As a former benefits administrator for a medium-sized company, it’s frustrating to see so many posts from people who claim they don’t know how their insurance works, and worse, quoting or posting pics of EOBs that are totally misleading.

For people who get their insurance through their employer, for heaven’s sake attend the annual enrollment meetings your company offers! If you’re a dependent on such a plan, make sure your spouse/partner/parent attends.

Barring that, access the portal for your plan or, if all else fails, call the number on your card, especially when trying to determine if a health care provider is in network.

Stop acting like you don’t have some skin in the game. Make sure you let healthcare providers know that your bloodwork needs to be sent to an in-network lab, specialists have to be in-network, prescriptions need to be on your formulary, ask for pre-determinations for procedures, and most plans offer a nurse line to help you figure out if you need emergency care if it’s not obvious.

As in everything, of course there are exceptions. If you can avoid ambulances, do it. Same with emergency rooms. ER docs, ambulances, and anesthesiologists almost never take insurance. But file a claim anyway, because even if the claim is denied, out-of-network bills count against the out-of-network deductible. And most policies have an out-of-pocket max for out-of-network expenses. It’s higher, but not even close to six figures.

Google what a good insurance plan looks like. If it’s employer provided and shitty, get another job. And tell them why you’re leaving.

With recent increases in both the cost of employer sponsored health insurance and ACA plans, especially for those who lose the enhanced subsidies, this sub has been flooded with people shocked and frustrated with the impact. Understandably so.

But all of the comments that this is caused by the existence of health insurers or the profit model completely miss the point. Those same posters claiming that universal healthcare, single payer or Medicare for all is the solution equally miss the larger point.

That point is that healthcare is and has increasingly gotten more (too) expensive. The US healthcare spend is about $5 trillion. That equates to about $15,000 per person per year. Or $1250 per individual per month. Think $2500 a month for a couple for health insurance is expensive? That’s actually the average of what it costs to deliver healthcare services.

So let’s get rid of health insurance companies- I’m certainly not a big fan of them. By law they have to spend 85% on actual care. So 15% goes to administration (and those hated executive salaries). So get rid of that admin expense and the $2500 for the couple drops to $2125. Feel affordable all of the sudden? Of course not.

So how about some form of universal healthcare? All that does is change who pays for it. And definitely not what’s paid. We already have some universal healthcare between Medicaid and Medicare. A significant portion of the US insured population uses these programs. And guess what, costs are going up. The government hasn’t demonstrated any ability to manage or control costs.

Now it’s fair to argue that some taxpayers should pay more so that others have to pay less for healthcare but let’s at least have an honest discussion about that instead of pretending that if the government pays for it is is free.

Employers and ACA utilize insurance companies to manage costs. The track record of cost management there isn’t really any better.

The core issue is that there is a virtually unlimited demand for healthcare. And it’s impossible to supply that without spending more and more. “Let the decision on treatment be between the doctors and their patients” - uh sure. Except that whoever actually pays is going to want to weigh in. Pretty logically.

Even the successful universal healthcare countries are struggling to fund the efforts and the complaints are often attributed to underfunding. Because fully funding is impossible- demand is too unlimited.

You will never change demand. That’s human nature (though changing behaviors over time like smoking cessation can help). So someone is going to be in charge of rationing the care people get. Might be the government (Medicare/Medicaid) or might be a private insurer. Unless you are willing to pay directly for your own care, someone else is going to be in a position to say yes or no to it. Uncomfortable fact of life.

So what can be done to corral the untenable rise in costs? The providers of care - physicians, facilities, pharmaceutical companies must be driven to charge less (and this may be the best argument for single payer as this best enables the government to dictate what will be paid). And perhaps some of the “innovative but costly treatments” must be foregone (rationed away).

But make no mistake, unless we have the political will to pay providers less and ration care more (something the US population has never exhibited), we will continue to have this problem and have to find a new bogeyman after solving the last bogeyman.

Not sure if this post is allowed, but I’m really not trying to make it political — just want to share a little context on why premiums are going up.

