LOS ANGELES — Every Tuesday, Naman Shah sees tuberculosis patients at a small public clinic in Los Angeles’ San Fernando Valley. Shah, a physician and epidemiologist at the Los Angeles County Department of Public Health, pores over images of battered lungs, listens to labored breathing, and checks medications.

It’s part of an initiative dating to the early 20th century to control infections so tuberculosis doesn’t spread. “We like doing things upstream,” Shah said, “meaning before they happen, not after the damage is done.”

Today, Shah and his colleagues are applying the same principle to medical debt. A key part of that effort is a new system to allow every hospital in Los Angeles County to easily screen patients for financial aid. The goal: to stop low-income families from getting a bill that buries them in debt.

Shah estimates this system could prevent several hundred million dollars of medical debt every year.

Vicious Cycle

Nationwide, an estimated 100 million adults have some form of healthcare debt. In Los Angeles County, the nation’s most populous, public health officials calculate that about 800,000 residents have medical bills they can’t pay.

“The impacts of medical debt were staggering,” said Shah, who used to staff a rural health clinic in India and, since 2023, has in Los Angeles to tackle the debt problem.

“People end up with credit card debt and then a vicious cycle of high interest rates and poverty,” he said. “People forgo their prescriptions. People forgo appointments. And then you get into worse health.”

Hospitals typically offer financial aid to patients with low incomes. But information about assistance is often hard for patients to get. Applying can be cumbersome. And many eligible patients never seek aid, research shows.

“Most people walk into the hospital and walk out without any knowledge of financial assistance,” said Jared Walker, founder of Dollar For, a nonprofit that helps patients nationwide apply for aid, often called charity care.

That’s fueling debt. It’s also driving costly collection efforts that even hospital officials acknowledge pointlessly target low-income patients who are unlikely to be able to pay.

“They’re turning their wheels trying to collect on debt that isn’t collectable,” said Adena Tessler, regional vice president for the Hospital Association of Southern California.

Presumptive Eligibility

One potential solution is a system that automatically screens and qualifies low-income patients for financial aid without requiring an application. This is called presumptive eligibility.

Some hospitals already use such systems, which rely on software that checks patient eligibility based on publicly available information such as credit history.

The strategy can be very effective. Shah said hospitals that have deployed presumptive eligibility systems have reported as much as a 50% increase in the amount of financial aid they give patients.

Under a passed last year, all California hospitals will have to start doing presumptive eligibility screening by next July.

But the systems can be expensive and difficult for smaller hospitals to implement. Only about 1 in 5 hospitals in Los Angeles County currently use them, Shah said.

Public health officials wondered if they could help more hospitals set them up.

The county, which, like many local governments, faces major fiscal challenges, couldn’t pay for this, Shah said. But the public health department could bring together healthcare and hospital officials in the county to figure out another solution.

“The beauty of government is not when it always has to do the work,” Shah said. “We have the ability to make sure that people cooperate.”

The Hospital Association of Southern California, initially wary of the county initiative, came to see improving hospital financial aid programs as beneficial to hospitals, many of which were wasting money on collections. “The billing process is cumbersome and costly,” said Paul Young, a senior vice president with the association.

The association agreed to procure a presumptive eligibility system and make it available to its members. This bulk-purchasing approach, which Young compared to “a Costco model,” would lower the cost for individual hospitals, he said.

At the same time, L.A. Care, a nonprofit health plan that administers Medicaid coverage for more than 2.5 million low-income county residents, committed $2 million to set up the system.

The investment reflected the safety net insurer’s mission to make medical care accessible to more people, said Melanie Fontes Rainer, who leads strategic planning for L.A. Care. “It’s going to make Los Angeles County better,” she said.

Making It Work

Getting the new system up and running by January, as the partners hope, faces challenges.

Hospital officials are figuring out how the system will be funded in the long term. And it’s unclear how many of the county’s 88 acute care hospitals will ultimately use it, even if it’s cheaper and easier to access.

The partners are also working to improve data that the system relies on to screen patients. One goal is to link the system to tax records maintained by the state of California. This would provide hospitals with more accurate information on patients’ income than current systems, which often rely on estimated income.

Walker, the patient advocate at Dollar For, said he’s heartened by the county’s effort. “I’m optimistic that we can make a better charity care system,” he said. “And the fact that hospitals in Los Angeles County are willing to be innovative and creative about ways we can do that is super encouraging.”

For his part, Shah said county public health officials recognize that a better screening system at hospitals won’t by itself eliminate medical debt. But he said the public health department couldn’t ignore a problem that affects more county residents than asthma or tobacco use.

“Prevention is our bread and butter,” he said.

This article is part of “,” an investigative series from and ³Ô¹Ï²»´òìÈ about how hospitals can protect their patients from the life-altering harms of medical debt.

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

Many will be stuck without a lot of options. In some cases, no other companies in their area may offer Medicare Advantage plans to replace them. This isn’t the first time this has happened. Last year, almost 3 million seniors found themselves in similar situations.

An Arm and a Leg host Dan Weissmann and producer Emily Pisacreta looked into what happened when those cancellations hit Minnesota. The collapse of a major Medicare Advantage carrier there led to “total chaos,” according to the director of the state’s Medicare assistance agency. Everyday people stepped up to help one another in the fallout.

Plus, ³Ô¹Ï²»´òìÈ senior correspondent Julie Appleby joins to discuss the role of private health insurance companies in Medicare. She explains how these companies shape seniors’ choices, including in Medicare supplemental plans, whose premiums have skyrocketed.

Credits

An Arm and a Leg is a co-production of ³Ô¹Ï²»´òìÈ and Public Road Productions.

For more from the team at An Arm and a Leg, subscribe to its weekly newsletter, . You can also follow the show on , , , and . And if you’ve got stories to tell about the healthcare system, the producers would love to .

To hear all ³Ô¹Ï²»´òìÈ podcasts, click here.

And subscribe to An Arm and a Leg on , , , or wherever you listen to podcasts.

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One way patients can avoid medical debt is through hospital financial assistance, also known as charity care. Most of the nation’s hospitals offer free or discounted medical care to patients with very high medical debt or low incomes.

Getting financial assistance, however, can be challenging. Many that hospitals offer financial help, surveys show, and leave others stymied.

Hospitals often demand that applicants turn over bank statements, pay stubs, tax returns, divorce filings, or other materials, and submit their applications in person, by mail, or by fax.

“They don’t make it easy,” said Neale Mahoney, a Stanford University economist who studies medical debt.

