about it though you'll lose because as it turns out a healthy educated populace is more productive than one that loses productive families here and there to lances of bankruptcy from the unpredictable nest of human disease.
I also feel the moral imperative that you're describing. Nobody should have to tell their child that they're too expensive - to be honest, I can't imagine anything worse.
We were literally using lives as an economic mechanism, but now that we're not doing that we need to use something else in their place. The price of healthcare will continue to skyrocket unless we find something a little less horrifying than other people's lives to use as a balancing weight; although I won't claim to know whether it would be more possible to design a working market system or socialize it successfully.
Priority 1, stop making Soylent Green out of people. Priority 2, re-establish the food supply in a better way, because we need to eat.
> The reason first world countries choose universal healthcare is that healthcare is a human right. Full stop.
I'm sure they said that in soviet Russia too. It's all good to say X,Y or Z is a right until you actually cash in on that right.
I mean you don't even have to look to the soviet union, what is goinig on with the VA? Obama was working to fix that smaller universal healthcare system from actually just waiting years for people to die but I haven't heard any good news comming out of there recently.
The rest of your claims are just nonsensical in this context since your just assuming universal healthcare works because the government decrees it to be universal.
On Reddit, to responses like this ("America is incapable of universal healthcare because... Reasons") I like to link to the Wikipedia pages of the multitude of other countries with far lower GDPs solving the problem.
I can probably predict the response but on the chance I'll be surprised - why can't America solve the problem when Taiwan, Switzerland, Sweden, France, Germany, the UK, Canada, Finland, Norway, etc etc etc have or nearly have?
(I have received healthcare in several of these countries and an readily prepared with counterpoints to the inaccurate "healthcare isn't good / lines are long in those countries" arguments, fair warning)
Americans pay double in health care costs per capital than any industrialized nation. And we don't have better outcomes. All of those countries have universal healthcare. Citation, OECD.
I'm not sure its fair to argue that universal healthcare is a human right despite the fact it makes economic sense.
Humanity survived just fine without real healthcare and healthcare is not essential to a fair balance of power b/t the government and its citizenry.
Universal healthcare needs to be argued on the economics of the issue because that is the only practical way to make it sustainable. The "feel good" stuff about it being a human right will fail when stress is applied to America and stress is coming. The US, frankly, has peaked and it is all downhill from here.
In law school we were always taught that there are no rights. Rights, in practice are nothing but duties, and should be looked at like that.
You have no right to "life, liberty and the pursuit of happiness", you have a duty to not interfere with other people's life, liberty or their pursuit of their happiness. But even that is a negative duty. Positive duties, like paying tax, are more like the right to healthcare.
So this should be looked on in similar fashion. Do you have a right to healthcare ? Well, answer the question : do you have the duty to take care of others' health problems, completely irrespective of how it affects you personally (for instance, what if it takes up 90% of your time, while still not doing much more than slightly prolonging a miserable short life for them ?).
These questions are not so simple and knee-jerk statements like "right to healthcare, period" are not helpful and will do nothing but get us into a lot of trouble.
No country has "right to healthcare, period". That does not exist. For the obvious reason that it simply isn't feasible. Providing a named (but finite) list of treatments and medicine free of charge if diagnosed by a licensed physician is the furthest any country goes. In some cases that list is pretty short.
I must say, I've read through his points on the CNN website, and I find 2 of them very wrong (capitation, and the shifting of money away from trained doctors into untrained "workers" "aided by computers"). Most others ... perhaps, but I can't see them making a large difference except the ones about medicine.
Capitation brings the insurance industry's incentives (ie. only work with healthy people) away from insurance companies and onto doctors. What is a diabetic to do when doctors just directly refuse to treat them directly (or delay, or ...). And before you say it won't happen because of hippocratic oath, we both know this rule will force doctors to do that for 90% of their time.
For such doctors and facilities getting people with longstanding illnesses that are just going to come in time after time after time and need expensive drugs and treatment, like MS patients (multiple sclerose), is going to be financially debilitating. That's not reasonable and absolutely not what we want.
As for replacing doctors with "workers" (presumably he means not even nurses), I feel like shouting at him. Doctor's salaries are high, but don't represent a decent fraction of expenses. You could give everyone in medicine a 100% raise and the cost would be in the low single digit percentages (2-3%). Let's face it, this is not what we need to save on. And if we are to save on it, let's PLEASE do it the right way: by subsidizing the training of more doctors, not by replacing doctors with idots.
What I keep hearing about US medicine is that 2 things are necessary:
1) legal changes limiting legal liability of doctors (doctors pay 5 digits per month in insurance in some places, money that is paid by patients but is definitely not going to better care). Something like the European system where a doctor can only be sued before a judge if he's found by the local ethics/hospital/national medical/... board (staffed with exclusively other doctors) to have gone overboard.
2) limit the cost of medicine and increase choices (e.g. mandatory licensing, importing of generic drugs, or just outright force the use of a generic alternative if available like a lot of European countries are doing)
This is the only point I agree with Mr. Sachs.
and for a bonus (just for bringing sanity into the system):
3) Outlaw any and all advertising for anything medicinal (something like if it requires a prescription, advertising it = jail time)
You also have to watch out that asserting positive rights that are sometimes impossible to provide (like healthcare) will confuse people when governments attempt to claim that other, deeper rights are "impossible to give." (For example, they might try to argue that they can't afford to not torture, comparing it to how their impoverished country can't give everyone free internet.)
Why is that? If a country tries to claim it cannot afford not to torture, can't we simply point to all the countries that manage without it, as I do for the healthcare debate?
As anyone who lived through the more recent Bush Administration witnessed nearly daily, people claim “not torturing” is an impossible right to give while denying all positive rights—and acted on that argument—so I fail to see the relationship.
Denying every right is the last step of the manuver I'm describing, the first step is to re-define right to mean comfort. Bush-era politics just went straight to step 2 and it didn't work on us.
I suspect that the current UN rights council may be an example of this in action. See: the track record of the members on negative rights, the number of positive rights on their list of rights.
> I'm not sure its fair to argue that universal healthcare is a human right despite the fact it makes economic sense.
“Universal right” is simply that which people feel all people ought to have.
> Humanity survived just fine without real healthcare and healthcare
“Universal healthcare” as a right is simply the right to a certain minimal level which is dependent on technology and resources. The fact that their have in the course of human history been times when no real healthcare by the standards of the early 21st century isn't material to that one way or the other.
> healthcare is not essential to a fair balance of power b/t the government and its citizenry.
That's quite arguably not the case; “government” is an a abstraction than the ultimately boils down to the subset of the citizenry with the most power in allocating resources, and it's quite arguable that that floors for allocation of resources in several domains, including healthcare, are essential for fair balance of power between that subset and the rest of the body of the citizenry.
Further, your implicit argument that a “universal human right” must either be something that prehistoric humans could not survive without or relate to balance of power between people and government is simply a statement of your political values, not a boundary on the what “makes sense” as a universal right.
> Universal healthcare needs to be argued on the economics of the issue because that is the only practical way to make it sustainable.
The actual concrete floor at any given time must be, but then again since every OECD country which guarantees universal healthcare, regardlesa of the details of the system, does it for less total (measured by absolute expenditures, per capita, or per GDP) than the US does spends on healthcare (and some don it for less by all three measures than the US spends in the. smaller public portion of its system alone, let alone the private expenditures), the economics aren't really an issue when you are talking about the US system.
> pressure on hospitals to find ways to reduce prices
This might be the case if hospitals had to actually show their prices rather than sending bills after the fact for a price you aren't allowed to know when you consent to treatment. It might also help if competition were allowed, but for hospitals it is pretty much not in a lot of states. To open a new hospital in many states, you need a "certificate of need", which is basically a document demonstrating that you won't be competing with the existing hospitals. So much for "free market health care".
Everyone on a boat has twenty dollars and absolutely needs an EpiPen to live. You have a supply of EpiPens and want to get as much of their money as possible. There's zero elasticity between 0 and 20 dollars, but you better not charge $21!
Now, imagine that there was only one person who needed an EpiPen, but everyone else was willing to pitch in as much as it took to help them out. If the supplier of the medicine was perfectly evil, the price would be $20 times the number of people.
Perfect self-interest is a pretty good model of any industry, including pharma, so I think this is a good picture of the situation. The ACA was careful to keep something like a market system in place, which is why we're faced with a problem that can be understood with microeconomics.
I'm describing market actors with phrases like "perfectly evil," so I hope my comments aren't coming across as policy proposals. All I was arguing is that uninsured people running out of money was a pressure that used to be restraining the price increases but now isn't.
I really feel like this discussion is suffering from false-dichotomy-itis: I've actually been very careful to avoid saying anything beyond my point, about (say) whether or not single payer is a good idea for the US.
