Health Insurance--a rant

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EdithKeeler
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Health Insurance--a rant

Post by EdithKeeler »

I always joke--although it's not really a joke--that we're all working for health insurance. it's actually pretty true for many of us here in the United States.

We're getting ready to have open enrollment at work, and we got advance notice that they're passing even more costs on to us. So my premium is going up to $71 per paycheck. The company used to, when we changed to a high deductible plan, deposit $1200 into our Health Savings Account. Every so often they cut it back and for 2021, the contribution is the lowest yet--$500. So to max out my HSA contribution, my portion will be $157 per paycheck (I'm over 50 so I get to contribute an extra $1000 per year). PLUS--our deductible has gone up! The old deductible was $3500, now it's up to $3800 (all this is for SINGLE, not family coverage).

So my health insurance/costs for the coming will be $1846 for the insurance premium plus $4100 for my personal contribution to the health savings account, plus whatever out of pocket I incur if I hit my deductible. (Our plan is that you have to meet your deductible, then pay 20% up to a certain amount--I think it's like $6K or so, and then insurance covers the rest. This year, I had surgery in February, a trip to the ER for my ulcer, and treatment for shingles (y'all get vaccinated if you haven't already and are over 50--it's miserable), and just barely hit my deductible. I was planning to do all kinds of health stuff this year to sort of get the most bang for my buck but, you know--Covid.

On the one hand, I'm grateful. I'm much healthier than I have a right to be and have barely used my health insurance over the years. As I get older, though, I know that will change and this year seems to be the beginning of the slide. But really--$6K a year for health insurance where I still have a large out of pocket exposure?

I really think this latest ploy gets me closer to pulling the plug on my job, especially since I'm mostly working for health insurance. I feel like I'm really not getting much. It seems to be I'd be much better off buying a super cheap policy off the exchange and making it work for the next 9 years until I'm Medicare age.
Last edited by EdithKeeler on Fri Oct 16, 2020 7:04 pm, edited 1 time in total.

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Alphaville
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Re: Health Insurance--a rant

Post by Alphaville »

100% agree. coupling health insurance to jobs is our national problem. until we have some sort of universal health insurance (either french or swiss model or anything in between) it will continue this way.

but i’d seriously wait to see what happens with obamacare + insurance marketplace with the new supreme court 😬

(especially if you happen to have any preexisting conditions)

a cheapo association plan joke is no substitute for real health insurance...

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Seppia
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Re: Health Insurance--a rant

Post by Seppia »

Assuming you can do that, think about going to work for a midsize european company.
One of those companies that is fairly attached to their home country reality and normally have many in the workforce who aren’t Americans.

Because of their culture, those companies tend to pay slightly less than their American counterparts, but they offer excellent health insurance by local standards.

When I was in the USA I was working for one of those companies and knew many people in similar ones (Italian Food and Beverage), and what I described above happened with great consistency across all of them.

Mister Imperceptible
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Re: Health Insurance--a rant

Post by Mister Imperceptible »

inflation is less than 2% and is nowhere to be found

Scott 2
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Re: Health Insurance--a rant

Post by Scott 2 »

Why count your HSA contribution as part of the healthcare expense? That is tax sheltered money you don't have to spend.

Mister Imperceptible
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Re: Health Insurance--a rant

Post by Mister Imperceptible »

If she depletes the HSA account now she might have to use taxed money to pay for healthcare later.

EdithKeeler
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Re: Health Insurance--a rant

Post by EdithKeeler »

Why count your HSA contribution as part of the healthcare expense? That is tax sheltered money you don't have to spend.
Well, one way or another, if I have to have health treatment, I have to pay for it. I generally pay run-of-the-mill stuff as I go and don't take it out of teh HSA, but this year I had surgery, etc. and had to meet my deductible. I did take it out of the HSA.

I mean... I'm lucky if I don't have to use it and my plan is to take it with me into retirement, but if I do have a significant medical event, I will have to pay something either way.

Scott 2
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Re: Health Insurance--a rant

Post by Scott 2 »

Got it.

