
Many See I.R.S. Penalties as More Affordable Than Health Insurance - e15ctr0n
http://www.nytimes.com/2016/01/04/us/many-see-irs-fines-as-more-affordable-than-insurance.html
======
jhulla
Personal experience with ACA: As of 2016, we're onto our 3rd insurer. Each
prior one has dropped our local doctors, physicians groups and hospital. With
each insurance change, our deductible has gone up, our premium has increased
and our co-pay, co-insurance has increased.

In effect, our ACA plan has become an extremely expensive catastrophic
insurance plan.

~~~
MCRed
Comparing to my "free market" insurance before the ACA was passed, I had much
more coverage (it was real insurance: eg: pay in advance against a risk,
rather than covering pre-existing conditions which violates the definition of
insurance, since you're not pooling money against risk, but paying for current
liabilities.) ..... and not only did I have more coverage, but my deductibles
were 1/5th what they are now and the costs were 1/5th as well.

Effectively obamacare is 25X more expensive for me (and this is comparing
plans in two different states since I recently moved.)

AND! On top of that-- rather than just getting insurance when I needed it (Eg:
you just sign up and buy it) you have to have enrollment periods and all kinds
of arbitrary limitations and a 60 minute application process on a
"marketplace" that really gives you minimal information about the plans, and
demands to know far more about you than you really ever had to give up before
to get insurance.

One thing about insurance-- and Warren Buffett has made a lot of money on
this-- is that they invested the proceeds between when they were paid premiums
and had to pay out claims-- and so insurers paid out more than %100 of their
premiums, because some of the investment returns would be spent on claims.
This allowed them to keep premiums low, and they still made a profit.

Obamacare basically made this illegal because now instead of selling insurance
(or good insurance which was demonized as "cadillac plans" during the
"Debate") you're selling "programs" \-- so the incentive is to not buy until
you get injured then sign up for insurance (and just claim you have a life
change to get around the limited enrollment periods.) Which means the
economics are on its ear and its completely unsustainable. And when it totally
collapses-- I predict that people will be claiming its because "insurance
companies are too greedy"

After all, they complained about "greed" when insurance companies were paying
out MORE in claims than they were getting in premiums (can you name any
government program that has provided more benefits than it costs-- effectively
negative overhead? Hell, as I understand it welfare spends %75 of its budget
on overhead and only distributes %25 as benefits.) No matter how much
government screws up this situation, they will blame industry and use the
utter failure as "proof" that they need even more power (and even more
intrusions into our lives) and even more money to "fix" it.

None of this is a surprise- it was all predicted by those opposing the ACA.

Fortunately, the asian countries are developing first rate hospitals and
medical tourism industry.

The only question is, will I be able to accumulate enough to retire to
Thailand or somewhere before I get hit with a serious medical condition?
Looking at how things have turned out in other countries (eg: New Zealand
where if you're "old" you're just not covered and you have to leave the
country for basic things like dialysis, even though there are dialysis
machines in the country)... I've got a ticking clock.

~~~
zrail
What was the lifetime cap on your pre-ACA insurance? Could you get it if you
had been sick before applying?

Here's a sadly common scenario: you have a baby born prematurely and they end
up in NICU for a month because of a heart condition. They exceed their
lifetime cap after two weeks because NICU has _always_ been atrociously
expensive. Because they have a heart condition, they are never able to get
insurance on their own.

Basically, your pre-ACA insurance was an implied one-shot deal. You have one
chance to get sick and get better, because after that you'll never have
insurance again.

~~~
MCRed
$2M IIRC, and yes.

The reason that NICU is so expensive is government has driven up the costs
astronomically by intervening in the market place over the past 100 years. The
ACA is not reversing that, but accelerating that. If the lifetime cap for
infant care was $1M, the effect of this intervention is $961,583. Or put
another way, that baby would cost %96 less or about $40k for the stay in the
NICU.

This is according to the study done by Milton Friedman in the 1970s showing
government interventions drove up costs 26fold, and drove down availability.
(So, there's probably 30 years more of impact not accounted for in that 26x
figure, its probably 50x now.)

Not true about never having insurance again, and anyway the reason pre-
existing conditions were excluded is that plans that specifically targeted
people with those pre-existing conditions (all diabetics need insulin, right?
why not buy it in bulk?) were illegal.

So, government is the cause of the problem in the first place.

~~~
zrail
NICUs were not very common until the mid-1970s so this component of care
probably wasn't covered in Mr Friedman's study. Prior to that time premature
babies with congenital issues typically just died.

And medical underwriting was a thing because people that have been sick before
are bad bets. There's no need to imagine some kind of conspiracy here, it was
just business.

But hey lets just make up some more numbers to fit the narrative.

------
methodover
> But plenty of healthy holdouts remain, and their resistance helps explain
> why insurers are worried about the financial viability of the exchanges over
> time. They say they sorely need more healthy customers to balance out the
> costs of covering the sicker, older people who have flocked to exchange
> plans.

