It's made up about 25% of his social media feed for the last couple of years. It probably seems absolutely bonkers to those outside of the USA.

It's truly incredible that this goes on and everyone just kind of accepts it because it hasn't happened to them yet.

I really like Phil Gaimon. This is terrible. But it is also a type of edge case brought about personal risk decisions that led to the financial exposure.

Since this was a article focused on health and health insurance, I wish it had deconstructed the insurance coverage, risk, and price decisions behind it. The article states that he was only paying about $500/month for insurance; that is cheap, even if it is only for himself and not a family. So, the policy would likely have a lot of guardrails that protects the insurer from unlimited expense.

Phil probably gambled that he could save $500 - $1,000 per month on the plan he selected versus a plan with broader coverage and maximum out-of-pocket limits if he could stay within the guardrails. But, I bet he had no understanding of what those guardrails were and what his personal financial and health risk would be based on that decision.

About 15 years ago, when health insurance was "cheap," good coverage for a family was about $12K/year and individual coverage was about $8K/year. (One of my responsibilities I was managing benefits costs for a large organization.) Now comprehensive health insurance is about double that. Those types of plans typically have $5K to $10K maximum family out of pocket and other features that probably would have covered Phil. Phil was probably paying 1/3 of what it truly costs to insure and protect against a financial health catastrophe.

The root problem is that people who are not covered by an employer-provider plan may not understand that trying to save a few thousand dollars on independent coverage could cost them tens or hundreds of thousands in an health catastrophe. So, they often end up buying a health insurance plan that is functionally worthless (they cost more than health costs during good years, but do not cover near enough in a bad year).

I think it's a bit more than that. Yes - he perhaps takes some blame for not fully understanding his coverage and that when he is out of state he is no longer covered under certain parameters. It sounds like that you have a lot of experience in that and some expertise. But most consumers don't have expertise in understanding medical insurance coverage and where the gaps are. So there's that.

The market is too complicated for the average consumer to navigate and many things don't make sense. Like in this instance where his insurance determined an emergency procedure was elective. My wife works in HR and does have some knowledge on how insurance works. I'll never forget when she was in an urgent care with a medical emergency about to be sent a local Hospital. She spent 90 minutes on the phone with her insurance company because the Hospital she was going to be sent to was out of network and she was negotiating that it be covered since it was an emergency situation. You shouldn't have to be on the phone with your insurance company when you're hooked to up an IV in an ER.

Or the time she was giving birth at an in-network hospital with an in-network Dr. But at the last minute another Dr. stepped in to help out unknown to us. We got an out of network bill because we "choose" the second Dr...

It pains me to think about how much money is wasted by the medical industry and people navigating, negotiating, explaining, and optimizing this system.

The US health insurance system is ridiculous!

This is exactly the problem. Health Insurance is massively complex, and it got a lot worse since ACA. And most people are not equipped for the current state of health insurance decision making. My personal opinion is that a lot of the health exchange plans are a waste of money, but no one is telling consumers that.

No clue how much that guy makes but maybe the coverage he bought was all he could afford like many Americans who “only” spend $500 on single coverage. It’s just insane that spending $10k a year still means you have to pay out of pocket in many instances.

I count myself in the insanely lucky group that I pay $110 a month for my insurance through my school district and my wife pays $500 for her and our kids. And even more lucky we have a huge network for our HMO. But I also know people who have double that for PPO then have like a $10k deductible. It’s just terrible how wrong our “health care” system is.

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Not necessarily a response to your post, but using your post as a starting point for my thoughts..........

While we can try to blame people for making that decision, there are people who were in the same situation as Phil who were NOT living their dream bike racing by making the decision. But instead working respectable jobs to support their families. And the choice coming down to eat, pay rent, get extra med insurance.

It's pretty ridiculous to fault someone for having to make that decision that wasn't Phil. Phil, whatever. You don't HAVE to be a low level bike racer for a living to support a family.

Also in terms of the "reading and understanding the fine print", that kind of thing ought not even be possible in a first world country. You can't expect people of a life skill level where their income is low enough to be driven to this decision to also be responsible for fine-combing things like that when it could bankrupt them for life.

This is why I personally think government should at least cover or take care of that risk for lower income and lower skilled folks who probably can't handle that level of decision making. Then offer advanced level care if you want to research/pay for it yourself in addition.

