
Employees Start to Feel the Squeeze of High-Deductible Health Plans - js2
https://www.npr.org/sections/health-shots/2019/05/03/719519579/employees-start-to-feel-the-squeeze-of-high-deductible-health-plans
======
mrosett
You can argue that the ACA improved the healthcare system overall. But it's
been tough for people who were already covered by employer insurance.

I think people fail to appreciate that prior to the ACA, when the healthcare
system worked, it actually worked really well. I got very sick at the age of
20 while I was still on my parents very modest insurance (pre-ACA). Within 48
hours I had an appointment at the best oncology hospital within 500 miles, and
I was able to get scans, tests, etc on a very short turnarounds. Ultimately I
had two major surgeries in 4 months, and the whole thing probably cost the
insurance company a couple hundred thousand dollars. Since my parents had
already hit their out-of-pocket maximum, the marginal cost to us was 0.

Now, the "when it worked" caveat is a big one. The story would be very
different if my parents didn't have insurance at all or if I hadn't been
eligible to be on it. But the same story today on my insurance would cost me
_a lot_ more money out of pocket due to a much higher deductible and a higher
out-of-pocket maximum.

My perspective is that the ACA made things significantly better for a small
group and modestly worse for most people. I'm open to moral arguments that the
tradeoff was worth it (although that's not what I believe.) But I dislike
rhetoric that pretends there's no tradeoff at all.

Edit: Added substance to a one-liner.

~~~
JMTQp8lwXL
Pre ACA, pre-existing conditions could disqualify you from insurance. People
with pre-existing conditions are the people that need health care coverage the
most. We can't under-weigh the moral obligation we have to this previously
marginalized group, when considering service may be slightly worse for people
who have employer coverage.

How I see it: if you were in the pre-ACA pre-existing condition pool, your
perspective would be vastly biased in a different direction. And nobody wants
to end up in that pool. Nobody chooses that. That's why it's a net win
overall.

People died because they don't have coverage (unfortunately, still happens,
but substantially decreased by ACA). If things are slightly worse for people
who already had access, It's such a small price to pay.

~~~
newsoul2019
I don't like the entire concept of "pre-existing conditions". It goes against
the entire concept of caring for sick people.

We are all people. We all get sick sometimes. Sicknesses can last a long time,
or a short time. Sick people need help. Help the sick people. Pay what you can
(a reasonable amount) into a common pool and take what you need (only as much
as you need)

~~~
munificent
_> I don't like the entire concept of "pre-existing conditions"._

If you have an elective health insurance system where people choose whether or
not and when to participate, it implies this restriction.

Say you have private health insurance companies but don't allow them to
prohibit members based on pre-existing conditions. Everyone will simply not
get health insurance to avoid paying the premiums until the day they need it.
That would make health insurance companies completely unviable financially.

This is why Obamacare both eliminated the pre-existing condition restriction
_and_ mandated people get health coverage. You can't have one without the
other or you get the free-rider problem.

This is another reason why healthcare should just be universal. It doesn't
work _at all_ like an actual efficient market product.

~~~
brewdad
Would a wait limit, like with hurricane insurance, help to mitigate this
problem? You can't wait until the NWS declares a Category 4 storm is barreling
towards you to buy coverage. I mean you can, but the coverage doesn't kick in
until 30 days later.

------
CptFribble
Every discussion on healthcare payment structures in this country is
completely asinine.

Healthcare is best managed as a risk pool. The bigger the pool, the cheaper to
be in it. The biggest risk pool is everyone. Therefore, we should put everyone
in a single pool.

How we manage this is a separate discussion. Private, public, maybe a
federally chartered non-profit like the Fed.

But as long as we keep ourselves fractured into thousands of different risk
pools, all these discussions about deductibles and HSAs and whatnot are just
chasing our own tails.

~~~
pdonis
_> Healthcare is best managed as a risk pool._

No, health _insurance_ is best managed as a risk pool, which, as you say,
should obviously be everyone.

But much of health _care_ is not health _insurance_ because it doesn't deal
with insurable risks. Your need to get an annual physical isn't an insurable
risk. Neither is a one-time appointment with a doctor to see if your headache
and runny nose is just a cold or an infection that requires antibiotics. The
first isn't insurable because it's a predictable recurring cost; the second
isn't because it's a routine service that shouldn't be so expensive that you
can't pay it out of pocket.

Health _insurance_ should be focused on the things that _are_ insurable risks:
emergency care, hospitalization, etc. Things that aren't insurable risks, like
the above, should be handled differently. But our health care system insists
on treating these very different things the same, which of course is going to
lead to huge inefficiencies and high costs.

