Health Isn’t Something You Can Plug Into a Spreadsheet

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This is a tense time for a lot of early retirees and aspiring early retirees, as we wait anxiously for things to shake out in the current rounds of health care reform. We’ve just learned that the Senate won’t vote on their version of the AHCA, but beyond that, it’s unclear whether this or any bill will move forward, whether we’ll have an intact ACA, or whether we’ll have a technically intact but not funded ACA that turns into de facto health care chaos. Super fun. Health care abyss in effect all the way.

As many of us sit on the sidelines holding our breath, waiting to find out if our health care costs will double, triple or worse, others have aired some version of this sentiment:

It doesn’t matter what health insurance costs because I eat healthily and exercise. So my health will be just fine. Health is mostly dictated by choices.

As though health is something you can totally optimize just by checking the right boxes. (Excuse me while I laugh out loud, and also cry and whimper a little bit.)

That sentiment is destructive because:

1.) It’s not true. You can eat right and exercise and do everything right and still have major health challenges. (See below.)

2.) It suggests that people who face health challenges are to blame for them, which is untrue in many cases, or at the very least, it’s more complicated by social and structural barriers to making healthy choices.

3.) It totally ignores economic principles and is just generally bonkers. Even if you think that the only people who get sick are those who are at fault due to bad personal choices, practicality tells us that it’s not okay for us all collectively to absorb the costs of unpaid medical bills and bankruptcies, and the labor market costs of lost productivity from illness. If you want your stocks to continue gaining value, that requires ever-increasing productivity, and poor collective health is the enemy of productivity. And one of the biggest factors in poor health? Limited access to health care, especially preventive care.

But let’s ignore economics right now, and just talk about the basics of health, namely whether health can be controlled like variables on a spreadsheet. (Spoiler: It can’t.)

Have We Met?

Indulge me in a little storytelling, beginning with some (re)introductions.

Hi, I’m Ms. ONL* (*not my actual human name), a long-time healthy eater who’s always been active way beyond the recommended guidelines. I’m also an ideal weight according to the charts, have excellent scores on all the blood tests (gold stars!) and take extra steps to be healthy like sticking to mostly organic produce, avoiding cooking in plastic, eliminating endocrine disrupters and antibacterial agents from the house, etc. I rarely drink and have never smoked tobacco. You know, your average health nut. My only real health sin is not sleeping enough these last few years of work. Here’s something else about me:

I’ve always been sick. I was born prematurely and racked up major health care bills in the NICU, which was the least of my parents’ concerns given that I almost didn’t make it. When I was eight, I got a serious bacterial infection that required a two-week hospital stay and drug doses more in the range of “elephant” than “little kid.” In high school, what should have been a standard case of strep turned into scarlet fever because my immune system is kind of a slacker, in case that wasn’t already obvious, and there are a handful of other times when some minor thing turned more serious for me. In my 20s, I found out that I have a small brain tumor I’ll always need to keep an eye on. In my 30s, I got diagnosed with an autoimmune disease that I’ve probably had for 20+ years, that increases my lifetime odds of intestinal lymphoma fairly dramatically, as well as my odds of getting other autoimmune diseases along the way. And there’s plenty I’m leaving out.

I’m thankful every day that I don’t actually feel sick, at least not anymore. But I know that I’m one big walking pre-existing condition despite only ever having lived a super healthy lifestyle (okay, freshman year of college notwithstanding). And if my past is any indication, chances are good that expensive care lies ahead for me.

bc-ski-skin-track
I’m a pre-existing condition.

Now meet Mr. ONL* (*not his real name either). A guy who’s always radiated health. A lifelong athlete with years of competitive sports and four marathons under his belt. Not always the absolute healthiest eater, but nothing terrible. A little smoking in his younger days, but not for a long time now. No heavy drinking. (Again, we’ll give him a pass for college.) Still super active, despite being an old man of 40 (kidding! not about the 40 part, just the old part).

img_7496
Meet another pre-existing condition.

And guess what? He’s sick, too. Apparently because we like to be well-matched in all things, he also recently got diagnosed with an autoimmune disease that increases his intestinal cancer odds. #soulmates (#intestinemates?) Now he’s on drugs that come with a gag-inducing price tag attached, and will require regular and costly screenings for the rest of his lifetime. Yippee!

Mr. ONL and Ms. ONL on a mountaintop, our natural habitat
What sick people often look like. (We’re not green under those emoji masks. That’s just the filter.)

I doubt many people who meet us think of us as sick (“But you climb mountains!”), but that’s our story. In our small sample size of two, we have two examples of how you can do everything right, or at least mostly right, and still be sick. And that’s not even going into our lifetime odds of being in a car accident or having another serious injury.

I could understand why someone might argue that our health histories dictate that we should keep working, to ensure that we always have employer-provided health care (reminder: the U.S. is one of only two major industrialized nations who use this system, by the way). But the flip-side is: we don’t know how many fully able-bodied years we have in front of us. Our health is exactly why we’re in such a hurry to retire in the first place. We’d rather risk financial ruin than risk spending all our good years working.

Health Isn’t Something We Can Entirely Control

I’m just about as health nutty as they come, so believe that I’m all about reducing our risk factors and increasing our odds of living long, healthy, able-bodied lives. I believe 100 percent that the choices we make impact our health. Though I also believe that not everyone is in an equal position to make healthy choices, and there’s much in our social and built environments that contributes to poor health beyond people’s control. Which isn’t even touching the whole spectrum of mental health, or of physical disability.

But as our stories show, no amount of optimizing can control for every variable. We all know people like us, who make the right choices and still end up with health challenges, or even who end up dying tragically and unexpectedly at a young age. We feel like our challenges are super minor in the scheme of things, and only disrupt our lives in minimal ways, which we’re grateful for. But they’re still expensive, and that matters when we’re talking about the cost of care over the long term.

Why It Matters

We as a society need to have a very different conversation about health than the one that’s happening now. What we’re all calling health care reform is really health insurance reform. It’s not really addressing how we deliver and price care, or how we help people get healthier well before they ever step into a health care setting.

It’s no secret that we’re over-testing and in some cases over-treating patients, and we all bear the cost of that. We compensate providers based on how many procedures they perform, not how they benefit patients, which creates all the wrong economic incentives. The U.S. foots the bill for pharmaceutical research for the world, and lines the pockets of big pharma with the exorbitant drug prices we pay (and can’t negotiate, by law). We also have far too many food deserts where it’s nearly impossible to find healthy, affordable food, and we have huge percentages of the country where there aren’t enough parks, trails and bike lanes to let people exercise outside safely. And we continue to cut back physical education classes and allow the soda companies to sell their products to kids in schools. All the while, agribusiness giants are developing ever-more-insidious ways to market addictive and borderline-toxic foods to us in ever-increasing quantities.

We have too many vicious cycles operating simultaneously to count them all, and if we want to have meaningful improvements in our health and our collective costs, we have to begin to unravel these things.

But we can’t have that conversation if we’re pointing the finger, blaming people for risk factors or illness that may not even be their fault, and acting as though health is something it’s not, something entirely within our individual control.

I’d love nothing more than for that to be true, to have total control of my health, but as I’m reminded every day, it just ain’t so.

The Health Discussion

Thanks for indulging my rant here. Now it’s your turn. Where’s your head in all of this? Witness anything that has assured you that there’s tons about our health we don’t understand and can’t control, like Penny’s recent visit to the neurologist where she saw a little kid there as a patient? (And anyone else suspect as I do that there’s some secret fat shaming and poor shaming behind a lot of this talk about controlling our health?) Or want to vigorously disagree? Bring it!

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131 thoughts on “Health Isn’t Something You Can Plug Into a Spreadsheet

  1. Excellent post. Spot on in about every way I can think of around this debate and problem of health care. Stating the obvious perhaps, but the debate (and thus whatever solutions are proposed) all seem to center on funding schemes, rather than as you point out, addressing some or enough of the structural changes
    to the health system necessary to make real improvement. I think of a persons health as genetically and environmentally random (read uncontollable) in spite of how personally focused they may be in “wanting” to be healthy (and thus try to control as best they can). As I have thought about the next chapter in my book should I be so fortunate as to become FI and RE, I have been pondering how I might be able to focus some energy on how to help try to improve and change the health system. I have no expertise in this area, but apparently nor do those who have thus far worked the problem…so why not give it a go!!

    1. Thanks, William! And you are SO right that those in charge of fixing the system fundamentally do not understand it. There are downsides to sending “outsiders” to capitol hill! ;-) I love the idea of more of us working to reform the system, and I hope you can devote some serious time to that after you FIRE! :-)

  2. Like William Taylor said above, I think you checked off a lot of the major boxes and are spot on.

    As a thought exercise, I’ve written a couple of articles on fixing healthcare (such as this one: http://www.lazymanandmoney.com/lets-fix-healthcare/). Some of the stuff is annoyingly easy to fix like negotiating drug costs and choosing NOT to fund the drug research for the whole world.

    You don’t even hear the politicians talk about these things unless there’s PharmaBro or EpiPen outrage in the news. A strange thing about that EpiPen outrage though… when people started to pay attention the pricing got (magically!) a lot better. CVS announced a $10 alternative. The FDA approved a new alternative a week or two ago.

    I feel like the rising premiums are largely the result of a system that isn’t designed to be efficient with financial resources. It feels like the idea in my cases is to be inefficient so that more can billed and more money can be made.

    1. The epi-pen alternative and the press of the price increases seem to have been effective… for now, which is great. However, there are many more conditions that only affect a small number of people, or that affect mostly women or minorities, and these conditions still have treatments with astronomical prices because not enough people care.
      Yes, with a smaller market it’s harder for pharma to recoup the research costs, but it still stinks to have the patients with the least ability to advocate for themselves facing the highest prices.

      1. The thing I find most befuddling are the drugs that have generic versions that suddenly go out of production, and then despite having been cheap for years, they’re suddenly expensive. Like albuterol, a very standard asthma inhaler (oh yeah, that’s on my list, too). It used to be like $6 for an inhaler, and now it’s multiple hundreds before insurance, despite being an old drug that LOTS of people need.

        1. The active ingredient is old but the propellant is new, so it’s like a new medicine.

    2. Thanks for that link! I will check it out, and others should too. Fundamentally, our lawmakers are in the business of getting votes,nothing else, and if they don’t think something directly impacts that very particular bottom line, they won’t focus on it. As for health insurance, one of the provisions of the ACA that the new bill would eliminate is the cap on how much profit insurance companies can make, which at least controls costs by not letting the companies line their own pockets while denying patient claims. Sadly, that provision likely won’t stand, and prices will rise even more.

  3. “Though I also believe that not everyone is in an equal position to make healthy choices, and there’s much in our social and built environments that contributes to poor health beyond people’s control.” – 100% agree! While people may like to believe they have complete control over their health, that is just not the case. Especially not with the state of the global environment.

    I’m in the same boat as you Mrs. ONL. Incredibly healthy lifestyle, and I still have tons of crap wrong with me. Now, I am Canadian (ducks behind bushes), so it’s a slightly different situation, but I do understand that sometimes, your health is beyond your control.

