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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)

  • Brenda E November 11, 2020, 10:19 am

    Thanks for this. I am looking at health care options for myself and family over the next month and you can bet I will be looking closely at the DPC option. I have been so angry at insurance companies in 2020! They have been raking in the same (super high) amount in 2020 as always, our premiums have not decreased – even though payouts to Doctors have decreased dramatically due to people putting off or cancelling visits & procedures due to Covid risks. Health professionals have been laid of or furloughed in my area due to this overall lower medical usage. Meanwhile insurance companies have been making RECORD profits during/off of the pandemic.

    Reply
  • Jimmy November 11, 2020, 10:42 am

    A point that could help this discussion is better defining the term “Insurance” in the context of healthcare for us FIRE-minded folks. For many of us, the small portion of possible healthcare needs that actually needs to be insured are the unlikely very large expenses in excess of $50K-$200K+ . Traditionally insurance is mostly counter-productive for all health needs that cost less than that (worse doctor experience and financially disadvantageous).

    Ideally, a “true insurance” product would be out there that specifically protects against only very large expenses that could wipe us out financially. This insurance would be very rarely used and be even less expensive than a Health Share. I know there are U.S. regulations against traditional health insurance plans from having deductibles/maximums higher than $8k or so, but there may be other ways to design something like this with a much higher deductible and much lower price.

    DPCs are definitely not “insurance” in this context, rather more of a doctor subscription with better aligned incentives as MMM alludes to. I think there is a ton of merit to this model to improve health and have a better experience with accessing everyday healthcare, but it shouldn’t be confused with insurance protecting against a large financial loss due to a unexpected health event. If it was possible to find, pairing a DPC subscription with a “true insurance” product with $50-$200k+ deductible would be a more ideal solution for many.

    [This post is updated to fix some typos]

    Reply
  • StuartKuz November 11, 2020, 11:48 am

    Does anyone have any experience with Sedera insurance and a Covid related ICU bill?

    Reply
    • Peony2019 November 16, 2020, 8:51 pm

      Sedera is not insurance in the traditional sense. If one were to need Covid testing or treatment they should present as uninsured and any organization/provider that takes Provider Relief Funds distributed under the CARES Act would be obligated to bill the Federal Uninsured program on the patient’s behalf. In theory the PRF could run out but to date that has not been an issue. One can go to the HHS website to obtain a list of providers who have accepted the funds and advise the billing agent of the obligation to bill the Uninsured Program.

      Reply
  • Suzzz November 11, 2020, 12:57 pm

    I had Liberty Healthshare for years until I actually had an accident. They misplaced my bill over and over despite my constant calls and following up until my bill wound up in collections and I wound up paying it myself. These sharing companies have no obligation to ever follow through on their promises. I checked out Sedera’s sharing guidelines and they say that they are “disinclined” to share bills that are exorbitantly charged. That’s literally every single hospital bill in America. Looks like another bad deal to me. If I ever have another accident, I’ll put a compress of horse manure like they did in the Dark Ages and hope for the best. Or, better yet, travel to a third world country to receive first class medical care. What I’m not going to do is pay $700/ month in premiums.

    Reply
    • Bill from The Fire Guild November 11, 2020, 6:37 pm

      Sedera has an entire team to help negotiate better rates, and they even lower your IUA if you get a second opinion. It’s called 2nd MD and you can read a bit about it here https://sedera.com/wp-content/uploads/2020/06/2nd.MD_.Flyer_.pdf
      This is why they’re “disinclined”; they want you to do your part (and in fact you agree to do so when you sign up) to lower costs, by shopping around.
      In fact, not all hospital bills are “exorbitantly large” – I needed an echocardiogram recently and called around to six providers in my area. I ended up paying 1/10th (yes – $250 vs. $2500) by driving 15 min vs. going to the place closer to my house! With Sedera, I feel like I’m paying so I want to save money and find the best deal.
      That’s the nature of the health sharing community.
      Not sure what they would have charged for the manure compress though…

      Reply
  • Lisa C November 11, 2020, 2:34 pm

    This is a hard conversation that needs to happen all over the US. There are certainly positives to what you’re describing and I think your naysayers have already outlined the issues with it.

