Employer-offered plans tend to be extremely good value, so the vast majority take advantage of them.

I was paying <~$300/mo on that plan. I now pay over $700 on a directly-acquired plan. So that's problem one.

The bigger problem, IMHO, is that quitting means changing your insurance, which isn't just a financial change. It can also end up requiring you to change medical providers, which is no small deal!

This adds massive friction and stress to the act of quitting/changing jobs, a major source of leverage on the employer's side.

And that's to say nothing of the fact that it's effectively an overly burdensome tax on new entrepreneurs. It's a reinforcement of the concept, "you have to have money to make money".

JMHO on the topic; for reference, I'm a new entrepreneur very early in the process. I'm just lucky enough to be able to risk the attempt.

> I was paying <~$300/mo on that plan. I now pay over $700 on a directly-acquired plan. So that's problem one.

This is relatively small pickles. Your employer paying a few hundred, maybe a thousand dollars on your behalf if you are old, per month. You can buy the same on healthcare.gov

You actually can’t. There are off market and on market plans. Even though it’s by the same insurer, on market insurance is only taken by 50% of the places that take the off marketplace plans. Been down that road a few years ago and it was a disaster. Ended up getting a great plan for my company through the state chamber of commerce.

In my experience in west and northeast coast states, the plans are the same assuming they are ACA compliant. The employer even shows the same gold/silver metal level labels when you select a plan, and I’ve always had BCBS plans, which has the same networks via employer or via healthcare.gov

They only things that I expect to change are total premium, deductible, out of pocket expense, copays, and network. Otherwise, the coverage itself is dictated by the same law.

I can see right now that the BCBS gold HSA premium from my employer (total, including employer portion) is the same as the BCBS gold HSA available on healthcare.gov.

Reimbursemenet rates are not the same. Some doctors will accept 1 and not the other.

I used a hospital for a new baby birth. Because my plan was on-market, the provider doing delievery didn't accept it (Despite it being on the in-network list). So I got to be stuck with a ~13k bill. Was super cool.

This was back ~8 years ago, so perhaps it's all been sorted.. but I have such a bitter taste in my mouth after having to pay this out of pocket, I won't touch on-market plans with a 100 foot pole.

In US buying medical services without insurance is very expensive. You choices are:

- get health insurance from your employer

- get covered by insurance of your spouse

- buy insurance from your own pocket

- don't buy insurance and risk loosing a lot of money in case of health emergency

My wife runs her own consulting business, I’m taking a break from tech work. This means we buy insurance on the federal marketplace (healthcare.gov).

It is expensive, but not insanely so. Family of four, living in Oregon, non-smoking, our premium is ~$1k/month. Granted it’s a high deductible ($12k), but it protects us from the kind of catastrophic emergency that could wipe out our savings. We are fortunate to not have expensive, ongoing conditions.

Granted, $12k/year is a lot for less affluent families, but government subsidies can bring the premium down considerably if your income is low enough.

And while the coverage is far inferior to my old FAANG luxury health plans, it still works well enough.

> Family of four, living in Oregon, non-smoking, our premium is ~$1k/month. Granted it’s a high deductible ($12k), but it protects us from the kind of catastrophic emergency that could wipe out our savings. We are fortunate to not have expensive, ongoing conditions.

Family of two, living in the EU, non-smoking, our premium is ~€0/month. Granted it's a €0 deductible, but it protects us from the kind of catastrophic emergency that could wipe out our savings.

Are you unemployed? Otherwise, this is just not true. Assuming OP and his wife earn average incomes for academics in the US, they'd pay 2x ~920 USD per month in Germany, totaling 80% more than the premium and only 9% less than the worst case scenario of OP having to pay the full deductible.

Average salary for a full professor in the US is $129K, which would put it closer to $800.

That being said, the average professor salary in Germany is around 84,000 Euro, so it's closer to $560 a month.

You also ignore that after the high deductible is paid in the US you're still paying co-insurance and co-pays. (I love how US health insurers describe these as "your contribution" to your healthcare costs, as if you weren't already paying premiums and deductibles, but the magical insurance fairy is...).

