308 comments

Two Years Without Health Insurance (and What I’m Doing Now)

Two years ago, I was unsatisfied with my options for health insurance. The premiums were rising even as the quality dropped in the form of an ever-increasing deductible. I am guessing that you might feel the same way these days – most of us Americans are in the same boat.

I felt like I was being squeezed from both ends and it was starting to piss me off. So I decided to take some action, by doing the math for myself using a spreadsheet. I needed to answer the question, “Is this insurance really as bad a deal as I think it is?”

Sure enough, the risks and rewards of the coverage did not justify the premiums, so I decided to try an experiment and simply drop out of the market and insure myself. In other words, just rolling the dice and going through life with no form of health insurance at all.

Doubling down on the bikes, barbells and salads, I did my best to eliminate any risk factors that are in my control, while accepting that there are still much less likely but more random factors that are not.

Figure 1 – DIY Health Care

Almost two years and $10,000 in premium savings later, I have found the experiment to be a success: I have slept well and not worried about the fact that I could be on the hook for a big bill if I did ever need major care. And as luck would have it, I also enjoyed the same good health as always over this time period – probably the best in my life so far because the extra healthy living has been working its magic.

But.

This situation has not been quite ideal, because my life is not a very useful model for everyone to follow. Most people don’t have the luck of perfect health, many have a larger family than I do, and very few people are in a financial position to self-insure for all possible medical bills.

Also, I found myself wishing I had a doctor that actually knew me, who I could call or visit on short notice if I ever did need help.

Finally, I wanted to switch back to having some form of insurance so that I could learn about it and write about it as time goes on. But was I really willing to be part of that unsatisfying and broken insurance model?

Then something magical happened: I learned about the new and vastly improved world of Direct Primary Care physicians.

What is DPC?

DPC is a fairly new trend in the US, but it is also a return to a very old tradition: a direct relationship between you and your doctor, with no insurance company in the way. 

As a customer, you pay for a monthly subscription (somewhere around $100), and in exchange you get unlimited access to super elite, personalized medicine for the vast majority of your medical needs. Diagnoses, prescriptions, skin conditions, stitches, even fixing a broken bone if you don’t need surgery. All covered, with no co-pay and in an environment that feels to me like Presidential-level health care, in striking contrast to some of my past experiences where I felt like an anonymous numbered ticket in a sloshing sea of bureaucratic institutional medicine.

Oh, and direct email, phone and text message contact with your doctor, prescriptions over phone or video call, and in some cases even house calls depending on the practice and the situation.

Through some sort of magic, the Direct Primary Care model offers much better medical care and much lower prices, at the same time.

How could it be? It’s because of the incentives.

Figure 2: The Insurance Model for Health Care

In our famously broken US healthcare model, an insurance company is wedged in between you and your doctors, and it has different objectives than you do.

You just want the best overall health for yourself, and when the shit does hit the fan and you need medical care, you want it to be quick, effective, and at minimum cost. And you don’t want to be hounded with years of stressful stray bills after an expensive medical procedure.

Your Doctor wants to help as many people as possible and make a good living, without having to wade through a sea of paperwork or stress or lawsuits.

Your Insurance company wants to make as much profit as possible, which means maximizing the amount they collect from you, and minimizing the amount they pay to your doctor. In theory, they benefit from helping you to stay healthy. But they have also developed elaborate contracts (putting in as many loopholes as possible to allow them to drop your coverage or deny claims), become masters of delaying payments, limiting which procedures and tests they will authorize doctors to do, and just generally throwing the biggest monkey wrench into the system that they can.

Over the decades, there has been a complex battle of lawmaking, lobbying, compromise and complexity to try to regulate away some of these problems. Sometimes the new laws help, sometimes they don’t, but the end result will never be optimal simply because there are a lot of people involved, and big crowds of humans make for slow and shitty decision making.

The Direct Primary Care Model

Figure 3: The Direct Primary Care Model

With DPC, it’s just you and your doctor. You both have the same incentives, but now the model works much better because there is no chaotic and expensive force in the middle to mess things up.

And because you operate on a subscription, the doctor gets paid whether you come into the office or not. At the same time, you are free to come in whenever you do need something, at no additional cost. So she has an incentive to keep you healthy, so that you have no need to come into the office in the first place. 

On top of this, you get to decide together what is the best course of healthy prevention and treatment, without the overhead and complexity of constantly fighting with insurance companies. This drastically cuts the costs by eliminating the large staff of paper-pushers and attorneys that you normally need to operate a medical office, and frees up the doctor to spend more time with each patient during each visit.

How could the doctor possibly make a living with such low fees?

As it turns out, a small practice with one or two doctors and a few credentialed medical assistants can handle over 1000 subscribers while still giving each person much more time than they get under the old model. At $100 per month, this is $1.2 million in annual gross subscriber income, which is enough to pay everybody well, and rent a suitable clinic space. And as you scale up the operation, some economies of scale on things like space and equipment make it even better.

Just as importantly, running a practice like this tends to make a dramatic improvement in a doctor’s quality of life. It’s better medicine, with more flexibility and less hassle and stress. No wonder this model is growing rapidly and has become a favorite of physicians who happen to be MMM readers, as I hear from more of them every month.

Direct Primary Care is now a nationwide movement, with many hundreds of practices spanning the country and many more opening each year. Today’s screenshot of https://mapper.dpcfrontier.com/ shows the current state of the market. 

Direct care locations everywhere

In fact, it turns out this whole trend might even be a Mustachian-originated phenomenon, as I joined my own local practice called Cloud Medical, met the founder Dr. David Tusek, and he revealed halfway through our introductory visit that he was both a founder of DPC pioneer Nextera Healthcare in 2009, and a lurking reader of this blog for several years before I discovered him right here in my own town. 

A note for locals: if you are considering joining Cloud, mention that you would like the MMM discount to save a further $12/month! (we have no affiliation, they are just looking to expand the practice and I’ll remove this notice if they fill up)

My experience (so far) with Cloud Medical

Cloud Medical’s Longmont office – definitely a step up over past medical office experiences! (although they do need to add a proper bike rack)

I signed up with Cloud this past summer, about five months ago. Although I have been feeling great, I figured it was time to put myself through an extensive battery of “middle-aged man” tests just to make sure I am not missing any hidden problems. 

With the doctor’s guidance, I did a very thorough blood test, plus an electrocardiogram scan of my heart performance and ultrasound Carotid artery scan which involves a practitioner lubing up your neck and sliding a Star-Trek-style probe around on it while recording images of your body’s most critical plumbing to check for signs of clogging. Plus the usual checks of an annual physical exam. All clear.

I also finally got around to a long-awaited diagnosis and prescription for my Adult Attention Deficit Disorder condition, something which took me seven years to get organized enough to achieve, paradoxically one of the crippling effects of ADD. Although this is a very personal health detail, I mention it here because there are many friends and readers who also suffer from this condition, and I encourage you to learn more about it and seek help if appropriate. It can be life-changing.  I found this process was much easier in a DPC environment, because of the more personal nature of the doctor-patient connection. 

This DPC model addresses perhaps 90% of typical medical needs in-house, and a “menu” of optional specialists knocks out another 5%. 

Cloud and other DPC practices have a “menu” of standardized prices, typically much lower than traditional offices. Full PDF here.

But there is still a chance you will need the more rare (and expensive) services of a hospital or specialist. In this case, your DPC physician can provide referrals and guidance to allow you to get the right help at a discounted, direct-pay price, or even handle your needs with a conventional insurance company.

Part Two: But What About Bigger Expenses?

Health share options, with the one I chose (Sedera) in the center.

At this point, you can add another layer of protection: High deductible conventional insurance, or a health share membership which offers a similar end-result while being careful not to be classified as insurance. 

A Disclaimer before we begin:

I think of health shares as a form of “emergency medical bill reimbursement”, rather than full fledged insurance. They are suitable for mostly-healthy people who want financial protection in the event of a major medical event. But they are not insurance, and often not too useful for someone with an existing, expensive condition.

Update 11/12: This blog post has triggered lots of fine-print-reading and discussion among readers, which led us to follow up with various insurance and health share companies.

The final word on one issue of debate: most conventional insurance and health shares do not cover voluntary abortions, while they do cover medically necessary ones, just under the different name of “Maternal Complications”.

Health shares in particular also don’t offer much ongoing drug reimbursement, which includes a lack of coverage for birth control. While I disagree with this policy, from a practical perspective it just means you need to budget for this expense separately.

For situations where a health share membership falls short, the subsidized and regulated insurance available through employer-based plans or the state exchanges via the Affordable Care Act, are probably a better bet.

But with all that in mind, I still chose one for myself, so let’s get into it!

Health sharing groups started out catering only to members of certain religions. Then a provider called Liberty Health Share opened up the market slightly while still requiring some fairly specific spiritual affirmations.

The latest incarnation is a company called Sedera* , which has addressed some of the shortcomings of earlier companies, has far less religious basis, and now seems to be the place that most of my more analytical friends and their families are ending up. Even my DPC physician Dr. Tusek is now recommending Sedera.

Sedera is worth a whole separate article in itself, and in fact I am starting a dedicated page for questions and answers and discussion on the experience. But for now, we’ll take a shortcut and just say that I was convinced and willing to give it a try, so I signed myself up as a Sedera customer.

A quick comparison of the closest standard insurance plan I could find on the standard Colorado health insurance exchange, versus what I got from Sedera (click for larger version):

For me, Sedera cuts my monthly cost in half, even while delivering better coverage.

Another thing I like about all this is that there is no concept of “in network” and “out of network” doctors or hospitals. You can even use hospitals in other countries while traveling, and get reimbursed in US dollars after you return home. It’s simpler, cheaper and more flexible.

So in the end, by combining DPC with a health share membership, I am hopefully ending up with the best of all worlds:

  • The best personalized, advanced medicine and quick response time, possibly anywhere in the world through my DPC subscription, with unlimited “free” (zero co-pay) doctor visits.
  • Flexible coverage for any additional needs and support for decision-making and billing, even when traveling internationally
  • A financial backstop just in case things get really expensive
  • At a total monthly cost that is still lower than the most basic ho-hum plan on standard insurance
  • A further bonus – Sedera incentivizes you to be a member of a DPC, with a solid discount if you are, because they know their costs to cover you will be lower if you are healthier and have hassle-free access to a doctor.

This all sounds good to me, but it is important to state that this is an experiment. I still don’t have much experience with the US healthcare system – it helped deliver my son in 2006, and then repair that same boy’s broken arm in 2016. Conventional insurance offered some halfhearted support for both of those expenses, but aside from that I don’t have many stories to tell. 

By collecting more information from readers and from my new helpers at Cloud Medical and Sedera, we should be able to make more sense of all this. And hopefully continue to expand and improve this new, better form of health care so it is accessible to more US residents.

If it gets big enough, we might end up solving this whole problem together – better, cheaper health care for everyone.

But What About the Affordable Care Act?

I think that DPC and ACA could work together perfectly – we keep the idea of the personal relationships, the subscription-based model, and the open and competitive pricing from hospitals for all procedures. But we just don’t need conventional insurance companies. If our society wants to help less-wealthy people to afford the best health care (which I think is a great idea), we could just subsidize their DPC memberships and offer a public insurance option at low or zero cost which covers hospitalizations. The reason this is better than the ACA: direct care and no insurance companies.

Conclusion

My past articles and experiences have shown that for many of us, a big hurdle when considering early retirement or self-employment is “what about health insurance”? Hopefully the is DPC + Healthshare method will put that question to rest for many of us. After all, shouldn’t our career and life choices be separate from our healthcare?

—–

Interested in Learning More?

A long-time friend of mine (and fellow early-retiree, and co-owner of the HQ coworking space) Bill and his family have been Sedera customers and enthusiasts for about two years. So much that he even took it upon himself to meet the company’s management, sign himself up as a representative to streamline some of the inefficiencies he perceived when joining, and then teach me about the whole thing.

Because of that, I am sharing Bill’s Sedera signup link in this article. His is unique among the Sedera affiliates in that he charges zero administrative fee, typical brokers charge $25 per month and up.

https:/sedera.community/thefireguild1

*note: Sedera does pay its affiliates a small referral fee for new customers, which does not affect your monthly bill – in fact, this link offers a lower price than subscribing directly through the company’s website. Thus, we believe this is the lowest cost way on the Internet to get this coverage.

As mentioned above, I’m giving Bill his own page to maintain on this site, where he can share his ongoing research and updates and answer questions: mrmoneymustache.com/sedera

Further Reading:

I was quite moved by this piece that Cloud Medical’s Dr. David Tusek wrote about “the ten heartbreaks” that led him to work since 2009 towards accelerating this better way to do healthcare.

An interesting story from Bill’s hometown, from a doctor who took this path way back in 2013:

South Portland Doctor Stops Accepting Insurance, Posts Prices Online
(from the Bangor Daily News)

  • Mr. Boy Millionare November 9, 2020, 8:59 pm

    Once again reading one article from MMM places another few dollars in my stache’! Health insurance was due for some optimization.

    Reply
  • Mary Ellen November 9, 2020, 9:54 pm

    The problem is not that it doesn’t work for you as an individual, but if healthy people do not participate in our current health insurance system, it will become unsustainable. The ACA is already a very fragile patch to provide care to millions of low income Americans (including hundreds of my patients). Everyone deserves high quality healthcare, and the healthcare sharing plans like Sedara do not accept people who have chronic health conditions. I understand why people would seek out lower cost solutions for themselves as individuals, but we as a country need to look at solutions such as medicare for all that would provide just, equitable health coverage for everyone, not just people that are healthy and prosperous. This is an important ethical decision that has collective consequences, similar to those that impact climate change.

    Reply
    • Ahoo November 10, 2020, 1:31 am

      Trump tried to dismantle ACA (which is unaffordable garbage), and Biden refuses to endorse Medicare for All. I’m 59, healthy, and looking to retire at 62, 3 years shy of Medicare. You can bet I’ll be signing up for DPC/Sedara.

      Reply
      • Phil November 10, 2020, 8:34 am

        You are better off with one of the very high deducible options on the Marketplace.

        Since you won’t be working your income will be low enough that you will get excellent subsidies from the government. If something big happens (like prostate cancer, etc) you are fully covered over and above the deductible. Yet you still get free dr. visits and the discounts on drugs that the insurance cos negotiate.

        At least look at it with an open mind. It is not as bad as the anti-ACA propaganda would have you believe.

        Reply
        • David Wendelken November 10, 2020, 2:42 pm

          We’re retired. I pay ~$1150 a month for medical and dental insurance FOR JUST ME. My wife is on Medicare and pays ~190 for a supplement plan and several hundred a month for medicare.

          And that’s if we never see a doctor or get a prescription.

          It’s our biggest single expense, even larger than the property tax AND insurance for 5 houses (4 of which are rentals).

          Thank God, hard work and savings that we can afford to retire and pay it.

          Our current system has got to be streamlined, simplified and made affordable. It’s none of those now.

          I do have a concern about what MMM is doing. I think there may be a hidden danger. Technically he doesn’t have insurance. Since he doesn’t have insurance, he may fall prey to the any pre-existing condition traps that still exist due to lapses in insurance. It’s the kind of thing that needs to be triple-checked.

          Reply
          • Andrew cannon November 11, 2020, 2:47 am

            I’m an engineer with a family of 5, and our marketplace insurance is literally $0 premium per month after the ACA subsidy. Look at a bronze plan. Click the box that says your work doesn’t offer a group plan if that’s true. Or if you’re planning on what to do when retired.

            Downside is the insurance is only useful inside our state.

            https://www.kff.org/interactive/subsidy-calculator/

            Reply
            • Mr. Money Mustache November 11, 2020, 6:53 am

              Yes, good point! I will update this article to make it clearer that even standard insurance is usually less expensive than people think, and the subsidies will help almost any early retiree (and most people in general unless you have a high income).

              Reply
      • Kerry O'Brien November 10, 2020, 6:43 pm

        Biden’s platform includes lowering the age of eligibility for Medicare to 60, which would help a lot of Mustachians.

        Reply
        • Lynne November 15, 2020, 6:17 pm

          I’m hoping for Medicare coverage 60 and up. ACA only works for those who get generous subsidies.

          Reply
      • Norm Johnson November 11, 2020, 8:12 am

        Med insurance was already unaffordable garbage before the ACA. With premium support based on income level, ACA plans offered through the state marketplaces are still too expensive, but in many cases more affordable. More importantly, at least under ACA you get mandated preventative care (like a colonoscopy for a copay instead of for $1500), you are covered for pre-existing conditions, mental health care is included and there are several other features meant to protect consumers from the unmitigated greed of insurance company executives and shareholders. I agree Medicare for All is where we need to be but that is probably not in the immediate cards. So, until we have something better, let’s not throw the ACA under the bus without a solid replacement. The direct plans and shared plans discussed here make sense for some but maybe not the best for everyone.

        Reply
    • Freddy November 11, 2020, 9:08 am

      When I watched the Sedera intro video on their website it seems that you are in fact accepted with pre-existing conditions. For year one, there is no support, year two they cover 15K, year 3 30K and then year 4 unlimited. Obviously this may not be helpful in some cases but it seems like it is something they have considered. Still, I recognize it may not be feasible for all.

      Reply
      • Bill from The Fire Guild November 11, 2020, 3:07 pm

        Hi Freddy! I’m Bill from The Fire Guild – Pete’s friend mentioned in the article above. My partner Jon and I will be answering questions throughout the comments here and simultaneously managing the FAQs on mrmoneymustache.com/sedera.

        You are 100% correct and thanks for taking the time to watch the video first!
        You ARE accepted by Sedera, even with PECs.

        Reply
    • Mark November 11, 2020, 3:04 pm

      This is a great argument for the civic-minded, Mary Ellen, and I agree with you 100% that we need a system that will cover everyone. While the young and healthy may feel it is unfair that they should have to pay for care the are likely not to need for the foreseeable future, they are actually paying forward to a time when they will be in the demographic that is more likely to need medical care.
      However, a more important reason to have actual health insurance (even less expensive, high deductible insurance such as my wife and I have) is the “Black Swan” argument whereby one should be prepared for the highly unlikely yet personally devastating possibility of an expensive chronic illness or injury which might easily wipe out one’s retirement nest egg. Hundreds of thousands of dollars in medical bills for cancer treatments or multiple life-saving surgeries are not unheard of. Having the peace of mind that my wife and I will be covered in such an event, however unlikely, is worth the seemingly high premium we are paying. To us, it’s not worth the gamble, though I’m certain (statistically) most people who roll these dice will feel vindicated when nothing bad happens to them. Just be aware of what you are risking if you choose this route!

      Reply
      • Bobby November 18, 2020, 4:58 am

        Mark, you make a great point about payments into the system, and touch on a big disconnect in the thinking of many on this issue. Here are some statements that on their own seem fine, but put them all together and we have our current problematic situation:
        A) It’s not fair to make someone pay for something that they don’t feel they need or want.
        B) It’s not fair to deny care to someone in need, even if they don’t have an ability to pay.
        C) It’s not fair to me to have to pay for your mistake.
        While many would agree with all three of the above statements, we just can’t have them all in practice. Currently, someone can decide not to have coverage, be fine for decades, and then have millions of dollars in medical bills either through their own poor behavior or just by random chance. Who ends up paying those bills? Well, everyone else that pays premiums! If you wanted to buy hurricane insurance after the storm hit people would laugh at you, but by allowing “opt-outs” to “opt-in” because morally we won’t deny care– well, that’s effectively our current system. There are obviously many other flaws in the system, but I don’t see nearly enough talk about the free-rider problem.

        Reply
    • Gonzo November 12, 2020, 8:26 am

      Mary Ellen – You are absolutely correct. If we want medicine to work in the US, we need to follow the examples of other countries. Greed is a great motivator, but for some things like medicine a Socialistic approach may be both desired and necessary. You may be in perfect health like MMM, but some unknown thing like an brain aneurysm can be lurking. Then, health expenses may take it all from you, all your money and your dreams.

      Reply
      • frank November 12, 2020, 8:31 am

        I wouldnt call it a socialist approach, you dont have individual insurance for defence – you have a colleactive army, navy and aire force. But you dont call it socialist military

        Reply
        • John Watkins November 19, 2020, 10:22 pm

          The military is a socialist organization of sorts. It’s organized by the government, funded by tax dollars that everyone has to pay, and everyone equally owns the military and benefits from its protections. Same with police, fire department, EMS, forest service, National Parks, etc. I believe in our democratic- republican foundation, but certain portions of our government are socialized by definition. And I’m in the military!

          Reply
        • Reed November 26, 2020, 2:31 pm

          Most people don’t have any qualms about sending their kids to socialist K-12 schools or driving on socialist roads or calling 9-1-1 to get help from the socialist police and fire departments. However, many Americans are willing to put up with a health care system wherein the strategy is to hold a bake sale if some kid gets cancer. Just ponder for a moment what must be going through a European tourist’s mind when they see a donation can in a restaurant for funding some kid’s chemo. They must think we’re somewhere between pathetic and nuts.

