You Don't Need Health Insurance

[jennypenny]

@Scott2- What I'm getting at, and what @Ego put more succinctly, is that what you described above is treatment.

Not just treatment, but establishing baselines and developing relationships with providers.

What you and Ego are advocating sounds totally reasonable for healthy people trying to avoid lifestyle diseases. That's not the whole picture though, and I think that's what Scott is trying to explain. There's no question that there are gaps when DIYing healthcare, and unfortunately it's hard to predict which gaps might be problematic in the future.

No one is saying people don't have the right to take the advice in the OP. But as Scott pointed out, it's not an apples to apples comparison. It's important to understand the differences before deciding what approach to take.

[Scott 2]

A personal health strategy, by way of exercise, diet etc., is a form of prevention that lessens or eliminates the need for such treatment.

I agree lifestyle factors offer high leverage. They are preventative and difficult to facilitate via insurance. I am finding with the right prompting and plan, it is possible to access some support. Especially with insurers using programs like gym membership as bait, to better weight their risk pool.

I see prevention and treatment as existing on a continuum. It's appealing to say, "how fortunate I am, so healthy!" while ignoring early signs. No lifestyle eliminates those needs. Bodies are born with defects. They suffer from aging. While we are young, the signs appear inconsequential. The puzzle is identifying failure paths early, so intervention can be small, without over-treating.

I'm not saying that's easy, or even that my strategy is optimal. Only that I have gone from one end of the spectrum to the other. In my experience - help from experts makes for a very different path. I value my insurance in facilitating that. Maybe still feasible otherwise, but much harder IMO, due to faults in the US medical system.

I also don't see the access to care as absolving me from personal responsibility. My session at physical therapy looks much different, than the seniors on Medicare. After the first session, I directly said - "there's no way this is hard enough to affect change". A switch flipped in the treatment plan. Let's go.


At a meta level - I don't care if the article's author attempts to game the system. My interest lies entirely in personal well being. I think there's a good chance she's shorting herself, on the early end of that prevention/treatment continuum. Because that's what I did. Youth masks our defects.

[Ego]

Not just treatment, but establishing baselines and developing relationships with providers.

But as Scott pointed out, it's not an apples to apples comparison. It's important to understand the differences before deciding what approach to take.

There is an underlying assumption that access to care is always good, but our current system is biased toward action and has very strange incentive structures that frequently cause more harm than good.

One need only to look at the list of large pharma scandals to see that most involve kickbacks. Kickbacks distort incentives. The recent, mind-blowing, Medtronic scandal (at the VA of all places) highlights how medical device manufacturers distort incentives to their benefit.

Providers have incentives to suggest whatever insurance will allow. Many preventative-medicine procedures are feeder programs for more risky, often damaging, procedures.

So, as you say, it is not apples to apples.

[jacob]

I think the conclusion in the OP link is the most telling:

In conclusion: American healthcare is broken. Navigating the system requires you to be high agency and advocate for yourself. This is true with or without insurance! And from what I've seen, it's not clear to me that insurance saves you money by default.

The bolded part is why the system is broken. The obvious reason is that people who are sick are generally the very opposite state of being high agency advocates. There only seems to be a couple of popular solutions to this problem.

1. Try not to get sick so as to avoid the healthcare system as much as possible.
2. Interact with the healthcare system on a regular basis in order to become familiar with it ("establish relationships and baselines") despite not being sick.

Option 1 undertreats the sick, while option 2 overtreats the healthy. These are two extremes albeit extremes that a lot of people cluster around. Workarounds for (1) include having a "sick friend" who already knows the system, alternatively someone who works in the system, like a nurse or even someone in billing. Workarounds for (2) include learning the magic words: "Is this procedure/test really necessary, doctor?" (Hint: it usually isn't).