    I certainly feel like every time I walk into a doctor or dentist office, I’m being charged for the 2 people who don’t or can’t pay because I have good insurance; they can drive up the nickle and dime charges to the max since I’m already out a copay ($26 for two IBProfen tablets? Really?). Insurance or similar pay models have always been predicated on the healthy paying more into the system than they take out. Meanwhile, as the population at large becomes more unhealthy and trapped at home in front of the television during quarantine, I think we’re going to see more healthcare cost spikes as a result. Soon the unhealthy will vastly outnumber the healthy, if we’re not there already, and all of these systemic inefficiencies will either come to a head or become nationalized. I have mixed feelings about universal/national healthcare, having been in the military, and I like how competition seems to drive innovation, better wait times, better treatment options, and much more hospitable environments. Walk into a VA hospital sometime – it looks like a mental ward from an old school horror movie, complete with zero windows and flickering fluorescent lights. These sorts of public options aren’t where you want to go to get better. Meanwhile, the fact that young people with families of 4 are getting gouged $36K a year for not even halfway-decent healthcare coverage for their families in order to pay for the old people receiving end of life care via the ACA is absolutely appalling. This is a prime example of wealth transference from the young/poor to the old/wealthy and it disgusts me that the so-called progressives pushed it. I get that there are plenty of poor people who are also old, but statistically there are far fewer of them and they are typically covered by medicare. Conversely, when I was 35, I was diagnosed with breast cancer and easily received million dollar treatment to cure it. All it cost me was my $300 deductible. If I were to get cancer today, it would cost me 10% until I hit the out of pocket max. I was grateful for my work-provided health insurance and wish we could go back to the way it was before all these copays and coinsurance fees were added in. I didn’t care that I had limited options for hospital/doctor choices or that acupuncturists/naturopaths weren’t on the list, free is a great incentive for less choice. Even between children, my first child cost $50 to deliver while the 2nd child cost $1400 to deliver (my part alone) as coinsurance was added in the interim 5 years. That’s with GREAT health insurance that costs me $15 per paycheck (Now $0.89 cents with a limited network). If having babies is no longer affordable, then your DPC/Health Share system or even regular insurance had better cover birth control or sterilization. When that happens, all the pyramid schemes like Social Security and the ACA will come crashing down as fewer young people are added to the system every year. /end rant

    Reply
  • Brenda E November 11, 2020, 2:59 pm

    I am wondering if you have any insights in how to add on dental insurance? Sedara or DPC don’t usually cover that, right? Thanks again for the helpful post!

    Reply
  • Salamander November 11, 2020, 3:25 pm

    Newsflash:

    Sedera does not cover pregnancy termination, even to save the life of the mother, even if the fetus is ultimately nonviable.

    Sounds like not a plan for people who have any chance, ever of becoming pregnant. So, like, half the population.

    Reply
    • Bill from The Fire Guild November 11, 2020, 6:41 pm

      What exactly is your beef with Sedera, Salamander? This article is a suggestion, not an edict and in fact MMM even calls it an experiment on his part (though we’ve been very happy with Sedera + DPC for almost 2 years). Sedera is very upfront with their guidelines and in fact they REQUIRE you to read and agree to them before you enroll. If you don’t like their guidelines or your lifestyle doesn’t match with those of the rest of the community, don’t join.
      It’s really simple: It’s not for everyone. Clearly you’re not into it; we get it – why keep grinding the axe?

      Reply
      • Salamander November 11, 2020, 7:10 pm

        My beef is that they don’t cover a lifesaving, emergent procedure for half the population. It’s a procedure no one expects, that is often emergent, lifesaving, and emotionally devastating Most patients would probably read those guidelines and think, hey, I will never need an abortion, or I can afford it etc, as Mr Money Mustache states in his post. He is a bright guy, but like most people does not appear to understand the full scope of what is seemingly excluded by this plan, which is not just a first trimester termination, but much more, including lifesaving procedures.

        The issue is that they seemingly won’t pay for even life-saving terminations, and many non-medical people are unaware that they could have a pregnancy complication that requires termination of even the most desired pregnancy; it’s just not something the average (or above average) person is aware of. So even though this is spelled out (sort of), without explicitly stating “we won’t pay for a lifesaving termination that costs tens of thousand of dollars” most laypeople are unaware of what the actual exclusion is, just like Mr. Money Mustache appears to be.

        I’ve cared for women who have had terminations that far along. They are destroyed. They are devastated. They never expected it or even thought this was a possibility. And then to be told that Sedera won’t pay because the fetus’s heart was still beating? Or it was elective? That’s just cruel, and I think if that is Sedera’s policy, they need to be clearer so people can avoid further unexpected heartbreak and expense. As in “even if this is lifesaving, and nonnegotiable, and you would die without it, we won’t pay.” Or if they will pay, they need to clarify.

        So that’s my axe. I hope it makes more sense now.

