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.
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