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... and why they don't.

Most people choose their health plan based on old wives' tales and other less than rigorous methods. Or rely on the recommendation of an insurance broker who's financial interests may diverge from their own.

Unless you're in the top 5%-10% of the individual health care expenditure distribution, you should be buying a high-deductible health plan with the largest annual out-of -pocket maximum you can afford. That way the health insurer has a smaller pot of your money to skim from.

https://wellnet.com/on-tap/the-healthcare-plan-mos...

intercst

How well does this work if you get cancer? I know two people with lymphoma and their medical costs topped $1 million each. If you’re planning for cancer, is a high deductible plan the right choice?

{{ How well does this work if you get cancer? I know two people with lymphoma and their medical costs topped $1 million each. If you’re planning for cancer, is a high deductible plan the right choice? }}

The deductible and annual maximum out-of-pocket is the most that you'll pay during the calendar year. That's true whether you have a $100,000 illness or a $1 MM cancer. The big worry is that your insurer may not approve the treatment your doctor recommends.

If you're on Medicare, the "Medicare reimbursement" is a fraction of what's billed. Something that's a $1 MM illness on your employer's health plan, might only be a $200,000 Medicare reimbursement. If the hospital bill is $150,000 and the doctor's bill and other out patient services are the remaining $50,000, your Medicare co-pay would be less than $12,000 for the year. People hear about the "20% that Medicare doesn't pay", and think that they'll be on the hook for $200,000 on a $1 MM illness. That's just not true.

A $1 MM hospital bill cost you just $1,676 in 2025 (that's the Part A deductible.) The non-hospital costs are the piece that gets the 20% co-pay, but it's 20% of the Medicare reimbursement, not the big number the hospital or doctor bills you.

I had about $400,000 in medical bills in 2025 after my leg was amputated. The hospital bill was $260,000, the Part B charges were $150,000 with a Medicare reimbursement of about $90,000. The total Medicare out-of-pocket for the year was about $20,000, but I had a high-deductible Medigap plan that capped that at $3,000/year.

https://retireearlyhomepage.com/medicare2025_prais...



intercst

Thanks, that is very helpful. My big fear is that once we get on Medicare in a couple of years we lose access to our oncologist and the excellent care our university hospital has provided.

I think I made a mistake this year with my high deductible plan. There is no out-of-pocket max for services which are out of network.
The in-network coverage is max $10k out of pocket. I should be fine as long as nothing sudden and severe happens, but it's a bit frightening to know I could be on the hook for a huge bill if the insurance doesn't align correctly.

I think I made a mistake this year with my high deductible plan. There is no out-of-pocket max for services which are out of network.

That's a good point. And no doubt your network, like ours, is very narrow. Out of network is a concern.

{{ My big fear is that once we get on Medicare in a couple of years we lose access to our oncologist and the excellent care our university hospital has provided. }}

Most academic medical centers seem to accept traditional Medicare. I'd be more worried about going to a university hospital with a private health plan since they generally charge higher prices.

https://www.cbsnews.com/news/colonoscopy-the-hospi...

If you're interested, here's the analysis I did about 5 years ago when I was evaluating my Medicare choices.

https://retireearlyhomepage.com/medicare2020.html



intercst

I'm sure most have heard stories like this but I was talking to someone who cut off a couple of fingers. His bill was initially under $2,000 without insurance but when he told them he had insurance it went up to something like $9,000. His $200 ambulance ride went to $1,200.

Sadly having a profit motivated middle man increases costs for everyone.

Rich

I was talking to someone who cut off a couple of fingers. His bill was initially under $2,000 without insurance but when he told them he had insurance it went up to something like $9,000. His $200 ambulance ride went to $1,200.

Sadly having a profit motivated middle man increases costs for everyone.


That's just a version of "Hollywood Accounting". If he looked at the EOB he would have seen that the actual payout was $2,000 and $200. The rest would be charged off as something like "Adjustments" or "discount".

When my wife had her pacemaker replaced the hospital "total charges" was $15,900, "adjustments" was -$13,200. Insurance paid $2,200. Our amount was $360 (mostly the annual deductible).

Another time there was an unexpected 2 week hospital stay, total charges around $200,000. The net paid by insurance was about $60,000. Our amount was $1,200.

When we talked to the hospital coordinator on the 2nd day and I expressed fear about being hit by the whole thing, since we did not get pre-approval from the insurance company, she said, "Don't worry about it. If the insurance will not pay it, we will only bill you for what you would have had to pay if they DID cover it."
BTW, the insurance company (Humana) did cover it.

-------------------------
If you think "a profit motivated middle man" is bad, take a close look at the Canada health system. M.A.I.D. (assisted suicide)
"In 2024, 5.1% of people in Canada who died received MAID."

"Medical System Savings: A 2020 estimate suggested that MAID could result in a net reduction in healthcare costs, with a projected $62 million in savings."

{{ If you think "a profit motivated middle man" is bad, take a close look at the Canada health system. M.A.I.D. (assisted suicide) "In 2024, 5.1% of people in Canada who died received MAID." }}

I always appreciate this strong, fact-based reasoning.