        Reply
        • Bill from The Fire Guild November 12, 2020, 2:07 pm

          Hi Salamander-
          Thanks for your explanation, your passion about this subject and the care you give your patients.

          To be very very clear: Sedera DOES consider “maternity complications” as Shareable events. This is covered in their guidelines.

          The issue I think is the wording – they don’t cover voluntary abortions (even if the result of rape or incest), but they do cover maternal lifesaving medical needs.

          As a man, I’m not in a position of authority in this regard. However, it appears that Sedera (and medical professionals like you) know the difference between an abortion and a medically necessary procedure. The former is not covered (I’ll stop using terms like elective, etc) and the latter is.

          I hope it makes more sense now.

          Reply
  • Dave November 11, 2020, 4:56 pm

    Great article for putting a new idea out there and letting your reader dissect it for the benefit of all.

    Reply
  • Kelly November 11, 2020, 6:17 pm

    What, no love for New York?? Oh well, I’ll stick with Liberty then. I’ve actually been very happy with them, maybe I’m in the minority but for me they have been GREAT!

    Reply
  • Salamander November 11, 2020, 8:28 pm

    Wow. I finally read the fine print in detail. Technically, according to their guidelines, they would not cover treatment for not only a life-saving, expensive, emergent pregnancy termination, but they also wouldn’t cover an ectopic (tubal) pregnancy. They state, and I quote, “needs resulting in the abortion of a living, unborn baby will not be shared.” While it’s not a baby until it’s born, they don’t put any gestational limits on this, so by their definition a woman with an 8 week ectopic pregnancy, which is both ultimately nonviable and life-threatening to the pregnant person, would not be an eligible cost sharing expense because it might be “living” as it is still viable at that moment? Do they truly mean this or have they not thought it through? Either way…far outside normal practice. Any insurer would have to cover this life-threatening problem.

    Caveat emptor if you are a potentially pregnant person.

    Reply
    • Bill from The Fire Guild November 12, 2020, 2:14 pm

      This is incorrect. “Maternal complications” and “complications of pregnancy” ARE shareable. You may have not have read all the way through their guidelines and appendices, but it’s in black and white:
      “Bills for all pregnancy and birth-related complications of the mother will be shared as a part of the
      maternity Need.” (page 38)
      and
      “If the member’s expected delivery date is determined (by a qualified medical provider) to be on or
      after the 1st year membership anniversary date any needs due to complication of pregnancy will be
      fully shareable after the maternity IUA has been met.” (page 40)
      “Complications from maternity: Shareable” (page 47)

      Reply
  • Mr_ADD November 12, 2020, 3:09 am

    Hello,

    I understand it is very personal, but I would love to read more about your ADD, how you organized your life around it and self-diagnosed it.

    I live in a European country where this is waaay under-diagnosed, and haven’t found a medical professional informed enough to talk seriously about it, even though from my English readings I think I may be suffering from it.

    Hope you’re open to write about that.

    Reply
    • Mr. Money Mustache November 12, 2020, 10:30 am

      Hey Mr. A,

      I’m not sure how much I’ll get to write about it here on MMM since it’s a bit too far from the core mission of this blog. But I would definitely recommend finding books about it (there are hundreds out there). In the most concise form, I would say you do these things:
      – read and learn about ADD
      – develop systems to make your life more resilient to it (tidy house, labeled shelves, extra sets of keys, etc)
      – keep life simple (avoid stress, don’t plan too much in advance, design interpersonal conflicts out of your life)
      – try Ritalin/Concerta or other medications and see if it affects your ability to focus. But don’t overuse!

      Coincidentally, I did just make a light-hearted post on exactly this subject on Instagram: https://www.instagram.com/p/CHf0-jNjlsb/

      Reply
      • Lisa Lou November 21, 2020, 4:50 pm

        I am a teacher and struggle with ADHD myself. Some of the most helpful resources I have found (for myself and students /parents that struggle) are:
        1. Research Executive Functioning. Smart But Scattered is a series of books that is fantastic that breaks down many of the areas of life that is difficult for someone that struggles to focus and get organized . . . and get moving in general.
        2. Read the first page of Driven to Distraction by Dr. Hallowell. He knows his audience well enough to lay out the main points of the book on the first page- in case they don’t read the rest of the book.
        3. ADDitude Magazine is a great resource for overall life hacks and tips.
        4. Focusing on the diet- nutritious foods to include into my diet, not just staying away from sugar, helps me have a more focused brain.
        5. Psychologists have typically had the most up to date information on this area, much more than a typical pediatrician will- at least in my experience.

