I'm on Medicare, but I still got stuck with a $25k hospital bill - <AUTHOR> https://www.spokesman.com/stories/2019/dec/27/andrew-taylor-im-on-medicare-but-i-still-got-stuck/ <comment><USER2> Is there an equivalent of a 'do not resuscitate' tattoo or something you can get that's along the lines of 'do not perform for-pay medical care on me'?

If I were in the US, travelling, I'd only want immediate life saving treatment (a heart attack, say) to take effect unless I was absolutely sure of the precise cost of what I was submitting myself for.

It baffles me that you can be billed unknown amounts for this. I don't do _anything_ without knowing roughly how much it costs. My rent? Known before signing. Utilities? Rates are published, there's a meter on the wall. Supermarket? Prices are right there. Taxi? Has a meter, or it's fixed price private hire.

The only example I can come up with right now where prices aren't generally known before the fact is the pub. If you serve me a pint and claim it costs 15 quid rather than the expected ~5, you better believe that you're pouring that down the sink.

I drove by a road toll today in Norway that cost $1. I'm given enough time to turn around and decide not to use that road.

Yet Americans are getting slammed for multiple years' income whilst they're essentially unconscious?

Absolute madness.

<comment><USER3> I know this will get downvoted to oblivion, but these stories are just anecdotal. Thousands of people utilize medical care in the USA without much fanfare.

<comment><USER4> Anectodal.

Getting hit with surprise medical bills is very common among my network.

Personally, I went for a physical and hospital billed me over $600 for it. They apparently performed things that are not covered by my insurance.

No matter how much you insist, hospitals won't tell you how much things would cost or if something is covered or not.

I try to be proactive about my health but surprise bills sometimes scare me out of visiting hospitals/doctors for checkups. Or even if I go, I'm always worried about getting surprise bills weeks later.

<comment><USER5> The same thing just happened to me. I scheduled a physical which is considered preventative which means it's free and covers things like the general blood panels..I go in, they order a blood test and a couple weeks later I got a bill for $800. I called the insurance and they said the doctor billed me as a "visit" and not a physical and I would have to call the doctor to have them change the billing code. So I did that but they wouldn't change, they said that because it was my first time at this office that they have a policy that all first appointments are billed as visits. keep in mind that this was stated no where and this was the first I was hearing about it. Anyway they refused to change the billing code and I'm stuck with $800 bill.

<comment><USER6> Here's the dirty little secret: in the kafkaesque industry that is 21st century medicine, a bill is like an offer to pay.

"$800 is what we think you owe us," isn't even quite the right explanation.

It's more like, "we think you're an $800 sucker who will cough up that number because it appears on this official-looking piece of paper."

And if you call one of them up (any of them: doctor, insurance, hospital, whatever) they're going to either: a) tell you to talk to one of the other two, or b) exactly what they think you need to hear so that they maximize their conversion rate, i.e. so that you send in your real money for their fake bill.

Did you put down your signature on a piece of paper stating to the effect that you owed them $800? Do they have in writing your acknowledgement that you supposedly owe them $800? No? Then why are you acting like it?

Collection is their problem, and right now they're playing a psychological trick on you because on works on people like you.

patio11 has some good comments on collections. I'm not going to dredge them up but anyone sufficiently interested can do so.

</comment></comment></comment></comment></comment><comment><USER7> I love how everyone is susposed to be an expert in medical billing now. It's hopeless. There's no way people can beat the system on their own. Hospital chains, private equity, billing software consultants, these people are gunning for you every day. There's no way you can compete with that.

<comment><USER8> It seems that that is what capitalism has become, the creation of many niche complex systems of which one can never be an expert.

<comment><USER9> This is mainly an issue with healthcare in the US, not "capitalism".

The fact that providers can perform services on you without telling you up- front what the price will be is the problem. That isn't how a lot of the rest of our capitalist society works - Amazon can't raise the price of something I order from them after it's shipped to me, my rent can't change once I sign the lease contract which clearly states the charges up front, and so on...

<comment><USER8> > The fact that providers can perform services on you without telling you up- > front what the price will be is the problem.

Of course. In an unregulated for-profit health care system that is definitely the problem and the way we got there was because of; if there are multiple vendors then prices will automatically go down.

I'm not anti-capitalism. It just doesn't work for certain parts of society but it seems that in the US everything needs to be capitalised and the government clearly doesn't want to regulate this industry.

<comment><USER9> This article itself is about someone who is on Medicare (government-run health insurance) getting a surprise bill because the hospital has mis-assigned his procedure to the wrong category to allow them to run up the bill.

FTA: "In a feeble attempt to ameliorate the problem, Congress passed the Notice Act in 2015, which requires hospitals to inform patients of the implications of their observation status within 36 hours after observation services have been initiated. In other words, hospitals must advise patients of their observation status only after they have already incurred the expense of surgery and hospitalization."

This type of thing seems like the most immediate problem. It makes no sense that the price can be raised 36 hours after a procedure has already begun. How is anyone supposed to negotiate that properly?

Just saying, I don't think "capitalism" is necessarily the boogeyman here. The government itself is failing to negotiate properly with the providers when running its socialist healthcare system in this instance. (And non-government payers will run into the same problems, getting unfair bills that couldn't be anticipated or negotiated before agreeing to the service)

</comment></comment></comment></comment></comment><comment><USER10> Medical debt in the United States is another one of those defining monuments to inequality we have erected in the past decade another being the student debt crisis.

<comment><USER11> Ironically, the severity of the student debt crisis would be reduced significantly if we made need-based scholarships illegal

<comment><USER12> Could you expand on this?

On first glance it seems like only the well-off would go to college. I won't respond further unless I'm sure I understand your proposal

<comment><USER13> Need based scholarships allow universities to have nearly perfect price discrimination. This allows them to charge different prices to different consumers and extract the maximum amount each consumer is willing/able to pay. If they had to charge everyone the same price, that price would be considerably lower than the sticker prices now.

<comment> Paul-ish Are there studies on this, or is this just what we expect from economic theory?

<comment><USER14> Just think of it like this. If Harvard would charge $2000 in tuition each year but they raise the price $1000 for every $10k your parents make.

Sounds ridiculous right?

So the make the price $30.000 and give discounts if your parents don't make $100.000 instead.

</comment></comment></comment></comment></comment></comment><comment><USER15> Another common misconception about medicare is that they won't deny tests or procedures that your physician deems medically necessary. Medicare can and does issue such denials. I worked next to a family medicine MD with a primarily medicare/medicaid patient panel and he would spend at least two hours per clinic day on the phone arguing with various counter parties about the medical necessity of certain orders he had submitted. He said it was by far the most frustrating part of his job. If you look at where CMS policy is headed, I would expect more care dictated by flow charts and algorithms and less autonomy in the hands of physicians.

<comment><USER16> Yeah, if the Americans on here were smart, they would investigate things about their healthcare system further, especially when it comes to being on Medicare and retired. For that they should study the Kaiser Family Foundation's Website, backwards and forwards. One can end up in a situation where they need an extremely expensive, lifesaving medication, that subjects them to Medicare Part D catastrophic coverage levels. I have Medicare and if I lose my employer based insurance coverage through a family member, I will have to pay $50,000/year to stay alive. This is something I cannot afford as I am disabled.

Not to mention, the third leading cause of death in the United States is preventable medical errors. If you do not believe me, then Google it. You can go to the absolute best institutions, hospitals, and doctors, but you cannot evade a statistic like that. It is way to pervasive. Our healthcare system, along with is quality, are absolutely deplorable.

But the good news is, most people on here are educated and are skilled workers. They can emigrate to other countries. I would recommend the European Union countries in general, but obviously Western Europe and Northern Europe are better. But, anywhere in the European Union really is a step up from American-style care.

I am a European Union citizen. I am Croatian, besides being American. I am leaving the United States soon. I cannot wait to start a new life and adventure. I am tired of living in fear about my healthcare.

<comment><USER15> In many areas of practice the US provides some of the best care in the world. Places like MD Anderson in Houston and Sloan in NYC attract sick people from all over the world for a reason. It's fair to credit these institutions for what they do well.

>you cannot evade a statistic like that

The best advice I tell people is to make sure you have a patient advocate (family member or friend) with you 24/7 when you are hospitalized aka "in the system". I stayed with a friend for a one week hospitalization and witnessed multiple preventable medical errors that could have resulted in intubation and admission to the ICU (and perhaps death). I had to physically intervene to prevent the administration of a contraindicated drug which my friend had explicitly declined. I had to diagnose and fix faulty bedside telemetry myself. I had to retrain the CNAs on how to accurately collect sublingual temperature readings. The entire experience was quite eye opening. I've never spent time in a hospital in Europe but I would be surprised if the benefit of an advocate was not somewhat universal.

<comment><USER17> Thank you for saying this as I'm sitting here bedside with my dad 2 months post intracranial hemorrhagic stroke and watching his care team make mistake after mistake, giving him aspirin, ibuprofen (blood thinners for a hemorrhagic stroke patient is not good!), not covering their face when visibly having a cold and coughing while he is in an immunocompromised state (can get deadly infection complications quick), not attending to his needs when he soils himself so he can be in bed for hours in agony and is not able to alert them (he is ESL and has stroke induced aphasia so can't speak much, right side paralysis so he can't really press the nurse call light let alone remember to).

To them he is just another patient and a number in the system. I've seen them cut corners and get frustrated doing their job (having to change him etc) and talking behind our backs in the hallways when I'm getting on their case to get his BP meds ASAP and notify doctor (high blood pressure >160 systolic is BAD for hemorrhagic stroke patients).

Anyone have any tips or resources for how I'm supposed to be optimizing his recovery and shield him from mistakes of his care team? Thanks, this is really taking a toll on me and I'm trying my best everyday to make sure he gets out of the hospital setting and on the road to recovery. I've been by his side every night switching with another family member for 24/7 coverage for months now.

