The face values on medical bills in the US are like a bizarre joke - to a first approximation, no one ever pays them. Everyone with insurance gets insurer-negotiated "discounts" to around ~10% of the listed cost.
It's tougher for people without insurance - my understanding is that you can negotiate with the entity that sent you the bill to get significant reductions, but I don't have first-hand experience doing this. Even so, it sounds exhausting, since a single doctors visit will often result in bills from 2-3 separate entities (doctor, lab, radiologist, etc.), so you'd have to negotiate with each of them individually.
But won't you be so proud when you sign up for a health plan! You can exclaim to everyone "well I did my due diligence and I signed up for a great plan! why didn't you??"
Meanwhile people in non-US countries are thinking "I don't have to think about any of this shit, at all."
... and half the time people bragging about the spectacular insurance they found have just fallen for one of those "fake insurance" scams that are now legal again. Sure, you get $1,000,000 per year of coverage -- with a per-incident cap of $1000 buried in the fine print.
And even though fake insurance is cheaper than real insurance in this country, it's not cheaper than real insurance in most single-payer countries, which is just nuts.
You'll 'sign up' for the only one your employer offers, because so few people ever consider getting direct coverage, partially because... if you have an employer that offers insurance, you can't effectively buy direct (you can't deduct the expense if you're 'eligible' via an employer, whether you take it or not). insane...
The entire system just assumes you have insurance. Everything outside of that is a totally unpredictable financial wasteland that cannot be compared to a real marketplace in any sense. Except obviously, in reality, many people don't have insurance. This is why the whole of it is so perverse and broken.
Lab test are particularly baffling to me. Except strangely, if buying lab tests without insurance (and without a doctor) using a company like https://www.directlabs.com you can get a panel of 100 tests for $150-300 (cholesterol panel, vitamins, thyroid, testosterone, etc - the whole works).
Yet when my doctor refers me to a lab for 1 or 2 specific tests, each individual test is billed at $150+ with a $60 copay paid to the lab.
With lab tests in particular, it’s sometimes cheaper to buy them without going through a doctor / without insurance.
my experience is similar, but never 10%. more like final bills end up being ~60% of original. We had a $3400 ER bill for a cut hand in November. Our 'final total' after 'negotiated pricing' was closer to $2400 - approx 30% reduction, not 90%. (fantastic savings for $10k/year premiums!)
wife sliced her hand pretty bad. took 9 stitches to mend up, and, she's lost the feeling in one finger. end of the day we were >$2k out of pocket - it might have been $2200, not $2400 - we got a few different bills, and paid some 'up front' in the emergency waiting area (after triage). Sitting in a room waiting for medical attention, and someone comes in with a rolling POS asking for payment. insane.
It depends on your deductible, though. If you’re on a HDHP, you could end up paying quite a bit more than 10% of the cost.
But the expectation is that you “negotiate”, which is one the dumbest things I’ve ever heard of. Why can’t my insurance company do that? I already have a ton of stuff to handle, and now I have to worry about negotiating my health bills? It’s a joke.
Even on an HDHP, the discount you get by going through insurance is significant. For a recent bill, my insurance website shows:
Total amount billed: $771
Plan discount: $699
Plan paid: $0
You may owe: $73
Because I haven't hit my deductible yet, the plan didn't pay for anything, but I got their negotiated pricing, so I'm only paying ~9.5% of the "billed rate".
> But the expectation is that you “negotiate”, which is one the dumbest things I’ve ever heard of. Why can’t my insurance company do that?
If you have insurance, you're not expected to negotiate - the insurance company does that for you. That's the "plan discount" quoted above. You have to negotiate if you don't have insurance.
Not defending the system - I think billing is incomprehensible and hard to stay on top of. Just pointing out that you get significant benefits from being insured even if you never hit your deductible.
In my case, an appointment with my GP was billed at $200. My insurance negotiated a discount of... $10. Based on this, my expectation is that this will only get worse with more expensive bills.