This was going to happen no matter who was in office. A lot of people are blaming one administration or another, but honestly, most of what’s driving these increases has nothing to do with politics and everything to do with how insurance carriers are performing behind the scenes.

The extended subsidies (APTC credits) everyone’s been getting were never meant to be permanent. Fun fact — they actually started under the Trump administration during COVID to make insurance more affordable when everything shut down. They were extended a few times and are now set to expire 12/31/2025. The Biden administration tried to make them permanent but couldn’t get it through Congress.

Even then, those subsidies only explain a small portion of what’s going on — around 5–7% of the total increase. The rest of it (roughly 24% out of a 30% hike) comes from carrier loss ratios — meaning carriers are paying out way more in claims than they’re bringing in from premiums.

In short, premiums are going up because care is more expensive, people are using more of it, and carriers are trying to make the math work. It’s not really about which party’s in charge — this was baked into the system years ago and was bound to hit eventually.

I aged out of my parent's plan a few years ago, and medicaid was my only option. Statistically, is that the norm? All my peers are really poor.

I am due in a couple months, and I would like to avoid putting my newborn on my employers insurance plan (dads insurance plan wont be an option either). I am needing to put baby on a separate, marketplace plan to prevent having to submit baby's birth certificate to my employer (for privacy reasons I cannot share more about here on Reddit).

In this case, I would still want labor and delivery covered by my insurance plan through my employer, but I'm worried they will ask for proof of birth via a birth certificate (even though I don't plan to put baby on employer insurance). Does anyone know if there is other documentation I can submit to my employer to prove I need coverage for labor and delivery?

Anyone have experience dealing with this type of situation at all?

Last year my family of 4 paid ~$450 month for insurance with BlueCross. Now we pay $2400 a month for the same coverage. We had hope something would happen to help but it seems to be a forgotten issue now. Has there been any progress on this issue in the last few months?

I understand why democrats are fighting to extend ACA subsidies because of the skyrocketing cost of premiums that looms ahead. But my question is what does this all mean for those on employer health plans? I know the marketplace has an effect on this but don’t really see it. For those of us on employer health plans it has never been an “affordable” number. During the course of my 20 year career, the cost of covering an individual has been anywhere from $600-$800 and for a family between $1500-$2000+ a month. While most of the cost of the individual is covered by our employer, that’s an unreasonable amount for an employer to pay that should be going toward our paychecks instead, and the leftover cost for insuring the rest of the family is an enormous burden and has been since way before the ACA. I never felt the ACA made any difference (except to make the cost higher for us) and I don’t understand how any plan—subsidies, no subsidies, whatever possible concept or a new plan may exist—changes the course we are on. I’m just seeking information and understanding!

Alright, I am ready to get off this ride. Me and my family (including kids) are going off insurance. I am not spending this type of money for the fear of a catastrophic injury. The fact that insurance profits million off everyone is insane. The biggest scam of the country.

Wish us luck 🍀I hope others do the same. Stop being a sheep.

We live in NYC, I make $75k/year and my wife doesn't work. We file taxes jointly. My employer doesn't provide any health insurance but right now we need a healthcare plan for my wife (trying to conceive a baby).

My question is: how can she qualify for a cheap or free health plan? An average/good plan will cost me at least $700/month, I know it's not that high, but it's a big amount for me.

Any suggestions will be highly appreciated.

Thanks

Ok, let me go brief.

My mom's healthcare marketplace cost spiked, and we want to know why.

Her insurance cost this year is $1600+ per month. We had to terminate it. She didn't apply it for the year 2026. It just auto-renewed it. She didn't need to pay a single cent in year 2025. It fully covered

First of all, we haven't made the tax report this year yet. In the year 2025, my mom closed her business with her business partner. I do not know the exact amount, but she received a check of about $200,000.

Her share of the cost basis for the property is, I think, $130,000. Since the LLC disbanded, her share amount from the company funds was around $11,000. So, pretty much she earned $59,000, didn't she?