~~~
pintxo
I might be mistaken, but here (Germany), regular checkups are paid by the
insurance on purpose.

The alternative being people not doing the checkups and thereby delaying
diagnosis until treatment get‘s really expensive as things get life
threatening.

In the end insurance has an interest in people taking regular checkups
resulting in early (cheap) action.

~~~
pdonis
Are people _required_ by the insurance companies to get regular checkups?

~~~
pintxo
No. But insurances are (to different degrees) heavily promoting checkups and
health/fitness improvement programs.

Some are even handing out coupons and benefits for those joining fitness
studies or sports clubs etc.

~~~
SOLAR_FIELDS
It would also be pretty easy to incentivize. Have an annual physical and save
$X a month on your premium. We do it for other things like smoking already.
Plus many examples in the car insurance world.

------
LarryDarrell
If you were designing a society starting from scratch today and said, "I think
we should make having health insurance largely dependent on having an
employer.", you would be laughed out of the room.

I think we are running along some tracks that were laid long ago, and rather
than all jumping off, some people in comfy Pullman cars are content with
letting the train run off a cliff.

~~~
briffle
I find it odd that some executive gets to pick which 401k and health insurance
plans you get, and that you must pick from their few choices that allow you to
have. I can see why the providers love it, they can target all their
advertising, marketing, etc, at a few key people at large employers, but not
sure how that benefits the average worker..

~~~
SlowRobotAhead
You can get an individual 401K or IRA and make all your own choices. If you're
talking about an employer matched 401K, I don't think it's unreasonable at all
for them to select it.

~~~
jogjayr
> If you're talking about an employer matched 401K, I don't think it's
> unreasonable at all for them to select it.

What's special about 401k matching that requires the employer to choose plans?
My employer doesn't force me to have a checking account with a particular bank
they chose if I want to receive my salary. They should be able to match
contributions to any account anywhere.

~~~
SlowRobotAhead
I don’t know if you understand how 401K matching works on the backend.

A lot of times the employers are capped on their own plans at a percentage
rate that matches their employee’s participating. So matching is often in
their best interest, esp at smaller companies.

But, easier version is this is a perk, not your base salary. They are paying
you with legal tender and there are freedoms associated to that. There is no
such thing for perks.

You aren’t entitled to make the administration choices for something they are
gifting you.

~~~
jogjayr
> I don’t know if you understand how 401K matching works on the backend. A lot
> of times the employers are capped on their own plans at a percentage rate
> that matches their employee’s participating.

I actually do not understand this. Could you please explain more? What does an
employer being "capped on their own plans" mean?

> But, easier version is this is a perk, not your base salary

When I make a decision on a job offer, the 401k match, health insurance
premium, free lunch and snacks etc. all factor in and they're all worth a
certain amount of money. Money is money and how it's labeled, "perk" or
"base", is irrelevant. If my employer ends 401k matching, I'll treat it as a
pay cut mentally.

My ultimate "fantasy" is to eliminate 401k altogether and instead let everyone
contribute whatever the 401k annual limit is to an IRA. The employer can
simply add matching funds to your IRA and you're free to have your retirement
accounts anywhere you please.

------
paxys
High-deductible health plans were always designed to benefit employers. My
company switched us to one with a big PR campaign highlighting how everything
would be better (contributions to HSA - free money!). The only "advantage" is
that companies have to pay smaller premiums and employees are greatly
discouraged from getting care due to high costs.

Funny enough, employers are rethinking this now since employees not getting
basic preventive care is actually more expensive for them in the long run -
[https://www.insurancejournal.com/news/national/2018/06/26/49...](https://www.insurancejournal.com/news/national/2018/06/26/493273.htm).

~~~
AnthonyMouse
> The only "advantage" is that companies have to pay smaller premiums and
> employees are greatly discouraged from getting care due to high costs.

In principle the advantage is that employees are greatly discouraged from
_paying too much_ for care. If the insurance pays for everything then what do
you care if your doctor is charging $1000 for a physical instead of $50? If
you're paying out of pocket, now you care.

The problem is we also have a lack of price transparency, so it's arduous to
actually determine the price you'll be charged for routine care and avoid the
places who are overcharging, which correspondingly becomes nearly everyone.
The states would do everyone a favor to pass and enforce some price
transparency laws.

And the advantage of lower premiums is that it allows you to receive that
money. If your employer is raising your plan's deductible and giving the
balance saved in premiums to you, that's the advantage -- you get the money.
If they're not, go ask for a raise or find another employer who will pay you
more, in the same way you would if they lowered your compensation in any other
way.

