Basic questions about American healthcare system
April 26, 2013 6:02 AM   Subscribe

I'm a Canadian and somewhat ignorant about the U.S. healthcare system. Some simple questions inside.

I had a conversation with a coworker this morning, who I felt was idealizing the financial aspects of living in the U.S. I pointed out that healthcare costs were significantly higher for Americans, and she said that if you had a middle class job, with good insurance, it wasn't really that expensive. That made me question what I thought I knew about the American healthcare system.

So, I have a few questions. I know that people without health insurance are in pretty bad shape. But if you have "decent" health insurance from a pretty good middle class job (say not the best insurance, but whatever would be pretty typical if you have a job that pays ~$50-70K a year and requires a university degree), could someone please explain the following:

- Do you pay the premiums for your health insurance (for basic coverage of seeing the doctor, not drug coverage) or does the employer?
- If you have to pay the premiums, about how much does it cost per month? Is that cost tax-deductible?
- When you go to the doctor, do you have to pay anything? Or is it all paid by your insurance?
- Say you get pregnant and have a baby. Are there any out of pocket costs? Are your prenatal visits covered 100%? When you go to the hospital for a typical vaginal birth, do you have to pay anything? How much? If you have a c-section, are there additional costs? How much?
- Say you get cancer. Are there costs that you have to pay out of pocket, or is it all covered by your insurance?

Sorry if these are stupid questions, I just have no idea. I'm used to showing my health card and not paying a thing. My impression was that Americans have to pay additional fees even with insurance... but maybe that's just Canadian fear-mongering? Or maybe you have to pay fees, but just very low nominal fees?

Thanks for any and all insight you can provide.
posted by barnoley to Work & Money (70 answers total) 14 users marked this as a favorite
- Do you pay the premiums for your health insurance (for basic coverage of seeing the doctor, not drug coverage) or does the employer?

Typically the cost is shared between employee and employer.

- If you have to pay the premiums, about how much does it cost per month? Is that cost tax-deductible?

The employee-paid component is in the hundreds of dollars per month and varies quite a bit with the particular plan, employer and employee circumstances (e.g. family or individual coverage). Yes, generally tax-deductible.

- When you go to the doctor, do you have to pay anything? Or is it all paid by your insurance?

Typically there are copays due for every doctor visit and prescription, as a disincentive against using medical services unnecessarily. There are also deductibles for some kinds of services, for which insurance doesn't pay anything until the deductible is met. The lower the deductible and the smaller the copays, the more expensive the insurance premiums will be. Again, this varies dramatically.

Everything else varies quite a bit, too.
posted by jon1270 at 6:12 AM on April 26, 2013

1) You pay premiums for the most part.
2) Cost varies
3) You have what is called a co-pay
4) Out of pocket costs for pregnancy vary depending on the nature of the insurance plan under which you are covered.
5) Out of pocket costs for cancer vary depending on the nature of the insurance plan under which you are covered.

Your questions can't really be answered as posed because they all implicitly assume that there is one type of insurance coverage that covers all Americans. That is not the case, though, there are many varying kinds of insurance coverage, all of which have different costs to the patient for different types of ailments and medical situations.
posted by dfriedman at 6:12 AM on April 26, 2013

You might be interested in Michael Moore's film Sicko, which is about high medical costs even for those with insurance. You'd really be amazed.
posted by Admiral Haddock at 6:14 AM on April 26, 2013 [2 favorites]

I'm not an expert, but:

- Its usually split about 50/50.
- Depends on the plan and deductible. $300-$500 out of pocket, off the top of my head. Its not tax deductible for you, but it is for the employer. Usually you can use pre-tax money for all or part of that, depending on what kind of plan you have.
- Usually yes. $10-$25, after to reach $1000-$2000 deductible. But really depends on the plan.
- I don't know. Depends on the plan.
- I don't know. Depends on the plan.

The bottom line though, is that in the American system your insurance is pretty much determined by your employer, so the individual typically has little control over the choices. (The system used by the Federal Government, where individuals can chose from a number of companies, has a lot more flexibility and efficiency.) And of course, where the US system really screws you is that you lose health insurance if you lose your job, so you are instantly doubly fucked.
posted by RandlePatrickMcMurphy at 6:14 AM on April 26, 2013

" My impression was that Americans have to pay additional fees even with insurance... "

Yep. People can and do go absolutely broke paying their medical bills, even when they have "good" insurance. It's not scaremongering. The insurance system in the US really is more insane and callous and inefficient and awful than you could believe.
posted by Ursula Hitler at 6:14 AM on April 26, 2013 [16 favorites]

My daughter and I are covered by my state government health insurance, which is generally considered to be pretty good. My employer covers a portion of my premium, but it still costs me almost $200/month. We pay a copay every time we access medical care. $35 to see the doctor, $70 for mental health, $90 for urgent care, $250 for emergency care. Generic prescriptions cost $12, non-generic $35 (I think). If we have additional expenses like tests or hospitalizations, my insurance pays 70% of those costs, up to a certain threshold (about $3500), after which they pay 100%. That threshold resets every year.

As an example, I recently went to the ER with severe abdominal pain. I had an X-ray, a CAT scan and some IV pain/nausea drugs. My responsibility totaled about $2500.
posted by Rock Steady at 6:14 AM on April 26, 2013 [8 favorites]

It really all depends on your coverage. I have had really good coverage, and crappy ass insurance.

Your employer usually pays part of the cost of your health insurance and then the rest of the cost comes out of your check- so on your withholding slips it may say "three hundred bucks for health, thirteen for dental, blah blah blah"

then you go to the doctor. usually there is a co-pay for doctors visits. The new healthcare reforms have changed this somewhat, as preventative care co-pays are more restricted (ie, getting checked out for your yearly at the gyno.)

Having a baby does have out of pocket costs- but how much depends on the coverage. Prenatal visits? I'm not 100% on because they've recently changed rules do to the reforms and my buddies with kids haven't given birth since the reforms.

a friend of mine is dealing with cancer now, and she switched insurance half way through. At first she had the bargen insurance because she was in her mid-twenties and figured catastrophic injury insurance was all she really needed. When she got cancer out of the blue, the out of pocket costs were staggering.

now she has much better insurance through her husband, and they sprung for the really nice plan. I was still shocked when i visited her in the hospital and while she was hooked up to the chemo they interrupted us to ask for her credit card so they could charge her co-pay of 200 bucks for that afternoon's treatment of just ONE of the multiple drugs that go into her cocktail. And again- this is the really good insurance that costs them hundreds more a month to maintain. I really hope they can get through these rounds of treatment and be done- not only because cancer is just hell- but because it's so expensive she's had to work through the whole damn thing in order to keep them afloat. That's just sick.

so no, it's not fear mongering. it really sucks as bad as it seems.
posted by Blisterlips at 6:15 AM on April 26, 2013 [7 favorites]

With regards to cancer, be aware that some plans have lifetime maximum payouts. So what can happen is that the insurance will pay everything, or most everything, up to a point, then simply stop. Then it's all out of pocket from there, which can be ruinous.
posted by tau_ceti at 6:16 AM on April 26, 2013 [2 favorites]

I have a health plan that I pay $60 a pay period for. It's a pretty typical plan. I have to pay $25 everytime I see my regular physician, and $30 everytime I see a specialist. Typically, my insurance covers 80% of most costs.

When I had my child back in 2010, I paid about $1,600 out of pocket to various physicians and places. (My OB/GYN, the pediatrician at the hospital, etc.)

I work with insurance also, and most american insurance plans only percentages of your benefits. Most private plans cover only 80%, though some cover 90%. You have to pay "co-payment" PLUS a co-insurance (which is just a fancy way of paying the percentage that you are responsibly for.)

Needless to say, if you're a healthy individual, health insurance isn't too bad. But if you're someone with a serious medical condition that requires a lot of care, (like cancer for examply), you're going to rack up some serious bills.
posted by AbsolutelyHonest at 6:17 AM on April 26, 2013

It really, really depends on your health insurance.

For mine:

1) I pay premiums, but the employer also does.
2) It costs about 80$ a month for me, but that cost is not tax-deductible.
3) When I go to the doctor, I don't need to pay for primary care visits, but if it's a specialist I pay a nominal fee - I think it's 8$ or 12$ or something.
4) There are no out of pocket costs other than my copays. Prenatal visits are covered 100% except for that copay. No additional costs for c-section.
5) No additional costs other than the copays for doctors visits and prescriptions. (I think those are also maybe $10 each? Don't remember.
posted by corb at 6:17 AM on April 26, 2013

Hi! I can answer this, based on MY health insurance.

