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*
And please report back on minor medical things! I find that most of us lack an intuition for how much various procedures cost. For example, I only recently learned that x-rays are very affordable; whereas MRIs run you at least a few hundred no matter where you go or how you pay, as far as I can tell.
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.
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/
Thank you, I'll read the post! And great points, especially about the charity care policy. In New York City, all hospitals are legally required to be non-profits, so there are many options for low income people, they're just left purposefully opaque. DollarFor seems like a very cool org...it's tough to navigate this stuff yourself.
> 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.
Yes, I've heard of open enrollment. However, many people qualify for the "special enrollment period," which allows you to enroll even when it's not open enrollment. For example, I qualified to get health insurance immediately when I became pregnant. In my friend's case he qualified due to being low income.
You make a great overall point though that this option is safest if you're low income. For high income people I now recommend joining a health share to cover catastrophes. You might find this post interesting: https://www.mrmoneymustache.com/2020/11/09/direct-primary-care/
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
Only if insurance actually helps you avoid debt, and I'm not convinced. Consider this from the Kaiser Foundation:
"Lacking money to pay a bill is often a reason people fall into debt, but complications in billing and insurance practices may also be contributing factors for some. Two-thirds (67%) of those with health care debt say that in the past five years, they have not paid or only partially paid a medical bill because they didn’t have enough money to pay it. But a roughly equal share (68%) say they have not paid a bill in full because they were expecting their health insurance to pay the bill. About four in ten (44%) adults with health care debt say that they did not pay a bill in full in the past five years because they weren’t sure the bill was accurate."(https://www.kff.org/report-section/kff-health-care-debt-survey-main-findings/)
Either way, I encourage people to make their own decisions, and definitely read the final section of my post, "The Fine Print."
Just came across this post. I don't fully understand the concept of "bad debt," but apparently now more than half of bad debt comes from people *with* insurance, which is a huge change from 2018, when only 11% of people with bad debt were uninsured
This was under the radar but in recent years Congress poured a lot more money into subsidizing ACA plans. Most people at financial risk (the “wouldn’t be able to cover a $400 emergency” question) can get very cheap bronze ACA plans which are catastrophic plus. The “plus” is that the out of pocket caps are much lower than the same plan without the subsidy. This year I decided to use a navigator to help me pick out an ACA plan and he was going to steer me to a silver plan which offers even more protection to the financially vulnerable. I am in good financial shape and don’t qualify for subsidies but I was glad to know this particular safety net seems to be getting stronger.
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.
Yes! I should add a clarifying comment that this is all only true since ACA was passed and insurance companies are no longer able to deny you for pre-existing conditions.
I'm glad that clinical trial worked out for you. How did you find it? Have they since brought the drug/intervention to market?
P.S. Even so my new ACA plan has zero, count them zero, network dermatologists in my area. (My area is Chicago!) So yesterday, this conversation still rattling around in my head, I picked up the phone and called the skin doctor of my choice and arranged to pay cash on the barrel for an annual check. It was $150! That’s all. And for a guy who has had one melanoma removed in the past that is so worth peace of mind.
That’s wonderful! Glad you checked the cash price...I think most of us don’t have an intuition about how much various procedures cost because it’s all abstracted away by insurance. Many procedures are lower than you’d expect! (And occasionally procedures are more than I’d expect, and that’s usually due to a technological limitation)
My existing treatment had stopped working. I was going to the infusion room more frequently and finally my body began reacting. All NIH did was combine that supposedly ineffective drug with another drug and boom! Complete and long-lasting remission. As a Nobel laureate once put it, combo therapy is proof that 1 + 1 = 4. The hilarious part is that my existing drug was state-of-the-art monoclonal antibody. The combo drug was bendamustine, a chemotherapy developed by the EAST Germans (which old timers will remember from their suspiciously buff Olympic athletes). Anyway, it worked.
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.
1) My uninsured friend had a cancer diagnosis recently. The hospital helped him get insurance to cover his chemo, and he wasn't bankrupted. Also, before you hit your deductible, you owe 100% of your healthcare costs. After you hit your deductible, you still owe a portion of your healthcare cost, just not the full amount. But the cost of that care with insurance is often much higher than the cost of that care without insurance. So even though you're only paying a portion, it's a portion of the insurance-inflated cost. You may still end up paying above what you'd pay without insurance.
