The Math of Medicine
Today I got a bill for $460.46 from Good Samaritan Hospital. This is the ninth bill we’ve paid to the hospital, ER docs, imaging centers and surgeons since my wife sliced into her finger with a bread knife over a year ago. And we have pretty good health insurance.
I grew up in a place where medicine is free, but now I live in California. Since we moved here, people from back home always ask us about healthcare. How much does insurance cost? Do you have to pay every time to go to the doctor? Will America ever join the other 96% of developed nations that provide universal healthcare? Why don’t you just move back home already? (sorry, mom)
It’s complicated but let me try to break it down for you.
Spoiler alert: I am not going to try to explain how the whole system works or the differences between HMO and PPO or on and off-exchange plans or the Affordable Care Act or any of that. We don’t have time for all of that. I’m just going to share the details on what it cost me and my little family to get health insurance and go see the doctor last year, so you can see what the math of medicine looks like here in the States.
We’re a married couple with one kid. Fortunately, we’re all relatively healthy. Although, we did have some big-ticket medical issues come up last year. More on that later.
We look like this:
We also have a dog who looks like this:
From a health insurance perspective, my family’s story is not uncommon, but I wouldn’t say it’s typical. The majority of Americans get health insurance through their jobs. Most companies pay for some or all the cost of insurance premiums for their employees. But my wife and I are both freelancers, so we have to pay for what’s known as “private” health insurance — meaning that we need to shop around, get quotes from different insurance companies and then sign up and pay the premiums ourselves.
Last year, our monthly insurance premiums were $958.47.
Now, if you’re one of my Canadian brothers or sisters, that probably seems like an outrageous sum of money, but here in California it’s pretty average. When you pay for private health insurance, you can choose a bronze, silver or gold plan. Gold plans cost the most and cover the most. We have a silver family plan.
At this point you might be wondering something like, “Why don’t you get a job, dude?”
It’s a legit question. If I had a job at a company that provided health insurance, we’d almost certainly pay a lot less. In fact, some companies have started to realize that having really good health insurance can help with recruiting. So — why not hunt for a steady job with good benefits, like so many other people? You make a good point but allow me to retort.
The larger issue is that it creates a systemic problem where people are dependent on their current job for medical insurance. And if you lose your job or need medical care when you’re not working, life can get impossibly expensive. There is a program that allows you to keep your old work insurance for short periods of time called COBRA, which not only has a ridiculous and ironic name, but is unaffordable for many people.
A few years ago, a friend of mine lost his job. When faced with $650 / month payments to keep his insurance while he had zero income, he decided to just go uninsured until he landed a new gig. I mean, he was relatively young and healthy — what could possibly go wrong in the few weeks or months it would take to secure new employment?
His appendix burst.
After an ambulance ride, emergency surgery and three days in the hospital, he was sent home with a bill for $35,000. Now you could argue that he gambled and lost, and it was his own fault he got into this mess. And if you did, I bet I could guess which way you voted in the last election. But, unlike that guy in the White House, my friend couldn’t call his daddy to ask for the money for his COBRA premiums and today he’s still working to pay the bill for an unexpected medical emergency.
When you hear stories like that, it’s easy to see why you’d want to find and keep a job with good insurance, but if everyone chose their career based on whether or not they’d get health insurance, no one would work for themselves or create their own start-up or, like me, move to Hollywood to sell screenplays.
And that, well — come on — I mean, that’s just not American, is it?
Plus, there are a lot of tax and other benefits to being freelance. So, we pay for health insurance privately, along with 15% of the population in the U.S. Let me do the math on that for you:
Annual cost of health insurance: $11,501.64
Damn. It always stings a little more when you add it up. That’s enough to buy a used car, take a safari or go see 768 movies. You know what stings even worse? That number doesn’t include the cost of going to the doctor. In fact, with the exception of annual check-ups and a few other things, it doesn’t cover a fucking penny until we reach our deductible.