Ah, the tragedy of the commons at work.

Healthy people don't buy insurance because it's too expensive. Insurance is
more expensive because there are too many expensive sick people and not enough
healthy people paying into it.

It's a terrible feedback loop, one which the IRS penalties were designed to
solve.

~~~
dibujante
As a Canadian, I am astonished at how expensive even the cheapest of these
plans are. My monthly healthcare cost amounts to $178, once you factor in the
taxes I pay that go to healthcare. That's cheaper than any of the plans in
this article. How do people find these prices bearable?

~~~
mikeash
They're cheaper than getting sick and not having insurance. I'll pay almost
anything to ensure that a sudden medical event doesn't bankrupt me.

~~~
eplanit
> "I'll pay almost anything to ensure that a sudden medical event doesn't
> bankrupt me."

Exactly, and reflects the mafia-esque choice imposed on the consumer when
rates are increased: pay the absurd rate or face absolute ruin if (when) a
sudden medical event occurs.

~~~
mikeash
It's mildly terrifying. If you're unlucky enough to break a major bone or get
cancer or something like that, you could literally be on the hook for millions
of dollars. I lived overseas for a couple of years, and when I got back to the
US one of the first things I did was obtain health insurance because of this.

~~~
geomark
This is one of several reasons I have written off moving back to the US. A
unexpected bonus of being an expat is I have no Obamacare requirement. I don't
have to buy US insurance (since I couldn't use it anyway) and I don't face an
IRS penalty.

~~~
tronreg
Where's your greener pasture?

~~~
geomark
Thailand. It's not for everybody. But you can get world class medical care at
a fraction of the price here.

------
ars
The plans have been a disaster. They got rid of the only plan that makes sense
for young people: Catastrophic insurance (deductible of over $10,000).

The plans that remain have high enough deductibles to be worthless, but low
enough to be expensive. The plans helps almost nobody. The only people who
gain value from the exchanges are those who get a subsidy.

To make things worse insurance companies are pulling out in droves, and prices
are expected to go up 40% year to year.

Things are not looking good.

~~~
vidarh
To me as someone living in the UK, this is bizarre. Why would you need an
deductables at all for it not to be expensive? This in itself indicates that
your entire healthcare sector is entirely dysfunctional.

In 2013/2014, the UK National Health Service spent $2928/year per person.

This is the average, and includes everything from the costs of births to the
costs of expensive heart transplants or cancer treatments. General
practitioners. Specialists. Hospitals. Ambulance services. Subsidized
prescriptions (in England there are prescription charges of 7 pounds per
prescription; in Scotland and Wales prescriptions are covered by the devolved
governments).

Since I moved here 15 years ago, I've been to A&E (accompanying my ex) and
hospitals (same) several times; I've had a son; I've been to the doctors many
times. The care has been excellent, and fast. We've never had to fill in a
single form that is not purely medically motivated. Never had to take out my
wallet other than the occasional few coins for a prescriptions (I'm Norwegian,
and while Norway also has an excellent socialized healthcare system, being
able to just walk straight out without going to reception to pay after seeing
the doctor was a novelty to me too - things like general doctors visits carry
a low co-pay in Norway). Best spent $2928 I could make.

Where is all this money going in the US? Surely someone, somewhere is making
ridiculous profits that must have investors drooling and looking for
contenders.

The US welfare system, or lack of one, is one of the reasons I'd never
consider moving to the US. It seems so totally barbaric and arbitrary.

~~~
ars
People have written about this before, but basically the US subsidizes medical
expenses for the entire world.

That was able to happen because, unlike virtually anywhere else in the world,
medical insurance in the US is private.

If the US changes that (which will never happen) I would expect medical costs
to go up everywhere else to compensate, either that or research slows down.

One thing that might, might, help is forbidding medical companies from
advertising at all, that might save some money. But the law of unintended
consequences tells me it would have other effects that might not be so great.

~~~
laurencerowe
It's true that the US has historically been a leader in medical research, but
that largely comes from the federal government through the NIH ($32 billion in
2016.)

~~~
rlpb
> US pharma companies like Pfizer gets more than 50% of their revenue from
> foreign markets.

To be fair, this statement doesn't really tell us anything. Pfizer's foreign
market profit might be 2% of sale price, and their US profit 98% of sale
price. So despite that figure, the majority of their R&D investment might
still come from sales in the US.

------
dpweb
I'm against Obamacare, but if I was for it, I would peg the penalties at 2x
the avg basic exchange coverage price.

Also, people with high deductibles should make sure you take advantage of tax
benefits, HSA for instance. The $6000 deductible may really only be a $4800
deductible once you figure in the tax deduction. If you're talking Obamacare
coverage being 20% higher than the penality (I'm assuming the penalty is not
tax deductible) that may end up being a wash and you're better off with the
coverage.

Now consider the guy paying the $1800 penalty instead of the $2900 coverage.
The coverage being effectively $2175 (considering a 25% tax break). He pays
$1800 for nothing instead of $2175. Passing up $375 coverage. Again, Obamacare
- pretty much a debacle as far as costs - but that guy maybe not be the wisest
choice.

