“It’s probably nothing.” That’s what I said to myself not long ago when I started feeling lousy. I should know, since I’m a physician. But I learned the hard way that those “nothings” can get serious fast — and without health insurance, the bill can be astronomical.

Just after Thanksgiving last year, it occurred to me that I was more tired than usual. I chalked it up to working a long string of shifts in the emergency department at the hospital. “I never get sick!” I told myself, and upped my caffeine intake.

About a week later, I started spiking fevers, and my appetite dwindled. Something was wrong but I couldn’t put my finger on it. I convinced myself it was just a virus and would pass with time and rest. But I felt worse over the following week, not better. I continued to convince myself that it, whatever “it” was, would fade away on its own. I thought of the cost of a doctor’s visit, blood tests, imaging, and the rest, then took another Tylenol and went back to bed.


You’re probably wondering why I didn’t simply see a doctor. I’m a bit reluctant to admit it, but I didn’t have health insurance. That’s right — I was a doctor without health insurance.

Earlier in the fall, in the transition from one job to the next, my insurance had lapsed. When I was prompted to sign up for insurance with my new employer, I was told that it wouldn’t go into effect until open enrollment on Jan. 1. I didn’t question that. I was healthy. A few months without insurance would be fine.

A colleague suggested I get covered under what’s commonly called COBRA. But I was flabbergasted by the cost, especially on top of student loan payments and living expenses. I then looked at Covered California, my state’s exchange for Affordable Care Act insurance plans, and was equally dismayed. Knowing my almost pristine health history, I opted to forgo insurance and instead pay the individual mandate penalty, which was a fraction of the cost of coverage.

In other words, here I was talking myself out of going to the doctor — even though I was starting to lean in that direction — because I knew that a hospital bill without insurance would be more than I could handle.

I’m not an anomaly. Many Americans do this every day.

You can probably guess how my story unfolded. When I finally couldn’t put it off any longer, and was barely able to get out of bed, I ended up in the emergency department I work in. A colleague, looking at my chest X-ray showing extensive pneumonia, asked why I waited so long to see a doctor. In tears, I tried to explain.

Later, hospital bill in hand, the explanation became easier.

The bill for my emergency department visit totaled $10,282.34. I had asked that intravenous medications be changed to oral medications when possible because they are less expensive, and refused some additional tests and medications. This kind of insider information, which most people don’t have, helped me keep costs to a minimum — though I was shocked to see a $10,000 bill.

Emergency department bill
The author’s bill for emergency treatment of pneumonia. Courtesy Jessica K. Willett

Consider a single-income family in the U.S. I pick that category because about 1 in 4 children in our country are currently being raised by a single parent, and that number is rising. The average median income for a single-income family is about $35,000. If that parent or caregiver gets sick and needs medical care, how will she or he pay a bill that could be one-third or more of the family’s total annual income? That’s a powerful reason to wait.

We talk about improving access to health care through health literacy, education, and outreach. These things matter. But until we address the cost of health care, a huge barrier to care will remain. Medicine is tightly intertwined with social factors, which affect both physicians and patients — and sometimes, both at the same time.

My story isn’t unique. I now have health insurance, which is a relief to me if similar circumstances arise in the future. Yet I know that many of my patients — and perhaps many of my colleagues — aren’t so lucky. Although I was previously aware of the many social circumstances affecting my patients’ access to care and the circumstances contributing to their overall health, I’m now able to relate to it on a more personal level. Now when I ask the question, “Why did you wait so long to see a doctor?” I can also say, “Yes, I absolutely understand why.”

Jessica K. Willett, M.D., is an emergency physician who works in Northern California.

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  • Wow! Thank you for sharing your story! I am not a MD. I take about
    5 – 500 mg or 5 – 1000 mg Vitamin C (purchased right off the shelf) as soon as I feel a scratchy throat or that pre-sick feeling or lower than normal energy. I take with orange juice and water. I take this amount for about 3 – 5 days until I feel back to normal.

  • One is paying for a lot of infrastructure, overhead, big salaries, nice facilities and “stuff” that most of the time just sits there until really needed. Insurance companies, particularly health plans never pay these in full prices. Most negotiate down to about 1/4 th or less. Poor Joe blow public gets screwed. That’s just the way it is folks.