You are taking a huge, basically unlimited risk with your now healthy family. And note that you will probably save at least as much by the discounts you get through the insurance company's networks as by how much insurance pays vs. patient. Example, had a covered but elective heart procedure. Insurance was billed around $220,000. But they got the hospital and doctors to accept less than $20,000. Yes, I paid some of that - but you see it's all in the under 10% part of the bill. Good luck negotiating your bill down 90% on your own.
I do have a catestrophic policy, I wasn’t clear above. Agree it is a risk, but it’s not unlimited. However, The list prices are sham values. Why do you think the doctors would be willing to accept $20k from one payor but not another? Medical billing ultimately becomes a game of persistence, and you can wear down the billing office and reach a settlement that ultimately. Been there, Done that!
Absolutely false to say ACA is not at fault. It’s not solely ACA’s fault, but it is complicit. dramatic annual increases occurred every year after ACA. I’m not looking at statistics but my family insurance premiums over time.
Years ago I purchased private insurance for my family in CA. As I recall I was able to get a plan for my wife with no maternity benefits since we were done having children at that point which was significantly cheaper than the alternative. We were paying something like $400/mo total for a family of 4 with an HSA and $4k deductibles.
Later, after some health issues <cough> first child diagnosed with T1D <cough> we were grandfathered into the private plans and the premiums did not change but the deductible was pretty high and the network was not great.
Later, and this was still pre-ACA - California had guarantee issue health insurance with little or no rating factor adjustment (surcharge) for companies with 2-50 employees. So I hired my wife and we switched to one of those plans. Premiums around $800/mo and $2k deductibles. That was about the time when our 2nd child was diagnosed with T1D.
When ACA passed all CA guaranteed issue small business plans disappeared and everything switched over to marketplace. Silver plans for $2,000/mo for the family and $2,000 deductibles with $12,500 our of pocket max. Basically every spare penny went to healthcare, and then some, and we were slowly drowning in debt because of it.
Finally, I stepped off the treadmill, stopped taking a salary, and we switch to Medicaid. And went from spending $35,000/yr out-of-pocket after tax on healthcare to spending $0.
ACA unquestionably increased premiums and total cost for my family substantially, until I stopped taking a salary and went on Medicaid at which point ACA was a god-send due to Medicaid expansion / cost-sharing reductions.
For a healthy family of 4 ACA is horrifically expensive and acts as an extraordinary tax on middle class families who start earning too much for the subsidies. The marginal effective tax rates are so high, the CBO doesn’t have the guts to publish them with the ACA subsidy phase-out included in the calculations.
Yes, ACA is bad if you don’t care about your others in your country getting healthcare. If you do, then you need to figure out how to spread the costs, and ACA is the best we could get with the legislature we had.
The ACA is bad for people that even do care and even initially supported the ACA, like myself. It has plenty of good parts, but I have to be honest, my choices of insurance options went to almost nothing, and the prices skyrocketed. Part of this may have to do with certain parties in Congress purposely underfunding the ACA to make it fail, so I don't know how much blame goes to the ACA and how much goes to those trying to sabotage it.
However, the fact remains that my health insurance options have generally been worse and more expensive since ACA passed. This year, thankfully, I am on employer healthcare plan instead. Because in my area, with the ACA, there is one provider only, and none of the plans are good, and they're all more expensive than before, and at least 2x what I was paying pre-ACA and with MUCH MUCH higher deductables.
ACA allowed more people to get access to healthcare. This means increased demand. ACA did not increase supply of healthcare. This means higher prices, implying higher premiums and deductibles.
Your options are fewer now because you have to be bigger to able to absorb the costs of the extremely high cost individuals such as those with anemia and premature babies and cancer patients.
Everything you’re experiencing is because more people are getting access to healthcare, and instead of everyone paying for it via higher taxes, we’re paying for it via higher premiums and deductibles.
Only way to bring relief is through more supply of healthcare, which means more doctors (they lobby against that) and more medicine (they lobby against that too).
One solution is to marry a doctor so you can take advantage of the situation.
Simplistic supply and demand analysis does not reflect the complexities of the US healthcare market. There are numerous public analysis of where the costs from our market come from - and they are strongly correlated with the fact that it's a "market" at all.
e.g. the US as more doctors per capita than the UK and Canada - both of which have much lower healthcare costs than the US.
Businesses were screaming about double-digit percentage, year over year premium increases for their employees.
As I see it, the ACA was a very middle-of-the-road policy initiative. Building upon a Republican governor's program, namely Romney's in Massachusetts. It was meant to appeal to and help business as much as uninsured individuals. It was conservative in that it didn't throw out the existing system of insurance; rather, it brought new customers to the existing insurers. Insurers became enthusiastic about increased marketshare.
Law consists of two parts: 1) The law itself, and 2) Paying for it.
Republicans made very clear statements about their primary, number one goal (really, the primary goal of their party and their Federal legislative presence) being making Obama's presidency a one term presidency.
The ACA was passed, in spite of their opposition. But they used their subsequent control in Congress to not pay for an essential component. The law provided two years of compensation to insurance companies for excessive expenses resulting from ACA Marketplace plans. The idea was to provide a buffer -- government security -- while insurers caught up on the population's deferred medical expenses and built an actuarial understanding of the population.
When the insurers sought that compensation, I've been told by a professional working in the industry, they received about 15 cents on the dollar.
Premiums shot up. Companies dropped out. Republicans cited the "failure" that they helped create in the first place.
This isn't the only aspect of the situation, but it's a very significant one.
The ACA wasn't perfect. Work could have been done to improve it. Instead, a lot of political effort went into killing it.
Oh, and as tptacek mentioned, it did bring many costs under more control. Something that benefited group plans such as those provide by employers.
You don't hear so much about that, eh? Or the enormous profits that insurers are reaping, in spite of complaints about the ACA Marketplace plans.
P.S. As I've mentioned before, I'm someone who was denied coverage, at all, outright, prior to the ACA coming into full effect. I had a minor condition that a very well respected surgeon would not operate on, while I was still on a corporate group plan. Risk/benefit favored simply monitoring.
That didn't matter. No insurance for me!
(Fortunately, a professional and personal contact in the industry pulled some strings. Something NOT available to most people.)
P.P.S. I should add that some people think that some insurers may have underpriced their ACA plans a bit, initially, eager to maximize their portion of the increase in market size and relying on the temporary government security for protection. I don't know whether this is true. Even if it is, no law/program is perfect, and the two year timeframe placed an inherent limit on this behavior.
When the repayments came up so short (15 cents on the dollar), this might have magnified the corresponding premium increases somewhat.
But all this was accounted for by the ACA law, including limiting its effect. It just wasn't, subsequently, paid for by the Federal budget process.
And if it is true, it reveals insurer's enthusiasm about the ACA. They wanted the increased marketshare.
Instead of working with this momentum, it was thrown under the bus for political reasons. As I see it.
And it worked for the Republicans, they used it as a wedge issue to regain control and ultimately the Presidency. That in turn allowed them to pick our pockets and hand out tax breaks to the wealthy. The media failed in its duty to protect the public by exposing these dirty tricks.
So you are saying the acceleration of cost went down? It’s bad enough we have to compare health costs on the 2nd derivative. Maybe soon will need to use the 3rd.
No it didn't, it reduced choice and drove up insurance costs by mandating that all private insurance cover everything + kitchen sink. My single brother's cheap catastrophic plan was OUTLAWED to force him onto the ACA exchange. The only thing ACA has done on prices is pass rising costs to taxpayers (more than 80% of ACA participates are subsidized) and the exchanges are in a death spiral because anyone who can escape them is doing so.
Another thing-- the data on prices are a flat out LIE, the government is also making massive payments to the insurance companies directly -- their prices don't reflect their actual costs.
I'm sorry you feel that way, but that's simply not what happened. I cofounded a company that provided insurance to ~40 full-time employees (and provided insurance before the ACA was passed), and the costs you're seeing today are in line with where costs were outside the ACA and prior to the ACA.
No matter what you think about prices, though, the most important thing the ACA did was create a nationwide requirement for guaranteed-issue insurance. However expensive you think insurance is, it's more expensive to be flatly and irrevocably restricted from buying your own insurance at all, which was the status quo ante of the ACA.
Nobody upthread of you is arguing that health insurance prices did not go up after the implementation of the ACA. The argument is that the rate of increase has decreased. I don't know if this is true, and don't have data to argue one way or another, but you and the other people in this thread are arguing about different numbers.
Stating "YoY" gives the false impression that this is the average increase over some number of years. However, this was simply the projection for 2018 and the article provides the reason:
"The price increases are fuelled by market uncertainty and the elimination of key federal payments to insurers."
That price increase was engineered by the GOP by cutting the payments from the budget followed by the Trump Administration's "finding" that they had no authority to spend the money.
I genuinely hope your posts are just virtue signaling created by a desire to appear as one of the faithful.
