> Given he has 3 children, 400% of FPL in 2026 is $150,600 so he's easily eligible for ACA subsidies
I am absolutely not eligible. I earn more than $150k. And "manipulating your income" is not really feasible with a pass-through entity.
> The premiums have nothing to do with the plans. Every single plan on the marketplace has to cover child-birth, that's sort of the point of the ACA.
As I mention in the piece, I check every year. I have no idea what subsidized plans include, but the other marketplace plans definitely do not include child birth.
I explicitly address this point:
> The Affordable Care Act (Obamacare) barred insurers from turning down applicants based on existing pre-conditions; the way insurers get around this for pregnancy and child-birth is not by rejecting pregnant applicants (illegal), but by simply refusing to cover the care those applicants need to survive pregnancy (legal and common.)
and
> My wife and I are healthy, but we’re building our family and I have yet to see a marketplace plan that supports child-birth. Maybe the subsidized ones do, but I earn too much money to see those. All of the ones I’ve found through eHealth Insurance or Healthcare.gov never cover it - and I check every year.
Love the over-confidence though. The best outcome for me in even writing this article would be to get some internet commenter pissed off enough to find me a cheaper version of my plan. That would solve my problem immediately!
Which does cover childbirth according to page 3. And has a 7150 deductible per person - the $14300 is the family out of pocket max, so the childbirth should top out at the 7150. Other expenses might put you at the same 40K cost for the year, but not the childbirth alone.
You know they charge you, separately, for both the mother's care AND the infant's during a delivery right? Those count as two people. I am, with 100% certainty, going to hit the out of pocket max - I have every time.
Like I've paid for three kids all on the same plan, including one born in January so my deductible got spread over two different billing years.
I'm not defending it. I'm correcting your misinformation. You are claiming that ACA plans do not cover childbirth. They do. You are claiming that this event alone costs 40K, which is not accurate. It hits your out of pocket max, exactly as designed.
It sounds like you have never looked at an ACA silver plan, which is the lower deductible/out of pocket max option. I also have a family of 5, and have a $1800 per year out of pocket max from an ACA plan. You would still have the same level of premiums as you do now for silver plans, but you would save 13K a year. You are picking bad plans, dude.
Our system has problems, but when you make enough to not be subsidized, yet still pick a crappy 40K per year plan, that is beyond the systemic problems. It is a bad choice. There are insurance consultants who work with people, especially high income people, to find good plans for their family. You should be calling them.
Dude, you don't even have your own facts straight and you are embarrassing yourself. It's clear you have no experience, don't understand your own sources you provided, or any clue how child birth actually works from a medical billing standpoint.
Edit: what do I have to gain from spreading "misinformation?" I just want better / more options?
That's not what the link the OP included said and not what I said either, but I concede your point - that's my fault for checking individual health care marketplaces (like eHealthInsurance and Aetna direct) or not looking closely enough on healthcare.gov.
Looking through some plans now, but TBH these are genuinely not much of an improvement in the cost department and a massive downgrade in the provider selection department. Hence my whole section on trade-offs.
The logic you're using about out-of-pocket costs versus your deductible appear also not to be valid, and are causing you to misstate your out-of-pocket liability by a factor of roughly 4x.
I can assure you they are, if anything, understated - as I am not including the expenses my health insurance will not cover. So no, you are fully in the wrong there. What do I have to do to prove it? Show you itemized receipts?
Moreover, what are you even trying to accomplish by asking for this? Please provide me with a forthright defense of the modern U.S. health insurance markets and why it makes sense for me to have to pay this much to keep our population above replacement level.
Do you have non-ACA insurance? One explanation for why your costs are so much higher than the national average is that you're on a non-complying plan (you can also still buy plans that will exclude preexisting conditions --- they just can't be sold on the ACA marketplace). I'm pretty confident KFF isn't making these numbers up.
As for your second question, one easy response is that prospective parents in other health care systems aren't paying less (with everything factored in) but rather differently: that people making your $119k "true" poverty rate in Europe tend to be taxed at their top marginal rate, which is substantially higher than ours (in fact, in a lot of places in Europe, a Chicago Public School teacher would also be paying the top marginal rate).
A thing worth pointing out is that while the system we have is especially punishing on the uninsured, it's actually not that bad a deal for the insured, demographically/actuarially speaking. That's because being insured definitionally puts you in the cohort that excludes Medicaid-eligible poor/working class people and fixed-income seniors. If you move the typical household from that cohort to the UK, they're likely to be worse off. In surveys, insured families tend to be satisfied with their insurance, which is why taking existing health insurance off the table is such a third rail in American health policy.
Anyways, unless you personally are responsible for keeping our population above replacement level (which sounds exhausting), your numbers just aren't probative for the cost of bringing new citizens online. Other numbers might be!
