Navigating Your Health Care Without Going Broke

Last week I talked about the problem many of you are facing with skyrocketing insurance premiums and deductibles so astronomical you wonder if you have any health insurance at all. We got into this fine pickle because:

  1. US healthcare prices are the highest in the world.
  2. With the passage of the Affordable Care Act (ACA/Obamacare), health insurance became available to everyone with no exceptions and, depending on your income, premiums could be offset by federal subsidies. Suddenly everyone who had been denied insurance because of a pre-existing condition now had health insurance.
  3. The health insurance companies failed at the math. There wasn’t enough money coming in (premiums) to offset the tsunami of cash going out. Blue Cross of Illinois lost $1.5 billion in 2015, and by the end of 2016 five health insurers tossed in the towel and left the Illinois market.
  4. With losses like this, you (or your employer) received word of extraordinary increases in monthly premiums and deductibles. And suddenly you realize you’re making do without other things simply to cover your health insurance.

With Obamacare now deep-sixed by V. Putin’s president-elect Trump and a Congress slightly to the right of Attila the Hun, unless a replacement is in the offing the federal subsidies will disappear and insurers will return to denying pre-existing conditions and dis-enrolling the 23-to-26-year-olds allowed on their parents’ policies. Even with these steps taken, knowing how insurance companies behave in general it’s unlikely premiums will drop.

Spending wisely
Today I’m going to offer several suggestions on how to spend your healthcare dollar more sensibly than on egregious premium increases. Although this information can be widely applied, I’m thinking specifically of those of you who are basically well (a big assumption, I admit). You’re more attentive to prevention than the average overweight couch potato, caring for yourself with healthful eating, exercise, stress reduction, no tobacco, etc. In other words, you’d fit right in with most of our patients at WholeHealth Chicago.

What follows describes a sort of financial reward plan for taking good care of yourself. It recommends a seat-of-the-pants, DIY approach to reducing insurance costs. It’s not for the person with a lot of potentially expensive health needs–for example, someone with diabetes, heart disease, cancer, autoimmune disorders, or the like. You will need more comprehensive coverage than what I’m going to describe.

If you’re basically healthy and don’t use the healthcare system much, compare your health insurance needs to your auto insurance. Would you really pay extra premiums for your oil changes, wash and waxes, and repair of every little dent? Of course not. You want the basics.

The plan
Here’s what I suggest for our essentially well group and their health insurance:

  • You want coverage that gives you an annual check-up with a Pap smear, mammogram, and blood tests.
  • You want coverage in case you need a specialist (though the odds are you won’t).
  • You want to be able to use an emergency room and get a hospital bed.
  • You may want prescription coverage for generics, though this is often not needed because the cash price for generics (e.g., with Walgreen’s Discount Club) is often less than what your co-payment would be if you used insurance.

If you sit down at your computer and limit your insurance requirements to what I’ve listed, with a few clicks you’ll discover the price drops dramatically. You can also save money with an HMO, a system I don’t particularly like because you’re really limited in the doctor choice department. On the other hand, you’re not marrying the HMO doc. You’re only seeing him or her once a year for a prevention exam.

Honestly, I don’t think most people really need any doctor component to their insurance. Years ago, the most popular health insurance policy was called catastrophic (sometimes referred to as “cost-sharing”) coverage. You were covered only for ER visits and hospitalizations. You paid your doctor and your pharmacist in cash. Insurance companies stopped selling catastrophic insurance because there was so little profit in it, but in fact that’s really all many of you need.

Let me give you a couple examples
One couple I recently spoke to are in their 40s and both are very healthy. They bemoaned that their individual policies had risen to $1,200 a month with a $5,000 deductible (this is $14,400 a year). They take no prescription drugs and come to see us just for a check-up. But with cost-sharing, their expenses are as follows:

  • A full physical exam is $175 to $200.
  • The accompanying lab tests (from any of several discount lab/x-ray companies), which might include a blood count and metabolic/cholesterol/thyroid profiles, are around $200.
  • Getting away from overpriced hospital radiologists, you can get a mammogram for under $200.
  • Other diagnostic tests are also much lower. An MRI of the brain or spine is about $500 instead of $2,500 at Northwestern.