~~~
pmorici
My current plan has an has an HSA component but the company that administrates
the account, BenefitWallet, has some fine print in the account agreement that
they charge an account fee for balances less than several thousand dollars.
Realistically I only spend several hundred dollars per year on healthcare
stuff so I don't think it is to my advantage to lock up that much money in a
non-interest bearing account or pay the bank 120 bucks per year.

~~~
mecameron
You are not required to use the HSA provider that your insurer/employer is
tied to. You can pick and contribute to your own HSA account elsewhere, with
one caveat. Your contributions are deductible from federal and most state
taxes, but are only deductible from payroll taxes (social security/medicare)
if the HSA contribution is deducted from your paycheck by your employer (and
thus deposited in their preferred HSA provider).

~~~
pmorici
Yeah, in my case it isn't though my employer either so there is another reason
to avoid it.

------
daurnimator
In Australia the penalty is 1% of your income (or more)
[https://www.ato.gov.au/Individuals/Medicare-levy/Medicare-
le...](https://www.ato.gov.au/Individuals/Medicare-levy/Medicare-levy-
surcharge/Income-for-Medicare-levy-surcharge,-thresholds-and-rates/)

This makes it a no-brainer for anyone earning over ~$90k to get health
insurance (as it's cheaper than not having it).

Yet it doesn't force low income earners into having private health insurance:
they fall through to the safety net of the public healthcare system.

It's not a perfect solution; but it's perhaps slightly better than what the
USA has at the moment?

~~~
davidw
> perhaps slightly better than what the USA has at the moment?

Pretty much anything would be. Health care in Italy was better than in the US,
and that's saying something - Italy is a nice place, but not always run that
well.

A more market-based system might be better too as at least for some things
there might be some downward pressure on prices.

The current system (including pre-Obamacare in that as well) just sucks.

~~~
Camillo
When the WHO ranked the world's health care systems in 2000, Italy was
actually the second best in the world:
[https://en.wikipedia.org/wiki/World_Health_Organization_rank...](https://en.wikipedia.org/wiki/World_Health_Organization_ranking_of_health_systems_in_2000)

That was 16 years ago, yes, but the country wasn't run any better than it is
now.

~~~
peckrob
Random personal anecdote. When I was a teenager, my family took a trip to
Europe. This was summer of 1999, IIRC. Anyways, near the end of the trip, when
we were in Italy, my dad came down with a cough and sore throat. Rather than
try to gut it out for another week and then have to fly back to the US sick,
we decided to try to find a doctor.

After consulting with the front desk at our hotel, we were directed to a small
clinic a few blocks away. Being that it was evening, we were surprised they
were open and even more surprised to be seen reasonably quickly (it was less
than an hour, less than I usually wait at a clinic here in the US).

We were seen by a doctor who conducted the very typical medical exam. We mimed
our way through it, and a prescription for an antibiotic was doled out. When
we went to pay, we were waved away. "No money" they said, in broken English.
They also gave us simple directions to a nearby pharmacy where we could get
the prescription filled.

We walked over to the pharmacy, presented the pharmacist with the
prescription. After waiting a few minutes, he came back with the pills. There
was a cost for this, but I remember it being very cheap. Like a couple euro.

The whole thing, from start to finish, was less than 3 hours and only cost us
whatever the antibiotics cost. Frankly, our biggest problem with the whole
experience was the language barrier. Dad knew some French and I knew extremely
basic Spanish and could puzzle out most things given enough time, but nowhere
near close enough for a complex interaction such as seeing a doctor in
Italian.

Fast forward 17 years (this happened to me last week). I'm visiting family in
Tennessee and come down with the same sore throat and cough.

First, I have to find a clinic that accepts my out-of-state insurance. Then, I
have to get there when they open because experience with these things has
taught me that if I'm not there when they open I'm waiting a few hours. Fill
out the 5 pages of forms. Pay a $30 co-pay before I even go back to see a
doctor. And then STILL wait 2 hours to be seen. After the same cursory exam,
the same prescription for antibiotics is doled out.

Walk down the road to the pharmacy and get it filled, waiting 45 minutes.
Another $10. The whole thing from start to finish was probably 4 hours and
cost me $40 out of pocket. No idea how much they billed my insurance yet.

The experience we had in Italy made a big impression on me. Even as a 17 year
old, I walked away from that experience wondering why our system in the US is
so broken. Surely we can do better.

~~~
yks
When I first started reading about American health care being a foreigner I
saw a persistent argument that in single-payer system "people will die in
lines". Yet here in the United States the lines in medical institutions are
greater than anything I've seen abroad, open slot for appointment with a
doctor in one month is a usual deal.

