Financial Risks
Medical bills undoubtedly contribute to many personal bankruptcies. Even if you’re relatively wealthy, if you have a serious illness or a bad accident, your medical bills could be unmanageable if you go without health insurance.

If you're uninsured in the United States before 2019, you'll also face a tax penalty unless you're exempt from the penalty. This penalty can be as much as 2.5 percent of your yearly household income, but it won't be more than the national average for a bronze-tier health plan on health insurance exchanges that year. The penalty is being eliminated after the end of 2018 by the Tax Cuts and Jobs Act that was enacted in 2017. But there is still a penalty if you're uninsured in 2018, and it will be assessed on tax returns that are filed in early 2019.

Health Risks
Being uninsured can negatively affect your health. In its 2017 report, the Kaiser Family Foundation notes that "uninsured people are far more likely than those with insurance to postpone health care or forgo it altogether. The consequences can be severe, particularly when preventable conditions or chronic diseases go undetected."

Risks to Your Loved Ones
You’re not the only one put at risk when you’re uninsured. Because how you live your life affects those around you, your loved ones are at risk when you go without health insurance. For example, they’ll suffer financially if they need to help you with medical bills. If they depend on you financially and you have a financial crisis due to health care bills, they’ll suffer the repercussions of your financial crisis. Worse, your loved ones will suffer if your health deteriorates because you can’t get care thanks to being uninsured.

Risks to Your Local Community
In the bigger picture, if you can’t pay your medical bills because you’re uninsured, your community and society as a whole suffer. For example, the healthcare providers who spent their time and resources caring for you will suffer by being unpaid. Businesses in your community will suffer when you change your spending habits due to large medical bills. Your coworkers and your employer will suffer when you call in sick more often because you don’t have access to health care or if your health deteriorates and you’re not as productive at work.

Risks to Society
Society as a whole can suffer if you’re uninsured. Even if you don’t make a lot of money, you still contribute to society in many ways. For example, if you do a good job of raising your kids, you’re contributing to society by raising future community members. Having a job, volunteering, looking out for your neighbors, and providing emotional support for your friends and loved ones are all contributions to society as a whole.

If you go without health insurance and that causes delays in treatment or access to health care, those delays can make you sicker, potentially even leading to disability. Society as a whole will suffer because you won’t be able to contribute as much as you did when you were healthy. If you become disabled because you didn’t have access to health care, not only does society pay your disability payments, but it loses out on your current and future productive contributions to society.

Many disabled people end up on Medicaid, Medicare, or both. If you’re on Medicaid, society as a whole is paying for your healthcare. If you become disabled and go on Medicare early, society loses out on the Medicare contributions that you would have paid if you'd been able to continue to work, as well as having to pay for your Medicare benefits.

[Note that there is no shame in utilizing Medicare and Medicaid benefits if you're eligible for them, and they're a lifesaver for disabled people all across the country. This article is focused on the problems that result when people could have obtained health insurance but chose not to have it—usually in an effort to avoid paying the premiums—and then found themselves in very poor health as a result of delayed access to medical care.]

Risks to the Entire Health Insurance System
All of the people who are covered under a carrier's health insurance plan are part of a risk pool. A stable, sustainable risk pool relies on having a large percentage of healthy enrollees to make up for the relatively small number of enrollees with significant health conditions.

One of the main reasons we saw spiking individual market premiums in 2016-2018 and health insurers leaving the exchanges (for 2017 and 2018, although that trend is no longer the case for 2019) is because not enough healthy people enrolled in coverage. As a result, the overall risk pools skewed more towards the less healthy end of the spectrum, and claims costs overwhelmed some carriers (the rate increases in 2017 and 2018 appear to have been adequate, and rates are only increased slightly for 2019; they would likely be decreasing if not for the impending elimination of the individual mandate penalty and the expansion of short-term health plans and association health plans).

The only way to keep the health insurance system stable and viable is for healthy people to enroll in coverage to offset the claims costs for those who are less healthy. And although you may be perfectly healthy now, that might not always be the case. If and when you ever need significant medical care, the costs will be borne by all of the healthy enrollees in your carrier's risk pool, assuming you're insured at that time.

