Hey all, I’m British so I don’t really know the ins and outs of the US healthcare system. Apologies for asking what is probably a rather simple question.
So like most of you, I see many posts and gofundmes about people having astronomically high medical bills. Most recently, someone having a $27k bill even after his death.
However, I have an American friend who is quick to point out that apparently nobody actually pays those bills. They’re just some elaborate dance between insurance companies and hospitals. If you don’t have insurance, the cost is lower or removed entirely. Supposedly.
So I’m just asking… How accurate is that? Consider someone without insurance, a minor physical ailment, a neurodivergent mind and no interest in fighting off harassing people for the rest of their life.
How much would such a person expect to pay, out of their own pocket, for things like check ups, x rays, meds, counselling and so on?
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I’ll put it this way:
At least 68,000 Americans die every single year due to not being able to afford healthcare.
We pay an extra $450 BILLION annually to enrich unnecessary middlemen and ALL of our politicians are being bribed (or primaried) to prevent Single Payer. You’ll hear people like Kamala and Warren talk about “access” to healthcare while they receive massive bribes from healthcare companies to pull support away from Single Payer and offer a “choice” or “access to health care”. Remember 2016 and 2020? The DNC pulled out all stops to prevent Single Payer. Remember when Bloomberg ran for office and claimed , “under my governorship, New York had less uninsured people than at any time in history” while failing to mention that he enacted steep penalties for being uninsured? That’s neoliberal gaslighting 101! Kamala loves to do it too! But yeah vote for her because she’s “one of the good guys” and certainly wasn’t one of the people that was tasked with preventing Bernie Sanders from winning the primary two cycles in a row, offering “Medicare for All who want it” so stacked with asterisks and legalese means-testing that probably like 50 people would qualify.
Edit: In my opinion, anyone who is paid to run for office and vote against Single Payer is a murderer guilty of (or at least partly responsible for) the slow, often-painful execution of these 68,000 American citizens per year.
I have student loans that I’d love forgiven but I don’t even mention that issue because true Single Payer (and Gaza obviously) are my moral lines in the sand that almost everyone in Congress except Rashida Tlaib has brazenly trampled.
https://www.sanders.senate.gov/wp-content/uploads/Fact-Sheet_Medicare-for-All-2023.pdf
In 2017, Harris was the first senator to co-sponsor Bernie Sanders’ bill, the Medicare for All Act of 2017. “Here, I’ll break some news,” she said that year at a town hall in Oakland, California. “I intend to co-sponsor the Medicare-for-all bill, because it’s just the right thing to do.” 15 other Democrats eventually joined her.
That bill, if enacted, would have abolished private health insurance for all age groups (including Medicare beneficiaries) and replaced it with a government-run single-payer system to benefit “every individual who is a resident of the United States,” including undocumented immigrants.
https://www.forbes.com/sites/johngoodman/2024/08/13/why-health-policy-problems-rarely-get-solved/?
yeah too neolib, better to stick with Trump, he’ll really get the single payer socialist healthcare going with the fascism and stuff, cause he really cares about people. /s
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You’re the one telling people not to vote for her.
That’s neoliberal gaslighting 101! Kamala loves to do it too! But yeah vote for her because she’s “one of the good guys” and certainly wasn’t…
Until Nov 2024 she is the only option. She’s not perfect but now is not the time to seek a perfect Bernie. Political realities matter. Criticism is fine but anyone saying “do you really want to vote for her” is either a Russian mouthpiece or very clueless.
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And regardless of differing opinions, calling someone an asshole and moron is not at all condusive to productive discussion, and is downright rude and disrespectful.
How does that help anything? We’re both for single payer healthcare as a human right, and support for the neolib right now is quickest path to get there. I don’t like it either, but infighting only helps fascists.
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You do realize she literally cannot win, right? Check back here in mid November.
Ok
HI! Was I right?
@RemindMe@programming.dev 87 days
I read something from last year that said about half a million Americans go into bankruptcy due to medical debt each year.
That’s it, that’s what happens. You lose everything and you start over, if you’re healthy enough.
Protect your NHS.
The real truth of what happens is substantially more complicated due to America being made of 50 states. The medical debt numbers are highly debatable (Related Snopes) and do not account for Regional differences. In some states such as New York there are catchalls/emergency funding so that usually anyone making below low six figures can get their bills paid. Other states make collections difficult such as New Jersey not allowing reporting to credit agencies, making ignoring a debt kind of a non-issue. Then there are states such as Florida that require the barest of insurance to keep rates low and provide no patient protections, so when an accident does occur out of pocket costs can be huge as your insurance covers nothing. In all these events the Hospital assumes that big pocket insurance is paying first so they break out the expensive menu, when they realize they can’t get blood from a stone they are grateful if you cover their wholesale price.
Funny you should mention New York actually, that’s where my friend lives so I guess it explains why he thinks it’s not that bad.
Thanks for the reality check. It’s definitely a horrendous situation to have a for-profit medical sector, whatever the exact figures are.
Luckily there doesn’t seem to be any large desire in the general population to move away from the NHS. Even the most conservative people I know support it (and I live in a pretty conservative area).