That article, aided and abetted by the terrible writing in the Brookings article it's criticizing, is comparing apples (the rate of increase) and oranges (the actual increase). There's no controversy that health insurance rates are increasing; they've been increasing dramatically since the turn of the century.
>ACA is horrendous, unless you're receiving a government subsidy.
I'm curious as to why you say "the ACA is horrendous" rather than "The income cutoffs for the ACA subsidies are way too low" - I mean, it seems obvious to me that if you make a median salary and have a family of four that you need some sort of health insurance subsidy, but I don't know where the ACA subsidy lines are, or even if they vary per state or not.
I personally am in favor of just expanding medicare or medicade so that everyone can use them to get minimal health care if they need it. I mean, sure, if you have money, you probably still want private insurance on top of that, just like retirees today, but we've got a reasonable system for giving everyone over 65 a minimal level of care, and healthcare for younger people is a lot cheaper than healthcare for old people, so it seems like a big rich country like ours should be able to cover that bill.
but I don't think that is politically possible. I think this last election was in some ways a referendum on the ACA, and I would interpret the results as saying that many, if not most Americans think that you should only get healthcare if you can pay for it. Which seems weird to me, because as you point out, if you make anything like average money, healthcare for a family for three or four is impossible to pay for without a subsidy.
>I'm seriously considering returning to wage employment for health care benefits.
In the days before the ACA, I'd just get a full time job every time COBRA and CAL-COBRA ran out, because I couldn't get a plan at all without. I mean, I was happy paying $6K/year just for me, and that's what I'd pay under COBRA or CAL-COBRA but, once that ran out, nobody would sell to me. Maybe I wasn't asking the right people, but it wasn't like they came back with high numbers, they just said they couldn't cover me. It was weird, because while I did have a chronic condition or two, none of them were particularly dangerous or unusual.
In 2016, I decided to take off from work and travel outside the US. I did what I thought was the responsible thing and purchased a travel insurance plan. In total, I was gone for a year...I had an amazing trip.
When I got home, I wanted to sign up for insurance again. But since it wasn't a life event, I wasn't eligible to enroll until the open enrollment period. And when that time rolled around, I wasn't eligible for the subsidized plans because I hadn't gotten a job yet and my monthly salary was $0/mo. Nevermind that I'd done enough contracting work during my trip such that if you divided my annual earnings by 12 to arrive at a monthly earning, it would've easily qualified me for a subsidy to stay on a plan that let me see my previous doctor. But I did eventually get signed up for Medicaid for the month between open enrollment and when I found a job, so...yay?
Then tax time rolls around and, it turns out, you need to be out of the country for 11 out of 12 calendar months to qualify as a non-resident. Since my trip didn't start on Jan 1st, despite being out of the country for an entire year, I didn't qualify as a non-resident for either 2016 or 2017 and had to pay the ACA penalty for the entire time I was gone because I didn't buy health coverage that would've only been useful in a country I wasn't present in. And adding insult to "please don't let me get injured", I had to pay a penalty for the time I was uninsured between when I got home and open enrollment.
In short, I feel like the ACA was rushed and they never seriously considered what was right for people not working a 9-5 job getting regular pay checks. By deciding to opt out of the workforce and do my own thing for a while, even doing it responsibly, the ACA cost me thousands because I somehow managed to find corner cases that were simply not considered or poorly handled by those writing the bill.
So there's a lower bound on how much you can make and still get the subsidized plan? that seems broken in a very American sort of way.
I think a lot of the bureaucratic issues might be the nature of insurance companies? My (pre-aca) experience was that any lapse in coverage and they don't let you back on. All this 'life event' stuff, I think, was part of how group plans worked back in the day, the rules about when you could change things and when they could kick you off.
I guess what I'm saying is that (aside from charging you the extra tax) I don't think it's worse than it used to be.
There is a lower bound on income to qualify for ACA subsidies because the ACA also expanded medicaid to cover people below that threshold.
Unfortunately, the portion of the ACA requiring states to expand medicaid was ruled unconstitutional. As a result, 19 states have choosen not to expand medicaid, leaving a portion of the population to poor to qualify for ACA subsidies, but too rich to qualify for medicaid.
I should also point out, that the medicade expansion is 90% funded by the federal government starting from 2020 into perpetuity. Prior to then is a ramp up period where the federal government pays an even larger share.
Am I right in thinking this is uniquely American? The states that need welfare the most seem to be most strongly against said welfare, even when the more wealthy states are footing most of the bill.
There was a similar thing here in the UK with the Brexit vote - the regions that got the least money from the EU voted most strongly to remain and the regions that got the most money voted to leave:
Once open enrollment rolled around, yes. But the point was I didn't want Medicaid, I wanted a plan that let me keep my previous doctor. And I was willing and able to pay (savings), but the ACA didn't allow me to take the subsidy in lieu of Medicare. And also, there was the matter of the nearly 4 months between when I returned to the US and when I was allowed to enroll during open enrollment. For a law that's designed to help people get healthcare, mandating that someone wait to get healthcare seems like an odd choice.
How do you make sure you're actually getting catastrophic coverage for $3k? The information asymmetry between insurance providers and customers heavily incentivizes the creation of "value" plans that achieve their "value" by appearing to cover more than they actually do. Since only a tiny fraction of customers ever make catastrophic claims, most people will be unaware that they are buying garbage even if a policy were to never pay out (100% lemon-drop rate). Is your due diligence sensitive enough to pick up even a severe 50% lemon-drop rate (affecting, say, 0.5% of customers)?
Last year I didn't care because I couldn't afford the ACA, and Christian Medishare met the Obamacare requirement to carry insurance or face a tax penalty. The "health care sharing ministry" operates differently than insurance, my concern isn't denial of coverage but that the entire enterprise will collapse.
https://en.wikipedia.org/wiki/Health_care_sharing_ministry
I'm not totally clear on the different situations here. I thought the tax penalty was only about $3k for even fairly wealthy families (family of 4, $150k/yr salary). It sounds like you felt you couldn't afford ACA insurance ($17k) and couldn't afford to pay the penalty either, so you went out and purchased $3k of "insurance" you don't actually have any faith in and didn't really want. Am I confused about the penalty amounts? Or you just felt that if you were going to pay $3k, you might as well give it to Christian Medishare?
We moved to Samaritan Ministries and have been really happy with it. Our “premium” is $500/mo and our total out of pocket costs have just been checkups and misc small prescriptions. Our two major medical incidents have been 100% covered by members and we got some nice cards in the mail, too. I estimate we have saved about $20,000 without increasing risk (possibly reducing it since the uncertainty of the claims process is gone.)
It’s been nice to see that a well designed system can help people take care of people so humanely.
$18,000 doesn't sound large, relative to the high prices we all pay. I have a good solid job, and my family plan is $24k per year. That's the most basic family plan my employer offers, but it isn't a high-deductible plan. Of course, most of that is paid by my employer, so I only pay about $4k directly out of my salary. If you are self employed, then you obviously have to pay the employer part too.
For a little perspective, I supported a family of 3 on less than $18k last year and we only had partial coverage. Even though we were homeless for most of the year, the ACA penalty is pretty painful. I am in the midst of filling out my taxes.
For a great many Americans, the figure you brush off as not particularly large is an unimaginable amount to come up with for insurance alone.
I agree, $18k for insurance, or $24k, is an enormous burden for most Americans. I was just trying to point out that that the ACA price the parent was calling an outrageous seemed completely inline with every other insurance policy I have ever had, ACA or not. Insurance in the US is just plain expensive, no doubt about it.
For 3 people, the federal poverty level is $20,160. $18k is less than that, and in California, you would have been on Medical. Even if you are on Obamacare, not Medical (in California: 138% of fpl and up), under 200% fpl the silver plans are close to free.
I don't really understand your point. I will note that since I could not afford housing for most of the year and struggled to get enough to eat, close to free is not cheap enough.
$18,000 for a family is high but within the range of what insurance costs today. Family coverage on the small group market (<50 employees, which is where Matasano was at), which approximates the individual market in price, was ~$1100/mo a few years ago.
(I just looked it up and, weirdly, average premiums on the large group market in 2017 were higher than those in the small group market; on the small market, they're around $17,000, and in the large market, $19,000).
That’s still roughly the case, I work for a medical billing company owned by a physician group, we have a pretty large group and are essentially self-insured.
I pay ~$220-ish a month for my family of three, the company pays $800+/mo. Boy am I glad to work for a company that pays such a large chunk of my benefits, many other places cover maybe 50% of your dependent costs.
You're still the one paying the $800, the only benefit is you get to do it with pre-tax money. It's not like that money comes out of the aether, it's part of your compensation.
Yes, but taken in context it’s still a huge benefit. You have to keep in mind we have a lot of employees making much more median salaries, a medical biller or coder making in the mid 10’s to low 20’s an hour gets the same benefit I do as a $89K/yr DevOps engineer.
The injustice of the system is that self-employed have to pay with after-tax dollars while your employer can deduct the cost of providing those benefits.