Prescription drugs, if you use generics, are fairly inexpensive, especially when you pay cash and avoid your prescription insurance benefit. You probably don’t know this, but pharmacies are among the many healthcare providers that price-gouge insurance companies. You might pay $20 cash (without insurance) for your prescription with a GoodRx discount card. If you fill the same prescription using your insurance, you pay a $20 co-pay but your pharmacy bills your health insurer an additional $50. That’s right. Your drug cost is $20. Use your insurance and the total cost is $70.

If you need a brand-only med and your insurer denies it or insists on a really stiff co-pay, just have your doctor fax your prescription to Universal Drugstore in Canada. Here’s one of my favorite examples: Six tablets of Alinia (nitazoxanide, for intestinal parasites) cost $458 (you read that right, $76 a pill) in the US. But in Canada, 60 tablets are $100 (cash or credit card).

Let me stop here and remind you that by paying cash for health care services, none of this is submitted by the provider to your insurance, and thus nothing applies to your deductible. You can, however, submit it yourself or, if you have one, use your HSA (Health Savings Account).

But consider the advantages. Would you rather pay $500 for an MRI (cash) from an unpretentious MRI center on Lincoln Avenue or have the exact same procedure at Northwestern for

$2,500? Northwestern is happy to submit the charge to your insurer, but with your $10,000 deductible, you’ll be the one paying it.

Unless you’re really enamored of going to a hospital situated in one of Chicago’s most gorgeous locations (and property tax-exempt to boot) and you like the hallways of Carrara marble, just go to Lincoln Ave. The radiologist reading your report probably works at Northwestern anyway.

I think the term for all this, health cost-sharing, is a good one. If you don’t have any expensive chronic health conditions and you’re rarely in contact with your physician anyway, why pay whopping premiums for services you don’t use? WholeHealth Chicago patients, who prefer alternative therapies anyway, often use conventional medicine only as a last resort.

They’ll visit their acupuncturist, nutritionist, or herbalist first. They’ll try some natural products, nutritional approaches, and lifestyle changes they’ve read about online. And since they’ve been taking good care of themselves all along, likely whatever’s wrong they’ll make a quick recovery.

Should every aspect of health care be an exercise in comparison shopping? The answer is yes, now more than ever. And until we agree to cover everyone with a fixed-price, single payer system (popularly called Medicare for All), if we don’t want to go broke we’ll all be doing a lot of bargain hunting in the future.

Be well,
David Edelberg, MD

Posted in Big Pharma Evils, Blog, Health Insurance Issues, Healthy Lifestyle, Knowledge Base, N Tagged with: , , , , , , , ,
24 comments on “Navigating Your Health Care Without Going Broke
  1. Tina Hepworth says:

    So true Dr.E- you’ve outlined exactly what we use our insurance for. We also order lab tests on line to be done at reputable nationwide labs like Quest Diagnostics, or Labcorp, at literally a fraction of the price you get charged at the hospital. ( e.g. Hs CRP $12.00 v $99 plus at our local ‘in-network’ lab.
    But, for folk who aren’t as healthy and already have ‘pre-existing conditions’, (which is a huge percentage of the population ),it’s disgraceful that the premiums and drugs prices are so high that they end up being a person’s/family’s greatest expenditure and can pose a real threat of bankruptcy. Out of 34 developed inc.even some 3rd world countries ,the US is the only country that WILL not( not cannot!) provide access to healthcare for everyone! Plus, despite the exorbitant cost, the US has some of the worst statistics on infant mortality and other health stats in the developed world! Thank heavens for WHC to put people on the right track to getting and staying healthy w/o for the most part needing to utilize ‘the system’, and the expensive drugs that keep Big Pharma making billions at the expense of sick people! Thanks for posting this Dr.E!