Some of our political parties however seem to pretend like they support it while quietly trying to undermine it. Let’s see what Labour do in the coming years.
Undermining it is how conservative parties will get rid of it. Keep decreasing funding. Do more with less. Quality drops. Wealthier people start moving to health insurance. Jobs start offering health insurance. Funding decreases further. People start to wonder why it’s even needed.
about half a million Americans go into bankruptcy due to medical debt each year.
That’s a huuuge shame for a country that calls itself civilized and developed etc.
Nobody sane who lives there calls it that
Because otherwise they do …what…to him? :)
But yes, I have heard some people from there who understood it right.
Have those people actually lost everything or is it just some scheme to pay less?
Bankruptcy is an expensive and not-fun process. Basically, similar to what happens on death all creditors are carefully listed out and prioritized, assets beyond the bare minimum to live are liquidated to pay creditors what they can and of course the bankruptcy lawyers fees don’t help with the mountains of debt and costs. Certain debts cannot be discharged through bankruptcy so basically you trash your finances, mental health and credit for a shot at maybe being able to fix your finances with less debt payments
https://apnews.com/article/medical-debt-legislation-2a4f2fab7e2c58a68ac4541b8309c7aa
I’ll let you figure it out.
Some people kill themselves (either actively or by refusing treatment) so that their families won’t be in debt and will have a place to live, that’s how lost everything it can get.
WILDLY depends. And it is never simple.
If I break an arm, and I go to the hospital, and there’s not much that’s done aside from a cast, and some PT at the end, I pay $0.
Now, what does that mean?
We have had our insurance for a long time, and as we pay our monthly premiums, a little money goes into an account called an FSA. This pays some of the co-pay, deductibles, etc. in the background for us.
What happens if I get cancer and need to have some care for 7 years? Eventually that FSA runs out. Every insurance has a deductible that you pay before they start paying for everything. So we might have to pay $5k out of pocket annually and then insurance pays the rest.
What if I need to travel to another city to talk to a specialist? There might be airfare, hotels, food, etc. that we pay that is “part of the treatment” but not paid for by insurance.
What if I need medication? Might be $25 every trip to the pharmacy. Might be $300. Depends on the medication, how new it is, are there cheaper alternatives?
What if I get sick long enough where I lose my job? I might lose my insurance as well, and then have to apply for government assistance, that might make other medical bills different.
I assume you need to have health insurance? As in, you mention paying 0$ if you break your arm. But do you have to pay monthly premiums for it to be 0 at the hospital ?
And I have no idea but - presumably you would claim on the insurance for the broken arm, does that then impact your monthly premiums or coverage afterwards?
As part of our employment, our employer has negotiated that we pay $400 a month for my family to have insurance under these terms.
If I had a different employer, those terms could be wildly different. I would have no choice.
It is EXTREMELY complicated, and extremely different for everyone in the country, and depends heavily on how your employer sets up the benefits. This is a major benefit for large corporations, and a major burden for smaller businesses.
If you buy insurance through the private market, it is usually far more expensive, but often subsidized by the government, since you often only buy from the market if you are unemployed or low income.
you often only buy from the market if you are unemployed or low income.
Don’t forget self employed or at a workplace with workplace insurance so bad it’s actually cheaper to go through private (so basically low income)
I know multiple small business owners who also have a regular corporate job JUST so they have insurance. The whole second job has nothing to do with salary, only health insurance.
Every family farm I know, the husband works the farm while the wife works a normal job for insurance and stable base income to help keep everything afloat
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I don’t contribute to the FSA, that’s an automatic part of my health insurance.
Some people contribute separately to an FSA or an HSA depending on their insurance, but that’s not an option for my situation.
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It’s understandable, the people I work with get them mixed up all the time.
The nice thing about an FSA is that I don’t pay any extra for it. The bad thing is that if I cancel insurance with this company, or change jobs, I lose that built up money and need to start over.
An HSA stays with me, but it requires extra deposits, and more work on the back end to get reimbursed for expenses.
If you have insurance through your employer, then no the insurance company can’t raise your rates. And part of the reason for the Affordable Care Act (ACA, sometimes called Obamacare) was to make it so people who are getting the insurance themselves also can’t have their rates raised or get turned down for insurance because they have pre-existing conditions. However insurance companies can raise everyone’s rates when the insurance is up for renewal each year.
Most insurance plans have several different costs: 1. The monthly premium you pay to have insurance coverage. Some employers pay this themselves, otherwise it gets taken out of every pay check.
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Co-pay: Usually a set amount ($30, for example) you pay to see a doctor for office appointments that aren’t an annual check-up*. So say I get an ear infection and see my primary doctor to get it treated, I’d pay the co-pay for that visit. Sometimes things like x-rays, blood work, CTs can be a set amount, other times it’s something like insurance will cover 65% of the cost. For some plans, co-pays are included when figuring out if you’ve reached your deductible.
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Deductible: The amount you have to pay before “co-insurance” kicks in. Co-insurance being the percent of your bill insurance will pay (for us it’s 75% after we pay $3500 in a calendar year).
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Out of pocket max: When you’ve spent this amount in a calendar year after that insurance covers 100%. Often plans have both individual and family maximums, with the family amount being higher.