Such hurdles leave many patients with unpaid bills they should never have had to pay in the first place. In a single year, hospitals and health systems billed patients for at least , one analysis found.

As healthcare costs climb and more people lose their coverage, states and hospitals are testing an emerging approach to fix this problem: automatically screening patients to see if they qualify for assistance and proactively wiping out debt when they do. This is known as “presumptive eligibility.”

Under this approach, patients may have the cost of their care wiped out before they see any bills — but not always. Hospitals differ on when, how, and for whom they use auto-enrollment, potentially impinging on patients’ finances.

Here’s what you need to know about how auto-enrollment works.

What is hospital financial assistance?

In many states, hospitals for whom they provide financial aid. Eligibility is typically based on income for the patient’s entire household. The closer patients are to poverty, the less they have to pay. Patients with middle incomes and insurance are sometimes eligible for discounts, especially if their bills would gobble up a big chunk of what they earn.

require hospitals to wipe out bills for low-income patients, though income cutoffs vary. Georgia, for example, mandates free care for anyone with income slightly above the federal threshold for poverty. In several states — including Oregon, North Carolina, and Maryland — patients can earn double that amount and still get free care.

But in most states, many patients must complete applications to receive assistance.

Several states in recent years have and designed to make it easier for people to get help. , however, suggests gaps persist.

How many hospitals use auto-enrollment?

Nearly all nonprofit hospitals say they screen and automatically reduce bills for certain patients.

Under the Affordable Care Act, nonprofit hospitals must make reasonable efforts to find people who are eligible for help before they take patients to court, sell their debt to collection agencies, or ding their credit over bills. Presumptive eligibility is one way hospitals can comply with the regulation, which took effect in 2016.

In the first year under the new rules, about 70% of tax-exempt hospitals nationwide said they screened patients and proactively reduced bills, according to an analysis of federal data for Tradeoffs by the independent research institute RTI International. As of 2022, that figure was nearly 90%.

The federal law doesn’t apply to for-profit and public hospitals, which don’t have to report the actions they take before going after patients for unpaid bills.

In six states, policymakers require hospitals to use presumptive eligibility and skip applications for certain patients. Those states are California, Delaware, Illinois, Maryland, North Carolina, and Oregon.

Who is eligible to be automatically enrolled in financial assistance?

In most states, hospitals decide which patients can skip the application.

Common groups automatically screened include people who are homeless, deceased, or already enrolled in state or federal programs to help low-income households with housing, food, or prescriptions. Other hospitals have more unique criteria, like , which will write off bills for anyone in a religious order who took a vow of poverty.

Eligibility criteria are often buried in official policies and hard to find or decipher. Some hospitals share little to no public information about whom they will proactively screen. Thirteen hospitals owned by Ascension, one of the nation’s largest Catholic health systems, state only that they may screen patients “with a sufficient unpaid balance.”

Across the half-dozen states with presumptive eligibility mandates, eligibility rules vary. Maryland, for example, requires hospitals to proactively wipe out bills only for patients who already get government help for food or utilities but are ineligible for Medicaid. In Illinois, lawmakers created less-stringent requirements for rural hospitals compared with urban facilities.

In Oregon, starting in 2024, hospitals had to screen anyone who owed more than $500 and every patient on Medicaid or who is uninsured. In 2025, roughly 80% of Oregon patients who got financial help with bills never filled out an application, based on data shared publicly by the first 26 hospitals to do so. The state’s legislature this year raised the screening threshold to include patients who owe at least $1,500 for a single visit.

Without an application, how do hospitals figure out who gets help?

Hospitals have several ways to find patients eligible for financial assistance.

Typically, hospitals turn to public records, any information patients have previously volunteered, or tools from consumer credit companies to estimate whether patients qualify to have bills reduced.

For example, if a hospital sees that a patient lives in a high-poverty ZIP code or has no address listed, that could be enough to deem them eligible. Many pay companies to run employment and credit checks on patients to determine whether they qualify for free care.

Hospitals may also consider how likely patients are to pay bills, regardless of how much they earn. This is called “propensity to pay.” California and Oregon prohibit its use, concerned that hospitals may try to collect more often from people who dutifully pay their bills even though their incomes qualify them for financial assistance.

When do hospitals screen patients for financial aid?

It depends.

Illinois, North Carolina, and Oregon require hospitals to screen certain patients before they send any bills. California hospitals will have to do the same starting in 2027.

Some hospitals voluntarily screen patients before sending bills; others try to collect money from patients first. As long as they screen patients before suing them for very overdue bills, hospitals can stay within the letter of the federal law that pushed many of them to embrace presumptive eligibility.

For example, the is to screen patients only “after all other eligibility and payment sources have been exhausted.”

Anna Stelter, vice president of policy for the Texas Hospital Association, said hospitals want to investigate other options for payment — like Medicaid or county safety net programs — before they give out financial assistance.

“We do want to make sure that whoever is financially responsible for that care is identified and pays,” Stelter said. “Charity care is the relief of last resort.”

Hospitals’ publicly posted policies may also be fuzzy about when they will screen for patients likely eligible for help. For example, in Fort Worth, Texas, says its goal is to determine a patient’s eligibility “as soon as sufficient information is available.”

Who pays the bills when patients get free care?

In one sense, we all do. Taxpayers cover some or all of the cost of financial assistance, though the amount varies by hospital.

About half the nation’s hospitals are nonprofit and legally get a pass on paying most taxes. KFF estimates that nonprofit hospitals in 2020 that they would otherwise have paid as income, sales, or property taxes.

Government-owned and for-profit hospitals have their own sets of tax benefits to help offset costs for low-income patients. Government hospitals often , and for-profit hospitals generally receive smaller government subsidies, like for caring for high numbers of uninsured and Medicaid patients.

Whether taxpayer dollars fully cover hospitals’ costs for financial assistance depends on the amount of government support they receive — information often not publicly available. It also hinges on how many patients need help, how many meet hospitals’ criteria for assistance, and how many get through an application. Research shows hospitals spend on financial assistance, from less than 1% of yearly expenses to more than 7%.

Philanthropy and hospitals’ income cover costs not absorbed by tax dollars.

This article is part of “,” an investigative series from and ³Ô¹Ï²»´òìÈ about how hospitals can protect their patients from the life-altering harms of medical debt.

Melanie Evans is a reporter for Tradeoffs, a nonprofit newsroom reporting on healthcare’s toughest choices. to get the latest stories every Thursday morning.

Tradeoffs’ reporting for this series was supported, in part, by the California Health Care Foundation, the National Institute for Health Care Management Foundation, and the Solutions Journalism Network.