          Reply
    • Randy November 14, 2020, 4:18 pm

      It is important to factor in tax advantages when evaluating health insurance premiums. Being able to pay for the insurance with pre-tax dollars, and pre-tax savings in an HSA (if a high deductible plan) take a lot of the sting out of health insurance premiums.
      I stopped renewing my health insurance three years ago, for much the same reasons stated in the article, but I plan to enroll for next year because of the new virus risk. I am self-employed and capable of covering the cost of major medical expenses from savings.
      I lost a friend to the virus a few months ago. He was exceptionally healthy, recently completing a half-Iron Man, but succumbed to virus-induced blood clots. There is still so much we don’t understand about this virus.

      Reply
    • drplastickpicker November 21, 2020, 10:11 am

      As a pediatrician Mary Ellen, I completely agree with you. Those devastating medical conditions can happen to kids as well, and there is no way to predict. I’m at a large non-profit HMO, and when ACA went live it was painful for us. We had so many new patients and had to work so much harder with the volume, but it worked. More people got coverage. We had to streamline things and figure out more efficiencies with still taking care of all our patients. It was like a tsuanami and my pay stayed the same, but it was the right thing to do for our population. It’s funny I’ve never complained once about working hard during ACA roll out. But everyone’s premiums did go up some – but that’s why it worked as a society. More people were getting preventative care from relatively cheaper labour from primary care providers and I was preventing lots of downstream illnesses that will cost all of us as a society more later. Much cheaper to have me as a pediatrician monitor a poor kid’s asthma well with controllers, than them ending up in the ICU or ED.

      Reply
    • Johan November 22, 2020, 1:59 pm

      Totally on board with M4A. We should all try to fight for it by electing officials who support it. Just about every person who ran on a M4A platform in this election won a seat in congress.

      Reply
  • Bernie November 9, 2020, 10:27 pm

    Looks interesting but please look at the fine print before signing up and thinking it is equivalent to health insurance. For example, they have pre-existing condition clauses, won’t cover any medications for longer than 120 days and generally have a lot more restrictions than insurance has. If you’re very healthy with no complications, it can be a good option, but be careful.

    Reply
    • Jonathan November 10, 2020, 6:11 am

      This. If you’re middle-class / decently wealthy and relatively healthy it is easy to cover the day to day costs of medicin and doctor’s appointments if you have them. What you’re covering against with insurance is the worst case: what if you get cancer, and spend the next years of your life doing chemo / radiation.
      And because of the absurd prices in the US health insurance system, this can cost millions. MMM may be able to afford this, but this is not a solution for most.

      Reply
    • Bill from The Fire Guild November 10, 2020, 2:57 pm

      Sedera is definitely not an equivalent to health insurance; it’s an alternative.
      As with all decisions like this, reading the fine print is absolutely the right thing to do, and luckily Sedera’s Guidelines are clearly written, in everyday language and they require you to have read them before signing up. They don’t want Members who aren’t aware of the guidelines, and as a Member myself, neither do I! From my years of being insured under both private insurance and the ACA, I am very familiar with both the PEC clauses other providers had (Sedera’s are actually much more accommodating), the rules about prescriptions (Sedera will cover cancer medications for longer than 120 days, for example) and their “restrictions” are meant to specifically protect Members from fraud or irresponsible behavior. Sedera works for me; it might work for a lot of other people who are interested in a much lower priced alternative, in a community with like-minded (and bodied) healthy people!

      Reply
      • Mike November 11, 2020, 11:26 am

        Care to add that pre-existing conditions are eliminated under the ACA? So any favorable comparison for Sedera against other carriers for that particular characteristic is either from before 2014 or only comparing against the shitty short term plans?

        Reply
        • JeffD November 24, 2020, 9:57 am

          I had a pre-existing condition when I joined ACA, and my high costs related to that condition have been fully covered. I’m not sure what you are refering to.

          Reply
          • Mike November 25, 2020, 1:25 pm

            I was referring to the statement that Sedera’s PEC clauses were more accommodating. I agree that the ACA covers all PEC. So there’s no way Sedera could compare favorably let alone equally unless he was referring to the two examples I gave. Those were not discussion points at all throughout the article so it would be pretty misleading.

            Reply
  • frank November 10, 2020, 12:23 am

    “ultrasound Carotid artery scan which involves a practitioner lubing up your neck and sliding a Star-Trek-style probe around on it while recording images of your body’s most critical plumbing to check for signs of clogging”

    In the UK we perform this on patients only when they have had a stroke or mini stroke. If its shows over 60% stenosis then we offer an operation to clear out of the Carotid arteries. But its not a necessary test unless you have a stroke or a mini stroke as the operation isn’t beenficial as a preventer due to the side effects.

    So in an asymptomatic individual its not going to affect our management as doing the procedure to clear the operation is harmful in patients who havent had a stroke or a mini stroke. So lets assume it showed you had a carotid stenosis, unless you went on to develop a stroke having the operation to remove the “gunk” wouldnt be a good idea.

    Reply
    • Mr.RTFM November 10, 2020, 1:41 am

      That’s true, but he’s not talking about the operation, only about an ultrasound exam, that checks the state of the arteries.
      I’ve got this done in Hungary as part of a standard cardiac health check for men, covered by private insurance provided by the company I work at.
      Sure if it indicates issues, that would be another matter, but it’s a good indicator of the general state of your body’s bloodflow.

      Reply
      • frank November 10, 2020, 11:46 am

        My point is that its been used as a screening test when it wont change management. If its normal or abnoraml your going to be advised to eat healthily and do exercise. But having an abnormal exam that may or may not lead to anything can lead to undue stress and anxiety, which can cause signficant problems when building up.

        Reply
        • Laura Fogleman November 10, 2020, 12:01 pm

          I agree with Frank. Several of these tests are not necessary. There are several U.K physicians that would argue the U.S. over test and over treats. Example, many tiny cancers form all the time in the human body but may never amount to anything that a person would die from or even know they had. The body may keep it in check, yet we do all these cancer screenings that can lead to biopsy, medication, intervention when there is no difference in mortality rates with some of these things. It’s gotten out of hand and btw, this is a way to bring in more revenue. However, on the flip side in the U.S., physicians are targets for malpractice suits if they didn’t do a test that was available and the patient ended up getting sick or dying too early because of this.

          Reply
          • frank November 10, 2020, 12:08 pm

            Exactly!
            I’ve had patients pay £100-£300 for this test that is completely not needed. Thankfull in the UK we have the NHS (this is not socialist medicine – simply only doing medicine when needed) althought people can still go private if they want to.

            I should add that this is not a criticism of MMM. No matter your perspective trying to cycle everywhere and eating healthily is a good idea. Even in the UK where we have the NHS and healthcare is free. It means fewer GP visits, so less time of work. Not being obese makes cycling to work easier and quickeretc

            Reply
            • Andy November 11, 2020, 3:31 am

              Hi Frank,

              Barbell Medicine has some interesting information on this very topic of screening and the benefits and downsides. Highly recommended and sounds like they would be of interest to you being a medical professional.

              Hi from the UK too!

              Reply
          • Condor November 10, 2020, 4:24 pm

            “Incidentalomas” or “VOMIT* lesions” as they’re known. :-)

            *Victim Of Medical Imaging Technology”

            Reply
    • Guenther Wilke November 10, 2020, 10:45 am

      An ultrasound of almost any kind is a (comparatively) low cost, non-invasive procedure. I one is to take heart attack and stroke prevention (not treatment) seriously, it is important to assess initial conditions to later evaluate any progression of arterial constriction. This way lifestyle and prescription plans can be implemented to mitigate chance of a stroke or MCE in the first place.

      Reply
      • frank November 10, 2020, 11:52 am

        As a GP who has worked in various stroke wards I to take stroke prevention seriously. But that doesnt mean I would advocate investigations that can lead to undue stress and anxiety. Lets say you have an US and it shows no stenosis patients may be unduely reassured as well. Equally you may do all the right things and still develop carotid stenosis despite being on a statin, controlling your blood pressure, weight, limting alcohol use, etc. and see your arteries slowly clog up. As its not something you would operate on (unless you actually have a stroke) this will lead to repeat examinations and worry and anxiety.

        Reply
        • frank November 10, 2020, 12:02 pm

          I should add I have seen this commonly where this test comes back as abnomral, a patient is doing all the right things but a vascular surgeoun isn’t going to operate as it isn’t beenfical in asymptomatic people. This has led to undue worry and stress, with patients spending many years of there lives pnaicking that they are going to drop down dead of a stroke at any seocnd.

          Reply
    • Mr. T November 10, 2020, 1:00 pm

      I suspected this when I read it, but lack medical training. Thanks for sharing.

      Reply
      • Chip November 10, 2020, 9:02 pm

        Uh, let’s back up my UK friends. The US preventive services task force recommends AGAINST screening carotid ultrasounds, and I’ve ordered one for that purpose exactly zero times. MMM, major fail from your physician for recommending and ordering one, the same could be said for the “in-depth” bloodwork you had if it was for screening purposes only. Beyond screening for Hep C and perhaps a lipid panel, you wasted your time (and blood) with the rest. A physician’s job is as much to protect people from unnecessary testing as it is to order it, yours does not get a passing grade with his first performance.

        Reply
        • wawot1 November 10, 2020, 9:34 pm

          100% agree with Chip here.

          The United States Preventive Services Task Force is a well respected, evidence based, impartial body and recommends against screening asymptomatic people for carotid stenosis. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/carotid-artery-stenosis-screening .

          I applaud the idea of price transparency for testing, however the Cloud Clinical Diagnostic menu that MMM linked is chock full of tests that are NOT evidence based and lack clinical validity. A+ for seeing what a test costs, F for offering a bunch of tests of dubious merit that are not ready for prime time.

          Reply
        • Mr. T November 10, 2020, 9:42 pm

          The “menu” looked particularly egregious in terms of both wasting money on unnecessary tests, as well as costing way too much for the specific tests/panels offered. It’s weird, but I’m seeing a bunch of basic medical tests/panels now being pimped for affiliate commissions, like the “hormone panel”, “micronutrient panel”, “mycotoxin screening”, etc.

          If anyone is curious why aggressive screening, like carotid ultrasounds for otherwise healthy middle-aged men, can even be very harmful, (https://www.youtube.com/watch?v=yNzQ_sLGIuA) provides an excellent overview. Also, Chip, it’s a UK doctor. Maybe y’all just intuitively understand and accept statistics better than us?

          Reply
          • Chip November 11, 2020, 7:27 am

            Not sure I follow. My comment referenced most of the folks above it referencing how things were done in the “UK” as a purported stark contrast to how we operate in the states. I was pointing out the similarity in our actual approach, not claiming to be more intuitive.

            Reply
            • b0rv0 November 19, 2020, 9:49 am

              My (US) doctor runs this test every year and uses it to support his recommendations of improved diet, weight control and so on – which can help regress carotid atherosclerosis. I like that approach better than waiting for a stroke or mini-stroke before running the scan, and maybe this preventative approach (while more expensive) is going to work better for me as an individual than potentially having an operation to remove the gunk even if the operation is nhs funded. For me, that’s less stressful than wondering how things are going.

              I’ve also had experience of both systems – NHS and US – and I far prefer the US as an individual that can afford health insurance even though I accept that “on average” the NHS system is better.

              Reply
              • frank November 24, 2020, 1:35 pm

                And if one day it does show signficant stenosis in your carotid artery no vascular surgeoun would do anything about it unless you actually have a stroke. This test doesnt prevent nor necessarily indicate a person is at increase risk of a stroke. Many people have signficant stenosis in this artery and never have a stroke. It’s only signficiant if a person actually has a stroke.

    • Mary November 11, 2020, 10:45 am

      In our case, my 56 year old husband had taken statins for 15 years and had decent cholesterol levels. He had no symptoms. At my urging he had a calcium scan done which quantifies calcified plaque in the arteries. He received a score of over 2000 which is extremely bad. The score should be zero. Any score of over 350 is very bad. His report said “expect a serious cardiac event within 3 years”. If you google it, it’s more like “you’re gonna die yesterday”.

      We immediately went on the Esselstyn heart disease diet and he lost 80 pounds. His cholesterol dropped dramatically. The 3 years passed with no issues. We have now continued our diet and exercise for 5 years and always will. We don’t consider it optional. His cardiologist says he did more for himself than they could ever do. The fear we felt initially is gone.

      In our case the test was lifesaving because it alerted us to the seriousness and progression of the disease (in spite of 15 years of statins and decent blood results). Doctors don’t think these tests are necessary because they don’t believe people will make any changes anyway. That’s BS. When you know you will die without action, most people will make a change. It’s not about your “management“ of the condition. It’s about ours! Before getting the test results we did not understand the extent of the problem or that statins were not controlling it. It takes a major dietary change. I wouldn’t necessarily advocate that particular test due to the radiation involved, another thing which doesn’t seem to concern doctors. But I believe there are safer tests which indicate the level of heart disease/plaque. Don’t count on your statin, especially if blood tests indicate a genetic propensity (high LDL, low HDL). Eat plants!

      Reply
      • Mr. Money Mustache November 11, 2020, 11:00 am

        YES!! This is one of the reasons I am in favor of heavy testing (at my own choosing) through a DPC.

        I want ALL the data on my body. Ideally, I would have a smartwatch app telling me what every single system is up to, constant measurements and scans and tests of active heart rate, resting heart rate, sleeping heart rate, HRV, glucose, oxygen, cholesterol profiles, inflammation markers, body and muscle strength and bone density and testosterone measurements – EVERYTHING. Second by second with unlimited history and monthly summaries. As long as the tests themselves aren’t destructive like X-rays.

        If my arteries had shown calcification, I would have used that as an input signal to experiment further with my diet and exercise regime. It is GOOD, but I know it is not the best in the world because I make some tradeoffs for convenience – for example I only walk a few miles per day and run a few miles per week. If I needed to double my running to address a problem, or cut my alcohol consumption from “low” to “zero”, I would do it. But if the tests indicate things are exceptionally good already, I will stick with this happy medium.

        Mary’s story is even more valuable – anybody who has 80 pounds to lose will see incredible benefits if they find a way to lose it. Motivations are different for everybody, but in our society there is also a lot of “fooling yourself” effect because obesity is the norm. If someone can be awakened from this dangerous complacency and have a much healthier life because of it, that is an amazing thing.

        Reply
        • frank November 11, 2020, 11:42 am

          But sometimes these tests do lead to harm.

          Take PSA, its a test often used to screen for prostate cancer but it has its limitations. It can actually be normal in prostate cancer and patients then are falsely reassured. Equally it can be high due to other conditions but once the test has been done and its come back as high it often leads to biopsies leading to infection, incontinence, anxiety etc when it wasnt needed in the first place.

          Equally inflammation markers such as CRP can be high due to infection, cancer, or just normal for you. But once its done it then leads to further tests, worry, anxiety or false reassurance if its normal. An inflmmatory marker such as CRP shouldnt be used as a screening test – it is best used to monitor treatment of an infeciton etc. Likewise PSA proper place is in the monitoring of certain cancers.

          People often come to me worried about there liver because they drink to much. I carefully explain that I have seen normal liver function tests in people with alcoholic deocmpensated liver disease. But they still do the test and then wrongly assume everything is ok when the test comes back as normal. But they may have seirously liver disease and have been falsely reassured.

          I am not against tests being used to help people manage there own health. But it needs to be done appropriately so that testing doesnt lead to inadvertent harm

          Reply
          • Warren November 25, 2020, 1:14 pm

            Hugely important topic, over testing / over screening. I’ve been an emergency physician for the past 25 years, and we are constantly calculating the value of tests. The concept that applies here is what is given that every these has a false positive and false negative rate, you must apply use that against the pre-test probability of finding true disease. Then you have a test with a 3%false positive rate and apply that test to a large population with very low likelihood of having the disease (low pre-test probability, like, say, finding carotid plaque in a totally fit man in his 40’s) you end up with a ton of false positives mixed in with true positives. All those positives can (often do, especially in ‘Merica!) result in further testing, some of which carries its own risk (like a biopsy of some incidental finding which results in infection, etc). You all can do the math. It’s a mess. It’s the story of the PSA test, and many other tests applied widely. Not rare either. I see someone mentioned Victim Of Medical Imaging Technology above. I see it very often. Our health care system is a mess people, you have no idea.

            Reply
        • Chip November 11, 2020, 2:26 pm

          No, Pete.

          You’re confusing patient-specific appropriate testing based on risk factors with across the board inappropriate screening. Mary’s story does not validate anything you or your physician are advocating for.

          I hesitate to say this because of the hubris it implies, but a good physician’s job is to protect people like you, MMM, from yourself. Doctors who score 99th percentile on patient satisfaction scores generally provide worse outcomes for their patients than those who occasionally upset them and score lower. Just because you don’t understand the risk of too much non black-and -white information doesn’t make the science less true. Overall, when a population is subjected to inappropriate screening tests like the ones you had, quite often MORE of them DIE than if they had no testing at all. And that should be your take away.

          Reply
          • Mr. Money Mustache November 11, 2020, 4:33 pm

            But in citing those studies, aren’t you are comparing typical people, who do indeed get confused and worried and make bad decisions based on tests, to a very different category of people (and I am in this category), that has the statistical and science and health background to understand it?

            The only reason I’m alive on this Earth, is to learn. Lots of stuff, and about all possible fields. And I need lots of data and books and consultation with experts to do it. Don’t shut me out of the learning game just because you have a medical diploma and I don’t!

            Also: although you are surely not in this camp, many doctors are operating on backwards and outdated knowledge – I don’t want them overriding my own desire to keep up with the most recent research. The field really is changing – remember the hazardous low-fat high-carb diet still recommended by the American Heart Association?

            Reply
            • frank November 12, 2020, 1:09 am

              Educated people can still fall into the trap of getting tests at the wrong time and place. A carotid US in someone who hasn’t had a stroke is one of them.

              If it showed singficant carotid stenosis that doesn’t necessarily mean you were doing anything wrong with your diet and equally if it was normal it doesnt mean the patient shouldnt make changes to there lifestyle.

              The right time to do a carotid US is in patients who have had a stroke. Then the test becomes meaningful become at that point surgery may be offered if it showed signficant carotid stenosis.

              Reply
            • Lisa November 16, 2020, 6:43 pm

              Hi MMM–

              I think you’d be interested in the work of Gilbert Welch, a medical doctor, researcher and instructor in medical statistics.

              I recommend his 2011 book, Overdiagnosed, or his 2015 book, Less Medicine, More Health. They are well written and fascinating, which is not something you hear every day about books focused on explaining statistical data.

              Counter-intuitively, researchers have found that frequent monitoring of the type you describe does not seem to improve outcomes, even for people with known conditions. Instead, it’s more likely to create problems.

              More broadly, it’s become clear that screening healthy people generally does little to save lives, but it often leads to more procedures, expense and stress — not to mention risks of a downward health spiral due to the procedures themselves and any new theoretical “problems” found by accident.

              This is despite what we hear in individual anecdotes; we really have to look at large data sets over long time frames to see if something is working the way we think. In the US, that’s hard because our “system” is so fragmented, but some work has been done here, and more has been done in countries with national health systems (which thus are more likely to have cohesive, broad-based, longterm data).

              I’ll note, for all you Googlers, that Welch took some heat at one point for allegedly including some data in one of his own studies that should have been credited to others. I wouldn’t let that discourage you from checking him out. And MMM, you’ll be especially fascinated since you love data. I literally re-read his books for entertainment and to help me in my bid to get more intuitive about statistical realities (impossible, the great Daniel Kahneman points out, but I keep hoping).

              Cheers, Lisa
              PS: Thanks for the ADD shout-out. We have that in my family and it can definitely be helped by treatments and life does improve. Sometimes it takes some experimenting to get treatments dialed, so to anyone going through that process and getting discouraged, take heart. You’re not alone, and you will get there.

              Reply
            • Mannekino November 19, 2020, 7:24 pm

              Thank you for this timely discussion around healthcare costs and coverage. Up until recently, I worked in this industry for over three decades and seen plenty.

              Harvard has studied the broader issues with the US healthcare system for a long time.
              https://www.hsph.harvard.edu/news/press-releases/labor-pharmaceuticals-administrative-costs-health-costs/
              https://harvardmagazine.com/2020/05/feature-forum-costliest-health-care

              Distilled into a short list of categories, this comes down to:

              • Excessive administration costs – the American insurance market is unnecessarily complex with little in the way of standardization beyond CPT codes, and hides behind proprietary agreements whereby up-front pricing transparency is mostly discouraged and lobbied against at many levels. All extra costs are simply baked into premiums, whereby insurance companies skim a percentage off the top. I am not sure how scaling up Sedera’s model would make a meaningful dent here, other than by acquiring low-risk patient pools. Administration costs related to insurers hover around 2-4% in comparable countries, yet even Sedera takes 9.9%?
              • Higher utilization of costly services per capita – Americans don’t see the doctor any more often, and are not hospitalized any more frequently, but when they do interact with the medical system, it is much more intensively at much higher cost per unit of care. This is experienced via a combination of defensive medicine by doctors as well as healthcare executives demanding maximum revenue generation for each microscopic unit of care via detailed “fee-for-service” reimbursement coding.
              • Greed and gouging – Excessive pricing not only for non-generic pharmaceuticals, but also for specialists and hospital services, especially imaging. US healthcare is run like a business and the mantra is “you get what you negotiate.” (fee-for-service) as opposed to “you get what it’s worth” (pay-for-performance). An underlying dynamic here, in my opinion, is greed and entitlement among various specialists and healthcare & insurance executives. I see public and private business structures similarly, as both seek to maximize revenues. Traditional family medicine seems far less sensitive in this category.