  2. A. Heisler says:

    Do you have thoughts for those of us who have Medicare and a supplemental insurance? I live across the street from one of those marble-lined hallway hospitals. I see one of their docs and use their labs and such. I’m fairly healthy for my age, 72, and see my doctor once a year if I’m lucky. I occasionally get referred to a specialist. After about $150 each year, I pay very little. I get one of my generic Meds from Canada because it is as you described. I’m not sure what the recent bill in Congress will mean. Currently, they send my prescription to Europe and have it sent to me from there to avoid some sort of excise (?) tax. Should I shop for labs and X-rays? There’s little incentive for me to do that. I did learn the hard way that that an extra visit to the doctor for wellness (travel related) would cost me dearly, $700, when neither Medicare nor my supplemental would pay anything. Anyway, I would be interested in hearing what you think about Medicare at this point when there is no single payer system in place with government control of big pharma and other health related expenses. Should we “shop” also? I know at one point you didn’t take Medicare since I was considering switching my healthcare to your group. Is that still the case?

  3. Dr E says:

    Hi Mr Heisler
    Unless Congress does something really stupid with Medicare, when you combine Medicare with a good supplemental insurance (like Blue Cross or AARP), you’ve got the best protection available in America.
    With the recent bill you referred to, I assume you mean their plan to defund and reverse the Affordable Care Act. Doing this will not affect your Medicare/supplement at all.
    You’re pretty much covered in all areas (MD visits, lab, x rays) and, if you have Medicare D, then prescription drugs as well.You shouldn’t need to shop for labs and xrays as these are almost 100% covered.
    Most generic drugs are fairly low priced so usually you don’t need Canada. If there is one specific brand drug you want, and Medicare D denies it, that’s where Canada comes in.
    I save the most $$ using http://www.goodrx.com and pay cash. Recently I was told that 30 pills of a drug was $20 with insurance and the insurance company wouldn’t cover 90 pills. Using the goodrx card, 90 pills were $20

  4. A. Heisler says:

    No, actually the bill I was talking about was a Bernie Sanders backed one that was defeated. It would have allowed for drugs to be officially imported from Canada to help drive down costs in the US. It would have allowed pharmacists in the US to import drugs from Canada. I guess I as an individual can still get a particular drug from a Canadian pharmacist.

  5. Dr E says:

    Dear A Heisler
    You can get much of what you need in Canada already.
    Go to http://www.universaldrugstore.com
    Set up an account
    Check the price of the drug and select a quantity
    FAX your doctor’s prescription to them
    It will arrive in 3-4 weeks

  6. Teresa says:

    Hi. Thank you for the article! Do you have recommendations on where to begin looking for this type of plan? I became self employed this last year and am new to this. have signed up through the marketplace, but am wondering if I would do better to look outside of that. Thank you again. I have been enjoying your articles for years.

  7. Susan B says:

    Seriously Dr. E, your words came at a perfect time. I spent over an hour on the phone with an insurance company yesterday trying to navigate through this coverage morass and all the while kept thinking there’s got to be an easier, more cost-effective way to access what I need for someone who is gratefully healthy. I’d much rather put my hard earned money toward prevention (massages, personal trainer, nutritionist) than on a high premium when I know I’m not even going to come close to the halfway mark on the annual deductible. I appreciate the links you included in your article too. I’m switching my plan today. Thank you for your timely, experienced wisdom. I’ll be at WHC in March for my annual physical. Cheers!

  8. Jane Brooks says:

    Dr. Edelberg, I usually always look forward to your newsletter with helpful health information. I really think the continuing bashing of our president elect (for a smart man you really think Putin had him elected?)there are more than Liberals living in the United States…..and it is unhealthy and quite frankly rude & disrespectful. When Obama ( am amateur) was elected most Conservatives didn’t use social media and their businesses or their seat in the Senate to publically “bash” him. The behavior you show continues to tear people apart NOT bring them together. Isn’t it about time you use your words for healthy living and not destruction? These opinions of yours cannot be helping the health of the healthy or help the others who are not healthy. Words are powerful and I would hope you could change your tone and stay on task and talk about HEALTH and how to keep us all healthy. Please use another venue to state your political views.