While I might not have been happier income-wise when I was on Medicaid vs now, I was much happier with my medicaid insurance than I have ever been with any private insurance. I could see basically any provider and didn’t have to deal with any of the typical insurance bullshit.
Also when you’re beyond the Medicaid threshold but not that much beyond it absolutely sucks. One year I was paying for dramatically worse insurance with a deductible that would have just made it better for me to just not make more money because if I hit that deductible I would be net negative on my income vs the threshold for Medicaid.
Also I think this is such a false premise. You can still have private plans if you want in the UK or elsewhere with a public health system. Nobody is forcing you to use the public system if you don’t want to. To wit, I don’t have children but I still pay for schools with my taxes. You might not want to use the public health system and instead go private, but yes, you should still be paying for a freely accessible healthcare system.
Here’s the rub on that too: The prices we pay here are so much higher than in Europe even if you go private in those countries. Our system is terrible. Point blank.
I would agree that the NHS in the UK has gotten pretty bad. A large part of that is the result of the Tory government actively working against it though for a very long time. The waitlists for a lot of things are quite long and my fiancé who is from the UK and still lives there has to do some things there are crazy to me. On the other hand she still is able to get care freely. She’s paid private for some dental work but that also cost her pennies on the dollar compared to what I’d be paying if I did the same thing here.
If you’re happy with your insurance I am truly thrilled for you because I don’t think of that as being a common experience.
> Most people with private health insurance like it.
Most people don't use it all that much, and in the common case of employer-paid premiums, the actual cost is significantly masked. As your link notes, the more care you need, the less likely you are to enjoy the experience. They dig their heels in more; sometimes egregiously so. https://www.propublica.org/article/unitedhealth-healthcare-i...
Seems like a just-so story given the numbers. Why would heavy users of health services be concentrated in the minority cohort that is dissatisfied with their insurance?
> Why would heavy users of health services be concentrated in the minority cohort that is dissatisfied with their insurance?
"Why would people who drive a lot care the most about gas prices?"
The more you use health insurance, the more chances you have to run into the kafkaesque bits. Someone who sees a GP once a year and thinks their premium is $50/month because that's the bit they have to chip in while their employer covers the rest is largely gonna go "this is fine!"
Right but there's no such selection effect for whether or not people have employer-provided coverage, and the cohort of households that do strongly approve of their current insurance coverage. I don't see how the argument you're making could hold up statistically. There are a lot of chronically ill people with employer-provided coverage; in fact, most non-senior chronically ill pts fall into that bucket.
> Right but there's no such selection effect for whether or not people have employer-provided coverage…
False. Someone with significant medical issues may well need a higher acuity plan than the employer offers. I, for example, was on the exchanges until last year, for this very reason; my employer's coverage would not have made financial sense.
> There are a lot of chronically ill people with employer-provided coverage…
The chronically ill are less likely to be employed.
> Do you have non-ACA insurance? One explanation for why your costs are so much higher than the national average is that you're on a non-complying plan (you can also still buy plans that will exclude preexisting conditions --- they just can't be sold on the ACA marketplace). I'm pretty confident KFF isn't making these numbers up.
Asked and answered in the piece dude - I wish I had the confidence of a Hacker News commenter who didn't read the article.
I read the article. It's extremely unclear to me whether you have ACA-compliant health insurance or not. I've been a startup principal since 2005 and have had PEO coverage at various points since the ACA passed, and it was always ACA-compliant. Could you just answer the question? It shouldn't be a riddle!
(Note that "non-ACA insurance" doesn't mean "insurance you didn't buy on the ACA public marketplace". I've got Anthem Blue Cross through our benefits provider. It is very definitely ACA-compliant.)
that link doesn't even say what you says it does - it said you can apply for coverage, not that there are plans that cover child birth. Have you never done this before?
> I pay that at least much for my family, hence why I used it
and your article says
> Having a $200/mo smartphone is now a participation cost for many things such as getting access to your banking information remotely, medical records, and work / school.
It sounds like you're trying to communicate that you pay at least $200/month per smartphone for your family? Or you don't value precision in communication.
I know you've got a lot going on with a small business, and a new kid... but if money is important to you, maybe spend the time to switch to prepaid phone plans. There's lots of options [1], whatever network you need, you can do direct operator plans, MVNO owned by the operator, or like actual MVNO. If you're short on time and T-Mobile's network works for you, MintMobile has a promo going right now where $180 pays for 12 months of "unlimited" which is $15/month if you divide it out.
> I also pay $1250 per month to TriNet for the privilege of being able to buy their health insurance in the first place - sure, I get some other benefits too, but I’m the only US-based employee currently so this overhead is really 100% me.
Do you live in a state with a reasonable healthcare exchange? You might want to shop and see if an off the shelf plan from the exchange is better than paying TriNet to get access to their insurance; it may well be, but you should check. If you only have one US employee, and it's you, there's a lot of expense for not a lot of value IMHO. It's not really Apples to Apples though --- I think a lot of the TriNet plans have out of state coverage where a lot of exchange plans don't.