2) Yes, you have to be flexible on who you'll see. I live in New York City and have almost infinite doctors nearby. I can still keep a high bar for quality, but call around and find a good price too.
3) I agree that you should be picky if you're getting dental work. I haven't needed any dental work in a long time, I just go in for cleaning and x-rays. If a dentist told me I needed work, I would get a second opinion. I also think going without insurance can make you more thoughtful about what care you actually need. If you know you're paying yourself, you're more likely to get a second opinion before having dental work done -- which in this case is a good thing because, as you say, dentists are often incentivized towards overly-aggressive treatment.
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.
I actually really hate spending time on stuff like that, and I would pay a company that could reduce those tasks for me. Unfortunately, my experience is that insurance cannot do that for me. Often, I end up having to negotiate with insurance companies, because they are charging me unreasonable rates (sometimes their out-of-pocket is worse than what I would have paid in cash). And sometimes it's harder to negotiate with insurance companies, because you're negotiating after getting care, rather than before, so you have less negotiating power and no ability to price shop at a different location.
I don't think my experience is unusual either. As mentioned in another comment:
> "Lacking money to pay a bill is often a reason people fall into debt, but complications in billing and insurance practices may also be contributing factors for some. Two-thirds (67%) of those with health care debt say that in the past five years, they have not paid or only partially paid a medical bill because they didn’t have enough money to pay it. **But a roughly equal share (68%) say they have not paid a bill in full because they were expecting their health insurance to pay the bill.**"(https://www.kff.org/report-section/kff-health-care-debt-survey-main-findings/)
If you have a reliable insurance company with fair coverage and no unexpected bills, I would definitely keep them though.
We’re actually starting up a company that disputes medical bills for people because - like you said - it’s so annoying. It’s called Remedy, remedymybill.com
I recently saved my girlfriend $300 by disputing her bills , but it took many hours
I love that idea! I just signed up. I finally received a medical bill for giving birth; I don't know if it needs disputing but in general I think all bills should be looked at carefully. My default plan was to ask Claude about the bill
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/ ?)
Link fixed, thanks for pointing that out
And please report back on minor medical things! I find that most of us lack an intuition for how much various procedures cost. For example, I only recently learned that x-rays are very affordable; whereas MRIs run you at least a few hundred no matter where you go or how you pay, as far as I can tell.
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.
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/
Thank you, I'll read the post! And great points, especially about the charity care policy. In New York City, all hospitals are legally required to be non-profits, so there are many options for low income people, they're just left purposefully opaque. DollarFor seems like a very cool org...it's tough to navigate this stuff yourself.
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.
Yes, I've heard of open enrollment. However, many people qualify for the "special enrollment period," which allows you to enroll even when it's not open enrollment. For example, I qualified to get health insurance immediately when I became pregnant. In my friend's case he qualified due to being low income.
You make a great overall point though that this option is safest if you're low income. For high income people I now recommend joining a health share to cover catastrophes. You might find this post interesting: https://www.mrmoneymustache.com/2020/11/09/direct-primary-care/
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
Only if insurance actually helps you avoid debt, and I'm not convinced. Consider this from the Kaiser Foundation:
"Lacking money to pay a bill is often a reason people fall into debt, but complications in billing and insurance practices may also be contributing factors for some. Two-thirds (67%) of those with health care debt say that in the past five years, they have not paid or only partially paid a medical bill because they didn’t have enough money to pay it. But a roughly equal share (68%) say they have not paid a bill in full because they were expecting their health insurance to pay the bill. About four in ten (44%) adults with health care debt say that they did not pay a bill in full in the past five years because they weren’t sure the bill was accurate."(https://www.kff.org/report-section/kff-health-care-debt-survey-main-findings/)
Either way, I encourage people to make their own decisions, and definitely read the final section of my post, "The Fine Print."
Just came across this post. I don't fully understand the concept of "bad debt," but apparently now more than half of bad debt comes from people *with* insurance, which is a huge change from 2018, when only 11% of people with bad debt were uninsured
https://amp.theguardian.com/us-news/2024/jan/11/hospital-debt-increase-people-with-insurance
This was under the radar but in recent years Congress poured a lot more money into subsidizing ACA plans. Most people at financial risk (the “wouldn’t be able to cover a $400 emergency” question) can get very cheap bronze ACA plans which are catastrophic plus. The “plus” is that the out of pocket caps are much lower than the same plan without the subsidy. This year I decided to use a navigator to help me pick out an ACA plan and he was going to steer me to a silver plan which offers even more protection to the financially vulnerable. I am in good financial shape and don’t qualify for subsidies but I was glad to know this particular safety net seems to be getting stronger.
