Phase III - Deja Vu All Over Again

[IlliniDave]

..

[classical_Liberal]

@idave
You're mostly right.

1)Yes you can be balanced billed for in-network services like radiology. It's pretty common. $1500 is a lot to me for a technicality, if I was supposed to be covered by a co-pay, but to each their own I guess.

2)In emergency situations an ACA plan must pay out to out-of-network services. However, they only have to pay out whatever the services would have cost in-network. The convoluted nature of healthcare billing means that this can be a very tidy sum. In many cases double costs out-of-network. So, now we are potentially in the 10's of thousands for a severe incident out-of-network.

3) if you get sick and need to see a specialist out-of-network you have zero coverage. It''s not an emergency so they don't even have to pay in-network costs. So imagine if the surgeon that can do your procedure isn't in your network? Again potentially 10's of thousands or more.

Personally, I will never pay anything close to 24K annual for health insurance for a single person. This is 150% of my total spending. Even if I was at a 1% WR with the cost, the thought of paying that kind of money for insurance sickens me (pun), I'd never do it. Especially since you don't have coverage in the above situations anyway. At that price level some combination of self insurance/healthshare/medical tourism is the only option, IMO. Unless, of course, I had a chronic illness that costs 100K a year to manage. Then again, that's why the insurance costs 24K.

If you don't have chronic disease look at healthcare bluebook and take a look at what things really cost without insurance. When dealing in numbers like 12K- 24K a year just for shitty coverage, they start to look pretty reasonable in a pinch compared to that recurring cost. Don't forget medical tourism too. Most medical expenditures are not emergencies.

[IlliniDave]

..

[RockyMtnLiving]

@idave
Personally, I will never pay anything close to 24K annual for health insurance for a single person. This is 150% of my total spending. Even if I was at a 1% WR with the cost, the thought of paying that kind of money for insurance sickens me (pun), I'd never do it. Especially since you don't have coverage in the above situations anyway. At that price level some combination of self insurance/healthshare/medical tourism is the only option, IMO. Unless, of course, I had a chronic illness that costs 100K a year to manage. Then again, that's why the insurance costs 24K.

1. "Self insurance" = uninsured

2. "Healthshare" = purport to be religious even if you aren't, and even then this isn't insurance

3. "Medical tourism" = somehow get to Costa Rica and figure out how, as an American, I can get a CR physician to do my cancer surgery

All this stuff sounds good on paper, until one ages and diseases hit

My impression is that the folks offering reduced cost HC options are (fortunately) healthy

[IlliniDave]

..

[Scott 2]

Apologies if this has already been discussed, but have you looked into the cost sharing reductions available against the silver aca plans?

https://www.healthcare.gov/glossary/cos ... %20savings.

Also, with out of network balance billing, I wonder how effectively they can collect on the medical debt. If I owe $200k until I'm dead, so what?


I am following this aspect of your journey closely. Healthcare is by far the biggest risk to my early retirement. Retail price for my wife's chronic illness is $50k+ a year, due to an expensive medicine. On employer insurance, we might come out ahead by a few hundred bucks, after benefits and co-pay assistance provide by the pharmaceutical company.

Without that safety net? I have no idea. Maybe if I keep my income at 139% of the poverty limit, it remains almost free? Or maybe I am screwed. It's really hard to be certain.

[RockyMtnLiving]

@IlliniDave:

You are a role model. I've been reading you for years here. I'm not qualified to park your car, let alone comment on financial issues.

I will say this. I'm post-55, and DW is post-60. In recent years we've unfortunately dealt with the U.S. health care system. If we were self-insuring, we'd be in a world of hurt. The problem with self-insurance is that it is impossible to know in advance if one has the means to pay the bills. Indeed, the whole purpose of insurance is to pool those risks that otherwise would be financially unsustainable for a single person or family unit.