Yeah but you need to put the 1k OP pays into the context of US salaries, not German salaries.

Worst case is significantly worse: deductible, out-of-pocket maximum, copay of X%, and potential for out of network costs.

:). If only people in America understood how they are being scammed by the Health Insurance Mafia.

Taxes you pay pay for this, or your employer pays it instead of paying you.

Now you can argue that health care costs less on a per basis, or even per productive taxpayer basis, but that's a different matter. Maybe the US could recreate your healthcare COST system, but it doesn't have to also take on your payment system (tax instead of direct)

Healthcare delivery in the US is — not good.

Absolutely, that's why you hear about rich Americans traveling internationally to have their medical procedures done.

But after taxes and lower salary, I bet you're more than $12k/yr behind an equivalent US employee's net earnings yes?

Yes 100%. You can make 50k as a developer in London or 250k in California.

Your premium is paid by your employer. Please revisit the statement when you are self-employed.

Also, turns out there is a deductible if you don't want to pay a fortune for self-insurance.

Well, at least there is in Germany. And the premium ends up being ~$1k/month.

US health insurance is crappy in many ways, but EU health insurance isn't a magic fairy unicorn either.

This is flat out not true. Your health insurance is paid by your employer, and it's not at all cheap. If you were self-employed, you would be paying for your own health insurance. This is de facto the same system as in the US, except it's a criminal offence not to purchase insurance.

In the next-door Czech Republic, it's even mandatory to buy health insurance if you're unemployed, unless you go and register with the 'Ministry of Labour' (which requires you to spend inordinate amounts of time jumping through insane bureaucratic hoops, and is ultimately time limited). Consider for a moment the effect of these laws on people with mental health issues, the homeless, and itinerant minorities like the Roma.

Had a tough year out on the streets, but now getting back up on your feet? Congratulations, here's your back-debt for the 'public' health insurance you failed to purchase, you criminal. Want to take a few months off between jobs? Gotta go down, in person, to your local health insurance office to purchase yourself some public health insurance. Want to start a new business, but haven't made a profit yet? No worries, here's your 'minimum rate' of mandatory health insurance - prepare to shell out several thousand euros a year and spend time every quarter filing paperwork with the government health insurance bureau.

There are excellent public health care systems out there (e.g. Australia, and probably the Nordic countries) but much of continental Europe has truly terrible ones. And that's before you even discuss the difficulty of securing a doctor, or the actual quality of medical care received.

I had the misfortune of suffering through a multiple sclerosis diagnosis when I was just 18-years-old, and the bottom line cost for that (only outpatient care) was approaching $50k in 2001. I imagine that price has more than doubled since. It caused my financial condition and professional development to crash and stall just as it was beginning. It’s impossible to know what might have been, but I sincerely believe that my circumstances, and the limited options for mitigating their long term effects, cost me (and by extension, society) at least 10x that initial bottom line cost in missed opportunities, and lost productivity/wages.

What makes the issue so terribly entrenched, apart from our peculiar association between health insurance and employment, is how utterly opaque everything about healthcare costs are. Both systemically, in that it’s much more difficult to craft policy, as well as practically, in that for many (most?) individuals it can be impossible to know in advance how much any given course of treatment might cost, and no opportunities for “shopping around” or price comparisons.

For most Americans, and companies, I think our healthcare system is essentially a very short-sighted and inefficient tax. For others—people in situations such as mine, and very probably for a meaningful portion of the ~30M-50M Americans still uninsured/underinsured—it’s an unreasonably high burden that accounts for so much more than just the money spent, and a constant specter clouding their lives in uncertainty and risks. For the self-employed and entrepreneurs, it’s a crucial consideration that defies simple calculations, and just by the averages will have prevented a significant number of potential endeavors from ever leaving the initial planning stage and/or denied startups access to otherwise valuable talent. We should be pursuing bigger picture policies, and while I’m not arguing that the federal government is a good answer to everything, it’s clearly the answer to this kind of management of universal needs with clear societal benefits.