I suppose it varies by plan and provider? Regardless, dealing with medical bills is indeed a nightmare in the US. I am not looking forward to doing this all with children in the mix.
Is begging (negotiation without leverage) a remotely reliable move for those without insurance or is it just an excuse dangled by apologists when in fact the reality is that it usually results in a very small discount unless you get the story to go viral?
That only applies once their demands are going to actually bankrupt you, and even then only if you're offering them more than a court would take. "No leverage" is the usual case.
"You COULD get a huge discount!!!" is, to first approximation, pure bullshit.
> Everyone with insurance gets insurer-negotiated "discounts" to around ~10% of the listed cost.
Except when they get screwed.
Friends are middle-class teachers in a good neighbourhood outside LA. Have been so for 18 years, have good health insurance.
She has a baby (should be a joyous time), emergency C section required. The following morning the insurance company says $60k/day is too expensive, and they need to move hospitals this very moment or they won't pay a dime. No transport provided.
A day after a C section he had to drive his wife and <1 day old baby in his own car to another hospital.
On one hand that's awful. On the other hand I can understand the insurance company balking at that price.
I'm in the UK. My ex considered private C section, and checked prices in the UK. We could have had it done by one of the top specialists in the country for ~12k GBP including the subsequent hospital stay.
In the end we chose not to, and our total costs were ~40 pounds/night for her to get a private room (NHS is allowed to charge for some extras) instead of sharing.
I agree. I briefly looked into moving to the US due to work, and dealing with US level healthcare was one of those things that just made it a lot less attractive.
You could buy 0.018 Tomahawk missiles for that or treat 54 people for every Tomahawk missile fired.
All of the Tomahawk missiles fired since 2001 would have provided 119.000 people with free Corona treatment.
I am thinking that countries with free healthcare care more about keeping their own people healthy than dropping missiles and misery on other countries people.
"Each Javelin round costs $80,000, and the idea that it's fired by a guy who doesn't make that in a year at a guy who doesn't make that in a lifetime is somehow so outrageous it almost makes the war seem winnable."
Other countries have price caps on their procedures. This makes sense to make the price for a procedure the same across hospitals. It's the same work. Marketing and Sales people should not be involved in the pricing structure of healing a broken leg.
We know that a good rule of thumb in the USA is that health care costs are roughly twice what they ought to be. So just multiply by two: We could have treated around 238k people.
Much more than twice. The per capita cost (across all Americans, not just those eligible) for Medicare and Medicaid is higher than the healthcare costs of most other developed countries before you even factor in private insurance.
While your point is valid, it also illustrates how the U.S. subsidizes European entitlement programs by implicitly reducing those countries’ defense spending. If the U.S. were to cut back on defense, European countries would have to cut back on social welfare programs.
Are you trying to say europeans have money to spend on an almost fair medical system because they are spending far less money on military because the USA spends enough to „protect“ the europeans? Because that would sounds like a joke.
Europe is spending less money in military because its not entering so many wars or conflicts.
I didn't say that. I said that, without the US presence in Germany and without NATO, Germany would have to spend more on defense.
I don't understand how anyone can disagree with that; it's obvious. The German government certainly knows it, which is they allow the Americans to keep 30,000 troops in their country.
A lot of people on HN have an extreme anti-US bias. It's pretty tiring.
My comment didn't display any anti-US sentiment, so your strawman falls down.
> I don't understand how anyone can disagree with that; it's obvious
No, it's far from obvious.
Those troops are now there to serve US interests, not German ones, primarily using Germany as a logistics base for deployments/missions in the Middle East.
Indeed, there's an argument to made that their spend could even reduce, since they might become less of a target.
It's obvious to people without extreme anti-American bias.
