You Don't Need Health Insurance

[theanimal]

You Don't Need Health Insurance

The post discusses the author's experience going without healthcare. Her method boils down to shopping around via price on the everyday things like glasses and dentists, and then negotiating later on for emergency items. She says that for her, going without insurance is more cost effective than what she'd be paying in premiums plus her deductible. She is not completely against using health insurance and under certain circumstances, like pregnancy, cancer diagnosis etc. she will find a health care plan. It's unclear how she would find one for the latter after open enrollment but she says that one of her uninsured friends was able to do so with the help of some hospital workers.

Some tactics that I hadn't heard about before:
-To get a prescription, she makes an appointment with a doctor on GoodRX.
-For dentists, she searches around for deals on GroupOn.
-For the times she needs to do an in person doctor appointment, she uses Zocdoc to find doctors and then calls around to compare cash prices.

In the comments, she states that the best option for high income earners is likely some type of health-share program, just like MMM.

Something that she doesn't mention in the post is that most hospitals have some type of assistance program that significantly reduces or eliminates the cost for those with lower incomes.

[Scott 2]

It's unclear how she would find one for the latter after open enrollment but she says that one of her uninsured friends was able to do so with the help of some hospital workers.

I wonder if her friend was eligible for Medicaid (monthly income qualification) or extremely subsidized health insurance all along. Or maybe they had a qualifying life event. New York is a very accommodating state. Hospitals have incentive to get a cancer patient covered.

I have a strong bias towards an exchange plan, specifically in states with expanded medicaid. I favor a preventive care strategy - building a medical team and health history while well. Planning for immediate and early intervention when sick, along with continuity of care.

As such, I'll refrain from criticizing the article.

[ffj]

If you read the comments one of the naysayers says sarcastically " One insurance please!". Pre-existing conditions be damned, haha.

I've been around people without insurance my entire life. When people criticize the United States about the cost of health care or that people don't have insurance they fail to realize that like any system it can be gamed, or manipulated to your needs if that sounds better.

The easiest way is to get the service and fail to pay the bill. Dammit, Johnny got shot again, call for an ambulance. Now these hospitals know that Johnny isn't going to pay the first cent for saving his life, and even though it would probably be better if he did die for everyone involved, they aren't going to base their care on whether he has insurance or not.

Another great method for saving money is to ignore your health problems. Toothache? Chew on the other side. And when that tooth falls out it won't be long before all of your toothaches go away. Just be prepared for some short face-to-face conversations with people that don't have decaying teeth.

You've ignored your problem and it's still there and worse? Call an ambulance! Preferably at 3 in the morning. Preventative care and scheduled visits are for the common people, just like paying for the ambulance ride.

Have a little bit of pride? Tell them you are poor and would like to make payments. Then send them $20/month until that $200,000 bill is paid in full.

By far the best way is to drag your half-dead corpse across the Medicare/Medicaid finish line, whichever comes first. Or shop for a disability. Then you don't have to pay those medical bills you weren't paying anyway.



I had a little fun here but some of the stuff she says here has merit but some of it definitely borders on abuse of the system. From a gambling perspective you probably could make the bet if you are healthy and keen on preventative care to forgo health insurance until your forties or so, knowing that any emergency care will not be denied whether insured or not. It's tricky though.

[ducknald_don]

By far the best way is to drag your half-dead corpse across the Medicare/Medicaid finish line, whichever comes first. Or shop for a disability. Then you don't have to pay those medical bills you weren't paying anyway.

Coming from the UK I'm not sure I understand the US system. Isn't most medical expense coming from the last year of life so for most people is going to be covered by Medicare?

[chenda]

Coming from the UK I'm not sure I understand the US system. Isn't most medical expense coming from the last year of life so for most people is going to be covered by Medicare?

I think ffj may have been joking

[theanimal]

To be clear, the author of the post is not advocating for neglecting your health or avoiding payment of any bills. There are responsible ways to go about this (as the author is advocating) and there are other ways as illustrated above.

Coming from the UK I'm not sure I understand the US system. Isn't most medical expense coming from the last year of life so for most people is going to be covered by Medicare?

Yes, nearly 100% of US adults 65 and over are on Medicare.

