What It Really Costs to Go Without Health Insurance

Photo-Illustration: by The Cut; Photos: Getty Images

When Ashley, 36, was laid off from her job at an advertising agency in Austin over a year ago, she asked how much it would cost to keep her health insurance through COBRA. “They told me, and I actually laughed,” she said. “It was $950 a month.” Instead, she opted for the cheapest plan she could find through the Texas health-insurance marketplace. The premiums were about $250 a month, but her deductible was over $7,000. She figured it was the best she could do until she found a new job.

Unfortunately, that’s taken longer than Ashley hoped (like all the uninsured people I spoke to for this story, she requested a pseudonym). “I think the term for me is ‘underemployed,’” she says. She’s been able to find contract work, but it barely covers her bills and certainly doesn’t offer benefits. Despite interviewing for dozens of full-time jobs, she hasn’t received any offers. And the tax credit that kept her monthly insurance premiums so low (“I mean, ‘low’ — in air quotes,” she says) will expire at the end of the year, pushing her costs up to more than $600 a month. She’s choosing to forgo health insurance instead.

“It feels like a terrible decision, but I can’t afford to pay that, especially for a plan that doesn’t cover very much,” she says. “If anything horrible happens, I’m going to have a huge bill. But that would happen anyway, because my deductible is so high. I feel like all I can do is roll the dice and hope I stay healthy.”

Ashley isn’t alone in her predicament. When health-care subsidies expire at the end of the year, insurance plans offered through the Affordable Care Act marketplace will become too expensive for millions of Americans who currently use them. Projections show that in Texas alone, 1.04 million people would have to drop their insurance coverage; nationwide, the Congressional Budget Office estimates that the number of uninsured people will jump by 3.8 million a year, on average, from 2026 to 2034. “It’s not looking good,” says Jared Walker, the founder of Dollar For, a nonprofit that helps people navigate medical expenses. “We’re going to have a lot of people choosing between paying a medical bill and putting food on the table or making rent.”

Medical bills are consistently the No. 1 reason why Americans file for personal bankruptcy. Health insurance is supposed to prevent that, of course, but as premiums skyrocket, millions of people will find themselves in an impossible position — unable to afford to protect themselves against unaffordable medical bills. The costs tumble downstream; when people can’t pay for medical care, they put it off until they have no other choice, and then they wind up in the emergency room with a disastrous bill for something that could have been treated (or prevented) far more cheaply if they’d addressed it sooner. “There’s a lot of concern from hospitals and providers about people ignoring the signs that they’re sick because they’re worried about the financial burden,” says Allison Sesso, the chief executive of Undue Medical Debt, a national nonprofit that works to improve health-care access.

Dhiran, who’s in his 40s and lives in Florida, is one of those people: He was uninsured when he got a serious infection in his foot three years ago. After hoping it would get better on its own for a few days, he wound up in the hospital — and got a bill for over $250,000. “We got financial assistance from the hospital, and eventually we reached a settlement,” he says. “It was less than half of the original bill, in installments.” They had to sell some property to pay it off. Now, his wife works the overnight shift at an Amazon warehouse, primarily for the health benefits.

Going without insurance means living with a constant fear of what could go wrong. “Last winter, right after I lost my job and my health coverage, I got a bout of COVID that really knocked me on my ass,” says Andy, 32, who works in public relations and marketing in North Carolina. “I had a fever of 103.5 and so much anxiety, knowing I couldn’t afford to see a doctor.” He recovered, but he dreads the possibility of it happening again: “It’s an awful feeling, knowing that there’s no safety net at all.” His current employer is a small business that doesn’t provide health benefits. “I really wish I could find a job that would give me insurance, but until that happens, I don’t know what else to do,” he says.

Realistically, how can you mitigate potential risks if you’re one of the millions of people who’s about to lose access to health insurance (or you already have)? “I hate to say this, but everyone’s going to have to become their own detective and patient advocate,” says Walker. “There’s no real way to ‘hack’ health care, but there are negotiation techniques and questions to ask that can get costs lower than they’d be otherwise.”

For starters, Sesso recommends that you research local sources of care before you need them. “To the degree that you can, figure out where there are discounted or free clinics in your area and seek out preventative care,” she says. Some of them will offer flu vaccines and certain screenings, but prepare yourself for a long wait (these clinics can be booked out for months). She also advises putting whatever money you can spare into an emergency fund — a tiresome refrain, she knows, but the closest thing to an insurance policy you can create for yourself. Meanwhile, familiarize yourself with your patients’ rights under your state’s laws, which can vary quite a bit (here’s a good tool for doing so).