1. I pay $60 per month, my employer pays the rest. I'd say it's a 30/70 split. Because I have a High Deductible policy, I contribute $100 non-taxed dollars to a bank account that I use exclusively for medical expenses.

2. My annual well-woman visit and one full physical exam is paid for by my medical insurance. This includes all testing. So is my Mammogram. If I have to go to the doctor for anything outside of my annual exam, I pay a pre-negotiated rate directly to my doctor. So if my doctors office visit charge is typically $60, my insurance company negotiates a rate of $25, and I pay that out of my medical fund.

3. Prescription drugs are another thing. I have a prescription plan. I take 4 prescription drugs. One is a free generic. Another is a very cheap generic. One is an expensive name-brand drug, but it's on my insurance's "formulary", which is a list of drugs for which they've negotiated a bulk rate, so it's discounted, and one I have compounded in a lab half-way across the country.

This is how it breaks down on a monthly basis:

Anti-Anxiety Drug--Free
High Blood Pressure Drug--$15 (On my other plan it was $35 per month)
Hormone Replacement--$30

I pay for this out of my Medical Account.

3. Don't know about pregnancy.

4. I did have a pre-cancerous thing last year. I had to go to an oncologist, have minor surgery and follow up. The deductible on my insurance is $4,400, they cover the rest. So I paid the $4,400 out of my Medical Account, and insurance covered the rest. I got all of my care at the negotiated, discounted rate, and even so the whole thing came to about $18,000.

I think my experiences are pretty typical.

But the important thing to know is that the quality and coverage of medical insurance varies widely.
posted by Ruthless Bunny at 6:21 AM on April 26, 2013

With regards to cancer, be aware that some plans have lifetime maximum payouts. So what can happen is that the insurance will pay everything, or most everything, up to a point, then simply stop. Then it's all out of pocket from there, which can be ruinous.

It's definitely worth noting that lifetime limits are prohibited by the ACA, aka Obamacare.
posted by Tomorrowful at 6:21 AM on April 26, 2013 [7 favorites]

It varies a lot by employer and some employers even change plans occasionally. Ours works like this:

1. My employer covers the entire cost of the insurance for me, but if I wanted a spouse or kids covered, I would need to pay for that myself.

2. I have a copay for office visits and prescriptions.

3. I have a deductible of $1500 a year for other procedures. That is, I pay for everything until I have paid for $1500 in a year, then the insurance kicks in.

4. After the deductible is met, the insurance pays 80% of most expenses.

5. When using in-network providers (who have agreed to accept the insurer's pricing for various procedures) the cost is substantially less than what the provider would charge someone who didn't have insurance.

6. I also have a flex spending account that can be used for anything the insurance doesn't cover. This is my money, but I don't pay income taxes on it, so it goes further than it would otherwise.

This is pretty typical except for #1. Most employers require the employee to cover some of the cost of the insurance.
posted by kindall at 6:21 AM on April 26, 2013

Also not always mentioned, because people don't know until it's too late, is that insurance carriers often find/make up excuses for dropping you if/when you're diagnosed with a serious illness -- this happened almost 50% of the time! Some of the Obamacare reforms are supposed to stop that practice, but I don't know what provisions have or haven't kicked in yet.
posted by acm at 6:24 AM on April 26, 2013

Best answer: A lot of people are providing good answers to your mini-survey, so I'm actually going to just directly address what your coworker said:

she said that if you had a middle class job, with good insurance, it wasn't really that expensive.

This is totally utterly true, as long as you don't have any really serious, chronic, ongoing, or catastrophic health problems. If you're reasonably healthy, it's totally affordable. If you get cancer, or your kid has diabetes, or you have a complicated pregnancy, things get very expensive in very short order.
posted by Tomorrowful at 6:24 AM on April 26, 2013 [9 favorites]

This also varies a lot state-by-state, because historically that's where insurance regulation happens (although the new federal healthcare law obviously changes this to some extent). Some states allow insurers to sell plans that are cheap but nearly useless (I would lump all plans that have "lifetime maximums" into that category). Other states have very strict rules about the minimum coverage that insurers are allowed to offer (which can mean that premiums are much more expensive). This is more of an issue at the individual level than at the group-plan level.

With employer-sponsored plans, the percentage paid by the individual vs. the percentage paid by the employer varies A LOT company to company and industry to industry. Also some employers who offer multiple health plans don't pay a percentage, they pay a fixed amount, so as to encourage workers to select the lower-cost plan (as a healthy single adult, I prefer this way of doing things - this way I can choose the lower-cost plan and pay very little out-of-pocket, and not subsidize my coworkers who choose the higher-cost plan).
posted by mskyle at 6:28 AM on April 26, 2013

I should also mention that some employers offer disability and/or accidental death/dismemberment policies, which are not strictly speaking health insurance but can help pay your other (non-medical) bills if you are in the hospital for an extended period of time or have a serious accident and can't work.

Some employers also offer plans (like those offered by AFLAC) which pays you cash if you are e.g. diagnosed with cancer, or some specific illness, or have to be in the hospital for an extended period of time, or whatever. You usually pay for these yourself but they are not that expensive if you are young and/or generally healthy, because they cover one specific thing.
posted by kindall at 6:29 AM on April 26, 2013

I'd like to point out that we've had both awesome and crapass but COBRA was expensive - which is when my husband got laid off and we paid out of pocket about $2000/month for family ins.
posted by lasamana at 6:30 AM on April 26, 2013

I used to have health insurance in a job in the U.S. that meets your criteria. I now have a similar job in Europe. I have a chronic health issue that requires expensive medication, regular bloodwork, and annual MRIs.

- In the US, my employer paid my health insurance premium. This varies so much per employer. In Europe, I pay it, and it's about €120/month. So that aspect was cheaper for me when I lived in the US.

- In the US, I paid €20 every time I saw a doctor. Again, this amount varies a lot per health insurance plan. In Europe, I haven't paid to see a doctor yet.

- I haven't had a baby but I do take birth control pills, which I had to pay for in both the US and Europe. In Europe, it's about €12 for a three-month supply. If I remember correctly, it was about the same in the US.

Not directly answering your questions:

- The expensive medication that I take was about $50 for a three-month supply in the US. It's about €20 in Europe.

- I paid less than $200 for each MRI that I had in the US. My insurance paid the bulk of the cost, which was a price that's negotiated between the hospital and the insurance company. If I had to pay out of pocket, the price would be much higher. I've never had to pay for an MRI in Europe.

- I paid around $30-$50 for bloodwork in the US. Never paid for it in Europe.

So my experience has been that, while my insurance premiums were covered by my employer in the US, I had to pay a lot of small fees, which can add up quickly if you have to see many doctors in a short time (for me, it was GP > gynecologist > neurologist > endocrinologist, then monthly visits to the endocrinologist). In contrast, I pay my €120/month now, but I never see any medical bills. My only regular out-of-pocket cost is birth control.
posted by neushoorn at 6:35 AM on April 26, 2013

Lots of good answers already that show what a wide range of answers there are. But one thing worth adding is that middle class no longer automatically implies having health insurance at all. The economic and unemployment situation as a whole has a big impact on this. There are fewer jobs period, and then more jobs that are precarious and unbenefited.

If you're an independent contractor you have to buy your own insurance with the cost ranging wildly. I work "per diem" in a job that would be a solid, "middle class" job in or above the income level you describe, if it were a benefited position, which it isn't.
posted by latkes at 6:36 AM on April 26, 2013

and she said that if you had a middle class job, with good insurance, it wasn't really that expensive

I sort of had this viewpoint, until my friends and coworkers started having kids and I started having normal health problems associate with aging (like heartburn, aches and pains, stuff like that) which meant I had to use the doctor beyond just yearly checkups.

Most employers in the US do not cover premiums for spouses and children. I pay about $100 a month for my premium by myself. Adding just my husband, it's closer to $350. We decided last year for my husband to use just the catastrophic care offered through his school. He doesn't pay any premiums but coverage is very restricted.
posted by muddgirl at 6:46 AM on April 26, 2013

Anecdata about previous jobs:

At a job that paid a little under your stated range, I only paid around $60 a month for my portion of the premium. At some jobs, your own portion is reasonable-ish, but adding a dependent can be very expensive.

