Honest question as a Canadian - what do you do about health insurance when you're 50 and get fired from your lifer job? Should you really have been paying for your own policy in parallel with your employer's so that you can continue with the low premiums post-employment?
Prior to the Affordable Care Act / Obamacare, you had up to 18 months of COBRA eligibility, meaning you could stay on your employer's plan but paid all premiums (expensive). During that time you frantically look for a job that includes healthcare coverage. Failing either of those, you might find junk insurance, or you simply go without and hope for good health. If your income is / remains low enough you might qualify for Medicaid, but you pretty much have to be at the poverty level for that.
Post-ACA you can now purchase coverage from any of a variety of companies through the exchanges. Rates are limited in that there's now a legal requirement that a minimum percentage of premiums must actually be used to pay for medical expenses (I believe 80 or 85%) so premiums are set accordingly. There are also income based subsidies that you're eligible for of your income is more than 4x the poverty level.
There was also an expansion of Medicaid eligibility up to 4x the poverty level with the additional cost being paid by the federal government, but some states have refused that expansion and money. This has left many poor in those states stuck unable to afford premiums and unable to get either subsidies or Medicaid.
I went through layoff six months ago. ACA definitely has helped with health insurance. If you are unemployed (no income), you are most likely to get subsidy as it is income based. Our premiums after subsidy is little bit higher than what we were paying when I was employed.
I wish there was something similar to ACA for dental insurance. Most dental insurance plans on open market are expensive and with ridiculous terms, like 18-month waiting period! We had to take dental insurance plan through COBRA (almost 6 times as expensive as regular employee). Not sure what we will do with dental insurance after 18 months of coverage through COBRA.
Dental is harder, and (at least in my dentist's opinion) private dental insurance just isn't worth it. I can see the merits of that, because you're less likely to have a catastrophic dental emergency that can bankrupt you. A lot of dental insurance also seems to only cover 50% of the more expensive items.
It may be worth looking at how much you're paying each month in premiums and comparing that to the annual out-of-pocket cost for preventive / cleaning visits plus perhaps a filling or two. You may find that all the insurance is really doing is smoothing those payments out without saving you much money unless you have a "years of neglect" situation that you're still working through.
It's probably also worth asking your dentist if they have "self-pay" rates comparable to what they're getting from the insurance companies. If they bill $120 but accept $80 from insurance, will they take $80-90 cash from you instead of that $120? Also, for more expensive procedures like crowns, it's very likely that your dentist's office will let you do installments to spread the cost over at least several months. That doesn't really help when you don't have current income and aren't sure when you will have it, but it does relate to smoothing out your expenditures the way insurance premiums do.
My dentist actually mentioned that she can't charge less than what she bills to insurance company (at least on the books). It appears that if a dentist is part of an insurance network, by agreement with insurance company, s/he can't charge less to patient who don't have insurance.
I have a dentist friend whose practice doesn't accept any insurance so he is free to set his rates and charge his patient. After COBRA finishes we might go to him.
Worried about insurance for your kid? Can't happen here, the government will deal with that. Losing your job? Get paid for one or two years by your work insurance. After that you fall back to a free basic income (for as long as you need). And still this system is generally not exploited: People work hard here.
And it's not just unemployment. There are people begging for money on HN regularly, because they are dying (often of cancer) and are now worried about their families. This is just cruel and can't happen that easily on this side of the Atlantic.
But it seems US citizens want to live like that. Why?
German here who lived in the US for a year. I lived there during the time when obamacare was presented and I had a lot of discussions about this. The main reason which I heard over and over again (and sometimes word for word) "The German system is communism. We don't want that here!". I am not even kidding, there are people who truly believe that a german insurance system would be the beginning of communism in the US. One guy who told me this broke his arm and had to pay about 15000 dollar because he had no insurance. An other couple paid 75000 dollar behause at the birth of their first child there were some medical problems during birth and they did not have insurance. And still both got angry at me when I told them that I'd prefer the German way.
After hearing this stuff for half a year I am really glad to be back in Germany. I am funemployed since a few months and I pay 150 euro per month. Next week I have an appointment at the doctor because of my severe hip problems. I might get some xrays done and perhaps some MRT. What will this cost me? Nothing! I am so glad that I live in a deeply communist country...
I'm an Aussie that's lived and worked in quite a few countries, including the US, and I share this experience.