              So, why is this? The majority of the US healthcare system is run as a business that seeks to maximize revenues, whether for profit or not. After the 1980s, when healthcare costs among industrialized nations were still largely equivalent, the US peeled away from other comparable nations and evolved with opportunistic “fee-for-service” business models that benefited from limited financial controls besides the regulatory FDA, CLIA and HIPAA rules.

              So, at a personal level, I agree with MMM about collecting pertinent diagnostic data points to be able to verify that a particular medical situation mandates a therapeutic solution, OR NOT. My most recent healthcare experience reinforced that perspective again where a surgeon specialist advocated for me to undergo a surgical procedure that was biased toward his latest professional interests, rather than best suited for my situation, as confirmed by peer-review studies. This guy is a top doc in his field, but apparently motivated to “practice” his latest method, even though various European studies have shown unacceptable side effects.

              In my personal experience, I have learned to ask 5 questions of a physician when decisions are considered:

              • Is it necessary?
              • What are the risks involved?
              • Are there other options?
              • What if I do nothing?
              • How much does it cost?

              At the same time, I always request full copies of all diagnostic test results, so I have that on hand should I want to switch doctors and/or review the latest scientific consensus from the published worldwide medical community. With that, I basically manage my own electronic health record.

              It really pays to do your own research (including reimbursement details) and find a physician who is truly aligned one-on-one with the patient, even if that means lower revenues and avoiding defensive diagnostics and therapies if not clinically worthwhile. For me, having a solid set of diagnostic results available enables me to ask the most relevant questions. If a physician is not comfortable with a highly-engaged patient who aims for reasonable and necessary solutions, and thinks that he/she is there to protect me from myself (a.k.a., the savior complex), that would not work for me.

              Reply
      • Chip November 11, 2020, 2:17 pm

        Let’s back up, shall we? We’re referring to screening tests on healthy people. Your previously obese, hyperlipidemic husband was not in that category. Not even close.

        As far as “Doctors don’t think these tests are necessary because they don’t believe people will make any changes anyway.”, well, uhhh, no. If we only counseled and ordered tests on people we thought strongly would change based on our words or test results, I suspect most GPs could work one day a week.

        Reply
      • Karlhungus November 13, 2020, 8:42 pm

        I looked up that Essel diet. Whoo boy. No chance I could do that. There are other, easier ways to achieve low cholesterol levels. And it turns out the opposite works as well, which I think is the way MMM eats. Anyway, for myself, I eat high fat (lots of eggs, coconut oil, bacon, meat, butter etc. ) Veggies, fruit, nuts, seeds. Low carb. Try to cut out breads, pastas, etc . When I do that, my cholesterol drops like a rock.

        Reply
  • Luke November 10, 2020, 1:39 am

    I’ve been a long time reader of MMM and turned many people on to your blog. That said, this is the biggest miss I’ve ever read on here, and given your influence on so many people who just do whatever it is that you do, I would say it’s a very irresponsible post as well.

    Insurance is not expensive because of broken arms and stitches, it’s expensive because if you or your child got cancer, an autoimmune disease, or some other kind of ridiculously expensive disease, the bills could be in the millions and you would be in a problematic financial situation.

    Those unpaid bills would get absorbed by the rest of us that continue to pay for our insurance.

    If insurance was an investment win for the insured, it wouldn’t be a sustainable business. Of course it’s cheaper to not have insurance than to have it for the vast percentage of people who are healthy. It’s a collective pot we all pay into for the handful of us that get sick.

    What’s next? Not paying your taxes?

    Reply
    • Mr. Money Mustache November 10, 2020, 7:47 am

      Luke, I agree very much with your point that we are trying to soften the risk of extreme health events by spreading out the costs, and insurance does that. Health sharing programs do exactly the same thing.

      BUT, I strongly disagree with your point about why these events are so expensive. They are only this costly HERE in the US, because we have such an inefficient system. It’s more complex, less transparent, and the insurance companies are a big part of that. Because of this, we pay more than TEN TIMES the amount for many of our procedures and our drugs, than in other countries. Which is why medical tourism exists.

      To be fair, our doctors and specialists also get paid much more. In some cases, in my opinion at $500k to well over $1 million per year, it is too much. But that can be moderated by making prices more transparent (more competition) and making the profession more desirable in the first place (to increase the supply of qualified practitioners). And of course loosening regulations on inter-state licensing: it is currently a huge and ridiculous hassle for a fully qualified doctor to cross a state line and practice in the next town over.

      Lots of issues, many that I don’t understand yet. But the DPC model solves a lot of them.

      Reply
      • Dave November 10, 2020, 9:00 am

        Add legal reform to this. My brother is a doctor and his malpractice insurance is ridiculous..

        Reply
        • Mr. T November 10, 2020, 1:02 pm

          Legal reform is important, but in terms of scale, it’s irrelevant. Roughly 95% of the excess cost of healthcare in America is profit to “insurance” companies. Roughly 1% of the excess cost is our litigiousness.

          Reply
          • Dave November 10, 2020, 4:01 pm

            Good point. I’ve seen 3% quoted but it all adds up.

            Reply
            • Brian November 12, 2020, 3:33 pm

              I love Mustachians. Educated, polite but not bashful to share their opinions. Mustachians as third-party for all future elections.

              Reply
      • Bernie November 10, 2020, 10:31 am

        I agree with you on all your points, but the key thing you’re missing is that most people live in the US that are reading this, and if they do get one of those diseases, people would get utterly screwed if they didn’t have traditional insurance.

        Yes, it is wrong but it is the current state of affairs. Wishing and knowing it’s wrong doesn’t change that. So, it’s definitely a more risky alternative that comes with cost savings. The reason sedera is cheaper is because it has a low risk group that it’s insuring and won’t cover the most expensive things, simple as that. It’s getting around laws like the aca that require no pre-existing clauses, etc.

        Reply
        • Bill from The Fire Guild November 10, 2020, 4:10 pm

          Bernie is incorrect:
          Sedera has NO LIMIT on a shareable event like one of the major diseases he keeps alluding to. I’m not sure if he’s read the guidelines, but as long as the health event is considered shareable, you are only responsible for your IUA and the REST IS SHARED.

          The reason Sedera is cheaper is because it has a low risk group, it has VERY LITTLE OVERHEAD (9.9% is the exact, transparent portion that they take for their services – you can find it right here https://sedera.com/contributiontransparency/) and they NEGOTIATE prices with health care providers. NOT because they “won’t cover the most expensive things”; there is simply no evidence to support this claim.

          So, one does NOT have to have traditional insurance to not get screwed. Or, fixing this double negative: If you have Sedera, you won’t get utterly screwed!
          :)

          Reply
          • Justin November 10, 2020, 5:46 pm

            “as long as the health event is considered shareable, you are only responsible for your IUA and the REST IS SHARED”

            While it’s true that they do have smaller overheads than traditional insurance… your statement that you are “only responsible for your IUA” is clearly contradicted by their own terms (https://sedera.com/wp-content/uploads/2020/04/Sedera-ACCESS-Guidelines-20200402.pdf )

            “WHETHER A SPONSORING ENTITY CHOOSES TO SEND MONETARY ASSISTANCE TO YOU AND/OR YOUR FAMILY TO HELP WITH YOUR MEDICAL EXPENSES WILL BE TOTALLY VOLUNTARY AND NEITHER YOU NOR SEDERA, INC. HAS ANY RIGHT TO COMPEL PAYMENT OF MEDICAL COST SHARING COSTS FROM ANY MEMBER. THE SEDERA MEMBERSHIP IS NOT AND SHOULD NEVER BE CONSIDERED TO BE OR TO BE LIKE A GROUP INSURANCE POLICY OR AN INDIVIDUAL INSURANCE POLICY… THIS IS NOT A LEGALLY BINDING AGREEMENT TO REIMBURSE OR INDEMNIFY YOU FOR THE MEDICAL EXPENSES
            YOU INCUR, BUT IS AN OPPORTUNITY FOR YOU TO ASSIST OTHER MEMBERS IN NEED, AND WHEN YOU ARE IN NEED, TO PRESENT YOUR MEDICAL BILLS TO OTHER MEMBERS AND SPONSORING ENTITIES AS OUTLINED IN THESE GUIDELINES. THE FINANCIAL ASSISTANCE YOU MAY RECEIVE WILL COME FROM OTHER MEMBERS AND/OR SPONSORING ENTITIES, AND NOT FROM SEDERA, INC.”

            So essentially you’re just signing up to a “lets all put our money in a pot and hopefully they’ll pay out to us if we need it later” plan. The whole thing is set up as a “help other people pay their medical bills” system, not a “making these monthly payments means we will pay your medical bills” plan (which would be Insurance).

            Yes, they can probably operate for a long time paying “fairly” to all those who contribute, but it’s also entirely possible that too many people get massive medical bills in the same time frame and they can just leave you on the hook for your entire medical bill.

            Reply
            • Matt November 10, 2020, 6:35 pm

              This is the most worrisome to me. Are there any documented cases of Sedera or Ministries not paying out large claims that should be covered?

              Reply
              • Fireby35 November 11, 2020, 12:54 pm

                Well, I don’t know. But I am 100% certain there is a clear record of health insurance companies denying legitimate claims that any rational person would expect to be covered.

                Make sure you look as carefully at your own insurance policy. I just represented a client whose amputation and follow up recovery were not covered because, guess what, car crashes are excluded under that policy.

                The above it totally legal and more and more common with REGULAR HEALTH INSURANCE.

                Whenever you are tempted to be fearful of the new, ask why you are comfortable with the old.

              • Bill from The Fire Guild November 11, 2020, 3:12 pm

                There are NO documented cases of Sedera not paying out large claims that should be covered.

          • Bernie November 10, 2020, 6:50 pm

            I wouldn’t really say I am incorrect. There is big bold letters that say they guarantee no payment…Also, the reason it is cheaper is because they have a low risk group, weird requirements, and some abnormally low benefits for certain things (expensive medications, doctors/hospitals that don’t “negotiate” with them to their satisfaction, mental health is largely uncovered, pre-existing conditions (one of the best things about the ACA), etc…I mean I could go on but it’s all in their info. All I’m saying is that I wouldn’t trust your entire net worth to this company paying if you get one of the more expensive outcomes. Or, you develop something that is on their list of things they don’t cover well. Say, you have a nervous breakdown and get diagnosed with bipolar disorder in your 40’s and need to be hospitalized to get it under control…1500 max coverage lol.

            I honestly think as long people understand the risks/rewards which this article does not go into great detail about, then go for it. But don’t sugarcoat it. Also, you have a financial benefit to people signing up…soooo I don’t know, hard to trust you have the people’s best intentions in mind, no offense.

            Reply
            • Joan November 11, 2020, 10:09 am

              I worked for a health insurance company in the IT dept for many years, so am familiar with many aspects of the health insurance business. One thing that these companies have is reinsurance for when there are cases that cost millions of dollars. Keep in mind that health insurance companies are required to maintain very large reserves to cover pandemics, local disasters, etc., reinsurance saves reserves from being spent if one company happens to get a larger share of high cost patients. Without reinsurance, if there are several high-cost patients in Sedara, there will not be enough money to cover all of them.
              I am now retired, on an ACA plan, with a subsiday, and will soon be on Medicare. Medicare will cost more than I am currently paying in premiums. As someone with no serious or chronic health conditions, my costs are low, but I know a serious illness or accident could wipe out my savings, so having insurance is important to me. If you have enough money that you can afford a $1,000,000 medical bill, then you can probably skip health insurance.
              Enrolling in the direct pay could be worthwhile if I had any chronic conditions, since I would pay less than my deductible. It’s cheaper than part B of Medicare, so something for me to consider, as I will need to enroll soon.

              Reply
              • Bill from The Fire Guild November 11, 2020, 3:16 pm

                Sedera has never been unable to meet their Needs. They’ve been doing this for almost 7 years. Clearly they know how to manage their funds.
                Also, those $1 million medical bills that everyone talks about? They’re incredibly rare and are BEFORE NEGOTIATION. Sedera’s not for everyone but that doesn’t mean it’s not right for some of us.

            • Fireby35 November 11, 2020, 1:53 pm

              Bernie – not to repeat, but don’t forget about the “Devil” you know. There is a reason health insurance companies are infamous for denying coverage. They deny coverage very often, and often when you need it most.

              Reply
      • Daniel Cooney November 10, 2020, 8:11 pm

        MMM – your comment to this is dead on, insurance is expensive because EVERYTHING that is done in US is absurdly more expensive. I can you give you a very solid comparison of bills since I have lived in Australia for 1 year in the not so distant past, and have been in the US the rest of my life..

        – When in Australia I went to the ER with a large gash in my foot. The cost of getting stitches was $95 AUD, which was roughly $75 US at the time
        – Recently my son had a cut on his head and I took him to a clinic. The clinic told me to take him to the ER because they weren’t comfortable doing stitches for some reason. For the ten minutes I spent with medical professionals to get staples in his head the bill was $3600!!!! That is roughly 36X higher than the price in Australia!!!!

        I will add that stitches are superior to staples because they leave less of a scar, and the US doctor who gave the staples said they were not stitching because staples were “faster and easier”. Perhaps they are not easy enough, because a resident who first tried to staple my sons head had to pull out the staples 2X before a doctor came in and put in the 3 staples!

        THANK YOU for posting about the ABSURD state of healthcare in US, NONE of which were fixed by the monstrosity called Obamacare . I am sure you knew you would be attacked by radical leftists who somehow think things are ok when our health care providers and pharma companies are given license to rob us blind.

        Reply
      • Luke November 10, 2020, 8:22 pm

        I am in complete agreement with you there on the ridiculous price of our healthcare relative to the rest of the world. Those problems are, however, unrelated to whether one is on or off health insurance. It makes health insurance and direct pay much higher than what they should be if we allowed a single payer system to negotiate with hospitals and drug companies.

        Healthy people being able to not pay into health insurance only to be bailed out by everyone else’s rates going up when they inevitably get sick and the hospital passes on the unpaid bill to everyone else, only exacerbates the problem.

        Thanks for all you do here, by the way. I wasn’t trying to attack you, personally. I just find the conclusions based on an anecdotal experience rolling the dice and getting lucky, rather than an entire market where people in fact do get very sick despite pumping iron and eating healthy, oversimplified and potentially harmful to many readers that follow your every move.

        Reply
      • Lisa C November 16, 2020, 3:48 pm

        I am an American Physician (board certified in Pathology and Laboratory Medicine) currently working in Switzerland and I can assure you that medical care is very expensive in Switzerland, so not only in the USA. You say that 500K to 1 Million is too much, but you are paying for expertise which took many years to gain and highly complex diagnostic modalities such as the things I work with: immunohistochemistry, SISH, Molecular diagnostics, Flow Cytometry, Electrophoresis, Liquid Based Cytology and image analysis, and so on. I really love what I do and have no intention of retiring early, but do you really think that you’re going to increase the “supply of qualified practitioners” by finding people who are willing to work for much less than 500K and spending 13 years on education (in my case) after high school to get to that point? You have to love it, but I’m not working for free.

        I also think that that the 1.2 million that you mentioned in the article would be very, very slim revenues for 2 docs, plus assistants, rent, malpractice insurance, supplies and all the rest. It’s just not enough. Oh, and the last thing you would want is any “loosening” on medical licensing. It’s not a huge hassle to get multiple state licenses. Most doctors have more than one. I have licenses in Georgia, Alabama, Switzerland and Germany (Hessen).

        Reply
    • Sarah November 11, 2020, 10:36 am

      Reply
    • Heather November 19, 2020, 9:46 pm

      I have to agree with this post. As a fellow Coloradoan up until this year (I’m 48) I would have agreed with you. I eat well, exercise and have a very healthy lifestyle. I really didn’t think I would have any issues because I believed I could control things with healthy lifestyle choices. But in May I was diagnosed with MS. The cost of the treatment to slow this disease down is outrageous and if I didn’t have health insurance I would be in a heap of financial trouble right now or just wouldn’t be able to get treatment.

      Reply
  • HighPlainsDrifter November 10, 2020, 7:26 am

    If I didn’t have a stellar health insurance at my work (nearly free), I would definitely consider DPC or a health share plan.

    Regular health plans, will lose a lot of money if all the young/healthy people switch to DPC or health share plans. It is kind of crazy that our health care system is set up to have the healthy individuals pay for Medicare & unhealthy patients. If or when the healthy people all jump ship… Regular health plan premiums will sky rocket.

    Reply
    • Bill from The Fire Guild November 10, 2020, 4:13 pm

      Just wanted to point out that your (or anyone’s, not picking on you HPD!) “nearly free” health insurance at work is costing your employer a TON of money. How much better would it be if you were either provided with health care through a national plan (aka single payer) or your salary increased by the huge amount that your employer is paying, and then you could spend it as you please (buy a bicycle/weights, spend more on healthy food, exercise more, etc)
      Wouldn’t THAT be something?

      Reply
  • Matt November 10, 2020, 8:14 am

    Echoing what Luke said, this post is a big miss for me. But I think Luke is burying the lede when he’s talking about altruistic reasons to not switch to a Health Share Plan.

    When you say that “a health share plan offers a similar end-result while being careful not to be classified as insurance,” you should be clear on what that means. Not classified as insurance means no guarantee of payment. Let me say that louder for the people in the back: NO GUARANTEE OF PAYMENT.

    This means that the reason they are so cheap is that if you get something really expensive, like God forbid you or your child gets diagnosed with cancer (which can happen to anyone, and is not prevented by barbells), they can just drop you. You submit your million dollar bill for leukemia treatment, and the health share can just go like “naw, man, you are on your own for that one.”

    So is it really Mustachian to sign up for an insurance-like product that literally is only there when you don’t really need it? No! Mustachian facepunches for that should be equivalent to buying a car that can only take you places you could have biked, but can neither haul cargo nor go on long road trips. Lame!

    These health sharing companies are frequently sued for deceiving customers, and tend to keep a very high % of totally-not-premiums for themselves. See, for example, https://www.nytimes.com/2020/04/21/health/christian-ministries-insurance-lawsuits.html; https://www.fresnobee.com/news/health-care/article242332111.html; https://www.ky3.com/content/news/Health-sharing-company-slapped-with-federal-lawsuit-569768671.html; http://www.symslaw.com/aliera.

    High-deductible health plans can be a frugal option, but signing up for something that won’t actually cover you when you really need it is just not a good idea.

    Reply
    • Mr. T November 10, 2020, 1:06 pm

      Strongly agree with your overall ideas, but want to push back on one thing you seem certain of: how do you know that cancer ISN’T prevented by (the correct and regular use of ) barbells?

      “So is it really Mustachian to sign up for an insurance-like product that literally is only there when you don’t really need it? No! Mustachian facepunches for that should be equivalent to buying a car that can only take you places you could have biked, but can neither haul cargo nor go on long road trips. Lame!”

      Love it. Perfect analogy.

      Reply
      • Bill from The Fire Guild November 10, 2020, 4:23 pm

        Love your passion, Matt (and your analogy)!
        BUT, NONE of the links you included are about Sedera. That’s because they have an A+ BBB rating and zero complaints on the BBB website.
        For those of you in the back: NO HISTORY OF NOT PAYING!
        Anecdotal evidence does not equal truth, and throwing Sedera under the bus isn’t fair. Yes, there are cases of other companies being less than stellar, but these few stories also are the exceptions to the rule – how many cancer treatments WERE shared successfully by those same companies? You seldom hear about good news online…

        Reply
        • Mr. T November 10, 2020, 4:35 pm

          Matt said, “no guarantee payment”, not “history of non-payment”. None of what you wrote contradicted anything he wrote.

          Reply
        • bernie November 10, 2020, 6:52 pm

          Honestly, the BBB means nothing. You can pay for rating. Not a good reason to trust.

          Reply
        • Katie November 11, 2020, 2:05 pm

          They’ve also only been around since 2014, so there isn’t much data to go on here. This company could go poof overnight and you’re SOL.

          Reply
          • Bill from The Fire Guild November 11, 2020, 3:20 pm

            I disagree; and you can bet Liberty *wishes* they could “pay for rating”. Liberty has over 800 complaints; Sedera has ZERO.

            Reply
          • Bill from The Fire Guild November 11, 2020, 3:22 pm

            Huh? They have over 35K members and zero complaints for six years. Companies like this don’t go “poof overnight”. But, if you’re averse to risk and are willing to pay a lot more for decades of history, you can choose alternatives (like Blue Cross, with 81 years of history and thousands of documented lawsuits from patients whose claims were not covered).

            Reply
  • caryatis November 10, 2020, 8:17 am

    Did anyone else notice this on the Sedera website?

    “I agree to refrain from using any form of illegal substances. I understand that medical needs caused by, or due to, the act of performing any illegal or unlawful activity will not be shareable with the Sedera Medical Cost Sharing Community.”

    “Medical expenses incurred by a member child who is injured while he/she is under the influence of an illegal substance would not be eligible for sharing. Note: Does not apply to dependent children under the age of 16.”

    So NO treatment for drug problems? Even if you don’t use drugs yourself, no treatment for a child who might develop an addiction? And no treatment for a child above 16 who is injured while under the influence? And you have to promise not to use illegal drugs? I wonder if MMM saw this part…(yes, marijuana is still illegal under federal law).