Yet the average Canadian struggling with the depredations of Gov't paid health care lives 3 years longer than the average American.

intercst

If you think "a profit motivated middle man" is bad, take a close look at the Canada health system. M.A.I.D. (assisted suicide)
"In 2024, 5.1% of people in Canada who died received MAID."

"Medical System Savings: A 2020 estimate suggested that MAID could result in a net reduction in healthcare costs, with a projected $62 million in savings."

I'm not sure why you're unhappy with that. It seems very reasonable that one out of twenty people would find themselves in a position that they wouldn't want to continue with expensive treatments that won't prolong their life. A treatment that allows you to lie in bed at home, etc., and watch TV is worth considering, but not one that leaves you in a hospital waiting for the next emergency, etc. 5% seems a reasonable for people who decide to end their lives.

If you think "a profit motivated middle man" is bad, take a close look at the Canada health system. M.A.I.D. (assisted suicide)
"In 2024, 5.1% of people in Canada who died received MAID."

I helped hospice at home both of my parents. Many of us have gone through this and appreciate being able to share the benefit we give our loved furry friends of a graceful exit out. I am encouraged by the ongoing legislation I see happening, state by state, to allow us the same benefit here in the US. I hope that it will be available when it is my time. No way I want to put my kids through what I experienced during hospice for my parents.

I didn't realize how compassionate the Canadians were in this regard. Thanks for sharing.

IP

I helped hospice at home both of my parents. Many of us have gone through this and appreciate being able to share the benefit we give our loved furry friends of a graceful exit out. I am encouraged by the ongoing legislation I see happening, state by state, to allow us the same benefit here in the US. I hope that it will be available when it is my time. No way I want to put my kids through what I experienced during hospice for my parents.

I didn't realize how compassionate the Canadians were in this regard. Thanks for sharing.

IP


I kind of only glanced at this thread so apologies if I misinterpreted it. My wife was telling me how the mother of one of her friends doesn't want to live anymore. The doctor said there really isn't anything major wrong with her so she isn't likely to die of natural causes anytime soon. I've heard a few stories like that. Most people don't want to suffer, others don't want to be a burden on anyone.

Of course it is easier for someone who isn't in any serious medical issue to say "I don't want to become a burden to anyone, etc. and would rather end my life when it gets close to that point" than actually go through with it. I can think of a number of medical issues I wouldn't want to live through but then again, would I have the courage to actually end my life? Wouldn't be an easy thing to do for most people.

My mother went through a very rare disease for about 8 years as it slower took away her ability to walk, show facial expressions, and eventually eat. It had to be terrible for my father who was there virtually every day in his prime retirement years. In my father's case, mentally he had no issues (with memory), but eventually his body slowed down and I think he no longer wanted to fight things medically since he was tired of getting home, getting sick, hospital, outpatient recovery/rehab, home and repeat. He didn't see a way out of it (sadly). I wished I was around more often but instead was frequently living out of state although I moved back and I thought he had longer than he did (only about 6 months).

Right now it seems like we are at a point where medicines can keep people along longer than their body can function adequately for self care. Both of my brother in laws have their mother in laws living with them and are mostly wheelchair bound and one is not doing well memory wise. Both are in their 80s. Fortunately my uncle (85) is fine mentally and so far physically (2 hip replacements) but isn't interested in any other major surgeries.

When younger I often thought the bad part of aging was getting old in looks or slowing down physically. I didn't realize how tough mentally it is for people aging as they see their friends, spouses and other family age, suffer and pass away. It isn't easy for most people.

Rich

Of course it is easier for someone who isn't in any serious medical issue to say "I don't want to become a burden to anyone, etc. and would rather end my life when it gets close to that point" than actually go through with it. I can think of a number of medical issues I wouldn't want to live through but then again, would I have the courage to actually end my life? Wouldn't be an easy thing to do for most people.

Lots of Alzheimers in my family and I have seen it up close and personal. Doing my best to avoid it, but if I get it, there is no way I wouldn't pull that trigger. I am not afraid of dying as much as have a fear of living while not being alive. NOT putting our kids through that.

IP

I didn't realize how tough mentally it is for people aging as they see their friends, spouses and other family age, suffer and pass away. It isn't easy for most people.

And the pain. If you're very lucky, you don't have any. But most older people have something that hurts. Sometimes, many somethings. Back, knees, hips. When it stops you from doing stuff, it's easy to get depressed. I expect to be able to "do stuff" for another 10 years. Maybe a bit more. Barring the unforeseen. My back (which had surgery) is slowly becoming more problematic. Also my ankle. 1poorlady has knee issues. We already can't do any major hikes.

1poormom always said "getting old is not for wimps". She was right.

I can think of a number of medical issues I wouldn't want to live through but then again, would I have the courage to actually end my life? Wouldn't be an easy thing to do for most people.

Two things-

My older sister got cancer and somehow two of her vertebra went bad after the operation and radiation and chemo. She became incontinent and had mobility issues. Fast forward and she's estranged from her adapted daughter, living alone and she's very large, bedridden, and her feet don't angle up and are flat in the bed. She comments on FB that she really doesn't like living alone and has to have a woman come in every day to feed and clean her. But she could drink wine and watch TV. She died about 6 weeks after saying she didn't like living alone. We may have some self regulating mechanisms we don't know about. Contrast that with my wife's grandma who turned 106 and everyone loves her. Still gets around.