Usually the more you pay in monthly premiums, the lower your deductible and out of pocket maximums will be. So each year people have to try and decide what they think their health bills will be next year when picking their plan (you can’t change plans mid-year unless something happens like changing job, getting married/divorced, having a kid). If you’re pretty healthy you might pick a lower monthly plan with higher out of pocket amounts because you don’t expect to have to pay much out of pocket. If you’re someone with a chronic condition or you’re expecting to need surgery or a costly treatment you might go with the higher monthly plan so you don’t have as high of out of pocket amounts.
For example, my spouse had to go to the ER a few years ago for what turned out to be a collapsed lung. They didn’t have to stay in the hospital overnight. I forget the total bill (or I’ve just blocked it from my memory), but our part ended up being about $5,000. Insurance kicked in after the bill got to $3,500, and they covered 75% of everything that was over $3,500. The most we would’ve paid was $6,000 (the individual out of pocket max), however we would still have to pay bills for myself and our kid up to $12,000 (family out of pocket max).
*Another part of the ACA was to make annual preventative screenings (like annual physical, mammogram for women over a certain age, prostate screening for men, etc) free.
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And not to forget that sometimes cheaper but equally effective drugs aren’t available under the insurance plan. Like auto insurance and their prefered shops and stuff.
Oh plus that FSA must run out really quick when private hospitals charge bug money for an aspirin because they trying to gouge the insurance company who probably doesn’t even care for other twisted reasons.
Not always. There’s still a max annual out of pocket expense, which is what is covered by the FSA. A single event, or an illness or accident that only requires care for a single year or two, regardless of how expensive, would not deplete the FSA. It’s only a chronic condition that requires hitting the max out of pocket for multiple consecutive years that would start to deplete that buffer.
That’s all assuming that I can continue to work, and don’t have any other non-medical expenses during the recovery.
“However, I have an American friend who is quick to point out that apparently nobody actually pays those bills. They’re just some elaborate dance between insurance companies and hospitals. If you don’t have insurance, the cost is lower or removed entirely. Supposedly.”
Partial Truth.
Healthcare providers have negotiated prices for services. These prices are negotiated per insurer.
Blue Cross and Blue shield will pay them X dollars for Deep Sleep anesthesia. United Healthe care will pay them a different amount. Medicare will pay them yet a different amount. Bob’s backyard healthcare will pay more because they don’t have buying power.
If you walk in without coverage, the provider “can” charge you a reduced rate. They are not required to. They do NOT universally offer that.
If you get the procedure done anyway, agree to pay and cannot pay your health bill, the provider “can” just let you off the hook or reduce your rate. They do NOT usually do that. That’s the exception.
If you go to a provider that accepts your insurance (they all do not) and book a procedure, the provider has to get the procedure covered by the insurer. If the insurer decides not to cover the procedure, you can call the provider and try to create a grievance. The back-and-forth is maddening.
My local doctor said I needed a colonoscopy (it’s just that time, no emergent issues)
My insurer authorized the procedure but not the anesthesia.
The office offered to pay out of pocket for the anesthesia ($1200), but I declined because I couldn’t afford it. They also offered to set up payments if I paid 50% upfront, but I declined because that didn’t help me. I can’t take on another $100 / month for 12 months.
I spoke with the GI doctor, a second GI doctor, and my General Practitioner. They all said that people here really don’t get the procedure without anesthesia, and it was a bad idea for both the doctor performing the procedure and for me.
I contacted the insurer, but they refused. Another GI doctor contacted the insurer, but they refused.
My insurer decided in January that they will not cover anesthesia for a colonoscopy unless someone can prove you’re frail enough it might kill you.
We have federal laws that mandate insurers to cover the anesthesia for this procedure, but state-level insurers (hint: they’re all state now) don’t have to follow their rules.
So here I am, two years late for a colonoscopy, wondering if I have pre-cancer or cancer brewing down there, but can’t manage to pay for what is considered by all providers here a necessary part of the procedure.
It’s not great here.
Plus all of that negotiating is baked into the end costs which is why in the US on average we spend twice as much on medical care with worse outcomes and not everyone is covered.
The insurance companies having more say than doctors about what procedures you can and can’t get is peak insanity, and yet here we are.
You need to consider your health first and only. You get the anesthesia and then you either ignore the bills or pay a little bit what you can. Either way eventually you’ll be able to close it out by paying maybe half.
Alternatively, you can tell the doc to either give you the anesthesia for free or go with the insurance attitude and have the procedure without it and - should something go wrong because it is not what you are supposed to do - then you have yourself a juicy malpractice suit for them.
The investors who make money from this bullshit write our laws. That’s the problem. We allowed it to happen by having such dumb fucking morons for citizenry who vote for these monsters who then turn around and rape them. And then they vote for them again. Our people are mostly absolute morons who can’t think for themselves and so they follow the shiniest trinket they obey the loudest voice with the bleached smile and the most promises.
And yes, conservatives are to blame and yes, there are awful liberals as well but the simple truth is republicans need to fucking die. They are a deadly cancer to our society because all they do is ruin everything except their own pockets.