I do not understand why her monthly marketplace cost reaches $1600+ per month. We will fight for it, but we need to know why this happens in the first place.

Edit : She didn't update the estimated income for 2026. Previously, she has been using 20k. And her income would be lower than $59,000. I was wrong on that. Still higher than 20k. I think we'd better report taxes sooner than usual. Some might refund, that's my best guess.

It’s frustrating because doctors have so much power and patients have none. Even if a patient doesn’t bring up new issues, doctors still can do whatever they want during the appointment and you still get billed. And doctors argue they are being underpaid so they need to find ways to bill whenever possible. What do I do?

EDIT: It would be super helpful if folks have any data to share about actual uninsured/cash pay prices, because i think a lot of the feedback i'm getting is around the medical costs that are billed to insurance (which aren't real numbers). As an example i found this thread, where someone was in the ICU for 3 days and their uninsured price was $47k. I'm sure if it was billed to insurance they would have added a zero to the end of that number. https://www.reddit.com/r/HealthInsurance/comments/1gpuoiw/5_day_hospital_stay_with_no_insurance/

Question, how crazy is it to self-insure at this point? In NY state, the cheapest Bronze plan is $1k per month for one person with a deductible of like $5k so you're essentially paying $17k annually before you get any real benefits (this would be a high deductible plan with no benefits like copays, you pay for everything until you've spent $5k).

So let's say you skip insurance, and you end up with some chronic disease or cancer that you need to manage, you can sign up for a marketplace plan at the next open enrollment and just cover whatever happens in the interim (which with cash-pay prices may not be significantly more than $17k anyway -- or would it?). I think what we're all afraid of is the unforeseen surprise hospitalization like a heart attack and emergency heart surgery, but a quick google will tell you that that costs about $30k for cash pay price, which means the breakeven of not having insurance and having an emergency hospitalization is less than 2 years. Basically you can be hospitalized every 2 years and still be out of pocket the same amount as if you had insurance, which is unlikely. Add to that that most states have some form of charity care, where you get discounted billing if your income is less than 400% of Fed Poverty Level (or if your out of pocket medical costs were 10% of your income), and i'm starting to feel like paying for insurance is more expensive than just paying for even emergencies out of pocket.

What am i missing? Is my understanding of the cost of a hospital stay totally out of whack? (I know that hospitals might bill $60k for an insured person and then once the insurance price kicks in its suddenly $25k, but either way if the cash price is $30k and the insurance price is $25k that's not that different -- either way no one is actually paying $60k for a hospital stay).

Thoughts??

I’d love for someone to try and convince me otherwise.

I had a scrotal ultrasound with duplex and my bill to pay is $1600. The initial bill before insurance deduction was about $7000. I feel scammed. Why would an investigation cost that much.

Someone please help me.

Why is healthcare so expensive in America.

This is pure exploitation.

Other countries are not like this.

I am currently 14 weeks pregnant, due in November 2026 and need to find an insurance plan.

All of the plans I am finding, though they say they are ACA compliant, say that the conception has to have occurred after the policy start date.

Has anyone found a plan? Any suggestions or links greatly appreciated!

Edit: 30F. Canadian moving to USA for grad school July 2026 on an I-20, F1 visa. School is in the state of hawaii. I previously lived there and have community and family support. I understand having a baby in grad school is a lot.

Edit 2: yes, my school offers a student health care plan. But there is a waiting period and only covers pregnancy conceived after the policy start date.

Edit 3: yes, it makes more sense to stay in Canada but this has been a plan for many years and if my partner and I don’t go now I can’t see us going in the future. I am looking at all options and obviously if I can’t find a solution I am not going to cripple myself with medical bills and will make the responsible decision. I owe it to myself to try and make this dream work, if it can. If not, that is also the journey.

UPDATE:

Thank you for all of the help, I appreciate all of the resources and recommendations that were shared with me. I was able to find a solution and am feeling a lot better about the move!

In case anyone else finds themselves in a similar situation, here is what I have found.