I'm still w*rking only because of employer-provided HC. DW and I are desperately trying to get to age 65. We're fans of the ACA, and when I was self-employed, that sustained us. I'm aware of the ACA subsidies. Unfortunately, a medical center we need doesn't accept the ACA. So we're stuck. ACA subsidies won't help us. The ACA could be free for us, and we still wouldn't get the care that we need.

We aren't religious. And even if we were, that healthshare stuff just seems iffy to me. You pay in, I guess, then submit a bill and hope the powers that be reimburse us. I can get similar returns playing slots in Las Vegas.

And we're unwilling to take our medical charts, get on a plane to [Country X] (even if we could do so in the Pandemic world in which we live), and have major cancer surgery performed.

I think the United States is moving towards a single-payer/Medicare-for-All system, but it will likely come too late for DW and I.

[classical_Liberal]

@RockyMtnliving
I'm sorry for your situation.
Deletion Edit: I'm going to leave it at that.

[IlliniDave]

....

[IlliniDave]

..

[Scott 2]

Before my wife developed her chronic condition, I would have agreed with you on the debt. I hate owing money so much, I even pay my property taxes early.


My experience with medical bills, is they cannot be considered individually. They are one move in a shell game, playing out between many giant, bureaucratic parties. The first number you see is only tangentially related to the costs you personally incurred. Providers have zero expectation that is the cash amount coming out of a patient's pocket. It is the starting point of a negotiation, where players try to push as many operating costs onto the other parties as possible.

My wife's medicine is a good example. Depending on the source - retail is between $5000-$8000 a month, about double the European price. But there is a biosimilar (blocked by law in the us, due to a 16 year patent extension granted in 2012) estimated to sell for 15-30% less. The drug company will happily pay $10k+ a year in copay assistance, to capture the back end of that monthly payment from the (secret but lower) negotiated rate they have with the insurer. US revenue for the one drug is 5 billion dollars. What should you expect to pay as an uninsured party? For the right paperwork - $0. You get on the drug company's assistance program, where they generously offer free medicine, probably to avoid kicking off a legislation storm over their cash cow. Why pays for that medicine? Must be buried somewhere as a cost of doing business.

I was talking to a pharmaceutical executive about this pattern - his point was a lot of the money is to cover R&D, FDA rules, etc. Not just on the good drug, but the failed ones as well. It is minimally related to the cost of production. Every player feels screwed by the others in the game.


I've concluded the patient has no choice but to play as well, exercising the (broken) rules as hard as they can. The US medical system will wipe out someone who has the misfortune of getting sick and agrees to all charges thrown their way. That is part of what would keep me away from a health share. When things go sideways, I want the weight of a blue cross blue shield or humana in my corner.

[classical_Liberal]

@Scott 2
Just remember, humana and blue cross have their interests to look after in any negotiation. Health shares also negotiate on your behalf. However, in that case both your interests and the health share interests directly overlap. They pay whatever doesn't get negotiated away. Whereas the large insurers have to think about the arrangement in consideration of their total costs within their network. ie balance billing is meaningless to them, it's your responsibility not the networks. The healthshare has to look at your individual transaction with a provider or facility and try to get the best deal for each situation.

On the dissenting side. I do think there is some risk of healthshares not ponying up. However, my healthcare experience with patients using them seems to show this doesn't happen. Although it's achedotal and not meta-data. IMO the risk of an unexpected high balance billing incident in an ACA plan is much more likely.

My experience with medical bills, is they cannot be considered individually.

Excellent observation.

I've concluded the patient has no choice but to play as well, exercising the (broken) rules as hard as they can. The US medical system will wipe out someone who has the misfortune of getting sick and agrees to all charges thrown their way.

In this vein, I want to remind people that ACA plans are REQUIRED to cover preexisting conditions. This is why they are so expensive. A healthy person, who then becomes unhealthy with a chronic illness has the right to get an ACA plan during enrollment each year. A flexible person can easily meet the criteria of a Qualifying Life Event even outside those windows. So, if we think of health insurance as insurance, and not some other magical thing. This is the equivalent of being able to buy homeowners insurance after your house has already caught fire! Something to think about. Although this does no good for people in situations in which expensive chronic medical care is already needed, it does help everyone else.

