[jjav]

> Still worth it for 'free' education and 'free' healthcare?

No brainer, absolutely worth it.

Even making good money in Silicon Valley I'm perpetually afraid of medical bankruptcy if something were to happen. And the cost of education here takes another 15% off my salary for schools far lower quality than in Finland.

[PopeDotNinja]

I had a six figure income in San Francisco & insurance, and still ended up medically bankrupt. Bike accident, head trauma, unable to work, work tied to job... employer sponsored healthcare sucks if your ability to work is compromised.

[pkaye]

Your employer didn't provide short/long term disability insurance?

[jjav]

Disability insurance provides a percentage of your salary while disabled. It does not provide medical insurance and often you'll get dropped by the company insurance because you're not working.

[soul_grafitti]

Do you live and work in America?

[pkaye]

Yes I do. If you have a six figure salary (or even a bit less), an employer will certainly buy a short/long term disability plan for their employees. Its a perk even small startups can afford.

Also California is unique among the states in that it runs a mandatory short term disability plan through payroll deductions but employers are able to buy enhanced plans which cover higher income thresholds.

[PopeDotNinja]

Even if they did, I was massively depressed with two broken arms and a head injury. I wasn’t thinking clearly about my options. Trying to navigate the healthcare system when you can't wipe your own ass is not a fun situation to be in.

[ryandrake]

Barring the few lucky people with those platinum-plated insurance policies, American workers with normal insurance are one random cancer diagnosis away from total bankruptcy. You can have a great salary, do everything right, be frugal, save in your 401k invest well——it all goes poof when you get sick. Honestly, I’d trade half my salary to not have to avoid the doctor because his diagnosis might ruin me.

[jlmorton]

There's an $8,500 annual maximum out-of-pocket per individual under ACA. That's a lot over several years, but it's not going to be retirement-destroying for most SV workers.

[geofft]

This is only true of Marketplace plans (which are, increasingly, very bad deals is you're not actively using your insurance - even back in 2015 when I was looking for Marketplace plans for myself, I could easily spend close to that amount on the premiums of plans that had high deductibles/coinsurance/etc. and it's not like the Marketplace has gotten more competitive since then), and I think it's only true of expenses that the insurance company is willing to cover - if you get treatment out of network, or if you get treatment beyond what's insured (e.g. you get "elective" surgery on the medical advice of your doctor to avoid a bigger problem later), I don't believe those are covered by the out-of-pocket max.

[jlmorton]

The out of pocket maximum also applies to non-grandfathered group insurance plans. There were some plans allowed to be grandfathered, so the plans wouldn't terminate as non-compliant, but in practice the vast majority of plans terminate every year, and essentially everyone with health insurance now has an $8,500 per individual annual out of pocket maximum. I'm sure if you look at your own insurance, you'll find $8,500 or less.

It's true this cap only applies to in-network, approved care. But that's the same under any health plan, whether universal, or not. For instance, Sovaldi and Harvoni are curative for hepatitis C, but it costs $50,000 for a 12-week course of treatment in the UK. There are 210,000 people with hepatitis in the UK, but the NHS only furnishes 10,000 courses of treatment per year. If you're not approved, you can't get it from the NHS, but you're free to buy it yourself, of course.

[camhart]

Don't most policies have a max out of pocket? Everyone I've seen/had did.

[jjav]

Out of pocket does not mean what normal people think it should mean. Your actual out of pocket can be far larger, up to unlimited.

First, every dollar you pay does not count towards the insurance company tally of "out of pocket". Often it is a tiny fraction. I've personally had years where my true out of pocket was in the several thousands but according to the insurance company my "out of pocket" was less than $100. With that kind of multiplier you can see one can easily spend many tens of thousands before reaching the nominal limit according to insurance company. How do they do this? Because they can and there's nothing to stop them.

Also, insurance plans have caps on what they'll pay. End up in the hospital for months and exceed the limits and it's all out of pocket, which can be in the millions.

Also, these don't include things like prescriptions. A friend (working at a FAANG in SV) spends about $50K/year out of pocket on medicines for chronic conditions.

[camhart]

"The current law bans annual dollar limits that all job-related plans and individual health insurance plans can put on most covered health benefits."

https://www.hhs.gov/healthcare/about-the-aca/benefit-limits/....