<comment><USER16> Also, I saw your other comment. I am definitely in on the project. I have worked on other health-related projects. My background is in electrical engineering. I have 1 year left of school. I plan on returning in the fall.

Obviously artificially intelligence has been overhyped. But what it really is especially capable of doing at this point is preventing human error.

There are lots of various things that could be done. I am not focusing on purely AI as one has to be open-minded in the design process.

I will contact you in the morning.

<comment><USER17> Awesome! HN is a wonderful place to find like-minded individuals :)

sorry if I'm slow to reply, my sleep schedule is all over the place but dad is being discharged soon so I promise I'll get back to you soon, added my email to bio.

</comment></comment></comment></comment></comment></comment><comment><USER18> The headline is incorrect. The patient did not get stuck with a $25k hospital bill. The patient co-insurance was 20% of $25k or $5k. Still a lot of money for surgery and 2 days in the hospital, but not $25k.

<comment><USER19> Since the amount billed typically is several times the negotiated rate between a healthcare provider and an insurance company and the 20% is based upon what the insurance company actually paid the patient likely paid significantly less than even $5k.

</comment></comment><comment><USER20> This is very misleading and surprising that a physician would make such a mistake.

It seems that he only had Medicare Part A, which is _not_ alone really health insurance it is strictly for hospitalizations and has no premium. I think of it more like catastrophic insurance.

Medicare Part B is actually health insurance and requires a premium. He casually mentions that he didn't have Part B but unclear why.

The 20% coinsurance he paid is what you'd pay under Part B, and unclear what other insurance he has, but for a high earner you should always buy Medigap which reduces the 20% since like in this example can still be thousands of dollars.

<comment><USER18> In fact he admits that he has a Blue Cross plan (probably a sort of Medicare Advantage plan) that covered 80% of the bill. But it's obscured by the headline and the long rant preceding the admission.

> I wasn't enrolled in Part B, but _did have Blue Cross /Blue Shield > supplemental insurance, which required me to pay 20% of the allowable > hospital and surgical charges._

<comment><USER20> Not sure what this means. Medigap is supplemental insurance that reduces the 20% coinsurance responsibility. If he didn't have Part B then he couldn't have bought this.

Medicare Advantage is just A+B from a private insurance company.

</comment></comment></comment><comment><USER21> Of note, the author is a physician and also a professor: " _Andrew Taylor is a professor of radiology and imaging sciences at Emory University School of Medicine._ "

</comment><comment><USER22> at this point it seems not unreasonable to say that the collective dark parasitic menace associated with the medical system in the US (to include all of the following: leadership, admins, providers, policymakers, etc. is actively hostile towards individual citizens of the US. the whole charade of nobly helping people should be pretty well dead and buried by now: it's all about dollars and extracting the maximum possible.

i am not surprised to learn that seniors are also exposed to some goofy backdoor likely engineered by some clever lobbyists ages ago.

from where i sit the risk of existential financial danger of being inside the US is probably not worth it for the vast majority of those no longer earning a normalish W2 income. what's the point staying in the US for "retirement" when you can get clobbered by some technicality?

some people may figuratively and literally live to fight another day but you'll probably do battle with this monster until you die warding off literal mercenaries trying to get you to pay the bill... and whatever assets you have tried to build up over the years as well.

given that a large percentage of the US economy is based on this behavior (and not really getting any smaller; it's big source of jobs - check job growth reports), it's fairly unreasonable to think it will get better before it gets worse. i am not optimistic that even if Sanders were elected he could fix this. there are too many grubby hands in the money pot, and it is too easy to sell the people on the """cost""" because second order effects (lost productivity, mental health issues, crime, ability to change jobs/situations without fear of death or permanent ruin, deleterious effects on youth without access etc.) are completely ignored. big numbers on federal budgets are too easy for those of the Free Market mindset to fixate upon.

i would humbly submit that if you are worried at all about this, there are lots of opportunities to take a social security income and live out a respectable life and/or death in countries where you are not treated like a financial bloodbag to be reaped and tossed aside. a lot of these places would be happy to have your dollars and you'd also reduce your contributions to this system.

<comment><USER16> Americans: Pay attention the the above comment and take it to heart.

I urge you to, as a dual national of both the United States and the European Union (Croatia). I am also on Medicare, as I am disabled.

One would be foolish to underestimate this comment and the overall situation it describes. It is unwinnable.

You can very easily end up paying a fortune every single year during your lifetime ($20,000/year-$100,000/year) for medications that are covered under Medicare Part D, due to a clause called Medicare Part D catastrophic coverage levels, just so you can stay alive. There are people in the top 1% that cannot afford these sorts of costs during retirement.

To top it off, the third leading cause of death in the United States is preventable medical errors. If you do not believe me, Google it. You can go to the very best institutions, hospitals, and doctors, but nobody can evade a statistic like that. The problem is just way to invasive and ingrained in to how we give healthcare in the United States.

If you want to stay alive long-term, then the best thing to do is to emigrate, particularly to a European Union country. They never discriminate on the basis of health status (including the cost of your healthcare or care), but you do have to be able to work to stay on a visa to eventually acquire citizenship. Obviously western or northern Europe is more desirable, but anywhere in the European Union is a step up in quality from the chaos of our system.

</comment></comment><comment><USER23> If you can ignore the title, [http://www.econtalk.org/keith-smith-on-free- market-health-ca...](http://www.econtalk.org/keith-smith-on-free-market- health-care/) is a fascinating view into the actual cost of delivering surgery/hospital service.

They price and sell surgery directly to patients and employers. Whatever one's view of their approach, I learned a lot from the episode.

<comment><USER24> Econ talk is a fantastic podcast. Yes, the host has a libertarian bent, but it doesn't stop him from interviewing people with opposing viewpoints.

When the 2008 crash happened, I listened to the episode and learned a ton. He always invites people with deep knowledge of the issues.

</comment></comment><comment><USER25> The answer is not what the author wants -- to close this one particular loophole. The answer is force price transparency, which is what we have in almost every other market. In other words, you have to be told what the price is, in advance, and you have to agree to it. If that doesn't happen, and the provider tries to hit you with charges you haven't agreed to, then it's fraud.

Let's give credit where credit is due on this: [https://www.healthaffairs.org/do/10.1377/hblog20190625.97459...](https://www.healthaffairs.org/do/10.1377/hblog20190625.974595/full/)

</comment><comment><USER26> Well, you had a good run, and a run from a system which probably paid out millions in salary over the years.

"My wife and I are both physicians, but neither of us had any clue that this could be the case."

</comment><comment><USER16> I have Medicare, as I am on disability.

I am working on finishing my education, as I only have 1 year left of engineering school, in electrical engineering, before I enter the workforce.

I require a blood product in order to survive. If I ONLY had Medicare (I don't --I also have employer-based insurance through a family member), I can expect to pay around $50,000/year for my care, due to Part D catastrophic coverage levels. I can definitely expect to have to pay $50,000/year soon if the Affordable Care Act is abolished. Fortunately, I am a European Union citizen, but it would be tremendously sad to have to leave the United States, my homeland, over this.

I really cannot go on a Medicare Advantage plan, which might resolve this issue, as I have a very rare condition that only a few doctors in my area are qualified to treat. Most Medicare Advantage plans are HMOs too. You also cannot switch back to traditional Medicare ever, once you get a Medicare Advantage plan. I live in one of the largest metropolitan areas by population too. It puts me in a strange place where I can almost be guaranteed not to get the care I need. My care is unbelievably complex.

It is very common to be admitted to the hospital by Medicare under observational status. I am surprised that the person writing this article was unaware of this, but almost everybody outside the healthcare field is unaware of it. There are also some really, really strange rules with respect to emergency room visits and being admitted under observational status by Medicare. It also takes a lot of time to look them up and understand them.

The Medicare Part B premium is typically $135/month for most Americans. This covers 80% of your costs for outpatient care, doctors visits, medical supplies, etc., under traditional Medicare (not a Medicare Advantage plan). To cover for the remaining 20% (which you should get coverage for--you are foolish not to) you need to get a Medigap plan. Those can be expensive.

I know this is unbelievably complex, and is a huge waste of time to have to go and understand, to prevent yourself from getting in trouble, if you have Medicare. It is ridiculous.

However, the author was being penny-wise and dollar foolish. It is very, very common for people to explicitly elect to have Medicare Parts A and B if they have traditional Medicare. Saving $135/month over something that could get you in trouble is not smart in the American healthcare system.

Yes, his situation should have never happened, in a decent healthcare system. It is sad. But he did make some pretty big mistakes, especially considering he is a doctor. But, he did not deserve this.

<comment><USER27> >You also cannot switch back to traditional Medicare ever, once you get a Medicare Advantage plan.

You can change plans during the annual enrollment period, from October 15 through December 7. You can enroll in or switch advantage plans or just go back to plain Medicare.

If you're on plain Medicare, you can also switch to a 5-star advantage plan between December 8 and November 30.

[https://www.medicare.gov/sign-up-change-plans/when-can-i- joi...](https://www.medicare.gov/sign-up-change-plans/when-can-i-join-a- health-or-drug-plan/5-star-special-enrollment-period)

<comment><USER16> No. This is not well known, but what I stated was absolutely true. There are endless unbelievably insidious tricks and rules like these:

If I were to switch from a Medicare Advantage Plan back to Traditional Medicare, I could never get a Medigap (or supplemental plan) which covers the 20% that Medicare Part B does not cover. This is due to the fact that I have a pre-existing condition. Actually, I probably have 50+ pre-existing conditions from a medical insurance underwriter standpoint, but that is beside the point.