~~~
kristjansson
> price transparency

And even list prices themselves are typically starting points for negotiations
when a provider is dealing with a large payor whereas an unwell individual
(y'know, one who is about to spend a lot of money on healthcare) is not in a
great position to bargain with her caregivers, and so is forced to negotiate
after the fact, from an artificially inflated starting point, under the guise
of bill reduction, or worse, debt relief.

~~~
WorldMaker
A lot of the issues with pushing price negotiation to the individual also seem
to be assuming (or worse, lying about) that most medical professionals,
procedures, facilities, et al are entirely fungible. Even if individuals had
full price transparency, that doesn't change the fact that certain facilities
will always be closer to home, certain procedures inescapable, certain medical
professionals decades or life-long relationships to build, etc. Medical
services aren't just interchangeable factory goods on a retail store shelf
that you can easily pick based on price alone and then slot it right into its
widget shaped hole, and never will be.

~~~
AnthonyMouse
> Medical services aren't just interchangeable factory goods on a retail store
> shelf that you can easily pick based on price alone and then slot it right
> into its widget shaped hole, and never will be.

Almost nothing actually works that way. Walmart doesn't stock exactly the same
goods as Target. One of them may be closer to where you live than the other.

Which is why price isn't the _only_ criteria. If the office closest to your
home charges $250 and one which is fifty miles away charges $200, you can
perfectly well choose to pay the extra $50 for the convenience.

The issue is that when the nearest office decides to charge $1000 and the one
fifty miles away is still charging $200, that should maybe change the outcome.
But not if you aren't aware of the price difference to begin with.

And this even applies to the beloved family doctor -- there is a limit to the
amount of price gouging that a familiar face is worth.

------
_bxg1
Healthcare simply does not line up with the incentive structure of the free
market.

People can't opt-out if they're getting a bad deal.

Risk outliers get turned down as bad business decisions, or the drugs they
need to stay alive are impossible to afford because of "low" demand.

It's left up to employers to choose the product that's best for their
employees (and ensure that market competition functions), but that assumes
they actually care about their employees' well-being, which most don't.

Denying care to the unemployed is a strong force deepening the poverty cycle,
preventing people from working their way back up to being productive members
of society.

Healthcare doesn't even really fit the model of insurance, because it isn't
just a guard against unlikely catastrophe, it's an ongoing, chronic,
inevitable cost of being a human being.

~~~
iheartpotatoes
Yet here we are. Remember when Obama fought to have healthcare prices made
transparent so that we could shop for the cheapest medical treatment, and that
was beaten back severely by the lobby? The compromises the ACA made to bend
over backward for for-profit insurance companies were an example of how much
power the lobby has. I think if we've learned anything is that we need to go
all in on single payer and completely remove for-profit insurance, IMHO,
because of exactly what you're saying about the free market: it doesn't work
for certain things (if anything, really): military, education, healthcare all
the three classic failures of the freemarket. I think this is why all the dems
are embracing Healthcare for All: everyone is getting screwed by healthcare
except the 1%.

~~~
_bxg1
I think the free market does a good job of _solving_ problems, just not of
deciding which ones are worth solving. The military follows a hybrid model
that (mostly) works, where a semi-free market is created and guided
exclusively through governmental leverage, theoretically giving the best of
both worlds. Utility companies work a similar way, as do (I think) some first-
world government-run healthcare systems. I think the ACA was aiming for this
type of thing, but was so hamstrung by compromises and by the sheer complexity
of the system it was trying to reshape, that it ended up being a pretty mixed
bag.

Maybe in the case of American healthcare, the current state of things is just
such a horrible rat's nest of problems that we really do need to burn it all
down and start over.

------
tptacek
Isn't the point of an HDHP that you're supposed to set up an HSA to go with
it? Premiums for HDHPs are significantly lower than for normal health plans;
the idea is that you're supposed to use the premium savings to fund the HSA,
which is then money that carries over year over year, right?

~~~
johnnyletrois
Not all employers offer HSAs to go along with their HDHPs. Mine doesn’t and
it’s very frustrating. I want to save pretax money in an HSA but I can’t.

~~~
kasey_junk
There is no requirement for your employer to provide the HSA. Frequently the
employer can get better deals on the HSA than you can individually (like no
waived maintenance fees and the like) but you can for sure open your own.

In fact once you have enough money in there that you are moving out of liquid
investments then you definitely want to shop around for HSA much like you
would for an investment account.

~~~
loeg
Can you actually fund a non-employer HSA with tax-deductible funds, or is that
a benefit that only applies to payroll HSA contributions? If not, a lot of the
benefit of an employer HSA disappears.

(FWIW, I have an HDHP, employer HSA, _and_ an individual HSA that I roll my
employer funds to annually for lower-fee investing.)