Every insurance plan I've had requires a copay to see a doctor. Usually it's $10 - $30 on the insurance plans I've had, it can be up to around $50.

Unsure about pregnancy questions.

I had a serious health care condition (not cancer) that required hospitalization. My insurance copay at that time was $100 / day to be in the hospital. So yes, there are almost always costs.

Some plans have an out-of-pocket maximum that you pay per year (say, $5000) after which you don't have to pay any more -- this is fantastic, but some don't have this.

And as mentioned above, some have a max coverage (say, $1,000,000) after which they will not pay anything at all, which is terrible.
posted by insectosaurus at 6:48 AM on April 26, 2013

Another data point from a middle-class couple with white collar jobs and decent insurance:

I have insurance through my husband. We pay between $200-300 per month, and that covers both of us. We have a $500 deductible. When I go to my primary care physician, it costs me $20 out of pocket. If I need to see a specialist, it's $40. BUT - this is only if the doctor is in the insurance company's network. If they are not in the network, they only pay a percentage. This can get stupidly expensive really fast; I learned the hard way to always check if my doctor's referred me to a specialist in network or not.

If I have to go to the Emergency Room, it's $100. I forget how much urgent care is, probably $50ish.

I can't answer any questions about pregnancy, that doesn't apply to me so I've never paid attention. Not really sure about cancer, either, but if I were in the hospital, they'd pay 80% up to a certain dollar amount, then they'd pay 100%. Testing is roughly the same.

Prescriptions are also covered. I pay $10 for generic and $20 for some non-generic drugs that are on a special list. Drugs that are NOT on that list are stupidly expensive, like $250 for 30 days supply.

We also have an FSA (Flexible Spending Account) that can only be used for healthcare items. Basically, a certain amount (that we decide) is set aside each paycheck. We have debit cards that we can use at the doctor's office, pharmacy, etc. It also covers things like hearing aids, mobility devices, etc.
posted by desjardins at 6:49 AM on April 26, 2013

I forgot to mention that we are limited in some types of visits - for example, only 30 visits to a physical therapist per year, x visits to a mental health professional, etc. Beyond that, we have to pay 100%.
posted by desjardins at 6:50 AM on April 26, 2013

I was still shocked when i visited her in the hospital and while she was hooked up to the chemo they interrupted us to ask for her credit card so they could charge her co-pay of 200 bucks for that afternoon's treatment of just ONE of the multiple drugs that go into her cocktail.

I was in the E.R. and got badgered for a credit card to cover copays and deductibles the very second it was clear the person in the E.R. was going to be pull through. (This is with pretty decent insurance.)

If you end up needing emergency or inpatient care, you'll get a bill from the hospital, and there's a good chance you'll then get separate bills from the doctors who attended to you while admitted, because they're not actually employed by the hospital. There are sometimes occasions where those doctors aren't "in network" for your insurer -- and other occasions where they won't accept your insurance at all. I think the assumption is that you're meant to be sufficiently compos mentis to ask about this at the time.
posted by holgate at 6:54 AM on April 26, 2013 [1 favorite]

Best answer: There are a lot of really excellent sources of data out there about the average health care costs faced by Americans. Just to point you to the two that are probably the most commonly-used:

1. Kaiser Employer Health Benefit Survey. In 2012, the average total premium (monthly costs) for a single person in an employer-based plan was $468 per month, and was $1,312 per month for families. Employers tend to pay the vast majority of that--employees on average pay 18% of the premiums for a single person (or $79 per month) or 28% of the premiums for a family policy ($360 per month). Keep in mind that this is a national survey and health care costs (which drive premium costs) vary quite a bit regionally; your average employee in Seattle or in the Midwest will pay far less than your average employee in Boston or anywhere on the Eastern seaboard for health insurance.

2. The Medical Expenditure Panel Survey. That data brief is a bit old now, but it gives you a nice overview of how out-of-pocket costs--that is, everything OTHER than the premium--are still quite high for people with employer-based insurance. Ten years ago, the average out-of-pocket spending for an adult with private insurance was about $663 per year for medical care --doctor's visits, prescription drugs, hospital visits, and so on. About 20% of adults with private insurance had more than $1,000 in out-of-pocket costs. Medical cost inflation has continued in the 10 years since that was released, so I'd guess the average out-of-pocket costs today are somewhere between 50% and 100% higher.

Your coworker is correct that for some people with employer-based insurance, medical costs aren't that high--or at least aren't perceived as that high. Premiums are pulled straight out of your paycheck before you get it, just like taxes, and many people don't spend too much time thinking about them, particularly if they're not rising fast. The out-of-pocket spending is quite skewed; you have a bunch of people with low costs (less than 5 doctor office visits per year, for a general check-up and some minor illnesses like the flu); a smaller group with a "major medical event" like a birth or a broken leg that racks up costs in the hundreds or low thousands; and then a much smaller number like maybe 5% who have a truly catastrophic event that bumps them up against their maximum out-of-pocket spending for the year, which is typically somewhere around $5,000 to $10,000 in employer-based plans. Surveys show that about 80% to 85% of people with employee-based health care are very satisfied with their coverage and health policy researchers often say these are the folks with very low costs who haven't really had to use their plans yet. (The people who actually USE their plans are very aware of how exposed they still are to medical costs, even after paying hundreds of dollars a month in premiums.)
posted by iminurmefi at 6:59 AM on April 26, 2013 [2 favorites]

Just thought of a few more things-

Something that has become popular lately is insurance tacking on monthly fees depending on your health habits. At our company, you pay $50 more/paycheck if you smoke. AFAIK, you don't currently pay anything for obesity, but I've heard of other companies doing that. We did have to submit a form saying we'd had basic bloodwork (cholesterol, etc) but individually, we're not charged differently based on the results.

Also - it makes a BIG difference if you're at a big company or a small one, because the risk is distributed more widely at a big company. My husband worked for a small company (~20 people) and one person's child was permanently disabled and required constant care. Our premiums were much higher just because of that, even though we were perfectly healthy.
posted by desjardins at 6:59 AM on April 26, 2013

I've been lucky to have good insurance and then great insurance at my last and current jobs, both for well known health-centered non profit organizations.

The good insurance (last job):
I paid about $75 out of each paycheck
I had a $25 copay for seeing any doctor that was in my insurance plan. My annual physical exam was free. All tests were paid for I believe
Hospitalization had a $250 co-pay, and then I was responsible for 10% of the total bill.

The great insurance (current job):
I pay nothing, and I pay $25 a month for my partner to be covered.
I have a $25 copay for my regular doctor, and $50 copay for visits to specialists. My annual physical exam and gyno visit are free. All tests are paid for
Hospitalization has a $100 copay, and pays 100%.

Here is how this has played out:
In 2008, I was diagnosed with thyroid cancer and had a thyroidectomy with radioactive iodine treatment following.

With my great insurance, I paid about $250 in co-pays to doctors during my diagnosis state, and $100 for the hospital visits. I think the radioactive iodine was considered a prescription and I paid $50 (the max on my plan for a prescription). Post surgical follow-ups were included under the surgical/hospital part and had no co-pay. I see my endocrinologist twice a year ($50 each time). My meds are $10 a month.

With my good insurance, I would have paid about $150 in copays during diagnosis. I would have paid $250 + $6000 for surgery and hospitalization. I think I might have had to pay $1500 for the radioactive iodine. So... I would have ended up with about $7500 in expenses. Which would have hurt, but I would have been able to pay.

In 2009, I discovered I had large uterine fibroid tumors (fairly common, but mine required treatment). I had a common procedure, which required one night in the hospital. However, I had a serious of rare complications, and I ended up in renal failure and with a massive infection. Multiple surgeries, blood tranfusions, total of 3 weeks in the hospital. And then I had a hysterectomy 8 months later. To be honest, I never totaled up the entire cost of my treatment, but it was probably close to $1million. One statement from the insurance company showed that they paid $350,000 for one of my 11 day hospital stays with 3 surgical procedures. What I ended up paying for the whole shebang was about $2500. If I had my old, "good insurance" I would probably have at least $80,000 in medical debt, likely more.
posted by kimdog at 7:03 AM on April 26, 2013

My health plan estimates that I would pay $940 out-of-pocket for an uncomplicated pregnancy and delivery; $500 of that is the copay for a hospital admission, $250 is the annual deductible. For prenatal care they make one global payment to the provider, rather than per-visit, and so the patient doesn't pay a copay each visit. I'm not sure if that's common; I think it's a newer model.