    Really excellent post, as always!

    1. Thank you! And I’m sorry you’re in the same boat, but it’s also nice for us uber-healthy-sick-people to find each other. :-) And your example shows that great health care isn’t the ONLY factor, because you’ve obviously had access to care your whole life.

        1. I do think our countries have very different attitudes toward health generally, though, but of course both could do much better to instill healthy habits younger in life!

  4. I’m definitely in the camp that you can try and do yourself as many favors as possible on the health front by “healthifying” everything in your control, but genetics is a bitch. A co-worker recently had a massive heart attack at 53 and he’s still recovering, like in the hospital recovering, 3.5 weeks later. And this guy ate well, exercised often, ran often, etc… but his genetics predisposed him to heart conditions. Definitely focus on what you can affect with your own body, but there’s no accounting for how genetics will play out.

    My brother and I were talking life expectancies last week and I mentioned how I see 80 as the “death milestone” because that’s around when most of my male family members have died. He scoffed and said, “Man, if I get to 65, I’ll be happy.” I was like, wtf?! 65?! Dude, that’s like 23 years away, tick tock, man, tick tock… To be fair, the way he’s going I’ll also be surprised if he gets to 65, but lord, way to sell yourself short.

    I agree with the above comments that the system itself needs a thorough overhaul. Why in the hell can other countries get lower cost medicines, the same damn medicines, as the US and we seem to be okay paying the premium. Like people that knowingly overpay just to show they can afford it. It’s ridiculous.

    I had hoped that Trump would actually work on healthcare pricing and getting that in line (omg, ok I’m back, I had to take a break because typing Trump and work just, well just, yeah…) but that doesn’t appear to be happening. Why not start looking into open bidding and changing the rules on medicaid and medicare to get companies to charge less. Talk about a monopoly. “Hey we make an Aids drug and noone else does. Why aren’t we charging $20k more for it? What will they do, not take it?” Insane… Just insane…

    1. I’d add a level to what you’re saying and add that genetics are an X factor, but not the only X factor. Most of the stuff I have doesn’t run in my family and has no obvious cause. I grew up in a polluted place… might that have caused things? I’ll never know. Did something bad happen while I was in the womb? Maybe. I know most people use genetics to more broadly mean “stuff you can’t control,” but there are plenty of non-genetic factors beyond our control, too. Just look at Flint, Michigan, and their polluted water. Or the pesticide pollution documented in Silent Spring that caused untold numbers of cancer cases.

      As for your brother, that’s nuts. 65 is still young!

      As for competition in health care, I’m super torn on that subject. Because all any of us need to do is look at the airlines to see how crappy service gets when downward price pressure from competition is the driving factor. Show me any innovation happening in that industry. You can’t, right? And that’s because it’s all about price-cutting, not innovation, and that is the last thing any of us should want for our health care!

  5. “It doesn’t matter what health insurance costs because I eat healthily and exercise. So my health will be just fine. Health is mostly dictated by choices.” Got this as a response in a recent discussion of health care costs. Got infuriated. Walked away without responding.

    And I am completely with you in your anecdotal evidence. My extended family is quite large. One of my aunts was by far the healthiest of all of us. By far. She died of cancer at 47.

    1. I’m so sorry to hear about your aunt, Matt! :-( Though don’t we all know someone like this? It’s crazy to me that people feel comfortable making that arrogant and blindly privileged statement (which, by the way, also feels to me like a big time jinx), when they’ve likely known people themselves for whom this is true. I don’t blame you for walking away from that conversation!

  6. My husband and I discuss this aspect of FIRE more than any other. After a 10-year struggle with a digestive illness that made every day life a real challenge, and trying to do everything “right” that I could to fix it, my GI doc finally put me on a drug that gave me back a normal life almost overnight. Nothing I could do myself, unfortunately, produced anything close to those results. And believe me, I was very disciplined and tenacious in trying to fix it myself. But the new drug costs more than the maximum allowable yearly HSA contributions I can make (but still less than my yearly deductible, fun!) which means my HSA will be slowly drained. And I know there are many people out there paying WAY more for whatever they need just to live life. Several diabetics that I know jump to mind, including a friend’s 5-year-old who certainly never made any “life choices” that can be blamed for his juvenile diabetes.

    Meanwhile, both my husband and I are constantly frustrated by the feeling that our full-time jobs actively interfere with our ability to be our healthiest selves. We do the best we can with it, but we both feel like the sooner we can stop working 50+ hours a week, the better off we’ll be physically. But we have to make sure we can cover our health costs later in life. My husband has chronic back issues that may someday require surgery and I’ll be on this expensive drug for the rest of my life. And I’m sure life will throw more than just those two health-related snags at us. There’s so much we can’t prevent, from accidents to genetically caused diseases.

    This is, by far, the #1 question in our minds as to “When can we actually retire?” Not only do I not know the answer, I don’t even know how to figure out the answer, given that healthcare costs have been rising exponentially and there’s really not a whole lot we can count on legislatively… If we could at least reach some sort of stability, it would be a relief right now.

    1. Oh man, I’m sorry you’ve been through all that! Though I’m glad the drug is working for you. Is it something where you could try taking it for a while and then see if your diligent efforts might keep you at a stasis level? I know I sound like an anti-drug crazy, which I am not, I just think doctors are too quick to say we need to be on something forever, when we might not actually need that. Either way, I totally feel for you and hope you have a much higher quality of life now! And yeah, the question of when you can actually afford to retire is a thousand times harder with all this uncertainty. As I wrote in that health care abyss post, it’s hard to budget for infinity. :-(

  7. I also agree that there are social and economical factors to health that most people glaze over. However, working at an intercity hospital for many years I’ve seen plenty of people who refuse to take charge of their health.
    Anecdotal stuff here but: “I can’t afford my 4$ antibiotics” says a pack a day cigarette smoker
    “I won’t wear my CPAP because it gets in the way of my eating” says a 500+ pound man
    Or how about the guy who in his early 30s has end stage kidney disease and has to go on hemodialysis because he refused to take his high blood pressure medicine!
    Choosing to have healthy habits can’t guarantee good health, but I’ve seen so many people under 50 whose health is in shambles because they have not taken personal responsibility in their health maintenance. At the same time, I’ve definitely seen people with lack of social support and who struggle financially and it’s heartbreaking.
    It’s almost like a nature vs nurture argument, and that they are both factors is closer to the truth.

    1. Definitely agree LZ. I would like to think that most people are compassionate (and realize a health issue out of their control could happen to them) enough to pay for the sick that had no control over being sick. It’s also tough to swallow the fact that you have to pay for those that smoke a pack a day and take no control over their own health. I feel like there has to be better middle ground solutions here.

      1. I can’t help but think that the answer is just an overall healthier culture and earlier interventions. Expecting someone to change who’s had a habit for 30, 40, 50 years, and who has no examples in their life of what health looks like, I wonder if that’s asking something unrealistic. But if we actually made the choice as a society to encourage healthier habits earlier and in all parts of life, I can’t help but think it would be easier for people to take that ownership.

    2. I have seen some of those cases myself, and I know how frustrating that is to see someone not take control of their own health. But I also wonder if those interventions are coming too late, after the bad habits are too ingrained, and for folks who don’t have any healthy role models around them to help them see the upside of adopting healthier habits. I think all of those factors matter a ton, too, and are rarely discussed. If someone lives in a super sick community and has no examples of what a healthy life looks like, why would they want to be the social outcast who has to eat something different or do something different for no visible upside?

  8. You’re absolutely right about the control we have over our health (or lack of). Out of the blue, my husband had a throat cancer at 40 years old. And he is NEVER sick, was a competitive bicycle rider in his younger years. Luckily, he recovered after chemo and radiation and is 58 now. But he definitely falls into the preexisting health issue category.

    1. Wow, I’m so glad your husband recovered! How terrifying that must have been. And re: pre-existing conditions, remember they’re looking at making that a state-by-state decision, so where you live could end up mattering in the future.

  9. Well said, and thanks for sharing your story. I tend to think people who say they’ll be fine because they have healthy habits are just trying to soothe their our concerns, or ignore them. But yes, the implications of that are pretty offensive, and it’s simply not true. The health factor is always in the back of my mind, especially as a mother, because I know that’s the thing we would spend any amount of money on, if needed. And it’s also the thing that you really can’t control. Neil’s grandfather turns 100 this summer, so I’m hoping he’s got those amazing genes!

    1. Oh totally, it’s absolutely a head-in-the-sand response! And I’m sure you think a ton about health and the cost of care for your kids, because of course you’d spend whatever was necessary for them. And fingers crossed that Neil lives to 100 and beyond, too! :-) (And that you do, too, of course!) ;-)

  10. I’m the opposite – I’ve always had excellent health despite the completely unhealthy choices I have made my entire life – until recently. Know that I am knocking on 50’s door, my knees hurt, I’m out of breath just thinking about any type of exertion, a very round shape to my body, and worried every time I get the least pressure feeling in my chest that the heart attack is coming. All this and I can’t seem to stop making poor food choices.
    And I’m lucky. Money and choice is not an issue. I’m not overly wealthy by any standard, but also not scrimping to get by. And what you mention about food deserts for some is so true. I have a grocery down the street that sells actual produce. I’ve seen people buy it. Some folks have to take a 3 hour round trip bus ride to do that. Try that while working 2 minimum wage jobs. I have no excuse, but they sure do.
    I don’t know what is going to happen with health care and I sure don’t know how to solve it. I can’t say I am a big fan of ObamaCare, but I guess it’s at least something. My big worry is costs. I have no data to back it up, but it seems like our nation’s debt is expanding much faster than our economy. I just don’t know how long a country can keep that up. But I guess healthcare will have to be paid one way or the other. I don’t know. I sure wish we could get to the answer without adding another entitlement, but I am not smart enough to know how to do it.
    Best wishes on your upcoming retirement.

    1. Thank you for sharing your story — I’m sure that wasn’t easy! And thank you for providing an example of how hard it is to change long-ingrained habits, despite knowing they are bad for you. I wish when we all talk health care we could talk about actual health. Costs are rising regardless of the ACA or anything else because people’s health is worsening, and a lot of that is due to poor choices and the higher health care costs that come from them. But we’ve also made incredible progress in smoking rates, seatbelt wearing rates, transmission of certain diseases that now have vaccines, etc. So we know we CAN improve the health of the nation, it’s just that there’s no political will to do it.

  11. I agree 100% with your post. I also have an autoimmune disease, which was completely out of my control, and now I have to take medication for the rest of my life. Being seriously ill once has me worried for what my future holds and has also made me eager to try to retire early.

    Seeing my parents age has been eye-opening. My dad retired at 65 (and my mom had been unofficially retired for many years prior to that) and their retirement has not turned out how they expected. The first couple years were great. Then my dad was diagnosed with glaucoma and my mom developed knee problems. They haven’t traveled in years and mainly stay home now. I’m so thankful that they’re covered by Medicare so the financial aspect isn’t a concern.