        Reply
  • Andria November 12, 2020, 3:35 am

    The link to the 10 heartbreaks article doesn’t quite get you there. It is here https://www.cloudmedical.io/2020/08/17/8-17-20-10-heartbreaks/. And yes. It’s a wow. I also recommend Being Mortal by Atul Gawande. He has excellent insights on living and seeking treatment as you age.

    Reply
    • Lynneo November 14, 2020, 8:28 pm

      And “Complications” and ” Better ” and “The Checklist Manifesto” . As you can tell, I think he’s a great writer! And now on Biden’s team I hear.

      Reply
  • Freedom Dreamer November 12, 2020, 9:58 am

    I think there is a middle ground too. If you’re not comfortable with Sedera or a similar model, you could do this combo (what I plan when we ER)

    1. Do a DPC, and like MMM proactively manage your health/lifestyle
    2. Buy a catastrophic plan on the exchange (if they don’t ruin this option), but really only use it for one of the big disasters (cancer, stroke, heart attack) and don’t mess with it day to day for the 3x a year you go to the doctor for “stay well” visits.

    I think, in many cases, you could end up with better care (DPC), good “oh crud” coverage through your traditional insurance, and low hassles (don’t bother to engage your insurance for anything unless it’s truly an emergency)

    Reply
  • Greg November 12, 2020, 9:59 am

    Two years in your middle age is hardly a long enough time horizon to justify any “self-insurance” conclusions, considering that the vast majority of most people’s lifetime medical costs are incurred at the end of life, not in the middle. Your high-deductible coverage, which you view as a “reimbursement,” is in fact exactly what insurance is supposed to be–coverage for unlikely but expensive events to spread costs around the risk pool. It’s one of the absurdities of our system that people choose to “insure” themselves for foreseeable low-cost medical events like yearly doctor visits.

    I would be very, very, very, very careful in entrusting my medical insurance to any health share plan at this time. These were created to fit into legal loopholes and lo, many people who had assumed their health shares would cover their care have learned otherwise the hard way. The insurance industry, corrupt as it is, is hemmed in by legal frameworks that health shares have been specifically designed to avoid by appealing to “religious exemptions” and claiming, in caveats that should serve as neon flashing warning lights, that these plans “are not insurance.”

    And arguably the worst aspect of this, as a bystander, is that “creative solutions” to the problem only cement people’s intransigence to the systemic change required to actually provide good care to everyone at reasonable prices, which is simply this: universal basic care funded by tax dollars. This is a solution that works in almost every other first world country in the world. It increases taxes but erases health insurance premiums. It does not eliminate the markets for supplemental insurance and concierge care. It puts the incentive on the government to reduce secondary and tertiary care costs by promoting primary care. It reduces hospital write-offs to ER care, which is the only way that uninsured people can get treatment, as ERs are legally required to treat those seeking care without regard to their ability to pay. Thus instead of treating gum infections and strep throat in the ER, they can be more affordably treated in primary care settings.

    It is clearly the best solution, and it’s so frustrating how resistant most people are to admitting it.

    Reply
    • Mr. Money Mustache November 12, 2020, 10:24 am

      Sounds good to me Greg – I would definitely vote for some version of single payer or public option health insurance system. And I think it would be even better if we keep direct primary care in the mix too, and lots of options for rich people to voluntarily pay more for even fancier care, if it can help drive some innovation and competition.

      But, since this blog is not about politics but rather what can *I* do as an individual *RIGHT NOW* without having to wait and beg the authorities to change the system for me, I choose to highlight things like this.

      Reply
      • frank November 12, 2020, 2:22 pm

        “But, since this blog is not about politics but rather what can *I* do as an individual *RIGHT NOW* without having to wait and beg the authorities to change the system for me, I choose to highlight things like this.”

        But they dont have to be mutually exclusive. As an individual I can donate to certain politicians, invest ethically so oil companies have less money to donate to political parties, I can reward politicians that highlight cycling and talk about the environment by voting for them or writing a letter of support. And not just in national, but at local level as well.

        Reply
  • ken November 12, 2020, 3:01 pm

    Been with cloud for some years and the Sedera setup. Been there when I needed it and the personalized service is great.

    Reply
  • Robert Boden November 12, 2020, 3:25 pm

    This is great, for people with a higher income level. However, with a low income (~38,000, family of 4) , I still pay less for very good (no co-pays) insurance through the healthcare marketplace (and medicaid for my 2 kids (Illinois)). There is a cutoff somewhere, depending on what percentage of poverty level you are at(and your family size, and where you live), where this option definitely makes more sense though. It might be worth mentioning that (I know you’ve written about healthcare.gov in the past, you were one of my sources of information when I signed up).

