Part of ACA is that insurance companies can no longer refuse coverage or charge more for pre-existing conditions. IMO the insurance companies agreed to this because everyone was going to be forced into either buying insurance or paying a penalty to be self-insured (not carry insurance). The penalty was later removed by Congress, but the insurance companies were stuck with the no pre-existing conditions rules.

https://www.hhs.gov/answers/health-insurance-reform/can-i-ge...

When I tried to get private insurance from major carriers, I ran into:

- circular phone trees that couldn't be escaped

- forwarding to "agents for my area" that never answered the phone

- forwarding to agents that did answer the phone but said there would be coverage limits for 6 months since I had a pre-existing condition. This is illegal. One agent did give me a quote for $2400/mo with a $10K deductible.

- I did find prices on the Internet that said private PPO coverage would cost about $800/mo with a $10K deductible, but no insurance company would actually write it.

IMO, only writing new individual coverage (not via company employment) during open enrollment is a way for the insurance companies to keep their limit on pre-existing conditions.

I ended up paying cash ($12K) for a 1-week visit to Mayo. In hindsight, paying cash was a better deal than if I had private PPO coverage: PPO would have cost $9600 in premiums (or more!) plus I would have paid the first $10K, so nearly $20K.

Insurance in the US is a mess!

I do have to add though, ACA has been a lifesaver for me.

I would figure out how much your current health insurance is (both the employee and employer contribution). This is the amount you would pay if you quit your job and went on COBRA. You can be on COBRA for 18 months and it's typically cheaper than finding an equivalent plan on the marketplace. That gives you time to grow your business and figure out a long term health insurance solution.

I could get reasonable short term plans for about a quarter of that. As a healthy individual that was definitely the right choice for me, but if you have high utilization already it might not be for you.

But... it's not "expensive"... It's just the price. And many people never see or think about it because "employer" pays some/most/all of it. Until... you don't have an employer. Then it seems "expensive". But... the price has always been there, we just don't see it sometimes.

Employer-involved insurance is one of the biggest things slowing social progress, imo.

We're in our mid-30s, healthy (run marathons), non-smokers, with no prescriptions. Not having insurance means carrying the risk of going bankrupt after one unlucky event.

Don’t be so lazy as to argue that a marathon runner makes comparable choices to an overweight layabout. It’s just not true that people’s lifestyles are in aggregate equal. Health insurance companies know this and are legally forbidden to charge obese people more under the ACA. It’s cold hard actuarial fact.

Rather than trying to falsify reality to fit your moral viewpoint, try to argue why he should subsidise.

Marathon running is quite hard on joints, with an increased incidence of osteoarthritis. (There are also overweight marathoners, smoking marathoners, etc.)

> It’s just not true that people’s lifestyles are in aggregate equal.

Certainly, but there's an infinite number of combinations, and there's a serious risk to over-dividing the risk group. Pre-ACA, some folks found themselves shoved off into "high risk pools", which often made them functionally unable to access healthcare. Making folks uninsurable pushes them into more expensive (back to subsidizing!) emergency care, and causes them to delay treatment in ways that often exacerbate a treatable condition.

I suspect the folks here would riot if "sitting in a chair all day" wound up with a massive insurance penalty. Should eating meat come with an insurance penalty? Living in a smoggy city? Overindulging in beer?

Most marathon runners are terrible athletes who have terrible training goals and usually stop running due to self-inflicted soft tissue injury. This isn't expensive to treat since normally it's only rest is required to heal from ITB-syndrome or even shin splints. So they're rarely able to turn it into a lifestyle. Those who are able to continue probably are at a higher risk of osteoarthritis. I still stand by these people just cost less to provide healthcare for in old age (and I don't think there's selection bias at play here).

> Pre-ACA, some folks found themselves shoved off into "high risk pools", which often made them functionally unable to access healthcare.

Like I completely agree with this, that it solves this problem.

I was more so trying to raise the moral point about socialised healthcare (and I mean socialised in that loose sense) demanding a sacrifice from those who do take care of themselves. People are willing to suspend notions of natural inequalities to a point because most people still feel they live in a society. But there is a limit to this where people feel their burden is so disproportionate that they seek to emancipate themselves from it. The bonds of society are only so strong.