And why can't I buy antibiotics without a prescription. Don't I have a right
to heal myself?

~~~
pavlov
_And why can 't I buy antibiotics without a prescription. Don't I have a right
to heal myself?_

Misuse and overuse of antibiotics is a huge global problem. Common bacteria
are developing resistance, and the reason is the overexposure to antibiotics
due to agricultural and medical overuse. If things continue like this, soon
we'll have people dying of tuberculosis again in developed countries.

If people can buy antibiotics without a prescription, they tend to take short
treatments for random flu-related symptoms. This is doubly bad: the antibiotic
doesn't do anything against the viral infection, and unrelated bacteria will
be exposed to a weak antibiotic and be able to develop resistance.

~~~
yks
This is a good point, but isn't it the agriculture which mainly drives the
overexposure? Even if it isn't I doubt that this is a reason why antibiotics
are prescription-only. Almost every other group of pharmaceuticals in the US
is also restricted.

------
tomohawk
Inevitable result of thinking that adding even more government intervention
would result in better, cheaper plans.

If they were really interested in making better, cheaper plans, they would
roll back most of the ACA, eliminate the restrictions on buying across state
lines (actually allow competition), and transfer the tax incentives for
getting insurance from employers to employees.

Basically, all they had to do to make healthcare more affordable was to open
up the Federal employees plan to everyone and transfer the tax incentives to
employees. This was actually proposed by both major parties prior. It would
have been about a 10 page bill.

~~~
yetanotherone
It's a little offtopic, but this reminds me of Lessig's "the corrupting
influence of money is the first problem facing this nation. That unless we
solve this problem, we won’t solve anything else."

In my opinion the public option wouldn't have cost us much as a nation on the
whole, and could have possibly worked out to great advantage, but was not
going to happen because health insurance companies are too powerful for that
sort of thing to get through.

~~~
iofj
> In my opinion the public option wouldn't have cost us much ...

If you look at the margins the insurers are using (the maximum a public option
might be cheaper), they're not much. 10% is rare. Given government
inefficiency, I'd expect a public option to have been at least as expensive,
and probably more expensive.

So why would a public option be cheaper ?

~~~
lukeschlather
It varies significantly by state, but existing public options are similarly
priced or cheaper in terms of cost per person than private healthcare.

[https://www.cms.gov/research-statistics-data-and-
systems/sta...](https://www.cms.gov/research-statistics-data-and-
systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-
sheet.html)

~~~
stvswn
Where in the link does it say that?

~~~
lukeschlather
Not the clearest source, I'll admit.

These are better, and show Medicaid spending roughly $5000/enrollee vs.
roughly $8000 per capita overall healthcare spending in the USA in 2011 :

[http://kff.org/global-indicator/health-expenditure-per-
capit...](http://kff.org/global-indicator/health-expenditure-per-capita/)
[http://kff.org/medicaid/state-indicator/medicaid-spending-
pe...](http://kff.org/medicaid/state-indicator/medicaid-spending-per-
enrollee/)
[http://data.worldbank.org/indicator/SH.XPD.PCAP](http://data.worldbank.org/indicator/SH.XPD.PCAP)

------
dguaraglia
I'm glad someone changed the original title to "health insurance" rather than
"health care". Using the two terms interchangeably has to be one of the
biggest reasons why we get the shitty system we get for the amount we pay per
year.

------
mschuster91
Every time I see one of these articles (or anything related to US healthcare)
and read the comments, I can't help but ask myself how rotten a country can
be. In this case, as a German, I dare say "rotten to the core".

It apparently is impossible to move the US healthcare system to a system where
every person in the US is eligible to even the most expensive emergency
healthcare without having to fear bankruptcy afterwards, and that's shocking.

~~~
Laaw
Yeah, the vast majority of us have healthcare, aren't really sick, and
occasionally when we do get really sick, our insurance pays the bills.

I had an emergency root canal earlier last year in the US, cost me zero
dollars, and I've got one of those high-deductible plans (it's the HSA that
covered that).

I'm actually a little surprised you (or anyone on HN) are so eager to jump at
the "worst case" stories and presume they're normal. This is a data problem,
not a "let's tell our horror stories" kind of problem. Every system has people
who fall through the cracks, these half-baked "I'd just do X" without any
research is exactly the kind of thinking that _causes_ problems.

~~~
mschuster91
> I'm actually a little surprised you (or anyone on HN) is so eager to jump at
> the "worst case" stories and presume they're normal.

These "worst case" stories should not happen at all in any civilized country!
One of them is one too much.

~~~
Laaw
Every country has people who fall through the cracks. It's noble and true to
say this shouldn't happen, but it does, and in every country.