    I really wish more people (politicians in particular) had the ability to view things from a perspective other than their own. Think of how much more could be accomplished if that was the case?

    1. What happened with your parents is my fear, and why I’m so eager to retire early! I don’t want to retire to a sedentary life at home. And yeah, the political aspect is so frustrating. If nothing else, I wish they could recognize that making people MORE dependent on employer-provided coverage is anti-innovation and anti-small business (which they always claim is the engine of our economy). If no one can afford to leave their employer to start their own business, remind me again how that helps our economy grow?

  12. This is probably my biggest hang up about FIRE. I wrote a post about it once when my parents had to run out and buy a $12 bottle of cherry juice as a wait-until-the-doctor treatment for my dad who was out of town. It’s $12, right? But’s SO MUCH MORE than $12. Being sick and being able to afford to run out to the store to buy whatever might make your symptoms just a teeny bit better is a complete luxury and privilege. And if it stings to do it now, it seriously keeps me up at night thinking about the old lady Penny version of it.

    Of course, we can’t know everything about our future selves, but shutting ourselves off to the possibility that we might get sick because we eat well and exercise is absurd. We’ve all met people who do everything right and are devastated by illness regardless. And we can also rattle off names of people who did the exact opposite and lived, seemingly, forever. It’s humbling and entirely necessary for all of us to consider these what-ifs.

    1. And since we mentioned the neurologist, people who think, “Oh, I’ll have Medicare” have another think coming. As soon as my mom mentioned that she was considering retirement, the doctor’s first words were, “I hope you’re taking out a supplement to continue this treatment.” Yup.

      1. Yes, 100%. I think what’s comforting about Medicare is that it’s fairly stable in its pricing, but it leaves TONS uncovered, including future nursing home care, which is where Medicaid comes in, except, oh yeah, we’re getting rid of that.

    2. Your story reminds me of the time in Canada when I got a UTI and went through — I am not joking — $150 of cranberry juice so that I could avoid paying cash to see a doctor out of network. The fact that I could spend that kind of money on JUICE is a total privilege, and the fact that we have a health care system where we expect that of everyone (okay, my case is not totally applicable, because it was international travel), is nuts. And yeah, everyone has that old relative who smoked and drank and ate eggs fried in bacon grease every day and lived to 100. But we should be paying more attention to the other end of the spectrum — the people who PROVE that healthy choices only go so far.

  13. Agree with a lot of the points on here. My issue with ACA and now the proposed bill is that it continues to ignore the largest problem in my opinion…the overall cost. Healthcare spend is ~3 trillion a year in the US and rising…nearly 10k per person living here, which is crazy high (and way higher than any other country). Yet 99% of the arguing is who is going to pay for it. Would it be that crazy of a concept to have real arguments about reducing cost? The whole system is designed to reward based on individuals getting or being sick…Doctors, insurance companies and pharmaceuticals would not make near as much money if the population became healthier. A doctor is supposed to make you feel better, but he or she will make more money if you stay sick. I know not all doctors think that way, but isn’t that incentive structure a little backward?

    While I certainly agree that there are many many people who are sick with no ability to prevent the disease (and I really feel for those), I think that an overall incentive by the whole system to improve health would take a massive chunk out of that 3 trillion dollar problem, leaving the healthcare cost issue much easier to deal with. There isn’t a simple and easy solution with this, but I feel shifting the conversation from “how to pay for it” to “how to prevent it” would go a long way.

    1. Great comment Derek and something I’ve been ranting about for years now. Med schools train doctors to do one thing – treat you when something goes wrong. They’re taught virtually nothing about how to “care for” a person to prevent things from going wrong and to keep them as healthy as possible. For instance, most doctors don’t even know the basics about nutrition science or even what foods are good vs. bad. The leading reaearch and breakthroughs on that come from the sports science community, acadamia, or other industries.

      I make no illusions that my healthy lifestyle and focus on fitness will have me breezing into my 80’s with the turbo’s on. Diabetes runs in my family – my brother got it when he was 3 obviously from no fault of his own. Once I was in my 20’s and stopped partying, I swore I would NEVER let myself become overweight because I no-doubt have a warped DNA strand somewhere inside me that would trigger diabetes if I did. I’ve kept that promise and will continue to. I work really hard at cycling, running, and mountaineering to stay thin and fit (plus I immensely enjoy those things). However, I’m well aware that genetics ultimatley rule the day and I could get diabetes anyway.

      We need a mediacl system that both treats illness and helps prevent it, with fair and equitable insurance available to all.

      1. I’ll be honest, I think by the time doctors are involved, it’s already too late for some people. So we can and should talk about those incentives and payment structure, but we need to do SO much more to promote health all across society, not just inside doctors’ offices and hospitals. In your case, it’s awesome that you were so motivated by that genetic possibility and have worked so hard to stave off diabetes — I hope that’s a genetic lottery you win!

    2. Yup, that’s why I wrote that we’re actually arguing about insurance reform, not health reform. ;-) And it’s not just about the care itself, but about our entire culture and how lousy we are at promoting health, and how good we are at promoting all the worst habits that have the greatest societal and personal costs. Like why is McDonald’s allowed to make huge profits while its products cause poor health that cost all of us trillions of dollars in health care costs? Or Coca-Cola, or Marlboro, etc., etc., etc.

  14. I think you brought up a lot of good points – health insurance reform instead of healthcare reform, personal responsibility can reduce risk but not eliminate health risk, healthcare providers incentivized by procedure and not outcome, and that using our healthy bodies for things I want to do when able and not degrade in a cube.

    I have to question the statements that oh s/he is healthy but had this potentially fatal disease. Maybe our definition of “healthy” is incomplete. There are many examples of this. I am wondering if are annual check ups are lacking in there thoroughness or we do not have the metrics identified. There are some articles that have come out in the past few years highlighting the fact that 1 hour of exercise daily is not sufficient to build and sustain the muscle while sitting for 10+ hours a day.

    Even thought I can climb and ski a peak, my muscles and bone alignment are far from ideal, which I see as an example of how the human body is amazing in what it can do in sub-optimal condition. The problem is that the sub-optimal condition wears down faster and eventually something fails, which is frustrating, painful and potentially expensive. I am excited to see what my (near) optimal conditioned body is capable of.

    Health is a complicated beast, as described in the kids song – the foot bone is connected to the leg bone, which is connected to your genes, which is connected to your local grocery store produce selection, which is connected to your health insurance, which is connected to the “negotiated” price for chemical treatment, which is connected to number of doctors on staff at your local health clinic, which is connected to . . . You get the idea.

    Thanks for sharing.

    1. Yeah, the emerging evidence on sitting should scare the crap out of everyone. Cannot WAIT to spend very little of my day sitting! As for the incomplete testing, that’s a double-edged sword, too. MORE testing often leads to over-treatment and undue stress on people, like the increased prostate removals resulting from more PSA testing, and the increased surgery and radiation for breast cancer resulting from earlier mammograms. No doubt a small number of people benefit, but many people end up having unnecessary and terrifying (not to mention expensive) procedures, and we see that the medical associations are rolling back those testing recommendations as a result. Of course this stuff is all impossible to look at objectively because we want those tests available for ourselves, but then we can see everybody else in terms of statistics. As for the future, totally with you in hoping that we’ll see some improved health and certainly improved fitness after we can quit these sitting jobs!

  15. I appreciate you posting this – You’re 100% right, you can do everything right and have health issues hit. We’re within two years from FIRE and could leave now, by my wife was hit with a complicated injury WHILE exercising at 35, a spontaneous CSF leak (lookup George Clooney or Steve Kerr) This has left us traveling for care and in six figures worth of medical expenses (thankful for good corporate insurance) and now she’s a pre-existing condition case when we go for insurance. Now medical expenses and the out of pocket maximums plus premiums are very real to us in our retirement plans, even though those plans are very secondary to fighting the complications experienced with no timeline in sight for resolution.

    I may be an outsider to this close knit FIRE community, but enjoy every day, don’t put off your life until later, and find balance. You never know when it’ll be taken from you.

    Oh and on the ACA or replacement plans, until they make it required for all people to buy insurance (not a penalty, just no tax refund or IDs issued without it), both plans are doomed to fail. We require ERs to provide care regardless of the ability to pay, so we can require all to buy insurance. Anything else is like allowing someone to buy car insurance after they hit the tree.

    1. With you 100% on taking nothing for granted. Appreciate what you have while you have it — no one has ever looked back at the end of their life and said, “I wish I’d been less grateful and appreciated things less.”

      As for you guys, the coverage on pre-existing conditions will be a state-based decision if the current bill passes. So it’s extra important to look at what state you live in! People in some states will be fine in terms of getting pre-existing stuff covered, and others won’t. Also with you on the mandate. Why do we require car insurance for drivers but not health insurance for people? In very non-human terms, we’re all potential cost liabilities for society, so why not try to distribute that risk as far and wide as possible?

  16. There is a LOT that people can do to increase their chances of leading a fairly healthy life, but you’re right, there are things that we just cannot control. Especially hereditary things. Some of us were born into families who have enjoyed a pristine bill of health over the centuries while some of us have not. My family? Pretty much middle of the road. There is a history of cholesterol issues on the side of the family that I take after, in fact. Knowing that going in, I try to control my diet and exercise as much as I can to help extend a good quality of life for me.

    For us, we aren’t holding out hope that we’ll find an affordable healthcare solution. Since we travel full-time, the ability to see *ANY* doctor at the time that something happens is an incredibly expensive proposition under most so-called “healthcare” plans. Ultimately, we went with a Health Share ministry and, while not ideal, it’s also the most cost-effective solution that we’ve found – by far.

    There’s no question that healthcare is stupid expensive. We have some of the best healthcare in the world from a technology and science perspective, but yeah, it’s expensive. The more that we can get taken care of in Mexico, the better. :)

    1. I will be curious to know how your experience with the health share goes over time — keep writing about it, please! ;-) And yeah, we’ll likely seek out care in Mexico and abroad, too, but obviously that doesn’t cover everything, like if we’re in a serious accident at home or discover an acute illness that needs to be treated NOW.

        1. That’s hilarious to me given that we are in medical cramming mode. So of course I’m like, “Go to the doctor! Don’t skip out on your preventive care!” ;-)

        2. I know I should…I did that about eight years ago, actually. Still remember it distinctly because the doctor was like, “I don’t usually see people who are perfectly healthy. Why are you here?”

          I made him do blood work on me. Everything was normal. :)

        3. I’m pretty sure docs only say that to guys. ;-) But Mr. ONL has gotten the same response!

  17. I used to work in health care and I even did some research that affected a small portion of health care provisions around prenatal screening in my home province. There is good and bad when the American system is compared to other systems like the Canadian one. The big plus is the ability to make enormous profits means great innovations. American health care innovations are second to none except possibly compared to Israel. The downside is one of the most fragmented, wasteful, inefficient, absolute-opposite-of-streamlined lunacy I have ever encountered. I wrote about it in detail in my own blog after my husband ended up in hospital in the USA. “Adventures in Wonderland: A Canadian navigating the American Medical System.” https://wordpress.com/stats/insights/fulltimetumbleweed.wordpress.com

    1. The (not) funny thing is that any American feels just as befuddled attempting to navigate our system. It is transparent to exactly no one.