    Reply
  • Chris November 12, 2020, 8:18 pm

    This post opened my eyes quite a bit more about Direct Primary Care.

    In our neck of the woods, we’ve got two DPC participants within biking distance of home. One just opened in September! It’s a small outfit with a fairly young doc. Great to see a changing landscape.

    Monthly subscriptions for folks up to 39 years old run $55 or $65 for our two options. That’s pretty great!

    We may have to join in on the experimentation with it.

    So far as insurance vs shares, well, we’ll stick with our insurance that runs more than our mortgage+interest payment—at least for now. Perhaps some additional legislation will remove concerns about health shares, but then again, that might wind up kicking the price up to match insurance.

    Thanks for the informative take.

    Reply
  • Vicky November 13, 2020, 9:41 am

    What made you think you had ADD? Has medication helped?

    Reply
  • Allwine November 13, 2020, 12:39 pm

    I looked into DPC a few years ago, to consider IN ADDITION to our employer group plan. I think this is the way to go if you have affordable coverage via employment (or aca subsidies). You only use the insurance for medication, hospitals, etc. I have not been able to convince my wife, as she works in medicine and seems to feel comfortable navigating the whole ridiculous system. We also get our premiums covered by employment, so our out of pocket is nil. The older I get the more I want DPC for my own health, as well as family health. The lesson here is to pursue your own solutions, and forget about waiting around for the government to help. You really don’t want gov help. That way lies madness and control.

    Reply
  • Chris November 13, 2020, 1:16 pm

    Best post in years MMM. Really interesting stuff. I will say that this model relies heavily on a doctor’s individual integrity. She/he has a conflict of interest when it comes to providing costly tests and follow up visits. In a perfect world there would be some sort of advocate that ensures your doctor is being straight with you. Unfortunately, our society has a way of making these “middle-men” roles screw everything up.

    Ultimately, the best health care plan is what you do and what you eat. Thanks for the reminder. Now I need to go jog off a buffalo chicken Sammy.

    Reply
    • Bill from The Fire Guild November 14, 2020, 11:51 am

      Well, one of the best parts of a DPC practice is that they make little to no profit on tests and ZERO profit on follow up visits since it’s an all-you-can-eat model. At my DPC, I can get an appointment, usually within 24 hours (and same-day if needed!) any time I like, as much as I like. Also, blood draws are $4 and various tests are so cheap it seems unreal (only in America).
      So, I’m not sure what you mean. AFAIK, the entire DPC model is in agreement about no per-visit charge, and finding the best pricing for their patients for drugs, tests, diagnostics, etc.
      I agree 100% with you and MMM; the best health care plan is preventive in nature (with a DPC for the minor issues and Sedera for the unexpected major ones).

      Reply
      • You are your best doctor November 26, 2020, 3:06 pm

        Tests (blood, chest x-rays etc.) are contrary to popular belief, cheap in America. In fact, some of the rather fanciful tests (like IGF-1 for healthy individuals) are cheaper in SoCal than they are in the so called ‘medical destinations’ like India.
        Also, many of these tests do not require a doctor’s order; you only need a specialist for his opinion on what the results of the test mean. And that is ~$200

        Reply
  • Peony2019 November 14, 2020, 6:22 pm

    I work in healthcare finance and would like to share some first hand experience related to DPCs, Cost Sharing ‘ministries’/programs, and pricing transparency that the MMM community may find helpful.

    1) Pricing Transparency: Effective 1/1/21 hospitals are required to post payer negotiated rates by service in machine readable format on their websites. This includes services offered by both hospital and hospital employed physicians. In theory, the consumer will be able to see how much each payer pays for a service across organizations so that they can make informed decisions as to where to obtain their services. In addition, organizations must provide at no cost, payer specific estimates for 300 highly shopped services in a user friendly format. The industry expects the 300 services to be expanded over time. While this is a great step in the right direction for the consumer, it is far from perfect. Contracts between hospitals and payers are often based on differing reimbursement methods so it will still be hard to compare apples to apples. I do expect payers and providers to move toward more aligned rates over the next few years so as not to be seen as outliers by consumers, other payers, or other providers.

