Excellent post—I love the “Actually, you can just do <blank>” genre.
I’m inclined to dismiss the fellow comments of the form, “Someone might read <this dangerous misinformation> and <experience horrible consequence>”—I suspect that the (hypothetical) lowest common denominator that your “advice” might harm is unlikely to be found here reading it. (And “fools might be misled” seems a poor reason to not write in general”.)
To the contrary, I’m now inspired to investigate the cash cost for a few minor medical things I’ve been putting off that would improve quality-of-life. If I go bankrupt, I’ll be back to complain…. *grin*
Great post! I wrote about my experience with low-cost and no-cost healthcare in CA a while ago (https://kzhai.substack.com/p/sabbatical-faq-healthcare), but the lessons in negotiating are super useful! An additional caveat: check if your state still has a health insurance mandate (i.e. tax penalties for no insurance). CA does but I don't think NY does.
Related note about hospital debt: check their Charity Care policy! It's financial assistance for people who can't afford to pay. If you make under a certain amount of money, many hospitals are legally required to forgive your medical bills Just search for "<your hospital name> financial assistance" or use this website: https://dollarfor.org/
What a ridiculous post. Such a disservice for all those that might eventually be confronted with a real medical issue other than buying glasses or some minor expenses.
My brother had a brain tumor at age 24. He survived and is glad he had insurance. The treatment would have bankrupted our entire family, across generations.
> Once, my uninsured friend was diagnosed with cancer. Hospital staff helped him set up insurance that helped pay for chemotherapy
>> Insurers can’t refuse to cover you or charge you more due to a “pre-existing condition.”
Have you heard of open enrollment? You can't just walk into and say "1 insurance please!", you need to wait till the end of the year, enroll, then wait till the next calendar year. This advice is not only stupid it's actively dangerous. Cancer is a race against time and putting off chemo/other treatment until you can aquire insurance is absurd.
66.5% of bankruptcies in the US are because of medical bills. One bad injury or major illness can result in huge bills, seems pretty irresponsible to recommend not even having catastrophic insurance
I do think preexisting conditions complicate the picture a bit. I didn’t feel comfortable leaving my job until the Supreme Court upheld ACA because my chronic leukemia instantly eliminated me from insurance plans. The irony was that I was in a clinical trial that wound up arresting my illness and costing me nothing. Since then I have paid thousands in insurance premiums and racked up next to nothing in claims.
Interesting perspective! This has inspired me to consider canceling my dental insurance.
I did want to bring up 3 concerns that came to mind:
1) INSURANCE AGAINST CATASTROPHE
I think of my medical insurance as a protection from catastrophe. If I have a very bad accident or a sudden cancer diagnosis, uninsured care could wipe me out financially. I buy a plan with a very high deductible to try to pay the cheapest price I can for protection from that kind of black swan catastrophic risk. Co-pays and deductibles would still be pricey, but at least I'd have my insurance's out-of-pocket maximum to preserve my net worth.
I can definitely see an argument against this though. Even high-deductible insurance is still very expensive. If you go without insurance and experience a ruinous catastrophe, bankruptcy is always an option, and you can enroll in insurance again at the next Open Enrollment or Qualifying Event. Bankruptcy is awful, but survivable. You're unlikely to end up in a Walter White situation.
As you suggest, this option could make sense for folks with a high risk tolerance. Even more so if your assets are limited (the money saved on insurance is more valuable, and you'd have less net worth to lose in declaring bankruptcy).
2) MY EXPERIENCE NEGOTIATING CASH PRICES
Since I rarely meet my plan's high deductible anyway, I often try this. Unfortunately, it has rarely worked for me. Possibly because most of the doctors and specialists I want to see are working in hospital-affiliated practices, and perhaps the hospital provides them less leeway.
I do expect that this would work if I were more flexible on provider and able to invest time into shopping around, as you suggest.
3) CHOOSING A DENTIST
This will be long - I'm opinionated on the subject. 😅
I'd recommend a different system for choosing dentists. There's lots of fascinating reading and research out there that boils down to: the vast majority of dentists overtreat. Researchers will show the same dental x-rays to 5 dentists, and in response get 5 different conflicting diagnoses, with each dentist spotting a different set of cavities on different teeth.
