The American health care system is broken, and there are few better illustrations of this than the story of Drew Calver, a high school teacher and swim coach from Austin, Texas, who suffered an unexpected heart attack and found himself $109,000 in debt because of it.
Calver, an avid swimmer at 44, was in his bedroom when chest pains forced him to the ground. He used his phone's voice recognition feature to text his wife and before long he was being treated at St. David's Medical Center.
A fair price for hospitalization in Austin involving 4 heart stents would be about $36,800. St David's Medical Cent… https://t.co/aCXOq9vlgQ— ᘜεɱ Ꮛℓεαɳσ૨™💎 (@ᘜεɱ Ꮛℓεαɳσ૨™💎)1535410375.0
On his hospital bed, his life in jeopardy, Calver had an important question for his doctors: will health insurance cover this? Every single day, countless Americans in life-threatening situations find themselves terrified of the answer to that question, because they know that, if their affliction happens to fall outside the limitations of their coverage, they'll be saddled with massive debts.
@NPR god almighty thank god I live in UK. Everyone in the US is being screwed royally by the entire medical industr… https://t.co/AFvgn1Blwp— katwoman (@katwoman)1535398892.0
The hospital told Calver not to worry; they would accept his insurance. Doctors implanted stents in his clogged "widow-maker" artery.
NPR reports that before long, however, Calver's worst fears were realized when he received his bill:
$164,941 for a four-day hospital stay, including $42,944 for four stents and $10,920 for room charges. Calver's insurer paid $55,840. The hospital billed Calver for the unpaid balance of $108,951.31.
@NPR Currently declaring bankruptcy due to medical bills ✌🏻— 🌈Gay Grandma Dave🌈 (@🌈Gay Grandma Dave🌈)1535398656.0
On June 26, the hospital sent a warning to Calver, saying it was his "FINAL opportunity" to pay his bill. Calver didn't know what to do:
They're going to give me another heart attack stressing over this bill. I can't pay this bill on my teacher salary, and I don't want this to go to a debt collector.
@MorningEdition Yes I listened to that story...which is why I will NEVER go to a hospital for such a procedure. Who… https://t.co/jb2U6bW7wj— P Edward Murray (@P Edward Murray)1535379145.0
Though he didn't know it at the time, Calver was the victim of two predatory billing practices: surprise bills and balance billing.
Surprise bills occur when you receive medical attention at a hospital covered by your insurance, but the doctor who ends up treating you isn't a participant in your insurance network, rendering your plan invalid. Surprise! Other times, the hospital and insurance company will disagree on what a reasonable cost for a procedure might be, as was the case with Calver's operation. When this happens, hospitals charge patients for the difference, or the balance.
The six-figure surprise bill because his heart attack didn't happen "in-network." For those of you abroad, yes this… https://t.co/Vtqw90YArL— Atul Gawande (@Atul Gawande)1535455023.0
In addition to the balance billing and surprise billing the shear scale of banditry here is amazing. $3,797 for 5… https://t.co/FM6NTDDYUi— Jonathan Reiner (@Jonathan Reiner)1535399747.0
Several states, including Texas, have laws against these practices, but hospitals were able to use them in Calver's case because of a huge loophole: employers that are self-insured, like the school Calver teaches at, are governed by federal law, which means state protections do not apply. About 60% of people work at self-insured companies, according to NPR.
Surprise Provider Medical Bills-Out of Network Emergency Admission & Self-Funded Health Insurance=A Big Mess For An… https://t.co/aUJhQTn4i1— Cindy Holtzman (@Cindy Holtzman)1535413765.0
Cases such as these are considered especially unjust by many in the medical payment industry because patients experiencing life-threatening emergencies often have very little say in where they're taken for treatment. When it appears a patient will not be covered by insurance, efforts are sometimes made to have them transferred to an in-network hospital as soon as possible, but St. David's said:
However, this is not always possible because the patient's health must come first.
@GlennThrush This really is an indictment on St David's Medical Center than anything else. We focus on health insu… https://t.co/5Y3dEgoVxA— Bentley Greg (@Bentley Greg)1535382552.0
After NPR and Kaiser Health News covered Calver's story, the hospital contacted:
Shortly after this story by Kaiser Health News and NPR was published and broadcast on Monday, St. David's said it was now willing to accept $782.29 to resolve the $108,951 balance because Drew Calver qualifies for its "financial assistance discount." In a statement, the hospital said this offer was contingent on Calver submitting his application for a discount based on his household finances. Calver disputed that he owes any additional money to St. David's and said this situation should have been resolved long before now.
Since we aired this story, @StDavidsHC said it was now willing to accept $782.29 to resolve the $108,951 balance be… https://t.co/sp1GPoUzFQ— Ashley Lopez (@Ashley Lopez)1535413545.0
Unfortunately, NPR cannot cover every patient's story, and countless Americans face similar problems every day.