[IlliniDave]

Yes, your risk pool consists of those in your age group, but the ACA snuck in a premium variation cap for all policies. No matter the true cost, older folks cannot pay more than 3x the cost of a 21 year old, so the risk pools of older people are subsidized by those of younger people.

https://www.kff.org/affordable-care-act ... -care-act/

Yes. Just in case I wasn't clear, the point I was making is that even though we are all in the oldest decade private insurers will insure (Medicare supplements aside), and even though we're not subject to the 3:1 cap (as a group we all pay the same per person and pay 100% of what the plan costs, and are not pooled with younger current employees) it's still $200-$300/month cheaper than the exchange plans (it's essentially an ACA Silver Plan) that we could buy. My suspicion is that it's because I, for example, couldn't have declined the coverage upon retirement (post COBRA), then waited 5 years until I was on an organ transplant list or some such, then rejoined the plan. With ACA I could do that, and I'd swag that $200-$300/mo/person additional that exchange participants pay is probably fairly close to what that requirement to accept people with substantial preexisting conditions costs the typical ACA participant.

[IlliniDave]

1. Try not to get sick so as to avoid the healthcare system as much as possible.
2. Interact with the healthcare system on a regular basis in order to become familiar with it ("establish relationships and baselines") despite not being sick.

As usual, I go for the both/and over the either/or. I think one of the biggest problems we have is almost no one exercises any agency. For a long time I didn't and it left me in a bad situation that agency fixed.

I am happy to pay for services that are not necessary, as part of my agency, for the purpose of gathering information. If a person educates themselves it's not hard to determine tests and etc that MDs and insurers would deem unnecessary that can inform someone of problems coming in the years or decades ahead. Means I have to shell out for them myself usually, but the data is invaluable in my quest to honcho my own health. IMO the biggest problem with the US system (can't speak to any others) is that the MO is to do nothing until it's bad enough to sell the patient drugs, with the patient having to do nothing more than swallow pills at the appointed time, all the while being told they are doing the right thing for their health by seeking out the pills.

[Ego]

Yes. Just in case I wasn't clear, the point I was making is that even though we are all in the oldest decade private insurers will insure (Medicare supplements aside), and even though we're not subject to the 3:1 cap (as a group we all pay the same per person and pay 100% of what the plan costs, and are not pooled with younger current employees) it's still $200-$300/month cheaper than the exchange plans (it's essentially an ACA Silver Plan) that we could buy.

Actually, the ACA changed the rules for ALL plans, not just exchange plans. You are subject to the 3:1 rule. Your private insurance premium cannot be more than 3x that offered to a 21-year-old, so younger people are subsidizing your private insurance. Interestingly, it also limited the smoking premium to 1.5x the regular premium.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4214269/

Allowed Rating Factors versus Uniform Premiums
The ACA allows individual and small group plans to rate premiums on four factors: age, tobacco use, family size, and geographic rating area. The age variation in premiums is constrained to 3:1 for 21 year olds and older, and the variation based on tobacco use is constrained to 1.5:1.

[IlliniDave]

Actually, the ACA changed the rules for ALL plans, not just exchange plans. You are subject to the 3:1 rule. Your private insurance premium cannot be more than 3x that offered to a 21-year-old, so younger people are subsidizing your private insurance. Interestingly, it also limited the smoking premium to 1.5x the regular premium.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4214269/

There is no one paying into the plan who is 21. All paying participants are ages 55-64. All participants pay the same. No one under 55 (55 is the minimum retirement age to be eligible) is paying into it. It is separate from the employee insurance, which is considerably cheaper for the same level of coverage because of the younger pool. Different plan, different group, and different administrator. In theory they could allow younger participants and charge them 1/3, but they don't. Those rules are moot (though maybe theoretically applicable if the company chose to implement the plan differently) because of the group definition for the group plan. And because of the way they do it--it is 100% funded by the company and the costs split equally between participants among their eligible retirees who choose to participate. I'm 59, so maybe the 55-58 crowd is carrying my actuarial risks somewhat, but I was in turn and still am carrying some of the age-driven actuarial costs of the older fraction of the participants. The loophole it's missing that I think makes it cheaper for roughly equivalent Exchange benefits is all of us have to join the plan at our first eligibility date and if we don't, or discontinue, we can't join later. No skipping out on paying in while while healthy and joining later when sick.

