Why your health insurance is so expensive

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Speaker 5 I'm wondering if having healthcare coverage is worth it from a financial perspective.

Speaker 6 It feels pretty bad to be in healthcare in America. It makes me want to move.

Speaker 4 I just stick with the millennial healthcare plan, which is don't get hurt, don't get sick.

Speaker 7 You guys, it's time. We got to choose our health insurance again.

Speaker 7 Gonna be honest, I've been off my parents' insurance for almost a decade now, and I still call my mom to try to figure out which plan is best for me.

Speaker 6 Because somehow it keeps getting more complicated.

Speaker 9 Hey, JQ, this is Natalie. When I signed up for my benefits, I was given a big book, and I was told, read the book and pick your benefits.
And I kept asking, what do these policies mean?

Speaker 9 Can someone help me understand all this information in this book? And I was told, no. The benefit specialist kept telling me, I cannot pick your benefits for you.

Speaker 9 So if the HR specialist isn't helpful, who else are we supposed to ask on what these policies mean for us?

Speaker 6 Well, Natalie, we got you. I'm John Glenn Hill and today on Explain It to Me from Box, we're going to make sense of open enrollment together.

Speaker 7 What all those acronyms mean, why we're paying so much more this year, and whether there's an alternative that actually works. First up, I talked to Lisa Jarvis.

Speaker 7 She writes about healthcare for Bloomberg and she says that like with any major decision, the key to choosing insurance is to start by looking within.

Speaker 12 I would say the first thing to think about is how you use your healthcare. Are you going to the doctor regularly?

Speaker 12 Do you have a standing appointment with a healthcare provider that you want to make sure you can keep seeing that same provider? You know, do you have prescriptions that you take regularly?

Speaker 12 And then you want to look at what your options are. There's a few different kinds of plans that might be offered to you.

Speaker 12 There's an HMO, there's a PPO, and then there's some other things that are kind of in between. So an HMO, you're going to have to pick a primary care provider.

Speaker 12 That person is sort of determining how many other specialists you can see. You have to ask for permission.
At PPO, you have a lot more flexibility.

Speaker 12 That one you can go see a specialist usually without a referral. You can also see out of network people, you know, with a PPO plan.

Speaker 12 So I would be looking at how you're using your health insurance, what you think your health care needs might be going forward. For example, you know, are you turning to an age where you suddenly need

Speaker 12 a little more, a little more visits to the doctor? Are you thinking that you might be growing your family in the next year?

Speaker 12 And just sort of weighing what you think you're going to need in the next year and then looking closely at the fine print of your plans.

Speaker 6 Okay, when it comes to price, how do these plans shake out?

Speaker 12 So you'll notice that the HMO is probably going to be cheaper than the PPO. And that's because you've got this limited network of providers.

Speaker 4 You're not allowed to go out of network, right?

Speaker 12 And you have to kind of ask for permission to see specialists. The PPO is going to give you a lot more flexibility.
And so it probably is going to be more expensive and you'll feel that.

Speaker 8 Okay, so we got HMOs, we got PPOs.

Speaker 7 There's more jargon that shows up in open enrollment and I'm hoping you can remind us what it means.

Speaker 8 The words I'm thinking of are premium, copay, and deductible.

Speaker 12 So there's a premium. That's what comes out of your paycheck.
There's the deductible. That's how much money you need to pay before your health insurance kicks in for certain services.

Speaker 12 And then there's the copay. So every time you visit your doctor, it might be $25, it might be $40.
That's how much money you pay and your insurance pays the rest of it.

Speaker 6 So there's another plan that I've heard about, and that's the high deductible plan. What is that? And how does that fit into these options?

Speaker 12 Yeah, so I think you want to think about how you're using healthcare. If you're someone who is not using a lot of healthcare, a high deductible plan might be good for you.

Speaker 12 What that means is you're paying very little in premiums. So the premium is is the part that comes out of your paycheck, right?

Speaker 12 You see that number and it can feel really good to have it be a low number.

Speaker 12 But what the trade-off could be a high deductible, meaning that you first are going to be paying a lot of money upfront before your health insurance starts to kick in and pay for your coverage.

Speaker 12 You can also pair that with some other things like a health savings account, which can allow you to put some pre-tax dollars aside to help pay for that deductible.

Speaker 12 So there's a, it's a, it's complicated, but you want to think about how much you think you're going to be using your healthcare.

Speaker 12 And, you know, sometimes a high deductible plan might be an affordable choice for you and make a lot of sense.

Speaker 6 Yeah, you talked about that health spending account. There's also a flexible spending account.
What's the difference between those two?

