One hundred million Americans carry medical debt. Research published in JAMA Network Open found that medical debt is associated with higher mortality across every leading cause of death, including suicide. A national study in the Journal of Clinical Psychiatry found that people carrying debt burden are more than three times as likely to attempt suicide. Sixteen percent of suicides in this country involve a financial crisis. I do not write that to shock anyone. Physicians see the early stages of this every day and may not recognize what they are looking at. The patient who nods along with the treatment plan but never schedules the follow-up, who fills one prescription but not the other, who stops coming without explanation. I coordinate medical care abroad for Americans. The people who contact me are not the ones you would picture; they are not wealthy, and they are not thrill-seekers looking for a deal on a nose job. Almost without exception, they are people whose doctors recommended a treatment that the system made unaffordable.
A close friend of mine, a woman in her mid-30s working two jobs, had a severe rheumatoid arthritis flare-up late last year. She had employer insurance through a nonprofit advocacy organization. For six months, she did what patients are supposed to do: She saw her doctors, followed up on referrals, and waited for approvals. Her insurer denied one treatment after another. Prior authorizations came back rejected. Her physicians were overruled on clinical decisions. Then federal budget cuts eliminated her position and her coverage with it. After six months of fighting for care, she was uninsured with an active flare and no path forward in the U.S. system. She is now exploring rheumatology treatment in China through my organization, where biologic therapies and specialist rheumatology care are available at a fraction of the U.S. price. She did not want to travel halfway around the world for medical care. Every other option had been exhausted.
Her story is not unusual. One-third of Americans skipped or postponed care last year because of cost. Nearly a quarter of insured adults are underinsured, and 57 percent of that group reports avoiding care for financial reasons. Over 27 million people have no insurance at all. Another 41 percent of the privately insured hold high-deductible plans that make them functionally self-pay for most elective procedures. And it is about to get worse, as the Congressional Budget Office projects that 7.5 million Americans will lose Medicaid under recent spending cuts, with up to 15 million losing health coverage by 2034. ACA premium subsidies have expired. Twenty-two million people face sharply higher premiums or lost marketplace plans this year. Most physicians do not see the price discovery process that self-pay and underinsured patients go through, and honestly, it is a mess. The CMS Hospital Price Transparency rule was supposed to fix this, but only 21 percent of hospitals are fully compliant. Where data does exist, it is buried in machine-readable files designed for insurers and practically useless to someone trying to figure out whether they can afford a procedure.
Cash prices for the same procedure vary by a factor of three to 30 across hospitals, according to findings published in Medical Care by Linde and Egede. Hospital posted charges run two and a half to 10 times the actual cost of care, and the RAND Corporation documented commercial insurance rates averaging 254 percent of what Medicare pays. In analysis we conducted across 424 procedures and 21 specialties, we found that publicly available Medicare data can predict self-pay cash prices with about 17 percent error. That is far from exact, but consider what patients have now: nothing. A patient facing a $30,000 hospital quote has no way to know if that number is reasonable or three times what they should be paying.
I am not suggesting every physician become an expert in international health care or pricing models. But there is something practical that would help: Ask your patients about cost before they stop showing up. Patients will not bring it up. They will not mention they are rationing medication, splitting pills to stretch a prescription, or quietly giving up on the procedure you recommended. One question changes that. “Is cost going to be a barrier to getting this done?” It tells the patient you see what they are dealing with, and it gives you a chance to intervene before you lose them, such as providing a referral to a financial counselor, a lower-cost facility, or an adjusted approach. Without that conversation, treatable conditions keep going untreated until they become terminal. Families go bankrupt paying for care that costs a fraction of the price in other countries. Parents face the choice between depleting their children’s futures and forgoing their own treatment. Some choose a third option that no one should have to consider. If the system will not change fast enough to help the people in your waiting room, the least we can do is ask the question before they stop showing up.
Adam Cunningham is a health care executive.