~~~
snowwrestler
Where do you have your individual HSA? I have an employer-provided one and I'm
looking for a place to move it.

~~~
kasey_junk
Fidelity has a pretty compelling offering:
[https://www.fidelity.com/go/hsa/why-hsa](https://www.fidelity.com/go/hsa/why-
hsa)

~~~
loeg
Yeah, that looks competitive. It doesn't have the one highly specific fund I
wanted at HSA authority but it's got everything you really need.

------
rb808
I really like the idea of high deductible plans. The idea for me is that
insurance shouldn't cover regular costs that most people pay every year.
Insurance should just be for unusual events, like car insurance is only used
if you have an accident.

So now I got a $2k bill from ER for something that wasn't really an emergency.
It makes me think carefully about next time this happens where before the cost
didn't really affect me. Changing people's behavior is important part of
reducing costs of the health care industry.

EDIT: Yes I'm not happy with how expensive prices are now. That is the problem
that HD plans have.

~~~
conorh
I like it too, except that my (bronze level in the marketplace) high
deductible plan is ~$1300 a month for my family, that is not sustainable. A
recent ER visit with 1 night stay cost us about 8k out of pocket, the family
deductible for the plan is $13k a year.

~~~
FireBeyond
Be glad that "recent" wasn't in December, prior to the deductible reset.

Fun fact - my company (who sells Health Benefits Management software) added
functionality so an insurer could do a "rolling window" for deductible / out
of pocket management, i.e. "In any given 12 month period, your costs will not
exceed $x" (where given unfortunate timing, your out of pocket could actually
be 2x).

Except it was less profitable to the insurers, so no-one was interested. But
spun as "will be too complicated for consumers".

------
angel_j
Insurance is not suited for health care. It's suited for emergencies.
Sometimes health care is that, although preferably not often, and less often
if proper care is given when due.

But general health care—the practice of keeping people healthy, rather than
fixing them when ill—is not suited to the insurance model, and the insurance
industry is too powerful to let control who gets which treatment.

A proper model pays the actual healthcare provider to keep you healthy on the
regular, and then it costs you nothing in the event of sickness or emergency
(like you need more stress at that moment).

The very idea of mutual indemnity is out the window with modern insurance,
it's all about squeezing stats for margins, at which point there is not real
mutuality, only competing risk profiles. Of course, a group of people might
want to pool for emergencies, or even general health, but is there any benefit
to the current scale of insurers? It only makes them more powerful.

~~~
rjohnk
I wholeheartedly agree. That and employer-based access to health insurance.
Imagine if you had to change auto/life/home/rental insurance every time you
changed jobs.

------
irrational
I have a HDHP with an HSA. When my company first rolled it out I barely gave
it a glance (why would anyone want a high deductible?) and stayed on the low
deductible plan. However, the next year I looked at it closer. I ran the
numbers and realized that I could have x dollars come out of my paycheck to
the insurance company under the low deductible plan, or I could have y dollars
go to the insurance company and z dollars go into my HSA. And y + z = x
(within a $100 or so).

So I could give all the money to the insurance company and that money would
disappear at the end of the year, or I could give a portion of the money to my
own HSA and I would get to keep any leftover at the end of the year. Well, now
I had instant regret that I didn't sign up the first year.

The first year was rather rough because we had to pay all health care expenses
out of pocket until we met the deductible, but we couldn't reimburse ourselves
out of the HSA until the money was in the HSA. But, we met the deductible by
April and after that our health care costs were equivalent to what they would
have been under the low deductible plan.

By the end of the year we had $4000 left in the account which we then used to
pay health care costs in the new year until the deductible was met. Now our
HSA is growing year over year.

------
tfandango
I have not seen mental health mentioned here yet as a factor in rising
healthcare costs. My HSA/HD Plan has almost ZERO mental health doctors in
network. Providers have been fleeing in droves (especially from UHC) because
the insurance companies continue to lower payouts.

I went from spending a co-pay for mental health care for 3 of my kids to
paying out of pocket until I reach my out-of-network deductible, which I never
do because it's 10K. I spend thousands of dollars per year on this and there
is not much I can do about it.

In some cases I've reduced frequencies of visits but the value of these types
of doctors cannot be overstated in some cases. I credit my son's psychologist
for his ability to function in society today. But she told me she can't take
UHC because after costs she was making 10/hour.

Lack of in-network mental health coverage is a huge travesty.

~~~
brazzledazzle
By all accounts we have a good PPO available but this is exactly why I haven't
even evaluated leaving Kaiser's HMO. Not that I don't like them. It does have
positives and negatives but I've been happy so far. I just can't even consider
it.

