“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.

  • There is also an underlying story here about how confusing it is for individuals to navigate their insurance choices and how difficult it is to get well-informed assistance.
    A fully-insured employer in CA cannot make a new hire wait longer than the 1st of the month following 60 days from date of hire to be eligible for insurance. If they are not insured but self-funding their risk, then the ACA mandates that coverage begins no later than the 90th day from date of hire. So the comment that she had to wait until Open Enrollment does sound a tad odd, unless that just happened to be the same timing.

    The COBRA benefit could’ve been elected anytime up to 60 days following receipt of the COBRA notice. Some employers get those notices out asap, others will drag their feet until the deadline which is 14 days after the loss of coverage. There are pros/cons to either of these which is even more in the weeds. Then let’s say you do choose COBRA and fill in the forms, you still have another 30 days before you have to send them the check. That’s 90 days from your loss of coverage. By then, hopefully you are on your new employer’s coverage and you just don’t pay them. (If you took time off between jobs and the waiting period was the full 90 days, yes, you could be in a gap with no enrollment rights).

    If you’ve just had one MD visit or 1-2 Rx in that gap, it’s probably less than paying COBRA retro to your term date. But if something major happens, like this, then you might gladly cough up (pun intended) the premiums.

    Now, how do you find out how to navigate all this? Call a broker? Well, we aren’t paid any commissions on either of these choices, and the commissions are so tiny now to help you buy an individual plan, even on CoveredCA/Healthcare.gov, that most brokers are refusing to take individual clients. And the nice salaried folks at the CoveredCA phone line aren’t trained to help you do much more than apply via their system.

    I think one of the big failings of the ACA and our healthcare financing system is how painful it is to navigate. People hate shopping for insurance, especially healthy people, and especially when insurance is more expensive than rent/mortgage. With the ACA we’ve basically forced everyone’s nose in the poop, and they didn’t like it. The lack of transparency and unpredictability in pricing, complexity in plan designs, the maze of employer/individual/medicare/ACA laws… it is exhausting.

    • Your point about the complexity of navigation hits the target, but please don’t lay the blame on ACA. That legislation was merely an effort to
      • get everybody into the system
      • without gaming the system,
      • standardizing what constitutes essential/basic care and
      • seek ways to standardize a national duke’s mixture to include the millions of uninsured.

      The challenge we face is that there is a difference between what can be called “basic medical care” and the many other alternatives now available by modern medical advances.

      Basic care (or “essential” as ACA would have it) is a baseline for everybody, and includes mental health, contraceptives and preventive medicine. Beyond that, however, are endless cosmetic and advanced sports-related “super care,” high-end dental and reproductive technologies and more.
      There is ample opportunity for profitable medical practices, simply because there will always be a subset of the population well-off enough to have anything money can buy — from cosmetic dentistry, hair transplants, fertility assistance and all kinds of body enhancements — to a personal physician on call 24/7. Most people, however, need access to less-dramatic (and hopefully more prevention-oriented) care.

      The goal of ACA was to adjust the insurance-supported segment of health care by defining what is “essential” and how best to distribute the risks.
      Two tax-supported delivery systems — Medicare and Medicaid — together with the VA & active duty military service systems, are categorically different from the insurance/private sector medical care.

      Seen from a distance the medical care landscape becomes a variety of different delivery systems. Even the tax-supported systems (Medicare, Medicaid, VA and active duty military) all have different funding streams and interfaces with the private sector. Neither Medicare nor Medicaid, both of which are solely administrative, employ medical professionals. The VA and service systems, on the other hand, have physicians, surgeons, nurses, labs, imaging departments etc. on staff, compensated in accordance with “market-based” professional scales — nearly all tax-supported. But even then, there are sometimes cases requiring private-sector referrals.

      From a funding standpoint the whole system is a convoluted can of worms. So there will never be a single one-size-fits-all system for everyone. It’s possible that during a single lifetime, someone may very well matriculate through the system from one end to the other. It’s not unlikely that some people growing up in poor circumstances may be cared for by Medicaid, become active duty military for a few years, get discharged to the private sector and expected to pay their own way (with or without some kind of insurance, HSA, MSA or combination thereof), perhaps qualify for VA benefits, graduate to Medicare, and finally “spending down” once again to become Medicaid dependent in a nursing home.

  • Absolutely, education, or as many call it, healthcare literacy is crucial. That’s why I formed a consulting firm to provide educational programs, lectures to undergrads and grad students, physicians and nurses and political candidates to address this issue. Do you know that 41% of Americans did not purchase healthcare insurance for 2018 because they said it was too expensive. And HALF of those never even went on healthcare.gov or their state exchange to find out what the cost would be. Those with incomes less than 400% of the poverty level received subsidies making there insurance and deductible quite reasonable.
    Please let me know if you are aware of any healthcare reform meetings, seminars, community programs where I can speak about these issues.
    I also help people who have difficulty understanding their bill, why it wasn’t paid and how to appeal.
    All you points were on target.
    Drrebeccaquigghealthcare Reform.com

  • Excellent article, but it brings us back to the point that since the POTUS is working to dismantle the ACA with no plans to put in something else to replace it, the people of the United States and providers are and will continue to suffer.

