That still does not negate my point which is that IMO those estimates are not worth anything and therefore that is not a sufficient solution if people have HSAs.
Neither sufficient, nor necessary. Since I don't pay my medical bills out of the HSA anyway, I'm effectively a cash patient, so I am in the habit of asking for a cash discount. Sometimes I can get one even if I'm going to end up getting billed, but I have always gotten one when I had any significant portion of the expected bill with me, in cash form. When I first started doing things this way, it seemed that most places didn't know how to handle it, but now most of them know what to do with a large cash payment and what kind of discount is available. How long ago was this experience that you refer to?
Seems to me you could obtain the "cash discount" price from the provider, and then turn around and reimburse yourself from the HSA.
I can, indeed. But I generally don't. I try to leave the HSA funds in there, as another retirement account. Better than a roth. If I need the cash later, I can reimburse myself at any time.
But more broadly, I don't get how far one can take this "cash patient" idea once you get into serious disease. I had breast cancer 6 years ago and just 3 weeks ago I had the last of 5 expensive surgeries. How would this HSA/cash patient idea work in a situation like mine?
Most of the cash discounts are small percentages, somewhere between 2% and 10%. It's really a discount for completely avoiding the costs & risks of medical billing, which can be considerable depending upon what we are talking about. If you have a large HSA balance, and you know that an expensive procedure is soon coming, you can arrange a discount from the sponsoring hospital in advance with a cash deposit. Even 2% would save you serious cash on a surgery. Honestly, if there is an emergency procedure in there somewhere, it would be difficult to get a discount after the fact, but I have actually done that also. After a certain point, though, I depend upon the high deductible insurance policy that comes with my HSA; I'm mostly talking about the more common expenses that occur in advance of hitting that deductible. If it were still an option, I'd only carry catastrophic care with my HSA, and participate in a health cost sharing group; but the ACA prohibits me from getting a catastrophic policy and also prohibits HSA's paired with a health cost sharing group. I'm not opposed to insurance to limit risks, but I want the option to be mostly self-insured, because it is both possible & cheaper than what the ACA now permits. If I could just get an HSA paired with a catastrophic policy that covers
anything over $50K in a single year, without also getting hit with the ACA uninsured tax, I'd do that. I actually still can get such a catastrophic policy, it just can't legally count as medical insurance, even though I can prove that I have $50K+ of HSA funds/Roth IRA contributions that I could withdraw in a pinch. Prior to the ACA, such a catastrophic policy was around $80 a year, as a rider to my "umbrella" insurance policy.
EDIT: I also have a set of 3 month rolling CD's, 16 in total, that function as my own unemployment insurance. I should be able to count those funds also.