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.
Yes! I should add a clarifying comment that this is all only true since ACA was passed and insurance companies are no longer able to deny you for pre-existing conditions.
I'm glad that clinical trial worked out for you. How did you find it? Have they since brought the drug/intervention to market?
P.S. Even so my new ACA plan has zero, count them zero, network dermatologists in my area. (My area is Chicago!) So yesterday, this conversation still rattling around in my head, I picked up the phone and called the skin doctor of my choice and arranged to pay cash on the barrel for an annual check. It was $150! That’s all. And for a guy who has had one melanoma removed in the past that is so worth peace of mind.
That’s wonderful! Glad you checked the cash price...I think most of us don’t have an intuition about how much various procedures cost because it’s all abstracted away by insurance. Many procedures are lower than you’d expect! (And occasionally procedures are more than I’d expect, and that’s usually due to a technological limitation)
My existing treatment had stopped working. I was going to the infusion room more frequently and finally my body began reacting. All NIH did was combine that supposedly ineffective drug with another drug and boom! Complete and long-lasting remission. As a Nobel laureate once put it, combo therapy is proof that 1 + 1 = 4. The hilarious part is that my existing drug was state-of-the-art monoclonal antibody. The combo drug was bendamustine, a chemotherapy developed by the EAST Germans (which old timers will remember from their suspiciously buff Olympic athletes). Anyway, it worked.
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.
1) My uninsured friend had a cancer diagnosis recently. The hospital helped him get insurance to cover his chemo, and he wasn't bankrupted. Also, before you hit your deductible, you owe 100% of your healthcare costs. After you hit your deductible, you still owe a portion of your healthcare cost, just not the full amount. But the cost of that care with insurance is often much higher than the cost of that care without insurance. So even though you're only paying a portion, it's a portion of the insurance-inflated cost. You may still end up paying above what you'd pay without insurance.
2) Yes, you have to be flexible on who you'll see. I live in New York City and have almost infinite doctors nearby. I can still keep a high bar for quality, but call around and find a good price too.
3) I agree that you should be picky if you're getting dental work. I haven't needed any dental work in a long time, I just go in for cleaning and x-rays. If a dentist told me I needed work, I would get a second opinion. I also think going without insurance can make you more thoughtful about what care you actually need. If you know you're paying yourself, you're more likely to get a second opinion before having dental work done -- which in this case is a good thing because, as you say, dentists are often incentivized towards overly-aggressive treatment.
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.
I actually really hate spending time on stuff like that, and I would pay a company that could reduce those tasks for me. Unfortunately, my experience is that insurance cannot do that for me. Often, I end up having to negotiate with insurance companies, because they are charging me unreasonable rates (sometimes their out-of-pocket is worse than what I would have paid in cash). And sometimes it's harder to negotiate with insurance companies, because you're negotiating after getting care, rather than before, so you have less negotiating power and no ability to price shop at a different location.
I don't think my experience is unusual either. As mentioned in another comment:
> "Lacking money to pay a bill is often a reason people fall into debt, but complications in billing and insurance practices may also be contributing factors for some. Two-thirds (67%) of those with health care debt say that in the past five years, they have not paid or only partially paid a medical bill because they didn’t have enough money to pay it. **But a roughly equal share (68%) say they have not paid a bill in full because they were expecting their health insurance to pay the bill.**"(https://www.kff.org/report-section/kff-health-care-debt-survey-main-findings/)
If you have a reliable insurance company with fair coverage and no unexpected bills, I would definitely keep them though.
We’re actually starting up a company that disputes medical bills for people because - like you said - it’s so annoying. It’s called Remedy, remedymybill.com
I recently saved my girlfriend $300 by disputing her bills , but it took many hours
Anywho, thanks for the great read Riya
I love that idea! I just signed up. I finally received a medical bill for giving birth; I don't know if it needs disputing but in general I think all bills should be looked at carefully. My default plan was to ask Claude about the bill
oh! thank you!