Doc will not provide anesthesia for free. The insurance company will not budge.
I’m not in a situation where I can just keep hopping over doctors while they all send me to collections, even though $600 is too much to swallow at the moment.
If I do end up with any form of GI cancer, a lawsuit against the insurer seems pretty reasonable.
The people here already spoke of the option of medical tourism, can’t you look up that ? A colonoscopy is not some advanced tech, any decent hospital in latin america will be able to do that. Since you earn US dollars, you could research about making a trip to Mexico (possibly the cheapest option, because it can be done by bus or car), Cuba (possibly the cheapest too, because of the conversion rate and short plane distance), Brazil, etc for the travel, lodging and procedure (and even a little tourism too if you have the time and will XD ).
I’m mid-atlantic. Procedure + flight + basic accommodation is still around 2/3 of the anesthesia. Medical tourism works well when you’re uninsured or when the whole procedure isn’t covered. Sadly, I’m already paying a fortune for the insurance. It’s a mid-high plan Blue Cross. F’ing insane they’re taking this line.
I’m really sorry for your situation. I would personally just get it done, commit to paying them and then just stretch it out maybe a few bucks at a time. Your health is more important. But I do wish you the best of health.
I was on Medicaid for many years but I’m really lucky now my wife is in the teachers union and we have very decent insurance. But the entire system is a big stinking chaotic farce to which the terms “broken” and “mayhem” are even too light to apply.
But as long as our government is in the employ of the 1% nothing is gonna change. We seriously need to start stringing up some billionaires and take their money for everyone.
I have Blue Cross and Blue Shield. a mid-upper tier plan. They just decided to stop covering this.
WTF? I have to say this makes no sense to me. I think you need to double and triple check, try another facility perhaps? Something. To cover a colonoscopy but not anesthesia is unheard of, and even freakin Medicaid would pay for it.
https://www.anthem.com/dam/medpolicies/abcbs/active/guidelines/gl_pw_a050126.html
Anthem BCBS classifies it as not medically necessary so they will not pay for it since April of this year.
Jesus. That’s disgusting.
Edit: Hang on I just skimmed that document it seems to indicate it IS considered medically necessary.
Edit edit:
* Prolonged or therapeutic endoscopic procedure requiring deep sedation such as endoscopic retrograde cholangiopancreatography (ERCP) or repeat colonoscopy due to tortuous colon; **or** * A history of or anticipated poor response due to cross tolerance or paradoxical reaction to standard sedatives used during moderate (conscious) sedation specifically due to narcotics or benzodiazepines; **or** * Increased risk for complication due to severe comorbidity (American Society of Anesthesiologists \[ASA] class III physical status or greater. See Appendix for physical status classifications); **or** * Individuals over 70; **or** * Individuals under the age of 18; **or** * Pregnancy; **or** * History of drug or alcohol abuse; **or** * Uncooperative or acutely agitated individuals (for example, delirium, organic brain disease, senile dementia); **or**Uncooperative or acutely agitated individuals. Tell the doc to tell the insurance that it makes you crazy without it and you can’t tolerate it. Jeez is your doctor new at doing these things? That’s what they do they submit whatever criteria is accepted that they don’t have to prove with charts.
I work for one of the largest healthcare providers in the US. I pay $450/mo for health insurance. This is not including vision, dental, or money I set aside for FSA (a pre-tax savings account restricted for use for paying for healthcare) and for and HRA (similar to FSA, but intended for when you’re older, and our company partially matches our contributions). The FSA has been refusing to pay for legitimate doctor visits that insurance has sanctioned. I pay out of pocket for a lot of procedures that the insurance ducks, such as laser eye surgery, vasectomy or even for birth control pills prior to the vasectomy.
The laser eye surgery was ~$5,000 out of pocket, the vasectomy was ~$2,000.
I had a visit to the ER - I was driven by my partner to avoid ambulance costs, and with insurance, had to pay $450 only for the doctors to stay they couldn’t figure out what was wrong and I end back up there later that week for another $450.
I was in a car crash a few years ago and my medical costs (again, with insurance) came out to ~$250,000.
This is while making $85,000/yr working as a Senior IT Engineer, and paying $2,700/mo for rent.
Generally speaking, with insurance, we’re probably paying about twice as much for any given situation, but insurance itself is also expensive and likes to dodge paying for as much as possible.
Thanks for the info! For a comparison I’ll give you mine:
Switzerland has the worlds second most expensive healthcare system, also with private insurance providers. There are some differences to the US though. Having health insurance is mandatory and there are state contributions for people who couldn’t afford it otherwise. And we have a certain defined level of base insurance with defined coverage that the insurers all have to offer and that you can’t be denied for.
Anyway I pay $480/mo for mine, which has a few extras over the base, like sharing a room with only one instead of three people in a hospital stay. I haven’t used it much though, so I can’t tell you from experience what sort of co-pay I would be looking at, but I believe it’s capped. https://www.bag.admin.ch/bag/en/home/versicherungen/krankenversicherung/krankenversicherung-versicherte-mit-wohnsitz-in-der-schweiz/praemien-kostenbeteiligung.html
This is while making $85,000/yr working as a Senior IT Engineer, and paying $2,700/mo for rent.