    Reply
    • Jon from The Fire Guild November 10, 2020, 8:25 am

      Birth control for the purpose of temporary sterility, voluntary abortion, fertility treatments and voluntary sterilization surgery are not shareable. Again, voluntary medical stuff is generally not shareable.

      The Guidelines say this about addiction:
      “Treatment for Alcohol / Substance Abuse/ Chemical Dependency is shareable to a maximum of
      $1,500 per separate Need.”

      The sharing community is basically trying to lower risk (and cost) by incentivizing less risky behavior.

      Reply
      • Mr. Money Mustache November 10, 2020, 8:44 am

        Thanks for clarifying this Jon – I am surprised to learn that and I disagree with this policy from Sedera. Because doing everything we can to make family planning easy is the biggest cost savings of all.

        HOWEVER, these things are cheap anyway. It cost me $600 (cash pay) for my own lifetime solution to family planning, and for women things like IUDs are even lower cost. And with the help of your DPC clinic, you can often find the best local options with help from the physicians.

        So, this could become more of an ideological battle than a practical one. In practice, you would not even reach your self-paid amount for birth control. But I still encourage Sedera to change this policy.

        Reply
        • caryatis November 10, 2020, 9:09 am

          Did you notice how they refuse to cover expenses related to HIV and other STDs unless the person can “demonstrate” they were not infected through illegal drug use? How would you prove that? Seems like they are trying to exclude gay people without actually saying so.

          I encourage you to look into Sedera’s policies, read the fine print, and see whether you want to continue recommending them.

          Reply
          • Martin November 10, 2020, 10:08 am

            Is there anything wrong with an insurance-ish company excluding coverage for intentional high-risk behavior?

            Insurers would refuse payments, if my DIY wiring caused an electrical fire. That seems analogous to me.

            Reply
          • Bill from The Fire Guild November 10, 2020, 4:31 pm

            I find this comment by caryatis slightly offensive; Are you saying only gay people are at risk for HIV and other STDs?
            Also, they do not exclude expenses related to HIV. This is directly from their Guidelines:
            “HIV, AIDS, or other STDs contracted
            without breaking any applicable laws (e.g.
            blood transfusions or medical procedures)
            will be shared”

            Reply
          • Fireby35 November 11, 2020, 1:02 pm

            Read your own health insurance policy and you might be surprised what is excluded. You only know the work “pre-existing condition” because it was a “regular health insurance” tactic to refuse coverage. They are always looking to deny coverage – it is in their DNA.

            They have all the new exclusions hiding in your contract. I’ll bet you didn’t read that, while you did go read Sedara’s?? Am I right?

            In all sincerity, I was helping a friend the other day whose leg amputation was denied by his ACA approved health plan bc they excluded injuries caused by car crashes.

            Think about that. That was regular insurance.

            I’m not trying to give a hard time, but this is an alternative to another distasteful choice. It is possible they both are less than perfect.

            Reply
            • Katie November 11, 2020, 1:43 pm

              I think the difference is that there is a whole lotta legislation limiting insurers’ ability to place onerous restrictions on coverage, while these cost-sharing companies don’t have nearly as many legal restrictions since they don’t have to follow health insurance laws.

              Reply
              • Bill from The Fire Guild November 11, 2020, 3:26 pm

                That goes both ways though; Sedera has NO history of denying Shares that fall under their guidelines. All of the big insurers have thousands of huge lawsuits from patients trying to get coverage. All of that legislation only lines the pockets of the lawyers.
                Sedera is a COMMUNITY and one I personally joined precisely because it’s not litigious, clearly explains their guidelines and holds us all to it. I like that!

        • Ann November 10, 2020, 2:58 pm

          Where did you find an IUD for less than $600? In 2007, the average was closer to $1000, plus the office visit charges. It is good for 5-10 years, depending on the type, so it’s not a lifetime price.

          Reply
          • frank November 10, 2020, 3:03 pm

            That is completely crazy. In the UK it would be free as it woul dbe argued that an unplanned and unwanted pregnancy would cost the health service and the rest of the economy far more in the long run

            Reply
          • Mr. Frugal Toque November 10, 2020, 5:37 pm

            It looks like our provincial health coverage here in Ontario pays about $380 for an IUD, if it’s the expensive hormonal type. Cheaper for the non-hormonal types.
            $1000+ costs may be an artefact of the U.S. health system.

            Reply
          • Adam November 18, 2020, 3:03 pm

            IUDs, and all sterilization options for women, are now fully covered under any qualifying health plan at no charge under the ACA.

            Reply
        • Lilah November 14, 2020, 1:34 pm

          Except that IUDs are not permanent, I believe that most of them need to be replaced between 3 to 5 years.

          Reply
      • Eleanor November 10, 2020, 7:33 pm

        If they want to incentivize less risky behavior, they should cover birth control! It’s a lot cheaper than covering a pregnancy.

        Reply
    • caryatis November 10, 2020, 8:37 am

      I read a little further, and they do cover alcohol and drug treatment up to $1500. Mental healthcare is very limited. No coverage for voluntary abortion.

      Reply
    • Bill from The Fire Guild November 10, 2020, 4:26 pm

      Sedera is not a healthcare ministry. It is 100% SECULAR (non religious) and is the #1 reason I searched for it in the first place!

      Reply
  • John Grover November 10, 2020, 8:19 am

    Also check out Surgery Center of Oklahoma
    https://surgerycenterok.com
    Posted online surgery prices all in for many common planned procedures.

    Reply
    • Bill from The Fire Guild November 10, 2020, 4:33 pm

      Surgery Center of OK is a FANTASTIC resource and a model for how a hospital can be run efficiently. Their prices are posted online (100% transparency), and they still turn a nice profit.
      Thanks so much for sharing this link!

      Reply
  • Laura Fogleman November 10, 2020, 8:29 am

    I work in healthcare, as a dietitian-nutritionist (RDN) for a large hospital system with an outpatient integrative medicine department and I also have a private practice here in Birmingham, MI. I’ve worked in healthcare for 30 years and completely understand the 10 heartbreaks mentioned by your new physician! For my own family of 5, we have used conventional employer based insurance forever. It costs our family of 3 (used to be 5, but 2 kids fell off due to age) 20K premium + 12K deductible every year. Most years, just as we entered December we had hit the deductible which meant the insurance company (Aetna) had to pay very little or nothing towards our bills. This is ABSURD and MADDENING! But due to a few joint surgeries for my husband and I who like to work out and burn out our joints (!) and one daughter’s 3 hospital admissions for an appendectomy, UTI, and abdominal pain of unknown origin, I decided to continue the insurance because of those bills which were enormous. It’s the unknown that we have this kind of insurance for.

    So, having said that, my thoughts on your article:
    *written in good faith with humor :) and excellent decisions you have made for staying healthy!
    *Physicians still need lawyers to make sure practice follows legal standards and for malpractice (which is always a concern no matter what set-up you have). We need reform in this area so that physicians are not always under the threat of lawsuits.
    *”share” programs are not true insurance – they are exempt from the requirements of the ACA and can therefore not accept people with pre-existing conditions, often have lifetime and single event caps on what they will pay out, and some plans can kick you off for what they consider immoral behaviors such as having pregnancy out of wedlock, smoking, drinking alcohol, or risky sports such as mountain biking (hmmm this is how my husband ended up with a rotator cuff tear).
    *there is litigation against several of these companies right now for failure to deliver payments and other problems. https://www.ncronline.org/news/justice/health-cost-sharing-ministries-leave-many-out-cold-critics-say.

    All in all, it’s risky to depend on these health sharing plans. I am evaluating another true insurance product that I came across from an RV group of people who retired early and were not eligible for Medicare yet. It is New Era Life Insurance Company (underwriting by Philadelphia American Life). There are caps on all benefits too (this is how they keep the premiums lower), but they are fairly generous and they also have a “bill negotiator” service that helps the insured get the cost of big bills down, but no guarantees! You are basically a cash paying customer who then submits your bills to the insurance company for reimbursement. Can be used across the U.S. – no in-network requirements. Deductibles for hospitalization only, so that’s a plus in my mind. It’s the season sign up and I don’t know if I will go for this alternative yet (still evaluating). I did hear that Medicare may be available in the future for people 60 and up. May wait for that if this becomes an option in the near future.

    Best wishes with your experiment!

    Reply
  • Vikingthor November 10, 2020, 8:37 am

    This model does not eliminate high end risk unless you have regular health insurance for that.

    There are many prescription drugs that cost hundreds of thousands dollars per year. Nor do they cover very high bills like an extended hospital stay/illness that can go into the hundreds of tbousands.

    The health share plans and direct care model do not cover this and that is the main reason why they are cheaper.

    Here is an example of 20 most expensive drugs and their monthly cost:
    https://www.beckershospitalreview.com/pharmacy/the-20-most-expensive-drugs-in-the-u-s-in-2020.html

    There are many prescription drugs step a below that as well that may not be 30k/month but that are in the thousands.

    Reply
  • Bernard Paulsen November 10, 2020, 8:47 am

    I’ve been a Mustachian for several years now, and it has changed my life.

    That out of the way, the primary problem of our health care system is that everything is too expensive. A 2-mile ambulance ride costs $160 in Europe, and $850 in the United States. A night in a hospital bed is $300 in Europe and $1,200 in the US. When you’re hospitalized, a bunch of specialists peek through the door for a few minutes on a daily basis and charge $200 each for this “visit.” The second problem is insurance companies.

    On face value, the ACA was a great step forward in including folks who were unable to get insurance due to pre-existing conditions. But if the health insurance companies charge $1,700 premium per month for a couple, and the taxpayer subsidizes $1,400 of it, we’ve just kicked the can down the road. Sadly, Congress with all its lobbyists will not eliminate the problem. Had El Presidente back in 2008/’9 offered a public option, basically and expansion of Medicare/VA benefits, things would look differently.

    We don’t know what the incoming administration will do to remedy the problem, but we all know that an overhaul is urgently needed. Even with low premiums of $350 per person, most are left with a looming out-of-pocket expense in the multi-thousands should the sh*t ever hit the fan.

    I personally appreciate this blog. I’ll definitely look into this, explore my options.

    Reply
  • Dominic November 10, 2020, 8:49 am

    This is beautiful, a free market healthcare system starting to emerge.
    Great idea to get insurance companies removed from the patient/MD relationship.

    Reply
    • Mr. T November 10, 2020, 1:21 pm

      It’s not parallel, and it’s not a healthcare system. DPC doesn’t compete with/replace megapayors. We still need reform/regulation of the big payors and/or competition from massive expansion of government payors like Medicaid/Medicare.

      Reply
      • Dominic November 11, 2020, 3:27 pm

        Mr. T,
        I think reforming this diabolically corrupt system is a pipe dream unfortunately.
        “You never change things by fighting the existing reality.
        To change something, build a new model that makes the existing model obsolete.”

        ― Buckminster Fuller

        Reply
        • Mr. T November 11, 2020, 3:52 pm

          Reform is the only way these things change for the better. Nobody can create a parallel healthcare system at the scale necessary to challenge/replace the current system, and, as I said, DPC is in no way a parallel or replacement to the American healthcare system. It’s only a comparable replacement for PCP/Urgent Care/screening, and it’s only taking low-risk, rich people and adding a little convenience and lower-response time in exchange for a LOT more cost for those services. If we bought DPC for every citizen, it’d be MORE expensive, and LESS effective than medicare/medicaid/big corps. It’s great for the rich people who are willing to pay more for convenience it offers. It’s not at all a healthcare system. Most people who have medicaid/medicare don’t complain about the things DPC supposedly does better, so there’s no reason to switch PC from, say, a Medicaid doc to a DPC subscription plan. It’s not comprehensive healthcare coverage. It’s just basic PC subscription. DPC is just more corruption from my POV.

          Every country with a better healthcare system than ours just wrote different laws to reform their systems. Of course, that’s what we should do to improve ours. No reason to start from scratch. Your Buckminster Fuller quote applies to physics theories (and any scientific theories), not national healthcare systems.

          Reply
          • Jon from The Fire Guild November 11, 2020, 6:21 pm

            My experience here in Maine with DPC: I pay $60 per month as does my wife. It’s not just for rich folk. There are plenty of blue collar and fixed income patients on my DPC’s roster.

            Three years ago over the course of 6 weeks for one case of bronchitis, it took my wife’s large medical provider at the time 3 visits with 3 different doctors and a few rounds of x-rays until they finally gave her a Z-pack to solve the problem. Our bill was over $1,000. The annual DPC charge is cheaper. And better.

            Reply
          • Dominic November 12, 2020, 9:14 am

            Mr T.
            “Every country with a better healthcare system than ours just wrote different laws to reform their systems. Of course, that’s what we should do to improve ours.”
            This is my exact point, our Gov is incapable of reform IMHO. Our politicians do not serve their constituents, they serve their donors. Take a look at the donations from insurers and pharmaceuticals companies to Congress and you will see what I mean.

            Do I wish that was different? Yes, but I don’t think waiting for politicians to see the light is an empowering strategy. We can collectively make economic choices that disintermediate and starve the insurance cartel as MMM has.

            Reply
            • Mr. T November 17, 2020, 1:07 am

              You’re not starving the insurance cartel with DPC. PC isn’t inefficient in Medicaid, Medicare, or even the big corps. You can’t make economic choices to reform this system. We have to make political choices to get money out of politics, yes. But, we can also make direct political choices to get Medicaid/Medicare expanded into a national health coverage, not just certain poor people, not just certain old people. These systems are great, and they are scalable alternatives to BCBS, Aetna, Cigna, etc.

              If everyone switched to DPC, we’d just have an even more expensive healthcare system, and we wouldn’t have replaced any of the costly parts of healthcare. PC is trivial, and Medicaid/Medicare do a great job of not only PC, but specialist care, emergency medicine, and more.

              Reply
  • Olaf November 10, 2020, 9:03 am

    The US healthcare system is broken in its current form and those between the ages of 18-65 that work as independent contractors, at smaller employers, or not at all do pay a much larger premium than those at large companies, have medicare, or qualify for subsidies in their healthcare coverage. With deductibles in excess of $7k and $8k being the norm, when you already are paying large monthly premiums that increase with your age, it is not surprising that some people are trying to find an alternative such as MMM.

    The biggest risk with the health share plans is that they are still an experiment as MMM notates and they also do not have the same protections under the law as normal health insurance plans for members on a state and federal level. Additionally the lack of coverage for pre-existing conditions is something that will force many of us to not even consider them an option. Now that doesn’t mean that we should not try to find a solution for a healthcare system that is absurdly expensive and that varies substantially based on your socioeconomic status, rather it highlights we need to take it more seriously and drill down to find a solution. As someone who dislikes the insurance business model due to the focus solely being profit driven, it still does not mean you should skip it all together as you could end up in severe financial distress otherwise. It is there for protection at the end of the day and unfortunately it is part of the cogs in a system that we cannot operate without yet. Currently Americans still need some form of coverage, whether that be a catastrophic plan or something similar where it only kicks in once you have paid $x,xxx.xx, as living without coverage is a large risk that can cause severe financial destruction without it.

    The biggest turnoff with a health sharing plan like Sedera that I see is their limitations to pre-existing conditions and the lack of guarantee that your bills will actually be paid by the sharing plan as referenced in the disclaimers on their website (per page 8 of their Access Membership Guidelines), “WHETHER A SPONSORING ENTITY CHOOSES TO SEND MONETARY ASSISTANCE TO YOU AND/OR YOUR FAMILY TO HELP WITH YOUR MEDICAL EXPENSES WILL BE TOTALLY VOLUNTARY AND NEITHER YOU NOR SEDERA, INC. HAS ANY RIGHT TO COMPEL PAYMENT OF MEDICAL COST SHARING COSTS FROM ANY MEMBER. THE SEDERA MEMBERSHIP IS NOT AND SHOULD NEVER BE CONSIDERED TO BE OR TO BE LIKE A GROUP INSURANCE POLICY OR AN INDIVIDUAL INSURANCE POLICY… THIS IS NOT A LEGALLY BINDING AGREEMENT TO REIMBURSE OR INDEMNIFY YOU FOR THE MEDICAL EXPENSES YOU INCUR, BUT IS AN OPPORTUNITY FOR YOU TO ASSIST OTHER MEMBERS IN NEED, AND WHEN YOU ARE IN NEED, TO PRESENT YOUR MEDICAL BILLS TO OTHER MEMBERS AND SPONSORING ENTITIES AS OUTLINED IN THESE GUIDELINES. THE FINANCIAL ASSISTANCE YOU MAY RECEIVE WILL COME FROM OTHER MEMBERS AND/OR SPONSORING ENTITIES, AND NOT FROM SEDERA, INC.
”

    Thus in summary I see why this is attractive to MMM but for most people this is likely not a viable alternative when weighing the risk to reward ratio. I have taken the approach of limiting my insurance coverage before and continue to pay for the lower tier plans and run the risk of having to pay a large chunk out of pocket before my out of pocket maximum is met. This has been beneficial in some years and a drawback in others when large medical events have occurred despite being a young otherwise healthy male. Overall one would hope for a better healthcare system in the US where the sole focus is not profit driven, but rather viewed as a public need as one cannot have life, liberty, or the pursuit of happiness without being healthy.

    Source:
    https://sedera.com/wp-content/uploads/2020/04/Sedera-ACCESS-Guidelines-20200402.pdf

    Reply
  • Bill November 10, 2020, 9:07 am

    I’ve been a member of Cloud Medical for several years have nothing but positive things to say about them and Dr. Tusek! About a year ago I crashed my bike on a Saturday and cut my face up and thought I might need stiches. I texted Dr. Tusek and he immediately called me a did a quick assessment over the phone and agreed to meet me at his office for a detailed lookover and got me cleaned up and on my way. Best part? No charge!

    Reply
  • jade November 10, 2020, 9:09 am

    What does Sedera cost without DPC?

    Reply
    • Bill from The Fire Guild November 10, 2020, 4:40 pm

      Hi Jade-Your costs depend on your age, how many members of your family are involved, what your IUA is and whether you use tobacco (in addition to whether you’re a DPC member or not).
      I suggest you use the cost estimator on this site to get an idea of what you’d be paying:
      http://sedera.community/thefireguild1

      Reply
  • Tom November 10, 2020, 10:23 am

    High deductible health plan + Health savings account + Direct primary care?

    I’ll have to price this out but seems like it should cover all bases combined with the tax benefits of an HSA.

    Reply
    • Ellen November 10, 2020, 10:28 pm

      I posed down below (awaiting moderation) but this is illegal as far as the IRS is concerned. Found a better link:

      https://www.dpcare.org/specialties

      “Today, IRS rules prohibit individuals with HSAs paired with high deductible health plans (HDHPs) from having an agreement with a DPC provider.”

      Reply
      • Steven S. November 12, 2020, 12:16 pm

        Is this updated as of 11/2020? I’m finding that Trump signed an EO that put it on the Sec of Treasury within 6 months (March 2020) to introduce regulations that treat DPC payments as eligible medical expenses for HSAs.

        Reply
      • Jon from The Fire Guild November 13, 2020, 12:17 pm

        Not sure about any specific executive orders. You can’t currently use money from an HSA to pay for a DPC. The IRS regards DPCs as a form of insurance (I suppose because you’re paying for a possible, future medical event). Nor can you set up an HSA based on your being a member in a health share. What’s interesting about Ellen’s link is that it appears you can’t have an HDHP (which allows you to fund an HSA) and also be a member of a DPC. Sedera’s CEO has been trying to get the IRS to change their stance and allow HSAs for members of health shares.

        Reply
        • Sendug November 23, 2020, 9:22 am

          I’m not so sure about that–this article seems to suggest that an HSA/DPC combo is currently kosher but that the IRS is currently planning on changing that, but may not. Sounds pretty speculative, which isn’t too surprising since it’s still a fairly new construct. I will definitely be keeping my eyes on this sphere: HDHP/HSA/DPC sounds promising if possible and better than the healthshare/DPC combo even, sweetened by the deduction/investment appeal of HSAs.

          https://www.thinkadvisor.com/2020/09/23/proposed-federal-regs-could-end-hsa-direct-primary-care-combinations/

          Reply
          • Jon from The Fire Guild November 23, 2020, 2:22 pm

            Hi Sendug,

            That article says that “many patients (more than 21 million to be exact) choose to pair it [DPC] with a high deductible health care plan and a health savings account (HSA) to provide for additional expenses like specialists or tests.”

            To qualify for an HSA, you need to have an HDHP. You can still sign up for a DPC, but you can’t currently use the HSA money to pay for it. The article talks about having all three at the same time. The potential legislation would be about allowing DPC members to use HSA money to pay for it, while others are also trying to get eligibility to fund an HSA if you have a health share like Sedera.

            Reply
  • mike November 10, 2020, 10:24 am

    Pete, what do you like about your dead-lift bar compared to just a regular bar for deadlifts?

    Reply
    • Mr. T November 10, 2020, 1:24 pm

      Trap bars are good for specific sports or people with certain body limits. Rippetoe is staunchly against the trap bar (https://www.youtube.com/watch?v=Z94qTzsa-24) lol. It depends on your goals. For people who need to build strength without adding mass, it’s likely best to do just pulls and drop the weight. Maybe even just break the weight from the floor without completing the pull. What are your goals?

      Reply
      • mike November 10, 2020, 6:06 pm

        Looks like with the trap bar you don’t get shin abrasions, but is a deadlift with a trap bar equivalent to one with a regular bar ?