Shopping for individual plans, the traps I am watching for are percentage based drug co-pays, prescription pre-authorization and step therapy. Once someone is sick, it's not enough to look at the deductible or even max out of pocket anymore.

nomadscientist
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Re: Health Insurance--a rant

Post by nomadscientist »

Something I have noticed living in the US for a few years is that medical providers bill my health insurance company ~10x as much as the insurance ultimately pays them.

I do not need health insurance to insure my health any more, at least at my level of financial risk tolerance. But I think I do still need the health insurance company's lawyers to negotiate the bill.

Is there a cost effective "lawyers-only" insurance alternative?

Has anyone tried hiring a lawyer privately to negotiate a medical bill? How much did it cost?

Has anyone received an invoice from a medical provider as a private individual, sent back an offer for 1/10th the demanded amount, and had it accepted?

Scott 2
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Re: Health Insurance--a rant

Post by Scott 2 »

Isn't this the purpose of the bronze ACA plans? Yes, you get catastrophic coverage. However, with deductibles around $8000, you are paying a significant portion of the premium for those negotiated rates, IMO. A health share even more so, I suppose.

You can find doctors who will offer cash pricing and it is possible to order things like blood tests direct. From what I've seen, rates are similar or lower then the insurer negotiated rates. A la carte medicine and/or concierge medicine are other terms I've seen for negotiating up front rates. People also engage in medical tourism. I think those tactics still need to combine with catastrophic insurance.

I cannot see a frugal US based scenario, where it makes sense to decline insuring for the high end downside risk. A common expensive Rx can be $5k a month. More even. A simple out patient procedure $10k. A serious condition - sky's the limit. It's realistic to think you'll have a medical event in your life costing multiple $100's of thousands. Millions is not out of the question. These costs are increasing faster than inflation.

I think to confidently self-insure, you are looking at assets in the 8 figure range. Even then, however, there's an aspect of interfacing correctly with the US medical system. It is run as a large bureaucratic business. The players are going to automatically assess your insurance position. In many cases, they will not provide care or medicine until it is pre-approved by insurance. You can pay up front, but IMO, unless you are buying into high end concierge medicine, you are risking quality of care.

Basically, if you are wealthy enough to self insure, you'll never feel the insurance premiums. If you are not, it will be more effective to work within the system to minimize your expenses. Catastrophic coverage and/or designing your income to get subsidies (possibly with cost sharing).


Negotiating after the fact, in my experience, is marginally effective. We've had the best luck getting items re-coded, so insurance will pay. Things that slip through, we've gotten 5% cash / pay right now discounts. We've also had an $80 bill that was missed sent to debt collections. The hospitals will try to recover their money. But, short of immediate life saving measures - they will not offer care they cannot get paid for.

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Ego
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Re: Health Insurance--a rant

Post by Ego »

EdithKeeler wrote:
Fri Oct 16, 2020 5:58 pm
This year, I had surgery in February, a trip to the ER for my ulcer, and treatment for shingles (y'all get vaccinated if you haven't already and are over 50--it's miserable), and just barely hit my deductible.
I'm sorry you are suffering with shingles. Thank you again for the reminder. The last time we were here I had a wrestling match with my doctor who insisted I get tested for antibodies before being vaccinated despite my assurance that I had chickenpox when I was a kid. The test came back negative so he refused to allow me to get the injection. I learned (after you posted this here) that they had changed the protocol in the past few years and now give it to everyone over fifty. I also learned that 1/3 of Americans will suffer a bout of shingles in their lifetime. I called to schedule the vaccination. Thank you!

nomadscientist
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Re: Health Insurance--a rant

Post by nomadscientist »

Scott 2 wrote:
Fri Oct 30, 2020 9:51 am
Isn't this the purpose of the bronze ACA plans? Yes, you get catastrophic coverage. However, with deductibles around $8000, you are paying a significant portion of the premium for those negotiated rates, IMO. A health share even more so, I suppose.

...

Negotiating after the fact, in my experience, is marginally effective. We've had the best luck getting items re-coded, so insurance will pay. Things that slip through, we've gotten 5% cash / pay right now discounts. We've also had an $80 bill that was missed sent to debt collections. The hospitals will try to recover their money. But, short of immediate life saving measures - they will not offer care they cannot get paid for.
Interesting information.