Another example they gave (we're in the annual period where we can make changes to our coverage, so I have a lot of info packets here) was that the annual cost to the patient for routine maintenance of something like diabetes could be $1330, mostly consisting of copays for prescriptions and office visits.

My plan also has an out-of-pocket maximum of $2000/year/person - above that, the insurance would pay everything, no more copays EXCEPT for prescriptions. I'm pretty healthy and usually pay a few hundred a year out of pocket - my monthly prescription's copay is $10/month (but could be up to $50/month for some medications), doctor's or therapist's visits $20 copay, specialist $35 copay. I'd consider it good coverage.

I pay 50% of the premiums; my share is about $300/month, and that's taken out of my paycheck before the taxes, so yes, tax-deductible. I work for local government. If I wanted to cover anyone else on my plan, my monthly share of the premium would be about $800/month (regardless of the number of family members covered - that would be for just a spouse, or for spouse + children).
posted by songs about trains at 7:05 AM on April 26, 2013

When you go to the doctor, do you have to pay anything? Or is it all paid by your insurance?

Under the last plan I had, I paid a "copayment" of between $40-$60 per visit to an in-network doctor, depending on the specialty. With the plan I have now, copayments to an in-network doctor are all $20.

For an out-of-network doctor, I pay out of pocket and then am reimbursed 80% of what the insurance company thinks the visit should cost. However, they generally think it should cost less than 50% of what it actually does.
posted by The Underpants Monster at 7:07 AM on April 26, 2013

Just to show you the variability between employers and plans: My wife and I work for different companies, but both of us have options to get insurance from our employers. I pay less to cover my family than my wife would to cover just herself.
posted by NotMyselfRightNow at 7:10 AM on April 26, 2013

I am a Canadian and when I lived among the Americans c. 1997-2001, one thing I found amazing was that I was tied to a particular hospital and tied to a limited number of doctors who were in the insurer's "network." If I had needed emergency care away from "my" hospital, a large bill would've resulted.

During part of that time I was married to an extremely well-paid person, and his job offered theoretically top-of-the-line insurance. You could choose your insurer! (Choice of: two.) It was still, for a Canadian, a jaw-droppingly crap deal where one was nickel-and-dimed for everything; there was so much HMO time-wasting nonsense built into the system that one ended up sure that that was meant to discourage making use of the insurance. If I needed prescriptions I could only get them from one of two (terrible) chain pharmacies. So it is apparently possible that one can be at the 95th per centile, income-wise (with "your" hospital being Cedars-Sinai in Beverly Hills, even) and still deal with all of the problems mentioned in this thread.

There are also tedious amounts of paperwork and rules and forms to mail in and so on and on, which is an expense in time.

(The other thing I found jarring was that I could see a gynaecologist without much hassle; all insurance schemes I came across were big on giving women at least a yearly check-up with a gyn. This was less of a hassle, and more of an entitlement, than having a family doctor. I have noticed a lot of threads on here that stress the need for 'your yearly visit with your gyn.' Here of course one would see a gynaecologist only if something gynaecological was in need of attention -- I've visited an ob/gyn for pregnancy and that's it -- and family doctors do your Pap and it's not a very big deal.)
posted by kmennie at 7:14 AM on April 26, 2013 [3 favorites]

- Do you pay the premiums for your health insurance (for basic coverage of seeing the doctor, not drug coverage) or does the employer?
I pay a part of my premiums. I pay about 1/3 of the premium, with my employer picking up the rest of the tab. This includes prescription coverage.

- If you have to pay the premiums, about how much does it cost per month? Is that cost tax-deductible?
My portion of the premium is $260/month, for just myself.

- When you go to the doctor, do you have to pay anything? Or is it all paid by your insurance?
I am responsible for a co-pay, which ranges between $30-60. A visit to the ER is $100, diagnostic tests also have co-pays.

You also have co-pays for medication. On my plan, it is generally between $10-60 for a 30 day supply. There are some medications that require extra legwork on my doctor's part to convince the insurance company that it is necessary and they should pay for it. My insurance company also completely refuses to cover certain medications, and I have to pay full price if I am prescribed them.

I pointed out that healthcare costs were significantly higher for Americans, and she said that if you had a middle class job, with good insurance, it wasn't really that expensive.
I work for a very large company that employs thousands of people in the United States. My premiums alone cost me over $3,100+ every year. If I add the cost of my doctor visits, prescription co-pays (for relatively common things like birth control and antihistamines), and I'm a relatively healthy, middle-class person, with decent insurance, and I spend well over 10% of my salary on healthcare costs. This is assuming that I don't get sick with anything more serious than a sinus infection, and never wind up in the hospital for anything.

plural of anecdote is not data, etc.
posted by inertia at 7:17 AM on April 26, 2013

...she said that if you had a middle class job, with good insurance, it wasn't really that expensive.

There is probably a non-zero number of people for whom that's true. If you're one of those lucky people who's blessed with good genes, never gets really sick, and only needs things like an annual physical and a rare small emergency, it could very well work out that way for you. At least until you get old enough to develop age-related health issues.
posted by The Underpants Monster at 7:39 AM on April 26, 2013

I pay $75/month, with a $2000 out-of-pocket maximum (which doesn't cover office visit co-pays, $20/each, some medication co-pays, $10-$80/each, and various other things). Adding a spouse or dependents would cost $150 ea. That does include dental, which has its own $2000 oop maximum. The dental insurance is cheap, but doesn't give me a huge discount, just a free cleaning, and coverage after I hit the cap. I will be paying just under 20% of my gross salary on insurance, and medical coverage this year.

If I lost my job, I would have to pay about $200/month to get insured at a comparable level. Most jobs require new hires to wait 3-6 months before the employer insurance kicks in.

Lifetime caps were mentioned earlier, but those are gone now. Also a number of preventative screenings, like HIV tests, mammograms, colonoscopies are offered without co-pay. Starting in 2014, regional rates will go into effect, making it illegal to price people with pre-existing conditions out of the individual market. Employers with 50+ employees will pay a penalty if they refuse to insure their workers. All great Obamacare stuff.

Individuals who make less than $15k/year will be eligible for medicaid next year, but until now it has only been open to low-income children, pregnant women, and people with disabilities that prevent them from working.
posted by Garm at 7:46 AM on April 26, 2013

Oh yeah, I forgot to mention networks. Most health insurances have "networks" of doctors that have agreed to accept certain levels of reimbursement. My costs are overall low, but if I were to go out-of-network I would pay 20% of the fee.
posted by corb at 7:51 AM on April 26, 2013

As Obamacare gradually phases in, certain things are changing. Preventive care, like a yearly gyn visit for women, and certain tests like screening colonoscopies now must be performed WITHOUT COPAYS. The visit and procedure must be coded correctly by the physician, so if you schedule a preventive visit (flu shot) and then say, oh by the way, I have this or that symptom, can you take a look, the visit changes from free preventive to regualr sick-care visit.

A friend discovered her GI could not charge the insurer's typical $100.00 co-pay for screening colonoscopies after this provision went into effect. She delayed her screening procedure. Next year policies MUST cover prenatal and maternity, which is not currently the case.
posted by citygirl at 7:52 AM on April 26, 2013

Besides all the nickel and diming that Americans have to put with even with decent plans the time and stress of dealing with insurance companies is astronomical.

For example when I group of us was down there storm chasing one of our group collapsed and was taken by ambulance to hosptial where they stayed overnight. As the EMTs were loading my half concious friend into the ambulance they were asking him which hospital he wanted to go to. Apparently getting this wrong, see the comments about in network coverage, can be extremely expensive. He also continued recieving bills for assorted entities (the hosptial, each of the doctors, the ER, the hosptial pharmacy, the janitor OK maybe not the janitor but it wouldn't have been surprising really if a bill from them had showed up) for years afterwards. This wasn't a hassle for him because he had good Canadian travel insurance that he just forwarded the bills to but it would be very stressful to have to handle this personally especially if dealing with a long term illness.

And the knock on billing is a side effect of another problem: it can be impossible to find out how much a procedure is going to cost ahead of time.