  18. You could remake this article about being a victim of a crime or being unemployed. Some people love to blame the victim, no matter the topic.

  19. I feel your pain on a crappy immune system. That is me! My husband and I both got the same cold recently – a bad one. He was out for 3 days, and completely back in 1 week. I’m still coughing 8 weeks later. As encouragement for you… I did find that I don’t get sick as often since I retired. I guessed that this would happen because I’m exposed to fewer bugs, but also the massive reduction in stress gave my immune system the best help it’s had in years. Improved sleep helps too.

    A healthy lifestyle makes a difference to our health outcomes, but also I think it shapes a better quality of life. You may still get diabetes and die of complications from it, but you won’t die 10 years sooner, bedridden for 3 years, blind and tired (my grandmother). Trying to live our best lives everyday includes making healthy choices about food and activity, even if giving up cake is a sacrifice. The price of abundance is restraint. This applies to food, as well as finance.

    1. Oh man, I can relate on that cough! I toured Europe before my first year of college, got a cough in a hostel, and it stayed with me until the following spring! :-( And gosh I’m hoping we feel better after retiring! Many folks have told us that’s true for them, so fingers crossed. If nothing else, I’ll encounter far fewer bugs on planes! And totally with you on quality of life and healthy lifestyle. It’s quite clear what happens for people who stay active all their lives vs. those who don’t, and eating well increases our odds of living longer, healthier. So there’s no reason NOT to make those good choices, we just have to know that the choices alone aren’t a guarantee. :-)

  20. Oh man, you are spot on. Regardless of how you live your life, there is ALWAYS a risk of disease, illness/chronic condition, accident or injury, etc etc etc. Take something as “minor” as a bad cut needing stitches or a broken wrist. No biggie, right? Well… if you add on possible ambulance, medical, emergency room, and all the other costs associated, a “minor” problem can become a major pain in the wallet!

    I am a healthy late-20s woman who is very active and anyone who looked at me would probably think I have no medical costs. Autoimmune diseases are nasty that way. Without insurance, the cost to keep my autoimmune disease in check and keep me mobile easily costs $4,400+/month. I pay nowhere near this amount, but damn, that was a wake up call.

    1. Oh my gosh, seeing that number made me feel nauseous. I’m so thankful that you have insurance to cover most of that! Autoimmune is on the rise, and while obviously that’s a terrible thing, it’s my hope that more people who see health as something that can be totally controlled will see friends and family (or themselves) struggle with illnesses they could not have prevented, and they’ll change their tune.

  21. Thank you for the thoughtful post and for sharing your story! Your life is so inspiring and both of you are beating the odds. It’s amazing what the human body is capable of surviving. I believe health is something we can and should spend energy looking for. It certainly matters more than most young people understand and maybe even more than financial health.

    For me, my financial awakening and health awakening happened around the same time last year. I had been throwing my life and time on Earth away in a sense by spending all that I made and indulging in almost any rich fattening food I could find. My body was giving me signs that it was unhappy – I had high cholesterol IBS and acid reflux as well as reflux aspiration at night which gave me terrible sore throats. These are problems that eventually lead to heart disease and cancer if not corrected. So I began doing the responsible thing and started taking medications to treat the symptoms. Then I met the woman who changed everything. Growing up in China, my fiance was raised with very different habits and a very different diet. She changed me without really trying to. I began to see myself as someone worth loving and turned my finances and health (diet) around.

    I want to say that you are right in so many ways. I won’t say that health is 100% based on your choices. I do depend on health insurance and I don’t believe health is just a spreadsheet where you can just check boxes until you’re healthy. And of course, there are some health problems that are totally out of our control. Genetic birth defects being big ones. But I will respectfully disagree with the notion that some people “eat right and exercise and do everything right and still have major health challenges.” I would say that they’re not eating right at all. In fact, my notion of healthy eating has been completely turned onto it’s head and I believe most Americans have no idea how to eat right. I’ll try to explain why I feel this way next.

    Now, this is my story and anyone is free to disagree with the claims I make. But I will say that I’ve studied health and nutrition even more than I’ve studied finance and the fire movement. It’s a desire I was born with. I am not a physician but I am a physician assistant who works in an acute healthcare setting doing anesthesia. I see the sickest patients in the country and most of them suffer from debilitating chronic diseases that are largely preventable. How? With diet. You’re on the right track Mrs. ONL in that procedures and medications are not helping people find health. They’re delaying the suffering or acting as a bandaid until more problems arise later down the line. (Ex. Taking cholesterol-lowering medications to prevent heart disease when the efficacy of these drugs is less than 5% and the main cause of high cholesterol is eating cholesterol containing foods such as cheese and meat.) I am also working on becoming a certified health coach in plant based nutrition and love teaching people how to cure their illnesses without medication. Yes, it’s entirely possible! I’m not so naive to believe that every disease is curable but the suffering for things that you wouldn’t even think would be related to diet can be at least partially alleviated by better nutrition. I’ve personally helped a few of my co-workers and my family members get off their hypertension and diabetes drugs without exercise or fancy surgeries. Simply whole foods.

    The very first source I found was recommended to me by one of the anesthesiologists I work with – nutritionfacts.org This website is a wealth of information about how diet and health relate to each other. Search for specific problems and you’ll find results that may help you. For example, how a high fiber diet helps prevent colon cancer, even in the genetically predisposed. Or how eliminating chicken and milk from our diet can reverse the symptoms of some of the worst autoimmune diseases. I recommend watching the video about the top 15 causes of death in the US which is on the homepage. Full disclosure, this website of course has a bias which is that the founder works for an animal rescue organization and cares about animal welfare. But the science he sites is legitimate. Much of what we see in mainstream media is not. Would you watch CNN for accurate information about personal finance? Then why would you believe a Time article about how butter is good for you? It’s industry sponsored science! After discovering nutritionfacts I read The China Study by Dr. T Colin Campbell and learned that some societies around the world have dramatically low rates of many diseases that we in America constantly suffer and die from. He analyzed the lifestyle factors of these societies and found some amazing correlations. I’ll let you discover those correlations for yourself if you’re interested. I’d also recommend Proteinaholic, How Not to Die, The Starch Solution, and The Cheese Trap.

    Now, my story is just 1 of millions but I feel it’s worth sharing. In September 2016 I switched to a whole food plant based diet and gave up all animal products as an experiment to see if I could drop the medications which weren’t really helping me. Within 1 week I stopped the meds because I felt better. Within 2 months my LDL cholesterol dropped 73 points. I found myself having more energy and better sleep as well as a newfound passion for life. And that’s what has led me here posting this comment.

    I don’t want to pester or accuse anyone of causing their own health problems. I just know that this diet worked for me and it has worked for countless others. I personally always thought I was a healthy eater. My typical day’s meals would be a 4 egg omelet with veggies and cheese, a turkey sandwich with spinach cheese and mayo, and a chicken thigh dinner with veggies and some casserole. I ate fast food fairly often and had high sugar drinks as well. Only now do I see the errors of my ways. There is no animal-based food that promotes health. If you’re thinking that your genetics are causing your problems you should evaluate whether those diseases you “inherited” are instead really from the diet choices you inherited from your family (who doesn’t love a good steak or mac n cheese?) If you find yourself wondering why health eludes you maybe you should experiment with diet. 2 weeks without meat won’t kill you. I’ve gone a year without it and I’m not dead yet (hooray!). Plus, I’m a cheese-loving Wisconsin boy and I never ever ever ever thought I would give up the food I loved. But sometimes, it’s important to delay gratification of something we love so we can earn something even better. In this case it’s health. Healthy food just makes you feel so good! At this point I’m completely convinced. It worked for me and I’m quite certain it will help you too :)

    Every bite of food we take can either promote health or promote disease. Foods that are grown generally promote health. Foods that are born generally promote disease. The choice is yours. And if we’re working on our finances with an open mind why not work on our health too?

    To your health,
    Josh

    1. I can definitely feel the passion you have for nutrition come through. However, I’m going to be blunt: you’re just straight up wrong about diet. I have spent virtually all of my life as a whole food eating vegetarian, and if you read this post, you’ve seen a partial list of the stuff that’s still popped up for me, some of it serious, and not all of it genetic. So that’s not to say people shouldn’t strive to eat healthily, but even the perfect diet is not magic. It doesn’t heal or prevent everything. I’m glad diet has helped you! But it’s worth considering that the research on vegan diets is mostly conducted by people who BELIEVE in vegan diets, and therefore aren’t neutral. That matters when we’re talking about science. And nutritional science is still too young a science for us to feel certainty about essentially any claim, especially when you consider that virtually every study ever conducted has been funded by a food company or an advocacy group. All of that said, keep up your great transformation. Whatever keeps you off meds is a very good thing!

      1. Thank you :) it’s been a good thing for me and my family. I do question my lifestyle every day, I am always reading and looking at both sides of the issue. My tendency to question everything is what led to my savings rate growing exponentially, it’s what turned my diet completely around and it’s what changed how I vote. I think it’s unwise to ignore all research on nutrition simply because we don’t know who to trust. I suppose time will tell what the perfect diet is and if there even is one. I hope I didn’t come off as attacking you personally. I really adore your writing and appreciate you what you’re doing for your readers. Best wishes :)

        1. I didn’t take it that way at all! :-) And I think that focusing on health and diet is super important, and totally applaud all you’ve done on that front. It’s just dangerous to claim that any diet, even if it’s the healthiest diet in the history of the world, can prevent or cure everything. I *wish* that was true. :-)

      2. I will also be blunt: jthom is correct on this one, not you. Your note that you follow a “vegetarian” diet is about as useful as saying you exercise “sometimes.” For example, there is solid evidence linking myriad autoimmune diseases to animal products, especially dairy. The difference between a whole foods vegetarian diet or a WF vegan one could be the difference between acquiring an autoimmune disease or not, or between needing a medication to control it or not. As a physician, I am concerned that your downplaying of the amount of control we all DO have over our health may harm someone by getting in the way of the facts. This information, as jthom states, is hard enough to find on its own for a number of reasons.

        I don’t think anyone is arguing that we have 100% control over anything, much less our health, so you sometimes come off as railing against a straw man on this topic. It’s more nuanced than that, and while I appreciate your knowledge of some of the social factors at play, it still sounds like you’re missing a piece of the puzzle. I don’t buy your uncertainty argument, either: this is the same line the climate change deniers are using. You have to dig beyond the industry claims to get to the truth. It takes more effort, but there is good science out there. Perhaps many of your readers would benefit if you read up on health policy and determinates of health, then wrote a more positive post about what we CAN do. I’ve seen you do this with financial matters that others are wringing their hands over, so I know you can do better with your thoughts on health. You’re right, the country is only talking about health insurance and cost. Why not improve on this by writing about what we can do to help our communities with food deserts, factual (rather than industry) nutrition information, volunteering with parks and free exercise programs, etc?