Also, maybe don't throw out terms like "strawman" when you bizarrely transfigured my innocuous comment:
> The 30,000 US troops stationed in Germany and the existence of NATO are significant factors in European countries spending so little on defense.
into:
> This is a total fallacy - those troops being stationed in Germany does not mean Germany would station 30k of their own should the US troops leave.
edit - It should be clear to anyone reasonable that the way you interpreted my original post evinces anti-American bias. What you don't seem to understand is that US interests and Germany interests have significant overlap. The idea that Germany doesn't benefit from pax Americana is absurd.
That doesn't mean that the US always uses its power responsibility, it just means that things are more complicated than the caricature of US foreign policy that often shows up on this website.
I believe that your position was strong during the cold war. From the end of WWII until the dissolution of the Soviet Union, American troops and bombs were a significant deterrent to Soviet imperialism in Europe.
However, the world has significantly changed since December 1991. I agree with the grandparent that today the primary usage of the large US bases in Germany are for staging people and material to the middle east. I also think that it's a reasonable opinion that these wars (or their scale and length) were unnecessary. Is that opinion evidence of "anti-american bias"? I believe that is an unreasonable conclusion.
So - from the 50's to the 90's did the US "subsidize" European economies to some amount by providing common defense from the USSR? Sure. It also served US interests as the policy was to "fight over there" instead of in the US.
Since then, the US has spent upwards of $3T on the GWOT, while declining in every health statistic year over year.
If we're tossing around charges of "anti-american'ism" - I counter than anyone who wants to continue on with an unchanged healthcare system is "anti-american" - as in literally in favor of a system that causes more children to die at birth, for people to live shorter, less predictable and more brutal lives.
Sorry, but I think you're seeing what you want to see.
I'm perfectly "reasonable", and it's rationale to question whether German military spend would increase just because some US troops leave.
I understand perfectly well that some US and German interests overlap, but certainly not all. It's also the case that the US does many things that there would be absolutely no appetite for in Germany (I'm not judging those actions here, just making a reasoned point).
Yes, that is more or less true. EU countries can afford to spend so little on military because the USA protects Europe's interests in other parts of the world including the ocean and middle east. Trump toyed with the idea of withdrawing from NATO and EU panicked because they have no military.
If the US was to cut back on defense, European countries probably would cut back on defense too. A large part of European spending goes to keep the US happy, and to defend against the fallout of US wars.
It's a price we pay for favourable trade arrangements, not something Europe would maintain on its own.
You are saying that as if US has defenses in Europe for sheer good will and charity. My country of Finland is doing quite alright with military spending despite being a highly militarized country. There’s a difference between spending money on a defense force and spending money projecting force.
There is no minimum number of missiles that must be produced no matter what. I think op was simply suggesting that fewer missiles total should be made across the board.
After this is over, the saddest possible outcome is if America returns to the same systems, having learned nothing. I don't expect it at all, but I've been more surprised in the past.
Unless there are millions of deaths in the US from this, a return to the status quo seems like the most likely scenario, as people will assume the scope and danger of the pandemic was overblown by the media all along.
Things would stay the same even with millions of deaths. "Socialism is nothing more than communism" and "communism is evil" are two concepts that are deeply embedded here.
On the other hand, this is sort of a once in a lifetime (possibly once in an era) event and the reforms that would have made this easier to deal with aren't necessarily good for "regular" conditions...
Much like people's sudden views on UBI, especially those claiming that the upcoming stimulus is somehow proof that we need UBI or that it works - we're in a national emergency where hundreds of millions of livelihoods are threatened, any experiment we do now won't necessarily translate back to peacetime life.
I can't wait until my $5,000 a year insurance with a $7,000 deductible here in the US comes up with a reason why it shouldn't be covered.
Fun Related Fact: I donated a kidney to my Dad in 2000. The Affordable Care Act is what finally made it so it was no longer a "pre-existing condition" that insurance companies could use to deny me coverage for anything semi-related to kidneys.