> It sounds like you're trying to communicate that you pay at least $200/month per smartphone for your family? Or you don't value precision in communication.
You're moving the goal posts here. You have to have service, realistically, in order to use it like a real person.
I'm trying to figure out what you're getting for $200/month.
Is it for "a smartphone" with service, and presumably financing the phone as well? Or is it the total for all of your family's smartphones, which is how many phones/lines?
Do they come with free mid-tier phones? What if you need 4-5 lines? What if, as a CEO, he needs a better plan than "basic prepaid, lowest-priority-subject-to-throttling"?
And what if the CEO needs international numbers across all continents?
What if the CEO needs to supply an entire 1,332 person company with business phones?
What about an assistant to answer them! What if we're sleeping!
Oh god!
But just to put my comment in context, here is what he said:
> Having a $200/mo smartphone is now a participation cost for many things such as getting access to your banking information remotely, medical records, and work / school.
Okay, so on the non-budget side, I pay ~$64/mo for T-mobile's "unlimited[1]" plan and a Google Pixel phone. ($57/mo for the service, and I've amortized the phone price to ~$7/mo based on my lifetime average phone lifetime. Even if you amortize the phone over only its ridiculously short warranted lifetime, that's $42/mo for the phone, or $99/mo, but that implies purchasing a new phone yearly, which most people do not do (the average phone lifespan is just under 3y).)
In over a decade, the only time I hit that cap was because I let my kid watch too many videos on it.
5 GB is pretty reasonable for the bulk of the country. The only common things that can make it go over are games and streaming - both of which really are luxuries if you simply can't wait till you have Wifi access. So yeah - of course you should pay a lot more if you insist on doing those things.
This is akin to him saying that average American needs X money for the car to participate in society, and you suggest that his numbers don't math because one could:
1. Walk around everywhere (Idaho, Iowa)
2. move to New York (with ok public transportation)
Mobile phone and unlimited high-speed internet are requirements for participation in society.
> unlimited high-speed internet are requirements for participation in society
I pay $7/mo (not a typo) for 1GB mobile data via US Mobile, and I have never hit that cap in many years. I just don't stream video or audio unless on WiFi, which is not a hardship. Respectfully, what on earth are you talking about?
My monthly mobile internet usage is 5-25GB. And this is me working from home using wifi, having cheap internet (slow, but unlimited) and barely being outside. Phone wifi usage is 150-250GB/month.
Well, I have to wonder what you are doing on your phone. I don't restrict my usage at all outside of video and audio streaming, so I'm befuddled as to how you use 10-50 times more data than I do.
Last month, 429MB used:
107 YouTube music
91 Google maps
70 Firefox
22 Amazon
Miscellaneous other small amounts
WiFi usage 26GB
I don't doubt that you use a lot of internet, but that amount is far away from a "requirement to participate in society" .
I watch a lot of videos (with increased speed). Also Telegram is a big consumer of bandwidth.
Also, since I live in Europe, I don't use car (otherwise would obviously not able to watch videos during travel), but public transportation. And using mobile internet is normal, nobody cares to ask for cafe wifi or to even type it in despite being visible on the wall. This is very freeing. Perhaps more than Americans can imagine, since the limits are internalized. Analogy would be the freedom Americans feel, after they move to Europe and realize that they don't have to worry about becoming broke due to sudden health problems. This is a constant worry that Americans have, but the extend of which is fully understood only after the shackles have been dropped.
Like, a lot of people here don't even have a separate internet connection at home, but are simply using their phone's shared internet with their laptops. That's how normal it is. And these "no limits" contracts are what allows the change in behavior to FULLY utilize the technology, without the need to limit oneself.
A lot depends on how one understands the word "participate". I mean, is eating the diet of only oats, eggs and protein powder enough to "have eating needs met" or is the requirement limit at "balanced food diet, with cost not influencing decisions"?
In my opinion requirement can be rephrased into "can fulfill all the phone/internet needs, without limits, without restricting oneself". So in this sense your internet requirement is 26.5GB and we have to look at the price of the phone connect that would provide at least this much at full speed.
Worrying about what the wifi password is for this place is such an old-school thing in America. Europeans and Asians find it baffling.
If you have internet access on your phone while you're actively moving, it should work all the time, without any traffic limits or the need to keep asking for shitty cafe wifi (because your mobile internet is even worse).
It really reminds me of the Healthcare System conversations, when Americans are justifying why their way of doing things is logical and correct, while the rest of the world shakes their heads.
I actually thought about including this in the piece (and how car sizes become a problem once you hit 4+ kids) but decided to keep it more focused on just the healthcare costs
My wife had to have an emergency C-section the first time around when they lost the heartbeat on our first baby, so we've stuck with planned C-sections - so yes, we are somewhat constrained in terms of our choices there.