Decreasing the Risks of Being Uninsured
Whether you choose to go without health insurance or you’re uninsured because you have no other choice, you’re taking risks. Some, but not all, of those risks can be decreased. ​This toolkit will help you prepare for being uninsured and, as much as possible, help you mitigate the risks associated with being uninsured.

The plaintiffs, including the nonprofit American Hospital Association (AHA), are looking to block the rule issued last month that mandates hospitals to publish pricing information of their services on the internet.

“The rule ... does not provide the information patients need. Mandating the public disclosure of negotiated charges would create confusion about patients’ out-of-pocket costs, not prevent it,” the plaintiffs said.

The rule, seen as a violation of the First Amendment by the hospital groups, also demands confidential information on individually negotiated contract terms with all third-party payers, including private commercial health insurers.

Such disclosures would eliminate hospitals’ ability to negotiate pricing with insurers that would undermine competition and blunt incentives for health insurers to sign arrangements that could potentially lower costs, the plaintiffs said.

This is not the first time that the industry has challenged President Donald Trump’s efforts to lower drug prices.

In July, a federal judge sided with drugmakers by striking down a rule that would have forced pharmaceutical companies to include the wholesale prices of their drugs in television advertisements.

​“Hospitals should be ashamed that they aren’t willing to provide American patients the cost of a service before they purchase it,” said Caitlin Oakley, a spokeswoman for the Department of Health and Human Services, adding that the administration would continue to fight for price transparency.

The AHA, along with the Association Of American Medical Colleges and Federation Of American Hospitals, among others, said it would press for speeding up the decision on the rule, so hospitals do not spend time and resources preparing for what may be invalidated.

The rule is expected to come into effect on January 1, 2021.

Hospitals are not happy, but advocates of well-informed, patient-centered health care should be cheering.

I am a professor of health policy at the Price School and Schaeffer Center at USC and have published several papers and worked with startups that aim to improve price transparency and consumer decision-making. I’m among those cheering.

Real numbers, real comparisons

Hospitals already post online their so-called standard or “chargemaster” rates for the thousands of codes used in their billing systems. Almost nobody actually pays these rates; they are intentionally inflated prices that give hospitals an edge in negotiating with insurers.

Under the new regulations, hospitals, which account for about one-third of all health care costs, also have to divulge the actual rates paid by health plans and insurers for those same codes.

To help consumers make apples-to-apples comparisons, hospitals will be required to go beyond the individual codes and post their negotiated rates for a list of 300 so-called “shoppable” services that consumers might examine before selecting a provider. This requires hospitals to link services that usually accompany each other, such as laboratory and pathology charges along with surgery.

As for insurers, there is still a two-month public comment period before new regulations become final. As drafted now, the new law would force insurers to disclose negotiated rates, as well as rates paid for out-of-network treatments. They would also have to give cost information to consumers in advance.

According to The Wall Street Journal, which first reported the news, the final rule will force hospitals in 2021 to report the rates they strike with individual insurers for all services, including drugs, supplies, facility fees and care by doctors who work for the facility.

The administration will also extend the rule to the $670 billion health care industry, meaning that insurance companies, including Anthem and Cigna, and group health plans that cover employees will have to disclose negotiate rates and previously paid rates for out-of-network treatment in computer-searchable file formats, the Journal reported.

GET FOX BUSINESS ON THE GO BY CLICKING HERE

The proposal will likely face a legal challenge from hospitals and insurers, which have previously warned that transparency could actually force prices to rise because they would know the price that competitors offer, and therefore be unwilling to settle.

“Right now there is too much arbitrage in the system,” a senior administration official told the Journal. “There are a ton of vested interests who will oppose this. We expect to get sued."

A similar health care transparency law in Ohio remains tangled in the legal web.
​
MEDICARE-FOR-ALL UNPOPULAR WITH VOTERS IN THESE KEY STATES

Still, the Trump administration contends that requiring hospitals to release the negotiated price is intrinsic to lowering costs. For instance, hospitals would need to disclose payer-specific charges for at least 300 shoppable services, 70 of which -- including vaginal birth, colonoscopy and joint-replacement surgery, are mandated in the rule. Hospitals can select the other 230 services they post online.

If the 6,000 hospitals that accept Medicare do not comply with the proposed requirement, they’ll be slapped with a $300 fine each day.