        Reply
        • Mr. T November 10, 2020, 9:36 pm

          In most situations, no, it is not equivalent. What are your goals?

          Some people cry about shin abrasions, but I’ve never had that problem, and I’m starting to get decent at deadlift, and have deadlifted for over a decade pretty consistently. If you start the bar over your midfoot, where it naturally balances, it doesn’t really hit shins with any speed in a normal deadlift, so my only guess for shin-scrapers is y’all have short feet?

          Reply
  • frugalwaiter November 10, 2020, 10:36 am

    Hello all. Long time reader first time commenter. I work as a waiter and have been purchasing and individual insurance policy since 2011 (before the ACA). When I left the world of employer provided insurance I purchased an Anthem Lumenos HSA policy, for a fraction of what COBRA would cost (even though it was the exact same insurance I was getting from my employer), with a $1000 deductible. Over the years my premiums went up and I increased the deductible from $1000 to $3500. Every year I would compare it with the ACA plans and both the premium and deductible were better than anything the ACA would offer (I don’t qualify for any subsidies). Last year my employer offered a health care plan that included a health share that would be cheaper than my HSA so I did some research to compare the two. After my research I decided that for me it would be best to not go with a health share plan, mostly for reasons already stated above. However I learned that I was drastically under utilizing my HSA and that it could act as a secondary retirement account. I used to only keep a minimal amount in my HSA account cause it was in a low interest bearing account and through my research I found that I could invest that money. I now contribute the maximum amount to my HSA ($3500) and have in invested in a Fidelity 500 index fund with a .015% expense ratio. HSA contributions like IRA contributions are above the line and come out before other deductions you don’t pay any taxes on withdrawals as long as you use them for qualified healthcare costs, and you don’t pay any taxes on interest on interest or other gains. You also don’t have to withdraw from the HSA at the time the expense is incurred, but rather you can pay out of pocket now, save the receipts and reimburse yourself after your investments have had ample time to grow. Plus once you turn 65 it becomes like a traditional IRA and you can make withdrawals penalty free you just pay income tax on them. Lastly unlike IRA’s that have to be contributed to income from work, there are no requirements like that for a HSA. As someone who doesn’t have access to a 401k its nice to be able to make an additional $3500 in tax advantaged contributions to an investment plan. Who knows what the future holds but for now I’m sticking with my HSA.

    Reply
    • frugalwaiter November 10, 2020, 1:16 pm

      I don’t know if anyone has mentioned this yet but the non sharable amount is nothing like a deductible as it is per incident. With my HSA once I hit my deductible everything is covered 100% so my max out of pocket expenses (aside from premiums) is $3500 a year. With a health share there is no limit to how much you might have to spend in a given year if something happens and you have multiple major health events in one year. That’s what really turned me off about the health share plan. The peace of mind that if I have a major health expense I have the money set a side for it, and if I don’t its sitting in an investment growing tax free, is worth the extra premium. Its still 40 to 50 cheaper than anything I’ve found on Healthcare.gov.

      Reply
      • Bill from The Fire Guild November 10, 2020, 5:21 pm

        Frugalwaiter – great screen name!
        With Sedera, you know exactly what your max out of pocket will be. If you go to the http://www.mrmoneymustache.com/sedera page, you’ll see that I addressed this:
        “Q: What’s my maximum out-of-pocket expense?

        A: You’re responsible for your IUA for each Need, but only for a maximum of three Needs per year (for an individual, five per family). For example, if you have a $500 IUA you pay the first $500 for your broken leg on January 1st, the first $500 for your kidney stones in March and the first $500 for your broken arm in April. After that (what a bad year!), you are no longer responsible for any more IUAs on subsequent needs (if you continue to have bad luck). Your total out-of-pocket expense for your three bouts of bad karma payback will cost a total of $1500, regardless of how long your recovery is or how much it costs. Of course, you’re also responsible for your Monthly Contribution throughout your Membership period.”
        So, there absolutely IS a limit to how much you might have to spend in a given year if something happens.
        Just thought you’d like to know another reason why Sedera is “not like the others”.

        Reply
        • Bernie November 10, 2020, 6:12 pm

          As long as they don’t decide to not cover it under one of their many options to not pay..
          Sure! It’s not health insurance, they don’t guarantee payment.

          Reply
        • frugalwaiter November 10, 2020, 6:39 pm

          Hey Bill, thanks for the reply and thanks for the compliment on the screen name. I’m actually thinking about starting a financial blog geared toward those that work in the restaurant industry (its probably needed now more than ever). Anyway I’m pretty sure Sederna was the health share that our employer offered. They also offered us something to cover regular doctor visits and some specialist stuff with co-pays and some other coverage as well that they didn’t go into detail too much, but for everything it was a little over $100 a month. They did a presentation about the health share talked about the advocates that would try to lower the costs gave examples ect. But then when it came to the member responsibility it would be $5000 per incident. The max out of pocket wasn’t well explained to me, but now that I understand it would be $17200 (including premiums). My current premium is $218.61 with a $3500 deductible so my max out of pocket including premiums would be $6123.32. My HSA also covers preventative services like annual physicals, flu shots ect. I also get a $3500 tax deduction by contributing to my HSA account, and if I don’t use that money I can keep it invested tax free. I can also reimburse myself for things that my health plan doesn’t cover like vision and dental. I’ve had this policy since 2011 so I may be getting a better premium than someone who signs up for it now, I don’t know. The American healthcare system is broken, but at least for me a HSA is the best way to keep playing within that system.

          Reply
          • Bill from The Fire Guild November 11, 2020, 3:32 pm

            If I had those options, I’d TOTALLY do what you’re doing! Unfortunately, the ACA marketplace (here in Maine) is super expensive, I don’t qualify for any subsidies, and I’m 52 with a wife and kid. So, the DPC/Sedera combo works best for me. I’m sad to see how many people are tearing apart this suggested solution as if it’s being shoved down their throats – but then comments like yours make me appreciate that there are still others who are thinking and solving vs. reacting and perpetuating misinformation.
            Kudos to you for coming up with an excellent plan, and I think the restofi blog is a great idea!

            Reply
    • Josh November 10, 2020, 6:58 pm

      Wow! That is pretty freakin’ good. I never understood HSA’s. I have to do my homework. I am 49 and human resources used to explain “all this stuff” to me, to the letter. Boy a lot has changed.

      Reply
      • frugalwaiter November 10, 2020, 7:45 pm

        Back when I was getting employer based health care I was working for a nonprofit. At first there was plenty of money for health insurance, but as funding got cut they looked for ways to cut costs. Back then a HSA was the way to do it. It really wasn’t that well explained to me by HR. They pretty much said it will be lower premiums, but higher deductible and once you hit your deductible everything is paid 100% so its good if you have really high or really low health costs. Money was automatically taken out of my checking account before tax to put into my HSA account. I didn’t find out till after I left that job that I was being charged a $3 a month maintenance fee by the bank. I researched and found a credit union that didn’t charge a fee for their HSA and switched over. It wasn’t until I did a google search on HSA vs Health Share that I learned how much I was under utilizing my HSA. https://20somethingfinance.com/health-savings-account-hsa/ this guy does a pretty good job describing the benefits of an HSA and how it can be used as a means for early retirement. He is also not a fan of health share plans, but out of respect for MMM I won’t post anything against health share. Health share might work great for some, especially if you are already FIRE, but for those of us who are still working on it there may be better options.

        Reply
      • Mike November 10, 2020, 10:42 pm

        Josh –

        Brandon over at MadFIentist did a great article on HSA’s a number of years ago. I work as a Benefits Manager, and even *I* didn’t know this at the time he wrote about it. It’s a truly amazing resource.

        https://www.madfientist.com/ultimate-retirement-account/

        Reply
  • MikeFI November 10, 2020, 10:53 am

    This reminds me of the Mike Tyson saying:

    “Everybody has a plan until they get punched in the face.”

    Your “plan” works so long as you don’t get “punched in the face” by a life changing and catastrophically expensive medical diagnosis, i.e. cancer, transplant, etc.

    Don’t get me wrong. My wife and I are in a very similar situation as you. We retired at 48 with a very substantial net worth to last us the rest of our lives and are both very healthy. Our company provided health insurance ran out 6mo’s post-employment (May 2020). When I saw the cost of COBRA compared to the benefits we’d receive it was a no-brainer to pass on it. We’ve got more than enough money the self-insure for our families ordinary medical expenses (slightly less than $2,000 since June of this year after our traditional insurance expired).

    Importantly, I’ve got desire to be “on the hook” for the large expenses so like you I researched most of the health sharing ministries. We ultimately chose to go with Samaritan Ministries. In doing my research I couldn’t find any reports of bad experiences (non or delayed payment) with them (but could with the others). So far we have not had to submit a claim because all of out expenses have been below the self-insure amount. I consider Samaritan to be our backstop for expenses in the $10,000 – $150,000 range. However, I do worry that if we were to face a major medical diagnosis like cancer, we might be hard pressed to “collect” or get reimbursed completely. Additionally, I worry that dealing with the logistics of reimbursement during such an otherwise challenging situation will be substantial. All of this has got me considering looking into the Healthcare.gov plans now that open enrollment for 2021 has begun.

    Reply
    • Bill from The Fire Guild November 10, 2020, 5:28 pm

      Congrats on the early and “fat” retirement!
      Yes, Samaritan Ministries have no reports of bad experiences and in my research they’re very well regarded. Unfortunately, they exclude you if you’re Jewish, Muslim or even a Unitarian Universalist (decidedly Christian) and of course if you’re an Atheist or just about any other alternative. Bummer. (If you’re curious, here’s their heavy “Statement of Faith”: https://samaritanministries.org/resources/requirements)

      For those of you (us!) who fall into any of the excluded groups, there’s Sedera. Similarly without complaints and accessible to all regardless of beliefs.

      In any case, health sharing is a great part of many peoples’ solution!

      Reply
      • MikeFI November 10, 2020, 7:23 pm

        Luckily we (just barely) fit into Samaritan’s requirements. I looked at Sedera and really wanted to support them being a fellow Texas company but one thing that gave me pause was that they are relatively new to this area having only been around since 2014. I’m definitely pulling for them though and maybe someday we’ll give them another serous look.

        Reply
        • Jon from The Fire Guild November 11, 2020, 8:33 pm

          MikeFi:

          Definitely keep them in mind. They may be relatively new as Sedera, but the parent company started out in medical bill negotiation and has over two decades of experience in this. Since 2007 they’ve saved nearly $300 million in medical bills for their clients with an average out-of-pocket savings for employees of between 40% – 70%. (In fact they’ve been negotiating Samaritan’s bills for over 16 years!)

          From their Access Plus Overview:

          “Inc. 5000: Sedera ranked number 193 in the Inc. 5000 list of the fastest-growing private companies in America, putting Sedera in the top 4% of companies overall.

          Austin Business Journal: In 2019, Sedera ranked #1 in the Small Business Category in the Austin Business Journal. In 2020, Sedera was placed on the “Fast 50” list for Large Businesses in the Austin Business Journal.

          Better Business Bureau: In 2020, Sedera was nominated as a finalist for the prestigious 2020 BBB Torch Award for Marketplace Ethics.”

          [In case you’re wondering, here’s BBB’s description of the award: “The Torch Award for Marketplace Ethics is the most prestigious award the BBB can present to a business. Being a recipient indicates that the business not only believes in the high standards promoted by the BBB, but also consistently acts on them and continuously integrates them into daily business practices.”]

          Reply
  • Dan November 10, 2020, 11:03 am

    You need to remove this post. These “non-insurance” health cost sharing groups are not required to actually pay for your health care if you get a serious (and costly!) illness: https://www.nytimes.com/2020/01/02/health/christian-health-care-insurance.html

    Honestly, this article feels like an advertisement. I’m glad you’re profiting from the blog and donating a lot of the proceeds but it’s a shame that this is changing the quality of the content.

    Reply
    • Mr. Money Mustache November 10, 2020, 11:54 am

      Dan,

      First of all, it is not your job to tell me what “I need to” do with my own blog. Your options are limited to choosing to read my articles, or choosing not to read them.

      Secondly, the primary purpose of this article is to promote the idea of Direct Primary Care. I believe this is a better model and has the potential to solve the main problem with US healthcare, which is the efficiency – i.e. the cost per visit/procedure.

      Third, health share organizations have proven to be very fair, and I have only made this recommendation after about five years of hearing about them from readers. Before Sedera, Liberty healthshare was widely used by MMM readers, with very high reviews. Sedera makes some significant improvements on Liberty, and Bill and his colleague JD have spent the last year digging to the core of the company to learn more (as well as making major improvements to the sign-up process).

      For my own situation, I would still prefer to self-insure for the major costs. But I’m willing to try Sedera in order to see what the experience is like, and learn from others. It’s not an advertisement, it is an experiment in a new model that has so far shown promise.

      If you don’t like the health share part of this article, at least consider the DPC. I believe that will play a much more important role in improving US healthcare.

      Reply
      • Bernie November 10, 2020, 12:16 pm

        It is your blog, but I recommend putting the downsides in the main article so people that are not savvy enough to dig into the finer details take you on your word and think it is essentially the same thing. Your article glosses over the downsides and I think that is problematic for your readers. Up to you of course, just an opinion on the internet from a long time reader.

        Reply
        • Norm November 10, 2020, 3:11 pm

          Agreed with Bernie. I was scanning for a “paid content” warning. This will come up in search results for people looking for these plans, and they won’t know anything about your unique circumstances.

          Reply
          • JOE C November 10, 2020, 3:35 pm

            you guys should relax, this is a blog not the NY Times. you aren’t paying to read this content. its like your complaining about free guacamole because you have to pay for the burrito.

            who cares what any of us think. If anyone reads this post and blindly follows all advice its on them and their results may vary. MMM is under no obligation to you or anyone else.

            Reply
            • Kevin November 21, 2020, 4:42 pm

              I agree with you, but the truth is a lot of people do blindly follow what he says. That’s not his fault, but I think it is something to be taken into consideration. For most bloggers this will never be an issue, but a certain % of readers of this blog are very cultish.

              Reply
        • Fireby35 November 11, 2020, 1:12 pm

          I hope your faith in regular insurance is never put to the test. There is a much higher probability your health insurance leaves you hanging in the wind than most people realize.

          Remember, it is regular health insurance companies who have such a clear and documented history of writing exclusions into their contracts that we had to pass an overhaul of the entire system to deal with it.

          They still look for more ways to deny coverage to this day.

          Perhaps you should consider who is saavy enough to understand those finer details. Perhaps you should consider whose word it is that most people accept (for profit insurers!).

          Reply
      • Mr. T November 10, 2020, 1:14 pm

        I don’t think the main problem with US healthcare is the efficiency – i.e. the cost per visit/procedure. Why do you think this? I think the main problem is the insurers being for-profit, and collecting billions of undeserved profit, as well as failing to collectively bargain prices down on behalf of the citizens. I agree that these plans sidestep those megacorp “insurers” (really payors), but I disagree that they replace them for the same product. The only solutions I see are introducing/expanding a government payor to do the right things and compete with these bad actors, or to change regulations in big ways and force some real and intense competition between the private for-profit payors to bring about the same changes. They wrote the laws to make them seem like non-profits, even though they extract massive profits. This needs to change. I don’t see DPC firms as competitors to Aetna, BCBS, Cigna, and the like.

        Reply
    • Dan P. November 10, 2020, 12:36 pm

      Hi there…I’m the Dan that was referenced in that New York Times article. My family and I did our own experiment with Libery Healthshare and documented it on a blog, which the Times article referenced (www.mylibertyexperience.com). While that experience was not good, we have been using short-term health insurance from United Healthcare for the last two years with no issues (we are in Ohio, so our short-term plans last the year). Of course, we also have been relatively healthy. Even having had a negative experience with a healthshare, I still appreciate MMM’s effort to share what options are available. The DPC model is interesting and might be a valuable tool for many people in addressing their health insurance needs. As for Sedera, yes I’m skeptical because of my experience, but that’s a decision for individuals looking for health insurance alternatives to make. My only advice: do your own research, don’t just rely on anyone else, even MMM, before you make a decision for your family. Call your healthcare providers, understand how they work with a healthshare, read the fine print, etc.

      Reply
      • Dan P. November 10, 2020, 12:37 pm

        Sorry, and to clarify, I’m different than the Dan who posted the link to the NY Times article! LOL!

        Reply
    • Bill from The Fire Guild November 10, 2020, 5:38 pm

      I’d also like to once again point out: Sedera is NOT a Christian Health Care Ministry. It is a secular health share and is not mentioned at all in the article you reference. Furthermore, unlike the alarmist anecdote the article leads with, there are NO CAPS with Sedera.

      Reply
  • Robert November 10, 2020, 11:12 am

    This was an interesting article, as I’m personally signing up for my fourth health plan in 21 months since FIRE. (COBRA, 2nd company plan from consulting gig, ACA, and now figuring out 2021).

    I will always have at least a catastrophic bronze plan from the ACA because we’ve unfortunately had some six figure medical events. I hate it, but accepted I’m paying $8,100/year for coverage that’s essentially bankruptcy protection from the US medical system. I stay out of the healthcare/political arguments, I figure as a FIREy person, I’d either pay more in taxes in exchange for having to save less overall in other places, so it all washes out.

    To the direct patient care model, it’s unbelievable. It was life changing for my wife to find a neurologist in headache medicine with a DPC model. Instead of being limited to 14 minute appointments based on insurance reimbursements, the doctor was able to take a lot of time in the first two months, get it on the right path, then have the appropriate level of follow up care to manage through improvements. It was such a difference from the horrors of traditional healthcare. We need to look into getting a new DPC relationship with a general practitioner at some point.

    Keep spreading the FI message!

    Reply
    • Katie November 11, 2020, 1:52 pm

      I think calling health insurance “bankruptcy protection from the US medical system” is a (sadly) accurate way of putting it!

      Reply
      • Bill from The Fire Guild November 11, 2020, 3:38 pm

        I agree, Katie. In fact, I call it “bankruptcy insurance” when talking about this with friends. It has nothing to do with health. Sigh.
        My true hope is that we’ll finally figure out that keeping people healthy (hello DPC!) is the best way to lower costs, AND have a happier population at the same time.
        Preventive care is a “new” idea in the US and it’s going to take a long time before anyone figures out how to make money doing it properly aka it being more “valuable” than gouging people for health care.

        Reply
  • Mark Asmus November 10, 2020, 1:47 pm

    My wife’s employer is doing something similar to this on a larger scale. They have joined a county wide consortium that basically rented 2 small strip mall locations and pay for a doctor and 2 nurse practitioners to staff them. Then anyone who is covered by the insurance plan of this consortium can visit the two locations for “free”.
    Basically the employer is sidestepping the insurance company as much as reasonably possible to keep their insurance claims (and thus premiums) down.

    No doubt that costs are getting such that individuals AND employers need to start evaluating all options out there.

    Reply
  • frank November 10, 2020, 2:17 pm

    I’ve just had a look at the stuff they offer. In the NHS we would only offer most of them if there was an actually symptoms that needed responding to. This isn’t a criticism of MMM, its just amazing how the US health system is so inefficient in terms of how it uses resources

    Reply
  • erishera November 10, 2020, 3:05 pm

    Could you not fly across the border and use Canada’s healthcare as a backstop to loss in the worst case scenario?

    Reply
    • Mr. Money Mustache November 10, 2020, 3:15 pm

      Even if I could, I would not – I find the care here in the US is more advanced and with shorter waiting times. And with this combination of coverage, there would be no financial point in doing so either.

      On top of that, even as a dual citizen I would not be covered by the Canadian (Ontario in this case) system until I established permanent residency for three months.

      If anything, I’d choose a different country like Mexico or Costa Rica if I wanted to save money on a medical procedure. In fact Bill did this to a European country at one point – he may share this story sometime.

      Reply
      • CapitalistRoader November 10, 2020, 5:39 pm

        I needed a non-emergency MRI and and am on a high-deductible Bronze ACA plan. Contacted local hospitals and they wanted ~$3000. Had business in Taipei and ended up getting it done there for $400 at a JCAHO accredited hospital affiliated with John Hopkins. Two months ago a client had a double hernia fixed in Taipei for $4K. I’ve also had cardiovascular diagnostic work done in India at 1/10th the cost of hospitals here.

        I know it’s not practical in these times of COVID-19 but planning a vacation around otherwise expensive elective health care has definitive potential for saving a lot of money.

        Reply
      • Bill from The Fire Guild November 10, 2020, 6:01 pm

        I did indeed do some amazing “medical tourism” in Europe last year! Maybe I’ll share my experiences if people are interested. It’s yet another part of my family’s health strategy and complements our DPC and Sedera involvement.

        Reply
        • Tara November 10, 2020, 7:16 pm

          I would be very interested to hear about this, since I am an EU citizen as well.

          Reply
        • Dominic November 11, 2020, 3:30 pm

          I would be interested too

          Reply
      • Gene Parberry November 11, 2020, 12:24 am

        Just like to weigh in on MMM’s comment, “…care here in the US is more advanced…” I was born in Canada and raised there but I have lived in the US for a few decades and I concur. The care that my aging relatives received in Canada is second rate and not something that I would willingly subject myself to. The cost in the US is certainly a challenge but there are different options to try to avoid paying a King’s ransom for quality care. Being a dedicated Mustachian certainly helps. Living in an ACA friendly state helps also. There is plenty of information online about which states support Medicaid with ACA and which ones don’t.