Plus there is the constant concern about losing insurance due to job loss at which point you are doubly screwed. Employees end up staying in horrible jobs because they can't afford a gap in insurance.

Or your employer switches insurance providers and you have to go shopping for all new health service providers because the networks don't overlap.
posted by Mitheral at 8:08 AM on April 26, 2013

My husband previously was on a high-deductible "cadillac" plan that cost his employer a lot and cost us a lot in premiums. In exchange for having to pay $3,000 out of pocket before any coverage kicked in, we had lower premiums and better coverage. So having a baby cost us basically $3,000.

Now we're on a state employee plan and it is THE SHIZ. Our monthly premiums are like half what they were. Having a baby costs $50, full stop. Going to the emergency room costs $200, full stop. Doctors' visits have around a $20 copay; preventative visits and vaccines are all free. (So I don't pay for a yearly checkup, only for an acute sinus infection visit.) It takes them like seven months to process the paperwork because the state is sloooooow so you finally get the bill in the mail and are like, "Wait, I was in the ER seven months ago?" But that's okay! The yearly out-of-pocket maximum is pretty low but you'd have to work really hard to meet it because co-pays are so low.

The only thing that's annoying about it is that they don't cover in-store clinics like Walgreens and other big drug stores have these days. I'm not totally sure why. So on a Saturday I can go to urgent care for $15 co-pay while insurance picks up $130 of it, and wait for two hours and then have to drive to get a prescription, or I can go to a store clinic and be in and out in 10 minutes and pay $70 myself and pick up my prescription right there. My last insurance LOOOOOVED it when we went to store clinics because they're so cheap, but my current insurance covers none of them.
posted by Eyebrows McGee at 8:11 AM on April 26, 2013

My husband has a middle-class job that does not provide health insurance, so we buy ours on the open market. Here are the particulars of my insurance policy:

1. Each of us has a $2500 deductible. What this means is that while my insurance company will negotiate costs down for us, they will not pay anything until we've hit $2500. This deductible is individual; I've hit it for myself already this year due to some CT scans earlier this year, but my husband and my kids are still paying into theirs.

2. After the deductible is met, we pay 25% of the cost of the insurance-negotiated rate, called "coinsurance." Our policy doesn't have office visit or Urgent Care copays, but we do have a $100 ER copay.

3.When our coinsurance totals hit $5000, the insurance company takes over paying 100% of our costs. Again, this is per-person, not per-family.

4. We have no prescription drug or maternity coverage. We pay out of pocket for those things. If I had a baby, the prenatal care + normal uncomplicated hospital delivery would probably run me $10K-$15K. I just picked up drugs to treat a sudden unwelcome bout of dishydrotic eczema yesterday; those drugs cost me $75. My husband goes without the drugs that would put his painful and crippling autoimmune disease into remission, because they would cost us $2000 a month.

5. We pay $715 a month for this insurance.

So, in the case of a truly catastrophic family event that affected all four of us, we could be out as much as ($2500 x 4) + ($5000 x 4) + ($715 x 12) = $38,850 for our health care costs in a given year, plus any prescription drugs not administered through a hospital. That's if we didn't need durable medical equipment or at-home therapy or anything else that our insurance just doesn't cover.

Several years ago, I had a good friend who became gravely, gravely ill. He was on life support in the hospital for 6 months, and eventually needed a liver transplant. His responsibility AFTER his high-quality, employer-provided, middle-class-job health insurance was done? $189,631. Obviously that's an extreme case, but only because his health care needs were also extreme.
posted by KathrynT at 8:11 AM on April 26, 2013

Like kmennie was, I am a Canadian in the US so I get to view the US healthcare system from both sides. As a lot of people are saying above, there is a lot of variation.

I have a good job (that pays less than your range but I'm more well educated - oh, joys of academia) and a really good health care plan. Every month I get 3% of my salary removed for health insurance for myself and my partner. My employer pays about five times more than me.

I get billed $20 as a co-pay for doctor's visits (barring tests or whatever extra, just the 'walking in the door' cost) and $10 for prescriptions (except birth control which is now free! Thanks Obama). I pay nothing as a deductible for health care if I'm "in-network" (i.e. at specific of the local hospitals). It is $250 otherwise. The maximum out-of-pocket cost for me, out of network, is $2,500 (which is amazing! Except I don't really have that much money); $0 if in network. No annual limit on what they'll pay (though I think this is also Obamacare related). Pregnancy is covered in network (pre- and post-natal) or covered 20% out of network.

This is the best health care insurance I've had in the US, it's amazing and only available because my university funds their own insurance. It's run by an insurance company but it's not-for-profit.

Canadians underestimate (or don't know!) the stress of dealing with insurance, especially when you're sick. Sure you might have 90% of your bill covered by insurance but you still get sent a bill that says "You owe $1000" and you're like "Oh, shit! But I thought I was going to die!". Then you get another bill that says "You owe $1000 less $900 paid by your insurance" so you're like "Oh, thank goodness" and happily pay $100. You're now happy to pay money because it's so much more than you thought it was going to be (or could have been).
posted by hydrobatidae at 8:15 AM on April 26, 2013 [2 favorites]

I am in a group insurance plan offered through my university. As far as US insurance goes, it is amazing. For about $1700/year, I am permitted infinite free medical services as long as they are rendered at the university's clinic. They don't have everything there -- an MRI would be at a local hospital, for example -- but they are fully competent to handle your average scratch-and-dent damage/sickness. They over-prescribe OTC pain-killers, in my opinion, and you have to go out of your way to get a doctor instead of an NP, but it's all free once you buy in. Prescription medicines are priced on a tiered schedule (10/25/50, maybe?), and some generics are cheaper yet. For example, penicillin cost something like $2.44 for a week's course.

That said, the plan is students-only, and being older than 26 or adding a partner/dependents earns one much higher premiums. I get one optometrist visit per year, a paltry discount for glasses/lens (these would still easily cost me $300 with the insurance, so I buy them online for more like $100), and no non-emergency dental work at all. Oh, and contraception is always free at the uni's clinic, but they don't do anything prenatal (or even very early-term drug-induced abortions) or take pediatric appointments, so that falls into the in-network pricing and if I had a kid I'd budget an extra $2000 toward meeting the deductible.

So no, it's not fear-mongering. If you look through AskMe, you can find any number of people asking what to do about fairly serious health concerns because they don't have insurance and can't afford to go to the doctor. Those people mean exactly what they say. Without insurance, I nearly died of heat stroke because I knew the ER bill would be devastating just for a few bags of saline. And when my partner finally dragged me in, delirious and crying about how much it would cost, sure enough the first thing they wanted to know was how I would be paying.
posted by teremala at 8:16 AM on April 26, 2013 [3 favorites]

On the basis of crude mathematical averages, you can expect your health care costs to roughly double, as someone making ~50-70k is going to probably be paying more in taxes for health care than they would be in Canada.

This report from the OECD is illustrative.

As you can see, the US spends more public money, both in dollar terms* and as a percentage of GDP, on healthcare. In dollar terms, the difference is especially stark, with Canada averaging ~$3000 per capita, per annum and the US spending ~$4000. Of course, as someone who works for a living, you are excluded from the public system your taxes pay for, so now instead of paying on average an additional $1200 or so for employer extended health premiums or out of pocket expenses for things like prescription drugs, dental, eyecare, physiotherapy, massage, chiro, homeopathy, chakra realignment, cranio-woo-woo therapy, etc. you are paying an additional $4200 for the entirety of your own healthcare, often hidden in employer-paid premiums.
*all amounts are for 2010, in USD adjusted for puchasing power parity

It's no exaggeration to say that the average middle-class worker in the US is being bled dry by the health care industry, both in taxes and in private costs. On top of this, health outcomes are worse in the US than in Canada, and you have the labour market distortions that result when people are too afraid of losing their heath care to change jobs, or start a business, etc, not to mention the disadvantage this has on small employers, who lack the bargaining power of big corporations when it comes to dealing with private insurers.

Then there are the social and human costs of this system, which are beyond the scope of this cold economic analysis, and are probably better left to people more personally acquainted with the system than myself, though I will offer one anecdote.