Speaker 12 There are other ways that you can try to save some money on your healthcare expenditures for the year. There's an HSA, which basically is a way of taking pre-tax money out.

Speaker 12 You have to have a high deductible plan. That's the key to know in order to have an HSA.
And then you can decide how much money you want to put aside.

Speaker 12 That money can roll over for year to year and it can also grow. So it can be invested.
If you don't spend it, you can use it the next year. An FSA is a little different.
That's through your employer.

Speaker 12 And there's a limit similarly to an HSA. And you're putting money aside and you have to spend it all.
in that calendar year. So you got to be careful about thinking about what you want to put aside.

Speaker 12 Usually there's either a a little bit of wiggle room around like tipping over that spending into the next year, or it could be that some employers could choose to let you carry a little of the money over a certain percentage of it for the full year.

Speaker 12 But you can use that for lots of things, the copay, the deductible. You can use it for what you buy at CVS.

Speaker 12 That's, you know, you'll look at the very end of your receipt at CVS and there'll be a line that says FSA eligible or HSA. That can be deducted.
You can get that money back.

Speaker 6 Yeah, I did discover that I could buy my fancy fancy sunscreen with an FSA. That was exciting.

Speaker 12 I mean, I nerdily save all my CVS receipts.

Speaker 12 And at the end of the year, when I realize I am running out of time to spend my FSA money, I go through them all and I find all sorts of things I never would have expected are covered by an FSA.

Speaker 6 This whole process seems like it can be so confusing. Do you find it confusing? I mean, you cover this.

Speaker 12 I find it very confusing. My mother-in-law was trying to pick a plan through the ACA.
I found it very hard to help her.

Speaker 12 Luckily, the ACA has navigators, so you can go to one of those people and they'll help you find your plan.

Speaker 12 When it comes to employer-sponsored insurance, you just really have to think about all the different ways that you might be paying or not paid, right?

Speaker 12 So you just have to think about how you're using your healthcare and how your insurance is covering what you might use. It's complicated.
It can be a really,

Speaker 12 it's like trigonometry and algebra and geometry combined. I don't know, trying to calculate all the right factors and come up with the right choice.

Speaker 12 But I think ultimately trying to understand what your family can afford and what they use, you know, is also going to help you as you try to do the calculation of what makes the most sense for you.

Speaker 12 This year, when you open that email and from your HR and look at what the premiums are, you open up the, you know, Obamacare to find out what your plan will cost next year, you might experience a little sticker shock.

Speaker 12 Healthcare costs are going up and employers are trying to balance absorbing some of those costs or managing some of them with passing them on because they can't afford it all either. And so,

Speaker 12 you know, look at the fine print. It might be that your premium doesn't change, but it might be that there's more costs on the back end that you should be aware of.

Speaker 12 So I just think really paying extra close attention, this is the year to not just accept the plan that you've had every year and just weigh your options carefully.

Speaker 6 You heard right, premiums are about to go up.

Speaker 4 A lot.

Speaker 8 Coming up, we'll explain why.

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Speaker 7 This is Explain It To Me. I'm JQ, and today we're explaining all things health insurance, including why it's so expensive this year.

Speaker 7 No matter where you get your insurance, whether it's through your job, the Affordable Care Act marketplace, or Medicare, the price is going up.

Speaker 7 To find out why, I went to DC's number one go-to for healthcare reporting.

Speaker 8 I am Julie Rovner. I'm Chief Washington correspondent for KFF Health News, and I'm host of What the Health, brought to you by KFF Health News and WAMU 885FM.

Speaker 7 Julie has covered the healthcare system for nearly 40 years, and she says that while the costs always go up, This time is different.

Speaker 8 Well, we are talking premiums going up pretty much across the board for every kind of health insurance right now. You know, we've had bigger inflationary spikes, particularly in the early 2000s.

Speaker 8 But for the last 15 years or so, healthcare costs have been rising, but not terribly fast. They seem to be accelerating again now.
Why now?

Speaker 8 Well, there's a bunch of reasons, but they come down to sort of two things, price and utilization.

Speaker 8 Utilization is how many healthcare services people use. And obviously, the more services people use, use, the more the nation's health care bill goes up.

Speaker 8 So there's a lot of things that are driving expanded use right now. One of them is the aging of the baby boomers.
I am one of them. As we get older, we suddenly get and need more health care.

Speaker 8 And to some extent, we're still catching up from health care that people didn't get during the pandemic when nobody was leaving their houses and when you basically didn't go to the doctor unless you absolutely had to.