        With genetics accounting for ~25%, environment ~25%, and our behavioral choices ~40+%, moping about the influence of luck and shooting down the best available science feels counterproductive.

        As always, thanks for writing the blog. I’m sorry to hear about your health problems, but glad that you find them manageable. Best of luck ;) moving forward.

        1. I appreciate your focus on getting correct info out there, but I think you misread my post. This was a very personal post, specific to our situation, meant to highlight the larger point of stigmatizing those who struggle in all things — health, finances, sexual assault, you name it. As you clearly know with your background in science, those stats on 25% genetics, 25% environment, etc., are in the aggregate, across the full population, which is how statistics work. That is not the same as them being true in each individual. In any individual, that mix could be entirely different, or could be 100% one thing. I don’t think the whole internet needs to know my health history, which is why I said here that I wasn’t listing everything, but in my case, I’ve got a bum gene that dictates a huge number of physiological things for me. None are curable, and if you’ve been reading me for more than five seconds, then you already know that I don’t half-ass things, and that I have tried every possible dietary solution to help improve things, on top of having maintained a healthy diet for years — veg since age 13, vegan for more than half of that. I’m frustrated that you’re forcing me to spell this out for you because you chose to assume that my assertions on diet and exercise must be half-assed, which they are not. But bottom line, this post is simply offering our case study of two people who make healthy choices, care a massive amount about being healthy, and yet have some significant challenges in spite of that. (And perhaps it should have also touched on the judgment I often face from physicians who sometimes assume I must be lying about lifestyle, until they see my labs and eat their words.) Surely you have met other people like us in your profession. We are not unicorns here. Some people do everything wrong and manage to stay healthy. Some people do it right and are sick anyway. Overall, it’s about half lifestyle, but not for every single one of us. All of this is in service or arguing for a more fair and realistic attitude toward health care, which I also presume you are in favor of. My response to the last commenter, which you commented on top of, was more about the attitude of having certainty about something after having done it for less than a year, and despite not being a scientist themself. That is an incredibly destructive mindset, it’s one I work to counter on money issues, and I’ll keep working to counter it on any topic. Had the comment come from an expert on the topic, it would have been a different conversation.

  22. Interesting read and I think I agree with about 99%, but can’t help but point out where I do not agree.
    “And one of the biggest factors in poor health? Limited access to health care, especially preventive care.”

    One part of the health care debate that bothers me greatly is the whole “health care is a right” mentality and the idea that much of the problem is that there is too little access to the current system. I think a big part of the problem that I witness daily is that there is way too much access to the system, which patients insist on having because they have no idea of direct costs of since they are mostly passed on to third party payers.

    Way too many people on diabetes, heart and BP meds b/c it is easier to let insurance pay for the meds than to first take appropriate non-medical actions to prevent/control/reverse these conditions. Way too much “healthcare” provided in the form of people taking unnecessary antibiotics that then increase super bugs that then increase the need for stronger and more expensive antibiotics to treat the strains that we create, way too many people getting unnecessary x-rays of their spines for simple low back pain, which exposes them to unnecessary and possibly even harmful radiation and then often leads to more inappropriate and expensive tests and care, let alone the whole opiod epidemic all b/c health care providers are incentivized to keep patients happy and give in to their demands (even when unreasonable and not in their best interests) rather than make them mad to just go doctor shop somewhere else where they will eventually get what they want while you lose the business and create unhappy “customers” who bad mouth you for doing what is ultimately the right thing by the patient and the system.

    Sorry for the rant, but I have grown to have no tolerance for our system nor the political gamesmanship that goes on around it while it makes it impossible for people like us to plan and manage risk, causes regular working people to pay exorbitant premiums while still paying high deductibles/co-pays, and is driving good people (even those with insurance) to bankruptcy on a regular basis.

    I think the only solution is to go to a system primarily based on catastrophic insurance, while forcing people to pay for all of their routine care so they see what it actually costs and causes people to think before using health care services and bring the ridiculous health care costs down. I realize that this will never happen b/c many people would suffer from less access in the short term due to having to adjust to this drastic change to the system, but in the long-term think the only way to fix a system that is drastically broken is to drastically change it.

    1. I agree – how insurance works confuses many, I like the pay for it out of pocket and buy a catastrophic plan approach (outlawed under the ACA except for those under 30) because for most families this is all they need – and it makes better financial sense. 5% of the people account for 50% of the cost / spending and we know outside of medical emergencies, most of those 5% are in their last years of life or dealing with cancer.

      Access to care is not our problem, access to affordable care is and the ACA and anything that replaces it frankly will not address cost, in fact anything the government subsidizes inherently becomes more expensive (higher education comes to mind – the subsidy being the guaranteed student loan program)

      I had a conversation with my doctor about compensation based on outcomes and patients remaining healthy and he laughed. Who decides he asked? Easy to game the system, just get 20 something’s, your patients will skew healthy and stay healthy – you will look like a rock star doctor. In fact under the ACA there were incentives created to try and pay for outcomes under Medicare, it was being gamed by hospitals by their listing patients as “not admitted but held for observation”. My father had a series of 3 days stays while dying of prostate cancer that were “observations” and not admissions. The subjectivist of “what is healthy / who is healthy) would require a medical bureaucracy that would be worse than claims adjusters. I shudder at the inefficiency of that, the posts here prove it, sometimes thin non smoking people get sick, overweight people who smoke and drink don’t. Bottom line is I don’t see “outcomes based payment” solving the problem. The cost curve is all we have to work with. For example in the U.S. An anesthesiologist can easily make a million a year. His counterpart in the UK as a quasi government employee makes as much as an accountant. So unless we address the costs of medical training, malpractice insurance etc etc, just subsidizing poor people’s premiums won’t lower costs.

      No easy answer but for FIRE folks you have to look at what is happening today and plan for possibly 20 years of fully funding your own medical costs. It will be your biggest single expense.

      1. Curious where you live, Phil. Living in a small place has made us realize that access to care is more of a problem than people realize, and we’ve dug into it more to see that the problem isn’t ONLY affordable care. And you’re right that the system is deeply broken. Unfortunately I don’t think catastrophic coverage helps the problem because one ingredient in affordability is spreading out the risk as widely as possible.

    2. I totally hear you, but I think something that’s impossible to know is what would happen if we actually had the resources to intervene sooner OR to truly PREVENT those unhealthy habits in the first place (what I meant by preventive care, maybe not what the industry means by it). I’ve definitely seen older people unwilling to change their habits because they don’t see the point, perhaps because they’ve never seen anyone in their own community actually get healthy and change their life and health. I think this stuff is massively complicated, and give that we’ve never actually done it right, we don’t really know what works, and we’re mostly getting frustrated that interventions don’t work which might very well be coming too late.

    3. Hear hear! I would support a very bipolar plan–one that covers actual *preventive* health advice/checkups and also *catastrophic* care, but not all the little stuff in between. Immunizations, health counseling, and getting run over are covered; stitches, mammograms, and non-genetic heart attacks aren’t. You’re so right about the public knowledge-access gap.

      1. How does not covering care address the knowledge-access gap? And not just perpetuate the wealth gap, making many forms of care something only rich people can afford? (I assume your plan would also eliminate prostate cancer screenings, which are largely a waste of resources, and not only care that’s specific to women.)

  23. I think you see this sort of issue come up a lot in our political thinking. There’s this false dichotomy that something is either out of people’s control or it’s dependent on personal responsibility. This could be related to health or financial success or whatever else. I think it’s a result of us as humans wanting issues to be easy black & white problems with simple solutions, rather than complicated and messy, as most of our societal problems actually are. So people in the “out of control” camp think we need more government involvement to solve the issue and people in the “personal responsibility” camp think that if individuals just lived their lives differently, there wouldn’t be a problem. I don’t think either side is right and, when it comes to health care, you rightly point out that there are aspects of the picture on both sides. It seems like that false dichotomy just results in a lot of finger pointing and animosity, rather than a real look at the sources of the problems and an attempt to fix the situation.

    1. Amen! The black-and-white thinking is essentially never correct, and it just keeps us farther from real solutions. So frustrating!

  24. Kudos for taking this subject on. I dreaded coming over here with the thought of seeing the haters spewing misinformation from both sides of the aisle. Happy to see your readership does not partake in that.

    Tackling autoimmune disease is brutally hard. In essence,driven by trying to walk the very fine line in dampening down a system that is there to protect us from all sorts of deadly pathogens. But not dampening it down too much to risk serious infection. I don’t doubt for a second what you and Mr. ONL need to deal with and wish you both well with a favorable prognosis and treatment.

    Great progress has been made in automimmune diseases like rheumatoid arthritis (with the anti-TNF blockers such as Humira, Enbrle) and psoriasis (the anti-IL12/23 antibodies such as Stelara and anti-IL17 antibodies such as Taltz, Cosentyx) from the likes of Novartis, Amgen, J &J, Eli Lilly and AbbVie. THese therapies have been transformational and nobody would have believed that 15 years ago.

    But huge unmet need remains in Crohn’s, Ulcerative Colitis, Lupus, Ankylosing Spondylitis, Sjogren’s. Scleroderma…..the list, unfortunately, goes on. Twenty plus years working in this field, a career / life endeavor to be honest, and a big part of WORK that I am actually going to miss dearly when I pull the plug. The fight continues and I am proud to share office space, walk the halls and laboratories each day with innovators taking this fight on.

    Pricing of pharmaceuticals is complex. Unfortunately, media focus on the likes of Martin Shkreli and his despicable behavior, tars the whole industry. He is utterly despicable, the industry in general is not. This comment is not intended to either protect or bash the industry.

    Here’s a different perspective that may be eye-opening for you and the readers. Merck, just yesterday, released a summary of the registrational trial (REVEAL) of their CETP inhibitor – it met it’s primary endpoint in a massive cardiovascular outcomes study. 30,000 patents involved, conducted over the past 7 years at >420 hospitals / clinics in >10 countries, coordinated by the CTSU at U. Oxford, UK. Will they seek approval? Who knows, but I doubt it, based on the vague messaging within the press release. Why did they conduct such a massive study? The FDA asked them to. How much did this single study cost them? I have no line of sight into Merck books but I will bet my house it is north of $1 billion. Fair play to them for having the guts and risk tolerance to take this on. And this is in a disease where we know so much about the key players (LDL/HDL) and associated genetics. Trying to make major inroads into treating diseases that we know a lot about is still very hard and costly. Trying to make progress in incredibly complex diseases in the field of autoimmunity is another level of hard. But please keep believing. Many of the pharmaceutical companies fighting this battle are weighted heavily in the SP500. Another reason to send a check to Vanguard each month and buy VFIAX – it may well turn out to be a great investment both personally and financially.

    1. I really appreciate you sharing this, Mr. PIE! I thank my lucky stars that my autoimmune is celiac, which is food-treatable, and restless legs triggered by the celiac. So I don’t have to take on any of those hefty biologics. And Mr. ONL’s drug needs thus far haven’t escalated that far, but it’s too soon to know for sure. In any case, I’m thankful for you and other folks who dedicate their careers to helping people who need it. I just wish the pricing wasn’t so complicated.