In my past life working for a debt buyer, the single largest delinquent debt I saw on someone's credit report wasn't a defaulted mortgage, it was a hospital bill for $3 million.
posted by [expletive deleted] at 8:19 AM on April 26, 2013 [1 favorite]

College professor here. Just another data point:

I pay about $340/month for health and dental for myself and my family. (I.e. it is subsidized by my employer, but not completely.)

When we go to the doctor, it's often a $20 co-pay. Not always, though. Well-child visits and immunizations are free, for example. Flu shots and stuff are free.

When I had a child, I ended up paying about $400 or $500 for an induced vaginal delivery with an epidural.

Ee do have prescription drug coverage. Many drugs are $5. Supplies for a medical device I wear run me about $60 for a 3 month supply.
posted by kestrel251 at 8:28 AM on April 26, 2013

Response by poster: Wow, thanks for all these responses! It is very interesting, if a bit confusing. I guess I did not realize just how wide the differences between plans can be. It sounds like things can be relatively inexpensive, but only if you are young and healthy with no dependents and you do not get a catastrophic illness or accident.

One additional question: for those that qualify for Medicaid (poor) or Medicare (old), does that system work like Canadian healthcare? That is, you get a card and then there are no user fees for doctor/hospital visits?
posted by barnoley at 8:33 AM on April 26, 2013

Sorry if these are stupid questions, I just have no idea. I'm used to showing my health card and not paying a thing. My impression was that Americans have to pay additional fees even with insurance... but maybe that's just Canadian fear-mongering? Or maybe you have to pay fees, but just very low nominal fees?

Since biscotti is Canadian, we talk to people up there pretty commonly.

The basic truth is that if you are Canadian and have not lived in the US, you cannot easily imagine how bad the US health care system is. Really. Whatever you're thinking, the truth is worse, because there are layers of callous horror that you can't think up. It's like trying to get Canadians to understand that there is No. Such. Thing. as a statutory holiday in the US.
posted by ROU_Xenophobe at 8:33 AM on April 26, 2013 [6 favorites]

for those that qualify for Medicaid (poor) or Medicare (old), does that system work like Canadian healthcare? That is, you get a card and then there are no user fees for doctor/hospital visits?

posted by ROU_Xenophobe at 8:33 AM on April 26, 2013 [1 favorite]

Another reference point for you, as an Australian now living in the US I was used to a similar sort of medical care as what you get in Canada and trust me, for people in my families position, the US system costs way more, even allowing for the % of tax and what have you that you pay to cover the medical costs.

We are a simple family of 2 adults in the pay range you are talking about, I work part time casual stuff so don't have my own health insurance and am on my husbands policy through his work. we pay around $240 a month for our share of the insurance for the 2 of us and that includes dental as I have shitty teeth. We get one free exam each a year and that includes a pap smear and mammogram, there is a $25 co pay each time we go to the gp/family doctor $50 for a specialist and $125 for emergency.

I pay $13 for a 3 month supply of a very generic bp medicine, which in theory should be partly covered by the insurance but I have yet to figure out how to actually get them to pay for it as there are a 1000 hoops to jump through and I can't be assed working it out to save $2 or whatever.

My mother came to visit from Australia, got sick and had to spend 3 days in hospital, she required no surgery but a few blood tests and a "bag of blood" (as she likes to call it) as she was anemic they charged her $12,000 for it. Luckily she had travel insurance and ended up with no out of pocket expenses but even that too 12 months to sort out and a lot of fighting and arguing and legal threats on both sides.

My MIL has a serious brain condition that requires a shunt in her head, she's had 3 brain surgeries in her life. No insurance company wants her on their books so she has to pay $2,500 a MONTH for health insurance and can't wait for all the Affordable Care Act bells and whistles to kick in, my Inlaws aren't rich and the insurance is more than my in laws pay for all other expenses in their life combined.

I have a friend who is pregnant with her third child, she has good health insurance and is still looking at expenses between $2,000 to $9,000 for the birth of her child, assuming nothing major goes wrong.

Remembering too that Health insurance is such a worry here I know of people too scared to leave shitty bad paying jobs to try for something better as they have health conditions and are worried they won't be able to get as good a coverage (or any coverage) some where else.
posted by wwax at 8:36 AM on April 26, 2013

I have a pretty great insurance plan. My employer pays about 80% of the premium, and my pre-tax monthly amount is about $80. I have a pretty comprehensive and awesome HMO. I pay $15 to see any doctor in a wide network; including physical therapy, psychiatry, and my therapist, $15 for urgent care, and $50 for an ER visit, which is waived if you're admitted. Preventative visits are free. Labwork, imaging, etc is all free. Hospital stays are free. I had two surgeries in 2009 and didn't pay a cent - and the follow-up visits were free as well. I imagine it would be the same if I had a baby, vaginal or c-section. Prescriptions are $5 for a month of generic, $15 for brand formulary, and $50 for non-formulary. Medications taken for chronic conditions have to be mail ordered, a 90 day supply is $10 for generic, $25 for brand.

And yes, one of the reasons I won't leave my job or strike out on my own to start a business is because I fear not having insurance.

That's actually my biggest argument for universal healthcare. Small business suffers if people are too afraid to work for themselves because they don't have insurance.
posted by elsietheeel at 8:39 AM on April 26, 2013

I know of people too scared to leave shitty bad paying jobs to try for something better as they have health conditions and are worried they won't be able to get as good a coverage (or any coverage) some where else.

And yes, one of the reasons I won't leave my job or strike out on my own to start a business is because I fear not having insurance.

Yeah, this is pretty much the thing that defines how different my life is than it would be if I had been born in Canada or Australia or England. I have enough chronic health problems that decent health insurance is literally the difference between life and death for me. I can't even begin to imagine the heady amount of personal freedom I would have if that wasn't the case. American jingoists like to talk about "our freedoms," but those "freedoms" are really only available to people who were lucky enough to be born with good genes or a wealthy background.
posted by The Underpants Monster at 9:03 AM on April 26, 2013 [8 favorites]

It sounds like things can be relatively inexpensive, but only if you are young and healthy with no dependents and you do not get a catastrophic illness or accident.

Well, sort of. If you have good insurance, things can be relatively inexpensive even if you are middleaged or old and have a giant family with lots of dependents and get a catastrophic illness - but because so many of these are tied to employment, you're effectively tied to your job. If you leave, you won't be able to find a comparable health insurance.
posted by corb at 9:23 AM on April 26, 2013

And then there are those of us who are effectively bullied into paying for what's a nearly useless private insurance plan just so that we don't have a gap in coverage -- because when you have a gap in insurance coverage, future insurers can deny you based on having a pre-existing condition, which covers a stunningly large array of health problems.

Obamacare is supposed to fix this next year, but I still don't trust that I'll be able to afford to have a decent insurance plan paying privately and with a pre-existing condition.
posted by fiercecupcake at 9:29 AM on April 26, 2013 [1 favorite]

I'm no expert, but as an American who has lived abroad in China and Russia in the last 5 years I can definitely say I worry less about health care- even quality of services and care- than I did when I was in the US.

When I got out of college, I had a middle class job on the higher end of your pay scale range in the US, and just had basic coverage. I never looked into paying more for more coverage and options, just the standard issue package. For a basic visit to the doctor, I never had to try so don't know. I wanted to visit a dermatologist, but by the rules I had to visit my general practitioner first, so never bothered to do so... since who the heck really has the time to do all that.

There was no cover for vision, so no eye doctor visits and no eyeglasses (I wear eyeglasses). So that's about $100 for a doctor's visit and prescription, and anywhere from $300-400 for a pair of eyeglasses without insurance.

For dental care visits I had to pay the first $80, then after that up to a certain limit the difference was paid by my insurance. I was looking into getting four wisdom teeth removed, but my insurance only covered half of it and it would have cost me an extra $2000.

For a gynocologist, again it was a $80 payment and anything more was covered by insurance. Birth control pills were a pain because you could only get them through a prescription of a doctor, and it was still at least $40/month. Whereas in Europe, Asia, Russia you just show up at a pharmacy and you can buy a pack for $20 without any insurance.

Living abroad, I no longer worry about the hassle of time/red tape and huge monetary expenses for healthcare as I did in the US.
posted by peachtree at 9:45 AM on April 26, 2013

We have fantastic insurance, but we pay a lot for it. My husband's company offers three levels of insurance, we have the highest level.