  9. Vicki Lewis says:

    I strongly second Jane Brook’s comment! This newsletter and website are a valuable source of medical information. Please stay on topic ! I do not want to read your political views. It isn’t helping those who come here looking for medical expertise and instead get blood pressure raising disrespectful commentary.

  10. Tara S. says:

    Ms. Brooks,
    There are those who do agree with Dr. Edelberg and greatly appreciate his commentary by helping to bring goodness to all, even if it is political in nature. I can only wish you health in a system that is not in the best interest of all and can only hope the best for the future of our society. Best of luck.

  11. A. Heisler says:

    Jane Brooks and Vicki Lewis. In a democracy it perfectly legitimate to speak One’s mind from whatever pulpit one has. And to say that Obama was not bashed from all corners of the population including our soon to be POTUS who could not stop himself from questioning his birth until he of course denied that he ever said it. To be so sensitive that a casual remark amongst many good ideas raises your blood pressure is concerning. I would not want Dr. E to have to stifle anything he would like to say. Lighten up.

  12. Andrea Holliday says:

    Dr. E, in listing the reasons this year’s Obamacare opportunities were so poor, you oversimplified a bit on the predictive mathematics. You wrote:

    “The health insurance companies failed at the math. There wasn’t enough money coming in (premiums) to offset the tsunami of cash going out.”

    But it was understood when ACA was enacted that it was impossible to predict how many healthy-vs-sick people would sign up, and what sort of cash flow would result. (Many healthy younger people simply refused to buy it, despite the government-imposed cash penalty.) For that reason, a safeguard was built into the plan: If insurance-company payouts exceeded premium income by a certain amount, a government subsidy would kick in to take the excess strain off the insurance companies. Had Capitol Hill Republicans not sabotaged ACA by defunding the safeguard provision, we wouldn’t have seen so many insurance companies either tank completely (like Land of Lincoln); withdraw from the Obamacare market (like Aetna); or jack up premiums enormously.

    I really appreciate your suggestions for a more affordable strategy for those of us who are healthy. But I’m over 50 and, pre-Obamacare, was denied insurance because of pre-existing menopause. (No, I’m not kidding.) So it appears I have to shop the Obamacare marketplace for coverage in case I get cancer or something…. in which case I would really not want to be stuck in managed care! Was there any alternative but to buy the lowest-priced PPO that BCBS-IL offered?

  13. Cathy says:

    Agreed, AH. One of the many reasons I love Dr. E is his willingness to be wholistic & address all areas of life . His suggestions on dealing w/ anxiety after the election were a Godsend. As someone who was triggered by the horrid sexual comments towards women, I can’t thank him enough. And many of us will never be ‘brought together’ unless it’s to support grace & compassion for all.

  14. Ellen says:

    Dr. E please keep your political views out of it. It’s very unprofessional. In the very least, if you’re speaking political views, make it balanced and comment on the fact that we wouldn’t even be in this present mess if our current president hadn’t forced obamacare through. But I noticed you didn’t put any responsibility of this mess on Obama or the democrats, who have been in charge the last 8 years!

  15. Dr E says:

    Hi Vicki, Jane, and others expressing anger at today’s Health Tip

    In times when elected officials who are not physicians are taking health insurance away from an estimated 20 million of my fellow American citizens, it would be irresponsible of me NOT to be political and NOT to voice my anger and resentment. I am not respectful of wealthy males and the billionaire president-elect so cavalier about the lives of human beings. You might prefer that I write about the best vitamin or herb to help you live longer but I simply cannot be silent about what is happening right now. Yes, Obamacare is far from perfect. Not only I, but virtually every medical association in the country literally begged Congress to repair its flaws but NOT repeal it.
    But now it’s too late. Unless replacement is immediate–which we all know won’t occur–I hold Trump and any congressman who voted for complete repeal personally responsible for every American death caused by their insurannce taken away. Maybe one of you is smart enough to come up with something to save some 6 year old from dying of leukemia because his family has no insurance. No tragedy imaginable exceeds parents losing a child.
    Until you have a solution to prevent such a tragedy, I cannot accept your opinion that I should remain silent

  16. Phillip says:

    First, we all should give credit to Dr. E for having this blog at all. How many doctors in Chicago, or even the country, have anything like it?

