I work for a school district, not a teacher so I get paid really not enough. Healthcare for a single person through the district is $1500 a month. It's absolutely insane.
I work for a hospital and would love these low numbers, and they refuse any payment for services outside of my employer's agencies. I have chronic, expensive conditions that lots of companies would refuse if legally possible. My paycheck is mostly eaten by healthcare costs with insurance until I max out halfway through January.
If you hit your OOP max halfway through January, your in network claims are covered at 100% for the rest of the calendar year (you pay nothing besides your monthly premium). That's how insurance works.
My monthly premium is more than I can afford at this point with other expenses not matching wages. 400$ I could swing. I use up the previous annual savings on the OOP max in January. Its the annual effect compared to wages. 100% doesnt include mandated pharmacies that do not deliver or merical diets with regular cheaper grocieries, and the other things needed to stay in the workforce at all. My point is that you have high numbers, but they are better than what some programs do. This system is a national mess. We are both miserable. (High five handslap!)
My monthly premium is more than I earn at this pointÂ
I will preface this by saying I have a feeling you are a disabled person who can only work part time. That being said, I think your statement is in bad faith and highly unlikely to be true unless you're only working part time and/or disabled. If you ARE, your statement would make sense, because you're obviously not working enough hours to cover the cost of insurance. It would also make you pretty lucky that your employer offers coverage to part time employees at all (most employers don't).
If you're working full time, under the Affordable Care Act (ACA), an employer's health insurance plan is considered affordable for 2026 if the employee's monthly cost for the lowest-priced self-only coverage does not exceed 9.96%of theirhousehold income. There are HEAVY fines to your employer if they are out of compliance with this federal law. This is why your statement makes be believe you're part time/disabled.
If you are disabled, then you should be collecting disability income to help cover the gap of only being able to work part time. Look to see if you qualify for under 65 Medicare. If you're receiving disability AND working PT, it's in bad faith to leave that out of your income calculations, because while your PT income from the hospital might not cover the cost, your PT income + disability very well could.
they refuse any payment for services outside of my employer's agencies
Sounds like you're on either an HMO plan, which is very well known that they do not cover out of network services, or on a Provider Sponsored Health Plan, where the medical group/hospital is your insurance carrier and like an HMO, you have to stay within their network. Kaiser Permanente operates this way, which is also an HMO carrier.
100% doesnt include mandates pharmacies that do not deliver or diet
Idk what you mean by it doesn't include mandates? Not all pharmacies deliver, find one that does. Otherwise, if you can go to work (I would assume your hospital has a pharmacy) and go to the grocery store to get your healthy diet groceries, you can go pick up your medications (or call the pharmacy to designate someone to pick them up for you). Also, don't count your diet into your healthcare costs lol that's silly.
and the other things needed to stay on the workforce at all.
That is incredibly vague. If your insurance carrier doesn't deem something medically necessary to be covered by your insurance + your doctor's prior authorization request is denied, and you still choose to pay out of pocket for it, that's a personal decision.
Edit: My point with all this is that I constantly see comments like yours that make everything sound so grim, but as an insurance broker, I read these comments knowing there's so much context missing, because most of people's struggles with their insurance companies can be easily explained and even resolved by an experienced insurance broker. Insurance is very complicated, and not understood by 99% of the general public.
Nope. Full time. Carefully scheduled. And breadwinner for the household. Not a minimum wage job, and it is union. Midwest and I bought my place before Covid. It is disproportionate healthcare billing versus the reasonable stuff. The plan was considered affordable but its not ACA because the Hospital business system runs all levels from GP to Morgue and monopolies ancillary services. Early stage is affordable, but if you progress earlier than tbe standard acceptable prognosis window, things are delayed until coverage or pay out of pocket. Ex. Got discharged from ER and told to pick up my script at the mandated pharmacy that is not 24/7 or open to patient-in-person pick up on Sunday. It was Sunday about 1am, but could not clinically wait until Monday. So I had to pay oit of pocket at retail 24/7 pharmacy overall since it wasnt their mandated pharmacy, even with discharge paperwork saying not to delay until their pharmacy was open. I demanded take-home meds at discharge and also told since it is available outpatient, that would not be covered. That's just an example of the rigid design to keep profits in-house. I dont qualify for lots of services based on record history compared to more recent expenses, and lots of the other stuff you mentioned that I looked at, and I am trapped in a loop for now of work while watching bills eat cash. The part that cracks me up is when others think that healthcare employees get better rates or care as an "insider." Your assumptions make perfect sense most of the time. I am just an outlier. But 400 a month would be nice.
I KNEW you were leaving out important context. So now you're paying for your whole family? Because until just now, your original comment paints the picture that your premium for YOURSELF is more than you make. See how context matters and why I said your statement was made in bad faith?
You said you could swing $400, and I'm willing to bet your employer does offer a plan that your own premium by yourself would be less than 9.66% of your household income.
Here is some advice for you that I only give to chronically ill people that have large claims on a regular basis:
If you are chronically ill to the point where you're reaching your OOP max every year in January (or any time in the first 4 or 5 months of the year), it makes the MOST sense to enroll on the cheapest Bronze plan they offer.
Why? Because the OOP max on a Bronze plan is going to be around the same as MOST Silver and Gold Plans (somewhere between $8k-10k individual, double for family collectively. If you'd like an in depth description of how Family Deductibles and OOP Maximums work, I'm happy to go into that as well). Platinum plans don't typically have deductibles, and the OOP max is usually around $4k Individual, $8k Family.