Oh shit, I thought IT people in the US made more than here in Switzerland?! Or is that only in specific areas of California?
I live on the outskirts of Zürich and rent for our 3 room flat is $3’200/mo. However, I started on about $100’000/yr as a Junior Network Engineer directly after completing my master’s degree in Computer Science in 2021.
What the heck? Hire me. Can I work remote from the US?
I had a vasectomy this year, it came at a negative price for me as food and three days in hospital were covered.
That’s what I said, but of course I paid a little for it out of my salary.
i have to pay ~1000/month just so i can walk in their front door of the hospital. after that, insurance companies do everything they can to not pay my bills.
america absolutely fucking sucks. insurance companies only make money when human beings suffer. think about that for a minute, their profits are literally built on the back of human suffering.
If you are and remain healthy it is very expensive. If you get sick or injured or ill
It costs more than you have
On average they actually spend $12.500 per year (total, PPP adjusted, at leat that’s the number for 2022)
https://en.wikipedia.org/wiki/List_of_countries_by_total_health_expenditure_per_capita
You as a Brit spend $5.500 (also adjusted) (And as a bonus, at the same time you’re also expected to live 2.8 years longer than the average American.)
Plus the Brit coverage is universal while the US has a significant number of uninsured. We pay double on average including for those that aren’t covered at all. Even though the long lines myths are overblown for countries with universal care, it is important to remember that in the US a lot of people never get the care and we still have massively long wait lines unless we can afford to be first in line. The wealthy have a fast pass.
it is important to remember that in the US a lot of people never get the care and we still have massively long wait lines unless we can afford to be first in line
This is really important for non-Americans to understand. Yeah there are waits to see specialists and so forth in countries with a public system. We also have waits…but it’s for people who can’t afford the procedure. They have to wait until they can afford it, and if they can’t they simply have to live with their condition indefinitely or until it’s bad enough that they go to the emergency room. People who are uninsured go to the emergency room for everything because, legally speaking, they can’t turn you away. They have to at least diagnose and stabilize you. Because these people are broke, they generally end up not paying the bill, which means everyone else’s costs go up.
You couldn’t devise a worse system if you tried.
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The United Kingdom provides public healthcare to all permanent residents, about 58 million people. Healthcare coverage is free at the point of need, and is paid for by general taxation. About 18% of a citizen’s income tax goes towards healthcare, which is about 4.5% of the average citizen’s income. Overall, around 8.4 percent of the UK’s gross domestic product is spent on healthcare (an amount of around 0.18984 trillion GBP). UK also has a
growing private healthcare sector that is still much smaller than the public sector.( http://assets.ce.columbia.edu/pdf/actu/actu-uk.pdf )
So it should be more like £1.200 for you?!
And I think the study I linked is total healthcare expenditure. So it also covers the extra private insurance and the medication you buy that isn’t covered at all. I’m not 100% sure.
But yeah, that’s how statistics works. For everyone who pays less than the average, there has to be someone who pays more than the average. And I also think it should work with solidarity. Rich people can afford to pay more.
I spend more than that just for insurance for two. Actually using it costs far more. Strep? $250. Video call a random person when I’m in bed after puking my brains out? $100 for a five minute call where they tell me to drink water. Minor surgery? Thousands of dollars in bills sent between two months and two years after the surgery.
I really wish you people that it’ll become better one day. It’s just a rip-off and and a way to funnel money from normal people to the rich. Looking at other countries, you could do away with the scary bills. And on top have an extra free $5.000 each year. Per person. And I think it’s extra cruel to rip off people with their health.
I have (what I believe) is considered “very good” insurance. I pay $100 a month for premiums.
When my child was born, there were some complications and we needed to move to another hospital for emergency surgery.
The birth: ~$2500 deductible/copay/whatever you want to call it. I think this is all I would’ve had to pay if there weren’t more complications.
Surgery and aftercare for baby: ~$5600
Care for momma: ~$2000
But here’s a crazy twist. When moving hospitals, we rode in an ambulance. But this was an “out of network ambulance”. What the hell is even that? Under what circumstances do you have a say in which ambulance you ride?
Out of network ambulance ride: $4500
Basically it’s all just bullshit.
Yea ambulance companies fucking suck. they never contract with insurance so they’re free to bill whatever the fuck they want. Buncha predatory assholes charging thousands for a ride and paying EMTs barely minimum wage.
So did you have to pay all of this? (~$14600 if i did the maths right) Or can you negotiate?
You can negotiate, demand itemized bills, request a payment plan, etc., but there’s no actual guarantee that those will be useful, and it can be a bit of effort. Sometimes your insurance also should cover something that they won’t pay for, but getting the money from them is like pulling teeth.
TL;DR: You can fight the system, but no guarantees.
I called the insurance company about the bullshit “out of network ambulance” and they said they would “negotiate on our behalf”, apparently. In the end we paid about $2200 for the ambulance if I remember right.
Everything else we paid sticker price. Fortunately I had some money in an HSA from a previous job so that helped.
