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I'm not a twentysomething kid so I have to buy insurance — and at this point I'm now spending about $10k a year. I realize that doesn't sound like a ton of money, but if you're trying to self fund your own projects while living off the income of client projects and while paying office rent in NYC it's pretty damn painful.

Ten years ago I was spending at least half that amount, and what kills me is that I'm a single guy — if I was paying for a spouse or a family plan it would be about double the cost. And the sad thing is that my coverage from ten years ago actually gave me more coverage.

I'm happy to pay for coverage and be responsible, but the insurance companies at this point are pretty much on the level of racketeering mobsters. I had hopes for healthcare reform: But without a public option or killing the insurance companies I don't see much changing any time soon. I really hope that more pressure builds and people demand a real change.




You're missing the whole point. It's not the insurance companies. At least not to any great extent. Their margins are usually under 2% (though their marketing and administrative budgets can be quite large). Hospitals' margins are ten times that. I see the bills that my insurance company pays and they are usually an order of magnitude higher than the Medicare rates.

As an aside, what you need to look up Medicare rates are the HCPCPS codes (call them "hick pick" codes on the phone so you sound like you know what you're doing). Just call your hospital and ask for them. They'll give them to you; they just mail you a new form separate from your actual bill. Then, just plug those codes in here:

http://www.cms.gov/apps/physician-fee-schedule/search/search...

(use a "specific locality" to get the rates in your area). Then you're ready to negotiate! But... good luck with that...


> It's not the insurance companies. At least not to any great extent. Their margins are usually under 2%

I'm with Anthem Blue Cross in California. In 2011 they spent 79.9% of premiums on actual medical expenses and due to law changes had to issue a refund for 0.1% This year they raised premiums by 22%.

Various administrative expenses are hidden all over the place. eg the cost of an appendectomy also includes the cost of recovering the money charged.

The problem with the US healthcare system isn't any one part. Every single part is broken in some way, with the interoperations between them compounding to make the problem worse.


I suspect that the main reason the single-payer healthcare system is so efficient is simply that there are less players involved.


I work for a non-health insurance company. I believe that removing insurance companies from the equation would definitely make things more efficient - at the very least my company doesn't have the motivation to really cut down on expenses, most managers are more worried about internal power struggles, I've seen so much waste I'd start my own company in a heartbeat if only it wasn't so capital-intensive to start, and a papework and political minefield (which of course lets the old boys get by with a lot of leeway in terms of actual efficiency improvements).


No, is the insurance companies.

Not the insurance companies as the entity which takes all that money, no, everyone here knows that.

It is the insurance companies in the sense that the insurance companies are in no way brake on costs, they are an accelerator. They take a cut of the whole and have an incentive to keep the whole high.


One big problem is that laws often restrict the ratio that insurance companies charge older people to younger people to at most 5 to 1. Starting in 2014, Obamacare lowers this to 3 to 1, so younger people with insurance are heavily subsidizing their elders (yet again). You'll be paying significantly more, with no direct benefit.

[0] http://www.buzzfeed.com/bensmith/obama-healthcare-young-peop...


This is how it works in Switzerland except...the insurers aren't allowed to discriminate at all. So ya, the young kids heavily subsidize the elders...the misery of that! (Also, everyone buys insurance themselves, poor people get help, your employer doesn't buy your insurance)

And what is wrong with this exactly? We all get old eventually, so this subsidy is actually fair.

> You'll be paying significantly more, with no direct benefit.

Only true if you don't plan on getting old.


Or if there are more old people now, when you're young, than there will be young people when you are old. :P


I'm in the UK, and the total cost of the NHS is around £130 billion. With a population of approx. 60 million, that means everyone pays on average £2200. Call it $3500.

Of course, that's an average covering every man, woman, child, pensioner etc. People in paid employment are paying at least double that (in tax). It's not far from your $10000 figure.

Of course, on the up side the NHS is hassle-free. I don't have to worry about co-pays, or money at all. I just go when I need it.

Source for budget: http://en.wikipedia.org/wiki/National_Health_Service#Funding

Source for population: https://www.cia.gov/library/publications/the-world-factbook/...


I'm an American living and working in the UK. I think it's telling that I pay less in NHS contributions than I did for Medicare & Medicaid in the USA, and I can use the NHS now.


  Of course, that's an average covering every man, woman,
  child, pensioner etc. People in paid employment are 
  paying at least double that (in tax). 
That $10,000/yr is just the monthly insurance premium. The patient still has to pay for things out of pocket. Because his premium is so high, I'm guessing GP has a very high deductible, eg $5,000, which is paid out of pocket. Then there's the copays, scripts, and misc fees.