I remember a Jack London story of an old man that was left behind by the moving tribe in the cold snow, because they couldn't take care of him anymore. He was a burden. He waited silently and the story ends with the wolves closing in. I'm glad we don't do that.

I'll go somewhere I'm allowed to exit on my own terms, should I feel old, burdensome, and/or terminal. We're graceful to our pets when they get to this point, but want to hook people up to machines or such, sometimes for an awful long time, when they're rather wizened. My grandmother was 93 when she lost memory and recognition of the last person familiar to her (her son who was close by and would visit often). Shortly after that she broke her him and they had to fuze her leg. From 93 to 100 she was confused and somewhat frightened, every day, and simply sat in her chair and stared out the window - that's where the staff would roll her. It was an awful and hollow existence. Not me.

I helped hospice at home both of my parents. Many of us have gone through this and appreciate being able to share the benefit we give our loved furry friends of a graceful exit out. I am encouraged by the ongoing legislation I see happening, state by state, to allow us the same benefit here in the US. I hope that it will be available when it is my time. No way I want to put my kids through what I experienced during hospice for my parents.

My FIL had terminal cancer, which caused him to be in a lot of pain. When it became clear he was on the downhill slide to the end, the hospice nurse had the doctor change his pain medication dose from a specific number to "comfort." She looked us in the eye and made a point of saying the prescribed dose was "to comfort." He died the next night comfortably in his sleep.

We're graceful to our pets when they get to this point, but want to hook people up to machines or such, sometimes for an awful long time, when they're rather wizened.

Even when you don't do that, it can still be awful. 1poormom had a stroke. She lost the ability to speak or swallow. The latter was a huge problem. She couldn't take in water. I knew she didn't want machines. But when the doctor said there was no chance of recovery, they just put her on morphine. As near as I can tell, she died of thirst about a week later. Not in pain, but almost gasping towards the end. We should have a system -with lots of checks!- to be able to put them to sleep as we would a loved pet. But no...put them in a mostly-unconscious state and let them die slowly. How is that better or humane?

I have many recollections of difficult passing of beloved patients. One stands out. They were as devoted a couple as I have ever seen. Adored each other. They were German emigrants to the US. He, a professor of forestry studying forest health around the world. A delight to listen to. Both were fearless outdoors-people. "There is not a such thing as inclement weather, only inadequate clothing."

She developed an unusual dementing process which manifested as abject terror on a daily basis. Impossible for her husband to give her solace, and very tough to calm her medically without excessive sedation.

It was a very unhappy end to a lifelong fairly tale relationship.

fd

That is the right approach. My goal is to treat pain adequately. If the patient expires as a result of adequate analgesia, that is not only acceptable but the standard of care.

fd

We should have a system -with lots of checks!- to be able to put them to sleep as we would a loved pet.

The problem is perverse incentives.

The organization that is paying the bills has a financial incentive to terminate the person who is causing the expense.

This is bad enough when it is family wanting to protect their inheritance from Granddad. It is worse then it is a company or a government healthcare system that has no emotional connection to the client.

It's a slippery slope, and has been seen many times.

And, y'know, people do it all the time with pets. You don't want to pay for cancer surgery for Fido, so you have a vet do the deed.


IMHO, the best way to handle it is unofficially. Like the "morphine to comfort" idea. Or as I discussed with my doctor, a bottle of sleeping pills and a fifth of scotch.

And don't forget to have a Living Will with "DNR" and "DNI" in big capital red letters.

The problem is perverse incentives.

Yes. Which is why the best you could do was to have multiple doctors agree, and family agree. Hospital administration should not be part of the process.

The "morphine to comfort" I could get behind, but I foresee the person administering it being brought up on charges. Not sure how you could get around that.

The "morphine to comfort" I could get behind, but I foresee the person administering it being brought up on charges. Not sure how you could get around that.

I spent a decade as a hospice medical director (layered on top of to my regular 30-year job as an oncologist).

The rule was always, What's in the patient's best interest?

My only sworn duty was to the patient....and they needed as much morphine as they needed.

The men with briefcases never bothered me, and if they had, it would have been see-you-in-court time.

--sutton
the bigger challenge was patients or their caregivers with preexisting drug abuse issues. There, the answer was very "one week at a time, ask the right questions, listen carefully to the answers, remember that drug abusers with cancer get cancer pain, too, and document the bejeezus out of everything"

FWIW, my wife is an LPN and she worked at several different hospitals when she was younger, 1970-1999.

She told me that she saw a number of times for an RN nurse to steal morphine that should have been going to a patient and using it themselves. It bugged the shit out of her, not just the taking of drugs by a medical professional but taking pain medication from a patient that NEEDED it.

But as a lowly LPN she could not say anything or report it.

But as a lowly LPN she could not say anything or report it.

That was a choice she made, not an impossibility.

IP,
not wired to make the choice she made, having taken on the "big boys" more than once

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