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The poll of more than 2,000 rural registered voters by The Associated Press in partnership with KFF found broadly negative views on the national and local economies, including from many Republicans. The costs of groceries, gas, and healthcare rank as top pain points for the rural voters, who were surveyed over two weeks starting in mid-August. And a larger share than among voters overall say they are worried about being able to afford groceries or gas.

At the same time, about half of rural voters approve of Trump’s job performance, more than among U.S. adults overall in separate AP-NORC polling.

The findings suggest that many rural voters haven’t turned on Trump but that they also largely don’t think he has delivered the economic renaissance he promised on the campaign trail.

Ed Westrick, a registered Republican and veteran, rates Trump’s job performance as “mediocre, middle-of-the-road.” Westrick, who lives in rural Texas, isn’t sure he will cast a midterm ballot, a troubling sign for Republicans in a key state in their fight to keep control of Congress.

Rural Americans skew Republican and historically have been an instrumental group of voters for Trump. The survey reveals that while rural voters seem unlikely to support Democrats on a large scale, Trump and the Republican Party could face challenges with them in November.

Deep Unhappiness About the Economy

As the election approaches, only about 4 in 10 rural voters approve of Trump’s performance on the economy. They rate him similarly on his handling of the Iran war, an entanglement that has proved expensive for the U.S. and increased oil and gas prices. And rural voters rank pocketbook concerns and fraud in government programs higher among the things they want to hear about from politicians than other perennial issues, such as gun policy and abortion.

Westrick, 59, is a technical trainer in the electronics industry and has seen an increase in business in part because he works with defense contractors, but he said he’s concerned about the cost of living.

“I hear the politicians talk about making groceries more affordable and making healthcare more affordable but yet none of them are addressing the issues,” Westrick said.

In the poll, about three-quarters of rural voters rated the cost of living in their communities as “only fair” or “poor” — up from about half in a KFF-Washington Post survey in 2017. Rural Americans, who have consistently lower wages than those who live in suburban and metro areas, have been hurting economically for decades, according to Tim Slack, a professor of sociology at Louisiana State University and co-author of the book Rural and Small-Town America.

“Many folks are connecting the cost-of-living crisis to many of the Trump administration’s policy choices: the war in Iran, tariffs, trade wars,” Slack said. “None of those things are going to bring down prices at the pump or the local Walmart.”

“Trump promised to lower prices on Day 1, and instead the cost of living’s continued to climb. And that’s especially painful in rural America,” Slack said, adding that he expects many working-class Republicans to skip voting in November.

Rural Republicans do have a brighter economic perspective than rural Democrats or independents, particularly about the U.S. as a whole, according to the survey. About 6 in 10 rural Republican voters say Trump has improved the national economy, compared with only about 2 in 10 independents and fewer than 1 in 10 Democrats.

But only 45% of rural Republican voters say Trump has made their local economies better off. About 1 in 4 said there are fewer good-paying jobs where they live than five years ago.

In Michigan, 37-year-old independent voter Brittainy Sosebee said she isn’t sure if she will vote in the state’s midterm election, which includes a tight Senate race seen as crucial to the Democratic Party’s push to win back a majority. Sosebee voted for Trump in 2016 and Democratic candidate Joe Biden in 2020; she didn’t vote in 2024.

Sosebee, who lives in St. Johns, a small town just north of Lansing, said she used to have extra money to take a vacation or buy a new pair of jeans without worrying. Now, she scrutinizes every expense, cringing at the rising cost of fresh produce when she shops for her three children.

“We hunt, so we have a lot of venison and things like that, so we don’t have to buy meat from the grocery store, but it’s still crippling,” she said.

Healthcare Policies Go Unnoticed

The KFF-AP poll found that rural voters overall don’t perceive much positive impact from the Trump administration’s healthcare policies even as they have been a top priority for Republican leaders, who have promoted efforts to lower drug costs and touted a $50 billion rural health program.

Only 17% of the voters said the Trump administration’s healthcare policies have had a “positive impact” on their healthcare costs, while 41% said they’ve had “no impact” and another 41% said they’ve had a “negative impact.”

Sitting on her front porch in Woolwich, Maine, 71-year-old Democrat Kathleen Hanning sipped a chai tea latte in the sun and recalled how she stopped voting for Republican Sen. Susan Collins in 2020.

Collins and Trump are “intertwined,” Hanning said. “She is not independently voting on what’s best for Maine.”

Hanning, a retired federal worker, said she hadn’t paid much attention to the health policies in Trump’s signature tax-break-and-spending-cut bill passed last year. The law reduces federal Medicaid spending by roughly $900 billion over a decade but also includes the billions of dollars for the Rural Health Transformation Program, which it created.

A year after the law’s passage, more than 8 in 10 rural voters said they’d heard either “a little” or “nothing at all” about the health fund. About 60% said they had heard nothing, according to the survey.

Rather than transforming, Hanning said, “hospitals up here in Maine are consolidating.” She travels an hour to see a specialist and noted that mothers will now have to drive farther for care because the hospital in nearby Damariscotta announced it would soon close its labor and delivery center.

Nine in 10 rural voters said it was “extremely” or “very” important for candidates to talk about healthcare costs, with more than half saying it’s “extremely important.” Mirroring the general population, rural voters ranked healthcare costs and gas prices as top economic worries.

Rural Republican Voters Still Trust GOP More

When asked which political party they trusted to do a better job handling issues such as the cost of healthcare or the cost of living, rural voters tended to side with their own party. The finding signals that Democratic candidates are more likely to benefit from rural Republicans’ staying home this November than from their voting across party lines in large numbers.

Republicans are more ambivalent about their party’s ability to handle key healthcare issues, compared with Democrats. About 8 in 10 Democratic voters say they trust the Democrats to address healthcare costs, while closer to 6 in 10 Republican voters say the same of the Republicans.

In Manassas, Georgia, a tiny town about an hour’s drive inland from Savannah, Republican voter Wanda Rogers feels the Trump administration is doing the best it can to clean up what she sees as an economic mess that Democrats left behind when they lost power.

“I kind of think people think like I do, that he knows what needs to be done,” she said. “It’s just taking them a while to get it there.”

Still, the 66-year-old said, “gas prices, they’re eating me alive right now.” She said she has stopped traveling to the beach because it has become too expensive.

Pamela Shaw, an independent voter who lives in a rural area near Asheville, North Carolina, said she sees the impact of rising costs in her community.

“When hamburger is over $7 a pound and steak is $15 or more a pound, a lot of people are not able to buy some of the things that they are used to buying,” the 59-year-old said in an interview.