IMO, this current crisis exposes a very strange dichotomy: government is essentially shutting down parts of the economy over shelter-in-place orders, but when people lose their jobs and (for some) employer health care, the government doesn’t deal with the repercussions.
Look, I think shelter in place is a great idea for humans. But this is a case of doing the right thing for the masses hurts the individual. Sad times.
It’s a shame that the only candidate that wants to tear down this ridiculous health system is getting the boot by the party he is aligned with.
The health system in the US is only accessible to those with money. It doesn’t have to be this way. I am not saying socialized healthcare will cure all ailments, but it would definitely be better than the current privatized system.
I have private insurance with a Fortune 500 company and I am still not happy with my insurance. I still have no clue what my bill will be after each visit.
Doctor's office bills for X and Y, but insurance will only pay for X and half of Y. Then I have to fight the insurance company to pay for Y.
This back and forth between the doctor, patient, and insurance company is highly unnecessary and the only benefactor is the insurance company. One could argue that the private health insurance industry is actually causing costs to go up because doctors, hospitals, and clinics have to submit detailed medical billing codes to get properly paid for their services.
You’re wrong. In Canada and most countries with government single payer insurance you can buy private supplemental insurance that covers more elective or less necessary things the single payer doesn’t. I haven’t seen a Medicare for All proposal that bans that.
"About 27.6% of Canadians' healthcare is paid for through the private sector. This mostly goes towards services not covered or partially covered by Medicare, such as prescription drugs, dentistry and optometry. Some 75% of Canadians have some form of supplementary private health insurance; many of them receive it through their employers.[63]"
By that argument there isn't any single payer healthcare systems in the world.
The reality is that when people talk about "single payer" they talk about systems where the essential services are insured by a single entity, not a system without any private healthcare, because none exists.
No. You said that in Canada you can choose between the public insurer or a private insurer. You cannot. You framed this comparison incorrectly this way in order to promote the idea of a public option which is very different. In Canada everyone gets the public single payer insurance. The parts that the public single payer insurance does not cover can be covered by buying supplemental private insurance. That is not a public option scenario.
We've banned this account. You can't do flamewar like this here, regardless of how right you are or feel, or how wrong others are or you feel they are.
you realize this is literally only as of the ACA in 2010? and if the trump administration has its way (there's a supreme court case on the docket to completely kill ACA) we're going back to that?
I agree that the US health system is beyond fucked up, but the statements in this comment are dramatization and not accurate on their own without a ton of qualifiers and clarifying statements.
“Out of network” doesn’t mean your health insurance plan doesn’t pay for anything. It usually just changes coinsurance rate. Anyone who has a major expensive hospital event while insured will just hit their maximum annual out of pocket amount and that coinsurance rate won’t matter. That’s not a good thing but it also means that this comment is misleading, implying that being out of network means that the insured person just has to foot the bill and that their insurance company dips out.
The whole point of the insurance network is that your health insurance company is encouraging you to take your routine doctor’s visits and scheduled non-emergency procedures to a place where they negotiate.
And acne and pregnancy aren’t disqualifying. What are you even saying they’re disqualified for? That’s a vast exaggeration.
1. Even in the event of Emergency visits to in network hospitals, one is often charged out of network fees if one of the doctors present is out of network. Which one is not notified of and has no say over, regardless. So going to an in nerwork hospital (which is the best one can do to align to their plan) means nothing.
2. When charged out of network, it most certainly does not mean only the coinsurance rate changes, you are also charged 10 to 50× more. So you are charged say 40% of $5000 rather than 20% of $300. Again, at an in network hospital.
3. Out of pocket max differs dramatically in network to out of network, in some plans going away completely in out of network scenario.
What you are saying above is not just a minimization its completely misleading and wrong.