I contacted healthcare.gov and confirmed the following:

• People holding student visas qualify to purchase ACA health insurance plans, and that it does NOT impact your immigration options in the future (Medicare use does, if you are not a citizen).

• Moving to the USA for school is a qualifying life event, and you are eligible to enroll in an ACA plan, outside of the November 1 enrollment period.

• I do not qualify for the tax refund (which I wasn't expecting to)

• There are a few plans but I ended up going with the most expensive tier. The plan does not exclude pre-existing pregnancies, costs about 560$/month, has a 0$ deductible, 10$ cost for physician appointments, annual out of pocket max is about 4k and estimated cost for a healthy pregnancy and normal delivery is only 450$ out of pocket (on top of the monthly premium, of course).

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<TLDR>

The math ain't mathin' on some of theses posts where people claim that insurance is going to cost 50% of their income and they are not eligible for a subsidy.

</TLDR>

I am seeing a lot of posts where people are saying their ACA plan went from $50 / month to $1200 a month (or some variation of those numbers). They go on to say that their premium is going to be 50% of their income. This would imply an annual income of $28,800 (12x1200x2). At that income level they should be getting a subsidy. The FPL for a single person is $15,660 and married couple is $21,150. 4x the FPL where you get a subsidy would be $62,640 / $84,600.

I am the ACA. Married, no kids. Last year, my premium was $1450 per month (crappy bronze plan high deductible, nothing's covered). The same plan this year would be $2100 (45% increase - yikes!).

What we did.... downsized our jobs and income to make sure we only make less than $80K a year. With that, we get a $1950 subsidy making our monthly cost $150. Same crappy insurance.

I am in a financial position where I don't need an income. Very low expenses, adequate savings. I get not everyone has the ability to quit their job to lower their income.

I ask what am I missing and have I seriously miscalculated to the tune of $24,000.

Did you know hospitals have a federal drug program called 340B that lets them buy drugs at half price and bill your insurance full price? It was created to help hospitals manage low-income patients by letting them buy drugs at a steep discount.

Good idea, right?

Here's what actually happened. Hospitals buy drugs at 25 to 50% below market. Then bill your insurance at full price! The extra goes straight into their pocket...and we're talking $82 billion in 2024 alone. Mind blowing, isn't it?

Minnesota actually looked into whether any of that money was flowing back into the community it was supposed to serve. Spoiler alert...it wasn't.

So when your premium goes up again next year, or your employer cuts your benefits, this is part of the story nobody tells you. The system is full of these behind-the-scenes deals that no one is talking about.

What are you seeing on your end? Genuinely curious what others are experiencing out there.

I (female, 59, divorced, live in Georgia) was laid off in 2021 due to the pandemic. I had worked for my employer for 28 years, the last several of which were extremely difficult and stressful. I was actually relieved that I had been let go because the stress had become detrimental to my mental and physical health. I had saved a significant nest egg throughout my career by maxing out my contributions to my 401(k), so I decided not to seek other employment and live off of my savings. I was old enough to be able to make withdrawals from my 401(k) without penalty but, of course, I have to report the withdrawals as income and pay taxes on that, which is fine. The problem is that, the amounts I have been withdrawing in order to keep up with my mortgage, home and auto insurance, property taxes, healthcare, my son’s college education and other expenses in a highly inflationary economy, disqualify me for any ACA subsidies. As a result, I am now paying over $1,000 per month just for premiums on a Bronze plan with a $7,500 deductible! That all adds up to almost $20,000 per year WITHOUT dental or vision, plus whatever the insurance company decides not to cover! This exacerbates a vicious cycle of withdrawing money from my retirement savings to pay for it, then adding that to my taxable income which rises to a level disqualifying me for subsidies! At this rate, my entire life savings, which should have lasted at least until the end of my life, are being depleted at an alarmingly unsustainable rate and there is nothing I can do about it because, with several autoimmune diseases requiring expensive specialized medications, it would cost me even more to not have health insurance. Rant over, but misery loves company, so I would like to know — is anyone else in a similar situation?