Prices charged for health care vary dramatically depending on several factors, including whether a patient is in or out of the patient's insurance network and what price the hospital negotiated with the insurance company. For instance, the cost of a mammogram ranges from $50 at a hospital in New Orleans, to $86,000 at a hospital in Massachusetts, according to Clear Health Costs, which publishes information on health costs.

By making those prices available to consumers, the Trump administration argues that hospitals will be under more pressure to compete, eventually causing prices to fall.

According to a September study conducted by the Kaiser Family Foundation, employer health-plan deductibles are outpacing wage growth and have increased to an average of $1,655 for a single plan. On average, workers contribute $6,015 toward the cost of coverage.

CLICK HERE TO READ MORE ON FOX BUSINESS

"They want to raid Medicare to fund a thing called socialism," Trump said, standing in front of backdrop with the words "Great Healthcare For You."

The speech is a part of the White House's efforts to put Trump's health care agenda at the forefront of his reelection campaign, hoping to attract swing voters uncomfortable with his attacks on the Affordable Care Act or a fully government-run health care system championed by two of his chief 2020 Democratic rivals, Sens. Bernie Sanders and Elizabeth Warren. Trump has recently rolled out a series of health care initiatives, including an overhaul of kidney care and proposed new price transparency measures, and plans to issue more in the coming months.

Thursday's speech, which was originally planned for August but was canceled in the aftermath of two mass shootings, gave Trump a chance to try to change the subject from the rapidly moving impeachment inquiry. But he frequently went off-script to recall old grievances and new — decrying the Russia investigation, lamenting the rise of Warren in the polls and accusing the Democrats of pursuing impeachment to hurt his reelection chances.

"That's why they do the impeachment crap, because they know they can't beat us fairly," said Trump, who also suggested without evidence that drugmakers played a secret role in fueling the impeachment effort because they're unhappy with his efforts to lower drug prices.

​Trump gave his speech at The Villages retirement community outside Orlando, alongside allies in the key swing state. They included Florida's first-year Republican Gov. Ron DeSantis, whose plan to import cheaper prescription medicines from Canada and other countries has been supported by Trump, eager to show progress on reducing drug prices.

Trump's strategist argue his health care efforts are meant to reclaim the party's advantage on the issue, a top concern for swing voters — and one that Democrats owned in the 2018 midterms. Democrats are accusing Republicans of trying to "sabotage" the Affordable Care Act and its insurance protections for preexisting conditions, a theme they will return to in the 2020 elections.

Trump’s advisers have been downplaying the failed effort to repeal Obamacare and they've insisted the president is doing big things on health care. Still, Trump showed he’s not ready to let go of that fight. He briefly criticized the late Sen. John McCain’s “thumbs down” vote that derailed the repeal effort — though he didn’t mention his former rival by name this time — and teased yet again the possibility of taking another run at the 2010 health care law after the election.

“If the Republicans take back the House, keep the Senate, keep the presidency — we're gonna have a fantastic plan,” Trump said.

Trump in the wide-ranging speech praised his administration's efforts on health care, including efforts to curb opioid overdoses and the new plan to end HIV transmission within a decade. He also touted efforts to take on drugmakers and teased his plans to allow "safe and legal importation" of prescription drugs.

Some of the efforts he mentioned, though, have had a limited impact. A law expanding access to experimental medications to terminally ill patients has only helped a few people. And a rule requiring drugmakers to disclose list prices in television advertisements has been blocked by a federal judge, though the administration has appealed the ruling.

Federal health officials said Thursday's executive order is aimed at beefing up Medicare and its rapidly growing offshoot run by private plans, Medicare Advantage. The order calls for bolstering telehealth services – which would reduce the need for visits at the doctor's office for a frail population – and supplemental benefits Medicare Advantage plans can offer.

Enrollment in Medicare Advantage plans has swelled to more than 20 million, or more than a third of all Medicare beneficiaries, and is expected to keep rising. The Trump administration, with support from Congress in some case, has already expanded the scope of supplemental benefits insurers can offer, such as in-home services, transportation to the grocery store and park passes. Critics have accused the Trump administration of favoring Medicare Advantage over the traditional program, despite concerns that the government overpays insurers and seniors could face limited provider networks.

Trump's order directed his government to expand Medicare Advantage beneficiaries' access to tax-advantaged medical savings accounts. It also calls for his health department to propose ways for Medicare Advantage enrollees to receive cash rewards or rebates as a perk for saving the government money when they receive quality care.

