Matthew Fentress was just 25 when he passed out while stuffing cannolis as a cook at a senior living facility six years ago. Doctors diagnosed him with viral cardiomyopathy, heart disease that developed after a bout of the flu.
Three years later, in 2017, Fentress' condition had worsened, and doctors placed him in a medically induced coma and inserted a pacemaker and defibrillator. Despite having insurance, he couldn't pay what he owed the hospital he went to in Louisville, Ky. So Baptist Health Louisville sued him, and he wound up declaring bankruptcy in his 20s.
"The curse of being sick in America is a lifetime of debt, which means you live a less-than-opportune life," says Fentress, who is now 31 and still works for the senior facility, providing an essential service throughout the coronavirus pandemic. "The biggest crime you can commit in America is being sick."
Financial fears reignited this year when his cardiologist suggested that he undergo an ablation procedure to restore a normal heart rhythm. He says hospital officials assured him he wouldn't be on the hook for more than $7,000, a huge stretch on his $30,000 annual salary. But if the procedure could curb the frequent extra heartbeats that filled him with anxiety, he figured the price was worth it.
He had the outpatient procedure in late January, and it went well.
Afterward, "I didn't have the fear I'm gonna drop dead every minute," he says. "I felt a lot better."
Then the bill came.
Patient: Matthew Fentress is a 31-year-old cook at Atria Senior Living who lives in Taylor Mill, Ky. Through his job, he has UnitedHealthcare insurance with an out-of-pocket maximum of $7,900 — close to the maximum allowed by law.
Total bill: Fentress owed a balance of $10,092.13 for cardiology, echocardiography and family medicine visits on various dates in 2019 and 2020. He has paid some portions of that but still owes $9,296. UnitedHealthcare paid $28,920.52 total, including $27,561.37 for the care he received on the day of his procedure.
Service provider: Baptist Health Louisville, part of the nonprofit system Baptist Health.
Medical service: Fentress underwent cardiac ablation on Jan. 23, 2020. The outpatient procedure involved inserting catheters into an artery in his groin that were threaded into his heart. He also had related cardiology services, testing and visits to a primary care doctor and a cardiologist before and after the procedure.
What gives: Fentress says he always made sure to take jobs with health insurance, "so I thought I'd be all right."
But like nearly half of privately insured Americans under age 65, he has a high-deductible health plan, a type of insurance that experts say often leaves patients in the lurch. When he uses health providers within his insurer's network, his annual deductible is $1,500, plus coinsurance. His annual out-of-pocket maximum is $7,900 — more than a quarter of his annual salary.
What's worse, he was already dealing with earlier medical debt. Fentress owed around $5,000 after his 2017 hospitalization, also at Baptist Health Louisville, and set up a monthly payment plan, but says he was sent to collections after missing a $150 payment. He declared bankruptcy after the hospital sued him.
He faced another bill about a year later, when a panic attack sent him to the emergency room, he says. That time, he received financial aid from the hospital.
When he got the bill for his ablation this spring, he figured he wouldn't qualify for financial aid a second time. So instead of applying, he tried to set up a payment plan. But hospital representatives said he'd have to pay $500 a month, he says, which was far beyond his means and made him fear another spiral into bankruptcy.
This precarious situation makes him "functionally uninsured," says author Dave Chase, who defines this as having an insurance deductible greater than your savings. "It's a lot more frequent [in the U.S.] than a lot of people realize," says Chase, founder of Health Rosetta, a firm that advises large employers on health costs. "We're the undisputed leaders in medical bankruptcy. It's a sad state of affairs."
Jennifer Schultz, an economics professor and co-director of the health care management program at the University of Minnesota, Duluth, says Fentress faces a difficult financial road ahead. "Once you declare bankruptcy, your credit rating is destroyed," she says. "It will be hard for a young person to come back from that."
A recent survey by the Commonwealth Fund found that just over a quarter of adults ages 19 to 64 who reported medical bill problems or debt were unable to pay for basic necessities like rent or food sometime in the past two years. Three percent had declared bankruptcy.
In the first half of 2020, the survey found, 43% of U.S. adults ages 19 to 64 were inadequately insured. About half of them were underinsured, which meant that they had deductibles accounting for 5% or more of their household income or that their out-of-pocket health costs, excluding premiums, claimed 10% or more of household income over the past year.
In Fentress' case, the $10,092 he owed the hospital was more than a third of what his insurer paid for his care. The majority of his debt — $8,271.56 — was coinsurance, about 20% of the bill, which he must pay after meeting his deductible. Because the bill covered services spanning two years, he owed more than his annual out-of-pocket maximum. If all his care had been provided during 2019, he would have owed much less, and the insurer would have been responsible for more of the bill.