Germany, too.

~~~
mschuster91
> Germany, too.

Yes, it's mostly either illegal immigrants or self-employed one man companies,
and I don't like that either... but even if you're not insured, you'll be
taken care of in a hospital in emergency cases and not be stuck with a 500k+
bill...

------
abawany
This is unfortunate. Health problems are unpredictable and very expensive, in
my experience.

I was grateful for ACA (unsubsidized) in 2015 in spite of being on a bronze
plan with a high deductible. Why? Because even though I was generally paying
for care out of pocket due to my high deductible, the insurance company had
negotiated much lower rates for this care than what the providers wanted to
charge me. I guess I could have dealt with the 10+ providers and negotiated
lower cash prices myself but I have a day job. In my estimation, the
negotiated rates saved me $3k compared to the billed rates.

People I know minimized the dent to their financial health as a result of it
of ACA as well. Life and health is unpredictable and one can be hale and
hearty one day and hospitalized in the ER the next. The thought of being
without health insurance and allowing one's meager savings to be wiped out as
a result is an outcome that sends chills down my spine.

I hope I don't come across as shilling but I am grateful for the ACA. It is
not perfect but just like democracy, it is the best that this country has been
able to scrape up after 200+ years of SOL-care.

------
gscott
I work with someone who has health insurance from the California exchange. His
assigned doctor is about a 2 hour drive away. Maybe he has picked the cheapest
plan but such a situation shouldn't really happen if this was well run.

~~~
magicalist
FWIW as of 2015 California requires there be "primary care network providers
with sufficient capacity to accept covered persons within 30 minutes or 15
miles of each covered person's residence or workplace", specialists within 60
minutes or 30 miles, and that there be sufficient capacity for doctors within
those limits to accept new patients[1].

Getting that enforced isn't easy, but that situation not only shouldn't happen
but should also be grounds for regulatory action against the insurer.

[1] [http://www.insurance.ca.gov/0400-news/0100-press-
releases/20...](http://www.insurance.ca.gov/0400-news/0100-press-
releases/2015/upload/nr012-NetworkAdequacyApproval.pdf)

~~~
DrScump

      Getting that enforced isn't easy
    

How is that even _possible_? How does the state _mandate_ that some random
provider step in and subsidize higher payments to providers in order to
encourage them to take on more new patients?

~~~
YokoZar
By preventing them from selling their insurance on the state-run exchange if
they don't meet the standards.

~~~
DrScump
OK, name one case where that has actually happened -- where the state has
successfully coerced a doctor to accept new patients at a loss or a provider
to overpay to make such a doctor/group choose to accept new patients.

There is a good article on this problem (many doctors not accepting new
patients, leaving regions without care except for ERs) on the front page of
the 5/18/15 San Jose Mercury News.

~~~
magicalist
> _OK, name one case where that has actually happened -- where the state has
> successfully coerced a doctor to accept new patients at a loss or a provider
> to overpay to make such a doctor /group choose to accept new patients_

It has nothing to do with coercing doctors. Why would it? If a insurance
network can't meet its obligations it will be fined or shut down. If an
insurer has to pay more money to a doctor in some area to meet its obligations
it will then have to (though undoubtedly that will be eventually passed on to
its customers).

Meanwhile it's an agonizingly slow process to get justice for the people that
need it, but insurance companies forced to refund money for not meeting their
network coverage requirements is in the news right now, specifically because
"more than 25% of physicians listed by Anthem and Blue Shield weren't taking
patients in the Covered California health exchange or were no longer at the
location listed by the companies, according to the state's investigation."

[http://www.latimes.com/business/healthcare/la-fi-
obamacare-n...](http://www.latimes.com/business/healthcare/la-fi-obamacare-
network-probe-20151103-story.html)

~~~
DrScump
That article talks about fines for _overstating their networks_ \-- stating in
marketing materials that they had more participating doctor availability in
given region(s) than they actually had availability for all policies offered.
False advertising, in a sense.

That is _very different_ from the problem statement: how do you make a network
offer inducements at a loss to recruit additional providers?

I'd guess that most people buying off CoveredCA.org don't even bother to look
at participating providers accepting new patients before buying a policy.
There is no element of law that says to an underwriter, "Hey, you gotta add
more providers in _this_ area and _that_ area now, or we will punish you." The
law doesn't give government that power.

~~~
magicalist
> _That article talks about fines for overstating their networks -- stating in
> marketing materials that they had more participating doctor availability in
> given region(s) than they actually had availability for all policies
> offered. False advertising, in a sense._

They weren't falsely bragging about numbers in marketing materials, they were
listing specific doctors at specific addresses in their tools for finding in-
network doctors that were not in their network or were not at that address.
Different from geographic density but related.

> _That is very different from the problem statement: how do you make a
> network offer inducements at a loss to recruit additional providers?_

It's really not complicated: by saying they can't operate in a certain area
without a sufficient network. They either recruit more doctors or they pack
up.

Perhaps you're missing that insurance companies in California don't usually
operate statewide? I assume this is common across the country. The key is that
care has to be available near your house or workplace. When applying for
insurance you are specifically offered companies that have coverage in those
areas (often at the county or city level of granularity).

You can't sign up for an insurance policy at the other end of the state from a
company's network of doctors and expect them to sign up doctors around you,
because, again, if they don't have sufficient density of doctors where you
are, they don't cover people there in the first place.