(For people reading this who live in more civilized countries: an HSA is a special type of account where you can put money and not pay taxes on it, with the caveat that it can only be used for health expenses. It’s similar to the much more common FSA, but with an FSA the account balance is reset to zero at the end of the year (not sure if the money goes to the government or the brokerage or what). This has led to a new absurd “FSA store” industry, where places sell only FSA-eligible items at a very high markup, with the idea being come December you’d rather buy their overpriced shit than just lose all the money outright. An HSA does not suffer from this nonsense (you keep the money indefinitely, because it’s your money), but it seems like it’s becoming more rare for an HSA to be offered on employer plans.)
You may have heard about “Obamacare” or the “Affordable Care Act”. This did a lot of things which helped some but also did not do much.
For example, insurance premiums can cost hundreds of dollars per month, but if you get subsidies you can reduce that cost down to, potentially, zero. Unfortunately these subsidies are in the form of tax credits, which means if you don’t work you do not get any subsidies.
Additionally, if you happen to live in a red state, then your state probably didn’t expand Medicaid. Medicaid is the government insurance for poor people. If your state didn’t expand it, then your state only gives Medicaid to families and disabled people (basically). So if you don’t have kids, you don’t qualify for it.
For me, this means that when I stopped working and got insurance through the ACA, I had to pay $500 per month in health insurance premiums (dental and vision are separate insurance plans and not typically covered in standard health insurance). Did I mention this was while I wasn’t working?
With that $500 per month, I still had a $900 deductible (so I had to pay $900 before the insurance company would pay anything). After that $900, my insurance company paid different rates depending on the service (often called coinsurance). A common percentage is 80/20, which means insurance will pay 80% and you will pay 20%. So hospital bills tend to be thousands of dollars. BUT insurance plans also have what’s called an “out of pocket max” which means your insurance will cover services at 100%. So any medical things you do after that magic number are basically free for you (you still have to pay the premium).
Ok, but you might have also heard that elderly folks have their own government insurance - called Medicare. Medicare is also available for disabled people like me.
Medicare is confusing AF. It has multiple parts to it - I will only talk about what’s called “traditional Medicare”, which basically means everything is between you and the government (There’s other Medicare plans through private insurance companies, and those plans are similar to what I described above).
So with traditional Medicare there’s Part A (hospital), Part B (basically outpatient services), and Part D (prescriptions). Part A is free for most people, part B currently costs about $75 per month, and part D varies but is much like the private insurance above. If you only have part A, then only hospital visits will be covered. If you only have A and B, then none of your medications will be covered! It sucks.
So remember how I said about the deductibles and coinsurance? So Medicare has their deductibles and coinsurance separate for each part! For my part A, if I go to the hospital, it comes out to about $1300 per DAY, but only for short hospital stays. Oh and that’s only for room and board. Longer hospital stays have different rates. Also, if you stay in the hospital too long, it starts going against your lifetime hospital days. That’s right, if you use up all your lifetime hospital days, then Medicare will just…not cover your hospitalization anymore. Ever. For the rest of your life!
And don’t forget you still have to pay extra for any imaging, medications, and doctor visits you had while in the hospital because the daily rate is basically for the bed.
Part B is a straight 80/20 coinsurance. But part B also doesn’t have an out of pocket maximum. So if you have a lot of outpatient procedures, then you will end up paying out the nose for it. Currently I basically just end up paying around $30 for each doctor’s appointment (not including lab work or any procedures).
Part D depends on what plan you get. Mine was basically 80/20, which means I was going to have to pay outrageous amounts for medications! I’m on like 25 medications and it was going to be hundreds of dollars each month just for the prescriptions. Luckily, we have programs like GoodRx! Which is basically a coupon but for medications. Unfortunately, you can’t use insurance if you use GoodRx. Also, the pharmacy won’t usually automatically compare the prices to see which method would come out cheaper for the patient. Oh, also, each pharmacy has a different price for the same medication! I’m not even talking a few dollars. Some medications can be hundreds of dollars different in pricing depending on which pharmacy you go to! And it’s not consistent either. So basically if you’re on Medicare you get to go on GoodRx every month for each prescription and see where you can get it the cheapest at and then either ask your doc to send it there or try to get it transferred. Imagine doing that with 25 prescriptions every single month!
Luckily for me, I qualify for what’s called “Extra Help.” This program pays for my Part B premium ($75) as well as part of my part D premium (it was about $100 but with the help it’s down to $75). They also bring all my prescription costs to $1.55 per medication per month. Unless it’s a brand name medication… 😬
If you’re following, when I had private insurance I was paying $500 per month in premiums alone, plus about $50-100 per month in doctor’s visits, plus about $50-100 per month in prescriptions until I met my out of pocket maximum. Then just the premium.
Nowadays, I have Medicare + Extra Help. So I pay $75 per month for my prescription premiums, plus currently about $200/month in doctor’s visits, plus about $50/month in prescriptions. So it comes out cheaper currently but if I have to go to the hospital again…well, I’m fucked.