I think some of the anger from people also isn't just the "bill shock" of the realization of a risk scenario, but the anger of how much it costs in the US for this stuff. Everyone in that supply chain of medicine has to be a mini millionaire. How? Because healthcare is an inelastic demand. You can't tell people "no no, let me die if you can't lower the price or drive me 6 hours somewhere cheaper". They fucking know that. So they can do WTF-ever. And the anger of "bill cramming" of itemizing everything then optimizing a price increase on every itemization.

While Phil's anger and issues around the "lack of coverage" is real in this conversation. I think equally so, if not more, is the gross greed and mismanagement of cost in that industry.

I've always had employer coverage so I've never really looked at state plans. But it had never occurred to me that a state plan would only (or primarily) cover you in that state and have limited coverage out of the state. Makes sense because Americans never travel outside of their own state...

Most folks do not know the level of employer subsidy, and educator subsidies are really high. Most employers probably cover 70% to 80% of the total insurance cost. I suspect school districts are north of 90%. So, your monthly $110 is the tip of the iceberg of a plan could cost $1,100/month, and your wife's is probably around $2,000/month total cost. You your family could account for a total $37/year health insurance bill. That is astounding!
The crime is that narrowing by state is a simple tactic the insurer uses to narrow its scope of payout. Super dangerous unless you know you will not need it out of state.

100% agree. And only going to get worse unless very radical changes are made.

Oh I count myself very lucky! I know they cover a lot for single person but then gets pretty high quickly when adding others to coverage which is why we went with my wife’s for the kids because hers was much lower than mine.

And to think many people, many who cannot afford it, have to pay $500+ for bad insurance is just awful. Hell there are so many things I look at and think “how much money do you need to have to afford this?!” because even at what my wife and I bring in there are many times that we don’t buy things.

Which is why I would be totally on board with a version of universal healthcare because in reality as a healthy person I’m already paying for someone else’s medical issues/procedures and I’m cool with because I don’t think anyone should need to start a gofundme or lose their house over medical issues! But that’s another discussion!

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There are currently no ACA individual plans with national networks. The last plan offered was in California by Blue Cross in 2020 - it's not a question of trying to save $$$, as an individual you can't currently buy a plan with national coverage through regular channels. (Reference: https://help.ihealthagents.com/...Outside-of-My-State- )

The problem here is hospital systems that balance bill (pass through what insurance doesn't cover to the consumer) and the (up until 2022) patchwork of state level laws that attempt to prevent that practice. As the article covers, that's been somewhat fixed at the federal level starting in 2022, but it's likely that some hospital systems will continue to try to/some things weren't covered (like ambulance companies).

There are probably some things he could have done once he was no longer in an "emergency" situation that would have been better covered (e.g., go in network in California for surgery instead of out of network in New York), but that vast majority of the $200k seems to have been from when he should have been covered for emergency care in Pennsylvania.

I'm not sure how an 'edge case' is defined in your industry, but medical expenses are responsible for 2/3 of the bankruptcies in the USA. It's not uncommon.

Most of the article is about wild markups, misclassifying billing, and out-of-network 'costs' that seem pretty tough to fight. Are there even individual plans with national coverage? Saying Phil didn't have an expensive enough insurance plan or chose the wrong one may be fair, but it misses the point entirely.

Again, two things pretty unique to the USA.

(Edit: I see one thing answered in the post above)

There are a bunch of ridiculous things about the American health care system.

But the most absurd is how much things cost.

And by "absurd" I am referring to meaningless (I.e. Camus).

How much does xxx cost?
Well...
How much might your insurance pay?
How much do we think you might pay?
How much if you knew before?
How much if you knew after?
How much could the average person pay?
If you don't pay, how much can we get if we sell the bill to collections?

Any ACA compatible plan has national emergency coverage. However, as the article highlights, until 2022 hospital systems are by and large free to balance bill (pass the responsibility for the portion that your insurance doesn't pay onto you) unless they're restricted by state law.

Balance billing aside, this isn't usually a terrible arrangement as most people don't see a primary care provider who isn't in their state and it allows for (typically) more competitive pricing for the first in state doctors (by driving volume). We could likely go a long way by allowing insurance companies to use some percentage of Medicare rates as fall back for doctors they don't have specific contracts with (which is somewhat how the federal balance billing law works) as a first class thing, but the Medicare rates as also super wacky (overpay on some things, underpay on others).

Saying Phil did not have an expensive enough insurance plan is exactly the point. Almost everything in that article happened because of the plan. The problem is that many people do not understand what they are not getting when they choose their own plan. The article shared a sad case, but it failed to come to a conclusion. It did not shout the obvious PSA: Everyone, educate yourselves on your heal insurance plan.

