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?
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.
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.
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.
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).
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.
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.