‘Do you pay the hospital
bill or do you pay the utility bill?’ Don’t count on your health insurance for
serious illnesses, a new survey warns.
Oct.
17, 2018
The whole point of
health insurance is protection from financial ruin in case of catastrophic,
costly health problems. But a recent survey of people facing such problems
shows that it often fails in that basic function.
The survey, of some
of the country’s most seriously ill people, found that even with health
insurance, more than a third of the respondents had spent all or most
of their savings while sick. They are often faced with deductibles and
co-payments; treatments their insurance won’t cover; and financial challenges —
like lost work — that health insurance alone can’t address.
The New York Times,
the Commonwealth
Fund and the Harvard
T.H. Chan School of Public Health used the survey to examine
the sliver of the American population who use the health care system the most.
To be included in the results, a respondent had to have been hospitalized twice in the
last two years, and to have seen at least three doctors. In some cases, when
patients had died or were too ill to answer questions, relatives who had taken
care of them participated in their place.
Their experiences may
serve as an early warning system for problems that all of us may face: Because
the estimated 40 million people in this population visit doctors, hospitals,
nursing homes and pharmacies the most, they are the likeliest to see the weak
points in the health care system.
ne of these is financial insecurity.
Among people with health insurance, more than 20 percent had trouble paying for
basic necessities. More than a quarter had bills in collection, and 13 percent
had borrowed money as a result of their illness.
Health insurance
provided some protection against such outcomes — those in the survey who were
uninsured were even more likely to face mounting bills and debts — but the
insurance was generally not enough. The intensity of care increased the number
of co-payments those surveyed faced, and it increased the chances of receiving
the kind of treatment that their insurance denied. And they were most likely to
get stuck paying insurance deductibles, which have been steadily
rising over the last two decades.
Thirty-one percent of
people in the survey said they were unsure what their health insurance would
pay for. Forty-two percent said they’d received a hospital bill that their
insurance had not fully covered. Twenty-six percent said a treatment their
doctor recommended was denied by their insurance.
“What’s staggering
here is there’s no way people could know what they would be in for,” said
Robert Blendon, a professor at Harvard who helped devise the survey. “They
don’t know what their insurance covers. The consequences for people are quite
extraordinary.”
Tristan Berger, 47, who was born with spina bifida, has had
16 reconstructive operations on his feet since age 13. A decade ago, he found
himself too disabled to continue working, after a series of falls. His wife has
health insurance through her job at Walmart, and he has some income from the
Social Security disability program, but nearly all of it goes to his medical
bills.
Mr. Berger, who lives
in Tucson, said he spent $12,000 last year on care not covered by his health
insurance. When we spoke recently, he had already spent a similar amount this
year, after his latest orthopedic operation.
“You sit there every
month trying to figure out what bill to pay:
Do you pay the hospital bill or do you pay the utility bill?” he said. “There’s
no savings. We’re part of that percentage of America that are one paycheck from
being destitute.”
Sarah Miller, an
assistant professor at the University of Michigan Ross School of Business, has
studied how health
insurance protects Americansfrom financial risk. The evidence is
strong that coverage, particularly Medicaid, makes a difference. But she said
it could still prove insufficient for people with complex needs.
“You’re kind of at a
disadvantage as a consumer going against these big complicated systems that
don’t always have your best interest at heart,” she said. “And I think that’s
why there’s so much financial burden, even among people with private
insurance.”
Health insurance, of
course, provides little help for people who have to cut back on work because of
their own illness or that of a family member. Mr. Berger had a steady income
and good benefits when he worked as the housekeeping director for a retirement
community. But once he became too ill to keep working, his income fell.
Fifty-three percent of people in the survey said their work had been
interrupted by illness, causing financial difficulties that can compound the
burden of medical bills.
Research suggests
that such work interruptions can have long-term consequences for people who
become ill or are injured. A recent
paper in the American Economic Review found that, for
middle-aged Americans,going to the hospital could mean an average income
reduction of 20 percent that persists for six years or more.
Illness can also put
financial strain on family members who are not sick themselves. Dana Lewis
thought she had become an expert at navigating the health care system after
caring for twin daughters born with cerebral palsy. But when her husband’s
dementia worsened and he needed nursing home care, she encountered new
logistical and financial obstacles.
To qualify him for
Medicaid in Oklahoma, where they live, she was required to spend down her
assets, including liquidating her 401(k) retirement savings. “Now I’m 60 years
old, and I have zero retirement,” she said. The survey found that those taking
care of ill relatives can often face such challenges. Twenty-three percent of
those surveyed said friends or family members caring for the ill person ran
into financial strain as a result of this responsibility, and 15 percent of
caregivers had to quit or change their jobs.
Maria Elena Flores,
64, had been working as a home health aide for seniors when she had to give up
her job in 2012 to provide the same care to her husband, who was recovering
from triple bypass heart surgery. Since then, his health has declined. He
developed vascular dementia and was acting erratically last year when he caused
Ms. Flores to fall and injure her back.
Even with her
expertise, she has struggled to find the right care for her husband
near their home in San Ysidro,
Calif. He was discharged from one nursing home because of his behavior, she
said, and her local hospital was unable to help her find another place to care
for him.
“Because he was a
headache for them,” she said. She continues to care for him at home.
More than two-thirds
of people in the survey said their doctors had never discussed the cost of
their care. Medical providers generally don’t, particularly among the most
acutely ill. But some clinicians have started talking more about such matters,
noting that the financial stress of unpaid medical bills should be seen as
another kind of side effect of certain treatments.
Khurram
Nasir, an associate professor of medicine at Yale, has adopted a phrase
from cancer research, “financial toxicity,” as he realized many of his cardiac
patients were struggling to pay for care and making tough choices like skipping
pills or cutting back on food.
“When I started
realizing this, I took it upon myself as a responsibility to talk to my
patients about these issues,” he said. “It was very hard for patients to bring
this topic to our attention.”
The survey included landline and
cellphone telephone interviews with 1,495 adults who either had a serious
illness or were caring for someone who did. Interviews were conducted in
English and Spanish. The results are nationally representative. The margin of
error is plus or minus 3.2 percentage points for most questions.
Margot Sanger-Katz is a domestic correspondent and writes about
health care for The Upshot. She was previously a reporter at National Journal
and The Concord Monitor and an editor at Legal Affairs and the Yale Alumni
Magazine. @sangerkatz • Facebook
https://www.nytimes.com/2018/10/17/upshot/health-insurance-severely-ill-financial-toxicity-.html?utm_source=Sailthru&utm_medium=email&utm_campaign=Issue:%202018-10-17%20Healthcare%20Dive%20%5Bissue:17662%5D&utm_term=Healthcare%20Dive
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