ETA: This approach also reminds me of the Surgery Center in Oklahoma that doesn't accept insurance. They list their prices for surgery online and claim that they can offer a lower cost due to not dealing with insurors. Russ Roberts talked to the founder a while ago on EconTalk. I'd recommend listening for those who are interested, it was very intriguing. https://www.econtalk.org/keith-smith-on ... alth-care/

[Ego]

I had a little fun here but some of the stuff she says here has merit but some of it definitely borders on abuse of the system.

It would be difficult to find someone willing to defend the American healthcare system in its current form. Those who are siphoning from it are willing to surreptitiously defend it, but even they refuse to speak out publicly in favor of it. So that begs the question, does the system deserve to be abused?

Is she doing something wrong if she uses all of the legal loopholes at her disposal to abuse the system?

[Scott 2]

Prices at the OK surgery center look similar to the negotiated rates my insurance gets from in-network facilities.

If all medical providers had similar pricing integrity, I'd have a different perspective on insurance coverage. As it stands, retail prices from large medical systems are not attainable. I've been quoted $70k for a surgery with overnight stay. That's only to pay the hospital. Figure another $30k for the surgeon and anesthesiologist.

The author's critique of our medical system is valid. Insurance negotiated rates might be 10% of retail. Broken.


From what I understand, ffj accurately describes one side of the bifurcated US healthcare system. A large portion of the population fails to successfully navigate the complexity. Their health outcomes are not good.

We can point fingers as to why. There's not a single responsible party IMO. As an individual though, it's highly preferable to be in the other group.

Those people are getting best in class medical care, often at very attainable costs. They can have a team of medical advisors, collaborating to manage healthspan factors.


The divergent paths are not always obvious, until one gets sick. The latter group might experience treatment decades earlier. It could be the difference between a minor nuisance and no option but palliative care.


When I see someone going without insurance, I wonder if they have the wisdom to stay in that latter group. I think it's feasible, but likely to erase any cost savings. Concierge doctor, enhanced labs, optional screenings, lifestyle factor education, surgical tourism, etc.

At some point it's smart to leverage outside expertise. Ideally you regularly consult with a team of trusted advisors. Doing that well is not easy, especially absent guide rails. IMO it doesn't start with a Groupon search.

[theanimal]

At some point it's smart to leverage outside expertise. Ideally you regularly consult with a team of trusted advisors. Doing that well is not easy, especially absent guide rails. IMO it doesn't start with a Groupon search.

Isn't that just a general issue? How many people here trust the state of their health to their primary care provider?

As you hint at in the paragraph above this one, people who are interested in maximizing their health are doing things outside the realm of insurance anyways. Even if you find someone you like, what happens when they are outside of your network or get booted from it? I think that speaks to the power of Peter Attia's medicine 3.0 idea. As an individual, I can tailor my approach to what best works for me. Yes, this takes time. But imo it beats the current norm that leads to 40% (and rising) of the country being obese. It's not as hard to keep up with current research with the internet, books and podcasts. You and a number of other people on here are testament to that.

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?

[Scott 2]

how does having a plan make me better off day to day health wise than not having one?

Given your nomadic lifestyle, high autonomy and state of residence, it might not. You're living in an extreme edge case.

Catastrophic coverage is a big caveat though, especially with dependents.

My response considers a general audience, and the author's residence in New York.


In my own case, I've found a few advantages:

1. Preventive care is baked in. I already paid for it, there's no financial incentive to skip it.

2. My incremental cost to seek care is minimal. I spent $20 for my last specialist visit. It was 2 hours, half of that with the doctor.

3. This makes it feasible to quickly assemble and afford a team approach to problems.

4. As medical systems and insurers consolidate, a majority of providers fall under the umbrella of my well selected plan. I have broad access.

5. Since I'm operating within the dominant paradigm, I coast through the administrative bureaucracy. Everyone knows how to deliver care.

I've been resistant on this point, to my own detriment. I put off that $20 specialist visit for 6 months. I was convinced it'd break the bank.


6. I have a team of providers I can message. I don't have to play games for an Rx or Test. Anything I want is a MyChart message away. This isn't specific to the health plan, but a side effect of the easy care.

