Complex Numbers

Medical Leeches

Today's article—something from NPR—mostly applies to the US. People from other countries, feel free to shake your heads in disbelief.

How to get rid of medical debt — or avoid it in the first place  

1. Move to another country; or
2. Just die.

But medical billing and health insurance systems in the U.S. are complex, and many patients have difficulty navigating them.

This is by design.

One of the great certainties in life, apart from death and taxes, is that you will need medical care at some point. Some people have figured out that we don't really want to die (or move to another country), so they find ways to extract money from us for that privilege. Some cost is, of course, unavoidable, but if you consider other actual needs, you'll find that they're free or heavily subsidized:

Air - generally free
Water - Low to no cost, depending on where you live. Mine is provided by *gasp* the government
Food - Can certainly be expensive, but some of the basics are subsidized
Beer - Okay, you got me there. The cheap stuff is basically water, anyway.

The only other basic need that's not cheap is housing. I'm not going to go into the reasons for that, but as with health care, the profit motive can get out of control.

If you're worried about incurring debt during a health crisis or are struggling to deal with bills you already have, you're not alone. Some 100 million people — including 41% of U.S. adults — have health care debt, according to a recent survey by KFF (Kaiser Family Foundation).

41% is absolutely mind-blowing. But as you should know, there's debt and then there's debt. I'm technically in debt, for example, paying for this dang computer every month—but it's a 0% interest promotional offer, and I'm prepared to pay it in full before the promotion period expires, which will probably piss Dell off, but I don't care.

"It shouldn't be on the patients who are experiencing the medical issues to navigate this complicated system," said Nicolas Cordova, a health care lawyer with the New Mexico Center on Law and Poverty. But consumers who inform themselves have a better chance of avoiding debt traps.

Especially when some of the patients aren't in a position to figure out complicated payment options. Mental health, for example. Or people in comas.

Even people with health insurance can land in debt; indeed, one of the biggest problems, consumer advocates said, is that so many people are underinsured, which means they can get hit with huge out-of-pocket costs from coinsurance and high deductibles.

I don't think I'm stupid or ignorant, but figuring out what my insurance policy will and will not cover is harder for me than understanding calculus. It seems completely arbitrary.

Get the best insurance coverage you can afford — even when you're healthy. Make sure you know what the copays, coinsurance, and deductibles will be.

And then watch as you get sick and you find out you're still not covered.

If you're uninsured but need health care, you might qualify for public insurance like Medicaid or Medicare. Ask the provider or hospital if they can help you check your eligibility before you commit to a care plan — and then stay with providers who participate in those programs.

Easier said than done. I've heard horror stories about people who, while lying helpless in a hospital bed, had a doctor come in to check on them. The doctor happened to be out of network. They got boned.

Note, I'm not blaming doctors here. Highly trained medical specialists deserve to be paid. It's a question of who's doing the paying, and how many layers there are between you and the actual doctor.

After your doctors map out your treatment plan, check whether all the providers you need to see are in-network and whether any part of the treatment needs to be preauthorized. Ask lots of questions of your insurance provider, doctor's office, or hospital, especially for planned procedures, said Joy Dockter, a lawyer at Central California Legal Services, a public interest law firm.

That's great in theory, and it may even work in practice for, say, a broken arm. But some medical emergencies are absolutely time-sensitive, and/or you're not going to be in any position to ask questions.

Additionally, said Mark Rukavina, a program director at health equity advocacy group Community Catalyst, if the drug you want isn't covered by your insurance, ask whether the drugmaker has a patient assistance program; many do, though eligibility requirements vary.

My doctor wrote me a prescription for a certain medication. It's very expensive, so the insurance won't cover it. They say they'll cover it when I get diabetes. Not before. Never mind that this medication is supposed to keep me from getting diabetes in the first place.

Another oddity: I'm on three pills. They're relatively low-cost compared to that other one. The doc writes me a prescription for a 90-day supply of each of them. I take it to the pharmacy, where I find out that my insurance will only let me get a 30-day supply of each at about $30 each. That's $90 a month. Or, if I tell the pharmacist to forget I have insurance, I can get the 90-day supply—also at a cost of $30. That averages out to $30 a month.

I also "forgot" to tell the eye doctor that I had insurance, and thus my cataract surgery was cheaper.

If you're uninsured, ask for a cost estimate in advance. Rukavina noted that the federal No Surprises Act, which took effect in January, requires providers to give uninsured patients "good faith" estimates of what planned care will cost.

From what I've gathered, those estimates would fit nicely in the Fantasy section of your local bookstore.

Almost every hospital offers some form of financial assistance, or "charity care." Each hospital sets its own eligibility requirements but typically will waive or discount bills for patients earning less than two to three times the federal poverty level. (Three times the federal poverty level for a household of four in 2022 would be $83,250.)

I'm a household of one (housemate doesn't count in this calculation), and my income is sometimes below poverty level, sometimes above. I assume the income calculation is based on last year's tax return. What if I need care the year after a slightly larger income?

Even if you're not sure whether you qualify, it's worth trying. Gather up documents such as pay stubs or income tax returns. Do not expect this to be an easy process. For example, Walker said, health care providers often require documentation to be faxed. "One of the most common refrains I heard from experts: Persistence pays," Walker said.

So, hypothetical scenario: I'm lying in bed, unable to move, barely able to even stay awake, and I'm supposed to gather up all my old tax returns, then find a fax machine (nearest one's at a Staples about two miles from me, and I don't have a car)?

Ambulance services, which can lead to huge bills, might offer charity care programs, so ask whether you qualify.

Another hypothetical scenario: I've just been hit by a bus, still alive but concussed, and I'm supposed to ask the EMTs if I qualify for charity care?

Keep an eye on costs as they come up, said Louisville cancer patient Lori Mangum, who is now chief operating officer of Gilda's Club Kentuckiana, a cancer support group she relied on. Ask a family member or a support group to help you keep track, she said.

I don't have family or a support group.

Consumer protections in the No Surprises Act should help limit out-of-network charges.

HAHAHAHAHA

Rukavina noted that if you are not insured or not using your insurance and asked for an estimate in advance, you can dispute bills that exceed the estimates by $400. For patients seeking more information about the No Surprises Act and what it covers, Rukavina recommended calling the government's No Surprises Help Desk at 800-985-3059.

I haven't called that number, but if I did, and got put on hold for four hours, that would be No Surprise. That's what happens when I contact any other business or government agency that's supposed to "help" and gets no direct benefit for it.

If you know you cannot pay the bill, negotiate with the hospital administration or billing department. "That's almost always possible" because hospitals want to avoid the costly administrative burden of sending bills to collections, said Ge Bai, a professor of accounting and health care policy at Johns Hopkins University.

You know what would avoid costly administrative burdens? A system where everyone pays based on their income, and everything that's not an elective procedure is covered. And isn't tied to work.

Yeah, we're back in the Fantasy section. But I look at it this way: I don't have kids, and yet I finance public schools in two localities through taxes. I'm okay with this, because an educated populace is in my—and everyone's—best interests. Similarly, a healthy populace is in everyone's best interests.

And in the end, there's no real difference between paying for health insurance, and paying taxes. But a simpler system would benefit everyone except the leeches who currently suck the blood out of every medical transaction.

Unfortunately, those leeches are also lobbyists, so it ain't gonna happen.