Kunal Gurav, an Atlanta cardiologist who wrote about medical costs for the American College of Cardiology, says ablation usually costs about $25,000 to $30,000, a range also confirmed by other experts.
The insurer's payment for Fentress' care that January day — around $27,600 — falls into the typical cost range, Gurav says, even without the additional thousands Fentress owes.
Schultz, a state representative from Minnesota's Democratic-Farmer-Labor Party, says nonprofit hospitals could potentially waive or reduce costs for needy patients.
"They definitely have a moral responsibility to provide a community benefit," she says.
Resolution: Charles Colvin, Baptist Health's vice president for revenue strategy, says hospital officials quoted Fentress an estimated price for the ablation that was within a few dollars of the final amount, although his bill included other services such as tests and office visits on various dates. Colvin says there appear to be some charges that UnitedHealthcare didn't process correctly, which could lower his bill slightly.
Maria Gordon Shydlo, communications director for UnitedHealthcare, says Fentress is responsible for 100% of health costs up to his annual, in-network deductible, then pays a percentage of health costs in coinsurance until he reaches his out-of-pocket maximum. So he will owe around $7,900 on his bill, she says, and any new in-network care will be fully covered for the rest of the year.
A hospital representative suggested Fentress apply for financial assistance. She followed up by sending him a form, but it went to the wrong address because Fentress was in the process of moving. In September, he said he was finally going to fill out the form and was optimistic he'd qualify.
As Fentress tries to move past his latest bill, he's now worrying about something else: racking up new bills if he contracts COVID-19 down the road as an essential worker with existing health problems and the same high-deductible insurance.
"I don't have hope for a financially stable future," he says. "It shouldn't be such a struggle."
Takeaways: Insurance performs two functions for those lucky enough to have it. First, you get to take advantage of insurers' negotiated rates. Second, the insurer pays the majority of your medical bills once you've met your deductible. It pays nothing before then.
High-deductible plans have the lowest premiums, so they are attractive or they can be the only plans you can afford. But understand that you will be asked to pay for everything except preventive care until you've hit that number. And your deductible may be only part of the picture: Coinsurance is the bulk of what Fentress owes.
Out-of-pocket maximums are regulated by federal law. In 2021, the upper limit for maximums will be $8,550 for single coverage.
Try to plan treatment and procedures with an eye on the calendar: People with chronic conditions and this kind of insurance could save a lot of money if they have an expensive surgery in December — when your costs will be part of the out-of-pocket maximum for the year that's ending — rather than January.
As always, if you face a big medical bill, ask about payment plans, financial aid and charity care. According to the Baptist Health system's website, the uninsured and underinsured can get discounts. Those with incomes equivalent to 200% to 400% of the federal poverty level — or $25,520 to $51,040 for an individual — may be eligible for assistance.
If you don't qualify for help, negotiate with the hospital anyway. Arm yourself with information about the going rate that insurers pay for the care you received by consulting websites like Healthcare Bluebook or Fair Health.
Dan Weissmann, host of An Arm and a Leg podcast, reported the radio interview of this story. Joe Neel of NPR produced the All Things Considered interview with KHN Editor-in-Chief Elisabeth Rosenthal.
SACHA PFEIFFER, HOST:
At least 29 million Americans lack health insurance. But even those who do have it can get into big financial trouble with medical bills. Our latest bill of the month is from someone facing a life-changing medical debt even though he has insurance. Dr. Elisabeth Rosenthal, editor-in-chief of our partner Kaiser Health News, is here to tell us about it.
ELISABETH ROSENTHAL: Oh, thanks for having me.
PFEIFFER: And, Elisabeth, who are we going to meet this month?
ROSENTHAL: This month we meet Matt Fentress, who's now 31. He lives in Taylor Mill, Ky. And he wrote to us because of a hospital bill that was more than $10,000 for something called post-viral myocarditis and complications. And that's something we're also seeing with the COVID virus and young people.
PFEIFFER: And Dan Weissmann, host of the podcast "An Arm And A Leg," talked to Matt. Let's listen to that.
DAN WEISSMANN: For someone with a $10,000 medical bill and a modest salary, Matt Fentress seems pretty cheerful. He answers a Zoom call wearing a friendly smile and a baseball cap that says Be Nice, which he designed himself.
MATT FENTRESS: I started this thing where I make T-shirts, and then I'll donate all the stuff to charity. I don't make any money off of it.