7. Coming back to playing within the dominant paradigm - everyone's using the same software. My doctors can trivially collaborate. Not impossible for independent providers, but less likely.

The electronic records also make it easier for providers to roll off my care, without a tremendous loss. I like my new GP more than the old one.


There is a tier of cash only providers I cannot afford. I live by people who will take that $100k surgery, without a second thought. I don't think that's who we're discussing here though. They can afford to self insure.

What I'm describing is not attainable on an ERE spend either. My personal healthcare spend will approach 1 Jacob this year. It's my biggest expense. I believe it's the wisest investment I can make.

Some of this cost is because I'm transitioning from the article's paradigm. I erroneously neglected healthcare, raising many varieties of resistance. It was to my detriment, and I'm now playing catch-up.

I could ignore these same problems for 20 more years, becoming progressively more feeble. Or I could invest in reaching a young 60, anticipating that octogenarian decathlon. After lifestyle factors, health insurance is the best lever I've found.

[theanimal]

Some of this cost is because I'm transitioning from the article's paradigm. I erroneously neglected healthcare, raising many varieties of resistance. It was to my detriment, and I'm now playing catch-up.

I think this is where our disagreement lies. I don't see the author as neglecting any care. She talks of regular checkups with doctors, going to the dentist, seeing an optometrist and getting a surgery done. The healthcare system in the US functions more like sickcare and is not designed to prevent illnesses and diseases as much as treat them. It sounds like you may have found an exception to that in your personal circumstances and I commend you for that.

In the author's case, it very well may be that she is eating poorly, not exercising and neglecting her mobility, which I would agree is short sighted. I may have misread it, but I don't remember seeing any mention of those topics in there. The vast majority of issues related to healthspan and lifespan are lifestyle related. For that, the above is going to have a lot more of an impact than making regular visits to a doctor. Even if we're buying solutions, I'd be far more interested in a trainer, nutritionist and a physical therapist than a doctor (with the exception of perhaps a concierge doctor). Unless someone has pre-existing issues or some type of injury, none of those are likely to be covered by a standard health insurance plan for preventive purposes.

[ffj]

It would be difficult to find someone willing to defend the American healthcare system in its current form. Those who are siphoning from it are willing to surreptitiously defend it, but even they refuse to speak out publicly in favor of it. So that begs the question, does the system deserve to be abused?

Is she doing something wrong if she uses all of the legal loopholes at her disposal to abuse the system?

It's sort of like cops that ticket people that will pay a parking fine while ignoring the homeless guy taking a shit in the middle of the road that I would say I have an issue with as far as fairness. And I don't know anybody either that would defend our system as it stands.

When you exploit a loophole that was meant for someone else under special circumstances than you are proclaiming to every person that dutifully pays their premiums they are chumps while ignoring or dismissing the very fact you can do such a thing is because so many others are carrying your water. It is a very distasteful form of arrogance.

"If that fails, you'll have to get creative. It’s hard for me to give blanket advice for these situations. You may need to get cost estimates from other healthcare providers, to find out the "true" cost. You may need to call the billing department and say you’re unable to pay. The hospital would rather that you pay a smaller bill than not pay at all. If necessary, escalate the situation to a watchdog organization or your state's government.4"

Now most of what she says is just good creative advice (which I love) but in the above quoted she is stating you should just refuse to pay. Escalate to a watchdog group that can find discrimination or some other flaky reason to not pay for services provided. Am I reading this incorrectly?

Is she breaking the system? Nope, she's just making her fellow citizens pay higher premiums to cover losses incurred on her behalf.*


*I know it's not a simple one to one ratio (this whole topic is very complicated) but the net effect of millions of people in essence consuming free health care has a consequence. You can argue who needs to pay that bill but right now honest people get punished.

[Sclass]

I liked the article. I think she’s pretty clever. I’ve considered self insuring - I don’t have the nerve yet. I’ve said before insurance is mostly for when you really cannot afford to protect the thing you have. In the case of your body you can’t really trade it off for something cheap - like trading your car for an e-bike. The big problem is the insurers can fight for lower rates than we can alone…or so I thought till I read this.