"The health care law stops insurance companies from limiting yearly or lifetime coverage expenses for essential health benefits."

https://www.healthcare.gov/health-care-law-protections/lifet...

I wonder what's included in "covered health benefits"/"essential health benefits" and what's not.

[disabled]

Well, wait until you get on Medicare. There are no maximum out-of-pocket limits with Medicare, unless you get a Medicare Advantage Plan (which is almost always an HMO).

Medical underwriting is permitted for Traditional Medicare Part B supplemental/Medigap plans, so pre-existing condition clauses apply, even with the Affordable Care Act.

In other words: once you go on a Medicare Advantage Plan (an HMO) you can never truly go back to traditional Medicare.

If you have cancer or a rare disease (it's not uncommon to have a rare disease--about 7% of the general population collectively has some sort of rare disease) you likely cannot risk being on an HMO if you want to stay alive.

I have 2 rare immune-mediated neurological diseases affecting my peripheral nervous system, and I have traditional Medicare. I require a blood product, called subcutaneous immunoglobulin (administered in that form--it is the only medication that has ever worked for me and has put me in pharmaceutical remission).

If I come back to the United States, I can expect to pay $50,000+/year for my healthcare (mostly due to the subcutaneous immunoglobulin) due to something called the Medicare Part D catastrophic coverage level.

A lot of people, and I mean a lot, get screwed due to the part D catastrophic coverage level. Actually, because of this "program" I never plan on living/working in the US ever again, unless things drastically change.

[thehappypm]

Yes. Out of pocket maxima are extremely common—basically the reverse side of high deductibles.

The parent is fearmongering for some reason. The real scenario is a 2-3 year illness that takes you out of work so long that your lose your employer sponsored plan, have to hoof it with whatever ACA plan you can find, and not have income in the interim.

[ciarannolan]

You're "making good money in Silicon Valley" and don't have health insurance? Are you freelancing and choosing not to purchase insurance?

[bleepblorp]

The overwhelming majority of Americans who experience medical bankruptcy have health insurance.

[purerandomness]

You're obviously not from the US.

In the US, they have this concept of a "pre-existing condition", and depending on your situation, a health insurance might cover it, or not, as far as I understand.

Even making good money in SV, you can still end up with a medical bankruptcy (or your family, for that matter).

[sgerenser]

Since the ACA became law in the US (10 years ago) all health insurance has to cover preexisting conditions.

[ciarannolan]

You're about a decade late with this comment.

Just like I won't expound on German healthcare policy, maybe you should reserve judgement on US healthcare policy until you actually know what you're talking about.

[misterpigs]

You're assuming that whatever you're stricken with leaves you in good enough health to continue working.

[refurb]

But that’s true in Canada as well. The medical expenses might not bankrupt you, but not being able to work will.

https://bankruptcy-canada.com/bankruptcy/causes-of-bankruptc...

[refurb]

You work in Silicon Valley, have good insurance and you’re worried about medical bankruptcy?

I was in the same shoes as you and had zero concerns about it (yes I realized that a very lucky position to be in). Even if I had something horrible happen my max out of pocket was like $4k for the year with no limit to coverage.

If I lost my job, had zero income and no insurance I’d qualify for Medi-cal.

[tclancy]

How did it go when you had a really serious medical situation? My eye opener was my first programming job when one of the owners had twins with really serious health problems at birth. Turned out a million dollars was the cap the insurance was willing to cough up for them.

[klipt]

I think lifetime caps are now illegal thanks to Obamacare?

[refurb]

No more lifetime caps.

[reader_mode]

>Even making good money in Silicon Valley I'm perpetually afraid of medical bankruptcy if something were to happen.

Let me get this straight - you are covered by medical insurance (assuming on "making good money"), and you're "perpetually afraid" that you will be forced in to bankruptcy after being treated for life threatening condition ? Not the fact that you'll first need to have a life threatening condition that requires a huge amount of money to treat, which you will need to overcome to get to the bankruptcy part, but the fact that you'll need to go through bankruptcy afterwards ?

I mean there are ways to hedge against that scenario if you have the money and are really afraid of it - maybe start treating family better and share your money so you have a support network to fall back to if you get in to such situations, or work on building it - going through those scenarios alone is going to suck without it - ignoring social safety net and economic factors.