  25. Fantastic post! It drives me nuts when people make the argument that just making healthy choices will protect them from having any health issue. Despite the fact that it just isn’t true, it certainly won’t help prevent them fro being in a car accident or any other type of accident. We are human beings so the variability of our health experiences is just enormous. There will always be extremes on both ends of the spectrum – health nuts who have major health issues, or not, terribly unhealthy people who don’t try to take care of themselves, or even unhealthy people who are lucky and just never get sick and live into their 90s. This is why we need to do what we can to control costs and improve efficiencies, while at the same time have a health care system that covers everyone so all those extremes are covered and everyone in the middle balances everything out. For every person you can point to who seems to be at fault for their health situation, there is someone else on the other side who just seems to have lost the coin toss.

    1. All well said! There are so many people who just see themselves as invincible and think they’re in total control.

  26. OH MY GOSH YES to this entire post! I work in big pharma and see the intricacies day in and day out – formularies, exceptions, authorizations, determinations, EMRs, etc etc.
    I know the idea behind EMR integration for was physicians to be awarded based on overall benefit to the patient rather than running an assortment of tests and throwing out the first treatment they think my be applicable, but I still think it’s too data driven. I read a great post just earlier today from an NP who said EMRs are triggered to alert doctors to take action if a patient’s BMI is outside the normal range. Patients need to be seen as a WHOLE PERSON! We are all an experiment of one in this world and it’s frustrating that our country is trying to treat everyone the same way through a variety of companies with a variety of mediciations.
    One of my biggest fears with the possible change coming down the line is that so many people will loss access to coverage. I think one of the biggest keys to healthcare success is preventative care – who’s going to seek preventative care if they are uninsured and have to pay outrageous costs for it?!
    #endrant

    1. Thanks for sharing all of this, Amber! So many things here — seeing patients as whole people, the need for more prevention, all of it! And I think “preventive care” is itself almost too late in many cases. We need a healthier culture from day one. Not that that will prevent everything (hi), but it would help a lot of people AND reduce our costs.

  27. Yucks didn’t know you guys are that SICK! (I’m being sarcastic here!)

    You’re absolutely right that health is not something you plug into a spreadsheet and calculate. Even if you eat healthy and do all the healthy stuff, it doesn’t guarantee you a clean sheet of health. For that reason alone I’m so glad the Canadian universal health system. Yes there are faults behind the system but at least everyone is covered and you’ll get health care regardless how much or how little money you make. I can’t grasp the whole concept of US medical insurance.

  28. The fact that people treat health care like it’s optional or only belongs to the deserving is so similar to the sentiment that only the “deserving poor” should be helped, and it makes me a bit sick to my stomach that people think that we don’t have the right to have access to health care. Of course people make poor life choices but as we can see just from the comments here, those choices can often have zero affect on our health.

    I was an incredibly active and healthy person before my chronic disease came down to bear – I participated in multiple sports and was more active that your average three people. That didn’t do a thing to help me out. A friend of ours was even more fit and active than I used to be when he literally dropped dead at age 25. Coming back from a workout, no less.

    Some people fail to take care of their health and that’s frustrating. I know that frustration first hand. But to base the availability of health care on preventing the “undeserving” from accessing those services … I just don’t know. It makes me question humanity some days.

    And the thought from a comment above that doctors make more money by not completely healing you — I have seen and worked with hundreds of doctors in search of a cure and while many of them weren’t good at their jobs, I haven’t ever seen a doctor who thought that way. Maybe some business people in big pharma do, but actual medical practitioners?

    1. I am TOTALLY with you, and just wrote that back in another comment. I have seen PLENTY of doctors and have never met one who didn’t genuinely want to help. Sure, some were too old school or just not that good, but none of them were in some way not trying to fix me.

      On the “deserving” question, YES. Exactly. And the privilege piece was hard not to include here, but I held back to keep the focus on health care alone. It’s exactly the same, though — not realizing that some people are luckier, and not everyone has the same opportunity to make good choices.

      Plus all of this focused on once we’re already sick. Changing long-ingrained bad habits is so much harder than providing support to not develop them in the first place, or to create healthier cultures and communities. Of course, that’s all aside from the stuff you face that’s seemingly random, and same for us though less severe.

  29. My dad ate healthy foods, was slim and walked three miles every morning and still got Parkinson’s, which is truly a form of hell on earth. It killed him eventually. I’ve run 15 marathons and played thousands of hours of competitive tennis but still have managed to survive two Gray’s Anatomy type incredibly rare afflictions that may be gone forever or might come back to see me again. When there is no known cause or cure for something then there is no real way to know. I’m early retired and my freakish medical history has me hoping they don’t eliminate the preexisting conditions thing! Outside of the unexplained I’m one of the fittest guys of my age in my world, but so what?

    1. I’m so sorry. I’ve seen Parkinson’s up close, too, and it’s a horrible disease. And I understand living in health limbo, so I’m sorry about that, too. As for the pre-existing condition piece, if some version of the current bill goes into law, the pre-existing question will be based on a state level waiver, so it might be worth considering what state to live in based on that!

  30. Although you and I will probably never see eye to eye on policy implications, I love the narrative and the personal implications you’ve laid out here (and the implicit dig at employer provided health insurance which you didn’t intend, but I will totally read into your story)

    If I could magically wave a wand and change the whole healthcare conversation, I would magically invite people to use nuance in their opinions. Not every healthcare decision is life and death, and not every person (nor every physician) faces the same decisions.

    And since I’m commenting on your blog, and not going to write a post about it, I’m going to share my pet nuance…

    I believe we need to consider the differing needs of at least 6 different healthcare consumers, and probably more. This is sort of a crude way of defining healthcare consumers in my opinion:

    Poor people (both healthy and unhealthy alike, since society will either implicitly or explicitly shoulder the medical costs of the poor in most cases)

    Healthy Middle Class and Rich People (Who can generally thrive under even the most ridiculous health policy regimes, and should generally shoulder their own medical costs)

    Moderately unlucky middle class people (Those with chronic illnesses requiring costly pharmaceuticals or frequent input from doctors. These are the folks- I guess including you- for whom the insurance model is probably just wrong. Doctors don’t have the right incentives to pay attention on a case by case basis, drugs are expensive, etc.)

    Very Unlucky Middle Class People (People who need regular surgeries, brain scans, and other high cost procedures. These people cannot possibly pay for all their expenses on their own and for whom medical bankruptcy would actually be somewhat devastating. This is another tough nut to crack).

    Unlucky Rich people- These guys should probably just pay for all the private care they want. They can afford the drugs and the doctors, and I’m not too worried about them.

    Very unlucky Rich People- Outside of the top 1% even rich people can’t pay for $300,000 surgeries, $90,000 bi-paps and $25,000 of drugs every month. They might muddle along for a while longer than the poor or middle class, but soon it would be devasting too.

    1. I tend to lean towards Mrs. ONL’s opinion, but this is interesting. If I understand correctly, you’re proposing some type of high risk only government-subsidized medical insurance. (Those living in poverty qualify as high risk, because without economic means you end up in the ER faster.) If so, I haven’t thought of anything I don’t like about it except for the fact that because middle class families will lose their subsidies, it would require more sympathy rather than less compared to Medicaid as is. And it would appear that a loud group of people don’t even have sympathy for that. Also, who would decide what qualified someone for each category? I’m getting denied benefits for my kid now within their current plan. If a treatment or piece of equipment qualifies as free under a specific dx, who will decide which diagnoses are deserving? All of this is just thought play.

      Or maybe I just read waaay too far into that.

      Mrs. ONL, is this a giant subtweet? If so, you took the words out of my mouth. The whole concept is gross.

      1. I actually tried very hard not to propose specific policies in this comment. That’s because health care is complicated.

        Under the current health model in the US, either the government or a corporation is imposing cost controls (ineffectively, but ignore that for now). I believe that market pricing is a superior method for controlling costs. I also believe that a market system tends to be superior for addressing the needs of a diverse population.

        That said, “efficient markets” wouldn’t be expected produce the distribution of health coverage that a society like ours requires. For one thing, some people would be priced out of health care. For another, moderately and very unlucky people may not find affordable care within a market system (even if there is a market price and they can shop around which isn’t a reality today).

        As a result, I suspect that government intervention is required at some level or other.

        Would that look like lenient bankruptcy laws? State run health care for some? Direct subsidies to people? Government insurance for high risk patients? I don’t know. I’m not a health policy expert, and I can’t pretend to be.

        Even if a well designed policy addressed the general cost questions, we would have to figure out a whole other set of policies for pharma and medical equipment.

        At the end of the day, I suspect that a free market would yield better results overall, but the market needs to supplemented with cash transfers (at amounts not determined by me) to some people (also not determined by me).

        Messing with taxes is far better than messing with market prices.

        But if the free market is utterly intolerable, then let’s just go ahead and have state medical care because the corporate insurance model costs a ton and is unbelievably stupid.

        1. I wish I could get on board with a free market model, assuming it would somehow cover everyone and not leave people behind. But in so many aspects of life that are free market, the result is that the service and product quality get worse and worse over time. When was the last time someone said at a furniture store, “Wow, this new stuff is so much better than the solid wood they used to use!” Who has ever said, “Airline travel is better than ever!” Who has said, “It’s such a nice problem to have that my electronic devices are so well made and never break.” I could keep going, but I know we’ve all had this experience. And if my future health care is the equivalent of Ikea furniture, I’ll be not only disappointed, I’ll be terrified. That said, I’m not remotely attached to corporate health insurance or to the employer-based model we’re so reliant on now. I’d rather see people feel more job mobility, which would spur innovation, and I’d like to see some health care system in which the incentives are built around making people healthier, but where cost-cutting is not the sole focus.

      2. This might be a giant subtweet. ;-) I think everything I’m writing these days is one of those. Haha.

        I think the thing that frustrates me more than anything is realizing that the people in charge of this stuff and arguing for it don’t even understand the things they’re talking about. Like the lawmakers who want to cut Medicaid but then say this won’t impact seniors. (Oh, really? Because Medicare covers nursing home care? Oh no, that’s right, it doesn’t. It’s Medicaid that does that.) If we could have a discussion from a place of shared understanding, I’d be more than happy to engage in the discussion, but it’s awfully hard to want to discuss this stuff when we can’t agree on basic facts!

    2. Amen to nuance! And I think the categories of people make sense under routine care circumstances. The problem is that anyone get cancer anytime and get wiped out financially, except perhaps for the super rich (way higher than 1%). Same for a car accident. I agree 100% it would be nice if there was a different payment model for chronic stuff, but I also hate that these discussions of incentives seem to imply that doctors only do things because of the profit model, and not because they genuinely care and want what’s best for their patients, which I don’t believe for a second. (Well, okay, maybe aesthetic plastic surgeons notwithstanding!) So I don’t know where that fits in your model, but I want it reflected in the record. ;-)

      1. With regards to very healthy people (middle class and up), I think health insurance or other forms of voluntary mutual aid make a lot of sense. That way if you get cancer or hit by a bus, others will pay for that very expensive treatment.