My wife likes insurance. She complained that our Obamacare may not be enough if something really bad happens. I told her I have her back if it gets ugly. Even good insurance has limits. Those actuaries aren’t dumb. The underwriters are going to make money. They’ve set it up like a casino.

I’ve told the story before how I “negotiated” a bill to zero. It was several grand. I landed in the ER with a kidney stone. I asked for IV meds and they said they had to cat scan me ($5000) to prove I wasn’t a junkie looking for a free high. It seemed like a lot and I had a high deductible. My wife scolded me and said “that’s what you(dummy) get for gambling with high deductibles.” I let my ego get the best of me and I had to prove her wrong. I called billing and said it was a hardship. I was hoping they’d cut the bill in half. They suggested I apply for charity assistance. It was a form and I had to mail them my 1040. At the time my taxable income was pretty low since I was surviving off long term capital gains. I mean if you read my return carefully you’d see I was wealthy but I think the hospital had this criteria like W2 earnings, taxable income etc. which put me in a good light. They zeroed the bill. I felt a bit guilty. Maybe I’ll contribute to their charity assistance some day.

I tried this tactic in grad school and made a huge bill disappear. I forgot but I think it was $30,000. A scoundrel I knew coached me through the process. He was an older guy who lived off my godmother. A real freeloader. “Don’t worry Sclass, I’ll show you how to make that bill go away, I do it all the time.” He had really bad health but he always seemed to get top drawer treatment at Stanford Med center. He taught me the hardship trick.

[Ego]

When you exploit a loophole that was meant for someone else under special circumstances than you are proclaiming to every person that dutifully pays their premiums they are chumps while ignoring or dismissing the very fact you can do such a thing is because so many others are carrying your water. It is a very distasteful form of arrogance.

When the ACA was first passed in 2010, it was unworkable without the Individual Mandate which required everyone to buy health insurance or be fined. They needed to get all of those low-cost, healthy, poor young people into the system to subsidize the high-costs, sick, wealthy, old Boomers. They needed chumps to pay premiums to protect the Boomer wealth.

The Boomers have largely transitioned to Medicare, and their benefits are now paid by all of us chumps in the form of general fund tax revenue (46%) and payroll tax revenue (34%). Only 15% of the cost of Medicare is covered by premiums paid by beneficiaries.

Distasteful arrogance, indeed.

I erroneously neglected healthcare, raising many varieties of resistance. It was to my detriment, and I'm now playing catch-up.

Did you neglect healthcare or health? It is easy to conflate the two, but they are very different.

What preventative care do you believe to be worth the cost?

[Scott 2]

I think this is where our disagreement lies. I don't see the author as neglecting any care.

She's making assumptions about equivalency of care, that simply aren't true.


My budget optometrist gave basic vision correction. A single sphere value per eye.

Another budget optometrist, with more prompting, diagnosed astigmatism. He also mentioned a floater I'd never noticed.

When I saw an optometrist at the local university, she confirmed I suppress the floater eye. Which is why I hadn't noticed. She traced the suppression to a misalignment of my eyes, explaining other vision and headache issues I'd been contending with.

When I finally went to the specialist opthalmologist, he was able to diagnose a specific nerve issue. And confirm it's likely been present my entire life. He even found a significant error in that original vision correction, due to the more thorough eye exam.

We've got some less invasive Rx changes to try, but there's also a surgical correction available. It would've been reasonable to perform decades ago. Maybe I didn't have to go through life hating left turns and ball sports.

My GP attempted the specialist referral around budget optometrist #2. I'm still learning.


I have a similar story with dental care. I chose the "conservative" dentist in my 20's and 30's, because they told me what I wanted to hear. Nevermind that I now have permanent bone loss and gum recession, because we ignored all non urgent problems.

Contrast with my premium dentist. He adjusts cleaning frequency to match my tartar build up. Every visit charts gum pocket depths. While there's standard x rays, he also does the occasional panorex. And he runs an iterro scan 1-2x per year, digitally comparing changes in 3d imaging of the entire mouth.

Hygiene instruction included not only ensuring I was on an electric brush, but also daily using a water pick.