I skimmed your 2400-word article a second time just now, and I still don't understand why your math is allocating 100% of your family's health insurance premiums to childbirth. And now I additionally don't understand your abrasive tone in answering this fairly straightforward question.
Multiple commenters are raising this point, so perhaps you should consider that you aren't conveying this information well?
1. I mentioned, in multiple places, that this is the cheapest PPO offered to me through a limited selection of potential brokers / marketplaces - and that's important because it covers our current health care providers AND child birth as a benefit.
2. If we weren't trying to have kids, our options for purchasing health insurance expand drastically. Individual marketplace plans become a viable, for instance, since the "not covering childbirth" issue goes away. I mention the short-comings of the individual health insurance marketplace at least twice in this regard, including a big pull quote explaining the ACA work-around with child birth coverage.
> If we weren't trying to have kids, our options for purchasing health insurance expand drastically.
Yes, but crucially none of those expanded options cost $0, so I still don't understand your math at all. I feel like we're talking in circles here.
You should be deducting a substantially non-zero number from the amount in the headline to account for your "normal" non-childbirth-year best-case medical insurance premiums (or out-of-pocket cash costs if foregoing insurance altogether).
What exactly does covering childbirth mean? We've had two children now and it's not something I've considered when choosing insurance (my company's vs my wife's), so maybe we just got lucky. Is there anything different about child birth vs simply in-network hospital coverage? I assumed we'd just hit our out-of-pocket max.
Could you explain how this would help? I'm struggling to understand where you're coming from here, besides perhaps a reflexive libertarian reaction to government.
Massive government subsidies for health care consumption not only eliminate, but disincentivize price discovery. If your biggest consumers of health care (seniors) have access to the best health insurance plan in the world (Medicare), that's going to drive costs up
Your whole argument is that the health care system should be optimized for the most productive members of society (like you, right now).
You are perfectly fine to have that belief, but the majority of people disagree with you, which is one of the primary reasons the system is designed as it is.
I think the market can do a better job of optimizing than central planning ever can - the problem is we have both the costs of capitalism and socialism concurrently with the model we have now. A worst of both worlds scenario.
When somebody is sick we generally save them even if the cost/benefit is poor. No market is going to solve this if you want to save sick people who don’t have a lot of money.
There is no place in the world where health care is solved, it’s one trade off vs another.
The US system is also far far from perfect but your solution is quite shallow and unlikely to fix things in a way society wants.
Have you ever looked into the way the market works for medical devices? And what happens if the implant or device you need to live is from a company that went bankrupt?
If you've ever spent even five minutes reading up on that stuff you would understand that health and medical cannot be a free market. It can never be a free market.
You know what actually drives costs up? The fact that healthcare doesn't work as a market. I can't shop for medical care. I don't have the knowledge and it's usually extremely time sensitive. This is a ridiculous statement that's only parroted by the most market-pilled right-wing economists.
I'm a single contractor and can't really justify it. It saves me about 8k per year and this would be a bronze plan through MediCali if I got it. People would say "well what if you get a cancer or something" and yea that may be true but in that instance not only would I be out that premium but also the deductible and it won't even cover everything so maybe I'm actually better off stacking cash until the inevitable.
I'm right there with you - this is a case study in "perverse incentives." There is zero benefit to "paying into the system" to be had under the current model. Better to chance it and then sign up for a plan at the last minute since insurers can't deny you based on pre-conditions.
This strategy is why there are open-enrollment periods for ACA-compliant plans. I had a startup back in 2014 where I had us on HC.gov/ACA market insurance. A billing SNAFU on Blue Cross's part (that year was really rough for HC.gov!) ended up getting that insurance cancelled for nonpayment about a month in, which is when I discovered that our only coverage options were all non-compliant short-term policies, all of of which excluded preexisting conditions and wouldn't underwrite one of my children at all due to an unexplained seizure several years earlier.
(We resolved the situation by finding a bank-shot qualifying event that allowed us to re-enroll --- it was extremely situational and had to do with my wife and I simultaneously leaving our jobs within a short window of time.)
That's indeed the play for non-corporate-insured consumers. Short-term insurance was $1,000 a year for a healthy person last time I checked. Just keep renewing until you need ACA-compliant insurance for some reason.
But back to my point: that does nothing to solve the root cause, which is the price inflation. And Washington is so deeply compromised that they will never fix it. The only solution lies with us just walking away. We hate to bargain a price on getting exposed to the ugly side of life, like disease, discomfort, and death, but indeed, everything has a price. And we will continue to be tested on our willingness to pay it with until we start playing hardball.
To be fair, that's because their own Azure.Identity org hadn't even shipped an update addressing this vulnerability and they work in the same building.
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