It's not about dentists being malicious. It's just that these diagnoses are more art than science. Literally chasing shadows (cavities appear on x-rays as "shadows"). The lines between "we should keep an eye on that," "we should fill this cavity," and "this cavity is beyond filling, we need a root canal," are all very blurry. And there's no feedback mechanism for a dentist to learn from experience when they make a false-positive diagnosis. If a dentist fills something that they think is an irredeemable cavity, there's no post-op biopsy to tell them if they were right. No malpractice suits either. OTOH, false-negatives become obvious when more serious treatment becomes necessary. So the feedback mechanism only points towards more treatment.
In addition - amid this empirical haze - the dentist's monetary incentives point clearly and universally towards aggressive treatment.
Patients are ill-equipped to identify overtreatment, and thus it's hard to identify the ideal conservative dentist from patient reviews. In general, reviews tell you more about a physician's bedside manner than anything else. Instead of judging from star-rating, I'd suggest looking for dentists with reviews that mention the dentist deciding to watch a potential cavity instead of treating it, or the dentist recommending against another dentist's more liberal treatment recommendations.
When I moved to Boston, I tried a few different dentists that were recommended to me by friends. All claimed that I had many cavities, and one said that I needed my wisdom teeth extracted. My original hometown dentist disagreed, and I kept searching. Eventually I found a dentist through the method above whose diagnoses lined up with my hometown dentist. It's possible that I'll need 10 emergency root canals in the future, but so far (~2 years) I've been happy!
The process takes a while and the dentist you find may not be the cheapest, but in the long run I suspect you'll save money by averting unnecessary procedures. You'll also be able to keep more of your natural tooth material, which I understand to be helpful in old age.
Interesting. It seems like you'd have to be a person with a ton of time/patience though, to make all of that effort negotiating and questioning bills. Time is money for some of us. Getting older, having kids and knowing that life threatening emergencies and health care crises can happen at any time are other reasons why I could never imagine doing something like this. But to each their own of course, and it's always good to know that there are other options available. Of course, we wouldn't even need to be having this conversation if the U.S. was civilized enough to offer universal health care coverage for all.
Excellent post—I love the “Actually, you can just do <blank>” genre.
I’m inclined to dismiss the fellow comments of the form, “Someone might read <this dangerous misinformation> and <experience horrible consequence>”—I suspect that the (hypothetical) lowest common denominator that your “advice” might harm is unlikely to be found here reading it. (And “fools might be misled” seems a poor reason to not write in general”.)
To the contrary, I’m now inspired to investigate the cash cost for a few minor medical things I’ve been putting off that would improve quality-of-life. If I go bankrupt, I’ll be back to complain…. *grin*
(The link to “Two Years Without Health Insurance” at the end seems to be broken—I imagine it should lead to https://www.mrmoneymustache.com/2020/11/09/direct-primary-care/ ?)
Great post! I wrote about my experience with low-cost and no-cost healthcare in CA a while ago (https://kzhai.substack.com/p/sabbatical-faq-healthcare), but the lessons in negotiating are super useful! An additional caveat: check if your state still has a health insurance mandate (i.e. tax penalties for no insurance). CA does but I don't think NY does.
Related note about hospital debt: check their Charity Care policy! It's financial assistance for people who can't afford to pay. If you make under a certain amount of money, many hospitals are legally required to forgive your medical bills Just search for "<your hospital name> financial assistance" or use this website: https://dollarfor.org/
What a ridiculous post. Such a disservice for all those that might eventually be confronted with a real medical issue other than buying glasses or some minor expenses.
My brother had a brain tumor at age 24. He survived and is glad he had insurance. The treatment would have bankrupted our entire family, across generations.
What complete and utter bullshit.
> Once, my uninsured friend was diagnosed with cancer. Hospital staff helped him set up insurance that helped pay for chemotherapy
>> Insurers can’t refuse to cover you or charge you more due to a “pre-existing condition.”
Have you heard of open enrollment? You can't just walk into and say "1 insurance please!", you need to wait till the end of the year, enroll, then wait till the next calendar year. This advice is not only stupid it's actively dangerous. Cancer is a race against time and putting off chemo/other treatment until you can aquire insurance is absurd.
66.5% of bankruptcies in the US are because of medical bills. One bad injury or major illness can result in huge bills, seems pretty irresponsible to recommend not even having catastrophic insurance
Nice to see you mythbusting again, Priya!