Speaker 8 So we're still seeing people not only getting care that they didn't get then, but people who didn't get care then and should have who are sicker than they might have been if they'd gotten preventive care or care early in the pandemic.

Speaker 8 So that's sort of driving up use. And then of course there's just new things that we can do.
Everybody knows about the GLP-1 weight loss drugs that are so popular and so highly used right now.

Speaker 8 We have lots more new drugs. I mean, some of these are sort of amazing advances.

Speaker 8 It used to be you didn't want to do things and, you know, it was always cost-benefit, whether the benefit was worth the cost. And the cost was not just monetary.

Speaker 8 The cost was in how long you would be laid up if you had a joint replaced or had some kind of surgery. Now we have much easier surgeries.
So it makes it much easier to do these things.

Speaker 8 So we're doing more of them. So that's just the usage side.
Then there's the price side. And the price side basically, you know, I can sum up in one sentence.

Speaker 8 We have the highest prices prices in the world because people who provide health care here can the government doesn't regulate it nearly as much as they do in other countries most other countries have do have hybrid systems they do use some private insurance and some government subsidies

Speaker 8 but they also most of them that don't have spending out of control have much more serious regulation of prices than the United States has

Speaker 6 It's really wild because we should be going to the doctor. We should be taking care of ourselves.

Speaker 6 But it feels like when it comes to the price of things and the price of insurance, we kind of get punished for it.

Speaker 8 Yeah, we do.

Speaker 8 And, you know, one thing that I didn't mention is that because we now spend so much on health care that it's like 18% of our GDP, lots of people who would like to earn money are going into health care.

Speaker 8 So we have people sort of encouraging possibly unneeded health care to make a profit. So there's that piece of it also, in addition to the things that we should do and that end up costing us money.

Speaker 6 Is there a difference in

Speaker 6 the rise in costs we're seeing for those of us who get employer sponsored insurance versus those of us who get our insurance through the ACA marketplace?

Speaker 4 There is.

Speaker 8 And one of the reasons that in 2026, ACA premiums are rising is because of these additional subsidies that made it easier for people to get health insurance under the ACA, the expanded tax credits.

Speaker 8 It basically doubled enrollment. And insurers, seeing that those extra premiums were scheduled to end, said, well, a lot of people are going to no longer be able to afford their health insurance.

Speaker 8 So we're going to have to raise premiums on the theory that the sick people are going to hang on to their health insurance and the healthier people are probably going to drop it if they see the prices go up.

Speaker 8 So although everyone will be affected if people can no longer afford their coverage and go uninsured, because

Speaker 8 like with the pandemic, they won't get medical medical care until they absolutely have to and then it's more expensive and then the cost of that care is going to have to get passed along to somebody.

Speaker 6 Are employers absorbing some of these higher costs for people who get that employer sponsored insurance?

Speaker 8 It depends.

Speaker 8 You know, during times when it's hard to hire people, we have tight labor markets, employers try to absorb as much of the increases in health care spending as they can because they don't want to load more onto their workers and therefore make it harder to win new workers and retain old workers.

Speaker 8 Right now, the labor market is not as strong as it has been and healthcare costs are going up. So it's expected that a lot of employers are going to pass along a lot more costs to their workers.

Speaker 6 What can consumers do to try to mitigate these costs? Like, you know, it's getting expensive. What can we do?

Speaker 8 It's really hard. You know, there are a number of people who think that price transparency is a big help.

Speaker 8 It's probably not the answer to everything, but knowing what things cost in advance certainly doesn't hurt. Being able to shop around for elective things also doesn't hurt.

Speaker 8 Sometimes, you know, if you go to a hospital, you can find the same care as an outpatient for much less because of the complicated ways that government and private insurers pay for these things.

Speaker 8 Sometimes you can offer to pay cash instead of use your insurance and you can save money. That's very true for things like generic drugs.

Speaker 8 So there are ways to save some money, but we're all sort of captives of the mess of a healthcare system that we have right now.

Speaker 7 Okay, so everyone is focused on premiums right now because they're going up, but that's just one symptom of what is going on with our health care system, right?

Speaker 12 Like there's a bigger problem here.

Speaker 8 There definitely is. And the health, and obviously Republicans are saying, you know, we're oversubsidizing for the ACA, which is a mess.

Speaker 15 Obamacare is terrible. It's bad health care.
at far too high a price.

Speaker 16 And it's become a boondoggle. It's a subsidy for insurance companies.
When you subsidize the health care system and you pay insurance companies more, the prices increase. That's been the problem.

Speaker 8 Well, we subsidize everybody else who gets health insurance. You know, the federal government subsidizes Medicare.
Federal and state governments subsidize Medicaid.

