"No Physician Would Design a $10,000 Deductible"

Sometimes the sharpest line about health care isn't in the article. It's in the reader mail.

In KFF Health News' Oct 19 letters, Clay Johnston of Austin, Texas, responded to a story about health care workers priced out of their own coverage. One person in that story kept her insurance but waited weeks to see a doctor because of a $10,000 deductible.

Johnston put his finger on why:

"Doctors design care. Insurers design coverage. The two are put together in separate rooms by different teams, measured on different things, then handed to the same person as if they were one plan."

Then the line every benefits broker should have taped to the monitor:

"No physician would design a $10,000 deductible; it just blocks people from investing in prevention and getting care early. But no physician was in the room when that threshold was set."

He's right. And he isn't describing a bug in the software. "That tension is not an accident," he wrote. "It is how the system was built."

You can see that tension play out in exam rooms every week. A man in his 50s notices he's thirsty all the time and waking up twice a night. He knows he ought to get it checked. He also knows the office visit and the blood work will hit his deductible at full freight. So he puts it off until spring. A clinician may say, "This is what you should do next," as Johnston put it, while the benefit design hands the patient a financial penalty for listening.

Waiting is the expensive choice. It just doesn't show up on the ledger until the complication lands in the emergency department.

Johnston's answer is to design coverage and care together. Direct primary care does that right now, at the scale of one patient and one physician.

If you're picking a high-deductible plan this fall because it's the only monthly premium that fits your budget, don't let that deductible ration your primary care. Pair it with a direct care membership. The office visit, the A1C check, the follow-up call, and the "this is probably nothing, but let's look" happen without touching the deductible. Your major medical plan stays in the drawer for surgery or a hospital bed.

A doctor designed the membership. You can tell the first time you use it.

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$3,600 a Month for the Plan, $93,000 for the Stroke: When Fear of the Bill Becomes a Symptom

Bill McAdams is a travel nurse. He is 45, from Holiday, Florida, and he has spent his career on the giving end of American medicine. Last year his agency offered him a health plan that would have cost $3,600 a month to cover him and his wife. He couldn't afford it. Then he had a stroke. The hospital sent a bill for $93,000.

That part of the story is bad enough. The next part is the one I can't stop thinking about.

In March, his vision and balance started going wrong. A nurse knows what that can mean. He went to urgent care instead of the emergency room. "I was so afraid of dealing with the billing issues again," he told KFF Health News, "that I did not want to go to the emergency room." Later that month, after a stressful call with the hospital about the first bill, he landed in the ER anyway, with a second stroke. He can no longer work as a nurse. The hospital eventually knocked the bill down to $50,436, which is still more than he can pay.

Renuka Rayasam and Sam Whitehead published his story today, alongside more than 130 others KFF reporters have heard this year. Read it here: kffhealthnews.org/health-care-costs/priced-out-healthcare-costs-medical-debt-insurance-disability-chronic-conditions/

The pattern is the same in almost every one. Sheila Robinson in Maryland puts her $659 monthly ACA premium on a credit card and says, "I am just afraid to even go to the doctor." Carmilla Collins in Omaha had her wages garnished over medical bills, then put off thyroid surgery for 4 months while a goiter pressed against her throat. She had coverage through work at the time. Her explanation is the sentence I'd carve over the door of every hospital billing office in the country: "I equated taking care of my health with debt that I couldn't afford."

We have built a system where the price is a secret, and the secret is frightening enough that people decide not to find out. Fear of the bill is now a symptom. It shows up in the history before the chest pain does.

I'll say the doctor part plainly. If your face droops, your speech slurs, or your vision or balance suddenly goes, call 911. Go to the emergency room. Argue about the bill later. But I understand why a smart nurse hesitated, and the hesitation is the system's fault, not his.

KFF lays out why the bills are so high, and it isn't a mystery. The prices are high. More than half of payments still run on fee-for-service, where every test and procedure gets billed regardless of outcome. The paperwork alone, the billing, the networks, the coding, costs hundreds of billions of dollars. "There's profit margins everywhere," Brown's Christopher Whaley said. And Washington, left and right, mostly argues about who pays. Yale's Zack Cooper put the problem in 1 line: "For the most part, health spending for us is income to someone else."