    2) Cost Sharing Ministries: I personally wouldn’t risk using a cost sharing product, however, if one choses to do so I will say that my particular system accepts payment from them and I have not heard any horror stories. The ‘ministry’ usually will try to negotiate a better rate than billed charges on the member’s behalf but the rates are, in my experience, 30-40 percentage points higher than what an actual insurance company with a provider contract will receive (and by extension an insured patient will enjoy). Tip in this space: Because a Cost Sharing Ministry is not insurance, at least in my system we consider the patient to be uninsured. Uninsured patients have access to financial assistance and significant ‘prompt pay discounts’. One with a cost sharing ministry should look to optimize all available ‘self pay’ discounts then take that to the company and see if they are able to negotiate better rates or if the assistance + prompt pay is preferable. Depending on where one lives, financial assistance can be State mandated and many organizations offer more generous discounts than required by law. It is not unusual, at least in my State, to see financial assistance of some kind extended to those making 400-500% of the federal poverty level.

    3) DPCs: I don’t see these as a cost saving measure, rather a way to enhance one’s experience with their provider and the horribly broken health care system. You will get more attention which may (or may not) translate to better care…especially if you are already healthy. I am familiar with a few providers offering this model and I personally would stay with larger groups who can hook you up immediately with specialists AND often have more resources to ensure they are staying up to date on the latest decision based medicine. I would love to see studies based on clinical outcomes as to whether these providers actually offer better care. I suspect it is a mixed bag. A previous commenter was correct in that Primary Care is really the least expensive of all care out there and with many insurance plans, preventative care is already covered at 100% .

    4) Bonus Insights: Telemedicine and the Covid Pandemic – Telemedicine didn’t used to be reimbursed by Medicare (and thus most other payers) pre-Covid. Once the pandemic hit and emergency declarations were made, Medicare and every other payer I am aware of , agreed to reimburse telemedicine visits (video) at the same rate as office based visits. Many providers and patients who resisted this way of practicing medicine had no choice but to try it and guess what? Many LOVE IT. There is no guarantee that CMS will continue to pay on par with face to face visits after the emergency declaration ends but there is hope that some of these changes will be made permanent based on the 2021 proposed and/or finalized regulations. As a result, I have seen some payers come out with ‘telehealth’ products – they will sell a plan at a lower rate to the consumer if the enrollee agrees to telehealth as a 1st point of entry. If needed, the telehealth provider will send the patient to an in-person provider who is ‘in-network’ but otherwise, visits will occur remotely. This has interesting implications for the patients, the payers, and the health systems. What does service area even mean under this model? What will patients prefer? There are a lot of remote companies in this space already (98.6, Doctors on Demand, Talk Space, etc.). A lot more to come for sure. For those in cost sharing ministries and or without insurance, some of these remote opportunities will likely be less expensive for you to access. For instance many will charge a flat fee based on visit type. With my high deductible plan, I have used these options a time or two and for a $40 flat fee have gotten great advice along with a prescription for medication needed to resolve a condition called into my local pharmacy.

    I appreciate the knowledge, insights, and friendly debates on this site. I hope the community finds this comment helpful and informative as it relates to such a complicated topic. We all have different circumstances and each must make our own best INFORMED decision accordingly.

    Reply
  • Kamil Chmielewski November 15, 2020, 12:07 pm

    I live in Illinois and can’t receive Sedera. Are there any recommendations on other HealthShare Plans for the state of Illinois?

    Reply
  • Daniel November 16, 2020, 1:14 pm

    MMM, you should next check out the Surgery Center of Oklahoma (surgerycenterok.com). I discovered them a few months ago from their appearance on the EconTalk Podcast (Nov 18 2019). An incredible discussion about everything wrong with American (an other) insurance/medical industry.

    Reply
    • Bill from The Fire Guild November 22, 2020, 1:47 pm

      They are a great resource, one that Sedera regularly refers people to either for actual procedures (if local or willing to travel) and for transparent price research.

      Reply
  • AB November 17, 2020, 2:56 pm

    Has anyone talked about short term insurance? It is good for 364 days and then you get another one. So I was 1 1/5 years from Medicare. ACA would be over $2,000 per month. Other private insurance would be more. I did not have an income to get a subsidy. I had just inherited some land, which was sold. Cancer or a Covid hospital bill would wipe it out. So I got a short term policy for $347/month with a $12,500 deductible. Pre-existing conditions not paid. Fortunately, I don’t have any big ones. Includes drug plan to $5K max. But I get the health insurance rate instead of the inflated self-pay rate when I go thru the medical system and for drugs. I figure I can get any routine needs under $1K or $2K. So i am basically paying $347/month for peace of mind. It is better than $2,000/month. A month or 2 before Medicare starts, I will drop it and take my chances.