See: [https://www.kff.org/medicare/press-release/in-all-but- four-s...](https://www.kff.org/medicare/press-release/in-all-but-four-states- seniors-on-medicare-can-be-denied-a-medigap-policy-due-to-pre-existing- conditions-except-during-specified-windows-of-opportunity/)

> Depending on their state, Medicare beneficiaries who miss these windows of > opportunity may unwittingly forgo the chance to purchase a Medigap policy > later in life if their needs or priorities change, OR IF THEY CHOOSE TO > SWITCH TO TRADITIONAL MEDICARE AFTER SEVERAL YEARS OF BEING IN A MEDICARE > ADVANTAGE PLAN.

This is a huge deal. I have type 1 diabetes plus 2 rare immune-mediated diseases that affect my peripheral nervous system. My insulin pump supplies are covered under Part B. A couple of my hospitalizations were covered under Part B under an "observational status". I used to receive infusions of a blood product in the hospital every 2 weeks that cost my insurance about $10,000 each time, under contract. I also need a couple of different infusions, although far less frequently, to stay alive.

So for me, unless I totally uproot my life and move to one of those 4 states that does not allow the pre-existing condition clause to preclude me from Medigap coverage, I am stuck on a Medicare Advantage plan. I am screwed. These plans only become more hardcore and strict.

I cannot be on an HMO, which many Medicare Advantage plans are. I have a very rare disease that maybe a few doctors can treat, even though I live in a huge, very populous city. I also need the doctors I currently have, which work like a team. I cannot afford the several prior authorizations and the delays that will happen from switching insurance.

I cannot afford to make a mistake. Switching to a Medicare Advantage Plan can be extremely problematic for somebody like me, due to logistical issues. They could cost me my life too, and that is no exaggeration.

I may have to switch to a Medicare Advantage Plan, as costs are capped and I have an exorbitantly expensive medication that I must take to survive. Under Traditional Medicare, under Medicare Part D, I am subjected to catastrophic coverage levels. I can expect to pay $50,000/year for my healthcare, if I lose employer based coverage through a family member via Affordable Care Act partial or full overturn.

In the case that I am forced to switch to a Medicare Advantage Plan, there is no going back to Traditional Medicare, due to pre-exisiting condition clauses in Medigap plans. That is extremely problemsome as it limits my access to doctors and other care, as I have a very rare disease.

Fortunately, I am a European Union citizen, so I can just leave. But, it makes me profoundly sad. What I mean is that I no longer feel welcome in my own country, my homeland. I have been in remission for a year now and I am close to completing my degree so I can work. I really want to work! But the United States makes it extremely hard for me. There are just way too many things tied to working, especially health insurance. It is really sad. My family is here, but I know I would be better off in Europe. Right now, I have been focused on language learning non-stop. Obviously you learn one language at a time. I am currently working on Croatian. All I can do is try to move on.

<comment><USER27> After you graduate, looking into employment in government might be a good idea. My grandmother is a survivor annuitant (grandfather worked for the federal government) and she has Aetna PPO through the OPM in addition to plain Medicare A/B. It acts as a medi-gap policy when a provider accepts Medicare, and acts as a normal PPO when they don't. I'm not sure if you would be eligible for something similar, but I think it's worth looking into.

The only thing that's a pain about it is Aetna conforms to Medicare's policies on covered care, so if you want something and Medicare won't authorize it, you have to go to a provider who does not accept Medicare to get it. You can also get coverage from a provider who accepts Medicare when the treatment isn't covered by Medicare by switching from Medicare to a 5-star advantage plan, since Aetna would not longer be able to fall back on Medicare not authorizing it, but then you lose the medi-gap aspect, although that's not too bad because Aetna has OK out of pocket maximums.

</comment></comment></comment></comment><comment><USER28> Why are hospitals allowed to withhold the price of service until after treatment? No other business that I know of is allowed to get away with this kind of behavior. You don't sign a contract to buy a car, then find out the price later.

Isn't there some precandent in law somewhere saying that one parting cant change an agreement after the fact or they would be acting in bad faith? Are hospitals acting in bad faith?

<comment><USER29> The Trump administration has a bill in the works that requires hospitals (and I believe all medical professionals) to publish the cost of their sevices.

Of course, it is being fought because Trump is behind it.

Politics is the relinquishing of critical thinking in favor of the interests of political parties. It is a disgusting, corrupt ecosystem populated by equally disgusting and corrupt people.

The only way someone like Trump comes into the scene is because things have become so putrid in politics that people decide their only option is to send someone into the White House who is perfectly comfortable throwing feces around.

<comment><USER30> He has had three years so far but besides tough talk I haven't seen much progress as far as health policy goes.

<comment><USER29> You are using the wrong time scale. Here's a depressing exercise:

Go back as far as you can find video of promises made by Presidential, Senate and House candidates of any political party.

Write down the problems they list and solutions they promise.

Here we are, 10, 20, 30, 40, 50 years later with the same problems, the same promises and the same incompetence and lack of action.

Election after election, campaign after campaign, we are promised the world and, in exchange for our votes, receive absolutely nothing.

Through that time every single politician becomes a multi-millionaire at the expense of the people they are supposed to represent and help.

Don't blame a guy who chose to step into a pit of vipers covered in fecal matter for what, in reality, is a monumental failure of our political system and the elites who run it.

The fact that we don't have a sensible healthcare system is not Trump's doing. It is the result of 50 or more years of people voting for charlatans and scam artists. It's embarrassing, it's a disgrace.

Yes, Trump is uniquely capable of inducing projectile vomiting. However, the real obscenity is what the political class has done to this country during the last several decades.

Imagine being the guy actually trying to fix that mess. Do you really think decades of corruption, partisanship and incompetence can be fixed in a couple of years? And, do you think fixing this putrid mess is going to be, say, dignified and clean in any way?

No, the way you clean a putrid mess is you open the doors and windows and you get to work. It's going to be horrible, disgusting, smelly and vomit-inducing. Eventually, if you persevere, things improve and you can go from throwing feces at each other to pretending we are civilized and return to decorum.

I certainly don't agree with all of his views and some of his social manner makes me want to vomit, but I am glad we have someone at the helm who is letting all the stench out for all to see and continues to fight them hard despite having been covered in shit for three years. Few people could endure such a thing. This is a remarkable time to witness.

The real obscenity is what our politicians have done to us for decades. Anything Trump may have said or done pales by comparison. I wish people could stop, think and understand this fact.

<comment><USER31> Bullshit. Obama passed the ACA. Johnson passed Medicare and Medicaid. FDR passed social security. Trump hasn't done shit even with a Republican congress. Almost certainly for the best, but the point is that passing proper legislation is possible. You're just making excuses for Trump's failings. Proper healthcare has been overdue for decades now in America and not having it is one of the reasons we are sliding back into 'developing' country status.

<comment><USER29> > Bullshit. Obama passed the ACA. Johnson passed Medicare and Medicaid.

If these things were actually good we would not STILL have every single politician talking about having to fix healthcare.

Look, I get that you hate Trump. There's a lot of that going around. No problem. The issue is not to be blinded by hatred and to try to be objective about reality. In my decades in business I've had to do business and work with lots of people I did not agree with and, yes, in some cases, didn't like very much. Life isn't a nice linear ride into utopia. It's a twisty, complex and sometimes unpalatable path through less than ideal choices and outcomes.

Trump, in this sense, isn't any different from anyone who preceded him, from Obama's lies about the ACA (I am still looking for my $2,500 a year savings...in reality our insurance costs QUADRUPLED due to ACA, coverage got worse, we could not keep our prior insurance and lost doctors) to Bush's stupid wars. This is life. We don't have to love all of it. All we can do is try to progressively make things better.

BTW, it is disingenuous to say that Trump has not done anything in three years. He has actually likely done a lot more than prior Presidents. If we want to focus on healthcare alone, here's a short article listing a few non- trivial important achievements:

[https://nypost.com/2019/09/21/five-smart-ways-trump-has- impr...](https://nypost.com/2019/09/21/five-smart-ways-trump-has-improved-our- health-care-system/)

I hope you'll read it because it is obvious your hatred for Trump has caused you to not be well informed on these points.

As I said in a prior comment, he takes me to the edge of projectile vomiting every time he opens his mouth. However, my aforementioned business experience has taught me to focus on results rather than style. The results he has delivered in three years --while getting dumped-on and attacked from every angle in way and at a scale never before seen in US history-- are nothing less than incredible. I struggle to comprehend how it is that this man is able to do so much while being under attack 24/7 by half the government and nearly all of the media.

Here's another list:

[https://www.promiseskept.com/achievement/overview/healthcare...](https://www.promiseskept.com/achievement/overview/healthcare/)

> Trump hasn't done shit

I wonder how you might support this statement? It is patently false. I am a Classical Liberal voter. I do not align with either one of the two main parties. All I care about are results, not style. Drama is of no importance at all. Results don't lie.

If you can ignore your hatred long enough to read through this larger list, perhaps you can comment on how this is, to paraphrase your comment, "not doing shit":

[https://www.promiseskept.com/](https://www.promiseskept.com/)

Most of my friends are Democrats and some even call themselves "as Left as you can be". I've had many in-person conversations with them over the last few months. Once emotion is removed from the dialog every single one of them is amazed by how much this man has achieved. My own parents are Democrats. They are voting for Trump in 2020. Why? Because of what what he has achieved while being the target of the largest political attack in the history of this nation.

People who can set ideology aside are recognizing what's going on here and starting to understand who --despite the lack of style and decorum-- is actually working for them.

What we are watching is a Democratic party living in abject fear of having become so incompetent and irrelevant that there's a real concern they will not win elections for some time to come if they allow Trump to win a second term and, perhaps, achieve super majorities in the House and Senate. The Leftist Utopia --you know, the one Aleksandr Solzhenitsyn describes in The Gulag Archipelago-- will evaporate from this nation if Trump wins another term and delivers results at a similar pace for the remainder of this term and another four years. That's the reason for this political war. We are witnessing a seminal moment in US history.

<comment><USER30> Honest question: what has Trump achieved? The right wingers talk as if he singlehandedly has lifted the country out of recession where in reality he inherited a boom and managed to keep that going (nothing wrong with that). He certainly has achieved exactly zero in terms of health care and this is what my initial response was about.

