[lotsofpulp]

Here is a good pdf where you can calculate it for your age:

https://www.state.nj.us/dobi/division_insurance/ihcseh/ihcra...

Basically, the metal levels are as follows: bronze, silver, gold, platinum are priced so that you the insurance company pays 60%, 70%, 80%, 90% of the healthcare costs.

Of course, this is an actuarial calculation, so it’s only true over a large population over a long timeline. But healthcare is a pretty certain need for everyone, so the cost for healthcare for everyone from age 0 to 65 (when government starts offering it called Medicare) is amortized into health insurance premiums for all of the 0 to 65 years.

The ACA law of 2010 requires a few things which cause the premiums to be adjusted such that younger people subsidize older people. The age rating factor table at the bottom of the linked pdf shows that the riskiest person (64 year old) must cost at most 3x what a 21 to 24 year old costs.

Also, healthy people subsidize unhealthy people because your health condition cannot be taken into account when determining premiums, and men subsidize women since gender cannot be taken into account (due to birthing).

As far as I know, smoking is the only activity that causes one’s premium to be higher.

Let’s take a silver HSA plan for example:

https://www.horizonblue.com/qhp/files/2021/2021_IHC_OMNIA_HS...

The out of pocket maximum for in network providers is $6,550. The premium is $350 per month. So $4,200 premium plus $6,550 out of pocket means a 21 to 24 year old pays at most $11k per year for healthcare if they get into trouble (most will only pay the $4.2k premiums since they are 21 to 24 and probably will not need healthcare).

A complication to these calculations is when employees pay, they can pay with pretax money, and HSA plans allow you to invest your HSA contributions tax free (max of a few thousand dollars per person per year).

[ChrisRR]

Wait, so insurance doesn't even cover 100% of the costs?

So when you hear about those people who get lumped with $100k medical bills they still have to pay like $20k of that on top of your insurance?

What happens if you can't afford the remaining percentage?

[wincy]

You just get the care anyway and get a bill later. It’s all pretty weird.

My wife got a medical bill for $100k after being hospitalized with a life threatening illness years ago called and told them she’d send them $6,000. They said fine and considered it paid in full. The whole system is really bizarre.

My uncle has cancer and no insurance and is on Medicare so all his costs are covered.

My daughter is disabled and is also on Medicare, which is a weird mix of private and public where Medicare pays her primary insurance deductible so if she gets a surgery any surgery or doctors visits we might need after that in the year are going to be free.

I was unemployed when my disabled daughter was born so it didn’t cost us a dime, if I’d been employed it would have cost at least several thousand dollars. I started a job a week later but that didn’t retroactively change the cost owed.

When my disabled daughter was in the NICU for six months while a recruiting firm was technically my employer, she ruined their health insurance plan by racking up a million dollars in fees because they only had 60 or so employees, so the cost was extreme and their health insurance renewal rates were more expensive for a worse plan. I left the plan and used a Health Insurance marketplace plan instead which was cheaper and better than what their organization was offering for the following year.

[rightbyte]

> she ruined their health insurance plan by racking up a million dollars in fees because they only had 60 or so employees

That is really bad. The gov or insurance providers (whoever is responsible) are essentially discouraging employing people with sick family members.

[lotsofpulp]

There was a lot of uproar from middle and upper middle class people when the original healthcare reform proposals in 2009 involved getting rid of all employer sponsored health plans.

Many leaders at that time did want to dump everyone into one insurance market so all healthy people subsidized all sick people, but there was tons of politics blowback from people who already had access to good healthcare who would see their costs rise because until then, they only had to share costs between healthy, employed workers.

Even today, you will read people lamenting how the ACA increased their health insurance premiums. Nevermind that it enabled millions more to actually get healthcare, so obviously the money was going to have to come from somewhere.

[lotsofpulp]

Insurance in general typically has deductibles (auto, home, renters, etc). for which you are responsible for first before the insurance kicks in. This is beneficial since it allows for lower premiums and lets customers pay out of pocket for expenses that they can afford. As a concept, it only makes sense to purchase insurance for expenses that you cannot afford.

>So when you hear about those people who get lumped with $100k medical bills they still have to pay like $20k of that on top of your insurance?

It depends if the person was insured or not, and if the care was provided by healthcare providers who have contracts with the insurance company or not (referred to as being in network).

In the US, when you go to a healthcare provider, the first thing they will ask you to sign is a form acknowledging you know you are responsible for anything your insurance company does not pay for (unless you go to a vertically integrated healthcare / health insurance company like Kaiser Permanente). In fact, health insurance companies are better referred to as managed care organizations (MCOs) in the US.

What happens is people are not capable of knowing what healthcare services they need or do not need. They have no way to determine if they are being ripped of or not. So the MCOs employ legions of doctors and pharmacists and whatnot to double check the doctors performing the services. They also have enough knowledge about pricing healthcare procedures that they are more able to determine a "good" price to pay.

Anyway, after the ACA law, there is an out of pocket maximum for in network providers, so you would not get a $100k bill. the out of pocket maximum for individual / family is $8,550 / $17.1k in 2021:

https://www.healthcare.gov/glossary/out-of-pocket-maximum-li...

So you would only be liable up to that amount at most in a calendar year for all healthcare you receive from an in network provider. Everything else is paid for by insurance.

>What happens if you can't afford the remaining percentage?

The healthcare provider can choose to go after you for it, since you signed the form that says you will pay them if insurance does not. If you feel your insurance denied the doctor inappropriately, you can appeal to a third party to determine if insurance is obliged to pay it (if it is evidence based medicine, then they most likely have to pay it).

[ghaff]

Decent insurance plans typically have an out of pocket maximum--at least for what they cover.

[lotsofpulp]

All US health insurance plans have an out of pocket maximum, by law per ACA of 2010.

https://www.healthcare.gov/glossary/out-of-pocket-maximum-li...

And they have to cover all non elective procedures.

[PeterisP]

Medical bills are considered to be the most frequent reason for personal bankruptcies in USA.

[ghaff]

Medical illnesses are the most frequent reason. Which can include bills of course. But also includes inability to work, a requirement for ongoing home help, etc.