------
jdoliner
I've been trying for a while to figure out what would be a good metric to
judge the ACA by. Most of the time it's success is talked about in terms of
number of people insured, but that doesn't really capture how well insured
they are. Life expectancy seems to be the only well known (at least to me)
stat that begins to capture the health of the nation. We've now had 3 straight
years of declining life expectancy in the US [0], a single year is virtually
unheard of in developed nations. Now there are lots of confounding variables,
and it's certainly not possible to say the ACA is the cause. And 3 years of
downward trend, isn't historically unprecedented. However, it certainly makes
it hard to paint the ACA as a success, I'd want to see some compelling
evidence that the ACA had made America healthier, which doesn't exist right
now. The question to me is how long we can accept a downward life expectancy
trend before we start looking at the ACA as a potential cause.

[0] [https://www.smithsonianmag.com/smart-news/us-life-
expectancy...](https://www.smithsonianmag.com/smart-news/us-life-expectancy-
drops-third-year-row-reflecting-rising-drug-overdose-suicide-rates-180970942/)

~~~
LarryDarrell
I hate on the ACA as much as the next guy, but the article you linked blames
drug overdoses and suicides. For that I would blame the for-profit health care
system pushing opioids and the (Great Recession + inadequacy of our mental
health care system). To blame that on a law that sought to eliminate
preexisting conditions and to establish a baseline as to what a health
insurance plan ought to provide seems like a stretch. Having a free yearly
physical isn't going to help your crushing depression and economic anxieties.

~~~
jdoliner
I was just linking that as a reference for the declining life expectancy. I
don't think they even come close to establishing opioid and suicide deaths as
the cause, that's just journalistic conjecture. If you look at the number of
opioid and suicide related deaths it's very small compared to the total
population of the US, so the math just doesn't seem to work out for me. I
remember an HN comment a while ago that worked out how many deaths you'd need
from those causes to lower the life expectancy as much as we're seeing and it
was a lot higher than what we're seeing now. Unfortunately I can't seem to
unearth the comment.

~~~
FireBeyond
Apropos of anything else, as of 2019, you are more likely to die of an opiate
overdose (accidental or deliberate) than you are in an MVA. That's staggering.

Of course, not unexpected in a country that has 3% of the world populace but
81% of the world's opiate use.

------
kxyvr
For those of us who are self-employed, I'll mention that low or no deductible
health plans may provide better value.

When they sort of work, health deductible health plans are nice because: (1)
monthly premiums are low and (2) they give access to a health savings account
(HSA) where some amount of money can be stored pre-tax and then used for
health related expenses. Of course, none of this saves someone that gets
hammered with a $5000 bill like those in the article.

Anyway, the pre-tax HSA account seems to be an attractive to many, and it may
be benefit some. However, if you're self-employed, you can deduct your
premiums off your income through the self-employed health insurance deduction:

[https://www.irs.gov/taxtopics/tc502](https://www.irs.gov/taxtopics/tc502)

This means that there may be higher tax benefit for a high-premium, but low or
no-deductible plan. Personally, I find it much easier to handle than going
through the trouble of an HSA.

All that said, it's pretty much all the same in a catastrophic case. Just take
the premiums x 12 + out-of-pocket max to figure out the "maximum" yearly
liability. At least on the ACA exchanges, this number is typically $11-15k on
what I've seen from either high or low-deductible plans. If you can't make
this number, you're not fully covered for catastrophic. Alternatively, if the
hospital sends a bill to an out-of-network operator, you're probably screwed
as well.

Anyway, this is not to detract from the article. This is a huge problem.
Mostly, I wanted to pass on some information that I had to sort through when
picking and choosing plans over the years.

~~~
lotsofpulp
The tax savings on the difference in premium between high deductible health
plans and low deductible health plans is probably $2k at most ($6k in extra
premiums @30% tax rate). That’s for single coverage, but even for family total
year tax savings can’t be more than $5k.

In either case, triple tax advantage of HSA is far more, especially due to
compound growth.

If you have the cash to be able to deal with $10k of medical expenses in an
emergency, HDHP + HSA is a no brainer

~~~
kxyvr
This is not to say that you're wrong, but I don't completely understand your
numbers. My understanding of the triple-tax advantage of HSAs are that

1\. Money going into the HSA is pre-tax

2\. Investment gains from the HSA are not taxed

3\. Money used from the HSA for qualifying health expenses is not taxed

That said, there are many restrictions and two of these benefits seem to be
included for self-employed individuals. For example, an HSA can not be used
for over the counter drugs unless there's a prescription:

[https://www.irs.gov/newsroom/affordable-care-act-
questions-a...](https://www.irs.gov/newsroom/affordable-care-act-questions-
and-answers-on-over-the-counter-medicines-and-drugs)

However, prescriptions can already be deducted without an HSA if one is
itemizing:

[https://www.irs.gov/taxtopics/tc502](https://www.irs.gov/taxtopics/tc502)

Alternatively, the above link also states that things like office visits to a
physician can be deducted, which are things normally an HSA are used for.

Basically, the one benefit that seems unique to an HSA is that the investment
gains from the money in the account are not taxed, which is great assuming
that this money is used for medical expenses or you make it to 65.

Again, I'm not saying you're incorrect, but it looks like self-employed
individuals automatically benefit from 1 and 3 above, assuming itemization. As
such, it's seems like the trade off is whether the higher premium, which is
less high due to the tax write-off, is worth lower the lower cost of a
physician visit. Assuming, of course, we haven't gone catastrophic. What am I
missing?