Trump’s Rural Standing Has Slipped

Trump remains relatively popular among rural voters in the KFF-AP poll, with 48% approval — substantially higher than in a July AP-NORC poll of U.S. adults overall, in which only a third approved of his performance. But he’s also down slightly, from 56% approval, among rural voters, based on a similar question asked in the earlier KFF-Washington Post survey.

Asunta Washington, 38, is a truck driver who lives in South Texas. He said he is not against voting for Republican candidates if he wholeheartedly agrees with what they stand for, but he has not seen that. Instead, he has seen a lot of flip-flopping, he said.

“Like, a lot of people that are giving us promises and the moment they get elected, all that’s out the window,” Washington said.

This year’s competitive elections feature key Senate races in states including Ohio, Michigan, and Maine, all of which have large rural populations. In close races, Democrats may have a chance to “show up and give a message that rural people might find appealing,” said Nicholas Jacobs, a political scientist at Colby College and co-author of the book The Rural Voter.

“But it’s nothing more and it’s nothing less than that — an opportunity,” Jacobs said. “And time and time again, Democrats have shown a certain proclivity for not seizing that opportunity.”

Many rural voters don’t think the major parties or the president respect people like them. About half, 48%, of rural voters say the GOP respects people like them “a lot” or “some,” while 45% of rural voters say this about Trump and 37% say this about the Democratic Party.

On a recent Thursday, registered Republican Nate Lawrence answered his phone after paying $57 to fill up his Chevy Equinox in New Concord, Ohio, a village of fewer than 3,000 people about an hour’s drive east of Columbus.

Lawrence, a middle school English teacher, said the candidates should be talking about spending power: “I need to be able to go to the store and feed my family on what I make as a teacher,” Lawrence said. “I should be able to pay for a house on a teacher’s salary.”

Lawrence has voted for Trump in the past but didn’t in 2024. For Ohio’s Senate race, Lawrence said he is torn and not sure whether to pick Democrat Sherrod Brown or Republican Jon Husted.

Still, even if the politicians say they will lower prices, Lawrence said, he won’t believe them.

“Trump said that, and it didn’t happen,” he said.

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

³Ô¹Ï²»´òìÈ chief Washington correspondent Julie Rovner joined WAMU’s Health Hub on Sept. 16 to explain how healthcare could play a critical role in the midterm elections. She said similar cost increases in the early 2000s led to the debate that became the Affordable Care Act. 

“We’re seeing people have to pay more in their — not just premiums — but their deductibles, how much they pay before their insurance kicks in, and how much they pay when they go to the doctor,” said Rovner, host of the What the Health? From ³Ô¹Ï²»´òìÈ podcast.

In recent years, it’s not uncommon for healthcare providers to ask for payment upfront. 

“Now you get there, and they say, ‘Can we have your credit card?’ before you even get to go in and get your care,” Rovner said.

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

That’s partly because Halver’s mother and aunt have had breast cancer. Her age and dense breast tissue also put her at higher risk.

Halver, who lives in Vancouver, Washington, said her doctor recommended she get an annual breast MRI, six months after her yearly mammogram. The scan would serve as an additional safeguard, since breast MRIs can detect abnormalities that mammograms miss.

Case in point, actress Olivia Munn had a breast MRI in 2023 that detected an aggressive form of cancer in both breasts, even though a recent mammogram had been clear, . Like Halver, Munn said her doctor recommended the MRI after a risk assessment score showed she faced a greater-than-normal chance of developing breast cancer.

Catching breast cancer early, before it spreads, improves survival rates, according to the . After Halver’s insurer preapproved the scan, she scheduled the MRI for September.

“Luckily, they find nothing,” Halver recalled.

Then the bill came.

The Medical Service

A breast MRI — short for magnetic resonance imaging — is a preventive and diagnostic tool that captures pictures of breast tissue in higher detail than a mammogram. MRIs may be recommended for patients at an increased risk for breast cancer, including those with dense tissue, a family history of breast cancer, or certain genetic markers.

But the scans are generally not recommended for women considered at average risk, according to the , because they can also yield false positives, subjecting patients to unnecessary follow-up tests and procedures.

Breast MRIs are also used to diagnose cancer when an abnormality is detected during a mammogram, and they can determine the cancer’s stage after diagnosis.

The Bill

$1,205: After an insurance payment of $13.90, the patient was responsible for $1,191.10. The clinic also charged $65.60 for “Injectable/Oral Med,” often used to keep patients still or less anxious during the scan. Halver’s insurance covered about half of that charge.

The Billing Problem: Not Always Preventive

When Halver received the bill from Vancouver Clinic, where the MRI was conducted on Sept. 26, she was confused.

She knew that the Affordable Care Act requires health plans to cover preventive care, such as Pap smears and mammograms, at no cost to patients.

What’s more, Halver’s breast MRI had been recommended by her doctor and preapproved by Blue Cross Blue Shield of Texas, of which she is a beneficiary through her employer-sponsored plan. The whole point of it was preventive. That’s why she assumed it would cost her nothing.

To make things more confusing, requires many health insurers to cover breast MRIs.

“I’ve had many phone calls trying to understand” the bill, Halver said.

It came down to this: The U.S. Preventive Services Task Force, a panel of outside experts that advises the federal government, is charged with recommending which screenings health insurers are required to cover at no cost to patients, and preventive breast MRIs don’t fall into that category.

The task force “the current evidence is insufficient to assess the balance of benefits and harms” of breast MRIs for women with dense breast tissue “on an otherwise negative screening mammogram.”

The federal guidelines are different for patients whose mammograms detect an abnormality, said Cathy Peters, senior director of state and local campaigns at the American Cancer Society Cancer Action Network.

In these cases, Peters said, by the federal Health Resources and Services Administration specify that additional imaging, such as ultrasounds and MRIs, are preventive.

After an abnormal mammogram, these services are recommended “to address findings on the initial screening mammography” and to “complete the screening process for malignancies,” according to HRSA.

Those guidelines are a step in the right direction, but women who have not had an abnormal mammogram may end up “running into a big bill,” Peters said. This can be a deterrent when it comes to future screenings, she said, because when “you get hit with that once, you’re going to be very careful the next time you go.”

Some states have enacted laws that require insurers to cover breast MRIs, Peters said, but they generally don’t benefit patients like Halver who are enrolled in large, employer-sponsored insurance plans. These “self-insured” plans are regulated by the federal government, not by state lawmakers.

“Sadly, these state-by-state laws,” Peters said, don’t “fix the federal problem.”