  • As a doctor who still reads EVERY edition of Harrison’s it was a known fact. Yes, books also should give disclaimers ..but you might have to bring out a small booklet, possibly Harrison’s Vol . 3 to disclose a contributor’s name and topic covered with associations and fees mentioned.

  • Jessica, I’m so sorry you had to go through this. In the interests of making sure others do not, I’m leaving this comment.

    You should have been covered for health insurance the whole time…in two different ways.

    First of all, whomever at your employer told you to wait until Jan 1st should be fired. As a new employee, you’re eligible for benefits as soon as you start work, or at the first of the next month at the latest. A corporate “open enrollment” period only applies to existing employees. If you had been hired in March, for example, an employer can’t tell you “sorry, wait until January when everyone else’s enrollment period opens up.” Someone was either misinformed or trying to get out of having to do paperwork for you twice over the span of a few months.

    Secondly, COBRA can be applied retroactively. You have a 60 day window from when your last job ends (or from when they mailed you your eligibility notice, if that was later) to apply…during which time you’re covered. So if you got sick 45 days out, you can apply, pay for those two months and have them pick up the cost of any medical bills just like under your prior plan. While COBRA is expensive, it’s not $10,000. You can also cancel coverage at any time if you get other insurance.

    The rules around insurance are so opaque most people don’t know when they’ve being given wrong information. They then end up stuck with bills they shouldn’t be paying. I hope that this information can serve to help shed some light for others to avoid a similar situation.

  • I’m curious about whether the ED physician that took care of you actually did an assessment and documentation that would justify a 99285 visit level. And, the fee is awfully high compared to what many payers would reimburse. This is a good example of cost-shifting, which in most cases punishes the most vulnerable.

  • I am a practicing physician; I also just graduated from law school (focused on health law). I learned a valuable lesson in law school: student health insurance. I had it all 3 years of law school- reasonable cost and deductible. Then I graduated and as an independent contractor, no option of COBRA, and living in Texas (ridiculous ‘options’ for the individuals) I figured out that if I took 6 hours of classes each semester at my local community college (online, thank you), I could still get student health insurance. Unless I get a job with insurance (I’m looking- just want to combine my medical and legal educations but not via litigation), looks like I will never be done with school. It’s a sad and ridiculous state of affairs that this is what I need to do to get coverage. Lack of health insurance is not just a problem for the poor or unskilled.

  • I am annoyed by those (such as the Obama administration) who have attempted to vilify health insurance companies. Not only do health insurance companies shield us from paying these charges all at once, they shield us from paying most of the charges at all. Typically insurers will pay hospitals or physicians a third of what they bill uninsured customers, and hospitals will accept the payments because they still make a lot of money. It is doctors and hospitals who should be vilified for charging these horrific rates.

    The health care industry needs competition to bring down these prices. We need a greater supply of physicians and hospitals to meet current health care demand. There are many who attempt logical gymnastics to argue that the laws of economics do not apply to health care, but this article is proof that they do. Economics is about the choices of consumers, and those consumers, including physicians themselves, often choose to be sick rather than having to pay for health care.

  • It’s not called COBRA for nothing. The acronym is for Consolidated Omnibus Budget Reconciliation Act but like the snake it can have a poisonous bite. It’s a relic of the past long due for updating. At the moment when someone loses income is exactly when the cost of health insurance virtually doubles — just when it becomes least affordable.

    Which brings me to that hospital bill. After a lifetime in the food business, busting my butt to squeeze a nickle or dime out of every dollar, I was shocked when I went to work for a healthcare system to have insurance for a few years before my wife and I would become Medicare beneficiaries. It was a so-called “non-profit” but the place was awash with money, not to mention various volunteer groups that ran the gift shop, welcome tables and a raft of other activities.