However, I am fairly sick as I have multiple health conditions. I am a kidney cancer survivor, with diabetes, hypertension, PCOS, bone and muscle disorders, amongst several other things. Our insurance (until 2014) has a lifetime maximum. I am not all that far from the maximum due to the number of surgeries, hospitalizations, doctors' appointments, medications,etc.

My medications, after insurance, run us about 200 dollars a month, if I have nothing new prescribed. If I have a short term med prescribed it will go up. Most of my medications are generics, many are only a couple dollars a piece, but others are much more than that, obviously.

Medical devices are covered at varying amounts and I am constantly fighting to get coverage on things (right now, I am fighting for a mobility device and I am losing.)

Medical coverage in the USA sucks.
posted by SuzySmith at 9:55 AM on April 26, 2013

Hey. Canadian in America here. I'm going to answer a question you didn't directly ask to help explain some of the "it depends" answers.

Different health insurance plans are structurally different in the US which explains much of the differences in cost.

The simplest is the HMO where you have a limited (but good) selection of doctors to choose from (the "network") and the insurance plan covers 100% of costs minus the co-pay which is typically on the order of $10 per visit. This is like the Canadian system where to see a specialist you have to go see your primary care doctor first.

Then there's the PPO. Here you only get covered 90% of costs (it varies). But you have a wider range of doctors to choose from - there's better "out of network" coverage. PPOs are also slightly more expensive in terms of premium costs. Basically you pay for the flexibility of being able to access more doctors.

Doctors and insurance companies operate at arm's length - mostly. There are organizations like Cigna in California where the insurance, hospitals and doctors are all operated by the same company. This is the most like the Canadian system. Where I work this is the cheapest option and care is good but you have zero coverage for seeing a doctor not employed by Cigna.

Then you have high deductible plans. These are cheap but they don't pay anything until you have more than a few thousand dollars of medical bills. basically they don't cover routine medical visits but do cover you for catastrophic events like car accidents or cancer or whatever. This is good for young people or single people or people who can't afford anything else.

THEN (yes, there's more) we have the Health Savings Account. This is high-deductible insurance plus a RRSP-like tax-free savings account. Basically it helps you save the first several thousand dollars annually that your high-deductible insurance doesn't cover. The bonus of this is that if you don't use that money, it's still yours and becomes saving for future medical events or retirement. Again, it's cheap because it generally doesn't pay you very much.

THEN there's the flexible saving account. This is administered as a benefit by your employer and goes in conjunction with your regular HMO or PPO-type insurance. Here you deduct money from your paycheque into a tax-free account, but you have to guess how much you want to put aside the year before and if you don't use it all you lose it at the end of the year. Yes, it's insane. It is helpful though if you knwo you have a big non-emergency expense coming up like glasses or braces. In those cases it's effectively a saving of your marginal tax rate - 25-30% off. You put aside $1000 but it only effectively costs you $700 because it's pre-tax.

So your premiums depend on which type of insurance you get as do your co-pays and where you can go to access doctors.
posted by GuyZero at 9:56 AM on April 26, 2013

Best answer: One additional question: for those that qualify for Medicaid (poor) or Medicare (old), does that system work like Canadian healthcare?

For both of those programs, there is one HUGE difference: you first need to find a doctor who will accept Medicaid or Medicare. That's no small task for Medicaid, especially if you're talking about specialists.

In terms of out-of-pocket costs, yes, for Medicaid you have a card and there's generally no out-of-pocket costs; there are some limited exceptions where higher-income Medicaid enrollees have a pay a really nominal copayment (never more than $5).

Medicare works a lot more like employer-based insurance, albeit pretty generous insurance. You generally have less of a problem finding doctors who will accept a Medicare card compared with Medicaid, but you are responsible for copayments and coinsurance. Additionally, there are premiums associated with Medicare--$105 per month in premiums to add coverage for doctor's visits, and an average of about $40 per month to add prescription drug coverage.
posted by iminurmefi at 9:56 AM on April 26, 2013

Our insurance (until 2014) has a lifetime maximum.

I forgot to mention that. Until the Affordable Care act passed pretty much all US health insurance plans had a lifetime maximum coverage cap for would typically not cover everything if you had an advanced medical condition like cancer or something else complex.
posted by GuyZero at 9:57 AM on April 26, 2013

One additional question: for those that qualify for Medicaid (poor) or Medicare (old), does that system work like Canadian healthcare?

Actually it works a lot like the Canadian healthcare system in that it dictates payment rates per procedure to the doctors. Unlike in Canada no one is forced to accept it though. That's the big difference. In Canada doctors can accept canadian medicare or they can bill privately, but never both. In the US doctors can do both and unsurprisingly they tend to not accept medicare because it doesn't pay very well.
posted by GuyZero at 9:59 AM on April 26, 2013

It sounds like things can be relatively inexpensive, but only if you are young and healthy with no dependents and you do not get a catastrophic illness or accident.

Yeah, I want to second corb and point out that there are certainly people covered by employer-based plans that are (relatively) protected from the super-high costs that some people are talking about above. Even before the ACA banned lifetime caps, about half of all employer-based plans didn't have any limit on how much they'd pay in total towards someone's care. Additionally, about 90% of employer-based plans to have what is called a "maximum out of pocket limit" (or max OOP) for the year, which says that once your copayments and coinsurance hits a certain amount, the health plan takes over totally and pays for 100% of covered benefits for the rest of the year. In 2012, about 1/3 of employer-based plans had a max OOP of less than $2,000; and another quarter had a max OOP of less than $3,000. It's very very rare for max OOP to go higher than $6,000. [More detailed stats on this available in the employee health benefits survey that I linked to above.]

Where people with "good" coverage get into trouble is: (1) your coverage is tied to your employer, so if you have a catastrophic accident or illness that prevents work you might not be able to retain that coverage as long as you need it; (2) they want or need care that isn't a covered benefit within their plan [e.g., many new cancer drugs are considered experimental, or certain transplants are excluded from coverage]; or (3) they want or need care from a provider that isn't in-network.

It's not totally straightforward to compare costs between places like Canada/the U.K. and the U.S. because the way your universal health care system handles #2 and #3 is so different. In my opinion it's kind of a dubious "benefit" that health insurance policies in the U.S. don't--and in most cases can't--do any sort of cost-benefit analysis to determine what is covered and what isn't. Nevertheless, that's a highly valued aspect of the U.S. system by a lot of people, to the extent that most people reject the sort of health insurance plans (HMOs) that look the most like universal health care systems in other places, even though many of those plans tend to both have cheaper premiums and to have very nominal point-of-service costs.
posted by iminurmefi at 10:27 AM on April 26, 2013

As several have mentioned, the US punishes people who start their own businesses, which is one of the main reasons I moved abroad. It's something to consider for Canadians who might move here for a job and then decide to start a business.

I'm self-employed, so when I was in the US I had to pay my own insurance premiums. For health care, dental work, and insurance premiums, my total cost averaged a little over $9,000 a year.

That included the monthly premiums of $412 for a plan that didn't start paying anything until I had paid $5,000 myself that year. Added to that were the out-of-pocket costs for the usual minor health issues, eyeglasses, and dental work.

I now live in Mexico. I bought private insurance that has a $400 deductible per incident. I pay roughly $82/month for that insurance, which also covers me when I travel out of the country. My out-of-pocket costs for medical, visual, and dental care are about one-third the US cost for the same or higher level of treatment.

I'm saving about $6,500 a year in medical costs alone, and I'm much more likely to seek medical treatment early on rather than to just grit my teeth and bear it.
posted by ceiba at 10:38 AM on April 26, 2013 [1 favorite]

"It sounds like things can be relatively inexpensive, but only if you are young and healthy with no dependents and you do not get a catastrophic illness or accident. "

If you are self-employed, that's true. If you work for an employer who provides health care, your coverage varies based on what your employer provides, but your coverage as a six-headed diabetic 120-year-old with no knees will be the same and cost the same as the 20-year-old triathlete in the cube next to you. In the U.S., risk pools are traditionally a group of employees at a corporation, which works fine if you're a big corporation (Ford, GM, Coca-Cola) but the screws people who are unemployed, work for small corporations that either have smaller pools (and higher costs) or don't provide coverage, or work for yourself. In most countries, risk pools are nationwide or province-wide, which lowers costs.