So I won't promise a bill that fixes this by spring. I'll tell you what we can fix this week, in the exam room.

The front door of medicine should never be scary. In direct primary care, a patient pays a flat monthly fee and knows it in advance. No copay surprise. No deductible standing between you and a visit. No bill 6 weeks later with codes you can't read. Text your doctor at 9 p.m. about the numbness in your hand, and the answer costs exactly what it cost yesterday. Labs and generic meds come at posted prices, often a fraction of the claim price, so the thyroid workup doesn't turn into a collections lawsuit.

And when the doctor says, "This is a stroke, go now," you go, because you have a doctor you trust telling you to, and because you didn't spend the last year learning that every medical encounter ends in a fight.

I am not anti-insurance. You need a policy for the wreck, the stroke, the night in the ICU. Keep insurance for the catastrophe. But a $3,600-a-month premium that people can't afford, sitting on top of a system they're afraid to use, isn't protecting anyone. It's a toll booth on the way to care.

Fix the front door first. Put everyday care at a price people can see. Then they'll walk through it early, while the problem is still small, while the fix is still cheap, and while there's still time.

Bill McAdams was once proud to be part of this system. Now, he says, his trust in it is gone. Trust is the cheapest medicine we have, and we've priced it out of reach. Direct care is how we earn it back.

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$12,000 Before Your Plan Pays It All: What Changes When ACA Open Enrollment Starts Nov. 1

$12,000.

That is the most a single person on an ACA plan can be asked to pay out of pocket in 2027 before the plan covers the rest of their in-network care. For a family, $24,000. This year it was $10,600 and $21,200. That ceiling just went up 13%.

Open enrollment starts Nov. 1 in most states. Julie Appleby at KFF Health News laid out what's coming, and it reads like a list of reasons to start early.

Premiums are slated to rise again, about 15% after last year's 26%. The enhanced subsidies are gone. If you use a broker on the federal marketplace, you'll need a one-time code to authorize them, and up to 1 in 5 people may have to prove their identity through a credit bureau first. And there may be fewer brokers to call. CMS put a moratorium on agents new to the ACA, so they can't help anyone with 2027 coverage until February at the earliest, after open enrollment ends. One Florida broker who planned to hire up to 10 agents was told he likely can't find any.

Georgetown's Stacey Pogue gave the advice I'd give: "I would reach out early."

I'd add one more thing. Don't let your plan auto-renew without looking at it. Same plan name, new numbers.

Picture a 40-year-old carpenter who buys his own coverage. He picks the cheapest premium he can stand. It comes with a deductible north of $7,000 and that new $12,000 ceiling. On paper he's insured. In real life, every sore shoulder, every rash, every "is this mole anything" is his to pay for, at a price nobody will tell him until the bill comes. So he waits. Most of us would.

That's the gap a big ceiling creates. Not just the catastrophe. The ordinary year.

I am not anti-insurance. Keep a policy for the wreck. A $12,000 ceiling is still a ceiling, and on the worst day of your life you'll be glad it's there.

But look at what you're really buying. For most people, most years, a high-deductible ACA plan is a catastrophe policy. Buy it like one. Then put everyday care somewhere it's affordable and you can actually use it.

That's what direct primary care is. A flat monthly fee. Your doctor's cell number. Visits that aren't rationed by a deductible, and labs and meds at prices you can see before you agree to them. Since January, a qualifying membership can be paid with HSA money, up to $150 a month for an individual. And if the big stuff still worries you, Atlas Direct pairs with a membership and pays cash benefits for hospital stays, ER visits, surgery, and childbirth.

The carpenter doesn't need a plan that pays for his sore shoulder. He needs a doctor who will see it this week for a price he already knows, and a policy that's there if he falls off the roof.

Book your broker now. Pull up your plan's real numbers. Then ask the question the enrollment forms never ask: who is my doctor, and can I afford to see them in March?

$12,000 is the ceiling. Your health happens on the floor.

Sources:

KFF Health News, Julie Appleby, "Shopping for an ACA Plan This Year? Here's What You Need To Know" (Oct 23, 2026): kffhealthnews.org/insurance/aca-obamacare-open-enrollment-marketplace-shopping-tips-premiums-costs-cms-changes/

$10 Million a Minute, and Half the Doctor Visits: Americans Pay More for Less Care

Read this slowly. In 2024 the United States spent $5.3 trillion on healthcare.