~~~
lotsofpulp
If you save your receipts for any medical care you or anyone else has received
that you paid for, you can withdraw from your HSA to "reimburse" yourself at
any point in time, including the future.

Q39 at bottom of page 18 of following IRS document:

[https://www.irs.gov/pub/irs-drop/n-04-50.pdf](https://www.irs.gov/pub/irs-
drop/n-04-50.pdf)

Have a baby? Save that receipt showing payment for $5k from your post tax
dollars, and let the money in your HSA grow tax free for however long you can,
and then when you need it (e.g. in retirement), reimburse yourself for the
birthing expenses.

It's the first place your savings should go. It's easiest to just model the
HSA as a triple tax advantage savings account as long as you pdf receipts for
payments for medical expenses. Which you might not in 20s and 30s, but surely
will into 40s and definitely 50s, and you can use it for payments you made for
other people's medical expenses too. And even if you need to withdraw from it
for an emergency, the penalty is only 10%.

~~~
kxyvr
Alright, if I understand you correctly, you're essentially using the HSA kind
of like a Roth IRA, except that

1\. Money contributed is tax free

2\. There is a $3.5k contribution limit

3\. Money can be withdraw tax free prior to 65, at any time, as long as
there's a receipt for the qualifying medical expense that occurs after the HSA
was established

Then, from what I can tell, the drawback to this approach is that there needs
to be enough cash flow to cover for medical expenses. Certainly, money could
be withdrawn from the HSA, but the real tax benefit comes from pretax
contributions and that capital gains, interest, and dividends are tax free.
Overtime these can provide a huge amount of savings, but they need time to
develop. Sound about right?

~~~
lotsofpulp
Correct. There's a higher contribution limit ($7k in 2019) if you have family
HDHP coverage. Also, after retirement, money can be withdrawn without paying
the 10% penalty and just paying the regular income tax, in case you don't have
receipts for medical payments from the past.

I wonder how the IRS would prevent a tax evader using the same receipts for
payments for medical expenses for different withdrawals in different years.

~~~
ixwt
I would assume if you got audited, you would have to justify all withdraws. I
doubt they would be impressed with multiple copies of the same receipt.

~~~
lotsofpulp
How many years do you get audited for? I thought it was just 7. So if you use
it every decade, I presume they’re not going through every year and it
wouldn’t be seen. Unless they’re keeping a database.

------
0xfeba
Of my past 3 employers over the past 8 years (all family plans):

$3000 deductible, no HSA

$6000 deductible, HSA

$9000 deductible, HSA

I pay $370/month in premiums... $100 of that a fee because my spouse is
eligible through her employer but the plans are even worse, so we declined it.

So we pay $4,500/year in premiums. Which equates to roughly a 20% effective
income tax instead of ~15% normally.

This is ridiculous. Whomever seems best to get a single-payer plan in place is
who I'll vote for. Absolutely no reason it should matter who my employer is
for what doctor I can go see or how much I pay in private, personal medical
bills.

Retirement accounts I feel the same way, but that's a long way off for the US.

Other countries have solved this fucking problem, I'm tired of elected
congressmen firing back with "BUT VENEZUALA" quips every time someone mentions
"Medicare for all".

And the proper response to that is "So we should eliminate Medicare altogether
then, right? Where's your bill for that?"

------
anonKeepMyJob
One of our company's primary products "helps employees make an informed
decision when choosing their health insurance plan". Basically, during open
enrollment they are presented with their choices of plans and the "expected
total cost" of each plan over the course of the year as calculate based on
either, if we have their consent, their historic data or, if we don't have
their consent, the historic data of a representative cohort.

The product wasn't getting traction based on employer's wanting to provide
such a service to their employees, so the sales pitch was changed. The sales
pitch became, "You can save your company money by moving your employees to
High Deductible Health Plans. Our product presents data that encourages
employees to choose HDHPs over other plans." I'm not sure if that is currently
the sales pitch, but it was the primary one for two-ish years. Our customer
base is now non-trivial.