    The difference between “costs” and “prices” appears to be non-existent in the world of health care.
    “Costs” in my experience included every dime spent on actual operational expenses, from paper clips to advertising to payroll outlays (including my own bonuses) and anything else for which the accounting people had a journal entry.
    “Prices” on the other hand were how much we charged the public for goods and services.
    Medical bills, I discovered, never seem to include operational NON-medical costs, yet they are the only revenue stream for the billing department. Patients have no information about behind the scenes machinations that generate those bills.
    I came to the conclusion after a few years that the typical healthcare system consists of a large hospital system, often but not always non-profit, surrounded by acres of very much for-profit clinics, private practices, labs, durable equipment, rehab and other ancillary goods and services — all clustered around typically in the most affluent parts of cities. As a result, rural areas and poor parts of metroplexes have become “healthcare deserts” (like food deserts) with what passes for “competition” too far away to be of much benefit.
    The best healthcare, I discovered, is for the carriage trade. Like most of the marketplace, healthcare is rationed by affordability.

    In my post-retirement avocation I took care of (other) old people for fourteen years, first in a retirement setting, later as a non-medical caregiver through an agency. I saw that most costly segment of American healthcare up close and personal all that time and came to that grim conclusion about rationing by affordability. I could tell a number of stories, but one that I recalled looking at that medical bill was the line about infusions. One of my assignments included a man who developed a hospital-acquired infection for which he was prescribed a drug that had to be administered by infusion. When he came home he had an open wound covered with black gauze (which I had never seen) coupled with a 24/7 vacuum pump to draw the infection as the wound healed. It was almost magical to see this modern medical stuff at work — and a home health nurse was assigned to come once or twice a week to replace the bandage — another wonderful improvement over reovery as a hospital inpatient.

    But that infusion, it seems, could not be done by the home health care nurse. Instead, he had to be taken to the hospital where that drug was disbursed by the same place that did chemo follow-up for cancer patients. He was wheelchair dependent, so those were not easy trips. Thankfully the family could afford my services (out of reach for anyone without the means for private pay and a nightmare, I’m sure, for any spouse/caregiver trying to do it alone).

    Do I need to go on?
    My point is that those healthcare costs are not only out of reach, but they also include a good many preventable inefficiencies in the form of both drugs and services. I have been blessed with pretty good health and am really glad to have made it to Medicare. Both of my parents were Medicaid beneficiaries at the end of their lives (which I hope to avoid for the sake or our kids — “spending down” is how the American healthcare system sucks generational wealth even from the lowest rungs of the income ladder) and I have become an evangelist for advance directives.

    Thank you for this caveat about the necessity of healthcare insurance, and for giving me a chance to vent.

    • What’s insane is that our healthcare system evolved to become what it is today, tied to employment and run for profit in most cases. Apparently this is what it means to be an American: to have lousy healthcare that blames the sick, the poor, and even the middle income people who work at jobs they hate just to get health insurance for their families. To live in fear of illness and not being able to afford meds. We are allergic to reason. My father, at age 90, has enjoyed far better healthcare coverage for the last 25 years [due to a combination of having a union-backed healthcare plan (that he STILL has!) and Medicare] than I ever have or likely ever will have. Medicare works. Oh wait, I guess that’s single payer. Better not say that. Say SOCIALIST instead so it’s dismissed. No doubt by the time I get there, Medicare will be gutted by the likes of Paul Ryan and his Ayn Rand-loving heartless minions. I worry every single day about my 27 year old son now that we can’t cover him and he has an expensive chronic condition. Read about RaeShawn Smith, dead at 27 from type 1 diabetes. This doesn’t have to happen. Insulin was made in 1932 by 2 Canadians who gave the patent away to academia. How does one explain insulin prices today, costing thousands per month? Here’s how: greed. https://player.fm/series/the-latest-stories-from-wwwwnycorg-1853180/sugarland-as-diabetes-rate-skyrockets-so-does-cost-of-insulin

    • Sorry Jackie, but Medicare can’t be considered an example of single payer, because it uses a healthcare system that accepts multiple payers. The only single payer system the US has as an example is the VA system, and we can all agree that system has major flaws.

    • Tom, the VA may have major issues, some of which are much worse if experienced in the private system. But, I grew up with Tricare until I was 23 years-old, plus my parents had supplemental insurance – I never remember us paying when leaving a doctor’s office. Three months of birth control pills only cost me $9. And, I wasn’t forced to see a base physician, we could go to almost any physician because Tricare contracted with what seemed like every doctor. Why can’t other insurers mimic these practices?

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