In January, it had been one year since I received a moderately substantial medical bill. Two weeks ago, I paid it off. The experience was grueling: I spent hours back and forth with insurance agencies, testing laboratories and my primary care physician, trying to understand why I was billed for a preventative treatment that is covered by next-to-all insurance plans. After months of fighting the bill, I was forced to pay or else face collection agencies. No payment plan was offered, and the residual stress from lost zeros in my bank account had taken effect during some of the darkest days of the pandemic.
After my experience, I wondered how medical bills would affect someone less well-off than myself, and learned about yet another phenomenon that COVID-19 exposed this year: disproportionate medical debt among marginalized populations.
Health care is a basic necessity that has significantly contributed to the debt of the American public. Not surprisingly, medical expenses promote exploitation — the fortunate maintain positions of power and the less fortunate succumb to debts. Reform is of the utmost importance.
American individual’s medical debt averages at $2,200, ranging from less than $500 to greater than $50,000. This adds up to a collaborative $45 billion in medical debt.
The BMJ records that the COVID-19 pandemic has worsened the burden of medical expenses. Between February and March 2020, 20 million layoffs left 5.4 million uninsured. These rates have since grown.
Health care expenses predominantly affect the marginalized. The Kaiser Family Foundation found that uninsured rates for the nonelderly population were 50 percent higher among African Americans, and 150 percent higher among Hispanic and American Indians and Alaska Natives between 2010 and 2018. Furthermore, African Americans are 160 percent more likely to have medical debt than white people. Collection agencies more readily contact Black Americans than white Americans in part to differing financial situations. And African Americans are more likely to borrow money to pay for medical expenses compared to their white counterparts, who may have greater access to savings.
These numbers point to the reality that minority groups disproportionately suffer from medical bills. The culprit: high copays and deductible rates. A copay is a single payment made for access to a provider or treatment, such as a surgical consultation. A deductible is a lump-sum owed by the consumer prior to insurance coverage going into effect — for example, a consumer may have to pay $2,000 for a treatment that costs $13,000 before the insurance will contribute its share. Copays may contribute to a deductible.
The marginalized suffer for two reasons. First, for those without financial buffers, any expenditure — especially something as unexpected as an ER visit or increase in medication — consumes proportionately more income. These expenditures tend to be more frequent for individuals with low paying jobs, as they more readily opt for high-deductible health plans that have lower monthly premium rates. As a result, the highest burden falls on Americans with lower incomes.
Another aspect of this issue is out-of-network providers. One in three patients struggling to pay medical bills received care from out-of-network providers — providers that are not covered under insurance plans. It’s often a surprise — 70 percent of these patients did not know that their provider was out of network. People with more comprehensive insurance programs, however, usually avoid these issues.
Over the last 10 years, deductibles have grown 10 times the rate of wages and inflation. Deductibles and copays were designed to incentivize efficient use of health care, but patients bypass lower-priced providers to get tests and procedures done where their physician recommends — recommendations may not be “in-network.” Thus, waste does not come from the patient or the physician, but from monopolies in the health care market that capitalize on the complexity of the health care system.
Our nation must consider a more equitable health care option before our livelihoods crash with the market.
We have all heard the term “health care reform” without truly knowing what politicians, physicians or journalists really mean. But I will be specific. Copays and deductibles need to be affordable and match the needs of the patient, never exceeding a single monthly insurance payment. Quality standardization and price-capping must be governmentally regulated and implemented across all insurance companies. And all out-of-network provider fees must be eliminated.
Some will argue that insurance companies must profit, and the advised reform metrics prevent this. While the question is valid, I must further question why profit must come from the poor. The marginalized bear the largest burden for health care costs. If the affluent do not want to directly contribute, perhaps a universal system that removes the individual is more appropriate, similar to what the U.K. or Canada has.
The fundamental issue with the health care industry is its for-profit status. The industry is bent on making money at the expense of others. COVID-19 has shown the true colors of large medical corporations and insurance companies. They stand to make money off a basic necessity which is, by definition, exploitation. Exploitation has no place in the medical field, profession or industry and must be eliminated via peaceful reform.
JOSEPH WILLIAMS is a first-year MPH candidate in YSPH. His column runs on alternate Thursdays. Contact him at joseph.williams@yale.edu.