Except the "socialized" healthcare systems of Europe have half our total per-capita healthcare costs; the US is and has been abberantly expensive for decades. It's hard to argue this point when we've got a whole bunch of counter-examples disproving the theory.

You make it sound like there is a specific provision in the ACA that says, “thou shalt not charge the obese higher premiums.” There is not. Insurance companies are allowed to adjust premiums based on the insured’s age and whether or not they smoke, end of list.

The situation you’re advocating for (charge people based on their known risk at the time of policy issuance) is basically how insurance used to work, and it was dystopian. I literally had a doctor advise me to never get a certain test performed because I might become uninsurable. This state of affairs did not lead to ideal health outcomes.

Capped at a percent of premium revenue, which gives them the perverse incentive to raise healthcare costs so their 20% maximum cut gets bigger.

1) are these amounts tax deductible?

2) given the size of these amounts, OP’s statement that these are a big barrier to going independent would seem totally reasonable. Doesn’t this have a chilling effect on new business formation? If so, how is the US still so well known for startups? It seems significantly riskier than in other countries with better safety nets.

So... you have a job, but there's no employer-provided health insurance. You make $60k/year. Your adjusted income (after some deductions) might be, say, $45k. You decide to buy your own health insurance, and it costs you $500/month. That's $6k/year. 7% of $45k is $3150. So... $6000-$3150 = $2850 which would be the amount that you could avoid paying taxes on.

Confusing much?

> If so, how is the US still so well known for startups?

Because there's metric-ass-loads* of money here looking for places to be invested, and we idolize the unicorn homeruns so much so that we have entire industries catering to their ecosystem.

* Note, this is one of the few times we use the metric system in the US. 2 liters of coke/pepsi, and metric-ass-loads of <fill-in-the-blank>.

2. I believe it does and I can’t answer the other question with any confidence. Insurance was a big reason my mother kept her job which covered us as a family when my dad started his own business even though she was basically working two jobs because she was also helping with the new business after work.

1) Given the size of these amounts, why aren't you all marching on Washington with pitchforks? Your healthcare system is INSANE.

$10k in premiums going away with taxes going up $5k is heavily portrayed as a "tax hike" when universal healthcare is discussed.

^^^

This. This is somehow one of the most disingenuous things brought up during every discussion.

I think some people do it deliberately, and others are just not thinking very clearly when considering it at all.

"Death panels" was another one. We wouldn't want govt officials being able to say 'no' to some particular treatment, dooming someone to death. We're totally fine with unelected corp overlords with shareholder value as a primary concern making those sorts of treatment decisions. Of course. What could be simpler?

I'm convinced probably 2/3rds of the people against 'single payer' health insurance (or some variation of universal health insurance) are simply scared in to submission by misrepresentations. What also gets overlooked is having one system could mean you get health insurance whether you are employed or not. Everyone goes through spells of unemployment. Trying to tie health care decisions to coincide with periods where you can get "good" insurance through a "good" employer is unbelievably insane, but we've had generations of people brought up like this, and many believe it's truly the 'best' way.

keep in mind that PPOs for independents aren’t the same as PPOs for companies even though the appear to be.

let’s say you have blue cross blue shield PPO with your current employer it’s not the same even on the platinum level blue cross blue shield PPO.

fewer doctors in network. lots of mini surprises await you if you actually use it.

that’s such bs.

in a way i was personally better of prior to ACA since i could get insurance for $150/month. yes it’s nice that i can’t be disqualified due to pre existing conditions but it isn’t the meca it’s claimed to be.

Moving back to Australia looks better every year.

Expect to pay ~$300/mo for a catastrophic plan that covers essentially nothing until you meet an $8K deductible, and ~500/mo for plans that cover more.

Terrible system.

It's a bit depressing (but not surprising) to see any comment using dollars paying tons for limited service, and comments using euros pay a cut for everything

Or €100/month (€1200/year) with a €885 per year deductible (the legal maximum in the Netherlands).

