Impatient

Helping make the health care system work for you

She has health insurance, but can't pay her medical bills. She's not alone.

Photo by torbakhopper HE DEAD via Flickr Creative Commons

A few weeks ago, I asked Impatient readers to share their experiences with high-deductible health plans. I also posted the request on my personal Facebook page.

One reply was from an acquaintance: Like more and more Americans, Celisa Flores, 34, recently obtained a high-deductible health plan through her employer. The plan, through Anthem Blue Cross, covered her and her son, and she thought it carried a $5,000 deductible.

At the time, the deductible "didn’t seem like a huge deal to me, because we never go to the doctor," says Flores, of Costa Mesa.

Even after her car was totaled in a hit-and-run in July 2014, she avoided going to the doctor. Flores visited a chiropractor for several months, until the pain drove her to seek more care.

That's when her financial nightmare began.

'Not manageable'

An MRI revealed that Flores' femur had detached from her hip in the accident, and she needed surgery.

She says she paid $3,000 upfront for the surgery. But after that, the bills kept coming – separate ones for the anesthesia, more MRI's, and x-rays.

"Every time I think I've got them all now, here comes another one," says Flores.

Then came the unpleasant surprise: She discovered that under her family plan, her deductible wasn't $5,000, it was $10,000. (Confused about health insurance terms? Check out KPCC's glossary.)

To make matters worse, she discovered that the physical therapist she was seeing - at a cost of $300 per week - was out of network.

Out-of-network care does not count towards her deductible; she has to pay up to $5,000 for out-of-network care, before insurance kicks in. (She's since switched to an in-network therapist, but is still paying $225 each week for therapy, because she hasn't reached her deductible.)

"Catastrophically, $5,000 is manageable," says Flores, a clinical psychologist. "Ten thousand dollars is not manageable, and $15,000 is definitely not manageable." 

Cost sharing – and suffering

Flores is one of many Americans who struggle to afford the cost-sharing requirements of their plans, including their deductibles, copays and coinsurance.

"Most people don't have a lot of money lying around in the cookie jar," says Matthew Rae, a senior policy analyst at the Kaiser Family Foundation and one of the authors of a February 2015 report on financial assets and cost sharing.

When it comes to $5,000 or $10,000 deductibles, only a "tiny proportion (of people) has that lying around in liquid savings," notes Rae.

The Kaiser report is based on data from the 2013 Survey of Consumer Finances – a nationally representative household survey conducted by the Federal Reserve Board. It finds that 51 percent of Americans have enough liquid assets to meet a deductible of $2,500 for a single person, or $5,000 for a family.

Lower-income households have more trouble raising that much cash, the Survey finds.

Mounting costs

For 2015, Celisa Flores bought a new health insurance plan for her son on the state exchange, Covered California. The Blue Shield of California plan comes with a lower deductible, along with a higher premium.

Flores says she has to stick with her high deductible plan for now because she can't afford to pay a higher premium for herself.

"I've already got a delicate balance of trying to make payments on my current medical bills, so adding an increased monthly fee might not be an option," she writes.

The good news, as far as she knows, is that she won't have to reach a family deductible of $10,00o this year. But she still has to reach a $5,000 deductible before her insurance coverage kicks in for 2015.

Already this year, she's paid $2,500 in medical bills, and says only a fraction of those costs - a measly $90 – has gone towards her deductible. Once she reaches her deductible, her insurance plan will cover 60 percent of her medical costs, leaving her on the hook for the rest until she reaches her out-of-pocket maximum. (Under the Affordable Care Act, the out-of-pocket maximum for Flores can't exceed $1,600 beyond her $5,000 deductible.)

All of that's on top of the medical costs and debt Flores accumulated in 2014: she estimates she still owes $4,000 for last year's bills. And that doesn't include what she's charged on her credit cards, she says.

The situation, she says, is baffling.

"I have a job and I have insurance, and I thought it would be helpful," she says.

Instead, she says, she's now overwhelmed with medical bills. She adds, "my car insurance may reimburse me for some of it after I'm done with treatment, but I don't know when that will be."

Insured and in debt

Another Kaiser Family Foundation report examines medical debt: The January 2014 study says one in three Americans reports having trouble paying medical bills. When people can't pay their bills, medical debt follows.

The Kaiser report finds that, like Celisa Flores, 70 percent of people with medical debt are insured. More than half – 54 percent – have employer-sponsored coverage.

The study uses case studies to illustrate a scary fact: "That cost-sharing need not be extremely high to be unaffordable," it says.

Those expenses can snowball if someone's health problem is big enough to cause him to cut back at work, take a leave of absence, or quit, says Karen Pollitz, a senior fellow at the Kaiser Family Foundation.

In those situations, she says, "you can foresee at least short-term income decline that can make it even harder to pay a high deductible."

No way out

Meanwhile, Celisa Flores sees no easy way out of her medical debt. On top of that, she's still in pain and might need another surgery.

"Maybe I'll win the lottery," she says wistfully.

If you're insured, and you're still having trouble affording your health care, we want to hear from you. Tell us about your experience in the comments section below or e-mail us at Impatient@scpr.org.

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