<comment><USER29> One of the links I provided is a good starting point to understand what his administration has been working on for three years.

[https://www.promiseskept.com/](https://www.promiseskept.com/)

Sorry, but you are wrong on healthcare. Please take a look at this sub-list and tell me how this equates with achieving exactly zero. I want to understand how one goes from a list of undeniable achievements in healthcare to concluding something like "He certainly has achieved exactly zero".

[https://www.promiseskept.com/achievement/overview/healthcare...](https://www.promiseskept.com/achievement/overview/healthcare/)

This article goes into a little depth on some of what they have achieved and the significance of the various achievements:

[https://nypost.com/2019/09/21/five-smart-ways-trump-has- impr...](https://nypost.com/2019/09/21/five-smart-ways-trump-has-improved-our- health-care-system/)

Again, echoing your intent, I am having trouble understanding how, in the face of clear evidence to the contrary, people can believe he has achieved nothing on healthcare.

Look, we all agree that healthcare in the US is a disaster. I hope we all agree that Trump had nothing to do with that. This is the result of lies, political games and incompetence going back 50 years or more. Let's be careful not to attribute the disaster our political class has handed down decade- after-decade to a man who --as all evidence indicates-- is actively trying to fix it.

The reason these things are not addressed after decades of promises is that politicians work for themselves, not for us. It should cause everyone pause that every single election in modern history puts exactly the same issues on the table as the most pressing issues of the time. The incompetence and lack of results is, at the very least, embarrassing and at some level criminal. Anyone delivering these kinds of results in the private sector would be relegated to using a hammer to turn big rocks into little rocks.

Trump is a nasty SOB, but if you leave emotion out of the equation and look through the list of what his administration has achieved in three years it is very hard to argue with the results. As I said before, this is all I care about. The theatrics will be meaningless in ten years. However, the results will have long-lasting effects way past his stay in the White House. That's the part that matters, nothing else.

<comment><USER30> I maintain that Trump has achieved zero in health care. His only achievement is undermining Obamacare ("repeal and then having no idea what to do"). So far I haven't seen any real effort to make health insurance any better (where is the "wonderful" plan he promised coming in?) other than bringing us back to the glory days before 2008 when people with preconditions couldn't get insurance and plans would dump you whenever you got actually sick. He also didn't "jumpstart" the economy as claimed on the site. I have no problem with you voting for Trump. Go ahead.

<comment><USER29> You can maintain that view if you'd like, but understand it does not align with reality at all.

BTW, this isn't a discussion about who I might vote for, please don't get defensive. This is a good conversation so far, no need to go there.

Let me add something about healthcare. I'd like to suggest you are focusing on the wrong thing (as are millions others).

The US healthcare problem is NOT an issue of insurance. Not even close. That's the biggest fallacy and lie told by politicians for decades now.

Put in very simple terms: You cannot fix the US healthcare system with insurance. Period. It is NOT an insurance problem.

I don't care if we pass Medicare for All, None or the Pink Unicon Plan. Insurance is not the problem.

What's the problem?

Costs. Well, it's layers of issues really. In no particular order at all:

The cost of medical education is ridiculous. The government needs to get out of the student loan game and allow the free market to drive education costs down. Today a doctor graduates with $300K or more in student debt. This means, in no uncertain terms, that this person cannot work for a salary lower than what's require in order to have a hope of paying back that loan and, on top of that, having a life, raising a family, owning a home, etc.

BTW, my wife is a physician, so I have first-hand data on some of the internals of the business side of medicine.

The next problem --and this affects everyone, not just doctors-- is that our education system loads-up degrees with a bunch of unnecessary pork clearly designed to add another year, if not more, to the process of obtaining a degree. In other countries, if you study, say, electrical engineering, you are treated to science and engineering courses, you don't have to burn months taking myriad unnecessary general education, sociology or other non- engineering courses.

When a university is charging you $50K a year to keep you within their walls it is quite profitable to require you to take a bunch of other stuff with the excuse of these things being degree requirements. This adds at least $50K, if not more, to the cost of getting a degree.

Moving on from there, the cost of malpractice insurance is ridiculous. Of course, there's variance from specialty to specialty. The range is from $5K to $50K per year and it also depends on where the physician might be practicing (which State).

These costs are an important element of the equation that ultimately determines how much we have to pay to have a dozen people attend to us during a surgery or half a dozen people involved in emergency care, etc.

Then there's tort reform. Yes, things have been getting better, with some States doing better than others. However, the consequences of our litigious society is that doctors are forced to cover their behind by sometimes ordering all kinds of unnecessary tests and medicine. This costs money and that cost is passed on to the patient one way or the other.

Now you start looking at medicine at the hospital level and things get worse. The hospital employs a bunch of people with huge student loans and varying degrees of malpractice insurance and office expenses to cover. The hospital itself has to cover itself through expensive insurance. And then there's the regulatory burden of actually running a hospital. Costs pile-up and, once again, they are passed on to the patient.

Then we move on to drug companies. The cost of developing drugs and obtaining regulatory approval is massive. Some drugs cost in the region of $5 billion. The FDA mandates testing that costs in the range of $300 million.

Drug companies have non-trivial costs associated with dealing with the regulatory burden. In addition to this they have to worry about lawsuits as well, which means they have expensive insurance, people to manage this (entire legal teams) and the cost of occasional settlements reached in litigation. Once again, costs pile-up and patients end-up paying for them.

Medical device manufacturers are subject to the same equation. I once tried to develop a relatively simple medical device that would help millions of people. The regulatory burden and FDA costs were so high I dropped the idea entirely.

The reason the same drugs and devices cost less outside the US is that drug companies charge US patients for the cost of doing business in the US. This makes sense, why would a company charge the US burden in nations where they have a far lower cost existence?

There's more, but I'll stop here. For example, we could talk about the truly horrific medical patient data system that adds untold cost to our healthcare system.

The bottom line is that one could pass the most wonderful sounding insurance scheme and it would do absolutely nothing towards dealing with any of the above problems. Not one thing.

These are basic business problems. When things cost you too much you go back and analyze the cost structure that leads to high prices. Our cost structure is horribly high. Which means our costs to deliver care are equally horrific. Insurance will not fix this at all. It's like saying that changing auto insurance policies is going to reduce the cost of buying a Tesla. No, the cost of buy a Tesla is associated with the cost of making a Tesla and not with the insurance the owner will pay to drive one.

<comment><USER30> You are making some good points. everybody agrees the the US system is f...ed. But don't forget how this discussion started. You stated that Trump is addressing things and I am saying he has done nothing and will do nothing other than talking tough. That point still stands.

<comment><USER29> No, sorry, your point is vacuous. It is based on a lack of information and an obvious refusal to read the material I posted. You are not informed.

OK, here, I'll post the list here. This list is not exhaustive. You can google each and every one of these and find further details. This is far, very far, massively far, from your idea that Trump has not achieved anything in healthcare. The exact opposite is actually true, what this administration has been able to achieve in this domain while being under absolutely brutal attack 24/7 on the part of the Democrats and almost the entire media is, well, nothing less than remarkable. He still has at least a year to go, some think he has five. I can only imagine what he would have been able to accomplish under more favorable circumstances.

This political war has cost this country dearly.

He has lists like this one in almost every domain affected by Federal policy. It's simply amazing. People don't know about it because the media are so incredibly biased and one-sided that they hide it all, they don't talk about it, they only focus on the hatred. And so it isn't a surprise that someone can actually believe that he has done nothing, despite all the evidence and documentation that shows otherwise. I mean, you can literally go dig-up the executive orders and read them. This is real.

I hope you re-evaluate your belief system, because you are 100% wrong on this. You don't have to believe me, go dig-up the executive orders and read them. Everything below can be corroborated. No lies. You can still, as I, dislike his public persona, yet you can and should be honest enough to accept the fact that the results he is delivering are likely without parallel in modern US history. It's amazing.

\- The Department of Agriculture provided more than $1 billion in FY2017 to be used to improve access to health care services for 2.5 million people in rural communities.

\- The Trump administration expanded access to Association Health Plans (AHPs) allowing small business to pool risk across states.

\- The Trump Administration allows for Short-Term Limited Duration plans to be extended up to 12 months.

\- President Trump signed a six-year extension of the Children's Health Insurance Program to fund healthcare for 9 million. Keeping CHIP is expected to save the Federal government about $6 billion dollars.

\- President Trump has mobilized his entire administration to address drug addiction and opioid abuse by declaring the opioid crisis a nationwide public health emergency

\- Trump created a bipartisan opioid commission that issued 56 recommendations to help defeat the opioid crisis

\- In October 2017, President Trump directed The Department of Health and Human Services to declare the opioid crisis a public health emergency, allowing grant money to be used to combat abuse

\- President Trump signed the International Narcotics Trafficking Emergency Response by Detecting Incoming Contraband with Technology (INTERDICT Act) that would give customs agents $9 million for screening tools on the border

\- In FY2017, HHS invested nearly $900 million in opioid-specific funding

\- Trump successfully pressured China to close dangerous loopholes that allowed Chines fentanyl manufacturers to legally ship the compound worldwide, much of which ended up in the U.S.

\- Under President Trump, The FDA has approved the largest number of generic drugs in history.

\- Generics increase competition in the marketplace and lower the cost of prescription drugs for all Americans.

\- In December 2018, year-end drug prices fell for the first time in nearly 50 years.

\- The Trump Administration issued guidance expanding options for individuals with chronic conditions. High deductible plans can now cover products such as insulin, inhalers and statins pre-deductible

\- President Trump signed an executive order to modernize flu vaccines and help protect more Americans by promoting new technologies to improve vaccine manufacturing and effectiveness.

\- Took executive action to strengthen Medicare and reform the Medicare program to stop hospitals from overcharging seniors on their drugs.

