At the Philadelphia ICU I worked at, it was always a miraculous day when we got to “liberate” our patients from the ventilator. After removing the breathing tube, one patient, after a week of fighting pneumonia on a ventilator, asked me in his weakened voice, “How much is this all going to cost me?”
I didn’t know what to say, but I knew the bill would impact him. He wasn’t well off. He lived alone, and he had heart failure, diabetes, kidney disease, and bad arthritis of his knees that needed many medications and close follow-up care.
As I watched him leave the unit a few days later and the automatic doors closed behind him, I couldn’t help but think about the bills that he would soon receive, and the choices he would have to make, all because he happened to get sick. And don’t forget, he had been paying his insurance premium every month.
It has been almost 15 years since the Affordable Care Act (ACA) expanded health insurance coverage for more than 20 million Americans. We reached historic lows in the uninsured rate. But even for those with insurance, coverage has not guaranteed financial security in the face of illness and disease, and we are realizing how fragile this expanded coverage is now more than ever, as cuts to Medicaid and ACA tax subsidies are imminent. Premiums are rising year after year, and the copays and coinsurance just to see your regular doctors and refill medications can quickly get up to hundreds of dollars. If you were already barely getting by, you better pray that you don’t need to go to the hospital. If you suffer a devastating illness that requires hospitalization or intensive care, you may be billed thousands, and this can be life-changing. The tragedy can compound, even for those with health insurance.
When patients arrive in our unit amid the alarms and chaos of the ICU, we say to them, “We will take good care of you.” And my goodness, we provide excellent care. We remove bullets, clear infections, and shrink tumors, but as our patients head home to recover, we — the health care enterprise — gently push a financial dagger into their sides.
In 2019, the average out-of-pocket cost for an ICU stay for a patient with private health insurance was approximately $1,500. In a recent national survey, half of Americans (49%) said they would not be able to pay an unexpected medical bill of $500 without going into debt. One in five (19%) reported that they flat out would not be able to pay the bill at all. Americans are just hanging on. An illness (never of one’s choosing) or just one serious encounter with the medical system (while it may save their life) can financially devastate someone.
There are policies in place to protect patients, but they are woefully insufficient. While almost 20% of Americans pay more than $1,000 as out-of-pocket cost annually, the ACA out-of-pocket cost cap is set at $9,450 for individual plans in 2024. For half the country that cannot afford even $500, a cap approaching $10,000 offers virtually no protection at all.
Ultimately, we must lower health care costs and increase real income for Americans. The costs of health care have grown substantially faster than wages. This affects not just patients and families, but also our employers and government. As the health care slice of our budget gets bigger and bigger, we have less and less to spend on other important things. We can’t invest in mental health. We can’t invest in schools. We can’t invest in housing, because we are busy paying our medical bills. For those of us who get health insurance through our employers, this also means more money spent on buying health insurance and less income for all of us. Health care is the most expensive automatic subscription service that we cannot cancel. But we have to lower it.
Solving the problem of health care affordability is not simple, but we can move now to protect the most vulnerable patients. Hospitals can implement longer grace periods for patient payment after an acute hospitalization and eliminate aggressive debt collection practices. Insurance companies can reduce or eliminate out-of-pocket costs for unexpected acute hospitalizations — we already do this for preventive care, a protection we must preserve. They can redesign health insurance benefits to consider potential harms of cost-sharing, using an equity-driven framework that takes into account patient comorbidities, income, and wealth.
But solutions must extend beyond government, hospitals, insurance companies, and pharmaceutical industry — they must involve us. It is time that we, as the front-line deliverers of health care and members of the healing profession, also take responsibility and examine the role we play in the financial harm caused by the larger health care enterprise. We remove bullets, clear infections, and shrink tumors, but to truly do no harm, we must also make health care affordable. When my patient in the ICU asks “How much will this cost me?” I hope I can say with a sense of conviction, “Let’s focus on your healing. We will take good care of you. It’s all going to be OK.”
James D. Lee, MD, MPH is an internal medicine physician and a fellow in the National Clinician Scholars Program at the University of Michigan. He is on linkedin.com/jamesleedh/ and X: @JamesD_Lee.
Image by claudenakagawa / Shutterstock