> _There is no element of law that says to an underwriter, "Hey, you gotta add
> more providers in this area and that area now, or we will punish you." The
> law doesn't give government that power._

Yes, it really really does.

------
0xcde4c3db
At least in retrospect, this doesn't surprise me. If Kafka had been a 21st-
century American, he probably would have written a novel about medical billing
instead of _The Trial_. An incomprehensible cost structure represents, in some
sense, infinite risk. Why _wouldn 't_ people be hesitant to engage?

------
graeme
I'm a Canadian. I'm curious to know what it would cost to match my level of
coverage in the US.

1\. Public medical care. Good care, normally easy to see a doctor. Excellent
quality. Can use this as much as you need. 2\. Occasional use of the parallel
private billing system. Costs less than $300 Canadian to see a specialist. 3\.
Private coverage for paramedical claims (Physio, massage, drug plan, dental,
vision, etc.). Pretty comprehensive. Costs about $100 Canadian a month.

I work for myself. Is it even possible to replicate such a plan without
employer coverage? What would it cost?

~~~
geomark
I'm genuinely curious about this, particularly the "easy to see a doctor"
part, because I know that quite a few Canadians travel to Thailand for non-
emergency medical care mostly due to long wait times. That's according to a
few statistics published by some of the private hospitals in Thailand. I've
seen few outbound studies published by Canadian researchers, although here's
one from last year [1]. From what I understand, out-of-pocket costs aren't
that much difference between Thailand and Canada.

[1] [http://www.ctvnews.ca/health/more-than-52-000-canadians-
trav...](http://www.ctvnews.ca/health/more-than-52-000-canadians-travelled-
abroad-for-medical-care-in-2014-study-1.2283121)

~~~
graeme
I think it varies a lot by jurisdiction, proximity to foreign centers, and
type of procedure.

For instance, I live in Quebec. On the chart in the article, Quebec only had
6284 travelers, despite having a large population. Quebec's private medical
system is more extensive than average, and I think you can buy more here than
you can in some other provinces.

BC also has easier travel options to Asia. It would be quite a trip from
Quebec, and possibly easier to buy locally.

Across the board, wait times tend to be long only for elective issues. I've
generally had no trouble with them for and neither has my family.

Though some specialties seem worse off. For instance, if I needed a
gastroenterologist in Montreal, I believe I'd have great difficulty finding
one.

Also, in Montreal, much depends on your local hospital. Some have longer wait
times than others, even within the same city. If someone doesn't know how to
navigate that system, going abroad may seem simpler.

~~~
geomark
That makes sense, the variation by jurisdiction. It's kind of strange that a
local person would find it simpler to go abroad than navigate the complicated
workings of the local care system. Although it is pretty simple when you go to
a medical tourism destination - you just get off the plane, taxi to the
hospital, walk in and ask for sevice, and you get it.

------
tvanantwerp
My wife is from Hong Kong, and we're both seriously considering moving back
there because of the cost of health care in the US. It's been a constant
strain on our finances--any little thing can set us back by hundreds or
thousands, even while insured! We never had problems like this back in Hong
Kong. I really wanted to make our lives work in the US, but I don't see how
we'll ever get ahead when raises and bonuses get eaten away by health care.

~~~
geomark
Can you summarize the healthcare system in Hong Kong? I'm particularly
interested in options for non-citizens. Can you just walk into a private
hospital and get treatment for cash? Or is it like so many places in the US
where they don't want to talk to you unless you have proof of insurance?

------
brandonmenc
The real problem is that no one knows how much anything costs - including
doctors.

Ever ask them "how much is this going to cost?" They'll either tell you they
have no idea, or give you a useless range like, "between $1k-$10k."

~~~
geomark
This drives me crazy. I walk in and want to pay cash, but they won't treat me
because I have to show proof of insurance because they have no idea what they
will charge when the bill is generated.

------
beatpanda
>"If something catastrophic happens," she said, “I feel like it’s better just
to die.”

This is the richest country in the world in 2016, no other country has this
problem, and this is the best our politics can do.

Sit with that thought for a little while.

------
tunesmith
Kind of a contentless article - of course there will always be people who
choose the penalty instead of coverage. Some will be rational choices, some
will be short-sighted. It looks like the overall forces, though, are good for
the ACA - the penalty is going up, more healthy people are signing up for
coverage, the risk profiles are stabilizing, etc. All of this should
theoretically help create more choice in the exchange over time.

~~~
CrowFly
I don't know. I think the stories from people who are actually trying to use
the ACA should bear a lot of weight.

~~~
Analemma_
No, they shouldn't. "The plural of anecdote is not data": of course you can go
around cherry-picking people who are unhappy with the ACA; health care is
extremely complicated, no solution was ever going to be perfect, and this law
in particular attracts people with an axe to grind. But I can find just as
many anecdotes of people who are a lot better off under the ACA. Stories are
pointless; the only effective measurement is the bird's-eye view of the
numbers as a whole: how many uninsured are there now, what is happening to the
mean/median premiums, etc.

------
pinaceae
As an European living in the US, the US health system is so utterly broken and
asinine, it's not even funny.

You take a non-free market (I get sick, I need help - no choice involved) and
apply seemingly free market logic to it. The result is a disaster, tada.

Single payer, all the way, everyday. Add private, optional insurance on top to
allow well-off people to get private rooms, etc. But no one should worry about
going bankrupt over medical bills, ever.

And yes, Austria is living proof that such a system can exist, with awesome
results. Including electronic health records, the e-card etc. - all sci-fi
ideas that US super genius companies like Google, MS, a myriad of startups
cannot create.