        If someone has recurring cancer, I think they stop qualifying as healthy, and pass into the very unlucky bucket.

        I’ll force you to read my reply to Femme with regards to “policy implications” of that (which are sure to disappoint, since I won’t really give any).

        With regards to physicians: I think it’s important to recognize that physician’s can and do simultaneously care in an emotional/spiritual realm while still responding to economic incentives. For example, my mother in law has a heart of gold, and I’m sure if she could have broken even in her practice, she would have continued as a solo practice as long as possible. Unfortunately, she lost money for 3 years and had to move on. Now she works at a larger non-profit practice that gets reimbursed by Medicaid (sometimes).

        The clearest way we see physician’s responding to economic incentives is in how they organize their practices and how they bill their patients. If more patients paid out of pocket for physician care, we would see different configurations of physician practices. What those would be, I’m not sure. I am sure that the fee for service reimbursement model of medicaid and health insurance plans does not lend itself favorably to diagnositic investigation or care for those with chronic care needs (especially undiagnosed chronic care).

        Of course, physician care is just a single element in the health care puzzle.

        1. I totally agree with the larger point that patients being insulated from costs is a big part of the problem, and think a lot more minor care would look different. But then when something big and scary happens, it’s a very good thing we don’t know what everything costs, or we might hesitate to undertake the needed treatment. I think about taking our dogs to the vet or taking ourselves to the dentist. Everything is a much more options-and-costs-focused conversation, instead of saying “this is the thing you have to do.” I wish, at a minimum, it weren’t taboo to have cost conversations with health care providers, but I’ve found when I’ve broached it, most doctors don’t even have a clue what the things they are recommending cost!

  31. Thank you for this post. I normally don’t comment but you really hit home with this one. I watch my husband suffer daily. It’s as if has a title of his forehead of pre existing condition..and you will will pay for me. We were planning on retiring early but one day changes your entire life. I will continue to work to make sure he has excellent health care and access to quality providers. I just so wish people were not so judgemental of others who know nothing about our lives. He was the hardest worker I ever met, was raised super healthy and as an young man took excellent care of himself. He should never have to explain that to a stranger. It’s actually super heartbreaking.

    1. It makes me so angry to hear stories like yours of people having to explain themselves to others. I’ve experienced forms of this watching loved ones with physical disabilities that you can’t see so obviously getting questioned by strangers for parking in a handicapped parking spot. As though it’s those people’s business. Heart breaking indeed. I’m so sorry. :-(

  32. Gosh we are so lucky to have medicare in Australia. At least when you are sick or elderly, you don’t have to worry about the financial side of things too much the basics are covered. Because you need treatment without the worry of cost! We might have high taxes, but I love that means if you are wealthy to dirt poor you will be treated. We just had baby #4, and went ‘public’ for all our babies. This means a hospital birth, with no costs to us and a great outcome. And since we don’t want any more children, DH got the ‘snip’ for $0 as well. It is interesting that one of the most wealthy countries in the world (America) can’t do this for it’s people. I love where I live!
    Health care for everyone is one thing I am happy to pay taxes for.

    1. Yes you are! And you’re right — it’s horrible that in one of the wealthiest countries in the world, we can’t at least provide basic universal care. I’m glad, though, to hear stories like yours to know that not everyone on the world has lost their mind!

  33. Not sure how to respond to your health reveal you just did. Kudos for doing so and at the same time living the life like you do.

    I agree, health is outside our control for most of it. I also have some health conditions I am born with, a random act of nature, part of the evolution. It tries things, some good, some bad. No need indeed to blame people for a health problem.

    The part missing is the health impact from accidents. Once I got hit by a car while on my bike. No real damage, lucky here. A few weeks later, I see a car catapult a biker, serious damage. And these are things we can not control.

    1. Thanks. :-) We really don’t FEEL sick most of the time. But we never forget that stuff is there. And you’re SO right about accidents. Fortunately car accidents are less deadly than they used to be, but you just listed two terrible examples of why we can never get cavalier about health care, even if we feel healthy.

  34. This one certainly hit a nerve! In the FIRE community, the cost of health care is of course a hot topic, but it’s also huge everywhere else. Buffet says that US health care costs are a much bigger competitive disadvantage to US companies than our corporate tax rate as an example.

    I’m a huge believer in the market and personal freedom but health care is different than other goods or services you guy. It’s exactly the type of thing that insurance is for. More to the point, it’s exactly the type of thing a government can actually help their people with (along with infrastructure, national security and a few other things). In Europe you pay high taxes, but at least you get health care and education with them. We pay pretty high taxes and I’m not sure what exactly we get. We criticize fellow American’s for being consumers and wasting money but the big costs compared to decades ago are childcare, education, and health care. These are big hitters that need to be addressed.

    Health costs are the leading cause of bankruptcy. And most of those people actually had insurance! That is scary.

    Plus, even if you plan to be healthy and not incur costly health care, you still have to pay for costly health insurance which is eating up a pretty large part of everyone’s budget.

    In the end, it’s the actual cost that needs to be addressed. We spend a lot more for the same or lower health outcomes. Unfortunately, that doesn’t even seem to be on the radar politically. At some point, just like student loans, it will become such a financial burden that it starts to crumble. Unfortunately we seem to need a crisis to act even though it’s much less painful to be proactive.

    Thanks for letting me add a small rant to rest :)

    1. Oh I think it’s on the political radar. ;-) It’s just all become too politicized, which means it might be too much on the radar. And since you raised the question, our biggest discretionary spending line item is military, and here’s a breakdown on tax rates by country, showing that we pay a LOT less than countries in Europe: https://www.forbes.com/sites/niallmccarthy/2015/03/19/the-countries-with-the-highest-income-tax-rates-infographic/#5b4572855371. That false narrative that we pay high taxes is part of the reason we’re having to have this discussion instead of already having health care under control. But I totally agree that health care is fundamentally different from other goods and services!

  35. I work in healthcare administration for a large provider, and yes, delivering healthcare is so unnecessarily complicated and inefficient in this country. It’s absurd and drives wildly inflated costs. (I left a role in industrial supply chain consulting, so the efficiency contrasts are stark) There are massive divisions, heck entire companies, dedicated to manage the “revenue cycle” or labyrinth of contracts brokered between providers and insurance companies on behalf of their clients. Private insurance companies essentially work as claims clearing houses, shuffling bills and payments between providers and employers/patients.

    The ACA created some incentives for providers to reduce unnecessary value-based care models, some of this resulted in large companies contracting directly with providers for certain procedures (joint replacements) or disease types (heart failure). These contracts were typically paid via “bundled payments” which left it up to the provider to drive their margin by reducing costs. So, cutting out the insurance company all together, which sounds good, but actually creates headaches and additional inefficiencies for companies because now they’re managing healthcare contracts for various procedures/diseases – which is not core to their business and (possibly) not worth the savings.

    Plans and providers have been racing for scale to out leverage each other for years now (also an ACA outcome due to the push to move away from fee-for-service), many providers have gotten large enough where they feel they can assume risk for a patient population to offer their own insurance plans and sell directly to consumers. Kaiser Permanente is an example of this. Again, running an insurance business is a whole new territory for providers, so it’ll be slow going, but possibly a more widely available option in the coming decades – could be an interesting avenue for early retirees if these provider-offered insurance plans end up in price competition with each other.

    Frankly, our healthcare system is a total boat anchor for companies in the US. The most efficient way to deliver healthcare is either via a single payor system or driving price competition by selling direct to consumers. AAAAND, sorry for the long comment…it is such a “FIRE-y” topic right now. #punwin

    1. Thanks for sharing all of this, Kate! There are always more layers to learn. (Also, yikes.) I am currently flying in a United plane at 36,000 feet, and that feels like the example people should keep in mind when they talk about things “improving” because of price competition. Are we all so much happier now that airlines are fully deregulated and cheaper than ever, or do we feel more like cattle and more disrespected than ever? It horrifies me to think about health care moving in a similar direction. And not saying any of this to argue with you, but to say not only how broken it all is, but how fraught the likely solutions are, too! (Though I’m fully on-board with single payer, if that’s not obvious.) ;-)

      1. I think price competition is great…when you’re buying a bag of potato chips or basically anything from a big box store, but healthcare services are different, because as you say, one doesn’t REALLY have total control over ones health. Single payor, plus a market for supplemental coverage is the way to go, in my opinion. If you’re interested, there is a book called “The Healing of America” by TR Reid that I found interesting, it outlines different healthcare systems around the globe and pros/cons of each.

        Its too bad that single payor has been associated with being socialist and un-American. I think if we could figure it out, private business, and thus, the economy would really soar.

        1. Thanks for that book rec! And yeah, things get so politicized so quickly these days. It’s easy to envision an alternate present in which the coin flipped a different way that day and the right decided that single payer would be their issue because it’s overall cheaper. Sigh.

  36. Fantastic post! So much is truly not in our control. It’s a perfect example of the kinds of things insurance with a big risk pool is designed for.

  37. Thank you for saying my health issues aren’t my fault! I’ve never smoked in my life. I’m a classically trained soprano. Nobody breathes better than me. And yet, when I’m active, I have to have supplemental O2 due to a lung disease. Even my pulmonologist cannot tell me why or how I developed this condition.

    But don’t feel sorry for me. We pulled the job plug at the end of 2014 so the DH and I could live a little! Make that live a lot. We’re booked on a round the world cruise leaving LA next January.

    I remember Bill Clinton’s Surgeon General Jocelyn Elders saying, “People all the time are dyin’ of something.” Truer words were never spoke. But I’d encourage you, Mrs. ONL, to remember the genetic arrow with your name on it is not here yet. And even when it strikes–if it strikes–, promise yourself to live each day with as much vigor, joy and love as you can.

    Health insurance or not, that’s really all any of us can do.

    1. I’m so impressed by your positive attitude, and also glad for you that you were able to make your escape from work! Your RTW cruise sounds wonderful! And it’s true — there are a bunch of health issues I DO have, but the big one that I’ve in many ways built this plan around doesn’t seem to be here, at least yet, and my chances get better with every passing day of dodging it. I am grateful for that every day!

  38. So there is a lot contained in this post, both explicitly and between the lines… I think you might be able to make health care discussions a little side series if you wanted. :) Health and health issues are good reminder that we have a lot less control than we like to think.

    I’ll start with this – the ACA wasn’t perfect when the legislation was implemented but it was never meant to be the be-all, end-all for health care in this country, merely a step in the right direction and while it is fraught with issues, it did give a lot of people access to health insurance who previously did not have access. Also remember that it was supposed to be a long term solution with some costs up front but lower costs in the long run. And then let’s look at the data… in states like *ahem* Kentucky who participated in the medicaid expansion the health outcomes have been positive. Here is an excerpt from an article:

    https://www.healthy-ky.org/newsroom/news-releases/article/81/the-aca-in-kentucky-significant-increases-in-both-public-and-private-health-coverage

    Chandler offered more detail: “Our uninsurance rate has dropped by more than half, more Kentuckians have a regular doctor, more have visited their doctors in the prior year, and fewer Kentuckians are delaying or skipping health care because they can’t afford it. Moreover, Kentucky has seen significant increases in the number of people covered by both public insurance ─ largely Medicaid ─ and by private insurance. And the increase is markedly higher than in states that did not expand Medicaid under the ACA.”