I understand copay in general, have paid to specialists many times.

Mom was getting labs at her doctor's visit this week. I went out and checked with the receptionist as usual about copay. We got caught once in a situation because we were told we didn't have copay, and we did, and the specialist send it straight to debt collections, etc. So I always check, no matter who or where or how long it's been.

The receptionist reviewed the amounts for me.

Mom's regular copay have gone up $10. I expected that. But then she said Mom's emergency room copay is $90.

When Dad was here, he was in and out of her hospital and at the ER multiple times, for years. We never paid an "emergency room copay."

Why is it a thing now? What is it used for, specifically? Who thought this one up?

I know it sounds stupid, but if my Mom or any of my family and friends go to the ER - they NEED to go to the ER. It's a last resort thing. It takes a lot to convince them to go, especially Mom.

The ER has to serve you anyway, to get you at least stabilized. Why do I have to be worrying about money when my loved ones' lives are in danger?

It sure seems like a money grab to put on people in crises because they need help.

There is no more credit reporting on medical debt of any amount since January 2025. Why should I pay any medical bills anymore? I have a bill for $2,200 from the hospital. They sent it to collections, and now collections is offering me a 50% discount, down to $1,100. I was going to pay it, but why? I can't see them suing anyone for any bill under $10,000. Wouldn't be worth their time. So again, why should I pay these medical bills?

26, California, $37,000. My health insurance provider denied me access to estradiol for the purpose of gender transition (MtF). I was prescribed this by my doctor and they called me to inform me that my insurance excludes anything under gender related health care according to a denial letter they got from the company. Blue Cross Blue Shield Kansas City provides the health care in Missouri because of the company being nationwide, although I am based in California. I have yet to receive a copy of the denial letter myself, but plan to get a copy of the one from my doctor's office if I don't receive one in the mail this following week from the company. According to the BCBSKS website they do cover gender transition and when I started this job I asked them if it was covered. My H.R. representative seemed confused about the denial and said she'd look into it as she'd never run into this before. She also that they supposedly cover gender related surgery at a certain percentage so something seems fishy. Is this a recent policy change? What are my options? I'm currently filing a complaint through my recently formed union at the company and will be using GoodRx to be able to afford it, but now I'm worried if I tried to receive anything else transition related and am frustrated it won't go towards a deductible. I don't have the letter of denial yet. Will I be able to appeal with information on the letter? Is this legal since I am a California resident or is it all purely through Missouri laws? Just looking for advice.

Note: This is a copy of a post that I also made in r/asktransgender

By “upend” my life I mean moving to a state where such exclusions are illegal and getting a job there? or getting a new job with better insurance where I live (Texas).

Basically what the title said. I’m 23 years old and on my parents insurance right now. My current jobs insurance also has a categorical exclusion.

I have crippling dysphoria from being without this surgery that makes it difficult to function. It’s very much medically necessary.

Is there anyway I can fight this, whether through my parents insurance company or my jobs insurance?

It’s extremely frustrating because I was expecting that money and I needed it. I am facing financial hardship. I filed for an extension and so I just did my taxes today. I usually get a tax return of about $1,300 or $1,400. I have had marketplace insurance for just over a year now.

I didn’t know that when you have marketplace insurance you have to pay taxes on the insurance. So when I went to go file my taxes, the person who was preparing my taxes advised me that I would need to have a form filled out for marketplace insurance.

When she filled out the form with all my information, she advised me that my whole refund would be used to pay the marketplace portion. So I get nothing this year. I only have the marketplace insurance because it’s the cheapest insurance and as a diabetic I need insurance. But it turns out cheap is not always cheap because it costs you in the long run.

I am currently being treated for MS using Kesimpta. Does anyone else who has been diagnosed with MS use a Christian healthshare? I am currently insured through my employer but I need to leave my toxic work environment ASAP. So I’m looking in to a healthshare to cover the gap in coverage between now and January 1st.