I've overheard some of the conversations as to how the "representative cohort"
is determined and about our data sources. It wouldn't pass a peer review.
Additionally, in the past we have re-worked the numbers because our customer
didn't like the results. That is, feedback from the company, not the company's
employees. They did, after all, hire us to get their employees to move to a
HDHP.

And to top it off, the product hasn't been a great revenue source. So we're
effectively compromising real people's health care coverage, for our company's
business interests, and it hasn't even been that profitable.

Our health insurance plan at this company is a HDHP...

~~~
anonKeepMyJob
I tell you all that my company works with employers to move their employees to
HDHPs based on sketchy data, sketchy calculations, no transparency, and based
on profit motive, and,,,, nothing.

Interesting.

Side note: The chances that some HN readers have used our software are, very
good.

------
jason_slack
I currently have a high deductible health care plan because it is all that is
offered by my wife's employer. The deductible is $4,500 per year.

If we just have normal well checkups, normal dental cleanings, normal eye
glasses, and a few recurring prescriptions we would never hit the $4,500
deductible.

It is insane going to the pharmacy and having them tell you that the cost is
$180 per month and have no choice but to pay it.

I went for a normal diabetes check and the lab work was over $600. No choice
but to pay it.

I needed new glasses and no choice but to pay the $150 eye exam and then many
hundreds of dollars for new frames and lenses (and I had no choice to get new
frames or be without my glasses completely for 1-2 weeks).

To make it worse, we don't have any other choice of plan.

------
lordlimecat
If you're taking a high deductible plan-- which you should be-- you should be
contributing the (often substantial) savings on your premium to an HSA. In
fact theres very little reason not to max out the HSA for the year. Once your
HSA is at the IRS annual maximum, you have an enormous buffer between the
often 20% rate post deductible and the Out of Pocket Maximum-- which the HSA
will usually cover most of. You should also participate in an FSA, which being
frontloaded can absorb early-year shocks.

An HSA is among one of the most tax-advantaged programs you can participate
in; I would argue that it is better to contribute just enough to your 401k to
get the full employer match and stick all the rest into an HSA.

------
goobynight
While I am satisfied with my HDHP + HSA, I'd be a lot more worried if it were
my only option (I'm only young for now) or if I didn't make/save as much.

People are getting hit with HDHP only and no HSA? That's rough.

~~~
rockinghigh
Anyone with an HDHP plan can get an HSA. Whether it's through your employer or
through another plan provider like Fidelity or Vanguard.

~~~
trynewideas
An HSA with no employer contribution, or even administrative assistance, is
like throwing money into a trash can, except at least if you throw money into
a trash can, you can wheel it down to any hospital and they'll probably accept
it.

~~~
lotsofpulp
What? It takes 5 minutes to open a free HSA account at Fidelity and transfer
funds to it.

~~~
rb808
I didn't know they were available. I thought it could be open to everyone, but
employer ones do have advantages.

[https://www.fidelity.com/go/hsa/why-hsa](https://www.fidelity.com/go/hsa/why-
hsa) > You could also use it in place of an employer HSA. If you do this, you
may miss out on opportunities like pre-tax payroll or employer contributions,
so check with your employer to see what they offer.

~~~
lotsofpulp
You can still deduct contributions from income taxes, and you can also
transfer funds after contributing to your employer sponsored HSA to your
individual one.

------
greendestiny_re
I was recently introduced to the idea of gluing and/or stitching one's own
body parts or open wounds in case of a severe injury due to the costs
associated with US healthcare. I found the nonchalant discussion of such
horrible suffering absolutely incredible and would advise everyone to try some
medical tourism. Here in Bosnia&Herzegovina, abdominal ultrasound is 20€,
colonoscopy is 100€, one tooth filling 15€ and a tooth implant 600€. Nearly
all my friends have settled outside B&H but I stayed simply because healthcare
is so cheap compared to other, wealthier countries.

------
sjb554
The ACA hasn't been what it was supposed to be since 2015. Republicans in
Congress gutted the market when they took away risk corridor payments. Small
health plans priced with the payments in place, then when they didn't come
through, everyone in a loss position went under. The big plans could weather
the storm, market consolidates, prices rise.

------
vosper
There was an interesting EconTalk recently that covered some reasons for the
rising costs

"Robin Feldman on Drugs, Money, and Secret Handshakes"

[http://www.econtalk.org/robin-feldman-on-drugs-money-and-
sec...](http://www.econtalk.org/robin-feldman-on-drugs-money-and-secret-
handshakes/)

------
etchalon
At Mess (my agency), we were sort of forced into going with a HDCP, but we
found a way for it to be a win for everyone.