The Resolution

Blue Cross Blue Shield of Texas declined to answer questions about Halver’s benefits or bill.

Halver appealed the insurer’s coverage determination, and in July she received a letter indicating that her appeal was denied.

Halver said she contacted her employer’s human resources department earlier this year and learned that mammograms are covered as a preventive screening under her health plan but breast MRIs are not. That means her annual breast MRI will be subject to deductibles, coinsurance, and other cost-sharing requirements.

In this case, the cost of Halver’s breast MRI was applied to her $3,300 annual deductible, an explanation of benefits from her insurer showed.

“I think I’m on the hook for this bill,” she said.

And because her risk of breast cancer is high, she said, “that’s a guaranteed bill every year.”

The Takeaway

If your doctor or medical provider recommends an annual breast MRI in addition to an annual mammogram, consider researching your state’s coverage rules on the . The nonprofit organization maintains a map with up-to-date information on state laws about breast cancer screenings. Depending on where you live and what type of health plan you have, preventive breast MRIs might be covered at no cost.

If it turns out you could be on the hook for a future bill, there are a few things you can do beforehand to potentially lower your out-of-pocket costs.

Ricki Fairley, co-founder of Touch, the Black Breast Cancer Alliance, recommended first finding a patient navigator at the hospital or cancer center to assist you.

She urged women to seek out resources in their communities or through national advocacy groups, including Touch, to find ways to lower screening costs. Programs funded by some states can help offset the cost of breast cancer screenings for low-income patients, Fairley said.

Beyond that, shop around for the best price. Freestanding imaging centers may charge less for a preventive breast MRI than a hospital. If possible, also consider scheduling the MRI at the end of your health plan’s deductible year. If you’ve already met your deductible, you could end up owing less out-of-pocket.

Bill of the Month is a crowdsourced investigation by ³Ô¹Ï²»´òìÈ and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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Then Medicare launched an 18-month pilot program that offers GLP-1 medications to some enrollees for only $50 a month. La Marca thought he might finally be able to afford the drug.

“I thought, ‘Thank God, there’s a path,’” said La Marca, who lives in Basking Ridge, New Jersey, and has tried numerous diets and exercise regimes.

But the 68-year-old’s celebration was short-lived.

His application to the pilot program was denied.

La Marca has severe obstructive sleep apnea, one of several diagnoses that exclude patients from the Bridge program’s $50 monthly price. The notification didn’t say why he was rejected. He thinks that if he didn’t have that diagnosis, he would qualify due to his weight.

“I’m obese, morbidly obese, BMI 42. I had quadruple heart bypass surgery. I’m at risk for stroke. I’m prediabetic. And yet I can’t get it. I’m livid,” he said.

A Temporary Patch for a Long-Standing Gap

About 1 in 5 American adults have taken a GLP-1 medication, and most of them, including those with health insurance, say the drugs are . Federal law has long barred Medicare from covering drugs prescribed solely for weight loss, which is why the Medicare GLP-1 Bridge program made a big splash when it launched in July.

It’s a short-term pilot program in which Medicare is offering coverage of three GLP-1s for weight loss and management, to see if that would save Medicare money later. Eligible patients must be enrolled in Medicare Part D, a prescription drug coverage add-on to Medicare. Even though people must have Part D insurance to qualify, the preauthorization request doesn’t go through the insurer; it’s instead submitted to a separate system run by a contractor for the Centers for Medicare & Medicaid Services.

The pilot includes Wegovy, the KwikPen formulation of Zepbound, and the oral medication Foundayo.

Under the pilot, many Medicare beneficiaries with a body mass index of 35 or higher — the — qualify for coverage of one of those drugs, if prescribed. Those otherwise eligible who have a BMI of 27 to 34 can qualify if they also have certain health conditions, such as prediabetes or cardiovascular disease.

But buried in the fine print is a distinction that’s tripping up patients like La Marca: The $50 price under Bridge applies only to people using the drug solely for weight loss. Anyone who has a qualifying medical condition that the Food and Drug Administration has approved GLP-1s to treat, such as Type 2 diabetes or moderate to severe obstructive sleep apnea, is instead routed back to their Medicare Part D prescription drug plan, which can require copays of hundreds of dollars a month for GLP-1s.

“The Bridge program was designed to target those people who can’t get GLP-1 coverage through Part D but would benefit from taking one for weight loss,” said Juliette Cubanski, who directs the Program on Medicare Policy at KFF, a health information nonprofit that includes ³Ô¹Ï²»´òìÈ.

The cost to Medicare of subsidizing the drugs will depend largely on how many people use the program, and the federal government hasn’t released an estimate.

Cubanski that 3.8 million people qualify and that, if a quarter of them enroll in Bridge and remain on treatment for the program’s full 18 months, it will cost Medicare about $3.3 billion. If three-quarters enroll, costs could rise to $10 billion.

If the government expanded the program to include the additional 5.9 million people who are overweight and already eligible for GLP-1 coverage through Medicare Part D, it would add billions more to the program’s cost.

The demonstration’s initial weeks have been positive, and most prior authorization requests have been completed in under 12 hours, CMS spokesperson Timothy Foster said.

“This has allowed thousands of eligible beneficiaries to access GLP-1 medications for weight loss at pharmacies nationwide,” Foster said.

GLP-1s Aren’t Covered

Patients like La Marca are left in a tough spot, qualifying for Part D coverage of a GLP-1 but facing much higher cost sharing.

“‘Coverage’ doesn’t always mean ‘affordable,’” said primary care physician , who describes herself as a “big proponent” of GLP-1s and practices at Sunflower Medical Group in Roeland Park, Kansas.

The Bridge program is leaving behind patients with the greatest medical need, she said. She noted that many Medicare patients already must navigate prior authorization and spend months trying alternate, often cheaper treatments, a process known as step therapy, before finally getting approval — only to arrive at the pharmacy counter and discover that their GLP-1 copays will run them $200 to $600 a month, if not more.

Researchers studying how Medicare insurers cover GLP-1s that recipients have faced increases in out-of-pocket costs and that almost all plans now require prior authorization, which can make getting the drugs more difficult.

Chris Bond, a spokesperson for insurance industry trade group AHIP, blamed drugmakers’ prices, “which they alone set and they alone can lower.”

La Marca’s insurer declined to answer specific questions about La Marca’s case.

Left Waiting

For now, La Marca’s GLP-1 prescription remains unfilled. The severe sleep apnea diagnosis that helps establish his medical need is also what excludes him from the discount program that would bring the cost within his reach.

