It’s interesting how it’s the same in Germany — a country which in many regards, but especially in this one, is on the opposite side of the spectrum in terms of how the underlying system works.
I saw this debate a few weeks ago between two guys re what's the best way to improve the current healthcare cost.[1]
I think both positions were untenable, but one interesting point that one guy made was that, while called "insurance", health insurance is structurally very different.
If you buy flood insurance, you have very low expectations you will actually need it. It's a way to pool tail risk and spread it out over a larger population.
Healthcare insurance, however, pays for all your medical costs, many of which you can reasonably expect to have to pay. So you're no longer socialising risk. You're not even socialising cost really, sonce plans have many carevouts, exceptions, copays, limits etc.
So a more efficient system would be one where you selfpay for regular procedures and have insurance for rare, life altering conditions.
> So a more efficient system would be one where you selfpay for regular procedures and have insurance for rare, life altering conditions.
This is sort of what a high deductible plan is, which were encouraged by the ACA. After premiums, my first ~$4,000 in medical expenses each year come out of my pocket. Then the next ~4,000 in medical expenses are shared between me and my insurance. Then the remainder is covered by my insurance. The difference is perhaps just what "rare, life altering conditions" means. For a lot of people the cost of medical care becomes untenable not at "oh god I need seven figures in surgeries" but instead "oh god that appendectomy is $50,000 before insurance" or even "oh god I don't have $10,000 to pay for that hospital visit."
But to be clear, you are socializing risk though. You're just doing it a different way, by genetics and age.
Your monthly payment (and what your employer kicks in) are for all those day to day costs. And of course there's the deductible. But people in their 40s to 50s often don't have young kids. Meanwhile, people in their 80s to 60s have more health risks.
So what happens elsewhere is that everyone throws money into the same pot for their entire lives, and your costs are averaged as per above. It's why a single insurer, the government, is perfect for this. And it works for rare conditions that might happen to some during their lives, and not all too.
And typically, for thousands of years, we've had more young than old. So while elderly people do have more issues late in life, they've paid into the system the whole time. And, now there are young people to pay just as they did.
The only downside is when you end up with an age skewed population, such as is happening with the entire planet. It's affecting all health care systems, private or public. The US has this problem too, as medicare is being hit by spiraling costs.
One thing I find really weird, is the need for-profit in the US system. Other systems have that too, sure, but not like the US. An example, the fire department isn't for profit. It'd be insane if so! Why would it be?! Yet, there is private sector work in the fire department, such as all the equipment bought from the private sector, chemical analysis done on debris post-suspicious-fire, and even training in some cases.
Most health care systems around the world are like that. The insurance is public, not for profit. The hospitals too. Many parts of the system as well.
If you are allowed to skim only 10% on top. Obvious solution to increase amount is to increase underlying cost. This goes for insurance. But also for many other players like hospital owners. When you have oligopoly there is no reason to drive prices down.
Because we treat it like a business instead of a human right and public benefit.
Because the only true guiding moral truth in America is that capitalism is the only economic system that could possibly work and we should allow capitalists to pursue profit by any means.
Indeed. I'd like to hear too, seeing as the admin cost caps for insurers in ACA are a pretty big stick to counterbalance the mandate carrot.
I know firsthand that a lot of insurers substantially increased internal efficiency as a result of no longer being able to pass excesses along to consumers in premiums.
The ACA bill was originally a republican bill that Obama agreed and pushed. And then the republicans flipped around and started blaming Obama on their own bill.
I’m self employed and literally have the cheapest (non healthcare.gov) plan I could find at $396 a month. The plan is absolute garbage with carve outs, high deductibles, limits, and caps. I fully expected if I ever really need to use it (knock on wood), they will screw me and deny claims. My premiums have nearly doubled in the last 5 years.
Seriously considering not having insurance and going cash. Any recommended plans for freelancers / solo self employed?
A better option than going cash is a HSA through the government marketplace. It will give you tax deductions on your savings, you’ll end up paying almost everything out of pocket (same as cash), but you’ll be protected against total ruin if you need emergency care.
Don’t buy insurance outside of the marketplace. The ACA places limits on what insurers can deny, and those limits protect you from the rampant problems that existed before the ACA. I’m not sure if those protections apply to insurance purchased outside the marketplace.
