Q: Are subsidies available to offset the high costs of health insurance premiums?

A: For 2025, income-based premium subsidies are available through the federal Affordable Care Act (ACA). However, the U.S. government is currently shutdown due to an impasse over food subsidies and health insurance subsidies. As it stands, health insurance subsidies will cease at the end of 2025. 🧵

Q: Researching and potentially changing insurances, selecting new physicians — these seem time consuming. Are they?

A: Yes, millions of people in the U.S. will spend quite a bit of time reviewing available plans and researching which plans are accepted by their current physicians. Annually, on average, I spend 20-30 hours on this research in order to identify plans that:

• meet my medical requirements
• are accepted by my physicians
• are affordable according to my budget

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Q: Are there people who can help refine the options available?

A: Yes, there are “brokers” or “enrollment assisters”. Some health insurance companies have employees to help facilitate direct-to-consumer sales. Some state exchanges/marketplaces offer phone- and web-based individuals to support the selection and enrollment processes. There are third parties who primarily help businesses negotiate with providers to acquire products at the right price. Some of these services will have a cost. 🧵

Ironically, I’m breaking out in a stress-related rash because of the angst health insurance open enrollment brings me — and today is only the first day of the period. 😑

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Q: But citizens have a right to good health, don’t they?

A: It’s important to remember that while there are countries which enshrine good health and access to health care as rights guaranteed by their constitutions, the U.S. Constitution does not endorse these as rights. In the U.S., access to health care and good health are luxuries available to those who can afford them. 🧵

Q: Does plan choice truly have so great an impact?

A: Indeed, it can. Plan selection influences those physicians to which one has access, prices of medications, accessibility to medications, the costs of ambulance and emergency visits, and coverage area. Some plans, while less expensive, may not include certain medications in their formularies, and may only provide coverage limited to the state in which one lives. One could rack up quite the bill if taken ill outside the coverage area. 🧵

Day 3 of #healthinsurance #openenrollment szn. Today I’ve spent two hours researching/contacting the 15 listed #health insurance entities my current medical practice accepts.

• four do not offer coverage in this state
• two only offer supplemental coverage for specific medical conditions
• five are “middlemen”, offering some form of health plan design/administration/networking
• two are owned by a single, larger parent organization
• three offer individual plans only through marketplaces

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Premium quotes from #healthinsurance providers I connected with are eyewateringly high.

• one company quoted products I didn’t request; range from USD$850 to USD$878
• one provider lists quotes ranging USD$511 to USD$870
• another’s range USD$796 to USD$911
• yet another provider’s span USD$702 to USD$1011

These prices are for one (1) person per month. Each plan requires a deductible* of thousands of dollars which must be met before coverage begins. 🧵

*premiums don’t count toward deductibles

To be clear: the #healthinsurance quotes requested were already limited by certain factors. Had my inquiry been broadly vague — such as, “coverage for one individual” — quotes for anywhere from 20 to 50 “products” would have been received.

For each of the groups of quotes received, based on the limitations, there were anywhere from two to eleven “products” listed, each with different premiums. 🧵

Day 4 of #healthinsurance #openenrollment.

I emailed the company that provided quotes for products which do not fulfill my requirements. An email response was received that required the creation of an account to access their secure messaging platform. The contents of the reply housed therein?

“Please contact our Sales Department at 800-XXX-YYYY for additional quote requests. Thanks so much.”

Evidently a consumer-oriented, low-friction, product selection environment is not their focus. 😑

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Day 5 of #healthinsurance #openenrollment.

As a member of SAG-AFTRA, the #union that represents approx. 160,000 media professionals, I was interested to see this news item indicating it has filed a formal complaint against an insurer which applied a 40.5% increase to its premium. While this action doesn’t impact me, I’m glad the union is engaged in protecting #news anchors and #reporters • https://www.sagaftra.org/sag-aftra-condemns-405-health-premium-hike-harvard-pilgrim-7news-employees

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I contacted my current #healthinsurance provider to verify that the notice received, which indicates a 36% increase in plan premium cost for CY2026, is correct. According to their sales department, it is, even though:

• the plan has not changed
• the coverage has not changed
• the model has not changed
• services have not changed

Apparently, everyone included in this plan received such an increase — an increase which was set through a filing with the state. 🧵

#openenrollment

I contacted the state to learn if there might be a state law, statute, code, or regulatory body which establishes limits or ceilings for #healthinsurance premium increases year-over-year — limits which cannot be exceeded.

Apparently there is no such regulation. Health insurance companies are free to decide for themselves what premium increases should be each year.

It was suggested I contact the insurance company to find out if I could negotiate a less expensive premium for the same plan. 🧵

Day 6 of #healthinsurance #openenrollment.