The executive order also includes lower-profile initiatives the administration has already pursued, such as reducing the administrative burden on health care providers. The order calls for minimizing the time between FDA approval of a drug and Medicare's determination of whether to cover the treatment.

The millions of Americans who have health insurance through their jobs are often viewed as fortunate, shielded from soaring medical costs as well as financial calamity if serious illness strikes. But the cost of those undeniable benefits is climbing—and fast.

Over the past decade, health insurance costs for U.S. employees of large companies have risen more than twice as fast as their pay, according to a recent analysis by the Kaiser Family Foundation. Between 2008 and 2018, families with coverage through a large employer (defined as a corporation with at least 1,000 employees), saw those costs jump 67%. That was more than twice as fast as their wages increased over that same 10-year span, and more than three times the rise in inflation.

In 2018, a family of four in the U.S. with coverage from a larger employer spent a total of $7,726 on health care, up from $4,617 a decade earlier, according to the analysis. Specifically, $4,706 was spent on insurance premiums, usually in the form of regular paycheck deductions. The other $3,020 consisted of deductibles, co-payments and coinsurance. 

​Employers, which pay for the lion's share of employee health coverage, also face rising costs. The amount they spent on premium contributions for employees rose 51%, from $10,008 to $15,159, over the same period of time.

​It's no surprise that health insurance costs have outstripped wage growth. As employers' costs have risen, money that companies might have plowed into worker pay is instead going toward providing health coverage, according to Cox.

"When you look at the whole picture and see that the cost to both parties is increasing much faster than inflation or wage growth, it becomes much more clear how rising health care costs are holding back wages," she said. 

"Ten years ago employers were spending $10,000 a year toward a family premium and now it's over $15,000 a year," Cox added. "So maybe not all of that extra $5,000, but some of it might have gone to employees' wages rather than going to increased costs for doctors visits or hospital stays or prescription drugs."

To be sure, a range of other factors influence employee compensation.

"Health care may be a consideration, but wage decisions are first based on company performance in the current year and the forecast for the upcoming year, and industry-specific data on pay competitiveness in industries. Those things factor more heavily into wage decisions than health care," said Brian Marcotte, CEO of the National Business Group on Health, a non-profit that helps businesses manage their health care initiatives.

​Health care spending—by workers and employees—has grown twice as fast as wages in the last decade

​Health coverage must be improving since it costs so much more, right? Wrong. The additional spending doesn't translate into better benefits or health services. And while health care becomes more expensive, health outcomes are worsening.

"It's one thing to pay more for health care if we are getting more out of it, but it's another if we are paying more and getting the same or less," Cox said. "Looking at broad health care outcomes like life expectancy, it's been decreasing over the past couple of years. We are not living longer, we are not having a better quality of life."

While the blame usually falls on insurers, they aren't the only culprits. Hospitals and prescription drug pricing are also responsible for driving up premiums and deductibles in the U.S., where doctor visits, hospital stays and drugs cost more than in other countries. 

"In a lot of places, hospitals have significant market power relative to employers or insurers doing the purchasing. Especially in places where there is not a lot of hospital market competition, hospitals can set prices and increase prices faster than if there had been competition in that area," Cox said. 

Some companies are moving to cut costs.

"There has been a big jump in the percentage of companies offering concierge services that help employees navigate where to go for care and make the best decisions," Marcotte of the NBGH said. "We are also seeing primary care models move away from the traditional fee-for-service or encounter-based reimbursement model to more comprehensive patient-centered population health management."

Many employers are also making more use of telemedicine and other forms of remote medical care. "Virtual products bring health care to the consumer rather than the consumer going to health care -- and you are seeing significant growth in this area," Marcotte said.

Hope for lowering the cost of coverage lies in these kinds of approaches, said Candice Sherman, CEO of the Northeast Business Group on Health. 


"It's a shared burden that unfortunately causes financial stress for employees and their families," she said. "Many of these initiatives hold promise for improving health outcomes and overall wellness as well as lowering costs."

Right now, Canada is the only high-income country with universal health coverage that bans its citizens from purchasing private insurance for anything deemed "medically necessary." "Medicare for all" would make the U.S. the second.

Supporters of the ban claim it preserves equitable access to care. Wealthy Canadians can't use private insurance to pay for faster access to care.

