The American “healthcare” system is fundamentally broken, and no amount of patchwork fixes will change that. We need to throw it all out and start from scratch.

It’s bad, a large percentage of bankruptcies in the USA are for medical reasons and a large percentage of those did in fact have insurance. The system is broken.

I lived in the US until a few years ago. I take daily ADHD medication and took birth control for several years, but not always. Otherwise, I was pretty healthy and didn’t have much medical intervention, but I have bad teeth.

I got the most cost effective insurance plan for me based on that medical history available at roughly $240 per two-week pay period, with a $5,000 deductible. The medication I took cost about $300/month and I had to pay for monthly drs visits and urine tests, to make sure I wasn’t abusing it. I don’t remember how much those cost, but I generally spent about $11k a year.

As a healthy (if neurodivergent) person in my 20s.

If I hadn’t had insurance, it would have been much more expensive, which is nuts. I got a tooth pulled and an implant put in, which cost about $8k all told, of which $2k was covered.

When I was in my early twenties, I got a chemical burn on my eye which required lots of treatments in the emergency room which I tried to pay, but there were twenty different places billing me for it and I just lost track of it. I had no assets and a bad job and they went into collections, but never showed up on my credit report and I essentially faced no consequences for doing so, except for much increased stress. If I had tried to do that with the tooth, they wouldn’t have given me the implant without upfront payment. If my payment had bounced, I had a better job and more money than earlier, so they might have tried to garnish my wages or sue me for payment.

I injured my arm in 2016 while working on a trailer. The doctor sent me to get an X-ray. With my wife’s insurance (the highest tier her company offers) the X-ray was $650. A visit to the doctor was $65 last time I went (2016), and an Emergency Room visit is $75.

In late 2016 I broke my nose on a movie set and had to get stitches. Production did not file the paperwork so they refused to pay the $2700 bill (ER visit plus 3 stitches, the set medic set my nose for them). I finally found a copy of the paperwork the set medic gave me in case production pulled anything. They paid the bill the day I emailed the paperwork, but that was almost 2 years of fighting with them.

“However, I have an American friend who is quick to point out that apparently nobody actually pays those bills. They’re just some elaborate dance between insurance companies and hospitals. If you don’t have insurance, the cost is lower or removed entirely. Supposedly.”

Partial Truth.

Healthcare providers have negotiated prices for services. These prices are negotiated per insurer.

Blue Cross and Blue shield will pay them X dollars for Deep Sleep anesthesia. United Healthe care will pay them a different amount. Medicare will pay them yet a different amount. Bob’s backyard healthcare will pay more because they don’t have buying power.

If you walk in without coverage, the provider “can” charge you a reduced rate. They are not required to. They do NOT universally offer that.

If you get the procedure done anyway, agree to pay and cannot pay your health bill, the provider “can” just let you off the hook or reduce your rate. They do NOT usually do that. That’s the exception.

If you go to a provider that accepts your insurance (they all do not) and book a procedure, the provider has to get the procedure covered by the insurer. If the insurer decides not to cover the procedure, you can call the provider and try to create a grievance. The back-and-forth is maddening.

My local doctor said I needed a colonoscopy (it’s just that time, no emergent issues)

My insurer authorized the procedure but not the anesthesia.

The office offered to pay out of pocket for the anesthesia ($1200), but I declined because I couldn’t afford it. They also offered to set up payments if I paid 50% upfront, but I declined because that didn’t help me. I can’t take on another $100 / month for 12 months.

I spoke with the GI doctor, a second GI doctor, and my General Practitioner. They all said that people here really don’t get the procedure without anesthesia, and it was a bad idea for both the doctor performing the procedure and for me.

I contacted the insurer, but they refused. Another GI doctor contacted the insurer, but they refused.

My insurer decided in January that they will not cover anesthesia for a colonoscopy unless someone can prove you’re frail enough it might kill you.

We have federal laws that mandate insurers to cover the anesthesia for this procedure, but state-level insurers (hint: they’re all state now) don’t have to follow their rules.

So here I am, two years late for a colonoscopy, wondering if I have pre-cancer or cancer brewing down there, but can’t manage to pay for what is considered by all providers here a necessary part of the procedure.

It’s not great here.

TL;DR: mine is $660/month for health, $42/month for dental

Most folks in the US aren’t aware of how much they pay for health insurance. I live in California, where law requires full time employees (>30 hrs a week, >130 hrs month) be provided some amount of health insurance. The type of coverage varies not just from job to job, but also within the same job the employee must often choose their own plan from several company selected options at varying price tiers and types/amount of coverage. Usually the employee only sees the amount of the monthly cost that THEY are responsible for, which is then automatically removed from their paycheck. What most folks are unaware of is that the employer is also paying some of the cost (which is the part that the law makes them do). The part that makes it extra frustrating to deal with an already broken and overly expensive system, is that the rate paid by employers is negotiated in bulk with the insurance providers. Larger employers (national corporations with hundreds of thousands of employees) are paying much less than an individual or small employer would. This is the one of the largest reasons becoming unemployed is so dangerous in the US. In addition to not having income for food or housing, people often forego health insurance due to the expense. If you lose (or leave) your job you’re eligible to keep your current insurance plan for 18-36 months with COBRA (Consolidated Omnibus Budget Reconciliation Act, which is such a ridiculous backronym that I had to google it just now). This is often the only time people realize the true cost of their insurance as the entirety of it is then passed on to them directly (at the employer negotiated rate) and it shows up as a new monthly bill.