I can grant that a 10-20% discount may come from actual economies of bulk purchases or cross-subsidy, that should reasonably be denied to people who aren't members of the bulk purchasing scheme.

A 90% discount means the original price is a speculative invoicing scam. The services never cost anything like that much and the provider never expected to recoup that money either, except perhaps from a few unwary individuals. That's why I wonder if they ultimately extend the discounts to anyone who asks. I always assumed so, but also assumed that "asks" meant grinding months-long battle of attrition that has its own implicit costs. One reason I assumed that is that ~10% is about what they'll get for the debt when they sell it to collectors, so there's no actual loss with a very recalcitrant client.

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Ego
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Re: Health Insurance--a rant

Post by Ego »

Scott 2 wrote:
Fri Oct 30, 2020 9:51 am
A common expensive Rx can be $5k a month. More even.
If I were in this position I would be active in the biohacking community. Backroom biologics, for instance. If I were diabetic I'd be working with the Open Insulin Foundation. I would also be working on alternative supply lines.

I am certainly no Marxist but being completely dependent on a treatment with no means of producing it strikes me as the ultimate vulnerability.

Scott 2
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Re: Health Insurance--a rant

Post by Scott 2 »

@Ego - in my wife's case, she takes a biologic - a TNF inhibitor. The specific drug has varied over the years, but pricing is comparable - about $5k per month. There are biosimilars outside the US for some, but blocked by patents inside the US. Depending how/if the drug company plays with insurance, our price can range from negative (they pay her deductible) to a few thousand per year (percentage based drug copay). All dosing is closely managed by the doctor, with visits and blood tests multiple times a year. They are watching inflammation markers (is the drug working) and liver/kidney values (is the drug destroying your organs).

The goal is to prevent progression of a chronic condition. It helps, but absolutely creates dependencies. I've accepted this as the necessary tradeoff of gaining the benefits of modern medicine. Obviously we are "winning" on the insurance trade in her case. People like nomadscientist are subsidizing her care. All though, one could also argue that we were "losing" in years prior to her getting sick. The whole annual re-roll of the dice feels arbitrary to me.


Are you saying you'd try to homebrew the drug and manage your own blood tests? That seems crazy to me. I must be missing something.


In my wife's case, the best we've been able to do, is build up a small reserve of medicine. If you have a cold/flu, or are living with someone who does, taking a immunosuppressant is a bad idea. You have to skip a dose. We order the next one anyways. I imagine most people in her situation do. Biologics do have to be refrigerated, however. They also have a shelf life. So you can only ever be so protected.

Admittedly - for her missing a does is much less traumatic than a diabetic.

classical_Liberal
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Re: Health Insurance--a rant

Post by classical_Liberal »

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Last edited by classical_Liberal on Fri Feb 05, 2021 2:28 am, edited 1 time in total.

classical_Liberal
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Re: Health Insurance--a rant

Post by classical_Liberal »

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trfie
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Re: Health Insurance--a rant

Post by trfie »

nomadscientist wrote:
Thu Oct 29, 2020 11:47 pm
Something I have noticed living in the US for a few years is that medical providers bill my health insurance company ~10x as much as the insurance ultimately pays them.

I do not need health insurance to insure my health any more, at least at my level of financial risk tolerance. But I think I do still need the health insurance company's lawyers to negotiate the bill.

Is there a cost effective "lawyers-only" insurance alternative?

Has anyone tried hiring a lawyer privately to negotiate a medical bill? How much did it cost?

Has anyone received an invoice from a medical provider as a private individual, sent back an offer for 1/10th the demanded amount, and had it accepted?
You have no power as an individual because they are legally allowed to charge those amounts, and hence also hiring a lawyer would not help you (and lawyers are extremely expensive). The insurance companies already have contracted rates that define how much they pay. The medical provider/hospital is allowed to bill whatever they want (eg 10x what they will get). If you do not have insurance, there is no legal basis to contest the amount.

