In a recent tweet that resonated with many, I shared my startling encounter with an unexpected medical bill of nearly $5,000 (originally $10,000). The incident shed light on a widespread issue that countless Americans face when grappling with the labyrinthine and often bewildering U.S. healthcare system.
My Run-In With the Emergency Department
While attending a conference in Arizona in January, I embarked on a popular hike up the renowned Camelback Mountain. Unfortunately, mirroring the experiences of many who preceded me, I underestimated the effects of the dry desert air and mid-day temperature. I consequently found myself dizzy and dehydrated, necessitating an emergency department visit. During my visit, I received three bags of IV fluids, two rounds of blood tests, and one X-ray -- and 6 weeks later, an array of medical charges approaching $10,000. Despite my insurance company negotiating it down to $4,800, the onus of the entire amount still fell on me due to my high-deductible health plan (HDHP).
When I contested the seemingly exorbitant charges (even after they had been negotiated down) with the health system, I was met with the response that their fees were legally sound and consistent with charges for all their patients.
This ordeal underscores a harsh reality: Millions of Americans face unforeseen out-of-pocket expenses, but few can shoulder such a burden. This contributes to medical debt or time out of work for medical issues being a factor in 66% of all bankruptcies in the U.S. My personal experience builds on a national discourse regarding the imperative for enhanced transparency in healthcare pricing and safeguarding patients from the specter of surprise medical bills.
The Affordability Problem
Surprise medical bills, such as the one I received, often stem from patients unwittingly receiving care from out-of-network providers, resulting in substantially higher costs that insurance fails to cover. These bills impose financial burdens on patients, precipitating stress and anxiety over the daunting prospect of affording necessary medical care. According to a study published in the New England Journal of Medicine, nearly one in five emergency department visits yields out-of-network charges.
Numerous Americans have found themselves ensnared in analogous predicaments while seeking medical attention, as evidenced by the myriad stories shared in response to my tweet. The opacity surrounding healthcare pricing makes it difficult for patients to ascertain the cost of their care upfront, engendering bewilderment, frustration, and financial distress when confronted with unexpected bills. Although the No Surprises Act (NSA) was passed to address just this issue, its implementation (beginning in 2022) has been contentious and some hospitals are still not in compliance.
In my case, had I been aware that I would be charged $10,000 for basic treatment that included IV hydration -- care that you can get in a hotel room or via mobile clinics in many cities for less than $500 -- I would have opted to hydrate at home. However, despite healthcare purportedly operating as a free market, I was not furnished with the requisite information to make an informed decision regarding my purchase. Moreover, I was not apprised of the cost of my care until 6 weeks later!
It is worth noting that emergency veterinary clinics furnish cost estimates to pet owners, enabling them to make informed decisions before proceeding with care. If we can do it for Fido, shouldn't we be able to extend comparable transparency to human healthcare as well?
Furthermore, the common practice of cost-shifting and up-charging in healthcare -- which many experts feel were exacerbated by policies like the Emergency Medical Treatment and Active Labor Act (EMTALA) under President Reagan and the Affordable Care Act (ACA) under President Obama -- emboldens healthcare systems to staunchly defend charging many times the market rate for services to insured individuals (or in many cases billing even more exorbitantly to self-pay patients, who don't have the market power of big insurance carriers to negotiate $10,000 down to $5,000). This practice is ostensibly justified by the assumption that charging some patients far more than their care actually costs is a perfectly legitimate way to offset the uncompensated care they provide (and to make a profit on the side -- healthcare is almost 20% of America's gross domestic product [GDP] after all).
The proliferation of HDHPs, encompassing almost 60% of individuals with employer-provided health insurance post-ACA, compounds the issue. Although these plans are coupled with health savings accounts (HSAs), many people -- especially Black individuals -- fail to maximize use of their HSAs, leaving them susceptible to substantial medical bills for unplanned care. Although I dutifully contribute to my HSA monthly, the exigency of my situation in January precluded any contributions for 2024. Consequently, I bore the brunt of the entire bill. Healthcare coverage should not be akin to sitting at the craps table in Las Vegas, where the prospect of financial ruin looms large.
Lastly, the absence of objective arbitration in billing disputes often compels patients to acquiesce to whatever the healthcare system demands, lest they incur medical debt and endure life-altering credit score repercussions. In my case, the health system wielded unchecked authority as judge, jury, and executioner -- determining charges, adjudging their fairness, and unilaterally deciding whether I would be referred to collections if I didn't pay, with attendant risks of elevated interest rates or credit denial.
Toward a Fairer Care System
To address the scourge of surprise and exorbitant medical bills and ameliorate the healthcare system for all Americans, I proffer several recommendations, some of which are components of the NSA but need to be better enforced:
- Enhance transparency in healthcare pricing: Mandate that providers disclose an estimate of charges upfront, whenever possible, enabling patients to make informed decisions about their care.
- Institute arbitration for billing disputes: States should implement arbitration to impartially resolve billing disputes between providers and insurers, shielding patients from exorbitant bills they cannot afford.
- Advocate for consumer protections: Educate and empower patients to advocate for themselves through measures such as the right to appeal surprise bills and negotiate payment plans with providers.
- Support legislative efforts to address surprise medical bills: Rally behind state and federal legislation, such as the NSA, aimed at tackling surprise medical bills and fortifying patient protections.
- Foster collaboration between providers and insurers: Encourage cooperation between providers, healthcare systems, and insurers to prevent surprise bills and enhance the healthcare experience for patients. Too often, doctors are blamed for high medical bills, when they are usually responsible for a minority of the actual charges.
- Improve HDHPs: Bolster understanding of HDHPs and the importance of contributing to HSAs through educational campaigns, while exploring ways to shield consumers from unforeseen medical bills and mitigate the phenomenon of "January surprises" like mine.
My recent and ongoing ordeal with an unexpected and burdensome medical bill, despite my professional background, underscores the imperative for enhanced transparency in healthcare pricing and safeguards against surprise bills. If I, with my knowledge, expertise, and connections, struggle to navigate the U.S. healthcare system, the average American doesn't stand a chance.
By embracing the policy changes delineated above, we can endeavor towards a healthcare system that is more equitable, affordable, and accessible to all. While my family and I can afford to settle our bill, my advocacy transcends personal interests; it serves as a clarion call for healthcare reform, ensuring that everyone can access necessary care without fear of financial ruin.
Jerome Adams, MD, MPH, is Director of Health Equity at Purdue University, and was the 20th Surgeon General of the U.S.