Any HN conversation that starts out as a debate about Obamacare and ends up saving someone a few thousand dollars a year is a good conversation, so you are very welcome.
Health insurance prices are a nightmare. Please don't let me come off as sounding like I don't think they are. The goal of the ACA was fix that problem, and though it fixed some very important problems, it surely didn't fix that one.
I think personally that the ACA is a great step toward affordable health care. We really need ACA++ that would address these small issues but unfortunately we probably aren't going to get it passed within the near term.
Repealing really isn't an option (due to the near impossibility of repealing an entitlement) and the public doesn't want that either. I don't know how you would fix the issue that the loss ratios will be more skewed negative since the fact that sick people pay more attention than healthy people for insurance (even when you introduce tax penalties).
Interesting! Are there no other options available? This is clearly an inferior option for the self-employed. I'd go with another provider with a higher premium and without this curious shares thing. How is that legally not health insurance? Baffling. What state are you in?
It's just the cheapest one to set up. I was assuming that if someone's self-employed and not deducting insurance, they're probably a sole proprietorship, and are probably sensitive to accounting costs.
You can typically deduct 100% of your health insurance costs if you have a sole proprietorship. It doesn't matter how you're self-employed, as long as you have no other coverage and your business income funds the insurance, then you can deduct 100%.
No, that's one of the wrong assumptions / myths I'm pushing back against: LLC is _not_ necessarily the cheapest to set up. I'm the sole employee of my Massachusetts S-Corp, and it was both less expensive and better tax-advantaged.
As I understand it, and your accountant is an expert while I am not, you have to be actually self-employed --- not moonlighting or doing side-work, with your money all coming in through the LLC --- and your spouse can't be eligible for group coverage through their job.
You should maybe ask your accountant why you couldn't deduct, then? I know there are conditions, but this is one of the better-known self-employment deductions.
18k for a small business is typical. My mom pays much less than that because she doesn’t even make anything near 18k. For a small business it limits who you can hire because their take home pay would be 0.
Basically what I’m saying is the loss ratio for a bigger pool will be much lower than a smaller one. For insurance companies who charge premiums if you are in say a Bigcorp sized pool compared to a small business size pool the bigcorp pool will be larger and can have smaller premiums .
I believe it completely, since it's just a small figure off what companies were paying for group coverage several years ago. The problem isn't that the figure is unbelievable; the problem is that the causal link being suggested isn't real.
As a Canadian observer I don't understand why Democrats don't go after the small business angle of single payer much, much harder. Don't get me wrong; the lack of health care for poor and at risk populations in the US is a complete disaster, but that argument hasn't swayed the debate for decades now, so it's time for a new approach.
Health care being tied to employment is anti-startup and anti-small business, full stop. In countries with single payer (or similar) systems you can change jobs without any impact to your coverage, you can start a business knowing your family's health and financial future won't be affected.
Democrats do not all want single payer healthcare. Only the left wing of the party really wants it, although this is slowly changing.
Center and center-right Democrats are pretty happy with the ACA as it was intended, although often not as it actually turns out in many states. Unsurprisingly, a lot of them take big contributions from insurers and pharmaceutical companies.
I think if single payer becomes widely accepted within the party, you probably will see the "helping entrepreneurs" angle as a big part of the messaging -- individual candidates do bring it up.
Ideologues on both sides have very specific ideas for how health care should be structured, but I think that most people on both sides can agree on basic principles: health insurance (if that's what we have) needs to be guaranteed-issue, premiums have to be reasonable, and pricing needs to be transparent. One thing the ACA got right is the name of the bill.
I dunno, the poor get medicaid which is great insurance. The real problem is that they are too poor to utilize it. The other issue is that medicaid has a state component so you see drastic differences in implementation even though there are Federal minimums.
Correct, anyone who plans to start their own business needs ACA. You might think "But if I own a business, I can buy insurance through it". What if you fail? What if you succeed moderately and sell it for a few million? What if your investors fire you? What if you get sick before it succeeds? What if your spouse or children get sick before it succeeds?
Pre-ACA - California had guarantee issue health insurance with little or no rating factor adjustment (surcharge) for companies with 2-50 employees. Definitely took advantage of that at the time!
This is a good article, but it only shows a few parts of a much more complex whole, and extrapolating from these anecdotes to a broader system is not really accurate
Many hospitals lose money on every Medicare and Medicaid patient. The only reason they survive is because they can charge private insurance companies more. So hospitals and health systems have been consolidating to strengthen their negotiating position against insurers
This article paints Medicare as the good guy, private insurance as evil, and hospitals as mixed. The reality is more complicated, and more regional, but overall healthcare is a zero sum game today between payers and providers fighting for dollars, and power comes largely from scale. In geographies where payers are bigger and stronger, they push hospitals and force many to consolidate or die. In areas where hospitals are stronger, they basically dictate price and rates can skyrocket
There's a lot of bad stuff happening on all sides, and it isn't clear that private insurance is always evil. If we become a single payer society, small providers that are struggling to survive will probably be the first to die, and providers will probably consolidate much more aggressively into massive national chains, like the Walmart of healthcare
The cause of a lot of healthcare issues is not one particular party (insurance, Medicare, hospitals) but a system that encourages monopoly seeking behavior without any good mechanism for regulating this
I think it'd be a good sport to make hospitals eat denied claims. If two giant institutions want to argue about whether something is covered, the patient should not be the loser.
We should also better fund Medicare and Medicaid. Taxes should be apparent.
It’s more complex. Medicare is outcome-based. Providers who do a shitty job don’t get paid, which is why hospitals complain about reimbursement.
Medicaid is like an ATM machine for providers in many states. There is usually little or no correlation between outcome and payment, and poor fraud controls. That’s why you always hear about providers in NYC and Miami who “visit” 900 patients a day. Additionally, you have the institutional racism aspect of Medicaid where services are unavailable in some red states.
IMO, the biggest issues in healthcare are for profit institutions and insurers and the trade guild practices associated with Doctors.
Single payer or regional systems supported by taxes are the way to go. Medicaid should be an institution that is replaced by something better.
The market would work better if everyone was paying the same prices without "denial-based" inflation.
I think the solution would be to give citizens disease/disorder "endowments." i.e. a yearly health stipend account - it's money they can spend at doctors, but they can't spend on unrelated goods/services (i.e. food). On top of that, additional "stipends" for major life ailments. The trick would be in finding budgets for those stipends. Once individuals have money, though, they have the ability to do the relative value assessment for various treatments.
actually, most medicare is not outcome based today, although that is the vision.
"value based care" has many meanings. simply using patient satisfaction surveys can be considered value based care, while participating in a double sided risk sharing ACO also qualifies. as of 2016, only 36% of physiicans participated in ACOs, under 30% in patient centered medical homes, 31% in bundled payments (which only impact a subset of diseases). howver, 75% used patients satisfaction surveys, 55% used PQRS, and 64% achieved meaningful use [0]
so the reality is that outcomes based care is still the minority, and real risk-bearing (two-sided risk sharing, full capitation) arrangements are even less common. most care is still reimbursed as FFS. and even as value based care is becoming more common, cost of healthcare is still not decreasing
and yes, medicaid can be fraudulent in some cases, but not always
a lot of hospitals do eat denied claims. look at this [0], the annual financial report for HCA, the biggest publicly traded hospital company. ctrl-f for "provision for doubtful accounts". this represents denied claims / treatments for uninsured patients. this is ~7-10% of revenue.
now look at EBITDA, a common metric representing cash flow. look at EBITDA / revenue, ie cash profit margin. this is around 20%, which is massive. this profitability is around the level of big tech and big pharma. however, most hospitals in the US have almost no profit. the profitability of large hospital companies is mostly due to their bargaining power. in fact, a decade ago, big hospital systems were some of the best private equity / LBO investments, bc they were massively profitabel, stable businesses that could take on a lot of debt. and this is before the ACA
before the ACA, this was even worse, especially for smaller hospitals. see [1], financial statements for Community Health Systems, a massive (but smaller than HCA) public hospital company, from 2009. for some hospitals this figure was 30% or higher
the problem is that not all hospitals are equal. the companies i mentioned are some of the biggest, most powerful hospital companies. however, many hospitals are completely different (often independent urban hospitals), and just bleed money. sometimes its because they have more under/uninsured pts, sometimes its because their contracted rates are lower, sometiems its bc they dont have enough commercial pts (instead having more medicare / medicaid). so a blanket law making hospitals eat more costs would just help the rich get richer and kill the little guys
i worked in investment banking and these big hospital systems were some of our best clients. a business that can write of 10-30% of its revenue as bad debt and still generate 20-25% profit margins is an incredible borrower, and we'd underwrite multi billion dollar bond issuances for these companies, so they could issue dividends to shareholders, and because they were so profitable they could afford tons of high yield debt without breaking a sweat
Did you get any sense of how they ran their businesses?