    Reply
  • ysette9 November 17, 2020, 9:22 pm

    I’d just like to point out that this paragraph from the post pretty much exactly describes Kaiser Permanente, for those lucky enough to live in states that offer it. The difference is that Kaiser offers complete medical services from pre-birth to grave and everything in between in a whole system that is designed to be your advocate and ensure that the easy thing to do is also what is healthiest for you.

    Having spent 6 months now outside of Kaiser (due to move) and in the wild west of the real American health system, I can finally understand what is so fundamentally broken about the model. I am counting down the days until 1 Jan 2021 when we go back to Kaiser and my mental load and physical health get a reprieve.

    “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. “

    Reply
  • Emma November 18, 2020, 2:20 pm

    I find this discussion very interesting. I am a frequent NHS users, female (2 complicated pregnancies), with chronic & pretty serious autoimmune disease- diagnosed in my early 20’s. In the UK the King’s Fund have done some interesting analysis of the costs of our Free at the point of delivery system https://www.kingsfund.org.uk/audio-video/key-facts-figures-nhs. I think we Brits often think that our system is superior to all others (clearly not true). However there are some important core principles that are preferable in my opinion to a free-market system.

    Universality and free at point of delivery. Treatment and testing is based on clinical need only (defined by evidence based national guidelines not an individual doctors preference), this is essential to ensure a perception of fairness. National bargaining power which means that medication prices are lowered. Similarly Doctors earnings are agreed nationally £85-130k/annum plus whatever they want to earn in private practice on the side.

    But our hospitals are shitty- ugly places and patients are just that not customers. You get what you need not what you want. Sometimes this is horrific to deal with as the patient, as peace of mind tests aren’t generally available. For example bleeding in early pregnancy, is left to take its course (clinically this is totally logical), but when your 9 weeks pregnant being told you can’t have an ultrasound to see if your baby’s got a heart beat or not, is tough to deal with.

    You don’t get to pick when you can access the service- everyone understands this and employers and schools have to let you attend medical appointments by law.

    the system works at nearly completely full capacity at all times meaning no slack for unexpected events (COVID-19),

    waiting lists for non-emergency treatment can be excessive and this does cause hardship and harm,

    not everything that is technically possible is available (particularly expensive treatments that only provide marginal benefit over cheap options and ‘electives’ like IVF)

    Doctors shortages especially in poorer areas in general practice, psychiatry and geriatrics, mean that there is still social inequality in healthcare access.

    I pay 42% income tax.

    Our NHS is only 70 years old, before then our system was DPC/self-insurance/union insurance and charity based. It was triggered by WW2 devastation and a landslide victory for the Labour Party. At the time many thought it was a nuts idea and would not work so radical changes are also possible.

    Despite all the issues outlined I am very grateful for our system, as one of the unlucky sick people; in the US I’d be screwed by healthcare costs.

    Reply
  • Asdf November 20, 2020, 2:24 am

    Let me put in a plug here for joining the National Guard or Army Reserve, which – on top of serving your country and getting paid – lets you buy Tricare at incredibly low rates, on the order of $200-300/month for full family coverage.

    Reply
    • Bill from The Fire Guild November 22, 2020, 1:50 pm

      That’s definitely an option, but if you’re a younger family with a high IUA, Sedera will provide service for $363/month and you don’t have to trade any weekends for it! Personally, I’ve opted to pay the “extra” in exchange for my time belonging 100% to me.
      :)

      Reply
  • Chris November 22, 2020, 1:51 pm

    Cool post! I am still trying to figure out how I am going to manage our health care if we every leave our jobs in the future (we have a few kids which makes it kind of daunting). Maybe DPC is part of the solution. To me, health care is still the missing pillar of FI and hopefully we can continue to grow strategies around it.

    Thanks
    Chris

    Reply
    • Bill from The Fire Guild November 22, 2020, 5:09 pm

      Hi Chris-
      If you head over to mrmoneymustache.com/sedera, you can see a price list for Sedera. It may not be the best option for you right now if your employer provides insurance as part of your package, but the prices will amaze you (they did the first time I saw them).
      As an early retiree with a family, I was always struggling with this issue (before I found Sedera). Personally, I can’t wait until the relationship between employment and health is severed for all (as in other countries). Healthcare no longer has to be the “missing pillar” of FI. Maybe one day there will be a Mustachian Health Share?!

      Reply
      • Chris November 26, 2020, 5:02 pm

        Thank Bill

        I will definitely check it out. I have heard about Sedera but have not dug into it yet. Looks like that link has a lot of good details.

        Chris

        Reply
  • Dave November 24, 2020, 12:12 am

    After reading this article I am glad I live in Canada. And I love winter maybe that’s why I’m so healthy because I get outside no matter what the weather.