You people make it seem like bankruptcy is worse than death.

[didip]

It is a very legitimate concern. All it takes is one cancer.

[geofft]

This is an entirely reasonable concern and I agree with it. If you're not in the US (or you're young / otherwise don't know people with horror stories) it may not make sense to you, and yes, it's awful that it's realistic, but it's still realistic.

1. Coverage by medical insurance, in the US, does not generally translate to 100% coverage. For a variety of reasons, including coinsurance, copays, out-of-network coverage (especially common if there's some sort of emergency), in-network coverage beyond what's covered (e.g., the doctor says "this is medically necessary" and some bureaucrat at the insurance company says "I disagree"), and so forth, you can have a medical insurance plan and still be on the hook for large amounts of money.

(I don't think you implied this, but just to clarify, "making good money" is typically not strongly correlated with having good insurance. Because of how byzantine medical insurance is, it's hard for a potential employee to figure out what their offered benefits will actually cover, so it's generally not a factor in negotiations at all, unlike actual salary, and in turn higher-paying employers don't have a particularly strong reason to offer better insurance plans.)

2. You can have a "life-threatening condition" that is easily manageable via modern medicine. Take diabetes, for instance - life-threatening if unmanaged, but very well-understood in how to manage it. I have a friend with a chronic condition that requires taking an (expensive, only partially covered by high-tech-employee insurance plans) injection once a month. As long as they take that injection they're fine; their body becomes effectively unusable without it. I know multiple people who have beaten cancer; I don't think any of them would say that the actual process of beating it was easy (or cheap). The whole reason you care about medical care is so that "life-threatening conditions" stop being life-threatening.

Also, we have this pandemic going around which absolutely can be life-threatening, but even among the people who get very sick with it, many of them come out of it fine provided they have immediate high-quality medical care.

3. Beyond the assumption that the person you're replying to is treating family poorly... the amounts of money in question are generally larger than can even be pooled across many family members and large support networks, even if they all have substantial savings on their own. And even if technically I can manage to pay off a medical bill by exhausting my life savings and those of my extended family, what happens when someone else in the family gets sick?

[reader_mode]

Coverage issues happen in EU with public insurance as well - years back one of my coworkers son had an eye tumour, the experts in country didn't want to treat him because they knew their equipment wasn't precise enough to treat it without blinding him, the medical insurance would not cover out-of-country treatment because the procedure could be performed in-country. He ended up asking for charity to pay for it out of pocket (can't cash out retirement fund). Another coworker needed to get a private surgeon for his father because he was old and the waiting list on cardiac surgery was months, he was not a priority because age/condition.

I don't understand how those amounts can be larger than you can pool from a support network if you have insurance. Even if you lose your job/insurance your spouse can cover you ?

[kaitai]

My friend in graduate school (making $18k a year) had a baby who had some complications; the final bill was $1.5 million dollars. She was an immigrant from the Caribbean; her family there was reasonably paid by national standards there, but... $1.5 million is a lot to cover. And remember, the spouse can't cover you unless you're registered on their insurance.

A few weeks in the NICU and a couple surgeries and there you are, and there is no 'lifestyle change' that really can prevent that sort of thing.

[reader_mode]

Don't get me wrong - the situation sounds terrible and I'm sure the US health insurance system is pretty bad for a lot of people (at least it sounds like your friend got the treatment and can go through bankruptcy to clear off the debt) - but from OPs perspective, being covered by insurance on a good income - being in constant fear of medical bankruptcy sounds bizarre to me.

[geofft]

It is bizarre! We live in a country with bizarre healthcare structures! No one is denying that it's bizarre! We're just saying it's true. You Europeans cannot imagine what it's like here thanks to being surrounded by competent social support structurs your whole life, and it's beyond frustrating that you think you know better than we do how awful it is in our country and how we could "just" do something to make it better. If we could, we would.

I feel like if there's a risk of needing to go through bankruptcy in order to have a child, I would be justified in being terrified of it. Childbirth is in fact a life-threatening event, but it's also one a lot of people go through successfully, and you want to end up on the other side of it with enough money to raise the resulting child.