When Patricia Mason was rushed to the ED with severe Covid-19, her focus was on survival. But after weeks in the ICU, Mason received medical charges totaling more than $1 million—and due to little-known quirks in health care laws, she was expected to pay more than $40,000 out-of-pocket, Maria La Ganga writes for the Los Angeles Times.

How Covid-19 will impact the financial outlook for the health care industry

Background

Mason first fell ill on March 22, 2020, burning up with a fever that in the following days deepened into flu- and bronchitis-like symptoms. Five days later, following two wrong diagnoses via telemedicine, Mason knew she needed to go to the ED.

The surprise billing legislative landscape

Her husband raced her to the nearest one, at NorthBay VacaValley Hospital, where she had to enter alone due to Covid-19 safety restrictions. She later texted her husband that she was being taken to a different hospital, although she didn't know the name. She said she would text again after she arrived.

She never sent that text. The following day, her physician called Mason's husband to inform him that Mason would likely have to go on a ventilator if her oxygen levels didn't improve. Fifteen minutes later, the physician confirmed plans to intubate. Mason ultimately spent two and half weeks in the ICU, remaining in some form of hospital care from March 28 to April 20.

According to La Ganga, the subsequent medical bills for Mason's nearly-month-long hospital stay shed some light on the details of her care. Her stay in a coronary care unit resulted in charges of $479,162.40, with additional pharmacy charges of $470,950.94 and respiratory services charges of $166,669.80.

Overall? Her medical charges totaled $1,339,181.94—and despite having insurance, Mason was on the hook for $42,184.20. And 10 months later, she and her husband—with five jobs between them—still have no way to pay for it.

What happened?

According to La Ganga, Covid-19 has given new urgency to already-complex issues related to patients' out-of-pocket bills. She explains that under the Affordable Care Act, the federal government imposed caps on how much insurers can require patients to pay out-of-pocket for medical care. However, the cap is fairly high: In 2020, for instance, it was $16,300 for a family plan, and in 2021, it's $17,100.

And more pressingly for Mason, not all insurance plans are subject to those caps.

As La Ganga explains, Mason is covered through her husband's union plan, which is administered by Blue Shield of California. But while the majority of health plans are subject to the federally imposed out-of-pocket maximums, her husband's plan predates the Affordable Care Act, which means it doesn't have to provide the same kinds of protections. As a result, Mason's plan does not have a cap on out-of-pocket costs.

In addition, while many insurance companies have said they would waive all out-of-pocket costs for Covid-19 treatment, most of those waivers do not include "self-funded" plans such as Mason's—those where members' premiums directly cover the cost of members' health care. And so while Mason's plan covered a "generous 95% of a patient's stay at an in-network hospital, for really sick people like her, the 5% that she is required to pay is a killer," La Ganga writes.

How common are bills like Mason's?

As La Ganga writes, of the 150 medical insurers included on America's Health Insurance Plans' website, 46% have either never offered a waiver for Covid-19-related costs, or their waivers have already ended.

And self-funded plans like Mason's aren't unusual; La Ganga cites the Kaiser Family Foundation, which estimates that 61% of Americans who are covered through their work participate in similar kinds of self-funded plans.

As for Mason, she and her family don't see a way out from the bills. "I don't have $42,000 to spare," she said. "We're at the point where we're trying to make it through the next 15 years, so hopefully we can one day retire…. I am lucky enough to be alive, so we take that into consideration. But the reality is I don't have (the money). It's not going to happen" (La Ganga, Los Angeles Times, 2/8).