I currently have awesome coverage (by USA standards) and still have to pay ~20% of visit out of pocket.

Actually, that last part I'm guessing. Because of the back and forth game played between insurers and providers, I get confused, and haven't expended the effort to figure out the actual monies exchanged.


One thing I didn't understand about your reply (sorry, I'm not an American!) is this: You say Because his premium is so high, I'm guessing GP has a very high deductible, eg $5,000 Surely if his premium is high, he would pay less for each visit to the doctor?


I'm sorry, you're right. My bad. Thank you for noting this.

Low premium usually means high deductible. GP's premium is probably high because his he's buying as individual or small company. Meaning he has little negotiating power.


It doesn't really have anything to do with the insurance companies. Their margins on paper aren't that great, and even if those margins are bigger than they look, it's probably not a big difference one way or the other.

The major costs here are two-fold: 1) old people 2) doctors and hospitals (those huge, beautiful new buildings aren't free: http://www.feinberg.northwestern.edu/gfx/news/2012-year-revi...)


Still, cost can be put under control. Here in the "outside world", we mostly have universal government funded care with country to country agreement for travelers and people living outside of their origin country boundary.

This is not "free", far from it, but, first, by taking no margins and then having tougher cost review for infrastructure/equipment purchase help reduce the cost. Then using generics drugs instead of branded ones by default also help. Remember, many hospital and doctors have official or under the table deal with private providers.

Then there are side benefits. People live longer and healthier. Their kids don't have to live in fear of having to spend 100k$ if their parent felt ill. My grand mother (91 years old) broke her arm and pelvic bone a few weeks ago. Of course, at her age, it wont heal, so it had to be replaced. How much would it cost in the US? 200 big ones (including a month or so of hospitalizations, the 2 surgery, the drugs and follow up). How much stress would it put on my family on top of the accident?

At some point, even for those who can pay, some level of social security, both health and monetary one reduce uncertainty and reduce crime rate. To some point, I understand US mentality on this. I tried to create startups a few times, it seem a lot harder here than everywhere else. It is not even socially acceptable to both succeed and fail. If you succeed, then you are a greedy asshole and if you fail you are a loser. But even giving that, I still think having universal health care and the other "big government" goodies is a good thing.


Other countries also have old people, and I don't have any reason to think that doctors and hospitals are more expensive in the USA than they are elsewhere.


> I don't have any reason to think that doctors and hospitals are more expensive in the USA than they are elsewhere

They definitely are. Doctors in the U.S. make more money. Drugs are more expensive, partially because the U.S. subsidizes R&D for everyone else. Hospital construction in the U.S. is insane in the major systems. They're "spare no expense" affairs, very different from the utilitarian facilities you used to find in the U.S. in say the 1970's and which you still find in the U.S. today.


Doctors in the U.S. make more money.

No, not really. My american, pediatrician drove a beat up Subaru. Doctors is a pretty big field that covers GPs (PCPs in the US), surgeons, anaesthesiologist, etc. Surgeons make a lot of money in the US and everywhere, but your typical GP is not ballin'. I'd even say doctors in other western countries make more because no student loans and no malpractice insurance means their take home pay is higher.

Drugs are more expensive, partially because the U.S. subsidizes R&D for everyone else.

This list http://en.wikipedia.org/wiki/List_of_pharmaceutical_companie... has the top 2 drug companies being in the US and 3rd, 4th, and 5th are european. The US does subsidize the worlds R&D in erectile dysfunction research ;-). There are plenty of drugs that have been approved elsewhere that haven't been seen in the US.


Don't bring an anecdote to a gun fight, or something like that:

http://economix.blogs.nytimes.com/2009/07/15/how-much-do-doc...

(US GPs make sharply more than those in Europe).


And as pointed out in the last paragraph. The table excludes cost of education and malpractice insurance.


tptacke's comment notwithstanding, I have a pediatrician friend who points out that among doctors, pediatricians are the lowest paid. This might be biasing your anecdote here.


It's the second and third vacation homes of the insurance/hospital administrators, equipment/drug suppliers, and doctors/surgeons you are paying for, not the hospital itself. The hospital itself is often getting massive tax breaks and other funding.

The problem is US health care is for-profit and the "American way" is that there is absolutely no limit on that profit, so they charge whatever they want.


"They charge whatever they want" is only the first half of the American way. The second half is that because its "whatever they want" someone else can cruise on up and "want" to charge $10 less and take all of the business.

The broken part is that they charge whatever they want and then stop anyone else from being able to charge less. If you do the first half, but not the second, its very much not the American way.