Our deducible: $3,800
Technically, there are lower deductibles for each individual on the plan, but that can get pretty confusing and I’m talking about the cost of healthcare for my whole family, so let’s just stick with the family deductible to make it simple. We pay eleven thousand bucks for insurance, and the insurance doesn’t kick in until we’ve payed $3800 out of our own pockets.
Once we reach our deductible, the plan covers 70% of medical expenses and we pay 30% until we reach our Out of Pocket Maximum. I’ve learned that this is really the most important number in your health plan — it’s the max number of dollars you can pay in a year. Once you hit your out of pocket max, your insurance pays for everything else for the rest of the year.
Our Out of Pocket Maximum: $12,800
Hopefully this all makes sense so far, because now we’re gonna get into the confusing shit. Let’s see what happens when Wyatt needs to see his doctor:
In March, the little guy developed a bad cough. Doc says it’s nothing to worry about it — just keep an eye on him and bring him back if it gets worse. A couple of months later, we get a breakdown from our insurance. Here it is:
- Amount charged: $210.00
- Your discounts: $107.88
- Amount due: $102.12
- Insurance paid: $67.12
- Total you pay: $35.00
This is where it gets a little weird. And a little shady. The doc says it costs $210 for an office visit, but ALMOST NO ONE will ever pay that amount. At most places, if you don’t have insurance, they won’t charge that full amount. I didn’t have insurance for a few years (long story for another time about a “preexisting condition” that made me ineligible for health insurance altogether) and was always amazed at the special prices offered to the uninsured.
If you do have insurance, this is what happens: the doctor’s office sends a bill to our insurance for $210. But, because the insurance company has “negotiated” discounted rates in exchange for keeping the doctor in their network (provided the doctor with access to patients on our insurance) we only owe $102.12 of that full amount. Then, the insurance company pays their share and we are responsible for 35 bucks.
A little confusing but nothing that’s going to break the bank, right? Unless you need more significant medical treatment. Like our whole family did last year.
Let’s skip ahead to the spring when I needed knee surgery. I suppose that technically I didn’t “need” to have knee surgery. My knee hurt all the time, but I could walk around. After over a year of physical therapy I finally saw a surgeon and got an MRI. I had a torn meniscus and if I ever wanted to surf or play basketball or chase my kid around the yard without pain, I was going to need an operation.
Now this is the part that is going to seem bananas if you don’t live in America. I seriously considered postponing the surgery or not getting it at all because I knew it was going to cost my family thousands of dollars. In the end I decided I was too young to give up surfing and playing tag with toddlers, so I went ahead with the surgery. Let’s take a look at how much that cost. The first bill I got back was from my surgeon’s office:
- Amount charged: $9,096.08
- Your discounts: $6,181.09
- Amount due: $2,914.99
- Insurance paid: $2,017.49
- Total you pay: $897.50
Now you might say, “You know, 900 bucks doesn’t sound like that much for knee surgery, man.” After all, the surgery was successful, and my knee is back to normal and I’ve blown that amount on a lot more frivolous things. But, that was just the first bill, man. For the rest I’ll just list the amount we had to pay to keep it simple. For months after the surgery we got bills.
- Surgeon’s office visit: $25.18
- Pharmacy: $37.18
- Hospital fee: $566.40
- Surgery fee: $897.50
- Knee brace: $147.96
- Anesthesia: $96.00
- Knee Surgery Total: $1,770.22
And let’s not forget about the two dozen visits to physical therapy after the surgery to help me get back on my feet at $22.50 per visit. But, enough about me. Let’s talk about my wife.
As I mentioned at the start, last year Lex sliced into her finger with a recently sharpened bread knife. It was a bad one. After a day in the ER and follow ups with a specialist they told us that she’d severed the nerve and would either need surgery to repair it or get used to having no feeling on one side of her index finger.
And again, we talked about. This is what happens in America — every time you need medical treatment you have to stop and think, “Can I afford this? Do I really need it?”
A lot of times, people can’t afford it. The number one reason for bankruptcy filings in the US is medical bills people can’t afford to pay. Fortunately for us, we could afford it and Lex didn’t want to live the rest of her life with no feeling in that finger, so it was time for another surgery.