\- The Departments of Labor, Treasury, and HHS issued a final regulation expanding the use of health reimbursement arrangements (HRAs) which will benefit more than 11 million people.

\- Created new insurance options though association health plans, short-term plans, and health reimbursement arrangements: some are up to 60% less expensive

\- HHS finalized a rule aimed at increasing transparency in the pharmaceutical industry that requires drug companies to disclose the price of medication in direct-to-consumer television advertisements.

\- Launched initiative to end HIV/AIDS in America.

\- Ensured Great Healthcare with initiatives to SAVE AMERICAN LIVES: $6 billion funded to fight the opioid, fentanyl, and drug addiction epidemic.

\- HHS Awarded $125 Million In Grants to 1,352 Community Health Centers Across All U.S. States, Territories And The District Of Columbia.

\- HHS Released A Tool For Medicare Consumers That Would Allow Them To Participate In Negotiating Lower Prescription Drug Prices.

\- Under urging by the Trump Administration, Pfizer and Novartis have agreed to voluntarily drop their prescription drug prices.

\- Passed Right-To-Try to give critically ill patients access to life-saving cures.

</comment></comment></comment></comment></comment></comment></comment></comment></comment></comment></comment></comment><comment><USER32> Is there a compilation of many of the "gotchas" (like this) that can be pulled in medical billing in the US? A wiki or GitHub repo would be a good place to start compiling them. Alternatively, post about any you know of here.

<comment><USER33> Well, hospitals aren't required to tell you what a given procedure is going to cost before doing it, so basically it boils down to:

If you get really sick, "gotcha".

</comment></comment><comment><USER34> There's no real fix for this outside of a banning providers from billing patients directly. As long as there is any legal route to people paying expenses directly, doctors will find sneaky ways to trick people into doing that.

<comment><USER35> > doctors

You mean hospital administration and private equity firms buying hospitals and squeezing them for all they can.

<comment><USER34> I mean doctors. Cost of medical care is directly attributable to doctors enforcing a cartel of care availability.

<comment><USER35> Yet the US has approximately the same number of doctors per capita as Canada and the UK [1]. And the cost of healthcare in the US has sharply risen in the past few decades - presumably due to some unreported restriction in the supply of doctors?

[1] [https://www.who.int/gho/health_workforce/physicians_density/...](https://www.who.int/gho/health_workforce/physicians_density/en/)

<comment><USER34> All three have few doctors compared to other rich countries. In the UK and Canada there are price controls which means this is bad for doctors but good (well, cheap) for patients. In the US this scarcity just means exorbitant pay for doctors. And yes those dreaded administrators too.

</comment></comment></comment></comment></comment><comment><USER36> Why didn't he have Part B? I'm guessing that would have covered it. There's more to this story I'm thinking.

</comment><comment><USER37> Every time I read a story about medical care in the US I am reminded why I decided to live somewhere else.

<comment><USER38> Which is funny considering we moved from Canada to the US because of the health care.

<comment><USER39> Care to elaborate on this? All we hear about is how behind the US is on health care, at least on the cost.

</comment></comment></comment><comment><USER40> Whats the pblem if you just dont pay ?

</comment><comment><USER41> [deleted]

<comment><USER42> > Your home, your 401k, is easy pickings for a bankruptcy court.

Your 401k and retirement accounts ( pensions, IRAs, trust funds, etc ) are legally protected from bankruptcy or legal judgments. In some states ( like florida ), even your home is protected from bankruptcy or legal judgments. Otherwise OJ Simpson who be homeless begging on the street rather than playing golf every other day.

Medical issues can be a source of financial distress for sure, but your statement about 401k is simply not accurate.

<comment><USER43> IRAs are state-dependent, not all states have an unlimited IRA exemption.

</comment></comment></comment><comment><USER44> Call them and tell you can pay 5k and they would most likely agree.

<comment><USER45> Not sure why you're getting downvoted another user pointed out he only paid $5k out of pocket...

[https://news.ycombinator.com/item?id=21910193](https://news.ycombinator.com/item?id=21910193)

<comment><USER44> Yeah, anyone who worked in this space knows that's how it works.

</comment></comment></comment><comment><USER46> Unethical behavior by providers (like this) hasn't been addressed by any of the candidates on either side of the aisle.

Getting rid of insurance companies is only part of the equation, as far as I can tell. It could help quite a bit. But until we address the adversarial position that _providers themselves_ take towards their patients, we're going to have galling and disgusting outcomes.

<comment><USER47> As an outsider, it seems Bernie Sanders is a candidate that seriously wants to tackle these serious problems in the USA.

Apart from that, I wonder why the society in the USA is so adversarial. It is apparent in many aspects and it is damaging for the society. There are ways to reduce to adversity, but it seems that many people support and favour an adversial system. Is that a cultural curse of the USA?

<comment><USER48> It's adversarial, because it's good strategy for winning elections. In a two- party system, there's no need to compromise. All you need to do is to beat one person (generally speaking). The worst way to do that is to agree on anything with the other person. You want as many wedge issues as you can, if your constituents are in favor of your position. If they're not, you attack the other person's character. Preferably you do both.

It's been this way for a very long time, and it's only getting worse.

<comment><USER47> My impression is that the adversity extends the formal political process. For example the hierarchy in work relationships seems adversarial, because of the treatment and behaviour of labour unions. In the justice system, the harsh sentences and the popularity of /r/justiceserved, which celebrates cruel and archaic ideas of justice, are another example. This is not just dumb, but also dangerous. So much that I doubt that the culture in the USA genuinly cheers these violent escalations but rather foreign intelligence services (Russia?) push things like those subreddits to make the USA look bad. But even in other subreddits and events like shootings people are happy when the shooter is killed and not arrested uninjured, and the cheering of that gets massively upvoted. That reveals an underlying adversity which makes the culture of the USA look immature, uneducated, dumb. I don't mean to judge all the people of the USA here, and I don't even trust what I've read, because all I received was through (social) media and that might be manipulated or portrayed disproportionately. The image of excessive adversity still remains after I take a step back and look sceptically and what I've been shown and told.</comment></comment></comment></comment>


Turmeric seems to have zero medicinal properties - <AUTHOR> https://qz.com/883829/a-large-scientific-review-study-shows-that-curcumin-in-turmeric-has-no-medicinal-properties/ <comment><USER2> Interesting. I read a study from Europe last year saying that tumeric was an anti inflammatory, and tumeric with black pepper is much more effective.

</comment><comment><USER3> Not shown to have any medicinal properties*

As it says at the bottom, if there are any, they're too difficult to isolate

<comment><USER4> Very clickbaity article and title.

</comment></comment><comment><USER5> What is in the Nature article is a bit different, it is that it will be, first difficult to know which chemical is really causing the effect that is seen, as curcumin is often composed of many molecules, second that it will be difficult to create a industrial drug from curcumin.So it argues to not spend money on another curcumin study when there are already around thousand. It would be a waste of money.

But if I am not wrong, the Nature article did not say curcumin has no effect, on contrary it has too many to know exactly what is going on.

</comment><comment><USER6> My anecdotal story: A friend who is a naturopath gave me some tumeric/black pepper capsules to try for arthritis swelling in my knees. I figured I'd try it with a dose of healthy skepticism. Indeed, no real reduction on the swelling or pain, but oh man did it give me the worst abdominal cramping and runs. So maybe it's effective as a laxative?

</comment><comment><USER7> I'll be really sad if that's the case since it's cheap as hell, and supposedly has (i'm gonna take this one study with a grain of salt for now) anti inflammatory, antioxidant, and antitumoral properties, as well as being a decent cox-2 inhibitor (without the nasty effects of long term use of a NSAID)...

</comment><comment><USER8> And, yet, study after study after study suggests that diet plays a significant role in health outcomes. But, foods and spices can't be proven effective in promoting health.

<comment><USER9> Just because a single food or spice hasn't shown to promote health doesn't mean that the overall diet doesn't play a significant role in health outcomes.

<comment><USER8> I think I failed to communicate my sarcasm or something. I got off all drugs and I manage my medical condition with diet and lifestyle. I am sneering at this dismissal of turmeric.

</comment></comment></comment><comment><USER10> Food isn't medicine; shocking. Turmeric is tasty though; I think I'll put some on some chicken.</comment>


Et in Arcadia Ego - <AUTHOR> https://www.theparisreview.org/blog/2019/05/15/et-in-arcadia-ego/ <comment><USER2> 'Let me give you a parallel case: writing poetry in Latin, in England, in the eighteenth century. Now, why would anyone do that. The mistake the modern interpreter is almost certain to make lies in assuming that the eighteenth- century literati must have done "X" for the same reasons we would do "X" now.'

In the first third of the 19th Century, Sidney Smith remarked that English gentlemen spent the best years of their lives in making Latin verses. For the gentlemen not yet of an age to leave school, the master's stick was a considerable incentive.

</comment><comment><USER3> Latin pastoral is not the only endangered form. This essay is a perfect example of its own, certain to be resented by impatient readers here.

<comment><USER4> I loved it, but i have a soft spot for Arcadia and Virgil's eclogues.</comment></comment>


Meet the Bot King Who Helps Trump Win Twitter - <AUTHOR> https://www.buzzfeed.com/josephbernstein/from-utah-with-love <comment><USER2> I've never understood the problem with being politically correct. I equate it with not being rude to others.</comment>


What's the most interesting problem you've encountered at your job? - <AUTHOR>

<comment><USER2> I made a proof of concept application that made it easy to combine different opencv image filters to make a filter pipeline. The neat part was the genetic algorithm on top that "tuned" the filters for best results for some task (finding circles in my test case).

</comment><comment><USER3> Currently, I'm working on integrating multi-sensor arrays into brick and mortar retail for analytics and interaction purposes. I'm also hiring, so if you have experience with ML and / or multi-sensor arrays / HCI, ping me. Email in profile.