Sorry for the lengthy comment, my hamster brain was apparently restless. For anyone who did, thanks for taking the time to read.

Thanks for sharing your story.

It’s a tragedy that universal healthcare and tougher regulation against unhealthy food is still not achieved.

If you don’t mind me asking, what advice would you share to deal with such diagnosis and making it through?

> buy insurance from your own pocket

In other words, buy it on the market, like the GP said.

With ACA subsidies, you'll never have to pay more than 8.5% of your income in premiums for a mid-range plan. And that's in the worst case -- it'll typically be less (if you make less, you'll qualify for larger subsidies or free healthcare, and if you make more, the proportional cost of insurance premiums will be lower).

I think it will be (much) more expensive, but I am not an expert.

In the US there is the affordable care act from ~2013, where anyone can purchase insurance from a pooled market subsidized by the government up to a certain income (50k I think). But that is also impacted by the state you live in, as the states negotiate the contracts paid by federal dollars (I know it's effed up). So the ACA is cheaper on the west coast than it is in Alabama. Today, a "gold" policy for a single man in his 40's is about $900/month through the ACA. The cheaper "emergency" plans (aka "trash" plans) appended by Trump are still a few hundred dollars, but cover almost nothing.

I now pay $120 for me and my wife for a plan that is better than the $1000 plan through the ACA in Oregon because I'm no longer self employed.

That's almost a 10x difference.

After working for myself for 12 years, hustling consulting and contracting gigs, I'm way happier working for a company that pays well, has great benefits, and I always know I have a paycheck coming.

I have a feeling your employer is paying the difference, so basically you're paying one way or another.

Exactly this. People feel like wages have not been increasing. In reality wages have been increasing, but employers are passing most of the increase over to health insurers.

No feeling that is the reality. But corporations get steep discounts. They pay about half to a quarter of what I would pay on my own.

> I now pay $120 for me and my wife for a plan that is better than the $1000 plan through the ACA in Oregon because I'm no longer self employed.

Look at box 12 code DD on your W-2. That is the total amount you are paying for your health insurance (it’s just that your employer is paying it directly). It’s still counted in the cost of employing you though, obviously.

Assuming you have a silver or gold level plan, total cost to insure you and your wife is the same on healthcare.gov or if your employer buys it.

The only broad savings are if your employer is self insuring and their risk pool (employees and their families) are disproportionately low risk (young and single).

It is much lower than what I would pay on ACA.

I wonder if your employer sponsored plan is not ACA compliant.

Health insurance has a 2% profit margin, and premiums are tightly regulated by state insurance commissioners. So a wildly different premium indicates a change in coverage, or a change in the underlying risk pool.

For an annual out of pocket maximum of $10k to $18k and age rating factors capping age 64 premiums to 3x age 21, the minimum bronze/silver monthly premium should be somewhere in the ~$400 to $1,200 depending on age. For example, see NJ’s premiums here:

https://www.nj.gov/dobi/division_insurance/ihcseh/ihcrates20...

This is very informative. I am investigating. Thank you!

You're probably not reading this, but I didn't include what I pay out of pocket to 12d DD ... turns out it is MORE than than the most expensive ACA plan, but I have way more coverage at my job. E.g., I can go out of network, where the ACA plans do not allow that; and the deductibles are less than 1/3 of the lowest deductibles on the ACA. Thanks for that nudge.

Where did you get that 2% profit thing? I've been googling for that too and insurance profits and all I can find is that ACA only allows 20% admin costs. Non ACA plans indicate that their profit is ~15-20% of their revenue.

Search UNH/Elevance/CVS/Cigna/Humama/Molina/Centene profit margins on macrotrends.

These are all publicly listed health insurers, so all their financials are public. It is not a very profitable business, as pretty much all insurance business.

Your employer typically pays the major of the premium.

The healthcare available on the open market wasn't good last I checked. The premiums were much higher than what my employer and I pay combined, the max out-of-pocket was worse, the deductible was worse, the coverage for uncommon medications was nearly nil, and so on.