When it comes time to do a filling, they are early and small. He favors a laser drill over mechanical. There are digital pictures of the work pre, during and post. He debriefs you on the screen, with clear evidence of the results.

He also proactively monitors old fillings, replacing them with evidence of decay. He literally rebuilt a couple of my wife's teeth, heading off what could have been very painful problems.

And of course there's the successful education as to my wisdom teeth removal, braces and eventually surgical bite correction.

If my parents had seen an orthodontist when I was 8, the surgery could have been avoided entirely. The gap is generational.


It's honestly a glaring difference. I can't overstate how disparate the standards of care are.


It almost feels like a throw away example - but combined eye issues and headaches lead me to a legit neuropsychological evaluation. Currently underway. It's likely we'll diagnose my autism over a couple appointments. Imagine having that at age 10, instead of slowly discovering it in my 30's. But neurodiversity was simply not in my parent's medical paradigm.

Even if we're buying solutions, I'd be far more interested in a trainer, nutritionist and a physical therapist than a doctor

I'm chasing my foot issues with physical therapy right now. It seems pretty trivial to get a referral. My PT is a marathoner and specializes in gait analysis. I'm expecting to average about $35 out of pocket per session. That includes home exercise plan, massage, strengthening exercises, and movement re-patterning. The last visit was about an hour.

There's another instance where by finally visiting a podiatrist for my foot complaints, I'm getting neglected care. Turns out the bunions I've had since at least my 20's, aren't best fixed going barefoot. And there's a host of related defects carrying up my kinetic chain.

Thanks to insurance, I could have both an X-ray and MRI. That confirmed not only undiagnosed Achilles tendinitis, but also a benign tumor we're now monitoring. Was it there 20 years ago? I never had the care to know.


Frankly - it's not feasible for every person to get this standard of care. But it's accessible if you understand the systems. Knowing how and who to ask is a big part of it.


@Ego - those are probably my biggest examples. I'm not sure there's a distinction between health and healthcare. There's an intertwined relationship, and it's very personal.

I guess one more would be my GP agreeing to Rx a continuous glucose monitor, via a single MyChart message. That one was out of pocket, but worth it.

I had great insurance through my 20's and 30's. But I grew up with a different standard. I didn't understand what was available or how to use it. That's what I see in the OP article.

I'm not special. Everyone's carrying medical issues. Only some of us are getting modern care.

There's a separate question of - is it worth it? I suspect yes - this type of care factors into why the wealthy age better and live longer. But it's too soon for me to reliably confirm.

[ffj]

When the ACA was first passed in 2010, it was unworkable without the Individual Mandate which required everyone to buy health insurance or be fined. They needed to get all of those low-cost, healthy, poor young people into the system to subsidize the high-costs, sick, wealthy, old Boomers. They needed chumps to pay premiums to protect the Boomer wealth.

You are making a comparison but what is the point? Because I can think of several directions this could go. Can you elaborate?

[IlliniDave]

I tend to agree with ffj that the gaming of ACA by opting out until you know you'll incur substantially more cost than the premium + OOP max is a little distasteful to me personally. I'm not going to be judgemental about anyone who exploits the rules as written, but I would not SWAN with the intent of doing that if things went awry while opting out during my relatively healthy years.

I also think continuity and coordination of care is pretty important. One of my sisters who used to go to "doc in a box"-type clinics out of convenience wound up on a combination of meds that really messed her up for a while until a pharmacist noted she was taking a dangerous combination. I could list a number of such anecdotes.

I go the chump route and pay for a mid-level ACA style plan with the intent of more/less self insuring up to the OOP max. It's a group plan for retirees of my former employer that the employer negotiates but does not fund. You have to start immediately upon retirement and once you discontinue you can never go back. Even though the entire risk pool is made up of people 55-64 in age, it's a few hundred bucks a month cheaper than an equivalent exchange plan in my state. That despite poor health driving a fair fraction of early retirements. I think that's largely because everyone in the group has been paying continuously since day 1.

If nothing else, I get steep "discounts" on most services negotiated my the administering insurance company which are likely better than I could run around and negotiate myself.

I'm beginning to be a bigger believer in proactively cultivating health. At 58-59 I reversed a number of chronic western lifestyle disease indicators, which will probably save me, my fellow premium payers, and ultimately fellow taxpayers, a fair bit of money going forward.