It seems maximum "maximum out of pocket" is 8200$ [0] I find it strange that it's not tied to salary. For people earning 30k/year 8200 per year is a lot.
the part about preexisting conditions is completely wrong since the ACA.
the person who replied to you is wrong about out-of-network services though. they seem to be describing a ppo plan. my high deductible plan is quite clear on the fact that out-of-network is not covered at all. doesn't even count towards the out-of-pocket max.
My plan will not even apply my out of pocket payments to the deductible. There are wide swaths of the U.S. where I'm 100% pay out of pocket for emergencies, heck, even inside my own state. Most people are completely unaware of how poorly they are covered when they travel on vacation, within their own country.
In Germany, does your health insurance cost >$600 per month for 1 person if your employer or government doesn't subsidize it (for example, if you are self-employed and earning more than minimum wage from it)?
There are upper limits for the national health insurance which is based on a fixed percentage of your monthly income. I've passed that border this year (earning around 66 k€/year) and from now on, I will not have to pay more, so my procentual share actually goes down from now on.
If I'd marry now, my wife and any children would also be covered by my percentage, it's called "family insurance". Pretty fair after all. (Some limitations apply, but if my wife would stop working, she would be covered through my insurance.)
Similar to Germany here: Insurance costs around € 100 per month per adult, kids under 18 are free. If you have a low income (below roughly 40k per year) you effectively pay less all the way down to zero (if your income is below about 14k per year), because the government pays part of your premium for you.
God I wish, it's about double that [0]: 162€ (health insurance) + 32€ (statutory nursing care insurance) for those making ~1k€/month or less. Not counting any gov support. Btw ~870€ seems to be the max, if you earn ~4700€/month or more.
And from what I remember there is a way to opt out of the public system and switch to private insurance, but this is kind of discouraged by being hard to switch back and requiring significant income in the first place.
In Germany insurers are required by law to provide a minimum standard of coverage comparable to some of the best employer-provided healthcare in the US, insurance costs are heavily regulated and progressive, all employers are required to cover part of the cost, treatment price is heavily regulated, and no one can be rejected.
They tried that in the US with Obama's mandate. You had a choice of getting of getting health insurance or paying a penalty roughly the same cost as getting the insurance.
Trump getting rid of that mandate is one of the few things I'm grateful for in his presidency. No longer am I forced to pay for terrible insurance that had high copays and ridiculous deductibles.
I'm a low income worker and in exchange for almost 7% of my income I get 1 free doctor checkup a year and catastrophic coverage.
Sorry but $2000 cash is worth a lot more to me than an imaginary $100,000 hospital bill. Anything less than $2000 I spend on my health in a year is cash money in my pocket. Being "rational" about insurance is a luxury for wealthy. I would rather dispute the cost with my hospital and let the debt go to collections where I can reduce it even further.
Obama basically made this happen, but the net result was that all of healthy young adults (the kind that least needed insurance) were forced to start paying for insurance to subsidize the unhealthy older adults (or pay a penalty).
So basically it was just a disguised tax targeting the young and healthy.
Insurance implies you have a choice in the matter (i.e. it is optional), but in this case (Obama-era health insurance) it wasn't optional. So why not just call it a tax, which is what it really was?
To me it sounds very similar to social security tax - the young being forced to pay to subsidize the old.
> the net result was that all of [low risk group] were forced to start paying for insurance to subsidize the [high risk group]
This is literally insurance.
Obama's plan failed because the public option was removed, employers and states refused to play along, and the Supreme Court undermined even the part you're complaining about. It was also not a great plan begin with, compared to European programs.
not really. most forms of insurance are not mandated by law and try to charge people something like the expected value of their claims over a certain period plus a profit margin. if health insurance were allowed to operate more like other kinds of insurance, healthy young people would pay a couple hundred bucks a year and old people would pay tens, if not hundreds of thousands of dollars. an eighty year old buying health insurance is the equivalent of someone with five DUIs, multiple at-fault accidents, and a ferrari trying to purchase car insurance.