My doctor was part of a medium sized practice that was swallowed up by a big regional system. Since that acquisition, they make the .gov that I work for look efficient and streamlined. They literally added 5-6 non-billable staff to an office that was staffed by 2. Per my doctor, that’s typical in most offices!
Most of them focused on two metrics: 1) increasing inpatient admissions (ie volume) and 2) increasing surgical volumes (biggest profit driver in HC services). To increase inpatient volume and surgeries they often buy outpatient clinics so they can control that patient flow. So they often view primary care as a loss leader that is directing patients to the profit center of surgeries. If those nonbillable staff are optimizing billing, or generating / managing patient flow, they are accruing profits to the health system even if they are losing money for the individual clinic
Negotiating good rates with payers is a top priority and a lot of strategy derives from that (which is another reason why they bought your doc: if they control all patient flow in and out of hospital, they have more leverage with payers)
how does your doc like working for a big health system?
It seems like they can direct book specialist referrals, so I guess that’s where the money is.
My doc hates it — they built a good practice and did a lot of innovative stuff. Now it sounds like 10/10 on the awful bureaucracy scale.
The only happy doctor I know is an eye doctor who pays the fine to Medicare instead of putting in an EMR. He keeps the staff minimal and avoids overhead like IT. According to him, all of his colleagues with the big systems are miserable, working 80 hour weeks and probably 50% have alcohol or other substance problems.
Is the doc you're speaking of a primary care doc or specialist? I've been working with some PCPs to try to find new models that allow them to remain independent without sacrificing too much financially. It's a tough needle to thread but I think happier, more independent primary care physicians are a good way to start righting the healthcare ship
Private, for profit insurance is almost certainly always evil. Their margins are dictated by how much they can delay or avoid coverage. That pretty much defines evil.
Medicare is why hospitals exist, period. Private insurers make it as difficult as possible to stay in a hospital, because they are more expensive and usually result in worse outcomes.
Reimbursement rates are being squeezed because there is a glut of hospital beds. As a result, hospitals, designed to operate with higher overheads, are losing money.
There’s a whole web of bullshit where the lack of universal coverage and rational allocation of resources results in strange behaviors.
> Medicare is why hospitals exist, period. Private insurers make it as difficult as possible to stay in a hospital, because they are more expensive and usually result in worse outcomes
this is not true. check out the annual financial reports for the UC hospital system as an example [0]. the majority of revenue comes from commercial payers. looking at data from HCA (largest public hospital company in US) tells similar story [1]. this is despite the fact that medicare patients are more costly overall
the bigger issue, however, are the margins. in 2010, UCSF, UC Davis and UCI had 3.5% profit margin for medicare, -27% margin for medicaid, and 21.8% margin for commercial. for UCLA they had -30% profit for medicare, -36% for medicaid, and 34% margin for commercial. private insurance literally subsidizes public insurance here. without private insurance, those hospitals die [2]
looking at other hospitals id imagine it is similar, though dont have data offhand
as to the reimbursement rates being squeezed bc of glut of beds, i dont think that is true and have seen data in the past to refute it, though i dont have the sources offhand.
Note that you never mentioned person who actually receives service. IMHO problem is exactly that - none of players you mentioned truly interested in long term cost control. Some might just care about short term budgets, but otherwise all of them will pass it down to the consumer. And consumer being on their own, with little to no competition and information asymmetry has very little leverage..
I agree. The current players in the healthcare system view people as numbers, and that is terrible. Doctors are the most natural patient advocates, but unfortunately physicians' ability to influence healthcare, on a system or patient level, has decreased significantly in recent years.
I would love to see (and am hoping to build) solutions that give more power back to doctors and patients, and focus on patient experience and outcomes.
I know that a lot of consumers want to take their health decisions into their own hands, and I support that, but i think most people want help from an informed professional who is on their side (ie not controlled by a hospital or insurance company with competing interests)
Allocating healthcare resources is numbers, and there is nothing wrong with that. If you want to decrease costs, then increase the supply of healthcare. Healthcare = doctors + medicines + equipment, so all you need to do is increase that supply. However, you’ll find that the doctors don’t want to increase their supply and they’re very effective. Drug manufacturers also don’t want to increase supply, and they’re also very effective.
I'm an Econ major so am totally on board with being analytical about allocating resources, but it's not quite as simple as just increasing supply
Healthcare services (doctor salaries + facility overhead) is 80%+ of US healthcare spend. At first glance increasing supply of doctors seems reasonable. But how do you do that? Number of doctors (esp primary care and mental health) has been declining because of decreasing reimbursement / payment and increasing burnout. Being a doctor requires a decade or more of making no money, working long and unpredictable hours, and tremendous stress -- literally making life and death decisions. Can't just spin up supply overnight. To really increase supply you'd need to increase doctor salaries or decrease the cost of becoming a doctor. The former would not reduce costs, and the latter also is not ideal
One perhaps better way to increase supply is by rolling back consolidation. So same # of docs, but more independent practices. Another way is letting nurses / others practice at the top of their licenses, although I'll grant your point that physician societies sometimes make this hard. Also, one could argue that having more work done by low cost providers would encourage more volume and potentially unnecessary care
The main overarching issue though, even if it was as simple as increasing supply, the healthcare system in the US is not designed to optimize cost efficient care. It is designed to maximize profit and regulations arent optimized around this. So when hospitals view patients as numbers, the implication is that they will milk every last dollar out of a patient (30% of healthcare spend is unnecessary care). Insurance companies are incentivized to deny as much care as possible. No organization with any power in the system is incentivized to view and manage healthcare costs in an optimally cost efficient way
Many (most?) of these “losses” for Medicare and Medicare claims is due to administrative bloat at hospitals. If the fixed that, then the amount of money they receive from these types of claims would be less of an issue, imho.
US healthcare (and education as well) are massively bloated with an abundance of low value-add administrators. These bubbles need to burst.
This story is couched in terms of how bad things were before Obamacare, but I’d like to point out that things aren’t great now either. To prevent Obamacare from bankrupting them, insurance companies are resorting to legally dubious mass-denials, one of which affected me personally.
A few months ago, I woke up the next morning after eating some fast food and began vomiting. I couldn’t stop throwing up, and I couldn’t eat anything, for 2 straight days. I had a 101 degree fever at the worst point. At the beginning of day 3, when I vomited so hard that I passed out for a few seconds and fell on the floor, I went to the ER. They gave me IV fluids and anti-nausea medication, which worked.
About 2 months later, I received a letter from my insurance company (Anthem). They had determined that my situation didn’t qualify as an “emergency,” and therefore they were denying the entire bill for this ER visit. I have appealed, and so far it has not been overturned. I am now on the hook for thousands of dollars, even though I had already covered my entire deductible for the year.
I thought that this had to simply be a mistake, but then I learned this is actually a new policy that insurance companies are implementing in the era of Obamacare [1]. Patients are expected to self-diagnose whether or not their situation meets their insurance company's definition of an “emergency,” and are rolling the dice as to whether or not an ER visit will be covered.
> To prevent Obamacare from bankrupting them, insurance companies are resorting to legally dubious mass-denials, one of which affected me personally.
What does the policy has to do with Obamacare? Completely unfair denials obviously happened before the ACA (see: this article), and the idea that Anthem is doing this to stave off bankruptcy is laughable (just see their financials since the ACA was enacted).
It seems to be happening more and more post-Obamacare. Further, this is an actual policy now, and this policy was created post-Obamacare (my incident occurred in Nevada, where they have not received permission to deny these claims like they have in other states, so apparently they feel the need to roll it out nationwide without telling anyone). There was no need for the policy before, but now apparently there is in an Obamacare world. But they can't expect people to diagnose themselves and determine whether or not a situation is an "emergency" under insurance company rules, since the symptoms of many non-life threatening conditions feel like they may be life threatening.
Unfortunately, in capitalist economies, when you use the law to put the hurt on companies, they will pass that hurt onto unsuspecting consumers. The money will come from somewhere, and it's not coming out of executives' pockets. Perhaps this is why Nancy Pelosi urged lawmakers and the public not to read Affordable Care Act before it was passed it into law [1]. Had everyone read it, they would have known that problems like this would eventually arise.
The fact that this cost that much is alarming too. I get that the staff and bed bay aren’t cheap, but the consumables for the situation you describe would probably cost less than $10, and at bulk buy prices perhaps on a couple of dollars.
True, but as patients we obviously have no control over that. Also, ironically, if my insurance had simply processed the claim as they were supposed to, they would have paid far less than I'm being billed. ER cash prices are purposely inflated because insurance reimbursements are typically 1/3rd or less of the billed amount. But when the claim gets denied, they come after the individual for the full cash price.
Call the hospital and offer to settle. They will cut the price almost certainly. Almost anything they can get you to pay will be more than they will get selling the debt to a collector.