One reason our coverage is so much less expensive now that my husband works for the state is that the state is an absolutely ginormous employer, so the risk pool is quite large -- around 70,000 employees. My husband's last job had something like 28 insured employees on the plan; we were the most expensive people on the plan the year I had a C-section -- the benefits administrator made sure to tell us so.
posted by Eyebrows McGee at 10:52 AM on April 26, 2013

This is getting tangential but many large US companies don't actually have insurance per se - they have an insurance company that handles their benefits paperwork but actual costs are actually just paid by the company. The company I work for is self-insured like this as are many other large companies. So it's not even a question of a risk pool - it's simply a straight expense. Small companies have actual insurance-insurance and as such can see their premiums go up and down as their insurance company reassesses their riskiness.
posted by GuyZero at 10:55 AM on April 26, 2013

Best answer: You might like this Wikipedia comparison of the health care systems in Canada and the US.
posted by ceiba at 11:04 AM on April 26, 2013

they have an insurance company that handles their benefits paperwork but actual costs are actually just paid by the company

Yes, this is called self-funding and the insurance company is called a third-party administrator in this scenario. The main reason a big company signs on with an insurance company is to get the discounted pricing that the insurance company has already negotiated with its network providers. My wife works for one of these TPAs (a division of a big insurer) and they offer services to companies with 100 or more employees, as I remember, which is where it starts becoming feasible to self-fund.
posted by kindall at 11:23 AM on April 26, 2013

Another thing I haven't seen mentioned is that all of the above gets reset at the beginning of every year. So if you get diagnosed with something in October, have one surgery in November and another one in January, all the accumulation of charges from the first year have a full stop on Dec 31, and then your surgery in January starts the accumulation again from 0. So you end up paying your 3-5000 dollar deductible twice. If you had been diagnosed in January and had both your surgeries in the same year, it would only be one deductible so your total costs are a lot less. A lot of people use this fact to try to schedule things if they can predict out how many incidents each diagnosis might cause. Which can be sad if your condition is such that waiting for year-end is causing your condition to get worse every day, but hey, it will cost less if you wait.

Also related to end-of-year unfairness is that the insurance companies base the "year" on the date of service, but they take forever to pay their portion of the bills and then you pay your portion afterward. The US Tax system bases the "year" on the date the bills were actually paid. If you have health costs over a certain percentage of your income, you can deduct those costs from your taxes. But if the bills are actually paid over the time from November - February, they cross that magic year-end boundary and they don't count as one big thing you can deduct. If all our bills were paid in one year, we could have saved over $2000 in taxes, but because the insurance denied payments for 3 months we crossed the line and half our expenses went into the next tax year, where we didn't qualify for a deduction.
posted by CathyG at 11:47 AM on April 26, 2013 [2 favorites]

Response by poster: Thank you again for all these responses. It sounds like such a headache... dealing with your insurance company, picking plans when there are options, deciding whether to take/leave a job based on the change in insurance plan, the disincentive to starting a small business, etc.

It honestly boggles my mind that this system (or lack of system, I guess) is still in place, in one of the wealthiest nations in the world.
posted by barnoley at 4:30 PM on April 26, 2013 [2 favorites]

As an American who spends a good deal of time in Canada, and not (yet) covered by Canadian Health Care, I wanted to add a few things.

For people who are not under Canadian Health, patient costs are considerably less than in the U.S. I spent 11 hours in the ER, had xrays, CT scan, IV, meds and my total cost was $750. In the U.S. it would have been ten times that. I can see a doctor in Canada for a basic appt for $40 (SK) up to $100(BC). Again, much less than a basic appt for uninsured in the U.S. Generally, Canadian prescriptions are anywhere from par to 1/3 the cost.

In regards to Medicaid, besides being hard to find a doctor who takes it, some states have a list of covered conditions, and very many of common conditions are not covered at all. Also, there is a list of covered meds. The average medicaid recipient lives on about $700 a month, so the $3 to $5 copays can add up fast, especially for those who are on a lot of meds. Also, some states only cover up to 5 prescriptions a month, while many of the people using medicaid are disabled, and have more than that -- they either forego some meds or pay out of pocket.

That being said, health care in the U.S. is generally better than in Canada, with the exception of major teaching hospitals. My SO has been in hospital about 14 times in Canada and 2 times in the U.S. over the past seven years, including in Saskatoon, Calgary, and Vancouver. While we had no out of pocket expenses in Canada, and U.S. bills totalled over $100k (thank you, travel insurance!), the emergencies in the U.S. came about because of conditions overlooked or not tested for in Canada, and both times were life threatening.
posted by batikrose at 6:01 PM on April 26, 2013

Statistically speaking The US has the edge in emergency medicine while Canada does better in preventative and long term care medicine. IE: you are better off in the US when you have a heart attack and better in Canada if you have diabetes.

This makes sense: The poor can get emergency medicine and the US spends more plus they have a higher population densities so ERs/trauma centers/ambulance stations/etc. are closer together and closer to patients on average when minutes count. But the poor and middle class often put off even relatively cheap preventative medicine worsening long term outcomes.
posted by Mitheral at 11:28 PM on April 26, 2013

I live in Massachusetts and up until a few months ago I was unemployed. I qualified for MassHealth since I made absolutely no money. Everything was covered, it was wonderful. Free IUD, mental health services, physical, colonoscopy, you name it. I had a weird bump on my neck and my primary care doctor sent me to see a specialist. I then had a ct scan (free) and eventually surgery (also free). I LOVED MY ROMNEYCARE! Now that I work part time I have to navigate a different type of coverage, but I'm pretty sure it will also be a pretty good deal.
posted by superior julie at 8:06 AM on April 27, 2013

- Do you pay the premiums for your health insurance (for basic coverage of seeing the doctor, not drug coverage) or does the employer?

I'm a PhD student in the hard sciences. My university pays my entire premium ($2,700 per year). This is one of the major benefits of being a student! My husband is a public school teacher. We pay about $150/mo. for his premium and the City pays the rest.

- When you go to the doctor, do you have to pay anything? Or is it all paid by your insurance?

I pay a co-pay. It is $25 for an office visit and $100 for going to the emergency room. Of course, this only applies if I go to the right place! Since I am a student at a medical school, I can only get care at our hospital and affiliated practices. I think there's some massive cost if I choose to go to a different hospital in Boston when I could have gone to the right one. I am able to go to the university clinic for free (no co-pay) but they only offer very basic care.

- Say you get pregnant and have a baby. Are there any out of pocket costs? Are your prenatal visits covered 100%? When you go to the hospital for a typical vaginal birth, do you have to pay anything? How much? If you have a c-section, are there additional costs? How much?

Prenatal care is covered under my plan, but you still have to pay a co-pay every time you have an appointment, which really adds up. Under my plan, birth (vaginal or C-section) is 100% covered, but there is a small hospital co-pay. This means my insurance is really, really good.

Sorry if these are stupid questions, I just have no idea. I'm used to showing my health card and not paying a thing. My impression was that Americans have to pay additional fees even with insurance... but maybe that's just Canadian fear-mongering? Or maybe you have to pay fees, but just very low nominal fees?

I basically have the best possible insurance - my university pays my entire premium, and the coverage is excellent. My husband has very good insurance; we only have to pay $1800/year. We are extremely lucky. Even so, it's not ideal. There are all kinds of ways that we could get in to trouble, even with great insurance: have to see a doctor every week or twice a week (co-pays pile up), have expensive prescriptions not covered by insurance, get so sick that the cost of care surpasses the yearly limit (after which it's 100% out of pocket), get treated somewhere other than the preferred hospital, get sick out of state, etc.

I have seen the lives of many, many people destroyed by medical bills. A friend of the family recently was hit by a distracted driver and nearly died. He was in the hospital for 6 weeks and has needed physical therapy for months to learn how to walk again, not to mention many reconstructive surgeries. Literally thousands of friends donated as much money as they could, and the family are still (last I knew) upwards of 50k in debt.

However: for 2 years after college, I was on Massachusetts' socialized health care plan. It was available to me because I was poor, with very little income. It was an incredible insurance plan. I had no premium and no co-pays for appointments. There was a yearly out-of-pocket maximum of $250. I had a fabulous doctor. Choosing the right care provider was so stress-free, because I didn't have to call up and haggle about whether they took the right insurance or anything... I never had to freak out about whether I could afford medicine. My god it was nice. It was a glimpse of what you civilized people have for health care.
posted by Cygnet at 10:13 AM on April 28, 2013

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