[Ego]

Interesting. I thought the ACA outlawed all of these edge cases. My apologies!

[theanimal]

@iDave-
Your rate is lower because the insuror is able to spread the risk around via a large number of people versus an individual plan. This is why there is the requirement for everyone to sign up at the same time and there needs to be X% of employees participating.

So yes, your plan is cheaper than your younger colleagues who purchase an individual plan. But if there was a group of 21 year olds at the company who got insurance, you would find their rate would be cheaper and your rate is still no more than the 3:1 ratio as the law still applies.

Some states have made their own laws that are even more restrictive, like Massachusetts, where it's 2:1.


ETA: I misread the post as Dave's colleagues having a more expensive plan. With that, the group plan is more expensive than the younger colleagues because of age but cheaper than if each member of group got an individual plan due to decreased risk for the insuror. The rest still is valid. Age bands can't be more expensive than 3:1 of the youngest age band. Here's a source for those interested in more info: https://www.cms.gov/marketplace/private ... ng-reforms

[IlliniDave]

Interesting. I thought the ACA outlawed all of these edge cases. My apologies!

They did "outlaw" the level of health coverage we used to get pre-ACA because it was considered a "cadillac" plan that would have subjected the company to excise taxes. I think they are maybe even required to maintain separate plans for retirees because of the same set of laws that allow employees purchasing insurance through their employer to pay premiums with pretax dollars. As a retiree it's all post tax, which I think is the same for ACA.

Edit for clarity.

[IlliniDave]

@iDave-
Your rate is lower because the insuror is able to spread the risk around via a large number of people versus an individual plan. This is why there is the requirement for everyone to sign up at the same time and there needs to be X% of employees participating.

So yes, your plan is cheaper than your younger colleagues who purchase an individual plan. But if there was a group of 21 year olds at the company who got insurance, you would find their rate would be cheaper and your rate is still no more than the 3:1 ratio as the law still applies.

Some states have made their own laws that are even more restrictive, like Massachusetts, where it's 2:1.

I think the major ACA providers are pooling risk as well, they almost have to be for it to work. I'd guess there are between 10,000-30,000 of us in this retiree group spread among the 50 states, compared to about 400,000 covered under ACA in my current state.

My younger former colleagues are paying less. The full costs of their plan is about 25% lower than the retiree plan, and the company pays 70% of the full cost, the employees 30%. Retirees pay the full cost of the retiree plan. The year I retired the total cost of the employee plan for an individual was around $5000/yr (of which the employee paid about $1500) and the retiree plan about $6,500/yr IIRC, all paid by the retiree.

I do believe I might be paying less than younger people buying ACA plans in some places. When I priced them at the end of 2021, I was comparing my retiree option versus Illinois ACA plans for me. The coverage of the retiree plan was marginally better and it was about $250/month cheaper. I didn't bother looking at prices for ages other than my own at the time. I'm fairly confident the ACA plans pool across all ages, but ego listed all the options the providers have to adjust premiums for relevant factors, one being age. I just don't have any insight to whether providers in Illinois actually do that.

The "insurer" for me is my former employer, but they hire one of the major insurance companies to administer it. I pay my premiums to my former employer, not the insurance company. I don't know how many companies do it that way, but that's how my employer did it the entire 34+ years I worked for them. My company was large, ranging from 70,000 us-based employees to well over 100,000 when I retired. I'm guessing the insurance covers 2-3X that number of people when you consider spouses and dependents less those that get their insurance elsewhere (e.g., from their spouse, VA, etc.).

[Laura Ingalls]

We currently are expanded Medicaid folks, but we are in Mexico currently. It’s sort of a combo of being uninsured and insured all at once. Previous jaunts abroad I have bought medical travel insurance.