Thanks for the advice. If all of my appeals are denied, I will follow it and try negotiate the price down. In any event, this won’t be a catastrophic financial event for me. But it sucks that it is happening to so many people under our current insurance regime, and not not all of them can handle it when their insurance decides not to pay.
It's interesting that you mention that. I have Blue Cross, and I've been dealing with seemingly procedural denials every month for a chronic condition.
It's getting to the point where I'm genuinely thinking there is some bad faith activity going on.
There's more likely than not some bad faith activity going on. They are essentially watering down what it means to have insurance, since they are required to sell it to people that they wouldn't otherwise have and are trying to make up the difference. One way or another, we're all paying drastically higher expenses than we would have before. If I have to pay the denied claims in my case, I'm looking at a $9800 out of pocket expense, on top of the $5K/yr premium I pay as a healthy nonsmoker.
Anthem pulled out of my state altogether for 2018, so I also had to switch providers at the beginning of the year (this claim was from late 2017). I think that's another reason they are giving me issues with this claim - they simply don't care because they no longer have to deal with my state's insurance regulator.
The new insurance provider (which was the only choice I had in my area, regardless of price) so far appears to be even worse and more expensive. Something has to be done about all of this. I don't pretend to have the answer, but the ACA was apparently not it.
It's hard to believe that the country is putting up with a system that can bankrupt you any time you get sick and there is pretty much nothing you can do other than being lucky or having a lot of money already. The actual medical care is fine but the billing practices are just ridiculous. I would call them fraudulent in a lot of cases.
Is it really hard to believe though? The ones who are lucky and have the money are fine with the situation. The unlucky ones with no money are too busy fighting diseases, insurance companies, and bill collectors, they don't have time to change the system. Dealing with insurance when you have a serious illness is a full time job. The people who need change most are literally fighting for their lives. Meanwhile, healthy people in America think "Gee, why should I have to use my money to pay for someone else's healthcare? What do I get out of it? I'm rich and lucky after all".
The richest don't even understand what health insurance is as a concept. I mean, just look at what our own President Billionaire has to say: "Because you are basically saying from the moment the insurance, you're 21 years old, you start working and you're paying $12 a year for insurance, and by the time you're 70, you get a nice plan." [1] What does that even mean? Or our Speaker of the House: "The whole idea of Obamacare is...the people who are healthy pay for the...sick. It's not working, & that's why it's in a death spiral" [2]. That's literally the entire point of health insurance. This is what we're dealing with here.
"The whole idea of Obamacare is...the people who are healthy pay for the...sick"
This is the whole point of health insurance! What a stupid idiot (I am overly nice to Paul Ryan. His budget plan was the most ridiculous thing I have ever read).
I'm sick of people making this comment because it's flat out wrong.
Insurance is about lowering variance, not about subsidizing high risk. The ACA tries to make insurance affordable for everyone, and in the process, some people pay less than their actuarial cost and others pay more. That is not just insurance, it's forcing people with a lower actuarial risk to subsidize those with a higher risk.
Insurance is about taking the chance element out of something that is inherently probablistic because the rare event would be catastrophic. By pooling risk, you make things more predictable. But everyone is still paying for their own, individual share of the risk pool.
I'm not arguing that we shouldnt, as a society, ensure that everyone can afford health insurance, but we shouldn't pretend that "it's just insurance" because it's something entirely different.
You seem to be making an argument based on “semantics” here?
The idea of extending an insurance program into a mechanism for subsidizing those who can’t pay the premium does not mean it magically transforms the program into a totally different thing.
In the limited definition, it is still the case that the healthy pay the cost of sick.
The extension of the concept of insurance fits semantically, because it is based on the idea that there is an element of chance inherent in who gets sick; getting sick includes many factors that are outside the source of an individual’s contol (as well as factors that are within an individual’s control).
The ACA included a “tax,” among other methods to socialize the cost of covering the “premiums” for those that couldn’t cover them on their own.
The whole system relied on the same actuarial principles as the previous system to smooth out variance in costs to individuals.
Paul Ryan sounds like an idiot here, because he is a mealy mouthed politician, who doesn’t have the courage of his convictions.
Ryan is libertarian minded tool, whose real opposition to the ACA is not that the healthy pay for the costs of the sick. His opposition is to the elements of the program that force wealthier members of society to cover the medical costs of the poorer members.
Yes, it's semantics...no quotes needed, that's what it is. But it's also people trying to make other people look stupid by being wrong, and they deserve to be called out for their improper semantics.
It's not "just insurance." That's not "what insurance is." We're talking about a form of socialized medicine, not insurance. That's the correct terminology. Anyone arguing for anything between Obamacare and Medicare For All (which includes me, BTW) needs to own up to that terminology or something to that effect and stop selling the notion that what they're arguing for is just insurance.
Insurance, as a concept, doesn't shift the burden for risk from people who can't afford to pay to people who can. It's something different and you don't get to alter definition of insurance just because the correct terminology has a stigma. So when the comment I replied to says,
> This is the whole point of health insurance!
No, it's not. That's the whole point of socialized medicine. Words have meaning and we should be using the correct ones.
It’s true “Obamacare” is a form of socialized health care. But the bottom line is that it chose to implement the subsidization of poor peoples’ health care through the mechanism of health insurance. It’s simply not the case that poor people included into the plans are having their care covered through the mechanism of increasing the premiums of the healthy, which is what Paul Ryan is implying.
Poorer members of the insurance pool have their premiums subsidized. From the insurance companies point of view, they are (theoretically) managing the pool and premiums using the same actuarial tools they used previously.
The rules about not being able to reject people for pre-existing conditions force them to broaden the set of (heterogeneous) members included.
The plans are provided by “health insurance companies.” The product you buy from them is called “health insurance.” The imaginary, purist notion of what you are declaring to be “insurance” is like a simplified model of economic theory you might find in a textbook. It’s used to gain insight about how an insurance product works. There are no real world example of “health insurance” that conform to your simplified definition.
Health insurance in the US has long included coverage for routine care, which already falls outside of your model.
I’m of the theory that the meaning of words is defined by how they are used in everyday language, not how I think they should be defined.
> because it is based on the idea that there is an element of chance inherent in who gets sick
That statement is true, but health "insurance" covers lots of non-chance things, because it covers lots of things that are not a result of "getting sick". Some examples:
* Birth control.
* Basic childhood vaccination.
* Well-child checkups.
* Annual health checkups for adults.
* Basic screening tests for adults (mammograms, colon cancer
screens, that sort of thing).
All these things should be provided, imo; insurance is the wrong vehicle for providing them. Politically, I _think_ (hope?) there would be a lot more support for "provide all children with basic health checkups" than there is for the ACA. Of course there would be less support for the "birth control" item, which is why people like to bundle these all together, and with things like emergency medicine and end-of-life medicine. Which are _also_ quite different in terms of their risk profiles, tradeoffs, and elements of chance.
It also covers some things that in an ideal world would not be chance but are in practie (e.g. routine births with no complications; they are more chance than they should be because as a society we suck at birth control, on both the organizational and personal level).
I really wish we separated our "health care" a bit more along some of these axes, because I suspect that the "right" answer is to have single-payer for some aspects of it, an insurance scheme (private or public or both) for other aspects, and "you're on your own" for still others, with expensive and invasive end-of-life interventions heading this last list.
That is the whole point of socialized medicine. The point of insurance is that you pay slightly more than the expected value of your claims. So if you know you need $5000 worth of medical treatment for asthma, your insurance premium should be definitely more than $5000.
This bizarre obsession with using the phrase "insurance" and insisting on a product that is not at all insurance is probably why the US health-care system is so fucked.
> That is the whole point of socialized medicine. The point of insurance is that you pay slightly more than the expected value of your claims. So if you know you need $5000 worth of medical treatment for asthma, your insurance premium should be definitely more than $5000.
How does that make sense? If I knew I needed $5000 worth of medical treatment for asthma, and I pay an appropriate premium based on that, but then I get cancer..... well then someone else is going to have to pay for that, because my premiums certainly won't cover the cost of cancer treatment.
You’d pay the 99% chance of asthma * $5,000 + 1% chance of cancer * $50,000 (or whatever the probability you get cancer * the estimate of cancer treatment costs).
If you do get cancer, the other 99% of folks who didn’t get it are covering your costs.
> If you do get cancer, the other 99% of folks who didn’t get it are covering your costs.
This is exactly my point, but it's this mechanism Paul Ryan said wasn't working. @powera claimed this is not the point of insurance. These things seem like exactly the same thing to me, so help me understand the nuance.
It’s the asthma for which you are near-guaranteed to need $5,000 worth of treatment for that’s the issue, not the small chance you get cancer.
You’re not looking to insure against the chance you get asthma: You have asthma, and you’re looking for someone healthy to help pay for it. If too few healthy people sign up for Obamacare relative to the sick (and remember, all else equal, they have to be charged the same regardless of their health) those healthy folks will get an increasingly bad deal as their premiums are covering the costs of more and more sick enrollees and more and more healthy folk drop out of the exchanges. That’s the “death spiral”.