        Reply
        • Mr. Money Mustache November 11, 2020, 7:06 am

          Yes. There are surely pockets of good and bad medical care everywhere, but watching my Dad die from a brain tumor in an understaffed and incompetent cancer ward (on the lakeshore of one of the country’s most expensive cities no less), and my Mom suffer months of pain from a completely incorrect antibiotics treatment due to the shittiest emergency room situation I could ever imagine, definitely tempered my former enthusiasm on fully public health care.

          Then I compare that to my experiences in the US: the birth of my son in what felt like a luxury hotel, and the incredibly good experience with fixing his broken arm: a room full of six well-educated and personable experts in a top-of-the-line facility working together like clockwork. I couldn’t believe these two experiences were taking place on the same planet!

          The downside: everything in Canada was “free”, while the US experiences cost thousands of dollars per day.

          Reply
          • Gene Parberry November 11, 2020, 7:36 am

            Everything was not “free” in British Columbia, Canada when I lived there, but was very affordable.

            I should have added previously, that I appreciate this blog post very much as I am thinking about changing States and the info about DPC and Healthshare options is very helpful as I will be looking at other plans outside of Obamacare.

            Reply
      • Patrick November 11, 2020, 1:18 pm

        Interesting that your experience is that the U.S. healthcare better than Canada. I wonder why life expectancy is 3.71 years greater in Canada than the U.S. and its been consistently growing over time. If the U.S. has better healthcare is the lower life expectancy due to the high cost of illness and people simply unable to afford treatment? The curious thing is in Ontario it cost the government approx $4000 per year per person for our healthcare costs and the cost of coverage in the US being quoted here today appear much higher.

        Reply
        • Mr. Money Mustache November 12, 2020, 10:38 am

          I *think* our different life expectancy is due to more social inequality and poverty and less education in the US, which leads to less healthy lifestyles – especially in things like higher sugar consumption, which is the cause of obesity, which is higher in the US than in Canada.

          I am not sure if Canadians are more active than Americans on average, but I would like to learn this (a quick Google search just now suggested that we might be pretty similar).

          Both countries are designed horribly around car-based transportation, which means most people only get a few thousand steps of walking (or even less) per day, when we really need to average at least 10,000 to maintain a good chance of ongoing health.

          Since the majority of our sickness (have heard 75%) is caused by preventable lifestyle-related diseases, it would make sense that even a small difference in the average diet of a population of people would make a noticeable difference in average life expectancy.

          In other words, longer lives don’t primarily come from better medical care – that’s a system of last resort. They come from living a life that allows you to NOT NEED medical care in the first place.

          Reply
          • Sendug November 23, 2020, 10:04 am

            My first guess would be relative health as well, but I’m not as sure that its entirely income-related. There may be more overweight people in lower income brackets, but the wealthy are not exempt. I’m seeing one CDC study that says that yes, obesity rates decrease as income increases, but they still give rates in the 30% range even for high earners. That’s way too high.

            In a straight-up comparison of obesity, Canada comes in at 26.7% for obesity (BMI>30) and 61.3% overweight (BMI>25). The US has 39.6.% for obesity overall, including 18.5% for kids 2-19. That’s just sickening. Just to throw another one in there, Japan (where I live) lists 32.2% for guys and 21.9% for ladies as being overweight. Obesity was only about 3%, but weights are rising here as well.

            At least in part, Americans and their general disinterest in their own health are driving up healthcare and insurance costs in the US. It has to affect costs in other countries as well to differing degrees, but 40% obesity and what all comes with it certainly takes its toll. I’m glad MMM preaches on biking and healthy living. Not only will it save your life, it’ll also save in health costs for you and the country as a whole.

            One other interesting tidbit I heard was that amounts spent on food and healthcare/insurance have flipped in the past 30-40 years: it used to be people would spend about 15% on food and 7-8% on healthcare; now we spend 7-8% on food and 15+% on healthcare. The argument was to spend more on buying better groceries, including locally raised grass-fed meat and organic produce. Eating better certainly will keep hospital costs down on average.

            Reply
      • Max November 14, 2020, 8:03 am

        There is technically a waiver in Ontario on the 90-day waiting period for OHIP coverage due to COVID-19 right now. Maybe a short term loophole in the system for you : ) Of course, residency is probably still required.

        Mrs. Max OOP (also Canadian) just signed up for Canadian coverage in Alberta while she completes some short term education (learning to become a butcher). She has been paying cash up there for some minor services. No complaints yet, but again, these are very minor doctor visits. She hasn’t used the system since she was very young.

        Sorry to hear about your parent’s experiences.

        Max

        Reply
  • Suchot November 10, 2020, 5:23 pm

    This comes at a great time; I’ve been thinking a lot about health insurance recently. I’ve had it easy so far. Great health insurance with my (part-time) employer. But as my business ramps up and I think of leaving my job, I have some decisions to make.

    Reply
  • Danny November 10, 2020, 5:56 pm

    I am a long time reader and DPC doc in the Detroit area. Glad you and DPC finally crossed paths. One of the things that drew me in to the movement was the mustachian-like elimination of waste and overall optimization. Hope you continue to have a great DPC experience.

    Reply
    • Bill from The Fire Guild November 11, 2020, 3:41 pm

      Hey Danny – you should include a link here to your DPC practice. I’m sure other Mustachians in your area would love to check out your services. I know I would if Detroit was my home!

      Reply
      • Danny November 13, 2020, 6:16 am

        Good idea, thanks! For those who are in the area, you can find us at http://www.saltadirect.com (website is still a work in progress). I’ll be working out of a new office in Auburn Hills starting in 2021.

        Reply
  • Shelley M November 10, 2020, 6:28 pm

    As Warren Buffett says, “Healthcare costs are a tapeworm on our economic system”. There are no good answers! Ditching health insurance is a REALLY BAD IDEA , because most will get diagnosed with a chronic or expensive illness at some point. Cancer alone has daunting odds. 1 in 2 women and 1 in 3 men will develop some sort of cancer in a lifetime (SOURCE: Medical News today). Treatment costs range, depending on severity, from $50,000 up to millions. Without true health insurance, most will be looking at bankruptcy or total savings wipeout.
    We have been on ACA plans since 2014; and of course, hate them. We keep a lid on costs by staying healthy, choosing HMO, maximizing HSA, having 2 businesses, so premiums are deductible. For a family of 4 in San Diego, premium is $1200/month, but monthly tax savings are $200 HSA deduction, and $400 health insurance business deduction, so we end up at about $600/month for family of 4. Not ideal, but manageable. No subsidies here at our income level. HMO in our area is way more efficient and of better quality, but we do have to take the time to go through primary doc for most procedures. I’m ok with this, though, knowing that the gatekeeper concept is one of the ways HMOs keep costs manageable. As a true fan of efficient processes (recovering Industrial Engineer), I mostly admire our HMO’s processes….when we were in the land of PPO for 10 years, there were errors, delays, and so much inefficiency….receptionists at every turn, horrible on-line tools for booking appts., etc.
    And, of course, the biggest problem of all…we are getting less and less healthy as a society, though I realize here at this site are fellow marathoners, gym rats, and yogis who have a fighting chance for good health for a lifetime. I would love to see health insurance options that reduce premiums if you meet certain biometrics and adhere to exercise program.

    Reply
    • Tara November 10, 2020, 7:19 pm

      Which HMO do you have? I’m in San Diego as well (for the winters, the rest of the year I’m in Canada for the health care).

      Reply
      • Shelley M November 10, 2020, 7:56 pm

        Kaiser HSA eligible HMO…good use of time is researching and selecting primary care docs.

        Reply
  • Stashja November 10, 2020, 6:34 pm

    I have followed this blog for 4 years, and have agreed with it less and less over the last 2. This really takes the cake. Hormonal birth control is really expensive and many mustachian women need it for an array of reasons, from not wanting 12 kids (very expensive! Very unsustainable!) to needing to not throw up or have constant cramps and headaches at work due to endometriosis (hello!). No health insurance + this medication = $450.month, at least for mine. My health insurance costs less than that. Maybe MMM intends for his advice and example to be of use only to men… And he also intends to save money by not paying for his partner’s contraceptive medicine. Otherwise… not workable for women or for any household with a woman under say age 50 in it.

    Reply
    • Tara November 10, 2020, 7:23 pm

      Wow, that’s a lot! My pill packs only cost $20 a month, but I don’t have any health conditions. I do agree it is short-sighted for companies not to pay for birth control. Way less expensive than pregnancy.

      Reply
    • Ellen November 10, 2020, 10:06 pm

      I completely agree. Calling birth control “elective” (it’s done on the sedera page) completely misses the mark and shows just how much fighting we still have to go to get our legitimate medical needs taken seriously and not brushed off. Not all women can tolerate all forms of birth control.

      Reply
      • Adriana R November 12, 2020, 4:28 pm

        I am a DPC doc in Michigan — part of the benefits for members is finding affordable medication prices. I recently prescribed a birth control medication that costs $9 /3 months — this is less than a Starbucks a month. I could get IUDs for less than $200- that is less than $40/y for contraception. Don’t feel like the insurances are covering so much if they mark up the cost of a $10 med to 1000, then offer you a “discount” to $600 to show you the “benefit” of paying 1200/mo in premium!

        Reply
    • Martin November 11, 2020, 3:51 am

      Condoms cost 10 cents on Amazon.

      Reply
      • MC November 11, 2020, 10:43 am

        There really should be another word for birth control because it does a lot more than prevent pregnancy; it alleviates a whole lot of other conditions. The example Stashja gave was endometriosis and I use “birth control” to prevent anemia (and my husband had a vasectomy! so obviously I don’t need it to prevent pregnancy). I know friends who use various “birth control” to manage PCOS, in collaboration with bipolar meds, migraines, amenorrhea, or PMS so bad it resembles stroke symptoms. “Birth control” should really be called “menstruation management” and not make it about contraception. Its about taking care of women’s health and it saddens me that people and apparently some of these health companies don’t understand it.

        Reply
    • Jon from The Fire Guild November 12, 2020, 12:58 pm

      I agree that birth control is a pretty vague term. Sedera considers these medications when prescribed for things like migraines or hormonal therapy to be maintenance medications. It would be shareable only if the original diagnosis was new under Sedera. If so it would be shareable for 120 days to support the therapy. Another example of maintenance medication would be blood pressure meds. If the condition existed before joining Sedera, then it would be a pre-existing condition. The opposite of this would be curative medications, which are prescribed specifically to “cure” a specific condition. Prescriptions for cancer medications, for instance, would not have a time limit. The reason for this is that Sedera is designed for large, unexpected medical costs and the community’s goal is to help each other out in times of crisis. It’s not a prescription drug plan.

      BUT they definitely provide resources for people who need medications to handle chronic conditions. Remember, Sedera allows people with pre-existing conditions to sign up. They just don’t cover that particular condition in the 1st year (15k in year 2, 30k in year 3 and fully in year 4). Check out this service, which is provided by Sedera to help members find good prices for all kinds of medications at over 67,000 pharmacies throughout the US:

      https://www.therxmarketplace.com/

      This would be a nice way to compare prices on any of the medications you have in mind.

      Reply
  • Caleb k November 10, 2020, 6:37 pm

    I insurance tends to be very bureaucratic, so this is a wonderful substitute. If anyone doesn’t want to use DCP and wants to stick with regular insurance Christian Care Medi-share which is apart of the Affordable care act is a great option. It normally is about half of the cost of other insurances and better coverage. unlike most insurance companies they don’t try maximize profits, but actually care about there customers. The only downside is that they don’t cover an expense below $500 which tends to not be a problem considering the savings.

    Reply
  • Matt November 10, 2020, 6:44 pm

    Hi MMM,

    I didn’t realize that I had become so much like you – lol. But then I used to live on the diagonal.

    When my wife & I decided to retire early in 2019, our biggest concern was health insurance cost. 3 months prior to retiring, my doctor’s practice decided they were opening a DPC office next door subsidizing the start of a health professional’s start. Perfect. So since September of 2019 we have been using a DPC as our primary care and a health share to cover major expenses.

    This has worked out so well this past year. When we need to see our doctor, we text, she responds and I have an appointment when I need it. The health share has worked just as well.

    thanks for your wonderful blog.

    Matt in AZ

    Reply
  • Katrina November 10, 2020, 6:54 pm

    I was in my 20s, healthy, rode bikes, etc. diagnosed with a random thyroid tumor and needed a 30k surgery after multiple diagnostic tests. Now I have a chronic condition that would exempt me from something like that. And what about ER visits from a fall on your bike? My son is currently going through tests for MS. He was a healthy 20 year old, fit, then just started having weird dizziness. Several MRIs later, we had to have a lumbar puncture and more tests. So far my insurance has paid out almost 20k for that. I’m glad I have it through my job, if I didn’t, I’d have to find it through the marketplace. Even a high deductible plan is better than nothing. I’d be worried about medical debt from something random. Can they go after your assets to pay it?

    Reply
  • Mark November 10, 2020, 6:54 pm

    MMM, you give really great financial advice. I admire you a lot for the way you link financial activity to the environment. And I think you provide a lot of really useful tips on how to save money, by not buying so much stupid shit that we Americans feel compelled to throw our money at.

    However, what you’re suggesting will really only work for “healthy people”. And even then, maybe not? Canada has it right. Health care is a human right. And although I have very few health concerns of my own, I am perfectly willing to subsidize those who are not so fortunate.

    I appreciate what Sedera is trying to do. But until we have a comprehensive system that everyone can actually utilize, I’m not willing to hand over my health care options to a tech start-up.

    Reply
    • Bill from The Fire Guild November 11, 2020, 3:57 pm

      I think it’s unfair to call Sedera a “tech start-up”; they have 35K members, have been in business for 6 years and their executive team all have decades-long backgrounds in the healthcare industry.
      Just like linking financial activity to the environment, health activity should also be one’s “global” guide…and it benefits the environment even more! Most of MMM’s health choices are also environmentally-conscious.
      Personally, I chose Sedera because they incentivize HEALTH and accountability. That’s the group I want to be part of!

      Reply
      • Mark November 11, 2020, 11:45 pm

        Six years is a pretty new business, and not nearly long enough to be fully evaluated, in terms of whether their model can work at scale. And while I’d love it if more Americans would take better care of themselves, many diseases and accidents have little to do with accountability.

        Reply
        • Jon from The Fire Guild November 12, 2020, 1:10 pm

          Hi Mark,

          The health share model has been in place in the US for over 25 years. There are now over one million members who have shared over a billion dollars in medical expenses. So the model itself definitely works for quite a few people. As for Sedera, their bill negotiating group has over two decades of experience on behalf of other organizations and businesses that predates their sharing operations. The following media accolades are encouraging:

          Inc. 5000: Sedera ranked number 193 in the Inc. 5000 list of the fastest-growing private companies in America, putting Sedera in the top 4% of companies overall.

          Austin Business Journal: In 2019, Sedera ranked #1 in the Small Business Category in the Austin Business Journal. In 2020, Sedera was placed on the “Fast 50” list for Large Businesses in the Austin Business Journal.

          Better Business Bureau: In 2020, Sedera was nominated as a finalist for the prestigious 2020 BBB Torch Award for Marketplace Ethics.”

          This is how BBB describes the award: “The Torch Award for Marketplace Ethics is the most prestigious award the BBB can present to a business. Being a recipient indicates that the business not only believes in the high standards promoted by the BBB, but also consistently acts on them and continuously integrates them into daily business practices.

          Reply
          • Mark November 12, 2020, 2:42 pm

            While the model “works for quite a few people”, it is most definitely NOT designed for people who suffer from chronic, or pre-existing illnesses, that are not their own fault. Don’t believe me, just ask Sedera:
            https://sedera.com/wp-content/uploads/2020/09/Sedera-ACCESS-Guidelines-20200901.pdf

            This model is predicated on the myth that people have total control over their health, if they would only make better choices. It’s insurance for healthy people. They can call it “a cost sharing community” all they want. But I recognize bullshit doublespeak when I see it.

            Reply
            • Jon from The Fire Guild November 12, 2020, 3:09 pm

              As Bill from The Fire Guild and I keep saying: Sedera’s not for everyone and we don’t want people to sign up without understanding how it all works. I’m most concerned with providing accurate information. And our posts here are part of that effort to make sure people understand.

              This model, like insurance, is actually predicated on the reality that people do not have total control of their health. Accidents by definition are out of people’s control. Anyone who joins can become sick and injured and then those needs would be shared. Cleansing a risk pool of any risk and charging people in that pool is a sure way to make bank no doubt and that’s why traditional insurance tries to limit payouts whenever it can. But there’s a clear correlation with certain lifestyle choices (daily fast food, 64 oz. sodas) and certain lifestyle diseases. Making healthier choices will make for less medical interventions overall and thus lower the costs we all have to bear in a given risk pool. So DPC helps with basic health issues and something like Sedera helps with large, unexpected medical expenses. Right now, there is almost no incentive in the healthcare and insurance worlds for people to make healthier choices. This is no moral judgment on my part. You can eat all the Twinkies and smoke as many cigarettes as you want. The question is, should someone else have to pay for it?

              Reply
              • Mark November 13, 2020, 3:32 pm

                The short answer to your question, is yes. Yes we should all pay for unhealthy people. Because in this country, we have repeatedly decided that personal freedom is paramount. But we have also put into place policies that guarantee treatment for people in emergency rooms, regardless of their ability to pay, or how they found themselves in that circumstance. We have purposely made the system as inefficient and expensive as possible, because, America.

                And again, I’m not saying the Serdera model doesn’t work for some people, but rather that it’s creating a problem, by removing healthy contributors from the larger system. There was an interview with Mark Cuban a few years back. And while Cuban isn’t a healthcare expert, by any means, he did bring up one very profound point when it comes to universal health coverage. He said that “The risk never leaves the system.” And he just kept repeating that phrase. We can choose not to cover millions of poor people, many of whom have made very bad health related decisions. But all of those people don’t just go away. They remain a burden on the system, just in a different way. It’s why the ACA required young, healthy people to minimally contribute.

                And for the record, no, I don’t eat Twinkies, or smoke. And I don’t particularly want to pay for other people’s stupid life choices. But since our country has repeatedly rejected the correct choice, of more heavily taxing unhealthy products to augment skyrocketing healthcare costs, then the money has to come from somewhere.

  • Dr. A November 10, 2020, 7:01 pm

    As a physician, I believe that what makes health insurance worth paying for is access to the pre-negotiated contracted rates that insurance companies provide. If you get something like a brain tumor or spinal tumor, your bill would easily exceed $1,000,000 in a single month at tertiary medical centers, if you don’t have access to negotiated contracted rates for your neurosurgeons, oncologists, radiation oncologists, radiologists, anesthesiologists, pathologists, neurologists, labs, MRIs, operating rooms, ICU rooms, hospital rooms, rehab, infusion centers, biologic chemotherapies, pharmaceuticals, etc. With pre-negotiated rates, the charges would perhaps be closer to $250,000, of which, you’d owe just a fraction with a cheap catastrophic plan. It is a horrible stressor to be negotiating everything while also trying to access the best care. My patients without insurance universally delay needed care, pick and choose what care they do receive very poorly, and suffer deep stress and anxiety before, during, and after each episode of care. Don’t pick up nickels in front of a steamroller.

    Reply
  • Carrie Willard November 10, 2020, 7:02 pm

    Fwiw we have had excellent experiences with Liberty Healthshare. When hubby.. healthy, young, no preexisting conditions- had a stroke that cost $80,000 – Liberty paid.

    Insurance even with a 10,000 deductible would cost my family $2000 a month. Untenable.

    Reply
    • Bill from The Fire Guild November 11, 2020, 3:59 pm

      That’s great to hear Carrie! As I’ve mentioned before in my comments, we almost never hear about the 100s of thousands of people for whom health sharing (either Christian or secular with Sedera) works.

      Reply
  • Tara November 10, 2020, 7:15 pm

    I chose to move back to Canada after early retirement at 49 and have been satisfied with this situation. We spend the winters in California on a Medipac travel insurance policy that only costs about $600 for six months. I pay for any office visits needed in the US out of pocket with a private doctor who doesn’t take insurance and charges the medicare office visit price (currently $117.41) for a 45 minute appointment. Thankfully at 54 I haven’t had any catastrophic medical events, but I feel comfortable knowing I would not be bankrupted by medical care. If I didn’t have the Canadian option, I would just get a high deductible major medical bronze policy through ACA and go with something like Kaiser Permanente. I do like the DPC model but it isn’t comprehensive enough to be a complete solution and I’m leery of the health share model.

    Reply
  • Eleanor November 10, 2020, 7:52 pm

    MMM, I think you would get most of these benefits by just getting a normal family practice doctor and self-paying for visits. They normally have a nurse line and you can email your doctor. Primary care is not gonna bankrupt someone with substantial savings. Why pay a $1200/year subscription fee when you’re unlikely to use that amount in services? I get that you like the concept and the practice, which is worth something, but it doesn’t seem very mustachian to waste the money.