As @dragonwriter said, the HSA doesn't protect you against ruin, the linked high-deductible insurance does. You use the HSA for your ordinary medical expenses and get a nice tax discount from it. The HSA is also acts as a retirement investment account.
So, if you're young with minimal healthcare needs, you can get multiple benefits:
1) High-deductible insurance that's (relatively) cheap but still protects you against financial ruin
2) After 10 years of maximum contributions, you'll have ~$10K in cash for emergencies and about $33K in retirement investment contributions.
Thanks for clarification, but I believe my private-market health insurance plan even though high deductible is not eligible for a HSA. I believe you have to use a healthcare.gov plan to be eligible for HSA which are significantly more expensive. So, not sure the benefits are there if your monthly premiums are 25-40% more expensive (HC.gov + HSA) than a private-market plan.
All health insurance plans in the US are private-market.* You may be confusing ACA-compliant plans (private insurance that's allowed to be listed on healthcare.gov and is eligible for subsidies) with non-ACA-compliant plans (not allowed to be listed on healthcare.gov, not eligible for subsidies).
Be careful about non-ACA-compliant plans. They're cheaper because they engage in sketchy behaviors that leave you without coverage when you need it.
They are probably using “HSA from the government marketplace” as shorthand for “a combination of an HSA with a HSA-eligible health plan from the state ACA marketplace”; the HSA doesn’t protect you from total ruin, thr linked high-deductible health plan should.
I've heard of co-op insurance, where self-employed people group together for better rates. No idea if it's good or not though. First google result was: https://opolis.co/insurance/
Insurance has always been about groups of people banding together to soften emergencies. Prior to the ACA, the groups were people with the same employer, and getting insurance as an individual was prohibitively expensive and had ridiculous limits. The ACA added the ability to purchase through the marketplace and prevented the rampant denials that previously existed. I’m not sure how folks are grouped in the marketplace, but I believe it’s by zip code.
I paid for my own insurance for decades and the ACA absolutely made things better, and cheaper, for individuals seeking insurance. Not even counting the subsidies for lower incomes.
This is a structural death blow to small business and something needs to be done about it if we think it's a good thing not to live under corporate feudalism.
Would going with Direct Primary Care help? It is like concierge care in that you pay a monthly retainer to a doctor's office for unlimited access. You then supplement that with insurance with a very high deductible for major issues. DPC seems to be a growing trend among new primary care practices in the USA.
$396 (if un-subsidized) probably means you are on a bronze tier plan. And yes many of those are hot garbage. However, if you are paying that for a crap plan and getting a subsidy too, you're probably getting ripped off. Most people on healthcare.gov or a state exchange who sign up for bronze tier are getting a subsidy, so the premium is reduced to near zero in some cases. Still often a bad plan, but a cheap bad plan.
I pay ~$400 but the government kicks in ~$350 too due to my low income. Its a Silver PPO plan and not bad, though, I haven't used it for anything serious yet. The Silver plans have extra subsidies so are usually better quality than bronze.
It also can be helpful to switch insurers if the plan is bad. My insurer up until last year was once decent but has gone downhill. They are also the dominant insurer in my area. The one I switched to this year is trying to gain market share in my area, so they seem to be a better deal, the plan is more generous and has less red tape.
When I was on the marketplace, I couldn't tell much difference between the metals. I'd pick a network, all the tiers covered only the mandatory stuff as best as I could see; really same deal with all the networks, but different providers. Higher tiers had higher premiums and lower deductables... for me, I just went with bronze because premiums + out of pocket max was lowest; I'm sure there's portions of the curve where care would cost less with a higher tier, but I figured lower cost with minimal use and lower cost with maximal use is pretty good.
IMHO, health insurance makes it hard to do cost control of healthcare. Patients can't do it, because they won't know how much stuff costs until 6 months after service, so they can't really make decisions on cost. Providers can't do it either, they have even less idea of what things cost for patients, and they have an interest in providing more billable care. Insurance companies could do it, but denying care for economic reasons is hard, so they just go with denying care for beuracratic reasons; also, ACA insurers have revenue limits based on ratios to covered care, so covering more things allows them to get more revenue. Even government paid healthcare has trouble because everyone gets grumpy when they can't get all the care available.