The known cost isn't really insurable. A premium based on expected costs would include the full amount of the known future costs and also some amount for less predictable costs.
Okay, now we're getting somewhere. Let's stay with the example of asthma. I pay a premium based on that condition, and the expectation that maybe one day I'll get cancer. Sure, I can understand that.
So then I get cancer, and the bill is more than I can afford. Where does the money come from? Not my premiums, because I've only been a subscriber for 3 months, and my premiums won't even cover the cost of treatment for a week of cancer treatment. If someone else isn't paying for me, and I'm not paying for me, who is paying for my treatment?
Other people do pay for the cancer treatment. Make up a pool of, say, 1000 people. Make up a cancer rate of say, 5/1000. Make up an asthma rate of say, 50/1000.
The people that are going to get cancer are unknown, but the whole group is willing to pay 0.5% of the cost of cancer treatment for a contract that covers 100% of the cost.
The 950 people that know they don't need expensive asthma treatment don't really want to pay for contracts that will cover expensive asthma treatment, so (in a pure insurance market) either the cost has to be included in the contracts for the 50 that do have it or the treatment can be excluded from the contracts.
You don't have to own a car. Everyone gets sick at some point, and everybody dies of something. Whether that's cripplingly bankruptingly expensive or not is partly the point.
Although I suppose if the singularity happens, that will also solve the health care crisis in this country. (sarcasm)
Your EV from holding a car insurance plan is slightly lower than if you’d put that money in bonds. The benefit is that you can spread your risk across multiple parties. It’s entirely different from medical insurance, where your EV depends strongly on individual circumstances (and can be very negative). Medical insurance providers aren’t allowed to give accurate pricing, so you basically end up with a really complicated subsidy program.
" Medical insurance providers aren’t allowed to give accurate pricing, "
Why are they not allowed to do so? I think it's more likely that they don't want to so they can make up prices as they wish.
"Your EV from holding a car insurance plan is slightly lower than if you’d put that money in bonds. The benefit is that you can spread your risk across multiple parties. It’s entirely different from medical insurance, where your EV depends strongly on individual circumstances (and can be very negative)."
This is exactly the same as health insurance. Spread risk over many people. EV depends on individual circumstances (driving skills or health). If health insurance is healthy people subsidizing sick people, then car insurance is good drivers subsidizing bad drivers. I don't see the difference.
But with auto insurance, if you're a bad driver, or even a driver with perceived higher risk (teen, unmarried, driving a little red sports car) your rates will be quite a bit higher. If you're a low risk driver, your rates are low. With ACA, if you are low risk (young and healthy) you are paying more than you would have otherwise.
This is a serious misunderstanding of what insurance is. Insurance is a net benefit for society because it linearizes individual risk curves even if you have to pay in proportionally to your expected costs, not because it makes less risky people subsidize more risky people. Perhaps you should avoid calling people “stupid” for misunderstanding insurance.
And by what mechanism does insurance linearize individual risk? The fact that if I get cancer, it's less likely to bankrupt me. But if it's not bankrupting me, someone else is paying for it. Who's paying for it? Someone who didn't get caner. So how is this not "less risky people subsidizing more risky people"?
It’s not healthy people paying for your treatment - it’s the underwriter. There don’t need to be any other people with different health outcomes involved. The only thing happening here is you’re outsourcing some risk to someone who has a lot more capital and therefore a more linear risk curve.
Let's say your odds of getting that cancer are 5% and you know that ahead of time. So, knowing that it would bankrupt you, you gather 20 other people who are also at a 5% risk of getting cancer to form a group where you all chip in no matter who gets sick. You've now spread the risk out across a pool of people and, yet, everyone is still paying their fair share because no one knows who will be the unfortunate cancer patient at the time the agreement is made.
But in your little group, there's still a 36% that no one will get cancer and that's offset by a small chance that multiple members of you group will get the disease. If even 4/20 members get cancer, that would now come pretty close to bankrupting everyone in the group. So what do you do? You increase the size of the group and lower the chances that no one will get cancer while also increasing the chances that only a proportional number of people (5%) in the group get the disease.
But then along comes Danny. We also know that Danny has a 10% chance of getting cancer. He also wants to join our group. If we just let him join, it won't be fair...after all he's twice as likely to need us all to pay for him. So we can either tell him to get lost, or we can just make sure that when the bills for someone's cancer show up, he pays twice as much as any other member. He's bringing twice the risk with him so he pays twice as much.
In poker, players learn to avoid being outcome-oriented when evaluating their decision making. Rather than looking at a decision they made and seeing whether they won or lost, it's more important to look at the decision and ask themselves if they'd made the same decision a million times, how many times would it lose and how many times would it win. Because any individual hand where a correct decision is made can still lose due to variance.
Insurance is the same concept. Actuaries use statistical analysis to determine an individual's risk so insurance companies can price that risk accordingly. Over a million lifetimes, your insurance premiums (less the insurance company's profits) would come very close to the overall insurance payouts. But since you've only got the one life, you'll be under- or over-paying. But you're still only paying for your own risk, you're not paying for anyone else's risk.
Where the ACA comes in is when Danny can't really afford the double stake. It forces us to let him join the group and pay less than double whenever someone gets cancer. That's a bad deal for all of us 5%ers, despite the fact that there's still a 90% chance that Danny doesn't get sick.
Now try to answer your question...do you see the difference between paying for your own portion of the risk pool vs lower risk individuals subsidizing higher risk individuals? If you were in one of those groups of 5%ers, would you just let Danny join without adjusting for his added risk or would you be looking for more 5%ers like yourself?
I’m repeating myself, but you are wrong in at least two ways.
Health insurance in the US is not conducted in any way like the over simplified, text book example you provide. There exists no real world example of health insurance that functions as you describe.
There is the obvious problem that there is nowhere near that level of precision in anticipating the given level of risk for any individual getting a certain disease, especially as most populations are fairly heterogeneous when it comes to health risk profile.
The insurance companies use statistical tools to estimate the average risk of insuring a pool of people with some element of similarity, like a pre existing conditions. This is a far cry from being able to evaluate the risk profile of a given individual.
The complaints people have about being rejected for coverage based on a pre-exsisting condition, when they think that condition doesn’t really make them that risky reflect the imprecision of the actual tools.
This is also illustrated by these blanket denials: insurance companies are rejecting populations that the feel cannot be adequately evaluated for risk.
There is another aspect of such complaints (about blanket denial of coverage) which come from the issue that some people simply do have a health condition that they cannot cover the expected cost of.
This is a societal issue, and different socities deal with it differently. It inevitably involves some sharp elbows between the various interests involved.
In the US, for historical reasons, a big method of covering the costs of those who can’t afford the full premium was through the patchwork system of employee health plans, complementing government run plans like social security, Medicare, Medicade, local government programs, and charitable programs.
As imperfect as the system is, it remains the case that the health care coverage of high risk individuals, meaning those who can’t cover the full cost of a risk based premium, relies on what is known as “health insurance.”
> There is the obvious problem that there is nowhere near that level of precision in anticipating the given level of risk for any individual getting a certain disease
This doesn’t matter at all, on account of the way variances from independent RVs add up. Look up the Bates distribution as an example. Variance over mean goes down as the square root of the number of independent RVs (insurees). That’s like half the point of insurance.
> was through the patchwork system of employee health plans,
These were the result of highly nonlinear tax policy during WWII, not the reasons you’re claiming.
I have much more money than most people but I'm not fine with it. I pay more than a mortgage payment every month for insurance that pays for almost nothing.
Ryan’s point was that Obamacare’s guaranteed-issue requirement means that exchange plans can only be viable if they attract enough healthy people to cover the costs of the currently or chronically ill. Both groups must be offered the same rates.
Surely you can see how that is different from (say) fire or auto insurance, where no one would expect to pay the same to insure two houses, only one of which is actually burning at the moment.
Yes. But the mandate was always pretty toothless and has now been completely defanged.
Regardless, the idea that under ACA “the healthy pay for the sick” as expressed by Ryan was certainly not an oblivious truism about the nature of insurance as it is being portrayed.
Why should young people subsidize the health care of old people who almost certainly have a higher net worth than the young people?
Remember with Obamacare about how there was a huge push to get young people to sign up for it, because without healthy young people paying too high premiums, the system would fall over with the costs of the elderly? Maybe that is why young people didn't want to sign up for the ACA, and they needed to enforce 'penalties' for not having health care.
If young people were actually charged a fair market rate for their health insurance, they would sign up in droves because it would be dirt cheap. But when you make them pay far more than is reasonable, because old people need health insurance too, then that is how you get a system where no one wants to sign up for it until they are legally forced to.
The ACA in this sense completely subverted the point of insurance. So, maybe the right doesn't understand insurance, but neither does the left.