By the way, most insurance plans do not have out of network coverage…so if you go somewhere that doesn’t have a contract with your insurance company then you will probably have to foot the bill. And a lot of the charity programs that hospitals and doctors have won’t let you apply if you have insurance soooooooooooo…
A few years ago, I went to a treatment center for a few months. My total bill was almost $200,000. My personal portion was supposed to be around $15,000. Did I mention I wasn’t working? Right. Luckily the treatment center enjoys the tax benefits they get when they write off people’s bills, because they wrote mine off. I still had to file for bankruptcy though, because that wasn’t my only medical bill.
PS insurance is often provided by your job here so if you lose your job you, at maximum, have until the end of the month with your insurance :) so don’t quit your job at the end of the month ;) there is a thing called COBRA which is supposed to bridge the gap between jobs, but it’s usually something ridiculously expensive like $700 per month for a single person’s premium (yeah, you have to pay more premiums if you want your spouse and/or kids to be covered).
Decades later I feel the biggest thing Obamacare changed was pre existing conditions. What I grew up with would horrify an 18 year old as much as what we have now horrifies a European. But yeah I’m pissed we couldn’t get single payer back then
Absolutely agree. I was a teen when it passed so did not really experience beforehand. But now I’ve been looking at pet insurance and the preexisting thing is crazy! I don’t know if it’s the same as it used to be for us, but the pet stuff is set up so even if you had one company the entire life of the pet, if you try to change companies the new company won’t cover any issues that the old company did because now they are pre-existing 😒 and a few months ago an insurance company dropped like everybody from their company so they couldn’t really get a new plan because now everything is preexisting. And it wasn’t even their choice to move. I think only 1 company allowed people to switch and honor what the old company covered.
Not to mention for us, long term disability insurance also doesn’t cover preexisting conditions. I think most life insurance doesn’t either.
In addition to the actual costs other people are talking about, the mental costs of dealing with the system are inmense.
You have to update your information whenever you change your job. It’s not like your social security number that’d given once and you memorize.
Every year you probably have to review your insurance options and pick one. This is essentially gambling- if you pick a low cost one you save money, unless you actually need to use it.
You probably need to find doctors that are “in network” or pay a lot more.
Sometimes bills are sent directly to you and that’s a mistake. But sometimes you’re supposed to pay and be reimbursed.
You typically don’t know what the costs will be up front, so you have to guess what the best option is. Take a nasty spill on a bike? Is it worth calling an ambulance? Does your insurance cover that? Maybe just walk into the emergency room. But does your insurance cover that? Maybe just call a regular doctor?
In short, there’s a lot of stuff you have to think about as the end user. I’d rather it was just “oh shit you’re hurt, let’s take you to the doctor. Don’t worry about money”
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Was that pre ACA? When we had our kid, we only paid a $175 hospital stay copay. Granted… we’re very lucky with the insurance coverage provided by my employer, but we were under the understanding that the reason we didn’t have OBGYN copays and otherwise throughout the pregnancy was because the ACA made sure it was covered.
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On top of your premiums, any insurance through a job means the job is paying thousands of dollars a year to insurance instead of paying you on top of what you paid.
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I think you may have read that backwards.(didn’t see edit till I finished posting so I’m keeping the rest)If the plan is ‘good’, then the part the employee ‘pays’ each month is low and could be in the hundreds each year before paying for any care they actually receive. But the employer is shouldering the rest of the costs behind the scene as part of the cost to employ. That means whatever they spend on insurance is money not going to your income so it really doesn’t matter if it is paid directly by the employer or employee, that is all smoke an mirrors.
As an example for state employee plans from 2020:
While health insurance premiums varied greatly across the states, the average per-employee per-month premium was $959; states paid an average of $805 (nearly 84 percent) toward premium contributions.
This means the insurance company is collecting $959 dollars per state employee per month just to have them on the plan ($11,508 /yr) -The state is paying $808 per month ($9,696 /yr) -The employee is paying $154 per month ($1848 /yr)
This is all before office copays, medicine, emergency room copays, hospital bills, care clinic visits, and any service where you pay something to access service. This is generally decent to good insurance in the US and we pay well over the cost per person in other countries just to be insured.
To drive home that this is not an outlier, this is the cost that each country spends on health care per person United States $12,555 Switzerland $8,049 Germany $8,011 Norway $7,898 Netherlands $7,358 Austria $7,275 Belgium $6,600 Australia $6,597 France $6,517 Sweden $6,438
Everyone in Sweden is covered for healthcare, they don’t need to pay at the point of service, and they spend about half of what the US does on average including the uninsured.
I had an explosive migraine a couple years ago and went to the emergency room because I thought I was dying. I had to wait for about 3 hours before being seen. Once I was seen they did a brain x ray and gave me an IV migraine medication. I had a bad sinus infection and inflammation that was pressing on facial nerves and triggering the migraine. They told me to take Claritin and sent me home.
After about a month I got the bill, over $8000. I forgot what my “good” insurance paid to the hospital but my part of it was $8k. For an x ray and IV. They also charged $200 for IV hydration which I didn’t ask for or consent to, and didn’t need because I keep myself well hydrated always.