    Reply
  • SBeck November 25, 2020, 8:45 am

    Yeah! DPC is the way to go!

    I was a healthcare improvement coach at a large hospital system in Michigan when I saw the difficulties that the system faces because of insurance.

    Long story short, I got interested in the idea of DPC and have been so glad to have switched over to a local DPC practice in Detroit. If anyone is in the metro Detroit area or Southeast Michigan, please don’t hesitate to hit up Dr. Paul Thomas at Plum Health!

    Reply
  • Fuzz November 26, 2020, 2:42 pm

    Like MMM, I am dissatisfied with my health insurance. And I applaud Sedera for trying something new.

    Here are some issues that either (a) aren’t addressed, but you could probably figure out; or (b) aren’t addressed, and the best you can do is a pay a CPA/lawyer to make an educated guess as to what a court would do.

    1) If Sedera pays $150K in meds, is that taxable income to the recipient? Does the recipient then itemize and deduct the medical expense to offset the income? Does Sedera advise the recipient on their tax implications?

    1a) What about the gift exception with the IRS? I think a max gift of $15K/year is allowed. Do they get around this by saying that you’re getting a very small gift from each of the members? Is that tracked? If you’re audited, would you have a right to the subscribers’ identities that gave you a gift?

    2) Recipient goes into bankruptcy from being unable to work, while Sedera continues to pay his medical providers. My understanding of BK law is that a trustee decides who gets paid. Does a bankruptcy trustee intervene, claw back the money, and give it to more worthy creditors? Will Sedera indemnify recipient while that’s is sorted out?

    3) Recipient is injured in a car wreck and incurs $30K in meds. Recipient recovers 100K in a settlement from the at fault party. Recipient’s insurance company has a contractual right of subrogation, which means they get reimbursed for their 30K from that 100K. Sedera does not have a contract. It does not get reimbursed. How is its business model obviously better than the insurance co in that instance? Is subrogation rights a significant income stream to an insurance company?

    3a) Recipient who was injured in a car wreck wants to pay back Sedera from settlement. Without a contract, what should his attorney advise him? What about the attorney’s own malpractice carrier?

    3b) There is something called the collateral source rule, which works differently in each state. Generally, if recipient is injured and his medical expenses are covered by his own insurance, then his insurance is not admissible at a trial. So the at fault party can’t argue that the recipient didn’t actually incur a loss by introducing evidence that the recipient’s insurance already paid for the loss. Anyway, how does this interact with the collateral source rule? In some states, the judgment against the tortfeasor for medical expenses is reduced by what the insurance company actually paid for those same medical expenses. Does that happen here?

    4) What is the long term equilibrium for Sedera’s ability to negotiate medical bills? What stops a provider from refusing to negotiate, sending the patient to collections, who then turns around and gives Sedera a negative review for not “always paying everything.” The provider may certainly take that negotiating position to increase their reimbursement percentage. Why don’t some providers so this some of the time? Does it matter?

    5) What would MMM say if Dave Ramsey said “trust this investment, it has a 7 year track record of always meeting expectations” Something about past performance not equaling future results I imagine.

    Of my questions above, the one that interests me most is the BK issue. I genuinely don’t know. But the idea of someone running around selectively paying your creditors while you’re in bankruptcy seems like it violates some rule.

    Don’t get me wrong. I dislike insurance companies and the system of paying for health care, but I’d like to see this tested in the crucible of the common law and tax system before I bet my family’s future on it.

    Also, 6, where are Sedera’s reserves held and how does that compare to where an insurance company holds reserves? I imagine that’s publicly available, but it’s a pretty basic omission from the post. Does Sedera take more risk than an insurance co? You would want to take more risk than an insurance co, but how much more risk? While Sedera is a presumably nonprofit of some sort, is there a for profit entity that is managing the reserves? How are there investment managers compensated?

    Reply
  • TuMo951 November 27, 2020, 3:45 pm

    For those in the US considering this idea and concerned with the cost of your medications, try downloading the GoodRx app and see what your medications would cost. They act as a type of insurance so you pick the local pharmacy where you want the script filled, and when you pay for it, just tell them you’re part of GoodRx to get the pricing shown in the app.

    I used them for a few years while I was part of a healthcare sharing plan and it works as promised.

    Reply
    • Bill from The Fire Guild November 27, 2020, 6:09 pm

      As a member of Sedera, you get an even better benefit – it’s like GoodRx with free shipping on top! Check it out at https://www.therxmarketplace.com/

      Reply

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