But the entry cost is prohibitive and create an oligopoly. So, no, they wont charge 10$ less. They can handle a limited number of patients and have an increasing potential market with median age increasing. It is basic offer, supply and demand. If it was only offer and demand, then yea, they could charge less, but they have an hard limit on the number of bed they can fit versus building+workers cost.


Who is stopping anyone from charging less?


http://en.wikipedia.org/wiki/Certificate_of_need

http://www.ncsl.org/issues-research/health/con-certificate-o...

Where these exist (most states) you'll have a hard time opening a new facility whose purpose to charge less than the incumbents. (In theory they'd have to charge more to make up for the business you take away so you'll be raising prices.)


Thanks for pointing that out. CONs are a fascinating rabbit hole of government regulation. They try to lower prices by doing exactly the opposite of the actions that usually lower prices. Only a regulator could think that restricting competition would force prices down.


Also consider car dealerships where there is all sorts of special regulation, and even prevention of manufacturers selling direct to the public. (See litigation against Tesla for more details.)

Heck in California (I don't know about other states) the sales tax is paid based on the purchaser address, not the address where the sale takes place like for other goods.

Or how foreigners aren't allowed to own more than 50% of an airline.

For a land of free business, there is an awful lot of protectionism going on.


Much of the health care system isn't for-profit, but that doesn't stop money from getting spent. When I lived in Chicago, the local hospital was Northwestern Memorial, which is a non-profit hospital attached to a non-profit university. But the university owns literally 5-6 city blocks of prime Chicago real estate (tax free, of course). It's interesting to note that between 1972 and 1994, there was no new construction on the Northwestern Memorial campus. Then in 1999, two huge new buildings went up, then a women's hospital in 2007, a new children's hospital in 2012, and a new outpatient facility is slated to open in next year. These are each $350-500 million high-rise buildings. And these aren't utilitarian buildings of the kind that were pervasive in the 1970's. They're nicer than most F500 headquarters.


I'm pretty far from 20something myself and I live on less than 10k a year (in the usa).

If I needed 10k for a medical problem I'd be completely screwed. It's not like they will treat cancer in the emergency room.


Actually, yes, they treat people with no insurance with cancer or other serious injuries all the time. I was literally sitting in an emergency room at Stanford when they flew in a poor illegal immigrant from Fresno and did the micro-surgical reattachment of a finger. I was there for someone with no insurance who had stage 4 liver cancer who was undergoing treatment (they survived). I grew up very poor, there was nothing unusual about this.

The idea that poor people do not get top notch medical care in the US is largely a myth. It might not be quite as nice but it is often nearly as effective. A large part of the reason medical care is so expensive for average people is that they are subsidizing the healthcare of poor people. This is why the average survival rates for most cancers are higher in the US than anywhere else in the world; people that cannot afford it still get treated with the state of the art and the cost is passed on to people with insurance.

A poor person with cancer in the US with cancer has a much higher survival rate than the average person in the UK. Poor people may not have official insurance but that does not imply lack of healthcare in practice.


You have no idea what you are saying and are under some kind of fantasy. I live the reality you are speculating about.

EMERGENCY CARE must be admitted, ie. loss of a finger - it most certainly is not free and that person will never be able to get credit for the rest of their life (unless they can somehow afford to repay it - but an ambulance flight in is at least $10k alone)

They are under no obligation to treat cancer. If you were bleeding out from the final stages, they might have to admit you. Otherwise it's not an emergency. You are free to die slowly.

If you don't catch the cancer early on and can get some federal assistance to get it treated, you are pretty much screwed. They pretty much know with cancer you aren't going to be paying them back for any services rendered, so none rendered.

If you are a step above federal poverty level yet still cannot afford to pay for medical or dental treatment in this country, you are screwed. Your entire income will be consumed as you get older by medical needs. If you get cancer, your best bet is to then make sure your income completely disappears and apply for all the assistance you can get, your job income then becomes a liability.


> If you don't catch the cancer early on and can get some federal assistance to get it treated, you are pretty much screwed. They pretty much know with cancer you aren't going to be paying them back for any services rendered, so none rendered.

So you are calling parent a liar? That his story can't be true because someone without insurance but with liver cancer would just die under our heartless system?

> If you are a step above federal poverty level yet still cannot afford to pay for medical or dental treatment in this country, you are screwed.

You definitely have a problem, but I think you severely underestimate the amount of charity care that goes on in the US, which is why our hospitals charge so much anyways. You can go to the hospital, get treatment, they will bill you later, and...they won't run a credit check first.

> If you get cancer, your best bet is to then make sure your income completely disappears and apply for all the assistance you can get, your job income then becomes a liability.

You can get charity care without being on medicaid.


This is the second time I have seen this claim (re cancer survival) posted to HN, both times it has been unsupported by any references-

Do you have any references?