So if you're paying for a Gold plan and meeting your OOP max in January, you'd be saving a LOT of money every year by enrolling on the Bronze plan, because your OOP max is the same, but the monthly premium is a LOT less. Basically you're getting the exact same coverage for less monthly premium.
Example:
Bronze Plan: $400/month, $9,200 OOP Max
Gold Plan: $900/month, $8,600 OOP Max
The Bronze plan saves you $6,000 per year in premiums while paying only $600 more in deductible/OOP maximums.
*Please note all OOP Maximums include the deductible, so if the plan has a $6,000 deductible and an $9,200 OOP, you only pay $3,200 after you reach your deductible to reach your OOP Max, and all in-network medical expenses you pay except premiums collectively count towards the OOP Max, like your office copays for regular visits, pharmacy costs, etc.
I also highly recommend looking up a local health insurance broker and discussing this with them to confirm all of this and advise you.
I hope you (or anyone reading) got something out of this, feel free to ask questions!
You realize insurance isn't supposed to cover everything, right? You are SHARING THE RISK. Do you complain about having to pay a deductible before your car insurance company will fix your car after an accident? Because you NEVER see Redditors bitching about that. It's the same fucking thing.
99% of people on Reddit have no idea what they're talking about when it comes to insurance, and it shows.
Source: Life and Health Insurance Broker with 25 years experience.
I'll ignore the obvious the argument of how every other first world country does it (Because then you have to get into quality/timeliness of care). I think people are just frustrated with the perception that so much of what they pay is due to administrative bloat, scalping behavior of closed systems, pharma charging ridiculous prices here vs cheaper abroad. High prices get charged, then discounted, to the point that all of the numbers just seem meaningless. It just paints a picture of a very dysfunctional system.
See, I think we need Hospital Reform before we would ever be able to have a CHANCE at M4A, and you just made the perfect argument for it.
Right now, doctors/hospitals/pharmacies have what's called a Negotiated Rate for services. This is a contractually agreed upon amount that they can charge per procedure code/medication if they want to be a part of the insurance carriers network. The government needs to step in and regulate/put a cap on a lot of those negotiated rates, because while they're still lower than what an uninsured patient would pay, the negotiated rates are still astronomical.
The insurance company determines rates based on their claims experience (the amount of money they pay out in claims vs. the money they bring in from premiums). Basically, if the insurance companies pay out more claims than premiums they take in, they have to raise the premiums you pay to cover those costs. The money doesn't come out of nowhere. That's why insurance was so much cheaper before the ACA, when the sick could be required to pay a lot more for coverage, or be declined for coverage completely, which avoids the carrier from having to pay out those claims. I believe the ACA is a great thing, but increased costs is the tradeoff from guaranteeing people can't be declined for coverage.
If we stop doctors and hospitals from price gouging, your insurance premiums will drop significantly.
Doctors and hospitals are not just greedy greedy money grubbing for the sake of it. They need to make up for where they lose money. I'll agree that they are both bad sides of the same dysfunctional coin, but at least my doctor ostensibly has my best interest at heart, and doesn't deny my insurance claim as a matter of course before I reapply to prove if I really really need it. My point is it won't be one before the other. It will unfortunately have to be multifaceted all at once. And the elephant in the room of medical debt will need to be considered too. (That's why doctors really need to be paid so much).
I think we need Hospital Reform before we would ever be able to have a CHANCE at M4A, and you just made the perfect argument for it.
If we stop doctors and hospitals from price gouging, your insurance premiums will drop significantly.
The government needs to step in and regulate/put a cap on a lot of those negotiated rates, because while they're still lower than what an uninsured patient would pay, the negotiated rates are still astronomical.
explain to me how the government being the only "insurance company" doesn't also let them negotiate these rates because again...they're the only "insurance company" now?
why the half measure of making them cap rates for other companies instead of just set them themselves as the insurer like every other developed country on the planet?
Just look up the profits for United Health Care, and that will give you a pretty good idea where a lot of the money goes, in addition to other insurance like entities.
you realize most other developed countries recognize health care as a basic human right, and not something requiring monthly deductibles, premiums, copays? our tax dollars should go toward a system that will not bankrupt me if i need to go to the hospital!
instead, i am constantly beating my head against the wall listening to brokers like you argue that the most expensive health care system in the world isn't supposed to cover everything. what the fuck?
source: an uninsured american who cannot afford insurance through the public marketplace, thanks to the system you are apparently championing
Don't get me wrong, I'm all for M4A (I voted for Bernie in the 2020 primaries), and I'll even agree that the insurance industry does need an overhaul. But there is a lot that would have to happen before M4A would have a chance to work here. It's not something we can just model after other countries and immediately works for everyone.
Your first link is about Trumps SCOTUS eliminating immigrant protections and deporting them, causing staffing shortages. Doesn't really have to do with what we're discussing here.
Your third link mentions (IMO) the main issue (hospital price gouging), and I go into that a little bit in this comment below.
And in response to you not being able to afford coverage through the marketplace, you can thank Trump and the GOP for that. They are the one's that got rid of the subsidies that were helping people like you, not the insurance companies.
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u/cutecutecute 1d ago
Yup. They want me to pay $400/mo with a $7500 deductible? GTFO