If you’re sick or need to talk to a doctor, your first step could be to pay out of pocket for an online consultation, says Walker. “I have done this many times when I was uninsured. Services like Sesame allow you to pay $35 to visit with a doctor on Zoom, which can be incredibly useful.” A few years ago, he had a painful lump on his neck, but a trip to urgent care wasn’t in the cards — without insurance, it would cost him hundreds. “I just wanted to talk to a doctor to make sure I wasn’t going to die. I went on Sesame, it was $35, and the doctor was like, ‘Oh, you have a swollen lymph node. It’ll go away in four or five days.’”

A Zoom appointment won’t cut it for more serious problems, obviously. If you need a procedure and you’re not sure what it will cost out of pocket, you can call in advance and request what’s known as a good-faith estimate. Make sure to do so at least three days before your appointment and get it in writing. Then, if your medical bill is significantly higher than the estimate, you may be able to dispute it under the No Surprises Act or certain state laws. At the very least, it enables you to compare costs between different providers.

For medications, Walker recommends GoodPill, a nonprofit that helps uninsured patients fill their prescriptions at lower costs. Other websites like GoodRx do the same, although primarily through coupon programs and price-comparison tools.

If you’re in a position where you do need medical attention urgently, be open with your doctor about your situation. “Increasingly, I have seen that having an honest conversation with your provider about what you can afford is better than not talking about it at all,” says Sesso. Sure, medical billing is not part of any health-care worker’s training. “But more doctors are recognizing that they have to be equipped for these questions. They might be able to give advice to patients about follow-up care that’s more affordable, even if it’s not the best.”

If the worst happens, and you wind up with a big bill — or a series of bills for an ongoing condition — do not pay anything right away, and, whatever you do, don’t put it in a credit card. “Once it goes on a credit card, it becomes consumer debt, which is regulated differently from medical debt and has much higher interest rates,” says Sesso.

Instead, take your time and don’t panic. “For the most part, you have a year before any medical bills can start to affect your credit score,” says Walker. (Right before Biden left office, his administration finalized a rule that blocked medical debt from affecting people’s credit scores, but a federal court has since blocked it — bad news for the approximately 15 million Americans whose credit reports are still being dragged down by $49 billion worth of medical debt.)

To prevent becoming one of them, start by requesting an itemized bill, says Walker. “Sometimes even just asking for it will get it reduced, because the billing department might catch errors before they send it to you,” he says. “Research has found that 80 percent of medical bills have errors in them. And I also know patients who have successfully used ChatGPT or Claude to check all the CPT codes on their bills and catch errors themselves.”

From there, see if you’re a candidate for charity care, a bill-reduction service that most hospitals offer depending on your income level, household size, and bill amount. (Dollar For’s website has a tool that allows you to check your eligibility.) If you don’t qualify, your next step is to see if the hospital or provider will reduce your bill if you can offer cash up front — a back-door settlement, if you will. “I just did this and saved a bunch of money,” says Walker. “You have to call and ask for the cash pay rate. Sometimes even if you have insurance, the cash pay rate is lower than what they’d charge your insurance, which you’d still have to pay if you haven’t met your deductible. It can be wild how different the price is.” The problem, of course, is that you still have to be able to pay it. “It only works if you have some cash on hand,” he says.

If that doesn’t work, you have two more options: One is to ask for a payment plan, which most providers will offer, although the installments might be higher than you like. “You often hear about people getting on these magical payment plans where they pay $10 a month toward a bill for hundreds of thousands of dollars, and they just keep paying it for the rest of their life,” says Walker. “From what I’ve seen, that doesn’t really happen very often. And even when it does, sometimes a hospital will still send your bill to collections because the outstanding amount is so high.”

That brings us to your second option: Wait until your bill gets sold to a collector, at which point you may be able to negotiate an even lower settlement fee (here’s a script to use). For a more detailed guide to dealing with medical bills you can’t afford, see here.

Finally, remember that we should not have to live this way — there has to be a better solution. “It’s ridiculous,” says Sesso. “So don’t do it in silence. Call your elected official. Talk about the fact that this is what’s happening to you. We cannot go on like this.”

Email your money conundrums to mytwocents@nymag.com (and read our submission terms here.)