Today I communicated with my physician to learn what would happen if I

• select a less-expensive insurance plan the practice does not accept
• go without #health insurance altogether

In both cases, I *should* be able to continue to visit the practice but would pay for all appointments, services, and laboratory tests as a “direct pay patient”. To gather more data and evaluate costs and pricing, the business office phone number was provided. 🧵

Day 7 of #healthinsurance #openenrollment.

I contacted the billing department within in the business office at the medical practice I’ve attended for 15 years to understand what a complete year’s worth of medical services could cost if paid directly by a patient. Fascinating details were learned:

• there is no available list of prices for services; no such list exists

• cost estimates for services can be provided if the “billing code” for each service is known

But wait, there’s more… 🧵

(Day 7, continued)

• most medical services have “price tiers”, ranked 1 to 5 (or higher?), which are determined by the level of required activities prior to, during, and after any medical visit; these data determine the exact “billing code”

• cost estimates, therefore, are always ranges and not precise prices

• the billing department cannot provide an estimate without a “billing code”

How does a patient find out what billing codes are?
Start by looking at past bills received.

Still more… 🧵

(Day 7, continued)

• price ranges do not vary patient to patient, but individuals can only acquire estimates for themselves; they cannot request estimates for other patients unless they are a parent or guardian

• “no one has ever” requested an estimate for an entire year of baseline services, according to the person with whom I spoke

Learnings continue… 🧵

(Day 7 and *fin*)

• estimates cannot be provided by telephone or email; one can only use the HIPAA*-authorized communication portal to contact the billing department by internal message

• all “billing codes” must be provided directly by the patient and/or must exist already within a patient record

——
*HIPAA is an acronym representing Health Insurance Affordability and Accountability Act, a 1996 Act of the U.S. Congress • https://en.wikipedia.org/wiki/Health_Insurance_Portability_and_Accountability_Act

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I’m attempting to imagine life in a capitalist society if every item for purchase could only be acquired with a “billing code” that is maintained by the vendor.

Buying grapes.
Purchasing shoes.
Attending the theatre.
Patronizing a sports event.

There would be no price transparency and it would be very easy to mark up or mark down a product’s or service’s price — perhaps even without consumers knowing. 🤔

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While not preparing for the #audition I should be preparing and, instead, brain rot scrolling, this interesting video on patient self pay discounts was served to me. https://www.instagram.com/reel/DQpvv4hDn5b/

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Day 9 of #healthinsurance #openenrollment.

Today I researched financial penalties for being without #health insurance.

One model under consideration for 2026 is going without health insurance, paying all financial penalties, and paying for all care as a “self pay” patient. It is possible a person in very good health who pays the penalties and pays for all care directly could still pay less than a person who pays:

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(Day 9, continued)

• insurance premiums
• health care copayments
• laboratory fees
• in-network deductible
• out-of-network deductible

(in the U.S., the deductible must be met before health insurance covers payments for medical services.)

For example, the costs listed above are approximately USD$25,000 for me in this calendar year — a threshold I will not meet this year, nor have I ever met it.

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I chatted with someone today about my research of the financial penalties and they inquired confusedly, “Why would someone pay a penalty for not having health insurance?”

“Because,” I explained, “the law requires everyone have health insurance coverage, and this is achieved only by paying third party health insurance companies money in order to acquire said coverage. If one violates the law, one pays a financial penalty.”

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In my research I learned:

• The Affordable Care Act’s federal tax penalty for not having “minimum essential coverage” was eliminated at the end of 2018 according to the terms of the “Tax Cuts and Jobs Act of 2017”.

• My state is one that still implements penalties for noncompliance. These costs range from USD$300 to USD$2250 per year per individual and are based on income.

While I’ve not yet got enough data to evaluate options, progress is being made.

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Though all data are not yet obtained for this penalty + self-pay model, it’s important to remember that were there to be a significant health crisis while operating this model, the patient would be quickly bankrupted by medical costs.

Bankruptcy due to medical debt is not uncommon in the U.S. There are portions of the U.S. unhoused population who became unhoused due to medical debt.

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Day 10 of #healthinsurance #openenrollment.

It’s interesting to wake to news of a potential change in the Congressional impasse » https://apnews.com/article/government-shutdown-congress-trump-641e7e2324f261da72395b604d9540e8

This “test vote…is the first in a series of required procedural maneuvers”. It’s a “move toward passing compromise legislation to fund the government and hold a later vote on extending Affordable Care Act tax credits that expire Jan. 1.”

Notably, the “agreement does not guarantee the #health care subsidies will be extended”, but…

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…does include “a reversal of the mass firings of federal workers by the administration since the shutdown began on Oct. 1 and would ensure that federal workers receive back pay”. It also would “protect against future reductions in force [layoffs/redundancies] through January and guarantee federal workers would be paid once the shutdown is over.”