~~~
novalis78
It's not a free market system. I wish it was. It's amazing how people vote for
government protected cartels. It took the press (Time magazine article two
years back) an incredibly long time to start digging into fraudulent
healthcare pricing - since then some things have started moving (legislation
in some states to force hospitals to show prices, at least to bring in some
semblance of a market and allow market forces to start operating). In a true
free market environment such abuse by an incumbent/system would lead to
innovation and new ideas that would quickly obliterate the monopoly, in this
case the monopoly has the guns (i.e. regulation/government protected insurance
and health care industry). Disclaimer: I lived in Austria/Germany for decades
and their system is worse because it's totally closed to any potential market
innovation while taxing the living daylights out of the middle class.

------
rdtsc
This is turning out to be a failure for some. It was for me personally. Was at
a smaller company. Insurance premiums had been increased by a huge amount
(probably 40% or so) in the 2 years _before_ Obamacare went into effect.

Representatives would come and would tell us a sad story about how all this
legal environment is punishing them, and there is a lot of risk and
uncertainty so they have not choice but to raise premiums.

So 3 years later premiums are way up, coverage is ... different. No lifetime
maximums, that's nice, some free preventice checks and labs (unless the find
something, then it becomes a paying lab or doctors' visit). Otherwise it is a
about the same or worse coverage as before.

So far as far as the pocket is concerned, as far as the story I am told by
employer, and by insurance representatives is that Obamacare is not a good
thing. I want to believe, but I can't.

I knew it was going to be a so or so or failure when they striped the single
payer option away early on. It wasn't agressive enough that's the problem.
Without cost controls it is like plugging holes in hunk of swiss cheese. "Oh
law wants to expand coverage for more people? Ok, everyone's premiums are
higher now by 20%...."

I'll grant it that it might not be just the insurance companies to blame.
Doctors, hospitals, pharma companies -- anyone in the money pipeline is guilty
of abusing and taking advantage as much as they can.

------
pbreit
Why would it not be more affordable? You're not getting anything.

~~~
swagv
You can pay and get something or pay and get nothing.

~~~
bdcravens
If you don't go to the doctor and don't need medicine, the "something" isn't
valuable especially if it's more expensive than the "nothing". (I say that as
someone with a preexisting condition who is happy to pay my premiums and get
the medicine I need; I also grew up in a family where we didn't have insurance
but somehow always had cigarettes and cable TV, so I know multiple
perspectives)

~~~
Killswitch
I'm 30 years old and haven't been to a doctor in about 10 years outside of
simple things that I paid out of my own pocket. Nothing that a year of
healthcare would cover, and considerably lower than it'd cost.

I'd have paid in tens of thousands of dollars over the course of that time,
and for what? What ifs?

~~~
DanBC
When you're 60 years old you're going to want doctors and nurses who know what
they're doing. That means someone needs to pay now to train them and their
replacements.

~~~
Killswitch
So what you're saying is if I don't go to the doctor for 10 years, but pay
$350/mo over the course of that 10 years for an insurance plan, the insurance
company uses the money to fund college education for nurses and doctors?

Doubt it.

------
transfire
Evey once in a while I have to go to the emergency room for a serious
migraine. All I need is a few drop of morphine. But I also get a bill for over
$3,000. Of course, it goes in the trashcan.

The real problem with the medical system is its total contrivance to prevent
people from treating themselves and having access to treatments at their
actual cost -- the inflated pricing for the non-insured is the racket of the
health insurance "mafia".

~~~
tshtf
Morphine? Why not get a prescription for Imitrex?

~~~
stordoff
Sumatriptan isn't a cure-all for migraines. I suffer from near-constant
migraine-like headaches (sometimes diagnosed as migraines, some not - depends
on the consultant), and they are actually worsened by sumatripan.

Morphine seems a little strong, but having tried every offered non-opiate
medication (amitriptalyne, sodium valproate, gabapentin, propranolol,
topiramate etc.) and only had any success with opiates (tramadol and codeine),
it doesn't seem that unlikely.

~~~
tshtf
Thanks, fair enough. I shouldn't have assumed the first-line approaches for
migraine would work for everyone.

------
fredliu
FWIW, reading the comments reminds me of Hilary Clinton's answer to "Is
Obamacare helping or hurting the average U.S. citizen?" on Quora
([https://www.quora.com/Is-Obamacare-helping-or-hurting-the-
av...](https://www.quora.com/Is-Obamacare-helping-or-hurting-the-average-U-S-
citizen)) The comments on Hilary's response seem resonate the comments here...