The maximum you can make and receive any subsidy is absurdly low. I don't qualify for any government subsidies yet I'm the one actually paying real income tax.
Usually you tax the ultra wealthy to reign in their influence and limit corruption/lobbying/political spending. That’s how it’s been done non-violently in the past.
"The biggest impact I have experienced so far has been that popups for cam sites, porn sites and other such affiliate marketting referal attempts lead to an age verification page rather than directly to all the "hot singles in my area looking for sex"
Yes, the internet advertising machine has been affected negatively when it spams me (and everyone else) thanks to the privacy invading adult verification requirements.
I don't feel sorry for them either, they were always parasites, but I am not sure what your point is or what it has to do with this conversation.
I suppose you want to personally take responsibility for the EU's current anti-encryption crusaide? After all, you chose this path! Clearly you think that we must all summit our private conversations and thoughts to your government for approval?
At this point the only tenable option is going to be some sort of single-payer healthcare. Small businesses can't afford the healthcare costs to employ people and your average worker can't afford the costs either. When I was looking for a plan earlier since I got laid off about a month ago, the cheapest plans were in the $500 or so a month range which is insane for someone that's had zero health issues so far and doesn't smoke or drink.
I fully expect the west coast states to implement single payer before the government ever catches on.
Or regulate prices. How can a hospital charge $250 for an IV bag while in Europe the same bag is 10€
Or an ambulance ride in the US STARTS at $500. An ambulance ride in the EU is 260€/hour (obviously is free in case of emergency)
I think the problem is that the US is in this weird dynamic in which hospitals charge more because "the patient is not paying for it, the insurance is" but in the end insurance are going to raise premiums to pay for that
Patients and providers should have the ability to shop and negotiate price directly with each other. No 3rd party will ever be in a better position to negotiate individualized care and prices for 350,000,000 people better than we (or our family) can for ourselves.
Currently, patients cannot price compare anything, not even for the exact same drug from two different pharmacies on the same street! To make it worse, most providers can't even make sense enough of the provider-insurer prices to shop on behalf of the patients.
To improve prices in healthcare, all care must have a price visible to all, paid by patients. Insurance should be required by law to publicly publish their reimbursement rates and immediately (48 hours) reimburse their insured patients for care at approved (in-network) providers.
This would end the current: impossible to self advocate, impossible for providers to advocate on behalf of patients, intractable insurer-provider price web.
Insurers and providers should never negotiate price. Providers should only be concerned with providing good care, how to classify/code it, and the amount they need to charge for that care to be financially viable. Insurers should only be concerned with how much they will pay out for each classification/code, and which providers they authorize as in-network.
Last, since there is a long tail of medical care that doesn't fit nicely into a code box, each plan should have a mandatory minimum coverage of something like 50% all unknown-care costs at in-network providers and pharmacies above $5,000 annually, with some annual cap.
As a society, if we want to further subsidize healthcare for those with lower economic means, and/or those who end up with catastrophic expenses, then that should be done on it's own, as two distinct standalone welfare programs.
https://archive.ph/x17re
It’s interesting how it’s the same in Germany — a country which in many regards, but especially in this one, is on the opposite side of the spectrum in terms of how the underlying system works.
I just dont understand why health insurance and medical cost in US are so expensive.
I saw this debate a few weeks ago between two guys re what's the best way to improve the current healthcare cost.[1]
I think both positions were untenable, but one interesting point that one guy made was that, while called "insurance", health insurance is structurally very different.
If you buy flood insurance, you have very low expectations you will actually need it. It's a way to pool tail risk and spread it out over a larger population.
Healthcare insurance, however, pays for all your medical costs, many of which you can reasonably expect to have to pay. So you're no longer socialising risk. You're not even socialising cost really, sonce plans have many carevouts, exceptions, copays, limits etc.
So a more efficient system would be one where you selfpay for regular procedures and have insurance for rare, life altering conditions.
[1] - https://www.thesohoforum.org/upcoming-events/2025/7/16/jacob...
> So a more efficient system would be one where you selfpay for regular procedures and have insurance for rare, life altering conditions.