    Reply
    • Teri November 10, 2020, 8:54 pm

      Right, self pay for medical care might actually be a cheaper option for someone who is male, can afford to self insure, and is generally healthy anyway. MMM is also presenting new ideas here, expanding options, etc…. And he is being brave in sharing his diagnosis of ADHD too, which is a lifelong, ongoing and very treatable health challenge. I don’t agree with everything in this article, and yet I appreciate everyone’s diverse views and MMM’s take on finding alternative ways of affordably accessing health care. Also, bloggers who write about things they spend money on can (generally) deduct the cost of those things as tax write-offs (business expenses) in the USA.

      Reply
  • Papa November 10, 2020, 8:12 pm

    We’ve stopped going through insurance altogether for many services. We’ve found its actually cheaper than the copay and to get bills later than paying a cheaper cash option upfront for stuff like Chiropractor visits and lab work. We still have insurance through employer, but by eating healthy and staying active, we haven’t actually had to use it. We’re getting gouged.

    Reply
  • Grizz November 10, 2020, 8:42 pm

    Wow, as a Canadian it’s shocking how much Americans think and worry about healthcare/insurance; it’s exhausting. You really need a single payer system.

    Reply
  • Kate, RN November 10, 2020, 8:48 pm

    The DPC model is emerging and interesting to follow but I would argue that it is not ready for wide scale implementation. It works on a small scale where patients are relatively quite healthy. Where is the incentive for DPC providers to take on sicker patients? If they do take on sicker patients, what will incentivize patients to stay when their costs and wait times increase? Circumventing Medicare/Medicaid also releases DPC providers from needing to comply with certain regulatory measures that protect patients from discrimination and privacy violations. While increased transparency can help in this regard, it is only beneficial to those who have the privilege of choice.

    Reply
    • Chip November 10, 2020, 9:49 pm

      DPC is a micronized version of public-option health, currently mostly practiced at a scale sustainable to not need extra administrators. The core principle of paying a base salary for taking care of a fixed number of people rather than being paid per visit is easily scalable.

      Your complaints about DPC aren’t unique to the model and there is nothing to stop physicians in “regular” employed or private practice from cherry picking healthy patients nor from choosing not to take Care/Caid. Moreover, most DPC practices become sustainable by engaging with local employers, thereby agreeing to take care of any/all of the employees that choose the model.

      Choosing to practice DPC does not give you amagic “out” from obeying privacy/discrimination law. The functional regulatory measures apply whether or not you choose to engage Caid/Care, they remain enforceable by the state board and your friendly local attorney.

      Reply
  • Chip November 10, 2020, 9:21 pm

    To those of you upset that Pete isn’t subsidizing the less fortunate by having traditional insurance, consider this: Wouldn’t you rather he saved that money and sent it elsewhere in a more efficient package that hasn’t had half of its value taken away by rent-seeking middle parties? System reform sure as shit isn’t going to happen by more and more healthy, wealthy people buying into the current mess.

    The truly cheap option for someone without chronic issues is to have straight disaster coverage (Samaritan/Sedera et al) and to pay up front cash for the rare time when you actually want to see the doc. By choosing DPC he’s voting with his dollars by paying more to support a more functional system. To a small degree, he (and other healthy people who choose DPC) already subsidize a system that couldn’t exist if all the players needed monthly visits and attention.

    Carry on….

    Reply
    • Mike November 11, 2020, 8:37 am

      The ACA capped the administrative portion of premiums at 15-20%. Subtract out overhead and that leaves you with a lot less than half of the value “taken away”.

      The DPC is not a system that attracts an average mix of healthy and sick members. By nature, it’s not going to bring in sicker members in its early stages. They are already paying premiums, copays, deductibles etc. for their regular health care needs and a DPC would be duplicate coverage. They are also more likely on the lower end of the socioeconomic ladder and not able to pay for this luxury.

      The less fortunate would much rather have the healthy and well-off in their pool under regular insurance than split out in a separate DPC pool. You can argue that causing disruption would make this worth it in the long term if a new system emerges. But in the short term, it will definitely make it more costly for those that aren’t well-off.

      Reply
      • Chip November 11, 2020, 3:04 pm

        Indeed the ACA did just that. Unfortunately, admin costs aren’t the only thing eating at this hypothetical money. Hospitals need to cover their own overhead and in some cases produce value for their shareholders as for-profit entities. They often do so by inflating prices, which serves a secondary purpose of balancing the write-offs from those who can’t or choose not to pay for services rendered. A backwards, and highly inefficient way of subsidizing those who don’t pay their bills.

        I think you and I define “less fortunate” differently. Those in that category in my world either qualify for Medicaid or for consequential subsidies on private insurance. DPC is not concierge medicine and is marketed largely toward the middle class with the current push being to engage small to medium sized employers.

        Aside from disliking the new options presented, I’m not sure what your opinion is. What do you see as the solution to a clearly broken system?

        Reply
        • Mike November 11, 2020, 8:45 pm

          Thought you’d never ask! First is to stop pretending like there is a magic solution that will advance the triple aim with no downsides.

          Transparency in costs including upfront pricing required for everything except ER. If I have to sign my agreement for a specific surgery plus some alternatives, I should be able to get a price for them.

          Out of network emergency docs paid at a legally arbitrated rate to kill that surprise balance-billing-while-your-unconscious bullshit.

          Reference based pricing to put more skin in the game for consumers and competitive pressure on providers. Especially with stuff like MRIs.

          Care properly assigned to the right level of expertise. Anything that doesn’t need done at a hospital shouldn’t be done there. Anything that could be done by an NP shouldn’t be done by a physician.

          Pull back a little on the patent protections for drugs. Trim down the time till expiration and don’t let them get away with easy shit like adding a stripe 5 min before it expires.

          Ban drug rebates to insurers and the use of manufacturer coupons by consumers (unless a generic is not available, not that they usually offer coupons in that situation but just in case). Conspicuous consumption!

          Full disclosure of financial arrangements between your doc and the manufacturer of what they’re prescribing at the time of prescription.

          Better education for consumers on where to go for certain services. Ideally a separate number to call so you’re not guessing if your case is ER worthy, urgent care would suffice, your PCP can take care of it, etc. Hopefully covids impact on ER and telehealth stays permanent.

          Limit the number of customizations on insurance options. I know it limits choice but it’s already confusing enough for consumers. More choices beyond like 3 per company doesn’t add much value. And it contributes to that whole overhead thing that nobody likes.

          If none of that makes a dent, I will gladly be on board with throwing my hands up and saying fuck it lets try a public option without seeing its clear path to success.

          Reply
  • Joanna November 10, 2020, 9:44 pm

    Aren’t you losing access to the pre-negotiated rates?

    I have a HDP plan, and initially tell them that I don’t have insurance, and then later add the insurance to be able to compare cash price vs. pre-negotiated price. Not a single time was the cash price lower than the pre-negotiated rate. Sometimes it was close, but often the difference was 3-10x more. Even a few simple bloodtests that cost me around $30, would cost several hundred dollars more when paid cash.

    Maybe I could haggle with them, or have it go to collections and negotiate then, but that seems even more of a hassle then dealing with health insurance companies. The cash price is often higher to make up for all the other “cash” payers who never pay.

    The comparison in the screenshot is not Apples to Apples, because a deductible counts any payment made in the calendar year, whereas the self-share amount is per illness.

    I imagine the sharing plans will work until they are hitting main stream. It would be interesting to see how many preventable diseases they are treating compared to the general population (diabetes, heart disease, obesity related conditions etc), but I bet it does not represent the general population.

    As much as I hate the insurance companies and the health care experience in general, I’m worried that the sharing plans will not come through when I need them the most, as they are under no obligation to pay.

    Reply
    • Bill from The Fire Guild November 11, 2020, 4:16 pm

      The screenshot fails to mention that Sedera has a max of 3 IUAs per year. So if you have a $1500 IUA, your max payment per calendar year is $4500. You can see this in the FAQs on mrmoneymustache.com/sedera
      So, while it is per Share (or “illness” as you put it), Sedera’s system covers you if you have a year of really bad luck!
      It’s true that they’re under no obligation to pay, but that’s because they need to state that in order to not be regulated by state insurance agencies (and then have to jack up your membership contributions, and then why exist at all? You can just pay Anthem if you want expensive coverage).
      What really needs to be viewed clearly is that Sedera has been doing this for 6 years. With no complaints. And they’ve never overextended themselves. Six years is a darn fine track record in my opinion, and if they were in the business of taking your money and not providing services, our tried-and-true free market system would crush them like a bug.

      Reply
  • Ellen November 10, 2020, 10:16 pm

    As a long time reader, very infrequent commenter, I do agree with others that a sharing program like Sedera seems unnecessarily risky when you look at insurance’s primary purpose, which is to prevent catastrophic medical bills. Also saying it has “no religious bias” is disingenuous when they seem to have religious morals based on what they will and will not cover. It might not be explicit, but the bias is definitely there.

    I did very much appreciate the DPC discussion. The DPC Frontier says that the IRS has ruled DPC plans as a “Health Plan.” More info here: https://www.dpcfrontier.com/health-savings-accounts

    The IRS also says that you are ineligible for an HSA if you have “other health coverage.” https://www.irs.gov/publications/p969#en_US_2019_publink1000204039

    Thus it would seem that enrolling in a DPC arrangement while contributing to an HSA account would violate IRS regulations. I was not able to find any more specific ruling from the IRS on this point. While one might argue that they would never know, if it WAS tax fraud that’s definitely something I hope most people would consider.

    I was considering a DPC plan to supplement my current HDHP insurance but now I’m hesitate that I could be running afoul of the IRS regulations.

    Reply
  • Kate Hampton November 10, 2020, 11:35 pm

    To preface, I’ve been reading this blog for years. It challenges me and makes me think more than most content. I’m a fan.

    I think it should be mentioned that even someone with millions of dollars in the bank would not have been wise to go without health insurance pre-ACA, when you could not get coverage if you had pre-existing conditions. To not acknowledge that in a time when the ACA could very well be taken away from us, and some of your readers vote for people who are against the ACA, is dangerous. With ACA, if you got extremely sick with cancer and had to pay it all out of pocket until open enrollment began again, the max you’d have to wait would be 10 ½ months. If you have millions of dollars, you could *probably* afford 10 ½ months of treatment before your insurance kicks in. The plural (millions) is important here: there’s a cancer drug that costs half a million dollars, and most of the cancer drugs from the last 10 years are in the six figures.

    If, on the other hand, there was no ACA and you could never get insurance because of the pre-existing condition you developed in your two years without insurance, millions of dollars would not be enough money to prevent financial ruin from a serious, multi-year health problem.

    Also, most MMM readers probably do not have millions of dollars, so I wish this article carried more caveats. Some people may follow this advice without doing the many, many hours of research they’d need to do to safely make a risky decision like this. Healthcare costs bankrupt half a million Americans every year (with ACA. That figure was much higher pre-ACA). The majority of bankruptcy claims are tied to healthcare costs. So extreme caution is warranted.

    On another topic, you say, “Over the decades, there has been a complex battle of lawmaking, lobbying, compromise and complexity to try to regulate away some of these problems. Sometimes the new laws help, sometimes they don’t, but the end result will never be optimal simply because there are a lot of people involved, and big crowds of humans make for slow and shitty decision making.” This is way oversimplified, and borderline inaccurate. Over the decades, insurance companies have done a ton of lobbying to cause these problems–to regulate them into existence. Big crowds don’t make bad legislation. Corruption (from lobbying, endless campaigning that is completely dependent on big money and corporate and Super PAC donations, etc) causes bad decisions (though they aren’t usually “bad decisions” at all–they’re politically calculated decisions that are bad for average citizens but advantageous to the people making them).

    Last thought: this is similar to psychiatry’s exodus from the insurance industry. There’s a great shortage of psychiatrists, so most good psychiatrists don’t take any insurance. They don’t have to. People will pay thousands of dollars a year out-of-pocket, year after year, to see the rare good psychiatrist, even when their insurance plan covers psychiatry. A tiny percentage of psychiatrists and counselors take Medicaid. In the rare case that a good practitioner does take insurance (or, even more rarely, Medicaid), they are not actually able to do a good job, because they are squeezing as many people into their schedule as they possibly can. We’re talking 10-minute appointments 3 times a year, even for people they’re prescribing a fistful of medication a day. This has been a disaster for mental health, addiction, and homelessness in this country. Generally speaking, only the wealthiest can access quality mental health services. The people who need it most (people whose mental health is too bad for them to hold down an OK job, etc.) can almost never access the care they need.

    Essentially, wealthy people–many of whom have *comparatively* good mental health, take up all the good seats. There’s a term for this habit of the privileged: “opportunity hoarding.”

    I hate the insurance industry as much as the next person–but jumping ship isn’t the solution and it certainly isn’t an admirable form of protest. Rather, it’s an immense privilege.

    Reply
    • Mr. Money Mustache November 11, 2020, 7:10 am

      Hi Kate, I don’t disagree with all that, but I wanted to point out: Cancer treatments (most notably chemotherapy and then the minor surgery and radiation afterwards) should NOT be millions of dollars. They only are here in the US. These drugs are just a few liters of nasty toxins, and many of them are decades old. They are administered by standard IV.

      It should be a few thousand dollars for the entire treatment, at any reasonable level of pay and profit margin. We are getting ripped off – only in the US.

      Reply
      • Chip November 11, 2020, 7:37 am

        Well Pete, I think you’ll need to call it turnabout. The same system that causes your stocks to gain value and produce dividends is responsible for the cost of chemo being sky high. If they couldn’t sell it at that price, the price would be lower. Nobody is being “ripped off” any more than when they buy a Tesla. Telling a for-profit company how they “should” price their product runs fairly strongly against how most people here live there financial lives.

        As to whether or not we should allow a captitalist structure in our health care? That’s an entirely different debate.

        Reply
        • Mr. Money Mustache November 11, 2020, 7:44 am

          In this case, I believe we are not operating under a market-based system, because the prices are not transparent, the product is often sold under duress, and in fact the customer does not even know what the price is – they just want their cancer fixed and nobody is shopping around for the best deal.

          My theory is that if we had more doctors, less regulation, transparent pricing and general awareness of what each type of treatment really IS, we would end up with lower profit margins on things like drugs. After all, why can I walk across a border to Mexico and get the exact same prescriptions filled for ten times less in so many situations?

          Reply
          • Chip November 11, 2020, 7:51 am

            Fair points, but medicine is not the only supposedly “free” market obfuscated by tons of bullshit intended to confuse.

            Your proposals are good, but you miss one point: Americans in general want it all, and we want it now. Unless we agree to meaningful rationing of what we provide, nothing changes. Note the massive public dialogue and fury when certain states attempted to prioritize what was paid for and, more importantly, what was not.

            Reply
          • MM November 16, 2020, 11:24 am

            Totally agree. The US has a weird mix of laws that stifles competition where only big players can afford regulatory compliance. It’s literally the worst of both worlds. In many countries these medication are not covered through goverment socialized care and there are no big private insurance companies, so patients have to buy their own drugs on the secondary market. They pay a fraction of the price than US for the exact same drug made by exact same company

            Reply
            • Sendug November 23, 2020, 8:51 pm

              On drugs, if developed in the US then yes, you’re paying more for the same product. For better or worse, this is Big Pharma using the relatively wealthy US market to subsidize its R&D for a product sold worldwide.

              If developed overseas, it depends. There’s still some of the same R&D subsidization factor, but also there’s the FDA to contend with. FDA standards are some of if not the highest in the world. For India- and China-based generics, there are documented cases of them having two or even tracks: 1 for US-bound stuff, produced up to FDA standards; 1 for developing countries using materials/purities that won’t pass FDA standards; and in some cases 1 track somewhere in the middle for the rest of the world. Consequently, you run into things in places like Ethiopia where generics are super cheap but not as effective, or even ineffective in extreme cases.

              Given the high percentage of generics and even active ingredients developed in Chindia, and even active ingredients developed in Chindia, it’s worth looking into whoever’s making the drugs that go into your body. Yet another reason to take care of yourself and prevent those ailments that are preventable.

              Reply
      • Mike November 11, 2020, 10:02 am

        I would argue that a clearer path to more generics and competition would be the best bet. I haven’t heard any arguments on a specific allowable profit and how it would be calculated. Part of the reason other countries get away with it is because drug companies know they can make all their profit here. If we fall the last domino, it’s going to decrease the research into new drugs to some extent. Would COVID vaccines have shown the preliminary promise that they have this early if drug companies weren’t as rich with cash as they are now and chasing the huge profit at stake? Maybe or maybe not but it’s a fair discussion point.

        Of course this comes with lack of access to current drugs due to the high costs but a downside is inevitable no matter what system is in place.

        Reply
      • Kate Hampton November 12, 2020, 10:49 pm

        That’s the truth, for sure.

        Reply
    • Fireby35 November 11, 2020, 1:21 pm

      So you are saying the current system costs money but provides no benefit for mental health situations? You are saying mental health professionals don’t want to be a part of the current insurance system?

      If so, why buy the insurance?

      A person definitely won’t have the money to pay for mental health care out of pocket if they give all the money to the insurance company who can’t get you mental health care.

      Can you see the problem?

      Reply
  • André November 11, 2020, 2:37 am

    I’m from Germany and I want to put those numbers into perspective. Not do delve too deep into the details, but by law everyone in Germany must have health insurance. There are two possibilities: Most people are insured “by law” meaning their health insurance premium gets automatically deducted from their paycheck. The more you earn the more you pay for health insurance, but everyone gets the same coverage regardless of their contribution (I can hear the SOCIALISM outcry all the way over the Atlantic). Under certain conditions (government employees, self-employed, high earners) you can opt for private insurance. And that’s what I want to compare: Full coverage for private health insurance in Germany: 450 EUR per month or 5.400 EUR per year. That is 0 deductible, worldwide, 0 co-pay, any doctor or hospital. No other shenanigans those US insurers invented. It’s hard to wrap my head around the fact that for less than your deductible I’m fully insured already. And just to make you jealous: I’m in an integrated degree program (I get paid to study) by the Bavarian government. That means half of my healthcare costs is paid for by the Bavarian government (not because I live there but because I work for them). So, I only have to insure the other half. And because I’m still a student, I get another discount from my insurer. So for a 50% coverage I’m paying no more than 80 EUR monthly.
    The German healthcare system has a lot of flaws but they pale in comparison to the absurdly crazy US system.

    Reply
    • Mr. Money Mustache November 11, 2020, 7:00 am

      This is true Andre – the US does not have public health care. But remember that the taxes and salaries are different as well, which makes it better here for high-income people, who (unfortunately but true) the are the ones who make the rules in this country.

      As is often said, the US is one of the greatest countries in the world… to be a rich person.
      That disclaimer is the bad part. But the good part is we are SO rich that we could afford to be a great place for all people if we chose to.

      Reply
    • Kevin in Providence November 11, 2020, 7:20 am

      To all the people on this forum talking about how much better health care is outside of the US: you are not helping. Most Americans are painfully aware of how brutally expensive (and ineffective) our health care system is (75% of all Americans want single-payer health care). Trumpeting how much better “your” system just makes it more painful.

      Reply
      • Bill from The Fire Guild November 11, 2020, 4:25 pm

        Actually, I appreciate hearing it. If more Americans knew how badly they’re getting screwed, things would change.
        Also, I took matters into my own hands and went on a medical tourism holiday to Europe last year. I got amazing treatment in the fanciest facilities I’ve ever been in, for so little that I still get people asking me “did you say ONE HUNDRED AND TWENTY DOLLARS??, are you sure you don’t mean $1200?”.
        I think medical tourism is another avenue Mustachians should explore.

        Reply
        • Kevin in Providence November 12, 2020, 6:32 am

          Yes, posting a solution and experience like medical tourism (“I did this and this part worked and this part did not”): helpful!

          No, posting about how great someone has it in their country and how terrible the US system is (“Wow you guys are really screwed.”): not helpful!

          Reply
          • Mirabelle1 November 14, 2020, 8:33 am

            Hi, writing from New Zealand. I’ve been reading these comments with interest and was just about to add my “it’s better here” comment, when this pulled me up short. As far as I can see, the only solution you have is to try to convince people to stop voting for republicans. I don’t follow your politics too closely but as far as I can see they mostly block anything moving in the direction of public healthcare or things like limiting the influence of money in your politics (like taxpayer funded advertising for political parties or limits on the amount you can spend- so the need for political donors and what they expect in return). But writing as an outsider so I could be wrong.
            I know you don’t appreciate the comparisons with other countries but the previous commenter did find it helpful- I could see that some people in the US might not be so aware of overseas systems? So I thought I would include a couple of comments on ours. We have family doctors, GP’s. I usually see the same one but sometimes if it’s urgent and she’s busy I’ll see someone else in her practice. I pay about $40 for a 15 minute appointment. It’s free to take kids, up to age 13 I think. If I had a low income or frequent appointments it would be much cheaper. If I needed to see a specialist or have tests done the GP would refer me and would be a point of contact to coordinate results and explain them to me. The specialists would be free, in the public health system. But as can be the case elsewhere, there can be a waiting list and you may have to wait for a while depending partly on how serious things look. So many people also have private health insurance that gets you to see a specialist more quickly. I don’t work in the health field so may not have everything exact but I think that’s generally right. The public health system is covered by taxes which are not excessive. If I got cancer or needed an operation everything would be covered by taxes. Probably you would have to share a room and it wouldn’t be flash hotel like settings unless you went private (on your health insurance), but no one goes bankrupt because of medical bills here.