But as a result, everyone must wait their turn for care paid for by the public system. Last year, Canadians faced a median wait of nearly 21 weeks to receive specialist treatment after getting referred by a general practitioner. Certain procedures come with longer waits. End-to-end, patients waited a median of 39 weeks for orthopedic surgery in 2019.

Private insurance could alleviate those waits. The Fraser Institute's research concludes that those using private insurance in other countries demand less care under the publicly funded coverage scheme. That frees up resources to treat needier patients, who must rely exclusively on public insurance. The result, per the new Fraser report? "A private health insurance market in Canada would reduce wait times for most, if not all, Canadians."

As Canada shows, government-provided universal coverage, and its ban on private insurance, isn't worth the wait.

Sally C. Pipes is president, CEO, and the Thomas W. Smith fellow in healthcare policy at the Pacific Research Institute. Her latest book is False Premise, False Promise: The Disastrous Reality of Medicare for All, (Encounter 2020). Follow her on Twitter @sallypipes.

His health insurance covered most of the $1,700 charge for the exam, X-ray, and injection. But there was an additional $1,375 fee for hospital operating-room services even though he wasn’t treated in the hospital. His insurance covered only a small portion of that fee, leaving him on the hook for $1,039.  
​
Sokol’s insurer said there was no error, though. That’s because the doctor he saw works for Cedars Sinai Medical Center, a major hospital in LA. Hospitals can charge a facility fee for services provided by any healthcare provider it employs and at any facility it owns, even if the patient never sets foot in the hospital.

Sokol eventually got the facility fee reduced to $700, which he paid. But he calls the charge outrageous. “If I was told that ridiculous facility fee would be charged, I would have declined having the injection and gotten it somewhere else,” Sokol says. 

Steep hospital facility fees aren’t new. Federal regulations have long allowed hospitals to charge patients a fee, on top of the tab for medical services, to help cover the high cost of running a hospital.

What is new is that patients are increasingly getting hit with facility fees when they get care outside of a hospital. It’s happening because hospitals are rapidly building or buying up not only doctor practices but also urgent-care centers, walk-in clinics, and standalone surgery complexes—pretty much all the places one might go to get healthcare.

As hospitals turn into healthcare behemoths, the ability to choose a doctor or health services provider who is independent from a major hospital system in your region is shrinking.

It’s often not obvious to a patient that a doctor is employed by a hospital or that a facility is owned by a hospital, which is why getting billed for a hospital facility fee can be so surprising. It’s especially painful for people who must meet high deductibles before their insurance starts to cover some of the bill.

While facility fees vary widely by hospital and service provided, they can add hundreds or thousands of dollars to a medical bill. The fees are often high relative to the cost of the service provided. In an example cited in Health Affairs, an academic health policy journal, a patient was charged $1,100 for a 30-second procedure to determine whether she had fungus under her toe. The facility-fee portion of the bill turned out to be $418, almost 40 percent of the bill.

Hospitals say they need to impose facility fees over their entire network to offset the cost of providing access to care 24/7 to anyone who comes through the doors of their hospital, regardless of the ability to pay.

“The cost of care delivered in hospitals and health systems takes into account the unique social good that only they provide,” says Ashley Thompson, senior vice president of policy at the American Hospital Association.

Thompson says a hospital outpatient facility is also costlier to run because these facilities tend to treat patients who are sicker and because they must meet stricter regulatory standards than independent healthcare providers.

But consumer advocates, health policy experts, and regulators say that the fees are poorly disclosed and that it’s unfair for patients to pay more than they would at an independent healthcare provider for the same services.

Patients see little benefit when they get outpatient services by doctors or facilities affiliated with large hospital systems, says Aditi Sen, an assistant professor at the Johns Hopkins Bloomberg School of Public Health in Baltimore. Sen is studying how facility fees affect patient care.

“The data we have shows that these big healthcare systems aren’t raising quality, but they’re raising prices,” Sen says. “We have to ask what you are getting for the additional fees.”

The revenue from facility fees is a major reason hospitals want to own doctor practices and offer outpatient services, says Christopher Whaley, a health policy researcher at RAND Corporation, a nonprofit policy think tank. Whaley says hospitals also benefit because hospital-employed doctors are encouraged to make referrals to other doctors or to order tests at health service providers owned by the hospital that pays their salary.