</comment><comment><USER4> Coming up with an algorithm to implement the "as if" rule for a C compiler, to avoid needless widening. (Not my current job, I hasten to add.)

</comment><comment><USER5> Designing a radar beam scheduling algorithm</comment>


MailChimp vs. Amazon SES – How I Reduced My Monthly Bill - <AUTHOR> https://coursetro.com/posts/other/95/MailChimp-vs.-Amazon-SES---How-I-Reduced-My-Monthly-Bill-by-92% <comment><USER4> In my experience Amazon SES is great if you only used it for transactional emails. If you start sending marketing emails you will soon find yourself being blocked by ISPs and email service providers. You will end up spending a considerable amount of time getting yourself unblocked. Some service providers will even block the domain name, so even switching the service won't help you. Everything will go to spam from that domain name.

I have built the tech for an ecommerce startup ([https://www.article.com](https://www.article.com)) from scratch. Using different services for transactional and marketing emails is probably one the best decision i made early on.

Pro Tip #1:

"Use a different domain name for the from address while sending out marketing emails"

For example if your primary domain is example.com. Use email@example.com as your from address in transactional emails. Use firstname.lastname@example.com as your from address in your marketing emails. Off course forward all emails received by email@example.com to firstname.lastname@example.com (Why? see Pro Tip #2).

Pro Tip #2:

"Never use fake emails like email@example.com for the from address for any email you sent. Yes not even for marketing emails"

You will be surprised how many time customer just reply to emails they have received even if it is an unrelated marketing email. You will regularly see customers receiving a monthly newsletter and they will hit reply asking "Can you change the shipping address on my order?"

<comment><USER5> "Use firstname.lastname@example.com"

Is this really beneficial? With all the domain-spoofing going on I would not click a single link in an email from a domain I have never visited.

<comment><USER6> We do this and thank God we do. Our marketing emails get down blocked all the time simply because of the scale (and our marketing team is a little over zealous) but after our transactional emails got blocked for the 3rd time we moved all marketing to another domain and gave been happy since.

</comment></comment></comment><comment><USER7> The article is missing deliverability stats. Sure, you can reduce your bill significantly by switching to SES, but that means nothing if all of your emails are being sent to a user's spam box or promos folder. Mailchimp does a lot out of the box to ensure deliverability and good email placement, and that's part of the cost you're paying for.

<comment><USER8> Yep. My networks refuse all mail from amazonses, as it is almost entirely spam and the abuse contact is completely unresponsive.

Mailchimp isn't spam-free but it stops the spammer hitting you straight away and has human follow-up for problem cases. If that increases the price of sending mail, so be it.

<comment><USER9> Amazon's abuse system is automatic. At work we got a warning and then disabled after 15 minutes because people reported our emails as spam.

(Apparently notifying someone they are in debt counts as spam to some)

<comment><USER10> I'm curious - do you work for a debt collector? I ask because I've been sent to collections multiple times over medical bills, and every single time it has taken hours of effort to eventually reveal that all of the documentation given to the debt collector was erroneous. Mentally, I treat it as spam because I've learned that it's going to end up being someone else's mistake that the debt collector didn't look at carefully.

I would love to understand better how to deal with it - and if there's a fellow HN user who understand the debt collector business, I would like to talk to them :)

<comment><USER11> Always deal with debt collectors via snail mail, not phone calls or email.

<comment><USER10> Snail mail is very hard to prove that correspondence happened. State law requires that I dispute their claims within 30 days via snail mail, which I did. They then have to provide documentation within 30 days via snail mail, which they didn't. They should be fined for that, but all I can prove is that I mailed them _something_ within 30 days, and everything else is he-said-she- said. I prefer to tell them I'm recording the phone call. Unfortunately, my state's laws don't require they cooperate that way, and many just hang up immediately. It does stop the harassment, though.

<comment><USER12> The US postal service provides certified delivery. It requires a signature and proves delivery. You show your proof, and if they can't show theirs, you win in small claims. At least, that is the idea...

</comment></comment></comment></comment></comment></comment></comment><comment><USER13> This looks more like a pitch for MailWizz, but I've found that sendy works well for me.

[http://sendy.co](http://sendy.co)

If you are comfortable setting up your own templates it does a great job sending and handling unsubscribes/statistics. It isn't simply hooked into the SES SMTP , it fully utilizes the AWS API. Sendy iteself has a simple api to add users to lists and do other common things. I've used it for years.

<comment><USER14> +0.5 for Sendy. I've been using it for [http://www.tittietime.com](http://www.tittietime.com) quite successfully for 2+ years now.

There have been a couple of bugs that caused me to have to dig into the source code - which as others have stated, is a mess. Though I suspect its been purposely obfuscated to prevent pirating.

If you ever wonder what's going on in functions.php, I've unwound it a bit - you can see its making a phone home:

[https://gist.github.com/anonymous/cb21dfc35e1d4b74e136ebc694...](https://gist.github.com/anonymous/cb21dfc35e1d4b74e136ebc694e42f10)

<comment><USER15> Holy God in heaven that obfuscation filled me with dread.

<comment><USER14> I think he must have a deployment script that generates all the database connection calls at the top of every file when he releases a new version. No one in their right mind would write code like that.

</comment></comment></comment></comment><comment> nothing-special We send hundreds of thousands of emails every month. We're by no means a high volume sender, but we've learned a lot dealing with a bunch of these email providers.

Years ago we started with AWS SES. The pricing was amazing but there was no useful customer service outlet. If you were sending via a blacklisted IP it could be weeks before you we're seeing inboxes reliability again. It wasn't uncommon for us to devote 20+ man hours per week in dealing with email issues while using AWS.

Next we moved to MailGun. This was a HUGE improvement, however we were having to request to be moved to 'non-blacklisted' ip's on a regular basis. The pricing was great, but we were still having to invest too many hours dealing with email problems. Mostly fielding 'here is why your emails went to the spam filter, or why they never showed up' questions from our customers. You shouldn't need a template explaining to your customers why emails are showing up in spam boxes!

To be fair, MailGun was fairly new at this point but they were VERY responsive. IP's that had been blacklisted did not stay that way for long.

Lastly we moved to PostmarkApp. They were by far the most expensive ($1.50 per 1000 emails) but I only now even think of emails maybe once or twice per month. Emails just get through, no spam lists, no outages, no carrier blocks, it's amazing. Also, if you do send with enough volume you can drastically reduce the price. I believe we pay about $0.25 per thousand emails now that we purchase 5 million at a time.

They could triple their price and I would eat the costs.

I'm not affiliated with anyone above.

<comment><USER16> > We send hundreds of thousands of emails every month

With that volume, wouldn't a dedicated Mailgun IP have been worthwhile? You've got enough mail to gain reputation on it, and the flat fee + lower per-email charges could match or be cheaper than Postmark.

Long-time Mailgun user here, but not affiliated with anyone either.

<comment><USER17> Amazon SES also support the dedicated ip option?

<comment><USER18> Yes, I use dedicated IPs and get 20%-30% deliverability. Same as with Mailchimp, except my list is over 100k

<comment><USER17> Eesh, thanks for the data point.

</comment></comment></comment></comment></comment><comment><USER19> "The main difference between MailChimp and SES, is the fact that SES lacks many of the features from MailChimp."

That's for sure. SES only has 1 feature in common with Mailchimp and that is the sending of an email. Mailchimp's primary function is managing distribution lists, email templates and receiver activity analytics.

<comment><AUTHOR> Author here.. yeah, that's why you have to use SES with Mailwizz, which gives you all of those features from MC.

So, a more accurate title would have been, MailChimp vs. SES + Mailwizz. ;)

<comment><USER20> I use Mailwizz, and NO it does not replicate the missing featues of Mailchimp. It may be cheap –– but you get what you pay for. It's value really depends on your needs. It is in no way comprehensive.

</comment></comment></comment><comment><USER21> I keep repeating this and just recently a friend sending large mailouts called me to confirm: you do not need Sendgrid or Mailchimp or anything else! IF you are truly not sending spam, all you need is $5/month DigitalOcean's 512MB server with not previously blacklisted IP. That's it!

Paying for Mailchimp a small fortune is like paying for bottled water where all you need is $15/year Brita filter and just drink tap water.

Nowadays all major email providers are really good at catching spam. If you are NOT spamming then you are good to go; the key is to start small and grow from there. Do not switch overnight and send 10,000 genuine emails letting your audience know your terms of service have changed; since they don't know your IP, they will consider spam. But if you are getting your newly subscribed audience into getting emails (confirm double opt-in) from your new IP, it will take you 2 months and approx +10% daily raise in sendout to get to $1MM emails per week from your OWN IP at $5/month rate and delivery rate will be similar to those big guys that claim they have the best delivery rate (noone can guarantee you that)! Tested and confirmed!

<comment><USER12> And if you end up on a blacklist, even if by mistake? And how do you monitor your system and stats? How do you handle throttling by different MTAs? How are you measuring opens and clicks? How are you managing unsubscribes, and soft and hard bounces? This is not to say that all of this is not something you can't tackle. Instead, many companies prefer to pay a small premium to not worry about any of that and instead focus on their core business.

<comment><USER22> As someone who's just getting into setting up mail newsletters, this is the most useful post in the thread for me, since it explains really _what_ you're buying at MailChimp, SES, etc. I wish they would advertise this. It would be much more straightforward to someone like me.

</comment></comment></comment><comment><USER23> Only tangentially related, but I could use some help. We have a nearly 10 year old newsletter service that was built long before I was hired. It's all self hosted and we're getting abysmal delivery rates now (~60%...). We're only sending about 5000 emails a week.

We want to offload, at the very least, the sending onto a third party service where our delivery rates won't be so bad. The trick here is that we send the newsletters on behalf of clients that we have built sites for since we launched our newsletter service and they currently send with a FROM and a REPLY-TO of the domain we are sending for. Obviously, this does not mesh well with current spam practices. Third party services usually require you to verify the domain, but the vast majority of our clients do not have access to anything related to their domain or DNS and it's not realistic to move to SES, MailChimp, SendGrid, etc for that reason.