I was in Mexico partying with a bunch of US college kids when Obamacare was on the table, and we talked about it for a while. All of them said "We don't want it because it's Socialism!".
When I inquired as to what that meant, or why that is undesirable to them, the entire room of 30 of them went silent. Not a single one even know what Socialism meant, or why they had distaste for it, but they sure were certain they didn't want it!
IMHO, people in the US have been lied to for multiple generations, to the point where they don't even know why something is good or bad for them personally, they just know what they're supposed to think about something.
A lot of people didn't like ACA because we would have preferred single payer. Many others felt we would just be sending much more money to the for profit insurance companies who were already treating us horribly and making record profits.
We also have heard many stories of people having to wait months if not years for non-emergency treatment. Such as getting an MRI for an injured knee in Canada for instance. As a very healthy avid runner it would be very frustrating to not be able to pay for something critical to me like that (once again I am not saying this is always or mostly the case but it is a scenario I have heard about). I suppose our imaginations extrapolate if health care is more or less free for all then our level of care will be much worse. I am not really sure.
If it was up to me, I'd kill all insurance companies with fire, have us all pay into a pot for medicare and just use that.
This business about having to wait months for treatment is always an odd objection to me. Here in the U.S., under our existing system, I have many times had to wait months to see a specialist or begin a particular course of (non-emergency) medical treatment. It's hardly as though our current system somehow gets rid of the problem of waiting for appointments.
We just have such distrust in our government that we don't want them running the health care system. Witness, for example, the recent VA Hospital scandals. Our government is dysfunctional. And it's already incredibly intrusive, too, and some of us don't want the feds knowing all of our health problems (even though they probably already do).
I would love government health care, just not from this government. The free market doesn't work for health care.
Most people don't want to live like that, but health insurance companies profit from the current system and they have deep pockets to influence the government to keep it that way.
>But it seems US citizens want to live like that. Why?
Well first, not all US citizens do.
Primarily this seems to stem from a free-market, conservative viewpoint. Central to this viewpoint is the thesis that not only is labor just, but the sociological outcome of labor is also, always, just (unless the government interferes). In other words, those who can afford healthcare have earned the right to it, those who can't were simply to lazy or ignorant to work hard enough to afford it.
Also, there can be a deep aversion to the government (any government) interfering with a person's property and income, where any program which requires people to give for the "greater good" is seen as not only theft, but an existential attack on the fundamental ideals of American individualism and personal liberty. The argument here is that governments are by definition corrupt, fascist and incompetent, and only a free market with as little regulation as possible could handle something like "healthcare" efficiently and fairly.
Therefore, advocates for limited government will see social programs as interference by an increasingly "big government" regime which has no right to force a moral imperative on people or relieve them of their property, and conservatives and free-market believers will feel that social programs undermine the moral principles of capitalism while insidiously creating a dependent class of lazy left-wing radical neo-immigrants.
Also, it's probably worth mentioning that not many Americans appreciate that there is a difference between liberalism, socialism and communism, and nor would they care.
There's a lot (a lot) to be said for universal healthcare, but to answer you question in the general case (why americans don't want to be more like Europe), this might give a good hint:
Becoming Germany, Britain or Sweden would probably be a tolerable tradeoff, but a lot of factors go into that, it's not something that happens as a result of a single policy or two. Do note that in Portugal the rich are worse off than the poor in the US, and Italy and even France aren't far off.
Germans get more benefits provided by the government than Americans because Germans pay more taxes. The trade off is Americans get more take home pay and get to decide what benefits they wish to buy on their own, in the private market.
This also shows Americans work more than the Germans and this doesn't say anything about how hard people are working, but don't forget the old adage: Don't work harder, don't smarter!
"Get paid for one or two years by your work insurance. After that you fall back to a free basic income (for as long as you need). And still this system is generally not exploited: People work hard here."
> But it seems US citizens want to live like that.
US citizens, in aggregate, want to live like that (or, perhaps more accurately, want other people in the US to have to live like that) when opinions are aggregated by effective political power, sure, but effective political power in the US is largely a function of wealth, which is extremely unequally distributed.
It is the health insurance lobby that doesn't want it. Also corporations don't want the flexibility because it encourages people to stay and keeps salaries down.
These days you go to your state exchange (for the putative ex-MS person, that's likely to be https://www.wahealthplanfinder.org/), search for a plan, click on it and sign up.