    The comment from Ellen is risible. Make it balanced? Present mess caused by Obama? The situation isn’t balanced at all: one party had at least a reasonable solution which would need fixes, and the other party has no solution whatsoever.

    One question for Dr. E, though: Why don’t you accept Medicare for office visits? What do you think someone should pay for an office visit with a physician in this country (apparently more than Medicare pays)?

  17. fmichaelsmith says:

    to Ellen, Vicki,Jane and those who feel Dr.E”s political opinions should be kept to himself, may I humbly suggest if you do not care for the message look for a different messenger. In this country we have the right to choose who we listen to. We are not, however, guaranteed we will like what we hear. In these articles, Dr. E has systematically been faulting the Affordable Care Act since its inception along with big pharm and the current state of medicine. Anyone who has been taking advantage of his wisdom over the years knows that. I do wish the best health to all of you. After all, isn’t that why we are here at this site? Isn”t that the most important thing?

  18. Cathy says:

    Silence is dangerous. And yes, those responsible for taking away anyone’s insurance must be held accountable. (Quite sure they have insurance for their loved ones-sinful). Thank you again, Dr. E.

  19. Dr E says:

    Hi Phillip
    Your question about Medicare is perfectly reasonable. When I first opened WHC, I did take Medicare. Like virtually all Medicare physicians, I was eventually audited. As the inspector reviewed my records, he commented that I was spending far too much time with patients (quote: “I bet you mainly talk about the Cubs”) and that he’d heard that anybody could diagnose fibromyalgia in 10 or 15 minutes (this from a completely non-medical person).
    When Medicare is unhappy with your charges, they demand a full retroactive refund (called a “clawback” by health professionals–happens to hospitals all the time). We had just opened WHC and didn’t want trouble with the Feds so we decided to avoid them altogether. However, our lab does bill Medicare as do certain WHC practitioners. The xray company I work with bills Medicare and I make sure that every specialist I refer to is enrolled in Medicare as well

  20. Carol HS says:

    Dr E,
    I am grateful for the care my husband and I received from you when he was working and had Blue Cross through his job. We miss your care not that my husband has retired and we are on Medicare. We continue to appreciate the help you gave to my husband for his headaches.

    I would like to know why you do not take Medicare. Does the current “crisis” as well as the one that appears to be looming give you any reason to reconsider this policy?

  21. Lynne says:

    I am now unsubscribing to your website. I do not care for your political comments. You are not an authority and it is just your opinion. Save it for the cocktail parties. Just because you have a platform, does not mean you should use it. I was surprised and disgusted with your comments. A neutral position is what should be taken on your site. Goodbye.

  22. Jan Szostek says:

    Thanks for all of your sharing, Dr. E. You rock!

  23. Dr E says:

    Hi Lynne
    Sorry you believe we should be silent when the situation in America, especially in heath care, looks like it’s circling the drain. This “silence” was the stance by the German citizenry during the rise of Hitler and the devastation that followed. Actually, by being a physician, I do have a lot of knowledge about the health care crisis that will be triggered when “President” Trump officially overturns Obamacare and 20 million are left without insurance.
    What’s really sad is that you believe people should remain silent and accept whatever is going to happen to them. Actually, rather than unsubscribe, why don’t you defend your position. Argue with me and let everyone know your point of view

  24. Deb says:

    Hopefully, Pres. Trump will provide an alternative health plan. People need to give him a chance & not believe everything they hear. Stop the partisan bickering. A house divided against itself cannot stand.

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