I normally pay $550/mo for high deductible for me individually, but actually pay $42/mo right now because I wasn't making much money this year. ACA FTW.

I just got a job that comes with great insurance, though, so that's the end of all that.

That covers everything from biannual dental checkups, physiotherapy and any & all GP visits to chronic medication, oncologic immunotherapeutics or months long stays in an intensive care unit, etc.

Not gloating/bragging, our family didn't create the system. Just lucky to be born here.

* including all own risk/"excess"

Decent calculator: https://www.kff.org/interactive/subsidy-calculator/

As a point of reference, in 2015 I quit to go indie and decided to keep my employers coverage through COBRA. It cost me $1100 a month for my family.

I rode it out until my wife got a job later that year, since we couldn’t find independent coverage anywhere as good as my former employer’s.

This is a contract so terms can vary. Here: zero deductible, vision and dental included, international coverage including US. Includes a savings-like provision required by law. It is designed to keep rates affordable over time.

I switched to an ACA marketplace plan this year, and... there are no caps for 'out of network' services. "Out of network" deductible is $35k/person. "Out of network" max "out of pocket" is "no max". Insane. And this is a $1100/month plan for 2 people.

https://www.healthcare.gov/glossary/out-of-pocket-maximum-li...

"For the 2022 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $8,700 for an individual and $17,400 for a family."

However, above that it also says:

"The out-of-pocket limit doesn't include:

Costs above the allowed amount for a service that a provider may charge"

The way this has always worked for me is that if the billed amount is $1000 and the max allowed amount is $600, then $600 is what is owed and the rest is "written off" by the provider. If I haven't met the max out-of-pocket yet, I pay first. Then insurance pays $600 - what I paid.

But the way it is worded on the ACA page, it sounds like the provider can bill me directly for the $400 that was disallowed. That has never happened to me (Ambetter/MHS insurance in Indiana), and seems bizarre to have a max out-of-pocket that is not actually enforced.

It's capped for 'in network' stuff. But 'out of network' - the infamous phrase that... you can hardly ever really know ahead of time... it's 'no max'.

This is a plan purchased directly from the ACA marketplace, so either they're all in violation of their own rules or... the "in network" is all they mean.

And that 'out of pocket' is still sort of crazy because "premiums" don't count. Our premiums would be around $12k year, but then we can have another ~$18k of fees on top of that before. $12k PLUS another $7k of 'deductible' before there's any insurance kicking in (beyond 'negotiated discount rates').

Had an ER visit last year - $4k. Miraculously, with all the insurance I have (earlier, before the ACA plan), we still owed over $2k of that... Insurance 'negotiated rate' brought things down some, but $2k (plus another $600 for ambulance ride).

I really fear getting sick or injured here the older I get

Private medical offered to normal employees doesn’t really plug the gap in the NHS services

- Switzerland

- 2500CHF / Year deductible

- 1 person

- ~30yo, good shape, no smoking, a beer now and than, office job

this is just the health insurance, here in Swiss we a shitload if insurances.

FYI the english term for that is “excess”

Public + private spending; the US spends $12k/person, the Swiss $7k.

The US is roughly double or more than any other developed nation in per-capita healthcare spending.

Taxes in Euroland are already quite high. That money is going to have to come from somewhere and likely will eat into your public healthcare budgets.

A quick google[1] reckons people on low incomes spend as much as 35% of their income on healthcare alone, before pay any taxes. You need to be earning a lot in Europe before you get even close to that.

If you're on a low-to-average income then Europe is probably better. If you're rich then America is better.

[1] https://www.advisory.com/daily-briefing/2019/05/02/health-ca...

Many (most?) people on HN are highly-skilled, highly-paid technologists and likely the latter.

Ideally (from the farmer's POV) you will utilize every part of the cow. Lips to lungs. Which is to say, rent will be collected on every single facet of existence.

It's like being wrapped in a rent-absorbing membrane. A rent-stomach.

This business charges exactly what the market will bear. Not what servicing the "biological need" actually costs them.

But that's obvious.

It's like charging for air.