It used to be worse, of course. But even then it wasn't a disaster for the case at hand: the COBRA act allowed you to continue to buy your existing plan at the same premiums for a year and a half until you found a new job.
COBRA is impossibly expensive for many people. When you simultaneously have your salary drop to $0 and your portions of your insurance premiums triple (say, if you have a spouse and kids covered by the plan), that's a rough situation to be in.
About the only good thing about COBRA is that it covers preexisting conditions.
The other problem with COBRA is that the insurance company has zero interest in customer service. Insurance companies are famously horrible to deal with, but if your employer's plan gives you trouble you'll probably complain to HR. If they get enough complaints, they could lose the contract next time around. They have at least some incentive to keep you happy (or at least non-furious)
When you're a COBRA customer you're basically on your own. Good luck getting them to pay up on anything.
Not to contribute to the ACA vs. non-ACA arguments further, but ACA plans for my wife, daughter and myself are more than double that in Maryland.
I don't know what the differences would be if I were earning $0 per year, especially as the relevant question (on the form I filled out) was something like "How much do you anticipate earning this year?" which is a question I have no idea how I would answer if I were currently unemployed.
And that within 60 days, you only pay the premium if you use it, because that's how long they give you to enroll in it. So if you get sick/injured within 60 days after being laid off, you can apply for COBRA, pay the premium, and you will be covered retroactively.
It's impossibly expensive because US health insurance is impossibly expensive. It's not like there's a significant extra cost associated with going with COBRA versus an equivalent individual policy. And prior to the start of this year, you might not be able to get an equivalent individual policy at any price. If you had any pre-existing conditions at all, then you definitely would not be able to get equivalent coverage.
> It's impossibly expensive because US health insurance is impossibly expensive.
And US health insurance is impossibly expensive because US health delivery is impossibly expensive. I believe 75% of the real US problem is not insurance, it is the cost of delivery.
Should be noted that in most cases your employer would cover most of that premium. My insurance went from $10/month (with my employer covering $580) to $590/month on COBRA when I was laid off.
As a mid 20's single male, I had the same experience. My premiums were fully paid by my employer, so it was quite a shock when the COBRA paperwork came stating the monthly cost would be almost $600/month.
As a mid-45 male with a wife and kid, my cobra 5 years ago was $1200/month, and I was glad to pay it. 14,000 a year is nothing compared to one major incident involving a hospital.
A very reasonable thing to do is ask for a higher salary and no company insurance. You end up paying a premium (because the extra salary gets hit by income tax, while if the company had used it to buy insurance it would not have been subject to income tax), but you get to choose your own insurance and it doesn't stop when you leave.
In the US this doesn't make sense (for most people), unfortunately.
Employers offer group plans which tend to be much cheaper and offer substantially better benefits than individual plans. The larger the company, the better the arrangement tends to be.
COBRA is designed to fill in that coverage gap when you leave, but as others have noted in this thread, it is not always economical.
COBRA rates are 3-4x higher than individual plan insurance every time I've heard about them.
In a rapid-churn economy like tech, where people often strike out on their own and companies cease to exist etc., the few $K a year it takes to maintain your own individual plan is something everyone should consider. As you age, starting a new private plan becomes frighteningly expensive, and if ACA doesn't stick, it may become impossible again for many people.
At various times, I've used COBRA, I've had individual plans, and I've had group plans for which I've paid the full premium. I've never seen a difference of anywhere remotely close to 3-4x for COBRA versus an equivalent individual plan.
I only have two personal anecdotes, one 3x and one > 4x. Both for people in their 20s, and I don't know the math but I can imagine that in group plans where rates are flat, young people cost more to insure than individually and older people cost less.
Couldn't find any good data but here's a post representative of the top few google hits for COBRA vs. private:
The times I was on COBRA in California, it's been around 3x what I would have paid if I'd been eligible for an individual plan.
Is it possible you've had individual coverage in a state where such coverage is guaranteed-issue? That would account for a lack of distinction between group and individual rates.
I'm in Texas. I know that at until the start of this year, if you didn't have any access to a group plan (including via COBRA), and you applied for an individual plan and were refused, then there is significantly more expensive coverage that you can get through some program offered by the state and Blue Cross. Though that may not exist in the post-ACA world where no one is supposed to be denied coverage any more.
Buying a parallel policy could help. I don't understand why the U.S. government has a tax code that effectively makes the most important type of insurance the easiest to loose.