I define edge case as something that represents a small percentage of overall occurrence within a particular cohort. That 2/3 of bankruptcies are related to medical expenses is irrelevant. But that does provide a helpful thought framework.

For a simple rubric, you could bucket insured people into 4 categories:

1. Insured by a comprehensive employer-provided plan
2. Underinsured and aware of the risks
3. Underinsured and unaware of the risks
4. Uninsured

Then, with those four, you could bin people into 2 simple categories: Experienced a very expensive health event, or have not experienced a very expensive health event.

Most medical bankruptcies are probably in categories 2-4. The saddest cases would be #3, because they thought they were protected.

My hunch is that Phil Gamon was in category #3: underinsured and unaware when he experienced this very expensive health event. While this is devastating, it probably does not represent a large proportion of individual circumstances in the U.S. It is material, and it is bad, but it is a special case.

Wild markups and out-of-network costs are a direct consequence of how health care billing and insurance works. Phil's insurance plan directly cause those two to occur in the provider billing systems. It is simple formula. I'm not saying its is right or wrong, its just how it works.

I would say the obvious PSA is that the system needs to be burned to the ground.

Amen.

From the article, 52k was paid out total between both insurance groups. Depending on the accuracy of the estimates and reporting on actual costs, the actual costs of the treatments may have been covered. However, the system allows providers to send out bills based on completely made up prices so it doesn't matter if costs were covered. Many of the charges were misclassified in the story as well. This extra 'unpaid' money (called bad debt) can be written off as a loss if the provider made a good faith effort to retrieve it. I think bad debt can be sold as well, but I don't know much about that.

Being the pedantic git that I am, I contemplated making the point you are making in the post quoted. But I didn't, because we just don't know enough information to make that assessment, and your hunch, less further evidence (and which you have not provided thus far), is no more insightful than guessing on which side an unloaded die will land. I actually found HealthNet's premium table from 2018 (presumably close enough to what was operative in 2019), and there is just no way to tell which level of coverage he had, based on the information given. Specifically, is the quoted $500 for an individual per se, a prorated portion for an individual in a family plan, entirety of a family plan, or something else? HealthNet's product availability also depend on the location of one's residence (some parts of LA county have a slew of options, including PPO; other parts of LA county are HMO only), and we don't know where he live (unless you've done the registrar of deeds search).

Yes, it's a sob story, and KHN probably excluded details that may show Gaimon being more careless than he ought to be, but that still does not detract from the absurdity of it all (the main one being the drastic difference in pricing between in- vs out-of-network and balance billing in emergency situations).

The injuries sound remarkably similar to the worst cycling accident that I ever had, except I had an additional 3 broken ribs (8 total), plus a broken elbow and wrist.

I didn't have any health insurance either (never have had).

6 days in intensive care, a few more in the general ward, months of physio and follow-ups with the orthopedic specialist. What a nightmare.

My out of pocket expenses: $0.00. But, yeah, outside of the USA.

It would probably have helped if you glanced at my prior posts and the context in between. Yes, there is absurdity. And yes I assumed because the article neglected to deconstruct the important context. But this scenario, in a typical low-cost plan, is normal. It is get what you pay for. In order to get down to a $500/month insurance plan, you have to delete or restrict a lot of stuff and shift the risk back to the consumer.

The little niggles you called out are not material. I assumed Phil is single, because his bio does not mention spouse or kids. And, we know his age. Regardless, $500/month plans are bottom-tier in CA and most states. It simply costs a lot more than that to insure someone with employer provided and subsidized type coverage. That is the point of my prior posts.

no, the root problem is we are forced into a "for profit system" thats sole reason for being is to rape us on premiums and deny us benefits, no matter what we pay in or level of coverage we purchase. healthcare shouldnt have any sort of for profit aspect to it at all.

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I agree with your reasoning and that’s decent hunch. The thing is gaimon already experienced a very expensive medical event in 2013 when he was *airlifted* from a crash at a bike race. Whether he was lucky then, had better insurance or just didn’t learn anything (concussion and all) requires more hunches.

Out of network coverage is always interesting because, while terrible in practice, is theoretically in everyone’s best interest. Since most medical systems are regional and each one requires their own negotiation, it makes sense to stick to the systems close to covered patients. Why would a California resident want their insurer to invest resources in negotiating services at a Lehigh Valley hospital they’ll never go to?