Speaker 8 There's a gigantic tax break for people who have employer-provided coverage that most people aren't even aware of.

Speaker 8 So it's really only been people who buy their own coverage in the individual market and small businesses who haven't been getting a subsidy. And that's what this is.

Speaker 6 If insurance just keeps getting more and more expensive, do you think we'll see more people just kind of opt out of it altogether?

Speaker 8 Well, that's a concern. And of course, that's where we were before the Affordable Care Act passed, when we had, you know, 14% of the population that didn't have insurance.

Speaker 8 Now it's down to an all-time low of about 8%.

Speaker 8 But, you know, we're definitely going to see people lose their insurance, even if they're not dropping it voluntarily.

Speaker 8 The bill that Republicans passed this summer takes away eligibility for a lot of people.

Speaker 8 And out-of-pocket costs, as you say, are going up dramatically, even if you do have insurance, deductibles, and co-payments, and just the cost of medical care in general means that even people with pretty good insurance end up owing lots of money out of pocket.

Speaker 8 So, I think we're sort of coming to another

Speaker 8 transition point where this is going to be back on the national agenda.

Speaker 6 Up next, we talk about some creative solutions to our healthcare problems and why finding a fix won't be easy.

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Speaker 6 It's JQ back with Explain It To Me, and it's safe to say most people agree that the American healthcare system is broken and that it's probably not getting fixed anytime soon.

Speaker 6 So, what are we supposed to do in the meantime? That's the question I asked my colleague, Dylan Scott. He's a senior correspondent at Vox, and he covers health and the healthcare system.

Speaker 15 You know, for some people, it's like, oh my God, like I broke my leg or I got diagnosed with cancer.

Speaker 15 And, you know, you see people going to GoFundMe or Kickstarter, just literally basically begging people, like, please help me with my medical costs.

Speaker 21 I just created a GoFundMe page and I'm trying to raise money to help me pay for my healthcare expenses.

Speaker 14 Obviously, we expected some out-of-pocket costs, but not this.

Speaker 18 I'm looking for help.

Speaker 15 Unfortunately, like, that's one predicament that the U.S.

Speaker 15 healthcare system puts people into if they have like a serious medical need is you might just have to like beg strangers to chip in to cover your bills.

Speaker 15 But short of that, you also have Americans, they're like looking for basically insurance-like products, you know, something where it's like you pay a monthly payment and if you have medical bills, hopefully it's going to cover you.

Speaker 15 And there's a few different variations on that.

Speaker 15 There is something called short-term limited duration insurance, which like ideally is supposed to be like a three-month plan that you get on when you're between jobs or something like that.

Speaker 15 But some people are trying to go on those.

Speaker 15 On a more permanent basis, there are things called association health plans, which are supposed to be like groups of businesses who pool their resources together to try to cover their workers' healthcare costs.

Speaker 15 And then, you know, what I think is one of the most interesting ones is something called healthcare cost-sharing ministry.

Speaker 6 What is a healthcare cost-sharing ministry?

Speaker 15 So like in their original form, Basically what this is, is like a group of people, you know, maybe literally a group of people who go to the same church together, who are like, okay, we're going to to pool our money together.

Speaker 15 We might ask people who participate to adhere to certain moral, ethical standards that, you know, reflect our Christian values.

Speaker 15 And then like, you know, it's in theory supposed to work like insurance, where it's like you pay into this, this pot.

Speaker 15 And if you have a medical claim or some kind of medical issue comes up, you receive healthcare services, you can take those bills back to the group and they'll give you money out of the pot to cover the costs.

Speaker 15 Technically, these kinds of arrangements have been around for decades. Like the first one started back in the early 1980s, but for a long time, I mean, they were really niche.

Speaker 15 But then the Affordable Care Act passed and was this big flashpoint politically, as people well know.

Speaker 15 Especially for like deeply conservative and religiously devout people, they had a lot of objections to the ACA.

Speaker 15 Some of them had objections to like the provisions that required insurers to cover birth control, things like that and so they were like you know what i want to like opt out of this law and actually the law and the way that it was written kind of gave them an out it said that if you sign up for a healthcare cost sharing ministry if you're enrolled in something like that then you can be exempted from the individual mandate and so i think all of those things combine together to start driving a lot more people to these healthcare cost sharing ministries.

Speaker 6 It sounds a lot almost like mutual aid.

Speaker 15 Yeah, I think that's the crux of it, I think, in a lot of ways. But increasingly, these are like sophisticated businesses with really well-funded advertising campaigns.

Speaker 22 Finding affordable health care can be stressful. And some people think that insurance is their only option.
Which is why CHM was the first to establish a cost-sharing ministry.