The only reason the whole situation is possible is because there is so much government intervention in health care. Competition lowers prices and increases quality, but there are government-mandated shortages of physicians, nurses, health-care workers, limits on the ability of insurance companies to open and where they can sell insurance, government limits on the number of hospitals that can be built, on which medications are allowed in the US and at what price, etc. Look at relationships between doctors and patients 100 yrs ago, and the prices. How is it with so much material abundance and technological advances since then, doctors are more pressed for time and the prices have skyrocketed? Technology leads to lower prices, although ppl will claim that expensive medical technology on the margins can somehow drive up all prices.

Qazwer
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Re: Health Insurance--a rant

Post by Qazwer »

Kenneth Arrow wrote the definitive paper on healthcare in 1963. Due to uncertainty and information assymetry, you simply cannot have a regular market in health care. There will always have to be some form of government intervention. There are all sorts of trade offs as to how and how much. It is not a normal market.
https://www.who.int/bulletin/volumes/82/2/PHCBP.pdf

Add in technology improving and no one wants care from 1950, you cannot self recreate the supply chain of pharmaceuticals and imaging technology. You have to trust in some ways. This requirement to trust is only going up over time. You cannot have simple market solutions for that trust - see Arrow’s paper above.

Riggerjack
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Re: Health Insurance--a rant

Post by Riggerjack »

Eh.

Everyone has a reason why *their* market needs government regulation.

What is a normal market, in America, in 2021?

Certainly medicine is not a normal market. It does have some oddness of it's own. The linked .PDF goes into details (though, by the same logic of the study, car repairs should also be priced through the roof, and maybe should be another 1/6 of the economy...)

But how many people are between you and your doctor? The receptionist who schedules you, the nurse who takes your history/vitals, the billing department, the insurance company's billing department, the admin and legal teams of your clinic and the insurance company, the profits of each...

1/6th of our economy is here. Fix any part, and the people making their living from the inefficiencies just fixed, will shuffle over to the next available niche. And since this is 1/6 of the world's biggest economy, there is always another niche.

This is merely an adaptive system adapting to any changes thrown at it. It can't be fixed with the same level of thinking that created the problem. There is no regulatory solution.

I don't know how a successful model could be made while this one is working, but tuning the existing system looks like a waste of energy.

trfie
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Re: Health Insurance--a rant

Post by trfie »

Qazwer wrote:
Wed Feb 17, 2021 2:18 pm
Kenneth Arrow wrote the definitive paper on healthcare in 1963. Due to uncertainty and information assymetry, you simply cannot have a regular market in health care. There will always have to be some form of government intervention. There are all sorts of trade offs as to how and how much. It is not a normal market.
https://www.who.int/bulletin/volumes/82/2/PHCBP.pdf

Add in technology improving and no one wants care from 1950, you cannot self recreate the supply chain of pharmaceuticals and imaging technology. You have to trust in some ways. This requirement to trust is only going up over time. You cannot have simple market solutions for that trust - see Arrow’s paper above.
Kenneth Arrow made tremendous contributions to economics and medicine but these ideas from 1963 are simply out of date for the times. Information asymmetry has dramatically reduced since then with the Internet (in munificent ways), tele-visits, and the proliferation of adjunctive health care workers like NPs and PAs. Similarly uncertainty has drastically reduced. There are statistics for practically everything in healthcare, including complications by specific surgical operation, hospitalization length of stay, life expectancy for particular malignancies stratified by a large number of variables, etc. There is also much more information to evaluate providers, including institutional reputation, provider reviews, statistics on surgical complications, and so on.

The vast majority of medications used today are generic and should be available at very low costs, without government intervention. Take a look at every case of supposed price gouging in recent years and in every one there was government regulation preventing low-cost medications in a particular market (the US), when they were available for reasonable prices in other countries. Similarly the cost of most standard imaging types is not high. X-rays can be done in many countries for the equivalent of a few US dollars in private settings, but in the US it would typically cost upwards of $75. Yes, there are very expensive treatments (the hepatitis C cure) and imaging (specialized types of MRI), but these do not raise the cost of all healthcare.

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