As he reflected on his appeals and the dead ends, La Marca paused, his eyes filling with tears of frustration.

“This is now my quest, because it’s my only chance to improve my health,” he said. “It’s the only thing left. I’ve tried everything.”

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If the state Office of Health Care Affordability adopts the fines next week, hospitals, medical groups, insurers, and others could face penalties that amount to as much as 125% of the total they spend above the state’s annual growth targets.

The penalty proposal comes after healthcare entities in California were asked to limit growth by 3.5% last year and ramp down to 3% by 2029. Seven hospitals that state officials consider particularly expensive face even smaller growth targets: 1.8% in 2026, dropping to 1.6% by 2029.

Consumer advocates argue that state financial deterrents are critical to bring relief to millions of Californians struggling with high insurance premiums and out-of-pocket expenses. Hospitals accounted for in U.S. health spending from 2022 to 2024, compared with 11% from retail prescription drugs. But adding teeth to those targets sets up a fight with the powerful hospital industry, which has a challenging the spending limits as unreasonable. Hospitals warned that they will cut back on vital services, including in emergency rooms, obstetrics, and behavioral health.

Healthcare industry representatives said the state affordability office hasn’t accounted for year-to-year volatility or other factors beyond the industry’s control, such as rising minimum wages, state earthquake retrofit requirements, and expensive new drugs.

“They’re building the plane while flying it,” said Ben Johnson, group vice president for financial policy at the California Hospital Association. “We know improvements in affordability are needed, but we have serious questions about how and about what the unintended consequences could be under OHCA’s rather stringent approaches.”

When calculating penalties, California regulators would consider various factors, including a healthcare entity’s financial situation, its market impact, and the gravity and number of offenses, according to a in June. And entities would first be given opportunities to implement performance improvement plans to bring their spending into line before penalties are imposed. For those that don’t comply, the board is considering penalties of $10,000 a day or a flat $500,000.

The penalties, which the affordability office’s eight-member board is required by to adopt, are slated for discussion, and a potential vote, at the board’s . The soonest healthcare providers would be subject to penalties is 2028, because it’s expected it will take two years to collect and publicly report spending data to measure against the 2026 targets. The state is still collecting data on how entities performed against the 2025 targets, which aren’t enforceable, according to Andrew DiLuccia, a spokesperson for the California Department of Health Care Access and Information.

States Set Targets

California is one of at least eight states that have set spending targets as part of an expanding effort to curb soaring healthcare spending across the nation. Connecticut, Massachusetts, Oregon, and Rhode Island have also authorized the use of some type of financial penalty. The specifics of each vary widely, although so far no state has applied them.

A by the California Health Care Foundation found that 4 out of 10 state residents said they had medical debt, and 6 in 10 reported that they or a family member had skipped or delayed medical care in the previous 12 months because of cost. Nationwide, about say it is difficult to afford healthcare costs.

After Rosalyn Book got stiches on her chin, the elementary school teacher received a $15,000 ER bill from a local hospital, despite having insurance. Many teachers in her district leave because they can’t afford the cost of healthcare and insurance premiums, she said.

“The healthcare charges are just insanity, and what we get as patients for the care, it’s not the best either,” said Book, president of the Monterey Bay Teachers Association. “If you’re a working, regular individual in terms of how much you make, the cost of living and especially the healthcare is just not doable.”

Meanwhile, hospitals are warning there’s a risk of more closures. According to Yale University’s , 17 hospitals have closed in the state since 2016, compared with only six openings.

Hospitals and other healthcare providers have said the proposed multimillion-dollar penalties are too steep and could destabilize their operations at a time when they’re facing funding challenges, including massive federal cuts to Medicaid, the end of enhanced federal subsidies for Affordable Care Act plans, and a sharp rise in uninsured patients. The One Big Beautiful Bill Act, passed by congressional Republicans and signed by President Donald Trump last summer, is expected to reduce federal Medicaid spending by more than — including by in California — and increase the rolls of the uninsured in the U.S. by over a decade.

Johnson said hospitals raise prices on commercial payers to offset the expense of treating uninsured patients, as well as patients on Medicaid and Medicare, which can reimburse care providers at rates that fall short of treatment costs.

In addition, said Anete Millers, vice president of legal and regulatory affairs at the California Association of Health Plans, tax increases on managed-care plans recently to offset federal Medicaid cuts will force plans to increase their prices for consumers.

“Some spending pressures originate outside of the control of health plans and are the result of public policy decisions rather than underlying changes in healthcare utilization or efficiency,” she told the affordability office’s .

Kristof Stremikis, the director of market analysis and insight at the nonprofit California Health Care Foundation, acknowledged that external forces can drive costs but said that plenty of unnecessary spending is within the healthcare system’s control, such as administrative waste and duplicative tests and procedures. of U.S. healthcare spending is considered wasteful, according to .

Elizabeth Mitchell, a former Office of Health Care Affordability board member whose term ended in May, agreed.

“Every business has external challenges,” said Mitchell, who is now president and CEO of Purchaser Business Group on Health, a nonprofit coalition representing large employers. “The hospital industry has not taken accountability to actually manage costs. I have heard those excuses for decades, and at some point, they have to make changes.”

First Step To Bring Down Costs

of five states with cost growth benchmarks, published in June, found that some have succeeded in modestly slowing healthcare spending, particularly those with enforcement mechanisms. However, spending growth in most states has still set. 

Jeremy Vandehey, a consultant with the Peterson-Milbank Program for Sustainable Health Care Costs, said setting benchmarks and collecting data to analyze which entities meet them is only a first step. Armed with information about what and who is driving up costs, states are more empowered to take additional action, such as imposing penalties or regulating prices, to bring down costs, he said.

“I don’t think anybody in any state is declaring victory on healthcare costs, but I wouldn’t say that that means the programs are a failure,” Vandehey said. “In all of these states, there’s much more robust conversations happening about, OK, we haven’t solved our cost crisis, so we need additional action.”

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When making the appointment, Zordani said, he’d been told the clinic was in his insurer’s network. Upon arrival, Zordani was summoned to the clinic’s financial office and told he had to make a $5,000 preservice deposit, because Mayo had since determined it did not accept his insurance. He was automatically designated “self-pay,” even though his plan had out-of-network benefits.

Not having that kind of cash on hand — and angry on principle — he refused. His appointment was canceled.

“I was so livid,” Zordani said, recalling that day in early April 2024. He later learned that Mayo had sent a message to him in his insurance carrier’s patient portal shortly before his visit with an estimate of the cost: $565, not the larger amount it later demanded.