Does anyone have any suggestions for how to approach fixing this? I've already asked about sending out from email@example.com and having a reply-to of the client's email address, but was shot down for apparent contractual reasons.

<comment><USER24> >It's all self hosted

>Third party services usually require you to verify the domain, but the vast majority of our clients do not have access to anything related to their domain or DNS

Do you see the contradiction here?

If you are sending it from your domain there is no issue migrating to mailchimp.

<comment><USER23> We spoof the client's email. So while we are sending from our IP address, the FROM is actually email@example.com, the FROM name is John, and the REPLY-TO is email@example.com.

10 years ago, that passed. Nowadays, it's unacceptable. I'm wondering if anyone has a solution that doesn't involve any DNS changes for the clients we are spoofing, because it just won't happen, unfortunately. Our entire newsletter is built upon email spoofing, which is a terrible practice but I cannot get management to allocate any more resources to fixing it than "just make it work again". I'm going to try to push sending out from our (verified) domain again using SMTP (so we keep our system other than the sending part), but I'm doubtful I will get the approval for that.

I see the contradiction and realize that the verification process is in place for an extremely good reason, but actually implementing a fix is not as simple as you would hope. I was just hoping for someone to have an idea that I had not already thought of.

<comment><USER25> I know that you said but I'm afraid a major part of a spam scoring is coming from DNS related checks (SPF, Domain Keys...). I would concentrate on that... offer yourselves to configure that on behalf of your customers, get those DNS things shorted out and your delivery rate will get higher.

<comment><USER23> Yeah, like I said, I realize that's how spam scoring works and that our methods are just extremely outdated now. Problem is that our clients frequently do not have access to their DNS and nothing has changed on the DNS in 5-10 years. The purchased a site and email service a decade ago and they won't think about it again for another decade.

<comment><USER26> > our clients frequently do not have access to their DNS

How could they not have access to a service that they pay for?

It sounds like you have a human problem on your hands, not a technical one. I would think about how to get an updated SPF into their DNS. If the boss said "just make it work" then to me that means to call the clients and hand hold them through figuring out who hosts their DNS records and how to open a support ticket or reset their self-service web portal login password, or whatever else the client needs to do to get those records in there.

SPF is very easy to configure and will improve your deliverability significantly. After you configure SPF, mail servers will acknowledge your servers as a valid sender for your client domain. It will no longer be spoofing. The only difference between spoofing and not spoofing is domain validation.

DKIM is not tied to an IP address but the 2 extra steps of complexity involved with DKIM have allowed for SPF to be the dominant domain verification method for sending email.

<comment><USER23> > How could they not have access to a service that they pay for?

Generally, they are on autopay and haven't had to sign in for several years. We often run into an issue where the person who set it up is no longer with the company and they no longer have the associated email address set up, so they can't do a password reset (without setting up the email, at least, which means hunting down how to do that; we're talking <5 person companies that haven't had a new employee in years)

> It sounds like you have a human problem on your hands, not a technical one.

This is definitely the problem. :/

</comment></comment></comment></comment></comment></comment></comment><comment><USER27> I'm assuming the author is hosting Mailwizz on his own desktop machine? I didn't see the costings for an EC2 instance in his AWS breakdown.

If it is indeed his own machine, I wonder if he has factored in the data transfer costs to/from AWS. If he had an EC2 instance fired up, then the data transfer is free, however there is the monthly cost of the instance to consider.

Also, what about the stack that Mailwizz runs on? It it available as a simple turn key virtual or docker setup, or do we need to install a LAMP stack etc. to get it running? Time to get the stack running (and maintaining it to keep running) should also be factored into the $54 licence cost of the software.

<comment><USER28> If the author is using a micro instance in the first year, there is no charge [0]. Also, the author only needs to start the instance when he needs it, so the costs would be minimal.

Furthermore, only transfer out of AWS is billed; there's no cost to upload, which is what I imagine would be the bulk of the work.

[0] [https://aws.amazon.com/free/](https://aws.amazon.com/free/)

<comment><USER29> how does he deal with unsubscribe if his server is offline after sending ?

<comment><USER28> Very good point! I guess the cheapest way to do that on AWS would be with a Lambda function.

Or perhaps he already has his own web infrastructure not on AWS that contains the list.

</comment></comment></comment></comment><comment><USER30> Aaaaaand that's why I no longer use Amazon SES for transactional mail for signupforms.com. It is frequently used by mass-marketers, which means my transactional email was frequently being dropped by some email providers because of SES's poor deliverability.

<comment><USER31> Are you sure SES was the problem? Did you correctly configured DKIM/SPF?

<comment><USER32> We've occasionally got bounces like "554 5.7.1 Service unavailable; Client host [184.108.40.206] blocked using dnsbl.sorbs.net".

Amazon say SORBS is worthless but unfortunately someone is still using them [https://docs.aws.amazon.com/ses/latest/DeveloperGuide/blackl...](https://docs.aws.amazon.com/ses/latest/DeveloperGuide/blacklists.html)

<comment><USER33> Seriously, doing bulk emailing you find that mail services are often the dustiest, cobwebbiest things on the internet. I swear some of these things have been sitting untouched for literal decades.

</comment></comment></comment></comment><comment><USER34> Hmmm, how about Mailtrain [0], which is free and open-source? I like Sendy [1], but it's per-domain licensing policy does not work for me - I manage a bunch of nonprofits on a single droplet and do not have any desired to license all of them.

[0]: [http://mailtrain.org/](http://mailtrain.org/)

[1]: [http://sendy.co/](http://sendy.co/)

</comment><comment><USER35> It would been nice to see inbox stats. How many emails made it to the inbox vs spam? Did he see a drop in email opens or clicks?

<comment><USER36> Random comment on Reddit, if it helps:

[https://www.reddit.com/r/startups/comments/3jnxep/good_ridda...](https://www.reddit.com/r/startups/comments/3jnxep/good_riddance_mailchimp_surprisingly_greedy/curewaa/)

<comment><USER37> That seems to conflate speed of sending a double opt-in with deliverability. Ideally you'd want to measure deliverability with something like Return Path.

</comment></comment></comment><comment><USER38> Mailchimp === great UI for ad hoc, "unstructered", newsletters, product updates etc. SES === great for transactional emails if you handle the templating yourself. As always, and it gets boring, it depends on what you need. If you're a typical startup you probably need both.

<comment><USER39> SES just launched templating! Seems nice.

[https://aws.amazon.com/about-aws/whats-new/2017/10/amazon- se...](https://aws.amazon.com/about-aws/whats-new/2017/10/amazon-ses- introduces-email-templates-for-sending-personalized-email/)

[https://docs.aws.amazon.com/ses/latest/DeveloperGuide/send-p...](https://docs.aws.amazon.com/ses/latest/DeveloperGuide/send- personalized-email-api.html)

<comment><USER38> Dang, I missed that one in the daily deluge of AWS product announcements. The Mailchimp HTML5 editor is REALLY nice though. Probably the reason everyone uses them.

Side story: At the former job, we used to create transactional emails with a marketing swing to them in Mailchimp. Marketing loved it! Then we'd copy and paste the HTML to our ratty Salesforce backend and replace some tags and BOOM: super nice transactional emails from SalesHorse!

<comment><USER39> Yeah, I haven't tried them out yet, but I'm a big fan of SES (for transactional emails).

I use [https://foundation.zurb.com/emails/email- templates.html](https://foundation.zurb.com/emails/email-templates.html) for templates, and they've worked well.

</comment></comment></comment></comment><comment><USER40> are there any services (mailwizz, mailtrain, sendy, email octopus, mailjet, mailgun, etc.) that supports the personalized newsletter use case (which is "one level deeper" than the personalized email use case)? it's not obvious from any of their sites, and i'm hoping someone here might know right off the bat. =)

meaning that each issue of the newsletter can include a set of like content items (e.g., articles) but the bundle of content is specific to each user (user 1 gets content items 1, 2, and 3, while user 2 gets content items 1, 3 and 5). this is one level deeper than just simple personalization like "Hi Joe, thanks for signing up with us on Saturday, Mar 4...".

i've yet to see a marketing email provider offer this functionality very well, if at all. for example, sendgrid (which i'm using now) supports it via a convoluted combination of section and substitution tags that is not very well documented. but most systems (including mailchimp, constant contact, etc.) don't even contemplate this use case.

<comment><USER41> I use Green Arrow engine + studio, by the folks at drh.net, and it can do that very well. You can basically get a hook that will execute your arbitrary code for each contact - database lookup on a remote service, whatever. So you can build very complex newsletters that are totally customized to each recipient. And it is fast as can be (can pretty easily push 1M+ messages per hour if you have that much volume to send)

In order to take full advantage of it you need to be a developer though.

It's got great pricing too, esp. if you get their perpetual license and then run it on your own dedicated server (they set it up.)

<comment><USER40> thanks, i can code so i'll take a look. =)

</comment></comment></comment><comment><USER29> Its not fair to compare mailchimp to amazon ses, mailchimp is a full newsletter sending platform that handles everything. if you need only email sending there is 100k mails for 20usd with sendgrid.

<comment><USER42> Sendgrid also does marketing emails now right? Your thoughts on it?

<comment><USER43> You'll ned a dedicated IP as their free plans use shared IPs which are often flagged as spam sources.

Source: Tried the free plan a few times.

<comment><USER44> If you use GAE, you get a free plan on SendGrid (up to a max) and I've used it to send mails to gmail and yahoo accounts. Don't recollect anyone ending up in spam but I haven't sent them in thousands. Will keep your comment in mind as I do so..

</comment></comment></comment></comment><comment><USER45> Check out mailforgood: [https://github.com/freeCodeCamp/mail-for- good](https://github.com/freeCodeCamp/mail-for-good)

</comment><comment><USER46> Lot of the IPs used be SES are already blocked because somebody used it for spamming...