I have been able to find this

Global Cancer Statistics, 2002 DOI 10.3322/canjclin.55.2.74 That shows essentially the same survival between the US and western Europe. (Link to table http://i.imgur.com/UWPxDEx.png )

Which contradicts the claim


I think they refer to http://www.thelancet.com/journals/lancet/article/PIIS1470-20... (I think http://healthcare.procon.org/sourcefiles/CONCORDCancerSurviv... is a freely available copy). It shows th USA consistently in the top 5, but not always the top.

I think they worked hard on getting comparable data, but I find the discussion on where they come from somewhat lacking. There is some discussion on inconsistencies between diagnoses (when is something Cancer X?), but I could not find a discussion on QALy's (http://en.wikipedia.org/wiki/Quality-adjusted_life_year). I expect that can make a decent difference in 5 year survival rates (if you give patients the choice between 6 months in bed in hospital and 3 months at home, the last on bedridden, quite a few would choose the 3 months)


Thank you for that.

I suppose I generally consider that when US/UK cancer survival is brought up in this manner it inflates US medical treatment and uses the UK as a proxy for western rest of the world medical treatment - however this isn't true as Cuba, France, Canada and Australia for example hve essentially the same survival from that chart as US survival...


Very rare around this area. In fact, the emergency rooms here won't fully treat people sometimes because of lack of a regular doctor, which requires payment and regular checkups and things the poor cannot do. "free clinics" drop off not too far from the poverty line.

That person with stage 4 liver cancer? What if it were skin cancer - it looked funny, but they can't get it checked out. Until it is an emergency... and by then it could be too late. Even then, the emergency room will say it is too big to treat from there and refer to the normal doctor most times. This isn't top notch medical care. This is "suffer until it is dire, and maybe you'll wind up surviving in pain"

I'd much rather pay an insurance tax so everyone is covered. I doubt it would be much more than people pay now for insurance since everyone would be paying in.


Look, I think the point is this:

We have universal healthcare coverage in the USA, the difference between the USA and everywhere else is we'll bankrupt you first in order for you to access it.

This is an incredibly inefficient, heartless, and needless way to run things, yet it's what we have. I see a few comments below you talk about no access to cancer or chronic care if you're poor but there are tons of programs, grants, etc. that you can access, except you must be genuinely poor. And spend a lot of time finding them, and filling out paperwork, and on and on and on. You'll get care, but it will be psychologically, financially and physically demanding for you and everyone around you.


> and at this point I'm now spending about $10k a year. I realize that doesn't sound like a ton of money

That's more than a third of the median US individual income.


If that was put in a savings account and used for health expenses, is there anyway it wouldn't be a better option? By the time something bad happens, statistically, there should be a fair bit of cash there. It's worth noting that I'm not in the US, and while I know care is expensive in the US, I may be under estimating it.


Unfortunately things are insanely expensive via self-pay. My wife's first pregnancy was in the realm of $25-30,000 if we didn't have insurance.

And that was just a routine pregnancy with no complications...


That's unbelievable - my wife had our child at no financial cost other than taxes and had a terrible experience. If we had used an obstetrician that we paid for out our pocket and she had a Caesarian (I only we had taken that option) it would have cost US$2500 - that's all inclusive with pre birth and post delivery visit and checks. New Zealand.


A friend of mine that had insurance cut off his thumb a few years ago; all told the bill to him ended up being around $80,000. It is unfortunate, but you can't really just save and hope that a tragic thing like that won't happen - it is possible.


> Ten years ago I was spending at least half that amount

The same thing happened to me. Over a span of 10 years, I went from having HMO $30 copay and no deductible to $5000 deductible plus another $7500 out of my pocket for co-insurance and the monthly payment being 2X as high.


Actually, I'm in the "state" insurance system in germany and I pay 10 grand per year as well. That might or might not be comparable to what you pay since our incomes might or might not be comparable, but the figure itself seems fine. Given that any major injury can cost quite a bit more than 10k to treat, I'm totally fine with that.


Really? In the Netherlands health-insurance is around a hundred euros per month (1250 Euros per year). The annual copay is 350 Euros (total). And if you make less than about 20k Euros a year, you get most of your insurance covered by the government. Looks like we've got things sorted over here.

(and in the UK, where I live now, things are even easier...)


> $10k a year. I realize that doesn't sound like a ton of money

Sounds like quite a lot to me considering i would pay (here in Canada) ~66$ a month, ~$800 a year (0 co-pay i think its called), if my employer didn't pay my insurance fee for me. And prescription drugs are also mostly covered... 10K really sucks :(


> I realize that doesn't sound like a ton of money

That's a fucking shitload of money.


thank you antihero — you're my hero!




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