I do think preexisting conditions complicate the picture a bit. I didn’t feel comfortable leaving my job until the Supreme Court upheld ACA because my chronic leukemia instantly eliminated me from insurance plans. The irony was that I was in a clinical trial that wound up arresting my illness and costing me nothing. Since then I have paid thousands in insurance premiums and racked up next to nothing in claims.
Interesting perspective! This has inspired me to consider canceling my dental insurance.
I did want to bring up 3 concerns that came to mind:
1) INSURANCE AGAINST CATASTROPHE
I think of my medical insurance as a protection from catastrophe. If I have a very bad accident or a sudden cancer diagnosis, uninsured care could wipe me out financially. I buy a plan with a very high deductible to try to pay the cheapest price I can for protection from that kind of black swan catastrophic risk. Co-pays and deductibles would still be pricey, but at least I'd have my insurance's out-of-pocket maximum to preserve my net worth.
I can definitely see an argument against this though. Even high-deductible insurance is still very expensive. If you go without insurance and experience a ruinous catastrophe, bankruptcy is always an option, and you can enroll in insurance again at the next Open Enrollment or Qualifying Event. Bankruptcy is awful, but survivable. You're unlikely to end up in a Walter White situation.
As you suggest, this option could make sense for folks with a high risk tolerance. Even more so if your assets are limited (the money saved on insurance is more valuable, and you'd have less net worth to lose in declaring bankruptcy).
2) MY EXPERIENCE NEGOTIATING CASH PRICES
Since I rarely meet my plan's high deductible anyway, I often try this. Unfortunately, it has rarely worked for me. Possibly because most of the doctors and specialists I want to see are working in hospital-affiliated practices, and perhaps the hospital provides them less leeway.
I do expect that this would work if I were more flexible on provider and able to invest time into shopping around, as you suggest.
3) CHOOSING A DENTIST
This will be long - I'm opinionated on the subject. 😅
I'd recommend a different system for choosing dentists. There's lots of fascinating reading and research out there that boils down to: the vast majority of dentists overtreat. Researchers will show the same dental x-rays to 5 dentists, and in response get 5 different conflicting diagnoses, with each dentist spotting a different set of cavities on different teeth.
It's not about dentists being malicious. It's just that these diagnoses are more art than science. Literally chasing shadows (cavities appear on x-rays as "shadows"). The lines between "we should keep an eye on that," "we should fill this cavity," and "this cavity is beyond filling, we need a root canal," are all very blurry. And there's no feedback mechanism for a dentist to learn from experience when they make a false-positive diagnosis. If a dentist fills something that they think is an irredeemable cavity, there's no post-op biopsy to tell them if they were right. No malpractice suits either. OTOH, false-negatives become obvious when more serious treatment becomes necessary. So the feedback mechanism only points towards more treatment.
In addition - amid this empirical haze - the dentist's monetary incentives point clearly and universally towards aggressive treatment.
Patients are ill-equipped to identify overtreatment, and thus it's hard to identify the ideal conservative dentist from patient reviews. In general, reviews tell you more about a physician's bedside manner than anything else. Instead of judging from star-rating, I'd suggest looking for dentists with reviews that mention the dentist deciding to watch a potential cavity instead of treating it, or the dentist recommending against another dentist's more liberal treatment recommendations.
When I moved to Boston, I tried a few different dentists that were recommended to me by friends. All claimed that I had many cavities, and one said that I needed my wisdom teeth extracted. My original hometown dentist disagreed, and I kept searching. Eventually I found a dentist through the method above whose diagnoses lined up with my hometown dentist. It's possible that I'll need 10 emergency root canals in the future, but so far (~2 years) I've been happy!
The process takes a while and the dentist you find may not be the cheapest, but in the long run I suspect you'll save money by averting unnecessary procedures. You'll also be able to keep more of your natural tooth material, which I understand to be helpful in old age.
Interesting. It seems like you'd have to be a person with a ton of time/patience though, to make all of that effort negotiating and questioning bills. Time is money for some of us. Getting older, having kids and knowing that life threatening emergencies and health care crises can happen at any time are other reasons why I could never imagine doing something like this. But to each their own of course, and it's always good to know that there are other options available. Of course, we wouldn't even need to be having this conversation if the U.S. was civilized enough to offer universal health care coverage for all.
oh! thank you!