I recently left my employer to start my own business and discovered that my true cost of insurance is ~$700/month ($660 Health/$42 Dental). Keep in mind, this doesn’t mean that I have zero medical bills should I actually visit a doctor or hospital. This is pretty good health insurance, but I still have to pay $5,000 out pocket (annually) before it kicks in at the full coverage amount. Since I had ear surgery earlier in the year and hit that limit, and wanted to be able to continue seeing the same doctors I had for already scheduled follow ups, I decided to keep the same insurance. That $5,000 isn’t the only expense that landed on my shoulders, there’s a bunch of rules that I honestly don’t fully understand and I’ve probably ended up paying somewhere between $7,500-$10,000 for the surgery I had (in addition to the monthly premium).

The main reason I keep paying insurance (in addition to the fact that you’ll now be charged a penalty on your taxes if you go uninsured for a month), is my fear that you mentioned in the original post. Having a car hit me while I’m walking down the street and ending up with a $50,000 visit to the emergency room is a very real possibility without health insurance. California recently limited ambulance rides to a maximum cost of $1,200, so that’s… good?

A lot of people simply don’t because they can’t. It’s absurdly expensive because the system isn’t designed for people to pay for it out of pocket. If someone doesn’t have insurance, they’ll either beg the hospital for mercy or ignore the medical debt because it doesn’t count against your credit score. Even if they do have insurance, it often doesn’t cover a portion of the cost, the insurance is extremely expensive, or both. The people with quality insurance through their employer have it good, but the system expects everyone to have that privilege.

Here’s a break down of my last healthcare stuff.

Weekly insurance out of paycheck: $127

Psychiatrist (ADHD) $150ish a visit, meds are ~$98

Last PCP visit (included some general blood tests) $217 (mostly lab which wasn’t covered)

Last ER visit: $792, waited over 10 hrs told to take an Advil and go home. Turns out I tore some of the sack (for lack of a better word) around my organs from weightlifting. it was thought a suspect gall bladder issue. I learned this from not the hospital.

And my appendix removal ended up costing me just over $9,000.

This is all what I paid out of pocket, the actual numbers for gross was, well, gross. I don’t need medical aid too often but it ends up pricey if I do.

America is a 2nd world country without universal health care. Just stick to your first world country.

mine is decently inexpensive through Obamacare, and I’m in a low enough income bracket. but it still isn’t ideal, I needed a sleep study. with or without my insurance it was going to cost $1,000 so I just never had it

The answer is “it depends”. There are so many hoops and loopholes and gotchas built into the system that 2 identical people with the exact same background and ailment(s) could go see the exact same medical staff and yet still end up having to pay 2 completely different amounts for their care. But it’s more complicated than that, because there are a myriad factors that come into play (insurance versus none, location/state of residence, etc) so there’s no one concise and accurate answer to these types of questions.

Most non-wealthy people who don’t have insurance, but who don’t qualify for government/public medical care, simply go without care. Or they use the emergency room loophole to get some kind of treatment. The loophole, with lots of nuance and caveats, is that the emergency room has to at least give you enough treatment to temporarily stabilize your condition, regardless of your ability to pay.

For check-ups and counseling - In a lot of places that sort of stuff requires you to pay up front. You can sometimes haggle or work out a payment plan. If you’re poor enough to qualify for government aid, it may be free. Otherwise, you’re expected to have insurance and pay the co-pay. If that doesn’t apply, these places usually have a “cash” price that’s slightly more affordable, but still usually require payment ahead of time.

For meds, you basically always pay up front. There’s really no concept of pharmacies providing medications in a manner where you can pay later. No money means no meds. It’s also ridiculous to even ask how much a person would expect to pay for meds, it could be as little as a few USD to thousands, really depends on the meds, quantity needed, location, etc.

Xrays - This is where debt might actually come into play. You usually pay for these after the fact. If you go to the doctor, you might have to pay the standard fee (or copay) up front, but all the other services/tests/etc are charged after the fact. So you’ll end up getting a bill after you’ve gotten the xray and consultation. To be honest, I don’t know the average out of pocket cost for an x-ray if you don’t have insurance, but it would differ from location to location and region to region. If you don’t pay that bill, you’ll get harassed and most likely you’ll have to change doctors because the office you owe money to won’t see you again until your debt is paid or you’ve worked out a payment plan.