Our absolutely-perfect no-deductible no-coinsurance plan was retired, and
every year, for five years, the cost of our reasonable-deductible no-
coinsurance plan kept going up.

Eventually, our broker convinced us that HDCP was the only way.

But I absolutely hated it.

We have quite a few employees with chronic, expensive conditions. Moving a
HDCP (in our case 2K/6K family), effectively meant we were cutting their
salaries. They were absolutely going to be paying that deductible.

We also employ a LOT of younger people, who just don't go to the doctor more
than once a year, maybe. The HDCP wasn't that big a deal for them.

We looked into HSAs – the thing our broker recommended. These are garbage. In
theory, we'd put in some amount of money each month, and eventually, over
time, the entire premium would be sitting in an account for the employee. For
the young and healthy, this was free money. The move to HCDP+HSA was basically
a raise for them.

For the chronically-ill, the rate we'd contribute to their HSA was never going
to be fast enough to keep pace with their expenses. And for most people, with
most savings levels (near $0), a $1500 bill you'll "eventually get back" is
just as unaffordable as one they'd never get bet.

I hate HSAs.

"Look, we know most of our folks are NEVER going to hit their deductible. We
know a few folks will. Can't we just give everyone a credit card with a 2K
limit that they can use to pay for stuff?"

Meet HRAs.

HRAs are like HSAs, but they're not incrementally funded. Instead, it's
basically a credit card whose balance I, the employer, pay. It has an annual
limit, which matches each employees annual deductible.

These things are amazing.

1\. The employee never has to worry about out of pocket cost. They go to the
doctor, the doctor charges their HRA.

2\. The company has MUCH lower premiums, because we're on an HCDP. I think we
saved like 30% or something moving to it.

3\. We have a maximum annual additional cost each employee can ring up in
medical costs. Worst case scenario (every employee hitting their deductible)
isn't fantastic, but we can plan for it.

4\. The normal-case scenario is a that a handful of employees hit their
deductible very quickly at the beginning of the year, and the rest barely use
their HRA at all.

I do not understand why more companies don't do HRAs given the above.

~~~
trynewideas
Taxes. HRAs can be a huge headache for employees (never employers). SEHRAs
also have a bad reputation for being the worst of both HSA and more
traditional insurance plans: underfunded, high overhead for employees, all for
severely limited provider choice.

ICHRAs (individual-coverage) are the real bridge between HSAs and traditional
insurance—you can use them as an HRA-style account _or_ use the money to buy
an insurance plan off a marketplace. While it still pushes the burden of
choosing and managing health care onto the employee, they at least have
flexibility in coverage as well as tax benefits for both employees and
employers.

They, uh, also don't exist until 1 Jan 2020, and they give total control to
the employer. If you're a good employer, that's great. If you're a shitty one,
the employee is easily fucked over.

~~~
etchalon
I don't get how they'd be headaches for employees? HRA contributions are 100%
tax-free and aren't treated as income. It's a pain for my co-founder and I, or
would be, if we didn't have someone else doing our taxes.

------
louwrentius
I live in The Netherlands. Single person.

I pay ~$2100 (converted) a year for healthcare.

This includes insurance and the first $430 worth of medical cost you have to
pay yourself. Any additional costs are covered by insurance.

------
bwb
I believe that ACA was partially designed just to get everyone in the same
sinking boat. That way one day you could actually fix fundamental structural
problems when the real crisis hit.

------
jkaljundi
NET::ERR_CERT_DATE_INVALID - it's interesting as it's May 3rd and the cert
seems valid until May 3rd as well?

~~~
robertgale
This error message from Google Chrome Browser is one of the most common
problems that everyone faces in our day to day life. Google Chrome warns you
whenever it finds out any abnormal tracks taken while you browse things on the
web. If you are getting the SSL error in chrome, it means your Internet
connection or your computer is preventing Chrome from loading the page
securely and privately. However, there are few changes or settings which help
you to get rid you of this error.

    
    
        Check System Date and Time
        Disable Antivirus SSL Connection
        Clear Cookies and Cached Files
        Reset Chrome Browser
        Open Chrome in Incognito Mode
        Expired SSL Certificates
        Update Chrome Browser
    

[http://net-informations.com/q/mis/ssl.html](http://net-
informations.com/q/mis/ssl.html)

------
drinane
This is the point of high-deductable... to cast more spend on the average
healthcare consumer. Also to make them price sensitive. Wellness programs are
designed around making unhealthy people pay more and not trigger any of the
non-discrimination issues as well. Single payer is best model proven at scale
in modern countries, but it probably will take a couple decades of watching
loved ones not get care before it escalates to action.