------
cmurf
Insurance I had as self-employed for 12 years gave up in 2015 and would not
renew. Crap bronze plan with highest possible deductible is almost 4x what I
was paying.

The part I particularly don't like is that this is compulsory. I'd rather see
private insurance destroyed than expanded under penalty threats. Or better, go
back to barter.

------
imh
Some people don't get insurance because the high deductibles mean they
probably won't get any benefit. I think an even scarier effect is that I
personally don't go to the doctor unless I really, really need to because of
those same high deductibles (and the high cost of time off of work).
Preventative care is expensive!

------
rphlx
I've heard that, based on how the ACA was written, the penalty is only weakly
enforceable; if you refuse to pay it, the IRS cannot garnish your wages or
seize assets for it, etc. They can subtract it from a tax refund if you are
owed one, but that's about it. So I imagine more and more people will find
ways to not have insurance and also not pay the penalty, as both continue to
become more expensive over time.

------
tyingq
Interesting to see the anecdotal evidence in the comments that the ACA has
been very good to some, and very bad to others.

It's been particularly bad for us. The covered employees are largely older
(40+), with families, and it's a fairly high-end policy with a low deductible
and a high percentage of covered inpatient costs.

We pay 100% of the premiums for employees. The cost, for one employee with a
family, is now over $1800/month.

It is a high end policy, but...WOW.

------
dawnbreez
This is actually further than I expected this to go. I'd figured companies
would charge up to the penalty, not more than it, as charging more would drive
customers away, and charging just a little less would net them the most money.

------
DougN7
My individual/family plan has gone up by about $1000/year for the past two
years. AND our deductible has increased as well! Not too thrilled with the ACA
- it's becoming less and less affordable as time goes on.

------
rdl
I've always been a fan of HSAs + HDHP w/ extremely good coverage (no lifetime
limits, etc.) beyond the self-insured amount. (Keep preventive care, birth
control, etc. in the exempt amount, too, and especially public health stuff
like vaccinations, since it reduces overall cost.)

I currently have an HRA (essentially a non-accruable form of HSA) through
employer; it gets the incentives wrong so there's every incentive to use as
much care as possible (slightly more convenient providers who charge 5x as
much to the plan; as much care as possible).

I still have some hope ACA 2.0 could include:

0) Transparent pricing and mandate that anyone prepaying cash gets the
medicare price. Maybe medicare prices have to rise.

1) Catastrophic/HDHP being encouraged for everyone. Potentially, subsidized
for some income levels (i.e. money goes directly into your HSA, and HDHP
premiums can be reduced.) I'd prefer if those premiums be market-based and
then explicitly subsidized.

2) End employer deductibility for health insurance (over, say, 5-10y window);
make it deductible, if at all, for individuals only. Employers for many many
reasons should have nothing to do with health care -- privacy, portability,
etc.

3) Pressure to reduce actual costs of health care delivery. End the AMA
cartel's reign on care -- there is a LOT of care where 5% of the cost could
produce a 90% as good solution, and people should be free to choose that if
there are no negative externalities. Really, only antibiotics and contagious
disease should have enforced minimum standards which can't be deviated from
even w/ informed consent. This is especially meaningful for terminal or end of
life care.

4) Any subsidies come from general tax and not from adjusting the underwriting
(which is essentially a tax on people buying certain classes of health plan
only, to cover others)

5) All government plans, except deployed active-duty military ONLY (i.e. care
in war zones), go via this plan; end the VA and tricare. Provide superior care
to gov/mil people by making this overall plan better, and for everyone. The
President can have a personal doctor for COG reasons, but all other senior
government people go through the plan, too.

6) Potentially fold medicare/medicaid into this as well.

7) Explore single-payer

8) Relatively unlimited access to medication (certainly imports from
overseas), outside of antibiotics. If there is patent protection, shorten
term. Reduce trials costs (safety must be shown, but not efficacy) -- efficacy
and superiority can be decided by informed consumers, who may not be
individuals, but could be insurers or other groups.

------
novalis78
Before ACA we could barely afford health insurance for our family. After ACA
it became evident that we can't afford to participate in this mafia racket if
we truly want some money left over to pay for necessary medical expenditure.
We were ready to face the tax penalty, but then my accountant found a loop
hole. It's time for a repeal and replace -with some introduction of market
competition. This unholy alliance of hospital-insurance-government mafia
cartel needs to be broken.

------
mrslave
Another Peter-Schiff-was-right moment.

------
exabrial
Obama said no one is losing their coverage. He didn't lie.

~~~
white-flame
That is the one flag-waving thing they can say about this, that more people
are eligible or covered (but that ≠ "no one lost their coverage"). Obama will
wave that raw number flag hard to try to tout his legacy.

Literally everything else in all aspects of the American health care & health
insurance industries is worse off because of it.

