I am going to tell what happened to one person who got sick in America
- when she was uninsured;
- after she was insured through an exchange set up under the ACA;
- after she bought market rate insurance; and finally,
- what happened when she bought medical care directly.
It will take a series of posts. This is the first of what will likely be four or five posts.
How We Met
K and I met in 2010. She was my Gyrotonic instructor. I was middle-aged and soft. I couldn't do one single sit-up. Not one. I could not even remember the time I had done a sit up. Yet, she took me on with all the enthusiasm and good will one often sees in people in that particular line of work. I expected our relationship to be a cordial, but somewhat distant one. Yet, one day when I came to see her, I was very sad. I was so sad that I shared my sadness with her and she absorbed it all, listened to me with her deep brown eyes and comforted me. I don't recall if I did much exercise or not that day, but I had made a shift. When she left the studio to open her own business in another location, I followed her there.
Then She Got Sick
In spring of 2011, she got sick. I didn't know how sick she was. She left town to go to a clinic in another city for treatment. Although, I did not know it at the time, she didn't get well. She got sicker. Scary sick. She was so sick she could die. She weighed about 85 pounds. Her electrolytes were so low, she was a heart attack risk. She could not keep any food down. She had fevers and boils, sore joints and crippling neck, back and shoulder pain. She came back to Atlanta after three separate hospitalizations, still sick, still weighing 85 pounds, often in a wheelchair, but now owing more than $20,000 of medical debt (she was uninsured). Further, she was suffering from, not only the effects of her illness, but also the effects of massive amounts of steroidal and other drugs she had been given.
As K had not benefitted from the care she received, she took her recovery into her own hands. By careful monitoring of her body's response to food and exercise, she weaned herself off the array of prescription drugs she was taking. Beginning by eating only miso broth with chives, she slowly recovered. She didn't get really well, but well enough to start teaching me and her other clients again. I didn't know much about her illness at that time and she wasn't one to share her own pain or suffering. Since I hadn't seen her at her sickest, I didn't know how ill she had been. She didn't mention all the money she owed. I thought she was doing well.
In November 2011, she called me out of the blue and asked me to take her to an ER. She was desperately ill, in tremendous pain, unable to retain food, suffering boils, fevers, debilitating joint pain, headaches, back pain and repeated bouts of bloody diarrhea. That is only a partial list. She was a person in her early thirties who loved to dance. She was a professional dancer. She was dedicated to health and fitness. Her body that she tended, nurtured and trained so carefully betrayed her. She was tremendously ill and this time, I was a witness to her suffering.
I was a witness to the actual physical distress she experienced and a witness to the experience of she had as an uninsured, poor person in the medical system. I left her at a local emergency room. I stayed only long enough to see that she was admitted. After a few days, I took her some broth made by a local macrobiotic cook. It was all she could digest. Given the inflammation in her digestive system, she could eat none of the food given to her in the hospital. I asked what the doctors had found. She told me she was going to check herself out. Nothing was being done in the hospital. No tests were ordered. Nothing planned. She had a room and someone regularly came in to check her vital signs.
Then Came the Bureaucracy
The likely reason the hospital admitted her and then wouldn't dump her was because of the risk to them of being in violation of EMTALA--Emergency Medical Treatment and Active Labor Act. EMTALA provides, among other things, that hospitals cannot transfer a patient if the patient is not stable. Stability has been so broadly defined that some hospitals rarely transfer non-paying patients. (We will see later that not all hospitals have that as a policy). If the patient is uninsured, as K was, they simply do not treat them. Because specialists who were on call could also be exposed to liability under EMTALA, following the passage of EMTALA, specialists limited their practices in order to avoid encountering a non-paying potentially litigious patient. K needed to see a specialist, but none would come to see her.
The Social Security Administration Did Not Help
After a week of being hospitalized, K checked herself out and went home to her apartment. That was the time we really got to know each other. It was then I found that she had more than $42,000 of medical bills, spread across 27 different providers, including $18,000 from her most recent hospitalization. Since she had barely worked over the preceding months, she thought she was now qualified for the SSI she had applied for months earlier.
K's initial response, when faced with all of the foregoing, was that it was her responsibility to handle dealing with her medical creditors and the SSA. Given the seriousness of her illness and the daunting prospects for her recovery, I felt it would be impossible for her to resolve the financial matters. Consequently, I offered to take on resolving her financial situation as a pro bono matter. In my experience, most lawyers take seriously the obligation to provide pro bono services. I hadn't gotten my hours in for the year and this was a good opportunity.
I began by attempting to assess the status of K's SSI application. She undoubtedly qualified since she was almost completely unable to work, had little or no income and no assets whatsoever. After several vain attempts to contact the SSA office directly, I contacted the Governor's office and, with K's permission sent the Governor's assistant photos of K, who at the time, looked like an Auschwitz victim. To her credit, the young woman I spoke with provided a real name and phone number for someone to inquire about the SSI claim.
Reaching the SSA, however, proved to be futile. The SSA had requested information while K was sick. Since K had failed to respond in a timely manner, her application was dropped and the file closed. If she wanted to pursue obtaining SSI, a new application would need to be filed. A decision whether she would qualify for temporary disability would be made in roughly six months from the date of that new application.
Dealing with the Debt
The process for resolving the medical bills is almost indescribable. I have worked on many, highly complex matters over the years. Resolving medical debt is not complex. It is instead, much like the case in Dickens' Bleak House, tedious, repetitive, and filled with traps for the unwary. One hospital gave me the wrong file number, i.e. they could not connect my response (with K's name, address and birthday) to their own file because of their internal error with their own file number. They were 24 hours away from turning the bill over to collections when I discovered their error. Their initial response was to refuse to accept my untimely response until I presented their letter with the wrong file number set out in bold typeface.
Many of the providers required dozens of pages of documentation, detailed financial information, job histories (with confirmation from the state labor department), bank statements, tax filings, sworn statements regarding the accuracy of the documents submitted and on and on. I am not complaining or even saying that they shouldn't require proof of indigent status prior to forgiving the debt. I am only noting that a sick or illiterate person is in no position to provide them with the foregoing.
None of the providers used email. All required information be faxed. Often I sent the same fax many times. I quickly learned that the appropriate action to take was to mail and fax identical letters on the same day, to keep copious notes of whom I spoke with at what specific time and the exact words that were told to me during that conversation.
In addition to all the written correspondence, I spoke with all 27 providers numerous times. I estimate that I spoke with all of them 4 or 5 times and the three major creditors no fewer than 8 times, i.e. a total of 120 phone calls. In the end, all of the creditors agreed to reduce the debt by more than 90% of the original amount due and all, except a handful, agreed to forego turning the remainder over to collection agencies.
The problem with "all except a handful" is that it still leaves just enough people demanding to be paid who cannot be paid to ruin one's credit. Further, the terrifying incompetence of the billing/collections departments doesn't end. As recently as August 25, 2016, two physicians and one laboratory, reported debts from 2011 as unpaid to a credit rating agency. The physicians had given us written confirmation that the entire debt would be written off and no further action would be taken in March 2012. So there's that. Medical debt--the gift that keeps on giving.
Moral of the Story
This is the end of this first installment of this saga, but there is a moral to the story. The moral of the story is, if one is uninsured, really, really sick and truly indigent, one may not get care or SSI, but one can --if one has dozens of hours of persistent, professional assistance-- have medical debt significantly reduced, but not eliminated.