You Don't Need Health Insurance

American healthcare is affordable, with or without insurance :)

I spent years without health insurance, by choice. I discovered one of America’s best kept secrets: you don’t need health insurance. 

Of course, if your employer subsidizes your health insurance it might be worth having. But you may want to consider foregoing health insurance if:

• Your employer doesn’t provide health insurance, and

• Your monthly health insurance payment is expensive, and

• You don’t live in one of the six states that charges a tax penalty for going without insurance (California, D.C., Massachusetts, New Jersey, Rhode Island, Vermont), and/or

• You want to take a sabbatical but are held back by the fear of going without health insurance

Everyday health care is affordable even when paying cash. And you can negotiate emergency hospital bills with or without insurance.

Everyday Healthcare is Just Plain Affordable

Regular health checkups are affordable with or without insurance. Here are some examples of my healthcare spend:

• My last dental exam, cleaning and x-ray was $40 through Groupon. The dentist I went to had 4.7 stars on Groupon, and 5.0 stars on Google Maps.

• For many years, I bought contact lenses from Britain. Their optometry regulations are more reasonable than ours. At the time I paid $55 for a 3 month supply from Daysoft, as opposed to hundreds of dollars from an American company. 

• I buy my glasses through Zenni. Their glasses start at $6.95, so there’s no need to use insurance to pay for them.

• A couple months ago I broke my pinky. I called a few emergency rooms and found I could get an exam and x-ray for $250 cash. While $250 isn’t cheap, it’s less than my monthly insurance payment would be if I had insurance.¹ Plus, I wasn't limited to emergency rooms that were “in-network.” Since I could go anywhere, I went to a facility that was only a 12 minute walk from me.²

• When I need to get a prescription, I go to affordable virtual appointments through K Health or GoodRX. I love that I can schedule instantaneous appointments and take them from my couch.

• For doctor's appointments that need to be in person, I browse Zocdoc. First I look for doctors that have availability soon. Then I check that the doctor has good reviews on both Zocdoc and Google Maps. If so, I call their office and ask for their cash price. Cash prices can vary immensely, but if I call 3-5 places I can find a well-priced appointment.

You Can Negotiate Without Insurance

The examples I listed above are all cases when you can know the price ahead of time.

What happens if you have an emergency? What if you don’t have time to research affordable care, and get hit with a giant bill later?

You may have seen giant numbers listed on your insurance bills. Those numbers are made-up. They don’t represent what the insurance company ultimately pays the hospital. After receiving the bill, the insurance company then "negotiates" the bill down. This makes the patient feel like insurance saved them a bunch of money. But the provider and the insurer know the original stated number is make-believe.

So what kind of surprise bill will you receive?

Often, the cash price is cheaper than what you'd pay out-of-pocket with insurance. So your insurance-less hospital bill might be extremely affordable.

However! 80% of healthcare bills are wrong so there's a chance you may get hit with a large bill even when paying cash.³ Wat do?

When you receive a healthcare bill, you should never pay it outright. First, check the bill to make sure that you weren't billed for services you didn’t use. If you are, email to ask that it be removed from your bill.

Here’s an example of an email exchange I had with a dentist a few years ago:

Hi,

This statement is wrong. I declined the Fluoride Rinse, so please remove it from my bill. 

Thank you!

Priya

Within a few hours, I received this reply:

Hello Priya,

The statement you received was an error from our billing department. Please disregard the statement.

Thank you,

Candy

It’s possible that this dentist knowingly mis-billed me, hoping I wouldn’t notice. Or it’s possible it was a legitimate error. Either way, I didn’t have to push too hard or provide evidence. I just stated that the bill was wrong and the charge was immediately dropped.

Yes, you can do that. (Source)

For services you did receive, assume that you are being overcharged and call to ask for a discount. Every situation looks different, and navigating this process requires:

1. Believing that a lower price is achievable

2. Exercising agency

Administrators know that most bills are wrong, so asking for a reduction often works. If it doesn't, call again the next day. You may have just talked to a stickler or someone in a bad mood.

If that fails, you'll have to get creative. It’s hard for me to give blanket advice for these situations. You may need to get cost estimates from other healthcare providers, to find out the "true" cost. You may need to call the billing department and say you’re unable to pay. The hospital would rather that you pay a smaller bill than not pay at all. If necessary, escalate the situation to a watchdog organization or your state's government.⁴

Of course, this might seem like a lot of work. But even with insurance, your co-pay in an emergency may be surprisingly expensive. Or your insurance might deny to cover the procedure at all. In fact, these scenarios happen to one-third of insured Americans.

Having insurance doesn’t free you from giant surprise bills. It doesn't free you from taking unreasonable measures to get those bills fixed. It gives you the illusion of safety, the illusion that all your medical bills will be taken care of.

Get insurance when it makes sense 

Health insurance might be a financially good decision in specific scenarios.

If you are diagnosed with a chronic illness, explore your insurance options. Determine if an insurance plan or paying cash will be more affordable. Once, my uninsured friend was diagnosed with cancer. Hospital staff helped him set up insurance that helped pay for chemotherapy.⁵

I’m pregnant, and I’m giving birth at home. Very few insurance plans cover home births, so in most cases, insurance wouldn't save me money. But there are a handful of insurance plans that do cover home births. I compared the costs of going forward without insurance or with one of those plans.⁶ Ultimately, I'd save money by going with a particular insurance plan, so I enrolled in the plan as soon as I could.⁷

So far I’m not sure if it’s been worth it. Customer service representatives gave me the wrong information multiple times. I was told that care would be covered that was later denied. I have now spent hours on the phone with my insurance company to get them to keep their promises. I bet everything will work out fine, but it’s been hard to navigate healthcare with insurance!

The Fine Print

I only have a few friends who go without insurance by choice. This is a frontier approach and a relatively untested solution. I’d only recommend going without insurance if you have a high risk tolerance. And if navigating the world without health insurance excites you more than it scares you.

If you’re curious about this approach but want to mitigate your risk, keep your insurance. But explore some of the cash options listed in the first section. You may find you have more choice and save money.

In conclusion: American healthcare is broken. Navigating the system requires you to be high agency and advocate for yourself. This is true with or without insurance! And from what I've seen, it's not clear to me that insurance saves you money by default.

Thank you to readers who pointed me to some other excellent posts about health insurance. I highly recommend reading Two Years Without Health Insurance.

If you’re going on sabbatical and expect to be income-less for the calendar year, read Sabbatical FAQ: Healthcare.

1. I’m on sabbatical so my insurance isn’t subsidized by an employer. On the New York State of Health Marketplace, my monthly insurance payment would be $500+.

2. I love living in a walkable city 🥰

3. Why are 80% of healthcare bills wrong? This is a complicated question that I’m only beginning to untangle. TL;DR healthcare suffers from misaligned incentives. Assume that many actors in the healthcare system are knowingly overcharging you 😕

4. To find out where to report healthcare fraud, google “surprise medical bills <your state>”. For me the very first result was this Department of Financial Services page. If all else fails, I can go file an independent dispute resolution (IDR) with New York State.

5. Insurers can’t refuse to cover you or charge you more due to a “pre-existing condition.”

6. This would have been impossible to check by myself due to the opaqueness of insurance. My midwife's billing department walked me through everything 🙏🏽

7. In my case, I was able to enroll in a plan right away because becoming pregnant is a “qualifying life event.” In other cases you may need to wait a few months to enroll in a plan. In the interim months, continue using market-based healthcare. Call around to find affordable care, and negotiate down high bills.