This is sort of what a high deductible plan is, which were encouraged by the ACA. After premiums, my first ~$4,000 in medical expenses each year come out of my pocket. Then the next ~4,000 in medical expenses are shared between me and my insurance. Then the remainder is covered by my insurance. The difference is perhaps just what "rare, life altering conditions" means. For a lot of people the cost of medical care becomes untenable not at "oh god I need seven figures in surgeries" but instead "oh god that appendectomy is $50,000 before insurance" or even "oh god I don't have $10,000 to pay for that hospital visit."
That might be more efficient.
But to be clear, you are socializing risk though. You're just doing it a different way, by genetics and age.
Your monthly payment (and what your employer kicks in) are for all those day to day costs. And of course there's the deductible. But people in their 40s to 50s often don't have young kids. Meanwhile, people in their 80s to 60s have more health risks.
So what happens elsewhere is that everyone throws money into the same pot for their entire lives, and your costs are averaged as per above. It's why a single insurer, the government, is perfect for this. And it works for rare conditions that might happen to some during their lives, and not all too.
And typically, for thousands of years, we've had more young than old. So while elderly people do have more issues late in life, they've paid into the system the whole time. And, now there are young people to pay just as they did.
The only downside is when you end up with an age skewed population, such as is happening with the entire planet. It's affecting all health care systems, private or public. The US has this problem too, as medicare is being hit by spiraling costs.
One thing I find really weird, is the need for-profit in the US system. Other systems have that too, sure, but not like the US. An example, the fire department isn't for profit. It'd be insane if so! Why would it be?! Yet, there is private sector work in the fire department, such as all the equipment bought from the private sector, chemical analysis done on debris post-suspicious-fire, and even training in some cases.
Most health care systems around the world are like that. The insurance is public, not for profit. The hospitals too. Many parts of the system as well.
But then some aspects are private.
> An example, the fire department isn't for profit.
https://www.huffpost.com/entry/firefighting-in-the-1800s_b_2...
What we call insurance is more like a Costco club membership where members get better rates
If you are allowed to skim only 10% on top. Obvious solution to increase amount is to increase underlying cost. This goes for insurance. But also for many other players like hospital owners. When you have oligopoly there is no reason to drive prices down.
Because there is no one to stop you. It's the perfect scam.
Because we treat it like a business instead of a human right and public benefit.
Because the only true guiding moral truth in America is that capitalism is the only economic system that could possibly work and we should allow capitalists to pursue profit by any means.
Because Obama rewrote the Healthcare laws to prioritize insurance companies above all else.
Their stocks have been doing great!
ACA is largely based on Heritage Foundation policy papers. Project 2010, if you will.
In what way were insurance companies limited before the ACA that “Obama” removed? Please be specific. I’ve never heard this take before.
Indeed. I'd like to hear too, seeing as the admin cost caps for insurers in ACA are a pretty big stick to counterbalance the mandate carrot.
I know firsthand that a lot of insurers substantially increased internal efficiency as a result of no longer being able to pass excesses along to consumers in premiums.
The ACA bill was originally a republican bill that Obama agreed and pushed. And then the republicans flipped around and started blaming Obama on their own bill.
I’m self employed and literally have the cheapest (non healthcare.gov) plan I could find at $396 a month. The plan is absolute garbage with carve outs, high deductibles, limits, and caps. I fully expected if I ever really need to use it (knock on wood), they will screw me and deny claims. My premiums have nearly doubled in the last 5 years.
Seriously considering not having insurance and going cash. Any recommended plans for freelancers / solo self employed?
A better option than going cash is a HSA through the government marketplace. It will give you tax deductions on your savings, you’ll end up paying almost everything out of pocket (same as cash), but you’ll be protected against total ruin if you need emergency care.
Don’t buy insurance outside of the marketplace. The ACA places limits on what insurers can deny, and those limits protect you from the rampant problems that existed before the ACA. I’m not sure if those protections apply to insurance purchased outside the marketplace.
I was going to say. This is probably one of those few things that Bush got somewhat right.
HSA limit is $4,300 annual, how does that protect against total ruin? That's a hospital trip in a Uber and a few tylenol.
As @dragonwriter said, the HSA doesn't protect you against ruin, the linked high-deductible insurance does. You use the HSA for your ordinary medical expenses and get a nice tax discount from it. The HSA is also acts as a retirement investment account.