So you mean about half my taxes? SS and MC/MA/CHIP are roughly ~50% of federal expense? Why am I paying for grandpa sitting at home retiring and going to the doctor, he should get a job and pay for insurance keeping in mind that the majority of healthcare costs go to cover the aging population?
Well, you know, at some time in the future, those "healthy young adults" will be the "unhealthy older adults" and other young people will subsidize them then. That's pretty much how those social insurance systems work.
Maybe Americans are missing something to understand that, but it's not socialism or communism if you actually care about all people in the state, no matter how healthy or old they are.
This person is actually going to pay less than many people who are insured precisely because they’re uninsured.
Someone who is insured in the US is not allowed to negotiate.
This person can call the billing department and say “I can’t pay” and watch that bill plummet.
The 50% or so of Americans who get their healthcare from solid employers will exhaust their deductible but otherwise be generally fine. Then there’s another chunk of people on Medicaid and Medicare (government healthcare for elderly or poor) who would be fine in this situation.
The group of people in the United States who are screwed fall into a few categories: hourly workers who aren’t offered insurance or who are offered bad insurance from their employers, or business owners that have to self insure.
The ACA (Obamacare) attempted to help this situation by making health insurance mandatory and essentially going the route of Germany, but the mandate has been handicapped by numerous compromises in the bill itself, court rulings, and political turmoil. Also the high unregulated cost of drugs doesn’t help. It was not able to defeat the for-profit health insurance industry.
It’s wild to me that these political parties that claim to be pro-business don’t support separating healthcare coverage from employment. This is probably because of status-quo lobbying and a desire to keep people wage enslaved until retirement age.
I think it works that way, you think it doesn’t work that way. So in that sense there’s no way to know based on “trusting random commenters.”
But I can tell you this: there aren’t a lot of ways in which that debt collector can collect. They can’t take your home, they can’t take your car (as if the uninsured person even owns their car outright), and I don’t even think they can garnish wages.
The statue of limitations on debt is as short as 3 years in some states, and it won’t even affect your credit score beyond 7 years.
If that person never answers the phone and never admits to the debt, it basically just goes away on its own from my understanding.
Even if they decide to settle, that debt collector purchased the debt for pennies on the dollar. That person settling is not paying anything close to the full cost. The hospitals know that a bill going to collections is already a lost cause, and is basically written off as charity care.
Unfortunately a credit report can be a part of some jobs. I found this out the hard way when I tried to do what you said - ignore the calls - and there was an unpaid debt from 6 years ago on my credit report anyway when I had to get a clearance.
Many people frame this as a "say this magic phrase to get your bill reduced" and I just don't think it's that simple any more. Some of the consequences from not paying just come back down the road.
Wait so there isn't a Healthcare cost problem in America then? I don't live in US but if your uninsured and can just call, say I can't pay and pay much less or just have your insurer pay, it seems to be OK either way?
It doesn't work like the comment described at all. If you can't pay you end up in debt collection and then get a lot of extra fees on top of the already ridiculously high bill. In the end it will bankrupt a lot of families.
The US healthcare system is messed up in a lot of ways.
I’m just saying that many people who are uninsured at the emergency room will end up with a lower total than people who are insured with unsubsidized low quality insurance.
The bill is crazy, but this person won’t have to pay a 10th if it if they call the billing department.
Being uninsured is actually something of a blessing in the United States in this situation. If you have health insurance (often with bad coverage and high deductibles), you’ve agreed to waive your ability to negotiate and to pay whatever bill they’ve sent you.
Not so for the uninsured.
The whole billing system in the United States is beyond fucked up.
It's tougher for people without insurance - my understanding is that you can negotiate with the entity that sent you the bill to get significant reductions, but I don't have first-hand experience doing this. Even so, it sounds exhausting, since a single doctors visit will often result in bills from 2-3 separate entities (doctor, lab, radiologist, etc.), so you'd have to negotiate with each of them individually.