This trip I haven’t. In part because minor stuff here is cheap, This part of the country is not known for great medical care and gringos go home if they need medical care. Three I have avoided driving and much of my walking is in a pedestrian only area.

I also had extensive diagnostic testing of my heart last summer (I had what I thought was chest pain plus my family history is pretty crummy.). I feel pretty confident that my major cardiac blood vessels can’t go from healthy to all clogged up in a few months. I still debate whether or not that was smart or overkill. I can overthink that but I do feel like I got some piece of mind out of that ordeal.

I thought the author had some valid points. There is some evidence that home birth is safer than hospital birth in part because over intervention just isn’t available in that setting. Totally on team Zenni and vision coverage/Luxottica is the biggest scam/rip off ever.

[Scott 2]

It's possible your employer has a self funded retiree plan and only pays the insurer for administration. That can help control costs.

Low income retirees might get diverted by subsidies to ACA plans as well. Coupled with the restricted enrollment period, that could be a very appealing risk pool.

My former employer did this, with the plan continuing past Medicare age. I presume the intent was to avoid Medicare's wealthy surcharge - the Income Related Monthly Adjustment Amounts.

There's also a small percentage of doctors opting out of Medicare. I think the plan let those wealthy retirees avoid that risk as well.

The gaming is widespread. I don't think any other strategy is rational at this point.

[ffj]

The average Boomer started voting in 1972 when the debt to gdp ration was 34%. Today it is 120%.

As a result, they are the wealthiest generation in human history.

The Boomer generation has spent a lifetime changing systems to benefit themselves while shifting burdens to future generations, but they judge others like this young woman who refuse to be exploited by the Boomers-designed system.

She is admirably creative in her refusal. While I certainly benefit from the status quo, I will not look down on her or others like her who come to the conclusion that refusing to play the game is a viable option.

The problem lies when enough people are admirably creative in their refusal, doesn't it? All systems, and this certainly isn't limited to insurance, have built into their models for dealing with dead weight. Unfortunately, the number one method of distributing creative refusal is to redistribute costs to others. Sort of like the hard worker at your job being rewarded by more hard work because they are dependable while the guys that smoked a bowl at lunch get to do light work because they can't be trusted.

Everything in life is a redistribution. And when a system isn't feasible anymore it either gets shut down, has its options severely limited, or is subsidized by another group. This young lady wants her options but also to be subsidized. I sense a trilemma here somewhere, haha. So what is the cost and who will be the next group to cry out victimhood against their oppressors? It's just a game of creating new winners and losers. Or you could pay for services rendered and leave the grandstanding to others.

Note: Our system needs serious overhaul, I am not minimizing this fact. Just like taxes, one should always look to limit their cost. But to outright refuse to pay anything? Come on man (Biden probably)

[ffj]

https://www.cnn.com/2024/02/02/politics ... index.html

Like all news articles it is scarce on in-depth details but here you go. I'm not quite sure what happens when the federal grant money dries up so I don't know if this would be a viable plan to get out of medical debt.

[The Old Man]

I agree that having a health care plan helps for avoiding catastrophic risk, but ignoring that, how does having a plan make me better off day to day health wise than not having one?

The purpose of "insurance" is for covering catastrophic risk. A plan will not make you better off day to day - that is not its purpose.

If you want health care as in preventative health care, then you have to do that on your own. There is no plan for it in the USA.

[mooretrees]

I’m gonna push back a bit on the “no plan for preventative care” comment. We’ve got a six year old and we haven’t paid for a single vaccine or well child check up his whole life. My mammogram is covered (at least the first image).

When I was pregnant, I paid about $300 for my whole care during pregnancy and a hospital birth; complete with a c section, antibiotics and three nights at the hospital. Now, one can argue that the hospital bit isn’t preventative care and I can agree with that. But I met with my dr a zillion times when I was pregnant and that sure felt like preventative care.

Not paying for vaccinations or well child checks (including lead and anemia testing) is not unique to my insurance, I believe it is nation wide (some limitations but that seems mostly true). The CDC has a program for vaccinations for kids under 18.