For people with insurance, there’s pretty much always a maximum yearly out of pocket amount, after which things are basically all paid for by insurance. Again there are nuances and caveats. And the maximum out of pocket varies by insurance policy, number of people insured, etc, but $8,000 - $20,000 are not uncommon amounts. To be honest, I don’t even know what mine is, I’ve never actually reached it. Not everything is covered by the maximum out of pocket, though.

$27,000 medical debt could possibly be from someone who was uninsured or it may be several years of medical debt.

To give you an idea of how crazy the system is: I had a hairline fracture several years ago and what was deemed as “good” insurance. By the time everything was done, it ended up costing me around $3,000 out of pocket. That’s for co-pays, x-rays, medication, etc over the course of months.

On the other hand: A family member of mine had a heart attack, required emergency surgery, had no insurance, and had no money to pay for anything. In the end cost them less than a few hundred USD out of pocket. Hospital wiped the debt clean. Government programs and drug company programs paid for meds. Eventually disability stuff kicked in and took care of everything else.

nobody actually pays those bills. They’re just some elaborate dance between insurance companies and hospitals.

Sometimes there is an elaborate dance between the two on pricing. Sometimes the insurance company dances on its own to determine why the service is not covered.

If you don’t have insurance, the cost is lower

Depends what you mean by cost. insurance is always out to make money, that means paying less, and negotiating lower prices with providers. However, there are some situations where it benefits both the service provider and the insurance provider to inflate the initial price, and negotiate a steep “discount” to a final price (a portion of which the patient pays) that is higher than the non-insurance price. But I don’t remember the exact details, and I may be conflating this with some other healthcare industry scheme.

or removed entirely. Supposedly.

If a hospital is nonprofit, I believe they are required to have a (self determined) charity care policy that they must follow. If you make below a certain amount, you can apply for relief, but that also applies for to after-insurance costs, not just no-insurance costs. For-profit hospitals will rake you over the coals and send collections after you. Part of the problem with charity care, is that you may have to ask for it, and few people know enough about it to do so. And you may have to ask for it in the right way. If you aren’t specific enough, they may offer you “financial assistance” which is just a payment plan. Then they’ll treat you the same as a for-profit hospital would.

If you’re interested in a deeper dive, the Arm and a Leg podcast is a great show about healthcare costs in the US.

I have (what I believe) is considered “very good” insurance. I pay $100 a month for premiums.

When my child was born, there were some complications and we needed to move to another hospital for emergency surgery.

The birth: ~$2500 deductible/copay/whatever you want to call it. I think this is all I would’ve had to pay if there weren’t more complications.

Surgery and aftercare for baby: ~$5600

Care for momma: ~$2000

But here’s a crazy twist. When moving hospitals, we rode in an ambulance. But this was an “out of network ambulance”. What the hell is even that? Under what circumstances do you have a say in which ambulance you ride?

Out of network ambulance ride: $4500

Basically it’s all just bullshit.

In addition to the actual costs other people are talking about, the mental costs of dealing with the system are inmense.

You have to update your information whenever you change your job. It’s not like your social security number that’d given once and you memorize.

Every year you probably have to review your insurance options and pick one. This is essentially gambling- if you pick a low cost one you save money, unless you actually need to use it.

You probably need to find doctors that are “in network” or pay a lot more.

Sometimes bills are sent directly to you and that’s a mistake. But sometimes you’re supposed to pay and be reimbursed.

You typically don’t know what the costs will be up front, so you have to guess what the best option is. Take a nasty spill on a bike? Is it worth calling an ambulance? Does your insurance cover that? Maybe just walk into the emergency room. But does your insurance cover that? Maybe just call a regular doctor?

In short, there’s a lot of stuff you have to think about as the end user. I’d rather it was just “oh shit you’re hurt, let’s take you to the doctor. Don’t worry about money”

I pay $30 per doctor’s visit and $40 if the visit is for a specialist. I also pay $0 for a yearly checkup and $0 for telehealth. For any hospital visits, I pay 20% of whatever the actual bill is after a $300 copay (basically a down payment), which came out to a total of $600 when I went to the ER. Lastly, my prescription drugs are capped at $10 per month for generics and $150 for some brand-name drugs.

I use a ton of healthcare and the costs have been super manageable, but affordability is going to vary wildly between people. A ton of insurance plans don’t start working until you hit an out-of-pocket minimum of several thousand dollars, and others work like mine except with way higher copays.

Lastly, insurance often doesn’t cover certain drugs or procedures. As someone with really good insurance with good customer service, it’s still an issue every so often, and the solution is either to find an alternative, try to find a manufacturer’s coupon and pay up, or suck it up and move on. There are insurance companies that use shady tactics to get them out of paying for certain expensive drugs that they’re supposed to cover.