Many doctors are happy to leave private practice because of the high overhead and heavy administrative obligations, says Fred Bentley, a managing director at Avalere, a healthcare industry consulting firm. Physicians who are part of a big hospital network deal with fewer of those burdens, and they benefit from being part of a big hospital network with more leverage negotiating prices with private insurers.

The transformation is happening fast. About 45 percent of all physicians work for hospitals today, up from 25 percent in 2012, according to a recent study [PDF] by Avalere Health and the Physicians Advocacy Institute, a nonprofit organization representing physician groups. The study also found that hospitals own 31 percent of doctor practices, up from 14 percent in 2012.

At the same time, hospitals are aggressively getting into outpatient services because that’s where consumers are going. Hospitalizations are declining as consumers seek out less costly, more convenient care in outpatient settings, such as surgery centers, walk-in clinics, and imaging centers, Bentley says.

Hospital outpatient visits have grown from about 600,000 a year in 2000 to 800,000 in 2017, according to the American Hospital Association’s 2019 Hospital Statistics report. At the same time, inpatient hospital admissions have stagnated at about 34,000 annually. 

Hospitals are expanding into outpatient services at a fast pace. HCA Healthcare—the largest for-profit hospital chain in the U.S., with 165 hospitals—has increased the number of urgent care centers it owns by 40 percent in the past two years and doubled the number of stand-alone emergency rooms it operates, to 64, according to Dimensional Insights, a data analytics firm. HCA also runs 113 freestanding surgery centers, the firm says.

Nonprofit hospital systems, including Sutter Health in Northern California and Advocate Health Care in Chicago, are also investing heavily in outpatient clinics.

Federal and state lawmakers are well aware of the controversy over facility fees in outpatient settings. In 2015, Congress passed legislation requiring hospitals to charge Medicare the same fee for outpatient services at its off-site clinics as independent doctor practices. But the law didn’t eliminate facility fees and applied only to hospital-owned facilities opened or acquired after 2015.

This year, the Centers for Medicare & Medicaid Services extended those limits by doing away with exemptions for off-site hospital clinics bought or opened before 2015.

Connecticut is aggressively cracking down on outpatient facility fees. It’s the first state to require clearer disclosure of facility fees at physician practices and outpatient facilities owned or operated fully or in part by a hospital or health system.

Starting in 2016, hospitals must notify patients who have used a doctor or an outpatient location in the past three years that ownership has been transferred to a hospital. The notice must also include an estimate of the facility fee that may be incurred. For example, when Oncology Associates, based in Hartford, Conn., was acquired by Hartford Hospital in 2017, patients were sent a letter estimating that facility fees could range from $117 to $309.

Connecticut also bans facility fees on certain outpatient services and limits what uninsured patients can be charged. For example, a doctor can’t charge a facility fee for new-patient visits.

“So far, only a handful of states have investigated and addressed consumer problems with facility fees,” says Chuck Bell, programs director at Consumer Reports, who works on surprise medical bill issues. “Congress and the states should investigate the fees, and ban or restrict their use. If they are permitted at all, the fee amounts should be clearly disclosed well in advance, along with whether they are covered by insurance.”

As facility fees proliferate, consumers need to be proactive about finding out whether they will incur one. Here’s what to do.

Check with your insurer. Many insurers don’t cover facility fees or cover only a portion. Talk to your insurer to find out what its policy is on facility fees.

Talk to your doctor. It’s hard to tell whether a facility is hospital-run or whether your doctor works for a health system. When you call to make an appointment, ask whether you will be charged a facility fee. Some doctors may practice at other locations that don’t charge one.

If your doctor refers you to a specialist or you need treatment, such as an MRI, at another facility, you also need to find out whether there is a facility fee and what your insurer will charge you if go to a nonhospital provider.

Negotiate. It’s difficult to fight a facility fee because it’s legal in most places. But you can always talk to the healthcare provider about waiving or lowering the fee. You can also appeal to your insurer to cover more of the cost.  

For more information on how to appeal a medical bill, use this free guide to health insurance appeals from the Patient Advocate Foundation.

​Are you tired of the endless stream of add-on charges that appear on your bills? On the TV show “Consumer 101,” Consumer Reports’ expert explains to host Jack Rico how to avoid these pesky fees.