[Ego]

You are making a comparison but what is the point?

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.

Even though the entire risk pool is made up of people 55-64 in age, it's a few hundred bucks a month cheaper than an equivalent exchange plan in my state.

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/

Premium variations based on age are limited to a ratio of three to one (meaning the premiums for a 64 year-old is three times the premium for a 21 year-old).

[7Wannabe5]

Prior to the establisment of the ACA, when the majority of my income was from my own extremely small business, I purchased private insurance with a huge deductible (I think my premium was around $150/month and my deductible around $8000), so I followed quite a few of the tactics suggested in the article to lower my out-of-pocket expenses. One year my sister/business partner and I also purchased annual passes to a hot yoga studio as our employee preventative medical plan If my memory serves, I believe I was then required to drop my private insurance and get an ACA plan, because my private insurance did not constitute minimum coverage. Then I was eventually kicked off of ACA and on to extended Medicaid, because I estimated my income above 150% poverty for 3 years in a row when it was actually below that level. There was one year when I actually had both ACA and extended Medicaid coverage without knowing that I had extended Medicaid coverage. I was trying to avoid qualifying for Medicaid, because my assumption was that I would have to deal with poor choice of providers, horrible bureaucracy, invasion of privacy, etc. Actually, it hasn't been too bad, and I lucked out that I did have Medicaid eligibility when I was struck down with non-lifestyle-related, chronic, expensive-to-treat disease.

As a single adult, the sweet spot for receiving most of the benefits/breaks/options aimed at the "working poor" is an income of around $18,000/year, which is around the median minimum full-time wage. Around 90% of workers in the U.S. are employed by small businesses that are either not required to provide minimal health insurance or are eligible for business health insurance subsidies under ACA. Many large employers who are required to provide minimal coverage insurance to full-time employees offer plans to their employees with premiums that are higher than they could receive on the ACA marketplace as individuals due to their low wages, and these employees will generally qualify for tax break. Therefore, the only Americans who are not subsidized/qualified-for-subsidy-at-some-level under the ACA would be high income self-employed or early retired individuals or high income employees/pensioners of large employers, and these groups combined are likely less than 5% of the working/retired-worker population, and the working/retired-worker population only represents a fraction of the entire population. IOW, it is not mathematically possible that those who are paying for health insurance without subsidy are covering the expenses of those who receiving subsidy at some level. IOW, medical care is already basically fully socialized in the U.S., but the complications of the system serve to cover this up, likely mostly due to the contingencies of political compromise. Therefore, rational practice would be that which best prevents broken window effect. Although many fear the "big brother" aspect, I think the ever increasing digitization of medical records and claims making personalized medicine more readily available will prove to be the most cost saving mechanism. For instance, I recently was offered a $25 gift card to encourage me to go get an overdue mammogram. It's very easy to use data science techniques such as k-clustering and logistic regression to target groups of patients/citizens who could use a nudge towards prevention. Similar techniques can also be used to determine if, for instance, the approximately $600/month cost of the highly effective new weight loss medications is more/less than the medical cost burden of obesity with or without various metabolic syndrome co-morbidities.

In conclusion, there is no good reason to go without health insurance, because if you are not adequately subsidized at your current income, then you are likely spending at least 50% more on your lifestyle than the $12,000/year PPP = 1 eco-Jacob. IOW, it's just a question of what exactly is going to collapse first; your health, the economic system inclusive of the health care system, or the planetary resources necessary to support your health and/or the economic/health care system.

[theanimal]

@Scott2- What I'm getting at, and what @Ego put more succinctly, is that what you described above is treatment. Healthcare excels at treatment. A personal health strategy, by way of exercise, diet etc., is a form of prevention that lessens or eliminates the need for such treatment. An example of prevention would be what @shaz does in paying out of pocket to see a physical therapist on an annual basis to identify weaknesses and places where she is lacking mobility. Another example could be buying an electric toothbrush or going to the dentist for regular cleanings. Most, if not all, of these preventative measures occur outside of the healthcare/sickcare complex. As such, they do not generally benefit from a health plan, whereas treatment does.