WEISSMANN: Working with a friend, he's designed dozens of T-shirts and ball caps and, of course, face masks. That all started around the time his $10,000 medical bill arrived early this year.
FENTRESS: I can figure mine out, but there's people who need it more than me.
WEISSMANN: Maybe one reason he's not freaking out is he's seen plenty of big medical bills. He's only 31, but he's already been sued by a hospital and declared bankruptcy. Six years ago, when he was 25, Matt passed out at work. One second, he was stuffing cannoli - he's a cook at an assisted living center - and the next, he was on the floor.
FENTRESS: I was sweaty. I was a mess. I just tried to get back up and keep working. I didn't want go to the hospital because I knew how much it was going to cost.
WEISSMANN: Good thing his colleagues made him go. A viral infection had weakened his heart.
FENTRESS: One of the nurses was like, yeah, you know, I'd say you were fine if you were an 85-year-old. So every time somebody is like, you're not that old, I'm like, I'm 85 at heart, literally.
WEISSMANN: He paid that hospital bill with help from his grandmother, but there would be more.
FENTRESS: Because you're going to be in the hospital when you have a heart problem. That's the life. You're going to get used to the needle sticks and the oxygen meters, all that stuff.
WEISSMANN: Three years later, when he was 28, he needed surgery. After insurance, Matt owed five $5,000. Rather than call on his grandma again, he set up a payment plan with the hospital. Then he missed an installment - ended up in collections.
FENTRESS: The person is like, if you pay double the payment this month, we won't sue you. And so I'm like, I can't do that. Then they're like, we'll sue you. And I'm like, well, then I'm going to file bankruptcy, and you're not getting nothing.
WEISSMANN: Which he did, at 28. Late last year, his doctors recommended a procedure that would improve his heart's performance and his quality of life. He says the hospital told him he'd end up paying $7,000. Great news, the procedure worked. Bad news, his bill was $10,000.
FENTRESS: I'm like, you know, 7,000 was going to be a stretch in the first place, but 10,000, yeah, is just a mess.
WEISSMANN: The hospital offered him a payment plan - $500 a month.
FENTRESS: A normal paycheck for me is, like, $700 every two weeks.
WEISSMANN: Matt's insurance is supposed to cap his medical bills at 7,900 a year, about a quarter of his income. But that cap is 7,900 per calendar year. This bill includes treatment from late 2019 and early 2020.
FENTRESS: That's the thing that hurts me the most about all this, is I love my doctors. Like, I am only alive because of them. I only have a quality of life because they fought so hard for me.
WEISSMANN: After a conversation with a reporter, Matt says he's applying for financial aid from the hospital. He says they've been very responsive, maybe because they know there are reporters watching. For NPR News, I'm Dan Weissmann.
PFEIFFER: Elisabeth Rosenthal, we heard that Matt was told to expect a $7,000 bill. It came in as $10,000. Is there any billing mistake that was made there?
ROSENTHAL: No. The problem with this case is it's all perfectly legal from a hospital and insurance standpoint, but it's far from fair to patients. Matt is one of tens of millions of patients who are what we in the field call functionally uninsured. That means they did their best and bought insurance but have a policy that requires more patient outlays than they can afford.
PFEIFFER: Is this a high deductible health plan where he's just left with more than he can pay?
ROSENTHAL: That's part of the problem. But really in this case, it's not just the deductible. And remember; insurance doesn't pay out a penny until you've hit that. In Matt's case, his deductible was $1,500 per year. That's really not so high compared to other plans. Some are over 8,000 now. On top of that, there's also what's called cost-sharing or coinsurance, so you may have to pay 20% of many charges after that. In a hospitalization, that can easily add up to tens of thousands of dollars.
PFEIFFER: Is there any lesson here for other people who don't want to end up in Matt's situation?
ROSENTHAL: Well, there are some. First of all, these high deductible, high coinsurance plans do have cheaper premiums. That's maybe all you can afford, so they are very, very tempting. But people have to realize they come with the possibility of huge cash outlays. Also, everyone should remember since it's September now and we've all avoided a lot of care because of COVID, if you've gone through your deductible for this year, start scheduling those medical appointments before December 31 because your deductibles, your out-of-pocket maximums, they all reset January 1, and you're going to have to start paying those bills again.
PFEIFFER: Elisabeth Rosenthal, thank you for being here today.
ROSENTHAL: Thanks for having me.
PFEIFFER: And if you have an outrageous or baffling medical bill, go to NPR's Shots blog, and send it to us. We'll take a look. Transcript provided by NPR, Copyright NPR.