Traditionally, patients usually receive bills for their share only after getting treatment. But what Zordani faced is becoming increasingly common — hospitals or other medical providers seeking prepayments.

“We regret that this individual’s experience did not meet the high standard of communication we strive to provide when helping our patients understand their insurance coverage and financial responsibility,” Andrea Kalmanovitz, Mayo’s communications director, said in an emailed statement. “When prospective patients don’t have clarity that Mayo Clinic is not in-network with their health plan, unexpected pre-service deposit requests may result.”

says it requires prepayments in a variety of cases, including for “noncontracted” — also known as out-of-network — insurance plans.

The trend of hospitals asking for money up front represents a double whammy for patients.

Medical providers are collecting larger shares of what patients might owe at a time when rising deductibles mean patients are owing more for care. The preservice charge could be all or part of a remaining deductible, for example, or a sizable percentage of what the visit or treatment might cost. Those deductibles go up when hospital prices, drug costs, and labor expenses increase, as insurers try to slow premium growth by shifting more costs to patients.

People are “basically being asked to self-insure,” said Richard Gundling, a senior vice president at the Healthcare Financial Management Association, an organization for finance professionals.

As that happens, hospitals figure more patients will have trouble meeting those deductibles, so they want to get as much up front as possible.

“Things like preservice deposits and those kinds of moves are probably going to become more and more likely,” said Chip Kahn, a visiting senior fellow at KFF and the American Enterprise Institute and former president and CEO of the Federation of American Hospitals. “That will make it harder on the provider, the clinician, and harder on the patients.”

The deposits can’t be viewed in isolation, Gundling said: It’s a bigger issue than just hospitals asking for money up front. The challenge, he said, is: “How do we maintain access to care when more patients can’t absorb the level of out-of-pocket costs?”

Already, consumers are increasingly worried about paying for healthcare. A recent found that lower out-of-pocket costs ranked as the top change insured adults would like to see from their coverage plans. KFF is a health information nonprofit that includes ³Ô¹Ï²»´òìÈ.

The average deductible in family coverage offered by employers is $3,762 per person, , while the average deductible in Affordable Care Act plans to a similar amount, $3,786.

A Consumer Concern

, a health insurance consumer assistance program in New York state, hears from people who are concerned about prepayments, said Diane Spicer, a supervising attorney.

“We see this mostly with insured folks who are seeking out-of-network care but who have out-of-network coverage,” Spicer said, “and also sometimes for care that is not covered.”

Just how many hospitals collect what are often called point-of-service payments is not known, according to Kodiak Solutions, a technology company that provides services to health systems to help manage their revenue.

“But it is becoming more and more the center of many of our conversations with health systems,” said , a vice president leading Kodiak’s revenue cycle intelligence team.

In addition to Mayo, Baltimore-based says that “it is our policy to collect all amounts owed before services are rendered” for non-emergency care. University of Texas-affiliated in Houston, one of the nation’s premier cancer treatment centers, says patients who pay for their own care “will be asked to pay an initial deposit determined by the care center, based on the type of cancer.”

On average, hospitals collect about a quarter of what they expect the patient will owe, Szaflarski said, based on what they estimate the insurer will pay — a percentage that has grown in recent years.

For example, if a person is coming in for imaging and the insurer will reimburse $1,000 for that scan, the hospital will seek $250 from the patient up front, he said. “That used to be closer to $150.”

It also varies by hospital, and sometimes by state.

“The state of Indiana has some of the lowest cash collections in the country. They are Midwest nice,” Szaflarski said. He added that California and Texas are among those that collect more.

Even as hospitals increasingly collect more upfront payments, however, their uncollected debt is also rising, according to data Kodiak collected from more than 2,300 hospitals nationwide.

said that’s because of a “fundamental shift” in coverage as plans “increasingly feature higher deductibles, greater coinsurance, and more complex cost-sharing structures: all elements that increase the nominal patient responsibility without improving—and often reducing—the probability of collection.”

While many hospitals are doing fine, some, especially in rural areas, have thin margins — and things could soon tighten further as cuts to ACA and Medicaid funding lead to more people being uninsured.

As a result, hospitals “have to be concerned” about every cost-sharing dollar, Kahn said.

After Zordani returned to Denver, he said, it took a while to find another specialist. He eventually had a procedure in late June 2024, at a Denver hospital not affiliated with Mayo, to fix a .

The following fall, he filed a in Arizona civil court. He was awarded $47,500 in economic damages and attorney fees after an arbitrator in September 2025 determined Mayo violated a state consumer fraud law because it failed to reach him to say that his plan was not in-network before he traveled. Mayo’s statement to ³Ô¹Ï²»´òìÈ did not include any reference to the settlement.

“Had they notified me in timely fashion as required, I would not have flown there,” Zordani said. He’s still angry that the clinic didn’t ask his permission before designating his care as self-pay, which meant he wasn’t going to use his insurance, and he’s still unclear on how they calculated the $5,000 preservice amount.

When Do Consumers Have to Make Preservice Payments?

There is one clear rule: In emergency situations, hospitals that accept federal Medicare financing cannot, , demand upfront payment before stabilizing a patient who arrives at an ER, said , a senior fellow and health policy researcher at the Brookings Institution.

Other consumer protections are less clear.

Patients who get in-network care may have some recourse in their contracts with their insurers, so they should check the fine print, experts told ³Ô¹Ï²»´òìÈ.

“In out-of-network settings, I’m not aware of any barriers that would prevent a provider from doing this,” Fiedler said of preservice deposits.

How those amounts are calculated also appears widely up to the provider and can be opaque.

“They could just say $1,500 and you’d be like, ‘Oh, is that 10%, or is that how much is left on my deductible?’” said , senior director of healthcare campaigns at PIRG, a national federation of independent consumer advocacy groups.

Yet, she added, the patient might be scheduling three months in advance, so the provider wouldn’t know how much was left on the deductible. She recommends consumers ask for an itemized bill and call their insurer to find out whether it has rules regarding the charges.

Also unclear are how and when patients get their money back if they overpay.

Overpayments can happen if patients don’t require the services originally estimated or when insurers pay other bills first, such as the anesthesiology cost or a surgeon’s fees. If those payments are counted toward a patient’s deductible, yet the patient had already made a prepayment to the hospital for the expected deductible, to the hospital.

How soon they get their money back can vary and can depend on state laws, though a small number of states directly address the issue. As of this year, medical providers to reimburse patients within 30 days of a determination of an overpayment. Some states, including Maryland, prohibit certain hospitals from requiring prepayment simply to avoid offering financial assistance.