So, if you're young with minimal healthcare needs, you can get multiple benefits:
1) High-deductible insurance that's (relatively) cheap but still protects you against financial ruin
2) After 10 years of maximum contributions, you'll have ~$10K in cash for emergencies and about $33K in retirement investment contributions.
Thanks for clarification, but I believe my private-market health insurance plan even though high deductible is not eligible for a HSA. I believe you have to use a healthcare.gov plan to be eligible for HSA which are significantly more expensive. So, not sure the benefits are there if your monthly premiums are 25-40% more expensive (HC.gov + HSA) than a private-market plan.
All health insurance plans in the US are private-market.* You may be confusing ACA-compliant plans (private insurance that's allowed to be listed on healthcare.gov and is eligible for subsidies) with non-ACA-compliant plans (not allowed to be listed on healthcare.gov, not eligible for subsidies).
Be careful about non-ACA-compliant plans. They're cheaper because they engage in sketchy behaviors that leave you without coverage when you need it.
*Well, except Medicaid, Medicare, etc.
You’re correct. I should be saying ACA compliant plans vs non-ACA instead of “private”. I have a non-ACA plan thus why I can’t have a HSA.
They are probably using “HSA from the government marketplace” as shorthand for “a combination of an HSA with a HSA-eligible health plan from the state ACA marketplace”; the HSA doesn’t protect you from total ruin, thr linked high-deductible health plan should.
One emergency visit is like 10k here now. Best of luck.
I've heard of co-op insurance, where self-employed people group together for better rates. No idea if it's good or not though. First google result was: https://opolis.co/insurance/
Also interesting ideas in this reddit thread https://www.reddit.com/r/HealthInsurance/comments/1hgg2q4/se..., probably skewed towards young/single people.
So the solution to healthcare for the self-employed is pansexual polygamy without the sex. Benefits without "benefits", if you will
Insurance has always been about groups of people banding together to soften emergencies. Prior to the ACA, the groups were people with the same employer, and getting insurance as an individual was prohibitively expensive and had ridiculous limits. The ACA added the ability to purchase through the marketplace and prevented the rampant denials that previously existed. I’m not sure how folks are grouped in the marketplace, but I believe it’s by zip code.
I paid for my own insurance for decades and the ACA absolutely made things better, and cheaper, for individuals seeking insurance. Not even counting the subsidies for lower incomes.
This is a structural death blow to small business and something needs to be done about it if we think it's a good thing not to live under corporate feudalism.
Would going with Direct Primary Care help? It is like concierge care in that you pay a monthly retainer to a doctor's office for unlimited access. You then supplement that with insurance with a very high deductible for major issues. DPC seems to be a growing trend among new primary care practices in the USA.
$396 (if un-subsidized) probably means you are on a bronze tier plan. And yes many of those are hot garbage. However, if you are paying that for a crap plan and getting a subsidy too, you're probably getting ripped off. Most people on healthcare.gov or a state exchange who sign up for bronze tier are getting a subsidy, so the premium is reduced to near zero in some cases. Still often a bad plan, but a cheap bad plan.
I pay ~$400 but the government kicks in ~$350 too due to my low income. Its a Silver PPO plan and not bad, though, I haven't used it for anything serious yet. The Silver plans have extra subsidies so are usually better quality than bronze.
It also can be helpful to switch insurers if the plan is bad. My insurer up until last year was once decent but has gone downhill. They are also the dominant insurer in my area. The one I switched to this year is trying to gain market share in my area, so they seem to be a better deal, the plan is more generous and has less red tape.
When I was on the marketplace, I couldn't tell much difference between the metals. I'd pick a network, all the tiers covered only the mandatory stuff as best as I could see; really same deal with all the networks, but different providers. Higher tiers had higher premiums and lower deductables... for me, I just went with bronze because premiums + out of pocket max was lowest; I'm sure there's portions of the curve where care would cost less with a higher tier, but I figured lower cost with minimal use and lower cost with maximal use is pretty good.
IMHO, health insurance makes it hard to do cost control of healthcare. Patients can't do it, because they won't know how much stuff costs until 6 months after service, so they can't really make decisions on cost. Providers can't do it either, they have even less idea of what things cost for patients, and they have an interest in providing more billable care. Insurance companies could do it, but denying care for economic reasons is hard, so they just go with denying care for beuracratic reasons; also, ACA insurers have revenue limits based on ratios to covered care, so covering more things allows them to get more revenue. Even government paid healthcare has trouble because everyone gets grumpy when they can't get all the care available.