Speaker 22 It's a collection of specialized care components, resources that help you through life's most challenging medical moments.

Speaker 15 You know, they've increasingly de-emphasized the religious aspect of it. You see them adopting more, like names like liberty, health share, and things like that.

Speaker 15 Even with like the moral and ethical standards that they want people to sign on to, they've kind of more and more de-emphasized, like, you have to believe in God and that Jesus Christ is our Lord and Savior.

Speaker 15 And it's more like, you know, you're going to be an upright person. You're going to, you know, be moral, but in a sort of vaguer, more secular way.

Speaker 15 And I think that's because these companies see a business opportunity.

Speaker 6 How many people use these kinds of ministries?

Speaker 15 Back in the day, in the mid-2000s, there were like 200,000 people enrolled in these plans. As of about 2018, there were a million people enrolled in it last year.

Speaker 15 So which is, yeah, like a pretty significant increase from the decade before.

Speaker 15 And then past that, as the most recent estimate that we have, and it's worth emphasizing, like, because these things are poorly regulated, it's hard to get really reliable data about them because these can kind of just operate without the government even really knowing about it.

Speaker 15 But the Colorado Department of Insurance tried again to estimate how many people have joined these ministries in 2023, and they came up with 1.7 million Americans were now enrolled in a healthcare cost-sharing ministry.

Speaker 15 So, like, that's pretty exponential growth if you go back to just like 20 years ago.

Speaker 7 And how has it worked out for people who are in these ministries?

Speaker 15 So, I think it's really important for people to understand these ministries are not subject to the same rules about pre-existing conditions, about not putting annual limits on people's benefits.

Speaker 15 All of the insurance regulations that people have gotten accustomed to after the ACA became law do not apply. to these healthcare cost sharing ministries.

Speaker 15 So you're basically just relying on sort of the goodwill of these ministries to pay out and just like hoping that they have enough money to cover whatever your medical bills may be.

Speaker 15 The way that insurance works is it needs scale. You need a lot of people paying into the pot.

Speaker 15 Frankly, you need a lot of people who are healthy, who don't have serious medical needs, who are just paying their premiums in and not taking anything out.

Speaker 15 And that's hard to do sometimes, as we see with rising costs across the whole system, with like hundreds of thousands or millions of people enrolled in your health insurance plan.

Speaker 15 And so you can imagine with some of these smaller healthcare cost sharing ministries, which like, you know, individual ones may have maybe hundreds or just like a few thousand people enrolled, there might not be enough money in that cost-sharing ministry to cover the costs.

Speaker 15 And so then you're kind of just shit out of luck.

Speaker 4 Yeah. I, uh,

Speaker 6 is scaling up the solution for these ministries? Is like,

Speaker 6 is that, would that solve that problem?

Speaker 15 The way to solve what's going wrong with our healthcare system is not to scale up these healthcare cost-sharing ministries that can then discriminate against people with pre-existing conditions.

Speaker 15 I think instead what we need to do is like we need to be looking at the whole system's costs, figuring out how to bring those down, which is hard and which is going to take some difficult work.

Speaker 15 But I do not think these plans themselves are the solution.

Speaker 6 What is the solution?

Speaker 15 It's the worst time of year because it's, yeah, it's like, hey, sign up for health insurance. And yeah, your premium's probably higher than it was last year.
year. And,

Speaker 15 you know, the deductible might be going up too.

Speaker 15 And it's like, I think in the long term, we need like policymakers and the industry and the payers to come together and figure out how to how to make just the overall costs of healthcare lower so that we can provide people with comprehensive coverage more affordably.

Speaker 15 But in the meantime, yeah,

Speaker 15 we live in America. We're individualists.
We're consumers.

Speaker 15 You kind of got to look out for yourself and just be really careful about how you're kind of making those calculations because it really depends on your individual situation.

Speaker 6 If you want to know more about health insurance and how to navigate open enrollment, head over to Vox.com.

Speaker 6 We have an entire guide on how to use your benefits and we even get into the history of why this all works the way it does.

Speaker 6 Soon on Explain It To Me, we'll be talking turkey. Thanksgiving is around the corner and we want to know what you think of this dinner mainstay.
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Speaker 6 This episode was produced by Avishai Artsy and Danielle Hewitt. It was edited by Ginny Lawton and our executive producers Miranda Kennedy.

Speaker 6 Fact-checking by Melissa Hirsch, and Adrian Lilly and Patrick Boyd did the engineering.

Speaker 13 I'm your host, John Glen Hill.

Speaker 6 Thank you so much for listening.

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