After alleging that some patients had to wait more than a year to get reimbursed, Arizona Attorney General Kris Mayes recently under state consumer protection laws against SimonMed Imaging, which has 170 locations in 10 states.

, SimonMed agreed to issue refunds within an average of 60 days.

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Now, the same pain had returned — on the left.

This time, Rangel was in the U.S. and lacked health insurance. In 2019, he moved to Portland, Maine, where one of his daughters lives.

As a green-card holder, he qualified to purchase health insurance through the Affordable Care Act marketplace. But he quickly realized that the premiums for someone his age were beyond his budget. He decided to go without insurance, even though it had been a priority for him.

Instead, Rangel signed up for a plan at a concierge practice where patients pay as little as $70 a month for services, including unlimited office visits and minor procedures such as stitches and biopsies.

But when Rangel was diagnosed with a hernia, surgery became unavoidable. Ben Hagopian, his primary care physician, helped him compile a list of hospitals and surgical centers to consider. Rangel has a PhD in management, a field he pursued while serving in the navy in Venezuela. Armed with that knowledge and a naturally inquisitive mind, he began researching prices.

His efforts paid off when the bill came.

The Medical Service

Rangel had what is called an , which occurs when the contents of the abdomen bulge through a weak spot in the lower abdominal wall. The condition is relatively common, particularly among older adults.

In most cases, surgery is required to fix the muscle wall and can be performed . There are three main surgical approaches to repair an inguinal hernia: open, laparoscopic, and robot-assisted. Studies have shown that the three approaches have similarly low rates of hernia recurrence and are .

Rangel underwent an open repair, an approach often preferred by physicians for recurrent hernias. He said his operation lasted less than two hours, and he walked out of the surgical center shortly afterward.

The Bill

$2,900: The flat rate Rangel ultimately paid for his hernia repair at an outpatient surgery center in Maryland, including the surgeon’s fee and anesthesia. He said he also paid around $1,800 to travel to the surgery center from his home in Maine, including airfare, meals, and lodging for him and his wife.

The Billing Problem: No Insurance — But Time To Shop

Because Rangel did not have insurance, he had no protections from high costs — except time and his ability to shop for an acceptable price for his procedure.

Rangel’s first stop was a nonprofit hospital close to home. He scheduled a consultation with a surgeon with MaineHealth, the state’s largest health system, and received an estimate showing it would cost approximately $23,000 to repair his hernia laparoscopically.

Laparoscopic procedures generally cost more because surgeons use more advanced tools. Still, the average laparoscopic inguinal hernia repair costs nearly twice as much at a hospital as it does at an ambulatory surgery center for a patient , which pays $5,280 for the hospital-based option.

“I wasn’t going to mortgage my life just to have surgery and spend the next 30 years paying off the debt,” said Rangel, now 64.

So, he kept shopping. He considered a surgical center in Oklahoma that was far cheaper, but he ultimately ruled it out because it was so far away. He also explored traveling to Universidad de los Andes in Santiago, Chile, where another of his daughters lives. There, his hernia repair would have cost about $7,000, but once he added thousands of dollars in travel expenses, that option no longer made financial sense.

Gerard Anderson, a professor who analyzes healthcare spending at the Johns Hopkins Bloomberg School of Public Health, said patients without health insurance are often the ones hit hardest by wide price variations.

A closer look at any hospital bill helps explain why. “Every hospital is different,” he said, “but generally about half of the total charge is the facility fee,” a charge added to hospital care to help cover overhead costs.

Anderson said hospitals often mark up prices far more than smaller facilities do.

Medical billing researchers say the price gap between hospitals and ambulatory surgery centers partially reflects the higher overhead costs of operating a hospital.

Hagopian, Rangel’s physician, acknowledged that hospitals have higher administrative expenses. “But that doesn’t explain the high costs.”

MaineHealth declined to comment to ³Ô¹Ï²»´òìÈ, directing questions about the hospital-based procedure’s cost to Jeffrey Austin, president of the Maine Hospital Association.

Austin said that, unlike surgery centers, hospitals must absorb the costs of providing “money-losing” services, such as behavioral healthcare and care for Medicaid patients. He added that revenue generated by large hospitals in a health system supports other facilities, improving access to care.

Hospital prices, which can vary widely, are also driven by negotiations with insurers and market concentration. For uninsured patients, those list prices can become the starting point for negotiations — or the full amount owed.

Anderson noted that standardized payment rates exist for Medicare and Medicaid but not for most privately priced medical services. “In the private sector, providers can charge whatever they want.”

The Resolution

Rangel has another daughter in Argentina, a son in Venezuela, and other family in Spain. But he decided to stop looking around the globe for a good price, because he finally found what he was looking for in Maryland.

In April, he traveled to the Affordable Hernia Surgery center in Rockville, where he said “an efficient, well-coordinated system” guided him through the entire process.

“I received professional and very human care,” Rangel said. He was fully recovered within two weeks, as his surgeon predicted, he said.

The surgery center charged Rangel a flat fee for his hernia repair. The added travel expenses for the two-day trip with his wife went toward airline tickets, transportation, meals, and one night in a hotel.

Rangel said he paid about $4,700 total.

Alan Kravitz, the surgeon who performed Rangel’s operation, said the price difference uninsured patients face compared with insured patients is far from fair. “In the predatory and strategic world of U.S. healthcare pricing, uninsured patients generally get charged more than providers would accept from Medicare or commercial insurance.”

Kravitz then pulled out an estimate another patient had received for an inguinal hernia repair from a different large health system. The price: $37,000.

The Takeaway

Without insurance, many patients are on their own to negotiate.

“With the help of their primary physicians, patients can dig into prices and compare their options to avoid falling into medical debt,” Rangel said.

That approach, however, is most feasible for elective procedures with several surgical options offering comparable outcomes.

Patients facing medical emergencies do not have the luxury of comparing prices before seeking care, though many hospitals offer cash-pay discounts or charity care for those paying without insurance.

Billing analysts say patients who do have time to shop should look beyond cost alone. They recommend checking the quality of hospitals and surgical centers by reviewing publicly available ratings and patient reviews. that higher prices do not necessarily translate into a better quality of care, but it’s also important to select a reputable care provider.

Comparison shopping for medical care can be time-consuming. But for patients facing elective procedures, the effort can pay off — sometimes saving thousands of dollars.

“This was a learning experience for me,” Rangel said, “and I hope it will be for other people, too.”

Bill of the Month is a crowdsourced investigation by ³Ô¹Ï²»´òìÈ and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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