    My sweet husband is a nurse, most of his career has been spent working in the ER in our large metropolitan area, many of which in the busiest ER in the county. Yes, there is abuse of the system. He has been verbally and physically assaulted. Yes there are drug seekers. Yes, too many tests are typically run (but some of that is so that doctors and hospitals can protect themselves from litigation). He has more anecdotal evidence of the BS that goes on than any one person should have but he also has a lot of empathy and knows that a lot of his patients over the years have really needed the ER’s help. For soooo many people, this is the only way they can access the health care system when they need it. It sucks.

    Hannah’s post about the nuances here are quite insightful. This issue is so freaking large and complicated, but since I like to bottom line things, I think that you either believe that universal access to healthcare is a fundamental right of citizens of our country or you don’t (access to public education is *supposed* to be a fundamental right of our citizens too). If our healthcare system were so excellent, our health outcomes should outpace every other country on the planet. Not only do our outcomes suck, the price we pay to access those crappy health outcomes is outlandish.

    On a positive note, I have this idea that folks who are part of this early retirement community might be able to create something sort of like those Health Sharing Ministries thing that Steve @ Thinksaveretire has discussed without having the religious component. Maybe we can use our collective outside of the box thinking to create something awesome?

    To bring it back down to the dollars and cents, you are totally correct Ms. ONL, this uncertainty can be disconcerting for those trying to plan appropriately for early retirement. Thank you for sharing some of your story – I can see why it weighs heavily. Even if our country can’t get their $%^# together on how to handle healthcare, I am hopeful that my home state of CA keeps moving in the right direction.

    Ok, I’ll get off my soapbox. Thanks for listening.

    1. And I didn’t even get into the ACA stuff in this post! ;-) This is the issue where it’s been toughest to stay non-political here, which is important to me, because some of the discussions that happen just have me violently scratching my head. Because they ignore ACTUAL COSTS. And, as I said at the start of this post, no legislation has ever attempted to take on actual health care costs, only insurance rules. We need a much stronger culture of health in this country, so that people are taught the benefits of healthy lifestyles from day one, they’re given access to preventive health care all along the way (not just after it’s too late and hardly counts as preventive anymore), and we either need to think of health care as a universal right or we need to stop griping about its cost to society if we don’t provide it to everyone. Okay, that was my soapbox in return. ;-)

  39. Very thoughtful post, and so very applicable to our situation. First of all, I’m a long time “preexisting”, having had type 1 diabetes for 25 years. College athlete, active as a young adult, and a resurgence of that in my 40’s that included many triathlons, half marathons and shorter and a couple of full mary’s. I’ve put on some weight due to menopause, injuries, and life stress, but in the grand scheme still do OK.
    Hubby worked for a major airline and “retired” after 35 years with them. I’m an accountant, and have worked for various employers for almost 30 years, mostly full time with a few part time years caring for my aging father-in-law. We pulled the FIRE trigger about a year and a half ago. Started our own part-time virtual bookkeeping business, and were ready to take it on the road for a couple months out of the year. The camper search had begun! Hubby’s company reneged on providing us with health insurance in retirement (he retired two years too late for that), so we stuck with my cobra for a year, and were looking at exchange plans for our future insurance needs. Turns out none of our doctors or local hospital accepts exchange plans, and due to me being “preexisting”, I cannot get a policy off the exchange no matter how much I’m willing to pay. Medishare arrangements also exclude my condition. Add to that my annual eye exam didn’t go so well this year, and I’m about to undergo some expensive treatments to fight to preserve my vision. Add to that also the crazy talk going on in congress with healthcare “reform” that will do nothing but make things worse. The stress of all of that was making me unable to enjoy the time that we had carved out. So I started a new full time job less than a month ago. We closed our business, and gave passed our clients on to colleagues/friends. Now I’m literally back to working full time JUST for the insurance, as we don’t really need the salary to lead the kind of life we want. That’s fine for now, but it seems those in our situation are looking at no way to actually retire before 65, no matter how much we have saved and planned. Sorry for the long comment, but your post was so refreshing to read as it states so much of what is true about our situation.

    1. Hi Carol — Congrats on having FIREd, even if you’re now back at work. No one can ever take that accomplishment away from you. And I’m bummed for you that you’re back at work for insurance. As for your pre-existing condition, the current rules in place under the ACA bar anyone from denying you coverage based on a pre-existing condition. You could potentially be forced into a high-risk pool, but not denied entirely. Have you explored any other states, since some states have deliberately sunk their exchange plans to hasten the demise of the ACA, and that leaves people like you with fewer options. All worth looking at. And if the new bill passes, then it may DEFINITELY make sense to consider which state to live in, because the pre-existing condition coverage will be a state-level waiver, and it’s likely that the states that have expanded Medicaid will keep the pre-existing condition coverage requirement in place, while others will take the waiver and leave you in a bad spot. Good luck!

      1. Thanks for you kind and thoughtful reply. We are definitely considering options on living in another state. In fact, my first vacation may be at least somewhat about exploring one of those options. I waver between being OK with the work arrangement, as I do enjoy the people, to being quite sad about it. I’m good with working towards a goal, but this just feels like treading water in the middle of the ocean. Hopefully we can carve a new plan out to start swimming towards shore again, just not sure which shore!

        1. Sending you good vibes as you figure out some of these big questions! You’ve done it before — I know you can do it again! :-)

  40. I think we may have heard about how health is the true wealth. Without health, all those great plans being made won’t come to much. But I also think its about we can control and what we can’t. For that which we can’t, we try to mnimize its impact on us. For that we can control – we do the plans and execute. But the common denominator is time. We are all short of time in today’s world. Now, in my parents generation, did it matter – this thing about time? Absolutely!! The most striking example I have took place in my own family where my dad retired from being an English teacher when he turned 55. But he did not really have a retirement as he spent the next 6 years caring for my mother who had a terminal brain illness. She passed on 6 years after my dad retired in a situation which I called as ” my parents were robbed of their retirement years”. The years should hve been spent together, enjoying themselves, their children and grandchildren. Alas, that did not take place. And we see many variations of the same across the years. Another one took place as recently as 5 years ago, when a close colleague of mine lost his wife to an illness and he was just 3 years shy of the retirement age at 55. After the funeral, he told me with tears from his eyes, ” Its not supposed to be this way…” .
    Very few folks I know are in perfect health of body. But you see the price people are paying to achieve that perfect, financial health at great expense. My wife and I decided 20 years ago that we would not follow that same path. Since then, we have made decisions around choices that put us in a favorable position to retire ealier while we still have got most of our health intact. We acheived debt free status 1 year ago and financial independance around the same time. We are now in the last phase of my planned work life/career and truth be told, its exciting yet scary.
    But we kept to the our plan and now have a self sustaining wealth engine that has been optimized to not just deliver what we need today and in the future for a married couple, but also to begin building the intergenerational wealth that will count as our legacy for generations ahead.

    1. I admire the fact that you’ve been able to pursue FI while also not working yourselves into the ground. We reached FI last year and are close to early retirement, but both goals have definitely come with a big cost to our health, especially in the form of high stress and sleep deprivation. So we’re hopeful — based on what we’ve heard from others who are already retired — that our health will improve a lot when we retire soon! I’m super glad for your sake that you’re able to achieve it all with your health still intact! Sending you best wishes that it stays that way for many years to come.

  41. My girlfriend was born with a disability. When her job ended she had to take a new job quickly because going without insurance could be deadly. This is true even though she barely uses her insurance and has not been doing the maintenance things she needs to live her best life. Coordinating all of that is hard in our system. Hard to navigate. Hard to pay for.

    I don’t have a disability but have paid more for healthcare in the past year and a half than she has. It took a long time to figure out that I needed PT, massage, and a new bed to heal some terrible pain. The only one that is even partially covered by insurance is PT.

    With all of that, barring an accident, my family lives forever. Even the smokers and people who’ve never tasted a vegetable. That does not make me more worthy of life than her.

    Then I see my friend with MS who literally needs medicaid to provide care to get her out of bed in the morning. Medicaid decided without notice that she is no longer disabled (hint, MS is lifelong and progressive) and removed all of her care. Including the emergency alert system she would use if she fell out of bed. She works a good job, but would not be able to pay the over $30K in attendant care costs per year without government insurance. She cannot work her good job without the government insurance.

    1. Stories like these make me so sad. I cannot understand the mentality we seem to cling to in this country that only some people are worthy of being taken care of. For your friend with MS, did she earn too much and go above the Medicaid threshold? Or does her state make some kind of different disability determination? That sounds like an SSI-type ruling, not a Medicaid one, so I’m just confused by how they could cut her off like that.

      1. There is no reason given for the sudden cut-off other than “new politics.” They just told her she is not disabled anymore. She definitely is since MS does not, you know, get better. Watching the disability justice community rally to try to stay alive with the new priorities that our government is attempting to enact is encouraging and infuriating. They are literally fighting for their lives. They don’t want to be forced into nursing homes or funeral homes. With one party trying to “limit” Medicaid, people like my friend could very well die. It’s terrible.

        1. Grrrrrrr. Stuff like that makes me so angry. Like we’re just talking dollars, not actual people’s actual lives. :-(

  42. Moderately long time lurker, first time poster. Wife and I are within 18 months of pulling the plug on full time work and healthcare keeps me nights more than anything else.

    The Mrs. had a few issues (migraines, early arthritis, prior cancer diagnosis) that would make things problematic. I am lucky in that I’m a marathon running guy with no preexisting conditions or medications, but all it takes is one serious accident with the wrong insurance to destroy wealth.

    Would be nice to see an outcome based approach to healthcare, rather than a politically engineered one.

    1. Thanks for leaving your first comment! Congrats on being so close to your goal! Your example made me think about Mr. ONL, who THOUGHT he was the same (marathoner with no meds or pre-existings), but that changed VERY recently, and now he’s one big expensive pre-existing condition. So it’s not something to take for granted.

      1. Trust me, I don’t. I had a false positive scare a little over a year ago, plus time catches up to everyone in the end.

        1. That sounds terrifying! But glad you were okay, and here’s to not taking life for granted! :-)

  43. I love this post I am also very health conscious but have an autoimmune disorder that may have a genetic connection, I hate when people say if eat right exercise you should never have health problems. I work in healthcare and understand lifestyle makes a huge difference but their other variables and people need to stop putting people down that have issues they can’t control (there is no cure just treatment for my condition, I do all that I also supposed to but still flares up).

    1. Hi Kelly! We feel your pain, maybe literally. ;-) Obviously you know, given your work in health care, how important it is to make the best choices you’re able to make and to give yourself the best chances. But there are still no guarantees, and acting like it’s *all* up to the individual stigmatizes a lot of people who really try hard to live healthy lives!

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