Also it turned out that this infection was bacterial because about a week after I went to the hospital I started getting 103-105°F fevers. I then went to an urgent care and had to pay $180 to get told that I need to wait at least 3 weeks with the infection before they will treat it with antibiotics. So I suffered like that for another 2 weeks and finally got antibiotics from a different place. The nerve pain I got from that infection was unlike anything I’ve ever felt before. I was literally screaming and thrashing around, completely delirious with fever and pain and my wife trying to keep me alive. I fucking hate this country.
Oh I just remembered, I also got sent an additional $300 bill for the specific doctor I saw at the hospital. Yeah that’s a thing in a America too. You sometimes have to pay both the hospital you went to and the individual doctor who saw you, separately.
Okay, so the American system is an employer based model, meaning that your health plan, if you have one, is determined by your employer. This means a few key things:
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Your plan may (and probably does) vary wildly in nearly every regard from someone else’s despite both of you being with the same insurer.
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You are not the customer, but the user. Your boss is the customer. As such, the insurance company doesn’t really care if they piss you off, because you can’t just fire them and go with some other plan. They only care about not pissing off your boss. Well, you can technically, but individual insurance is so expensive and bad (and there’s only a few big players in the market anyway) that it’s an obviously better choice to just get jerked around by your employer’s plan.
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The entire healthcare payment process is so arcane, unintuitive, and complex that no lay person outside the system can be really expected to navigate it if someone says “whoops, we’re not paying because the florp code was misapplied during Venus Wednesdays, and though you flipped your florp last month, some businesspeople made a deal just last week to agree that florps will only be covered by approved Todds (the closest is a convenient 600 miles from you). This judgment is final, may God have mercy on your soul.” As an example, I’ve had insurance pre-approve something and then turn around and deny it once it got billed, and because I didn’t think to get physical proof of pre-approval first, the insurance basically just ended it with “nuh uh, we never said that, do you have a receipt?” Lesson learned. And a lot of times, the people inside of it don’t have the full picture. There are people whose entire profession is either arguing with insurance companies all day to force them to pay what’s due, or helping patients navigate the system. It makes it really, really easy to rip off both patients and health providers.
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Government insurance like Medicare also sucks. Their reimbursement rates are terrible, among other factors, and it’s caused more and more providers (those who can choose, anyway) to stop seeing these patients, meaning that you start ending up with a few Medicaid clinics whose soonest appointment is months from now and spend about 20 seconds per patient. This is largely a result of our conservatives trying to prove that government doesn’t work by making the government not work. Just so we’re clear, private insurance holders also have long wait times and doctors that are pressed for time, it just tends to be a little less bad.
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Since insurers have figured out that there’s money to be gouged in medication, they’ve gotten into the mail order pharmacy and pharmacy Benefit manager (if you want to get a tummy ache, read up on PBMs, they’re the biggest bastards in a field full of absolute bastards) game. Since then, they’ve managed to kill off most small business pharmacies and turn just getting your medication into the same bureaucratic, clown energy pain in the ass as trying to arrange an MRI. (YMMV by insurer, plan, medication, etc)
On top of all that, about a decade or two back, private equity figured out that healthcare in the US is practically a license to print money, so they’ve come in, taken all kinds of stuff over, made everything worse for everyone involved but the businesspeople, all while jacking up prices and cutting services. Yaaaaaaaaay
Dr. Glaucomflecken on YouTube provides a pretty good (and funny / simultaneously infuriating) insight into the mess of healthcare in the US from a providers perspective.
To your point about billing -
My insurer recently informed me that a claim submitted last September had been denied. Looking at the original explanation of benefits from September, it indicated that the insurer didn’t think the medical code was appropriate for the appointment, and wanted more information - stating they would work with the hospital to work it out.
I haven’t heard anything from the hospital, but I’m growing concerned they may just send the bill to collections due to the time elapsed.Yeah, I’ve had the experience of paying off a bill, only for the hospital to, about a year later, send us a newly adjusted bill from the same encounter where they discovered we actually owed them a further three hundred. Healthcare is the only field where this kind of shit is tolerated as a routine matter. Any other business doing that would be shamed in town square, but it’s Tuesday for healthcare.
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Currently $1700/mo for a very healthy, young, family of three. That comes with a $5000 deductible per person (or maximum out-of-pocket of $13000 for the family).
Oversimplification, but we basically pay $33,400 per year before insurance kicks in to cover costs.
That’s ridiculous, yes. But my last uninsured trip to the ER was for an unbearable stomach pain. The 4 hour visit consisted of a shot of pain killer, a scan that showed nothing, and observation by a couple of nurses during that time. I got a RX for some chalky pill and was told to cut back on NSAIDS and alcohol. Fair enough.
The bill from the hospital was $16,000 for the bed, nurses, and scan. Then there were separate bills for the radiologist and the ER doctor, and some lab work bringing the total to ~$17,500.
I currently do not have insurance because I cannot afford it. People treat me like I’m crazy for being overly cautious about getting COVID-19, but without insurance , I could easily go bankrupt if I get it.
American healthcare is truly awful.
that is insane… I had diverticulitis and had a ER visit also here in chile… RX and everything I think the total account was something like 250 usd… of which I paid maybe 30 usd because of my health coverage plan… how can it be 50 times more expensive ?? I pay 80 usd for my plan monthly.
