Individual Mandate – Shared Responsibility Penalty ISR
for not having Health Insurance  in California!

3 comments on “Mandate Penalty California Individual & Family”

1. Great question — and this is exactly the right way to think about insurance: **What’s the real risk?**

   I’ll give you a practical, real-world answer based on population data for U.S. women in their late 50s and 60s.

   —

   ## Short Answer

   For a healthy 58-year-old woman:

   * **Chance of having $10,000+ in medical expenses in any single year:**
   👉 Roughly **10%–20% per year**

   * **Chance of having at least one $10,000+ year over the next 10 years:**
   👉 Approximately **60%–85% cumulative probability**

   That’s much higher than most people expect.

   —

   ## Why the Risk Is That High

   Medical spending isn’t linear — it’s **lumpy**.

   You may have:

   * 5–7 very low-cost years
   * 1 year with surgery, cancer, hospitalization, or cardiac issue
   * 1 year with unexpected diagnostic workups

   It only takes **one event** to cross $10,000.

   —

   ## What Typically Pushes Someone Over $10,000?

   Here are common triggers for women age 58–68:

   ### 1. Cancer Diagnosis

   * Breast cancer treatment can easily exceed $50,000–$150,000
   * Even with early detection, surgery + radiation often exceeds $10,000

   ### 2. Orthopedic Surgery

   

   

   

   

   * Knee replacement: $30,000+
   * Hip replacement: $35,000+
   * Even arthroscopic repairs can hit $10,000

   ### 3. Cardiac Events

   * ER visit + stress test + angiogram = $10,000+
   * Stent placement: $25,000+

   ### 4. Gallbladder or Appendectomy

   * Very common in this age group
   * Hospital + surgery = $15,000–$40,000

   ### 5. Auto Accident

   * Even minor trauma with imaging + ER visit can hit $10,000 quickly

   —

   ## Statistical Perspective

   Healthcare cost studies consistently show:

   * The **top 10% of patients account for ~70% of costs**
   * By your 60s, the chance of landing in that top 10% at least once increases significantly
   * Average annual spending for women 55–64 is already around $7,000–$9,000 — and averages hide spikes

   You’re not buying insurance for the average year.
   You’re buying it for the **spike year**.

   —

   ## A Simple Way to Think About It

   If your risk is roughly 15% per year, over 10 years:

   The chance you *avoid* a big year every year =
   0.85 × 0.85 × 0.85 × … (10 times)

   That equals about **20%–40%**

   Meaning there’s a **60%–80% chance you’ll have at least one big year**.

   —

   ## The Bigger Question

   The real issue isn’t:

   > “Will I spend $10,000?”

   It’s:

   > “If I do, can I comfortably write that check without stress?”

   If yes → high deductible strategy may make sense.
   If no → insurance is protecting liquidity and assets, not routine care.

   —

   If you’d like, I can:

   * Compare that risk to a $900/month premium scenario
   * Run a break-even analysis
   * Show you catastrophic-only strategy math
   * Or look at what self-insuring actually requires in reserves

   Just tell me which direction you want to explore.

   Reply

2. Totally fair question — and honestly, a lot of people your age who are healthy are asking the *exact* same thing right now. You’re not missing something obvious; the system just isn’t built for people who rarely use care.

   Let me break it down cleanly and without the marketing fluff.

   —

   ## Why would someone like you even use Covered California?

   ### The **only real reasons** are:

   1. **Subsidies (APTC)**
   If you qualified for subsidies, Covered California would usually make sense.
   You don’t anymore — so this benefit is gone.

   2. **Guaranteed issue & protections**

   * No medical underwriting
   * No exclusions for pre-existing conditions
   * Caps on out-of-pocket costs
   These matter *only if* something big and unexpected happens.

   3. **Future-proofing**
   If your income drops mid-year, Covered California can **restart subsidies immediately**.
   Off-exchange plans cannot retroactively give you APTC.

   That’s it. If none of those matter to you right now, Covered California loses most of its value.

   —

   ## “I’m healthy, I use Teladoc once or twice a year — why pay $900/month?”

   From a **pure cash-flow perspective**, it doesn’t make sense.

   At 58, you’re paying for:

   * Age-rated premiums (steep jump after 55)
   * ACA-required benefits you don’t use (maternity, mental health parity, etc.)
   * Risk pooling (you’re subsidizing sicker members)

   If you’re spending:

   * $0–$300/year on actual care
   and
   * $10,000+ per year on premiums

   That’s not insurance — that’s prepaying for something you don’t consume.

   —

   ## The silver plan issue — yes, it’s infuriating, and here’s why it happens

   > **“How dare they charge more in Covered California than direct?”**

   You’re not imagining it. This is real, and it’s called **Silver Loading**.

   ### What’s going on:

   * Insurance companies must offer **extra cost-sharing reductions (CSR)** to lower-income silver plan members
   * The federal government stopped reimbursing insurers for those CSRs
   * Insurers recoup the cost by **loading it onto silver plans sold through Covered California**

   So:

   * **On-exchange Silver = more expensive**
   * **Off-exchange Silver = cheaper**
   * **Gold plans can sometimes be cheaper than Silver on-exchange**

   It’s backwards. And yes, it feels like punishment for buying the “official” way.

   This pricing strategy is used by carriers like:

   * Blue Shield of California
   * Kaiser Permanente
   * Health Net

   Covered California allows it. They don’t control base premiums — insurers do.

   —

   ## So what *actually* makes sense for someone like you?

   Here are the **rational options**, not the brochure answers:

   ### 1. Off-exchange ACA plan (same coverage, lower price)

   * Same doctors, same benefits
   * No silver loading penalty
   * No subsidies, but you already lost those anyway

   ### 2. Bronze or catastrophic-style strategy

   * You’re insuring against a *disaster*, not routine care
   * Pair it with Teladoc + cash-pay urgent care
   * Accept higher deductible intentionally

   ### 3. Self-insure + plan for worst-case risk

   Some healthy, high-income 50-somethings do this:

   * Pay cash for routine care
   * Keep a large emergency fund
   * Understand the risk if something catastrophic happens

   Not for everyone — but financially coherent.

   ### 4. Short-term or alternative coverage (California = very limited)

   California heavily restricts this, so options here are slim — but worth understanding the limits before dismissing it.

   —

   ## The uncomfortable truth

   Covered California is **not designed** for:

   * Healthy
   * High-income
   * Low-utilization
   * Pre-Medicare adults in their late 50s

   It’s designed for:

   * Subsidized buyers
   * Chronic conditions
   * People who need predictable care

   If you don’t fit that profile, you’re paying a premium to support the system — not because it’s the best deal for *you*.

   —

   If you want, I can:

   * Compare **on-exchange vs off-exchange pricing** side-by-side for your age
   * Show when it *does* make sense to switch back to Covered California
   * Help you think through a **“bridge to Medicare at 65”** strategy so you don’t overpay for the next 7 years

   You’re asking the right questions — most people don’t.

   Reply

3. https://www.healthinsurance.org/faqs/which-states-offer-their-own-health-insurance-subsidies/

   Reply

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