            Reply
            • Johan November 22, 2020, 2:51 pm

              The problem is not only with Republicans but also the Democratic party who has been pushed “center-right” as the years go along. Both parties accept money from the healthcare industry donors. The DNC has orchestrated ways to make sure their puppet candidate gets into the General Election to keep the status quo. The good thing is we are getting more progressives in Congress who run on a Medicare 4 All platform. If anyone is interested in learning more about a movement for a third party please visit the https://peoplesparty.org/

              Reply
        • guest November 12, 2020, 2:25 pm

          can you and MMM pls pls pls write an article about medical tourism???

          Reply
    • Lisa Culton November 16, 2020, 4:33 pm

      Hi André, I am a Physician and I used to work in Germany (Frankfurt) and I hate to break it to you like this, but because the reimbursement for procedures is so unbelievably low, doctors there have all sorts of “creative” ways to increase the amount that they bill (without going into details). It is one on the reasons why I left Germany and now work in Switzerland. When I last lived in Germany in 2015, my Krankenkassen Prämien were around 650/mo. , which is significantly higher than what I pay for my son and I together here in Switzerland.

      Reply
  • Salamander November 11, 2020, 3:46 am

    As a physician, I can only laugh and shake my head. DPC is great for physicians and makes patients feel coddled, but it offers little in terms of outcomes beyond regular old primary care. I can’t speculate on the care MMM received as I don’t know his underlying health status, but DPC is known for ordering a lot of tests to keep patients happy, not necessarily for medical reasons.

    As to health saving ministries, they are basically unregulated and seem to rarely pay for the big things in my experience, like heart attacks or strokes. They aren’t required to pay for anything, and patients that have them are considered charity cases or self-pay at my institution. The scandals surrounding these ministries are legendary.

    None of this will hurt MMM as he’s well enough off for self pay and spending this extra money won’t hurt him. I personally would go bare rather than paying for an HSM from what I’ve seen, but their marketing is slick and ensares many people. I would caution people to remember that health sharing ministries are exempted from all insurance mandates and are not legally required to pay for any care at all. Ponzi scheme much?

    Reply
    • Chip November 11, 2020, 7:14 am

      As I physician, I wish you wouldn’t laugh and shake your head. It just furthers the haughty, smug image our profession too often presents. And you’re missing the point. The argument is not that the care is better for DPC, but rather that it’s more cost effective, provides a better patient experience, and provides an alternative to paying into a system broken by rent-seeking.

      Whatever your n is with health sharing plans, the data simply don’t support your experience, and the exceedingly rare circumstance when a bill which meets the transparent guidelines isn’t met certainly isn’t “legendary”. Further, stories abound of traditional insurance companies refusing to cover reasonable procedures and studies. That happens daily. Your Ponzi scheme claim is just ridiculous and doesn’t even warrant comment. Fear-monger much?

      Full disclosure: I do not practice DPC nor do I work for a health sharing plan.

      Reply
  • Kevin in Providence November 11, 2020, 7:15 am

    Here is what gives me pause about this otherwise enticing solution (that I want very much to subscribe to): this appears to be fully unregulated.

    Yes, I know that even fully regulated health insurance is a terrible value.

    Yes, I know that the regulations and the oversight of health insurance is an opaque nightmare, unknowable to the typical human (often referred to as the “health consumer” lol).

    But, just knowing that SOMEONE is publicly watching over health insurance companies, their premiums, their claims feels like a backstop on the system. Sedera could go the way of anything else on the internet; with little warning it could disappear along with all the cost-share I put in it. Blue Cross Blue Shield, even though it is a terrible value and I resent every dollar they take from me, is not going away. And they are held to SOME regulatory standard, even if I do not know what it is, exactly.

    I hope Pete or Bill can clear this up for me. I need to convince my son’s mother that this would be a viable alternative. She is an attorney and is always, rightfully, circumspect about these things.

    Reply
    • Chip November 11, 2020, 7:44 am

      “Hey, if you want me to take a dump in a box and mark it guaranteed, I will. I got spare time. But for now, for your customer’s sake, for your daughter’s sake, ya might wanna think about buying a quality product from me.”

      If the specter of health-sharing plans disappearing after decades in the marketplace scares her enough to accept the absolute shit performance of the “traditional options”, well, then that’s what she should choose. If the shit truly hits the fan, you adjust your income to qualify for Medicaid (which can be backdated) and you’re still covered.

      Reply
      • Bill from The Fire Guild November 11, 2020, 4:47 pm

        I’ll take this one, and try to deliver it in a way that’s palatable to non-coprophagics:
        What really needs to be pointed out is that Sedera has been doing this for 6 years.
        With no complaints.
        And they’ve never overextended themselves.
        Six years is a darn fine track record in my opinion, and if they were in the business of taking your money and not providing services, our tried-and-true free market system would crush them like a bug.
        Your wife has every right to be skeptical (and to be fair, she spent a lot of time and money being trained to be). Don’t forget to remind her that when all you have is a hammer, everything looks like a nail.
        Personally, I feel much better that the “someone” looking publicly at Sedera are OTHER PEOPLE JUST LIKE ME (aka fellow Members of the community). I don’t trust insurance companies and if insurance regulators were trustworthy, we wouldn’t have a million lawsuits against insurance companies by patients trying to get their bills paid. We also wouldn’t even HAVE the term “pre existing condition” which was made up by insurance companies precisely to avoid having to cover you!
        In the end, you can tell her it works for us. I’m a fellow Mustachian, in my early 50s, with a wife and a daughter and a good experience with Sedera. I’ve spent a lot of time talking to many people in their various ranks and to a person, they’re all true “believers” in their product. They’re also Members, using their own product.
        One more thing: Remind her that I’m in Maine – I’m not one of these fair-weather wimps like Pete in Colorado, living the high life of beautiful sunsets and people! Haha! From one east-coaster to another: Sedera is worth considering and if you want to come up to Maine I’ll try my best to help you convince her (but bring a shovel as it might snow tomorrow)
        :)

        Reply
        • Kevin in Providence November 12, 2020, 6:38 am

          Bill:
          Thank you! Compared to a decades-old company like BCBS, Sedera’s six-year track record still does not feel like I have faith that they will be around six years from now. But, I suppose if they go away, I could just go back to the over-priced, poor-value BCBS premium, right? And in the process, I will save about $8,400/yr on premiums with the same deductible. I am going to give this more serious thought and see if I can convince her. (PS- She is not my current wife, making it a little trickier!)

          Reply
          • Bill from The Fire Guild November 12, 2020, 1:52 pm

            Definitely trickier, but $8400/year in savings is probably a great point of agreement!

            Reply
  • Adrian November 11, 2020, 7:56 am

    Hi,
    Obviously this is a super complicated subject and alot of people have weighed in with good information and insights. I support MMM on his use of DPC’s but this is something that only middle and upper middle class people can do. Individuals who are on state Medicaid due to disability or poverty could never afford to pay even $100/month to join a DPC. If they are a family of four, would they then have to pay $400/month to join the DPC? Almost 5k per year and it starts to look like a bad deal just to see a primary care doctor unless your whole family of four is sick all the time. I see the big costs coming for ER visits when they give you every test under the sun and all of a sudden a tummy ache turns into ultrasounds and then MRI’s and blood work and $10k bill for a night of fun at the ER. Big costs are related to getting cancer, or the whole family is in a car accident and you are looking at a million dollars easy in medical bills for a catastrophic accident. MMM, you can eat all the kale and lift all the weights you want but when a teenager is texting and driving and they run you and your bike off the road and you have five surgeries and chronic pain so what if you have a DPC and so what if you have Sedera or a cost sharing. If I was part of a cost sharing group, I would drop you like a hot potato when re-enrollment came around!!! Insurance is a huge scam. Medical prices at hospitals and treatments for some illnesses like cancer or hepatitis C start at six figures and go up from there. Chronic conditions…Sedera and the other cost sharing plans exclude you. Listen, I have mostly sent my kids to private schools because mostly I am not a huge fan of the “product” that public schools offer. However, if you have a kid with severe emotional or physical or mental disabilities, they can’t goto most private schools because private schools can be “picky” and so can a cost sharing plan. Obamacare, for all its flaws, tries to make sure that everyone gets covered and subsidizes people. It may also still allow the insurance companies to make far too much money along with the medical establishment and big pharma. Sedera is great for young healthy people who chafe at being fleeced by insurance companies. But we pay to get “fleeced” so when the horrifically expensive illnesses happen, we don’t go bankrupt. Of course alot of middle class people can still have enormous difficulty even paying their deductibles or total out of pocket expenses for the year. But people who self insure can be and are often on the hook for six figure bills. Sedera sounds like a pretty good attempt at a solution for some people some of the time but I am doubtful Sedera would or could (even if it wanted to) be there for you if too many members got too sick. The big insurance companies will always get handouts or dispensations from uncle sam so they don’t go broke paying bills for too many sick people. Or Uncle Sam will pay for some kind of catastrophic pool of really ill people.

    Reply
    • Chip November 11, 2020, 8:29 am

      Wow.

      1. Cloud is $317/mo for a family of 4. The referenced “family on medicaid” doesn’t need to afford it because their Medicaid already covers primary care. I disagree with the assertion that $100/month is not affordable given the disposable income often on display by those asserting they don’t have it.

      2. Fortunately you don’t run Sedera as they don’t “drop people like a hot potato” if they have a catastrophic event. In both scenarios you mention (getting hit on a bike, going to the ED) those services will be covered under most scenarios.

      3. You’ve chosen to send your kids to private school because you don’t like the largest system on offer in this country. Yet you now argue that those choosing to do the same thing in the health sphere by electing what they perceive to be a better option for themselves is a mistake. Sounds fairly hypocritical to me.

      4. Fortunately your doubt about large organizations’ ability to pay bills doesn’t trump actuarial math.

      Reply
      • Mike November 11, 2020, 8:58 am

        What if this family on Medicaid needs a high level of services but has trouble getting appointments because doctors are drawn to DPCs or reject Medicaid’s low reimbursement?

        I agree that this country sucks at identifying needs vs wants and has medical bankruptcies that are really vacation bankruptcies as described in another article. But if your solution is to just get everyone to do better at this, I don’t see it as realistic.

        If a hemophiliac doesn’t have one of their million dollar incidents for 36 months, will Sedera allow them to sign up and stay on the plan forever? There is nothing legally forcing that so if a financial crunch happens, it’s a reasonable expectation that the member would get dropped.

        Agree that the situation with the school is similar. If you don’t want DPCs, it would be consistent to also not want private schools that take resources from public education.

        Are actuaries employed at Sedera or any other health ministries? If not, it’s hard to argue that actuarial math factored into their ability to pay catastrophic claims.

        Reply
        • Chip November 11, 2020, 9:16 am

          Ah, now we’re getting somewhere.

          If DPC became an enticing enough option that a mass opt-out of Medicaid by primary care physicians ensued, you’d hear the resultant cacophony of now in-crisis Caid/Care beneficiaries screaming for a solution. And then we’d have a real chance at change.

          I proposed no solution, but since you asked, it’s basic coverage for all with a private option for those who want a higher level or faster services than we as a public have chosen to provide. My opinion is that access to health care services is not a right as some would claim, but it is something a society I want any part in should choose to provide for its members.

          I don’t work at Sedera nor know anybody who does. But I find it a much larger stretch to imagine they have nobody employed to crunch risk numbers to ensure continued viability than the opposite. Don’t you?

          Reply
          • Mike November 11, 2020, 10:38 am

            What would that change look like? If it’s basic coverage with an option to pay for enhanced services, how does the basic coverage get funded? DPCs are cheap because their members are generally healthier. That advantage is lost if everyone is back in the pool through a single payer or guaranteed issue/pre-existing condition exclusion. Would you rather pay higher taxes or higher insurance premiums to cover these people?

            I’m an actuary so I was curious if I could find any colleagues that work there. Searching both the Society of Actuaries website (which doesn’t require you to list an employer) and Google didn’t turn up anything. Not that I couldn’t have searched more but it’s unlikely there are many. There is a difference in being able to crunch numbers generally and knowing how to price insurance. The risk of screwing up goes down substantially though if you can just boot out any financial problems if shit hits the fan.

            Let me ask your question in a different way. Do you think that these health sharing set ups all did their pricing correctly from the get go with no historical data to estimate their price? If there is a magic new answer, why haven’t insurance companies jumped all over it to lower their own costs? If not, how is it that we haven’t heard about some of the ministries failing or struggling like what would be expected in this disruptor situation with multiple new entrants? If the answer is that they excluded coverage for those that need it most, they aren’t part of any solution that desires that coverage.

            Reply
            • Chip November 11, 2020, 11:21 am

              Well, you’ve exposed my lack of understanding of the nuances of risk assessment.

              DPCs are not cheap only because they cover generally healthy people. They are limited in the services they provide and their overhead is dramatically lower than the average for profit insurance company. A basic universal option could be affordable because of reasonable limits on what is covered (no new knee when you’re 85, having a reasonable approach to end-of-life care, etc), a significant reduction in overhead due to economies of scale, and the removal of the currently existing profit motive. Taxes to cover such a scheme (which I support) would go up less than what the average person gains from not funding a capitalist private market.

              As to your last question, no, they didn’t get it right on the first stab. Hence most having policies to pro-rate coverage when demands exceed funds and a vote the membership makes to increase shares, or not, if that happens repetitively. They’re not magical, and they don’t purport to be the solution for everyone. But they are a good choice for a subset of the population that has the option and chooses not to further support a broken system.

              We should have a beer….

              Reply
              • Mike November 11, 2020, 12:07 pm

                Alternatively, could you not require health insurance companies to offer the essential health benefits so they could lower their services and costs? If a basic universal option declared that knee replacements stopped at 85, that same regulation would help to lower costs for private insurance.

                My argument is that the regulation can be carved out from the need for a full public option, which would need its own separate justification. To me, it boils down to the profit motive vs lack of government efficiency that ends up being the choice in a lot of these conversations.

                Health insurance companies generally aren’t in the business of being the only ones to offer a particular benefit. That’s a loss waiting to happen. Most of the services offered today are required by law (99% of ACA claims) or are so tiny like with your example that they aren’t worth the individual fights and potential bad press. But those tiny examples have surely added up over time.

                To your last point, I agree that it’s a good choice for those that choose it. But not that it doesn’t come at the expense of others for whom it’s not the economical choice. It may be worth the disruption that leads to a better system. But that new path might lead you back closely to where you started once all factors are considered.

                A beer indeed! Nobody I know enjoys this type of conversation. I’m holding out hope for a friend that’s halfway through residency to give me more of the perspective I’m missing on this.

    • Joan November 11, 2020, 10:27 am

      Health insurance companies enroll in “reinsurance” which covers the million dollar cases, so that a company isn’t wiped out by having more than expected number of high cost cases. They also have large reserves so that in years with high flu, or pandemics, they have the ability to pay for the higher costs. Many years they actually pay out more in claims than they receive in premium, but still make money on the investments in their reserves. Sedara is not a regulated insurance company. If you can accept the risk that Sedara will go bankrupt, i.e. you can self-insure, or have no assets and don’t mind going bankrupt yourself, then go for it. States have back-stopped bankrupt health insurance companies, usually requiring that they be sold to a company that is financially solvent.

      Reply
      • Chip November 11, 2020, 11:10 am

        Good point on the reinsurance. Sedera et al are unlikely to go bankrupt because they’re essentially a large co-op. “They” don’t reimburse your bills, everyone who is a member sends a check to someone else who has a claim. It’s a bit of a Locke-ian social contract, and for it to fail, some dramatic societal/financial event would have to happen. The likelihood that such an event will fall right at the time when I need to submit a large claim is a risk I’m comfortable bearing.

        Reply
  • Mike November 11, 2020, 8:18 am

    Your assessment that it’s 90% of “typical needs” might be true depending on how you define typical needs. But it’s nowhere close to 90% of average health care costs.

    You are overpaying for the services you’re getting. Did you compare the $100/month to what your cost would be if you paid piecemeal? Like others have said, why not just go see a doctor without buying into a DPC? It’s not like you can’t find a doctor and develop a relationship with them without an insurance arrangement. On the rare case you need something super quick, you still have ER/urgent care options that can be followed up with a visit to your regular doc. Will there be a new reason to add to the 3 from your original article about insurance that justifies DPC only?

    This DPC model is what’s known as a capitation arrangement where the doctors take all the risk (for that defined set of services). When offered by insurance companies, they are generally rejected. Doctors have resisted risk sharing through insurance companies where there is any downside. This is despite less claims submission and other paperwork that would result once capitation is set up. Why would they be ok with all the risk under a DPC and none when through an insurance company?

    The sick who need more services aren’t going to sign up for this as much because it doesn’t get them out of buying regular health insurance. Doctors running a DPC then benefit because they have a healthier-than-average pool of customers. And it will likely stay that way unless the sick get a way to jump in that pool without paying full price for duplicative services. If they did under your proposed public option and/or subsidies, the DPC would be a hell of a deal for them since they would pay the same as you but use the services a ton. I don’t see how doctors could keep the DPC model going at that point without higher prices, longer wait times, or cutting back on the unlimited nature of the services.

    And the idea that a public option will come in and save the day means your taxes will go up. Is that better than paying a premium to a health insurance company? You can have that opinion and there are legitimate reasons both for and against. How does it compare to your preference on government vs private ownership of other industries?

    The idea of disrupting something that badly needs lower costs is generally worth trying. How do you envision the endgame though? The way I see it, the more DPCs that pop up, the fewer doctors available to care for those on regular insurance plans (aka the ones that need it the most). If it gets to be too bad, the sick will, in desperation, end up paying for duplicate services and crash the DPC model like I outlined above.

    There will always be some kind of bad incentive no matter the setup. Get paid a flat amount each month? There is an incentive to provide minimal level of care and refer as many services as you can to somewhere outside your practice.
    https://www.medicaleconomics.com/view/do-doctors-give-hmo-patients-fair-shake

    Get paid by the service? There is an incentive to perform too many services at the expense of quality.
    https://www.sciencedirect.com/science/article/pii/S0277953617301417

    Thankfully financial incentives are not the main driver for every doctor. But that doesn’t mean they can be ignored entirely.

    If this took off it would be subject to the same bad actors that infect the current setup. Some asshole doctor would undercut the monthly premium and take on too many customers, putting price pressures on the others. Some asshole member would sign up, get all their services, then stop paying the premium. These would change your experience over time and not in a good way.

    My main point in all of this is that you shouldn’t pretend like the insurance companies do nothing except vacuum up a bunch of profits (<5%) and are your main obstacle to making everything ideal. Of course there are problems with them. You can argue that another setup is better and worth trying. But this article and many others make it out like single payer, DPC, public option, or something else will automatically be better solely because private insurance isn’t part of it. There will always be some kind of trade-off.

    Reply
    • Chip November 11, 2020, 11:36 am

      Right. Except for the fact that a publicly-funded option is already in place for less money in many countries who place far higher on the WHO’s list than the USA. Are there barriers and pitfalls to pursuing that change? Sure. But that’s sure a shitty argument for maintaining the status quo.

      I’ve experienced healthcare both as a patient and a provider in places with universal basic coverage, in the US in private practice as a GP, employed as a GP, and now as a GP for the IHS. I know, hands down, which option I prefer as both patient and physician, and it sure as hell is not the current privatized situation we have going on.

      Reply
      • Mike November 11, 2020, 1:04 pm

        Keep going with the rest of the story. Let’s say the private options are abolished and replaced with the public one. Profit is gone. Let’s assume the government can manage the admin costs to the point they disappear. Despite nobody around to investigate fraud and manage utilization, claim costs stay the same. That means you save only 15-20% even with 2 major unrealistic assumptions. Is that the end or what else happens? How do we cut another 30% get to the spending levels of other countries? Who is gonna take the hit and how do we convince them?

        I’m just pushing for a complete picture that doesn’t assume we get a substantial savings just by shifting to another country’s insurance setup. Seems like any downsides are always glossed over.

        Reply
        • Chip November 11, 2020, 2:40 pm

          The government already manages admin costs for a large health care insurer called Medicare. Their overhead is on the order of ~3%. They aggressively police fraud and are, if anything, heavy-handed about managing claims. So much for your two “unrealistic assumptions”.

          The “rest of the story” is more complicated than I care to spend writing out here, as others have done it much better than I’m capable of. Arguing that spending far more as a nation per capita than most developed countries for worse outcomes is some unfixable quirk of the USA is fatalistic bullshit I have no interest in discussing further.

          Reply
  • Carter Coe November 11, 2020, 8:20 am

    Great article as always. Having spent more time in the ER and at specialists than your average 38-year-old, I’m terrified to not have a broad health plan.

    Reply

Leave a Reply

To keep things non-promotional, please use a real name or nickname
(not Blogger @ My Blog Name)

The most useful comments are those written with the goal of learning from or helping out other readers – after reading the whole article and all the earlier comments. Complaints and insults generally won’t make the cut here, but by all means write them on your own blog!

connect

welcome new readers

Take a look around. If you think you are hardcore enough to handle Maximum Mustache, feel free to start at the first article and read your way up to the present using the links at the bottom of each article.

For more casual sampling, have a look at this complete list of all posts since the beginning of time or download the mobile app. Go ahead and click on any titles that intrigue you, and I hope to see you around here more often.

Love, Mr. Money Mustache

latest tweets