The maximum you can make and receive any subsidy is absurdly low. I don't qualify for any government subsidies yet I'm the one actually paying real income tax.
I struggle to have sympathy for the people of a country that has collectively chosen, time and time again, to have a thing they now have.
Congratulations you have what you wanted.
Very cool take.
So, how have you fought off similar oppression in your utopic part of the world, wherever that may be?
Please, enlighten the rest of us.
Usually you tax the ultra wealthy to reign in their influence and limit corruption/lobbying/political spending. That’s how it’s been done non-violently in the past.
[dead]
"The biggest impact I have experienced so far has been that popups for cam sites, porn sites and other such affiliate marketting referal attempts lead to an age verification page rather than directly to all the "hot singles in my area looking for sex"
oh my, empathy stat is high on this one
Yes, the internet advertising machine has been affected negatively when it spams me (and everyone else) thanks to the privacy invading adult verification requirements.
I don't feel sorry for them either, they were always parasites, but I am not sure what your point is or what it has to do with this conversation.
I suppose you want to personally take responsibility for the EU's current anti-encryption crusaide? After all, you chose this path! Clearly you think that we must all summit our private conversations and thoughts to your government for approval?
Grow up already.
But, voters indeed punished politicians that wanted reforms like price transparency or single payer.
Voters consider it bad socialism.
It's too bad most Americans came to get away from Europe and it's 500 years of bullshit problems.
Like Mexico after us, we didn't send our finest.
At this point the only tenable option is going to be some sort of single-payer healthcare. Small businesses can't afford the healthcare costs to employ people and your average worker can't afford the costs either. When I was looking for a plan earlier since I got laid off about a month ago, the cheapest plans were in the $500 or so a month range which is insane for someone that's had zero health issues so far and doesn't smoke or drink.
I fully expect the west coast states to implement single payer before the government ever catches on.
Or regulate prices. How can a hospital charge $250 for an IV bag while in Europe the same bag is 10€
Or an ambulance ride in the US STARTS at $500. An ambulance ride in the EU is 260€/hour (obviously is free in case of emergency)
I think the problem is that the US is in this weird dynamic in which hospitals charge more because "the patient is not paying for it, the insurance is" but in the end insurance are going to raise premiums to pay for that
Patients and providers should have the ability to shop and negotiate price directly with each other. No 3rd party will ever be in a better position to negotiate individualized care and prices for 350,000,000 people better than we (or our family) can for ourselves.
Currently, patients cannot price compare anything, not even for the exact same drug from two different pharmacies on the same street! To make it worse, most providers can't even make sense enough of the provider-insurer prices to shop on behalf of the patients.
To improve prices in healthcare, all care must have a price visible to all, paid by patients. Insurance should be required by law to publicly publish their reimbursement rates and immediately (48 hours) reimburse their insured patients for care at approved (in-network) providers.
This would end the current: impossible to self advocate, impossible for providers to advocate on behalf of patients, intractable insurer-provider price web.
Insurers and providers should never negotiate price. Providers should only be concerned with providing good care, how to classify/code it, and the amount they need to charge for that care to be financially viable. Insurers should only be concerned with how much they will pay out for each classification/code, and which providers they authorize as in-network.
Last, since there is a long tail of medical care that doesn't fit nicely into a code box, each plan should have a mandatory minimum coverage of something like 50% all unknown-care costs at in-network providers and pharmacies above $5,000 annually, with some annual cap.
As a society, if we want to further subsidize healthcare for those with lower economic means, and/or those who end up with catastrophic expenses, then that should be done on it's own, as two distinct standalone welfare programs.
> One of the insurance companies, UnitedHealth, has cited tariffs from President Donald Trump’s trade wars as a reason for the increases.
My understanding was most of the cost of healthcare was human services.
[dead]
Is this the most predictable outcome in a for-profit competitive health insurance market?
Was this the outcome of Romneycare in MA?
Do other countries with single-payer health care have these types of sudden mass price increases by health insurers?
If there's one "positive" in the labor stats the past few months it was an increase in employees in healthcare positions.