So, I think of my Healthshare as an emergency gap policy, to ensure I have some coverage in an unexpected event. However, if I ever get really sick (house starts on fire), you can bet I'm gonna get an ACA policy (homeowners insurance) if I want treatment in the US. Is this cheating? You be the judge, but it's completely legal. (Edit: and it's not like this is some backdoor, or technicality. The system was specifically designed to be this way). It also insures I don't help pay into and support a broken payor system I want changed, unless it's life or death with no other options. So ethically there is plenty to think about.

[classical_Liberal]

What I would like to see in the US is universal catastrophic coverage funded by taxpayers with a private insurance market/employer coverage/Medicaid on top. Insurance policies would be much less expensive because the underwriters wouldn't have the huge downside to worry about.

This would be a great start. Some form of federal reinsurance. FYI in some cases medicaid is already doing this. People on hemodialysis automatically qualify for it, because it's so expensive in an ongoing basis insurers would bankrupt covering it.

[nomadscientist]

The biggest problem with US healthcare is reconciling two competing expectations:

1. market funding

2. extremely high level of provision (world highest, perhaps by a large margin)

In other words Americans want "affordable healthcare" but do not want to wait 2 months for an MRI like in the UK. Does waiting 2 months for MRI significantly reduce your life expectancy? No. But in reality far fewer Americans are willing to accept the wait than in the abstract want "affordable healthcare."

The biggest risk with reforming US healthcare is that you keep the over-provision and associated costs but simply create a new and wasteful DMV-like bureaucracy managing it*. After living in the US, I find this to be the actually most likely outcome. Even if provision control were attempted (questionable) it would be buried in lawfare establishing all sorts of "rights" to provision, many of which already exist. And so, I begin to understand at last why the Republican Party exists.


*Admittedly it's not totally clear whether DMV sclerosis making one determination of one final price would actually be worse than the multiple highly efficient agencies chasing each others' tails negotiating fake prices.

**If you have the stomach for it maybe the best way to handle health costs in the USA is to only consume emergency services and then simply reject the bills. It'll wreck your credit score but if you are wealthy who cares? Can/would they ever truly attempt to enforce a physical collection?

[ertyu]

lawfare establishing all sorts of "rights" to provision, many of which already exist. And so, I begin to understand at last why the Republican Party exists.

Well, the lawfare is their idea in the first place, isn't it. God forbid we have a freeloader or two - so in the name of work ethic calvinist cruelty, we must sacrifice the efficiency of the system -- which actually costs less to run if it's a bit "inefficient."

This is fine, though: even though our ridiculous demands that no "freeloaders" ever sneak in have made the system mindbogglingly inefficient, that's not an issue. We just use it to argue that the government is clearly not any good -- and thus shouldn't provide (so many) merit goods -- and thus the very rich clearly don't need to pay so much taxes.

The republican party exists so that the rich have someone to bribe into getting them out of paying taxes. There, US politics explained ...

[classical_Liberal]

@nomadsceintist and @ertyu

I don't necessarily disagree with either of your points. This situation is... interesting. However, I may have taken this a bit too far, when my ultimate goal was only to provide some good options wrt ERE and healthcare for relatively healthy people. We probably shouldn't muck up @idaves journal with a US medical system debate.

[nomadscientist]

@ertyu

The system is full of freeloaders. There are a lot of rights to provision that must be paid for by people who have health insurance, which is why the bills became fake. If people could only be billed for actual cost of services rendered every hospital with an ER would go bankrupt. I'm guessing plenty of judgement proof people consume non-emergency services and skip out on the bills too.

This system really has no redeeming feature. It is an example of path-dependence in politics only, no underlying design principle.

[IlliniDave]

..

[IlliniDave]

..

[IlliniDave]

..