    It is my opinion, the Administration and the Republican congress and senate are abandoning their responsibility as lawmakers. The insurance system is a mess. It is costly and the offering less and fewer resources. The prevented services that were part of the ACA are being taken out, so any progress we made in helping people to understand the importance of prevention is going to be forgotten as the resources that covered under the ACA are being taken away.

    This story shows how an intelligent person (a doctor) opted to go without healthcare insurance because it was expensive. What is the average American or the underprivileged to do if a doctor can not/will not pay for healthcare insurance?

    As the article points out hundreds of healthy people, who could afford healthcare insurance but choose not to buy it because it is too expensive. When they get sick, they know they will have to pay the price, so they put off seeing a doctor due to those costs, yet eventually have to give in and find themselves with more debt and poorer health or worse.

    Each person has a responsibility to take care of themselves. If they don’t do that, doesn’t/shouldn’t the government enact law to encourage change. We do it with car insurance, why not healthcare insurance?

    I wrote a blog post on this topic. Please feel free to share http://www.nursesadvocates.net/2017/03/i-am-sure-you-know-that-republican.html
    We as a country can and should do better.

  • I am a cardiologist now working as a Healthcare Reform Policy consultant. First of all if your employer had a small business insurance plan (SHOP) on the marketplace these policies DO NOT have a special enrollment period and employees can be enrolled year round. Same for an off marketplace employer plan. So I suggest you ask your employer why they told you that you were not insurable until a special enrollment period?? Possibly to save money? Secondly, the reason for the exorbitant costs of health care in the country .. “ it’s the prices stupid!” We both know that each and every part of your services are charged at 800-1,000% of true costs. Of course that varies hospital to hospital and certainly since there is absolutely no price transparancy patients cannot choose the facility that overcharges the least.
    Lastly I agree, we both know that the diagnosis of pneumonia in a stable patient is not a level 5 ER visit. And I’m wondering whether that was just the facility charge and the physicians bill was not included. We all know that medical bills are typically 90% charges from the facility labs and tests and 10% for the physicians.

    United Health Care is clamping down on ER bills that are inappropriately billed at a higher level and they will not be paying for an inflated level. I suggest that you talk to your employer and hospital about the risk they are taking in overbilling. As physicians we know how to fix many of these problem. Bring charges in line with actual costs.
    I would negotiate your bill down to what their contracted rate would be with most insurers. Insurers would never pay a total bill of over $10,000 for pneumonia!

    • Dr. Quigg, your points are good and on point. I am a nurse advocate and help/education people all the time on their bills and to question ‘the rules’. Yet the average person doesn’t know they can question anything or ask for a discount or how to find alternatives that are less expensive. People look for help when they are in an emergency which we know is the worst time. We need to educate the public to be proactive and more informed and better shoppers of health care services. When we all start to do this, the status quo will change. As I noted in my reply above, we as an industry/country can and need to do better. Keep up your work!

  • Curious about that Level 5 E and M code–CPT 99285, $3476–I wonder if that is justified given your “nearly pristine health” history and your fairly routine pneumonia diagnosis. And, even if that level of billing were justified, why didn’t your colleague cut you a little professional courtesy justice? The story seems a little sketchy.

  • I wonder what it would have cost even with insurance. Many people have high deductibles and high out of pocket costs. So, it could easily have still been $5000 – $7000 out of pocket. That also is a story worth covering.

  • Health Insurance system is a black hole. It increase the expenditure on health. Instead if the government provide a better health care , the expenditure on health will be minimized . While the govt spending trillions of money for wars , why cannot they spend billions for free health care to its citizens. Is it not their duty to provide free better health care for everyone

  • Uninsured physician shocked by $10k emergency department bill.
    Emergency Department shocked by uninsured emergency physician!

  • 10,000 is a bargain! (your bill would be a joke if it were not so serious) You should have seen my ER bill for EGD before it was adjusted/paid by BC/BS. Health care “pricing” is not directly subject to the laws of economics. We (in the system) know that the bill has a lot of funny money and is adjusted drastically in some cases (unfortunately not so much for the individual). The fact that the consumer is not affected in such a way as to notice the cost of our (oversupplied and overused in many cases) system is part of the problem (my benefits are FREE).

    Ask any CFO of a facility how this works and why they price the way that they do. If we could instantiate a direct pay system from the patient, that would put some realism into the system. Many hospitals would close (we don’t need 25 CT scanners in a medium size city), and we might get a hold on the monster that is health care in the United States.

    But, ain’t never gonna happen, too many players with $$$ at stake. So, IMO, UNIVERSAL HEALTH CARE! SINGLE PAYER! This coming from a life-long libertarian/republican who despises government on every front. I also am a life-long member of the health care industry (MD) and from a practical point of view think that this is the best solution. Paradoxical viewpoint, but possibly the only viable political alternative in this environment.


Comments are closed.

A roundup of STAT’s top stories of the day in science and medicine

Privacy Policy