- ER visit: $825.75
- ER doctor: $194.39
- Imaging: $1.77
- Anesthesia: $54.43
- Surgery: $1.028.40
- Surgeon’s fee $230.70
- More imaging: $29.61
- Hospital fee: $460.46
- Hand Surgery Total: $2.825.51*
*If you think that’s a lot of dolla dolla bills, wait til I show you the invoice for having a baby.
Again, this number is the amount we personally paid for all of this. Our insurance company paid a lot more, but these are the bills we had to pay. But the year wouldn’t be complete if we didn’t all need surgery, which brings me to Wyatt and his Trigger Thumb.
When our little guy was two, we noticed that one of his thumbs was stuck in a bent position for a number of days. We took him to the doc. She said it looked like “trigger thumb” and sent us to see a specialist at Children’s Hospital. Turns out that’s exactly what it was. Apparently, a pretty common condition. She recommended that we keep an eye on it for a number of months to see if it resolved but if not, he’d need surgery to fix it. Or, spend the rest of his life without the ability to give a movie two thumbs up.
Now some people might say, “Is that really such a big deal? Are you sure he needs surgery?
But those people are fucking monsters. He’s a kid. Of course we discussed it and of course the conclusion was that our son needed to have surgery to fix his thumb. Sure, his condition wasn’t life-threatening and we are lucky enough to be able to afford it, but speaking on behalf of dads everywhere, no one should ever have to choose between money and the health of their child.
I’m sure we’re both getting tired of math, so let me skip to the total number for that one:
Wyatt Surgery Total: $2,558.35
You’ll be happy to know that the doctors and nurses at Children’s are all angels and superheroes and that Wyatt now has the full use of both of his thumbs, just like the Fonz.
But back to the math. Those were our big-ticket medical expenses for last year, but there were also other smaller ones that slowly added up over the year. We didn’t quite hit our out of pocket max, but we got pretty damn close:
Total cost of medical expenses: $11,409.00
Before I do the final tally, you should know that our medical insurance doesn’t cover vision or dental work, so every time we get a filling or need new contacts, we pay cash for that. I’m not adding those numbers into the total here.
In summary, last year my family of 2 adults and one very small kid spent this much money on medical stuff:
Health insurance premiums: $11,501.64
Medical expenses: $11,409.00
TOTAL COST FOR THE YEAR: $22.910.64
Fuck me, right?
Thankfully Lex and I were both working last year, and we didn’t have to go into debt or go on Kickstarter to pay these bills, but it hurt. All fingers crossed we don’t need more surgeries this year. One really interesting thing that I wish I’d known at the start of the year is that if we’d signed up for the cheapest bronze insurance plan we would have saved a bunch of money. Turns out that the out of pocket maximum in California is set by the state, so everyone with private insurance has the same out of pocket max whether they had a bronze, silver or gold plan. The surgeries would have cost the same, but we’d have paid almost $2,000 less in insurance premiums.
The irony is that we’ve switched to bronze for this year, but thanks to our current government’s obsession with ending the Affordable Care Act, the cost of private insurance has gone way up. So even though we downgraded to a bronze plan with a different company our premiums for 2019 look like this:
Monthly insurance premiums: $1,089.39
Annual : $13,072.68
Well, that’s all the math and emotional abuse I can take in one day. If you’re reading this back home in Canada, I hope it was as educational for you as it was demoralizing for me. Hug Vancouver for me and tell mom that we’re still not moving back home any time soon. The surf and the tacos are just too good down here.
If you live in the States, I hope you have good insurance. I hope no one in your family gets sick. I hope you never have to choose between bankruptcy and the health of your children. I hope that America gets its shit together and realizes that the well-being of your family shouldn’t be tied to your job or how much money you have in the bank. I hope that when our kids grow up they don’t have to worry about the math of medicine. I hope.
Originally published at www.writerman.com on January 13, 2019.