番茄社区

In this exclusive video interview, Jeremy Faust, MD, editor-in-chief of 番茄社区, and Jerome Adams, MD, MPH, discuss Adams' recent surprise emergency department (ED) bill and the failures of high deductible health plans and health savings accounts (HSAs). Adams was the 20th U.S. Surgeon General and is currently the director of health equity at Purdue University in West Lafayette, Indiana.

Click here to watch part 1 and part 2 of this interview.

The following is a transcript of their remarks:

Faust: Let's talk a little bit about something on a different side of the wonkism. I think we've covered some of your perspectives on the system-level things -- and I think those are extremely important and there are tough conversations and, as you say, in some cases we're not even really willing and ready to have -- but then there's also the issue of what people are doing with their pocketbooks on the ground level.

You hit this head on in your piece talking about the high-deductible healthcare plans. I want to take the devil's advocate [position] here and say, isn't that the point of a high deductible? In other words, you are going to possibly pay $5,000-$10,000 out of pocket for what amounts to 'cover your ass' medicine or overpriced medicine in exchange for when you hit that, if anything really terrible happens, your risk of ruin and going bankrupt is a lot lower.

Adams: Again, that's a wonderful question. This conversation generated all sorts of interactions on Twitter and on LinkedIn from people, and some of those people said, 'Hey, you signed up for this, this is your own fault.'

I think number one, it's important to understand this isn't about me. This is about the fact that 66% of bankruptcies in the United States are driven by medical debt. So regardless of whether you feel like it's a person's fault or not, we have a broader societal issue when 66% of our bankruptcies are being driven by this kind of debt. That's number one.

Number two, as I mentioned earlier about the Affordable Care Act [ACA], we're now in a place where almost 60% of people with employer-provided health insurance -- the 'good insurance' -- are forced onto high-deductible health plans. It's not that they made a choice, it's that that was the only option that they were given, or the plans are priced such that that's the only one where I can afford the premium to go on. So it's not like people out there are making the choice that they want this high-deductible health plan, they're being pushed in that direction.

The final point I'd make about the high-deductible health plan -- and this is an important one that I make in the article -- the whole premise of the high-deductible health plan was also to include HSAs, where you contribute to these HSAs on a monthly basis so you've got something in the kitty in case you have an emergency.

But I had, as I call it in the article, a 'January surprise.' Had this happened to me in December, I would've had my HSA full and it wouldn't have been a big deal. I would've used my money from my HSA, paid this off, and been fine.

We don't even have time to go down this road, but many people said I was stupid for that because most people who actually can afford to max out their HSA use it as an investment tool and never actually take a dime from their HSA -- but that's another example of putting something in place with good intentions and it goes in directions that you would never think.

But also we know that many people, particularly from marginalized communities like Black and Brown individuals and individuals from under-resourced communities, often are uneducated about their HSA or don't contribute to their HSA.

So you have a system set up that's dysfunctional because people aren't educated and they aren't contributing to it. Even when they do everything right -- like I do, I max out my HSA -- you still could get hit with a bill in January as opposed to December. Mayo Clinic, in this instance, isn't waiting until December to get their money. They want their money now. and so I've got to come up with it now.

So [there are] lots of faults in the logic that you signed up for this plan and that's just what you get.

Faust: Right? But I think most people, as you say, either don't have options or they're not really fully educated about what their plan says and doesn't say. And the last one is that most people are not really good actuaries. They don't really think, 'Oh, I'm going to need this.'

Adams: Nobody thinks that they're going to need emergency medical care! Heck, I didn't think that I was going to pass out at a medical meeting after a hike.

Faust: And the whole point of the ACA is to say, 'Look, people who think they're invincible, aren't. Let's get them in the payer pool and make this system more sustainable.' The problem is that the prices have gone up and up and up and the question is, what are we getting for that?

Dr. Adams, does it bother you that in an election year, this is just off the radar?

Adams: No one's talking about this on the campaign trail. You don't hear Biden or Trump talking about this on the campaign trail. You don't hear people running for Congress talking about this on the campaign trail, but it is 66% of bankruptcies. It's literally just obliterating our country's future in terms of putting people in medical debt.

Faust: Dr. Adams, any final thoughts on what you learned from this whole experience?

Adams: Again, I raised this because I want people to really understand that this is hitting all of us and it is not sustainable.

In the article, we highlight the need for increased transparency and pricing. We didn't even talk about the billing dispute back and forth that I had. I, as a surgeon general, have been actively engaging with Mayo Clinic over my bill and have gotten nowhere. I don't say that, again, to try to advocate for myself here, but to say that if I can't get any traction, the average citizen has zero chance of winning a dispute over a bill where I'm being charged 10-11 times market rate.

We need to make sure we're really advocating for consumer protections for folks and supporting efforts to address surprise medical bills such as the No Surprises Act. You all, I think, covered in MedPage, that there are real challenges in terms of implementing that at a federal level. But we also need to look at state policies to help people avoid surprise medical bills, not just for out of network, but again, from January surprises and all sorts of different ways that people run into surprise medical bills.

We need to make sure we've got collaboration between providers and insurers. This frustrated me -- the fact that many people perceived my complaints as being against physicians. The physician fees are usually a small portion of the overall fees out there, but physicians are put forward as the bad guys. We need collaboration between providers, insurers, and healthcare systems, to really figure out how we unstick this broken system.

Then, we need to improve high-deductible health plans. I think that it's still workable, but my situation showed that high-deductible health plans are actually setting a lot of people up for medical bankruptcies and the burden of medical debt.

Faust: And on top of that, as you mentioned, the legislation that is meant to protect consumers and patients has been very bipartisan. This is an issue that both sides care about, and yet there are still plenty of holes to plug. I think that your contribution to the conversation hopefully will alert a few people to keep looking into that and make some progress.

Dr. Jerome Adams, thank you so much for joining us here on 番茄社区.

Adams: Thank you so much. I really appreciate the conversation.

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