So would't rely on it for anything business critical to be delivered - <USER2> a company who only asends mail (Sendgrid, Mailgun of Mandrill (know they are owned by Mailchimp).

The most annoying part that i's not deterministic, sometimes it works sometime gmail blocks it or puts into spam ..

</comment><comment><USER47> Mailchimp pricing has always struck me as a bit perverse. I have a mailing list of about 20k people for A Soft Murmur[1] and I send _very_ occasional emails. A "pay as you go" Mailchimp plan costs about 1 cent per email, so in my case $200 per newsletter. But a "monthly" plan only costs $150 per month for 20k subscribers, with "unlimited" emails per month.

So it's cheaper for me to go on the monthly plan for one month, even if I know I'll only send out one newsletter during that time. If there's any chance at all that I might send more than one email in that month (rare but it has happened), then it's less than half the cost.

It just strikes me as weird.

I should really switch to a cheaper provider, but given that I only send a handful of emails per year, I haven't found the time yet.

[1] [https://asoftmurmur.com](https://asoftmurmur.com)

</comment><comment><USER48> We switched from MailChimp to SES+Email Octopus. EO gives us the layout+list management stuff we needed, and SES gave us a huge drop in mail sending cost. The costs we were dealing with though was a lot higher-our small list has over 100k people on it and we were sending out multiple emails a month to that list and bigger.

</comment><comment><USER49> If you are looking for an alternative to Mailchimp that uses Amazon SES with dedicated IPs under the hood, check out Kevy [0]. Full disclosure, I'm the Founder of Kevy.

We verify the domains of each of our customers and thoroughly review their sending practices to ensure their email sending reputation stays high. Futhermore, you can talk to a real person if you have any issues with sending / deliverability. If you are interested in a comparison of Kevy and Mailchimp, check out this blog post [1].

[0]: [http://kevy.co/](http://kevy.co/)

[1]: [http://kevy.co/2017/03/31/kevy-comparison-mailchimp- klaviyo/](http://kevy.co/2017/03/31/kevy-comparison-mailchimp-klaviyo/)

</comment><comment><USER50> Having used both I love SES. It's great. But I also like Mailchimp. One big gripe I have with SES is that it tends to have more servers on spam blacklists than Mailchimp.

You also need to code a lot of the stuff Mailchimp has out of the box (like templates and delivery reports) yourself. But the capabilities are there.

Another great thing SES has is the ability to receive emails not just send.

But overall I like both products. Mailchimp is easy for non-tech people to use, SES is bare bones, pay as you go, and highly scriptable once you add in Lambda.

<comment><USER28> I personally only ever used SES for forgot password notifications. My mailing list is really small right now but if I had large lists I'd probably run it myself using SES and pay for a private outbound IP. The costs aren't outrageous - $25/mo.

<comment><USER51> Wouldn't spammers just do the same? Does a private IP address on SES completely absolve the senders of SES's spam reputation? I've just started using SES and did notice everything going to spam. Looking for a solution.

<comment><USER28> I've never experienced an issue with e-mail going to spam. You might want to look at debugging it [0], to see if it's really SES's fault. It's possible your outbound domain has a reputation issue, but I have no idea how you address that I'm afraid.

[0] [https://sendgrid.com/blog/5-ways-check-sending- reputation/](https://sendgrid.com/blog/5-ways-check-sending-reputation/)

</comment></comment></comment></comment><comment><USER52> That's quite a savings. Has anyone else done this? Do you see more bounces due to using the AWS servers from using SES? Ending up in more people's spam folders?

<comment><USER53> I've done something similar for my side project which needs to _receive_ emails. My side project is a monitoring tool, and inbound emails is one way of sending "I'm alive" messages to it. Link in profile.

I started with Mandrill inbound emails. Friendly UI, easy to understand, works as advertised.

Then I moved to AWS SES for inbound emails. I wrote a small Lambda function which dissects the email and forwards it to my HTTP endpoint.

With usage growing, SES was getting expensive as well. So I wrote a SMTP server in Go using this: [https://github.com/mhale/smtpd](https://github.com/mhale/smtpd) It's very basic, doesn't support SSL, but seems to work OK in practice. My inbound email handling is now basically free.

</comment></comment><comment><USER54> I made the same move last year for my mailing list, but instead of Mailwizz I choose Sendy. Same setup though, using Amazon SES as the e-mail sending service.

It ended up saving me $600/year back then and would - at this point - <USER3> saving me roughly $2.000/year.

Here's my write-up from back then; [https://ma.ttias.be/mailchimp-sendy- saved-600-year/](https://ma.ttias.be/mailchimp-sendy-saved-600-year/)

<comment><USER55> $2/year doesn't sound like much to me ;)

</comment></comment><comment><USER56> We use an older piece of software called Campaign Enterprise. It runs on a Windows VPS, connects to our server at Rackspace that actually sends the email, and we can send as many newsletters, welcome emails, etc we want - every day. I think it was a couple hundred dollars to buy outright.

Once every few months you get on a blacklist but an email or quick phone call gets you removed.

</comment><comment><USER57> Does anyone know of a newsletter management system with an actually decent development workflow? We don't need the WYSIWYG editor. Just something with git integration for templates that are coded manually in Zurb Foundation for Emails.

You can import zipped templates into MailChimp manually. But if you made a typo, it's painful to export and reimport each time.

<comment><USER58> Check out this Grunt workflow [https://github.com/leemunroe/grunt-email- workflow](https://github.com/leemunroe/grunt-email-workflow)

Automates most of the painful tasks of putting an email together. You could also add a task that sends the templates to Mailchimp once built.

<comment><USER57> Yeah, I pretty much have that with the Foundation stack ([https://github.com/zurb/foundation-emails- template](https://github.com/zurb/foundation-emails-template)) but it's the MailChimp import that is painful!

</comment></comment></comment><comment><USER59> While very impressive, always nice to save a lot of money, I hope someone can explain why SES is not good enough many times as I seen here on HN before.

There are supposed to be issues with deliverability from SES that many can't accept and so they use other services (of which, the main one, I'm blanking on) that handle sending mail better.

<comment><USER60> _> There are supposed to be issues with deliverability from SES that many can't accept_

I don't know about this. At my previous employer we used SES to send service emails to our users on two domains (Office 365 hosted) and we didn't notice any delivery issues. Our volume wasn't huge though, above 10k but under 20k emails per month.

That being said, Amazon will really quickly suspend your SES account if your bounce rate is too high. They also don't keep hugely detailed logs, so restoring service generally relies on you keeping good logs from your app/MTA and figuring out which email addresses are bouncing.

</comment></comment><comment><USER61> That is the exact reason why we launched MailGet which is a hosted solution for sending emails using Amazon SES.

Check it at [https://formget.com/mailget-app/](https://formget.com/mailget- app/)

</comment><comment><USER62> Anyone who uses Amazon SES knows deliverability isn't that great. When you use mailchimp you're practically paying for a higher chance for any of your emails not ending up in the spambox (even if they're transactional).

</comment><comment><USER63> Has anyone has a weird issue where a recipient gets emails delayed by up to 45 minutes via SES, but sending via Google is received immediately?

They aren't ending up in a spam folder, just delayed.

Note that the email address domain is the same between these two.

<comment><USER64> If you're new to ses, they can throttle emails to the same domains to protect you

<comment><USER63> Mmm, this recipient has their own domain and they only get one every two to three business hours. Other places with public (gmail, yahoo) or personal domains work just fine.

Sendgrid exhibited the same behavior, last I heard, sendgrid is also using SES.

But sending from a gapps email was instant.

<comment><USER12> I work at SendGrid. We don't use SES. All our receiving, processing, and delivery software (and more) is developed in-house. We also run our own data centers. However, we are looking at how we could leverage Amazon for more elastic scaling and faster API response times for our customers. But nothing with SES.

<comment><USER63> Thank you for the clarification.

</comment></comment></comment></comment></comment><comment><USER65> I did this with Sendy/SES and switched back to MailChimp. You can possibly watch your inbox rate plummet with your costs if you do this, maybe they improved SES since two years ago though. "You get what you pay for"

</comment><comment><USER66> the absence of delivery stats is a key omission

<comment><AUTHOR> Mailwizz provides all of the delivery stats. Here's a screenshot I just took of a recent campaign:

[https://imgur.com/a/PSMm3](https://imgur.com/a/PSMm3)

<comment><USER67> Delivery stats aren't really very accurate these days. It's impossible to get stats for gmail web users (due to the new image caching), or for non-gmail-web users who haven't clicked "load images".

<comment><USER68> Isn't that "open stats"?

<comment><USER67> Yes, but that's the only way of knowing that it hasn't gone into the user's spam folder.

</comment></comment></comment></comment></comment><comment><USER69> Forgive my simplistic question, but... if SES creates issues with deliverability/spam flags, is Pinpoint an option for MailWizz, Sendy etc? It looks like it's more appropriate for non-transactional email.

</comment><comment><USER70> Does MailWizz or any other similar service that support the same with Mailgun?

</comment><comment><USER64> I did the same and saved like 100x</comment>


Snails, Hedgehog Heads and Stale Beer: a peek inside premodern cookbooks - <AUTHOR> https://www.bunkhistory.org/resources/1544 <comment><USER2> This guy: [https://www.youtube.com/user/jastownsendandson](https://www.youtube.com/user/jastownsendandson)

If old recipes interest you, that's the Youtube guy to watch.

<comment><USER3> wow that guy releases a lot of videos per month for this type of channel. almost ten each month if I'm not mistaken?

<comment><USER4> He runs one of the more prominent historical re-enactment suppliers in the country, so I think they see it as a form of advertising. Plus, you get the impression that he just genuinely loves to share his interests with people.

Somewhere there's a list of all the Hollywood movies that use Townsend clothes or props, it's not a short list.</comment></comment></comment>