You realise that is literally how insurance works though, right? If you tranched age groups or risk profiles then you would have those needing to use insurance unable to afford coverage. Which defeats the purpose
No, that is not how insurance works. Insurance works well when you group people with similar risk profiles together, not by grouping people with dissimilar risk profiles together.
Imagine a world where a 20 year old would be able to buy a 10-year term life insurance policy for the same amount that a 90 year old can. That is essentially what the ACA attempted to provide.
Young people also will get old and not all of them will be multimillionaires so it makes sense that one generation pays for the previous because one day they will be in the same place.
How well does that system work for a generation that produces fewer adults than are present in the generation?
Instead of paying for other peoples health insurance and then other people pay for mine, why can't I just save the money that I would be paying in premiums above and beyond what the rational amount would be and then pay for my own health care when I get older(or, pay for the higher premiums when I get older)?
It's ridiculously amazing that you're getting downvoted for your general point. Wishful thinking won't change market incentives, although it will help make some profiteers rich.
The young (and healthy) paying for the old (and sick) is a function that can only be provided by government, or bona fide charity. It's impossible for this to be provided by private companies because, in line with the denial behavior we're seeing, it's rational for any company to take on the overpaying low-cost customers, tell the underpaying high-cost customers to go elsewhere, and then pocket the surplus.
Having said that, I'm not personally a believer in single payer fixing everything. It certainly should be possible for routine care for financially able people to be provided completely on the open market. Immediate common-sense based reforms would go a long way. For example, hospitals/providers should be required to have one and only one price list for all payers, published months in advance. And the bundling of "insurance" with employment should be outright prohibited
I'm not arguing against insurance - I'm arguing against the government forcing insurance upon groups of people with extremely dissimilar risk profiles and forcing the younger, poorer group to pay to subsidize the older, richer group.
My long-term plan is to get something like a million dollars in retirement accounts and a home and retire in Texas, where your retirement accounts have unlimited protection against creditors. If any random incident can bankrupt you, then your best bet is to ensure that you cannot be forced into bankruptcy.
I don't know if this is relevant to your plan but you are aware that Texas has like the 3rd worst healthcare system in the country and maternal and infant death rates on par with most 3rd world countries, right? Good luck, don't get sick.
I plan on picking up solid health insurance coverage as well, of course. This is just so that my insurance company and health care provider can't screw me over through balance billing.
Look at how much political heat Obama, and Clinton before him, got for attempting to fix things. The other political party was more than happy to tell their constituents that their health care would be ruined, and grandma would be denied care by a "death panel".
Even though I don't like the ACA, I give Obama a lot of credit for trying. There is no political benefit to doing so.
Every health care system rations care since no current system has enough resources to care for everyone without some form of waiting. The U.S. health care system rations care in the most immoral way of the advanced nations. A person should not profit by denying care to someone else.
As a nation we should try optimizing for a more moral, just system. As I see it that would be something like Medicare for all but I'm open to suggestions/solutions.
There is no silver bullet in health care. The field is too large for any one single solution to cover everyone (3 Trillion USD per year is spent on health care). There needs to be a lot of innovation in a lot of different areas in order to solve the problem.
I started a company with my brother that is attempting to drastically lower costs for primary care. (https://scalpel.com) We build software that allows physicians to set up their own direct primary care clinics. Our beta clinic in South Carolina charges $49 / month for unlimited visits and charges people at cost for things like labs and procedures. So instead of dealing with a labyrinthine medical system people are just working directly with a doctor. We really only care about making money off our memberships which we charge what we believe is a reasonable amount.
I think there's plenty of room for innovation but we should start from the principal that everyone gets full access to medical treatment regardless of their ability to pay.
We technically have this in the United States (for emergencies). It is illegal for someone to be denied emergency services regardless of ability to pay.[0] No government system guarantees "full access" to medical treatment there is some form of rationing everywhere.
Emergency rooms are required to stabilize a patient, not treat them or cure them. This is not universal care and it not giving everyone access to the medical system. One does not got the ER for things like cancer screenings.
From the link you provided:
Hospitals are then required to provide stabilizing treatment for patients with EMCs.
Access is a function of cost. If medical care is affordable for people near the poverty line then we will be able to solve the access problem entirely. (this is my goal) Governments, charities, and businesses will pick up the slack as they already do.
I'm old and deal with the health "care" system more than anyone else here. What I've learned:
1) You are responsible for your own health. Eat less, eat better, and exercise more. Get enough sleep. Don't over worry. Don't drink too much. Don't touch recreational drugs. Your own health must be your number one priority. Teach your children this, too.
2) ACA, for whatever problems it caused, will save many of us from bankruptcy. "Us" being everyone who is or wants to be a founder.
3) The biggest problem with health cost is lack of transparency. If I could shop around, even a little, I could save tens of thousands of dollars a year. But it's hard to negotiate for price when nobody knows what anything really costs, or what you actually get for that cost; even the people selling it.
5) Every day you are in good health is a good day. Thank God, nature, or other deity(s) of your choice for your lack of health problems.
I've begun to suspect is that "universal healthcare" means "you weren't denied, you're just on a waiting list, and every physician is an interchangeable cog".
I often wonder why health insurance companies don't use a similar tactic.
Edit: Try finding a pediatrician in Berlin. (Seriously, I would love to hear recommendations)
Because doctors will happily tell you that whatever they plan to do will be covered by your insurance. So the work gets done, the money spent, before they get a chance to screw with you.
Waiting lists for doctors can be long for non-emergencies. This applies to most countries with a public health system.
Typically they are prioritized based on need, not money.
Also arranging regular appointments weeks/months before allows for less downtime in the doctors office thus cheaper healthcare. It's annoying but it works.
Also Germany suffers from an ageing population which is why there aren't that many experienced professionals of any kind.
That's a very interesting insight into the world of American healthcare and privatized healthcare in general.
Previously I thought that all these statements about the US healthcare system were seriously exaggerated, but I guess I was wrong. It's kind of terrifying that being sick excludes you from access to healthcare. In my experince, public healthcare has many problems, but you get what you need.
Healthcare is a basic infrastructure problem, not that it is considered this. As a basic infrastructure problem, there are many who see a profit to be made in supplying services. Each country views healthcare from a specific point of view and that dictates how they will, as a country, provide the general healthcare service.
A country like the USA see this in the light of healthcare as a business, make as big a profit as you can, irrespective of the actual services that you provide. In other countries where the relevant governments provide universal service they allow private businesses to dictate the price that the government pays for the supplies required.
So, we have general commodities when supplied into the healthcare system being charged at 10x or greater for on item which, if not used in a healthcare environment, is charged a much lower price. This applied to things like computers, phones, chairs, tissues, matches, paper, toilet paper, gloves, etc,
The suppliers get away with this because of the perception that these goods are of a higher quality. These goods often come off the same production lines as those sold in a normal commercial market.
I have seen up to date medical equipment that cost a large fortune that looked pretty, but if you actually looked at the basic equipment was technology that was anything up to 10 years old and was superseded by stuff your could get commercially.
The amount of money charged for drugs is based on the amount of money spent of research, which if you actually looked at the figures thrown about were spent by the public purse not the private.
It is a captive market and those supplying into it want it that way to maximises their profits. Morality questions are not considered to be important unless it has regulatory considerations that will significant reduce your profit margins if you fail to live up to them.
The problems within the healthcare system (insurance included) will not be solved any time soon. Even if there was a revolution that changed the entire basis of how and when healthcare was supplied, it will soon return to what we see today as greed is the basic motivator for society as a whole.
To bring about real change requires people really changing and this will not happen because we are basically looking out for ourselves and our own. This occurs on the local level, on the regional level, on the state level and on the national world levels.
The healthcare system is an area that needs a complete overhaul worldwide. It is not going to happen since most people do not have the ability to see past their local situation.
The list of conditions for which insurance outside the ACA will be denied is long and opaque. The story makes it sound as if they're looking for reliably diagnosed conditions like diabetes. No. They're looking for indicators of a long list of potential conditions. If you or your spouse has a functioning female reproductive system, the chance of your family being denied is high, even without a diagnosed or treated condition. We were denied for something like that, and also because my daughter had an unexplained seizure when she was 4 (she's now 16 and just fine). To get insurance for the first couple years of Matasano, my wife had to take a crappy full-time job with group coverage.
Without insurance, a typical working family is one major medical incident away from zeroing themselves out. My daughter has never met a pickleball net that didn't break her ankle (she has met one pickleball net). Even with insurance, the cost of that injury was high single-digit thousands of dollars. Without it? The cost of a pretty decent car. Find a friend who's had an appendectomy some time and try to find out how much the insurance company was (nominally) billed for it. A down payment on a house.
If you work in this industry, intend ever to start your own business and potentially have a family at the same time, you should be extremely alarmed at the prospect of guaranteed issue regulated health insurance (the ACA) being replaced.