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Without #healthinsurance subsidies, many people in the U.S. will see monthly premium payments double, triple, or quadruple. Without such subsidies, it’s possible people could:

• opt to go without #health insurance altogether
• choose to avoid medical care
• stop receiving treatment for disease
• die

It would be difficult for many in the U.S. to understand life in a country where #health and #healthcare access are benefits of a centralized process wherein the government cares for all people. 🧵

Day 12 of #healthinsurance #openenrollment.

Sent a message to the state insurance access bureau to inquire about the status of limits, if any, to #health insurance premium increases year over year. I reread this notification letter several times each day wondering if, somehow, I have misread or misunderstood what it says. (I have not. I can read and do basic maths.)

I’m hoping there will be a considerate response to my inquiry. 🤞🏻

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Day 14 of #healthinsurance #openenrollment.

I received an engaged reply to my message and there was an informative exchange. I was also able to chat with someone by phone and learn more about how premiums are facilitated for insurers and consumers statewide.

This person has offered to make an inquiry on my behalf to understand why the premium increase is higher than anticipated. 🤞🏻

While the outcome isn’t known, it’s encouraging to have someone willing to help to understand.

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Day 24 of #healthinsurance #openenrollment.

I’ve received a response to my inquiry about cost as a self-pay or direct-pay patient at my medical provders’ facilities. The reply includes ranges of prices for typical services and encounters which I, as the patient, might expect to pay as an uninsured person.

Because costs for #medical services in the U.S. are ranked according to a complex, tiered system of type and duration, these initial results are approximate yet informative.

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As a reminder, the U.S. #health access system is a network of third party, mostly commercial “providers” to which one pays a monthly premium for access to health care providers.

In addition to this expense, one also pays facilities fees, laboratory fees, copayments, coinsurances, and must meet a minimum declared deductible (an additional out-of-pocket expenditure) before greater health insurance coverage becomes available.

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Sometimes there are two deductibles: one for payments made for medical services provided “in network”; and a second for payments made to medical servicers not in the provider’s designated network, called “out of network”.

*n.b.*, The U.S. #health access system does not typically include #dental coverages for adults. In the U.S., the mouth is not usually considered a part of comprehensive body health. As a result, dental records are housed separately from all other types of medical records.

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In the 2025 calendar year, I will pay USD$6850 for premiums.

The plan-associated in-network deductible is USD$4,000.

The plan-associated out-of-network deductible is USD$8,000.

According to the data provided in this recent response, the cost range for one average year’s worth of services for me, were I to be uninsured, in the same good health, and pay directly all expenses myself, is:

USD$1950 to USD$3000

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To date, because I strive to maintain a high #health standard for myself, I have never achieved a deductible, though there have been years during which I’ve paid for additional #medical services and those costs have counted toward the deductible.

Deductibles “reset” every calendar year in the U.S. because health access plans begin anew every calendar year, and contributions toward deductibles made one calendar year do not carry over to the next calendar year.

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While I do understand the concept of pooled public #risk for #public good (and, in this thread, the good of #publichealth), especially under the expectation that not all members participating in such a shared scheme would likely encounter a catastrophic health event simultaneously (exceptions: epidemics and pandemics 🦠), I look at these financial numbers and wonder: could I optimize my monies more advantageously as an uninsured person?

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It must be noted, again, in this thread that to be uninsured in the U.S. and to experience a catastrophic #health event is how many people end up bankrupt, houseless, and/or destitute.

Certainly I’m not advocating being uninsured in the U.S., but, the option to be uninsured is one model to consider during #health #insurance #openenrollment “season”.

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Day 29 of #healthinsurance #openenrollment.

Today I researched “catastrophic health insurance”, a term I learned recently from conversations in a closed group of tens of thousands of #women business owners. Many, similarly impacted by exorbitant premium increases, are considering other potential avenues for #health access plans in the U.S.

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In these exchanges, some women are evaluating going without a traditional health access plan and making use of “catastrophic health insurance” instead.

According to readings, a “catastrophic health plan” (CHP) has a very low premium and a *very* high deductible, must cover certain preventive care required by the Affordable Care Act with no cost-sharing, and has no coinsurance requirement, as the deductible must be equal to the maximum allowable out-of-pocket (OOP) limit.

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CHPs aren’t available in all states in the U.S.

Through the 2025 calendar year, only people age 30 and younger, or those who qualify for a hardship exemption, could purchase a CHP.

For the 2026 calendar year, changes have been made to allow more people to qualify for an automatic hardship exemption and, therefore, become eligible to purchase a CHP.

The Summary of Benefts and Coverage (SOB or SBC) documents for these plans seem to always include the term “Catastrophic” in their names.

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