That's more than $14.4 billion a day. More than $10 million a minute. By the time you finish this paragraph, another few million dollars have gone out the door.

KFF Health News laid out the federal government's own numbers this week, and one sentence stopped me. Health spending per person rose to $15,474 in 2024, "not necessarily because we're sicker, but because of increased prices."

Then the next line. According to the Peterson-KFF Health System Tracker, Americans get half as many in-person doctor consultations per person as people in peer countries.

Half the visits. The highest bill on earth. KFF said it in 6 words: "we pay more for less care."

I'm not shocked. Every doctor who has spent a morning on prior authorizations knows where some of that money goes. It goes to the billing department, the claims processor, the coding consultant, and the people on the other end of the phone who deny the claim the billing department filed. None of them see patients. All of them get paid.

Picture the system as a kitchen faucet left running. We keep arguing about who pays the water bill.

KFF makes the same point more politely. Many federal proposals, they write, "focus on shifting costs from one funder to another rather than lowering them." The 2025 One Big Beautiful Bill Act moved more of the cost onto households. Restoring the old ACA subsidies would move it back toward government. Either way the water keeps running. Healthcare was 18% of the economy in 2024, and the government projects 20% by 2032.

Harvard's Michael Chernew put it best: "We'll all end up with healthcare and no clothes or houses or cars."

So where do you turn the faucet off?

Start with the part of the bill that's pure friction. In direct care, a patient pays their doctor a flat monthly fee. No claim. No code. No denial. No billing department. The time that used to go to paperwork goes to the patient, which is how you get longer visits and a doctor who answers a text on Saturday. That's more care, not less, and it costs less because nobody in the middle is skimming.

Then go after the price. Many direct care offices sell generic meds and labs near wholesale, with the price posted before you buy. When the price is visible, it falls. When it hides behind a claim, it climbs.

I am not anti-insurance. Hospital care is still the biggest line in that $5.3 trillion, and you need a policy for the night you end up there. Keep insurance for the wreck.

But the everyday stuff, the visit, the lab, the blood pressure pill, never needed to run through the most expensive plumbing in the world.

$10 million a minute is not a law of nature. It's a faucet. Somebody just has to reach over and turn it.

Source: Lydia Zuraw and Renuka Rayasam, KFF Health News, "Digging Into the Money Behind the US Healthcare System" (Oct. 23, 2026): kffhealthnews.org/health-care-costs/money-us-healthcare-system-gdp-economy-nhe-prices-graphics/

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Diagnosed in 2 Months After Searching Since 2022. Her Doctor Still Says Keep Insurance for the Big Stuff.

Dominique Spagnola had just had a baby. Then her body started acting wrong, and she couldn't get in to see her primary care doctor or the specialists she needed.

She'd been chasing answers since 2022. So she reached out to Dr. Meghan Montie, who runs Heirloom Family Medicine, a direct primary care practice in Albany. "She immediately got me right into these specialists that I needed to see," Spagnola told CBS6.

Within 2 months she had an official diagnosis, primary aldosteronism, a condition where one adrenal gland malfunctions, and a pathway to a cure.

Years of searching. Then 2 months.

That's what happens when a doctor has time. Heirloom patients pay a monthly membership of $250 to $600 and get 24/7 access by phone, text, or email, same- or next-day appointments, and longer visits. Montie even sees some patients at home if they're postpartum or have trouble getting around. "It really just allows me to go much deeper with my patients," she said.

Spagnola's verdict on the fee: "The monthly membership is something I don't even notice." She figures that if she'd started with Heirloom sooner, she'd have saved about $2,000.

Here's the line I want every direct care patient to hear, and it came from the direct care doctor herself:

"Health insurance is still very important for catastrophic events."

She's right. Spagnola kept her insurance through work alongside the membership, and Montie says that's common. Some of her patients pick a higher-deductible plan with lower premiums and pair it with direct care.

So direct primary care handles the everyday. It fixed a diagnosis that the old system dragged out for years. But it was never meant to pay for the night you end up in the hospital.

The catch is what those higher-deductible plans actually do when something big happens. You hit the deductible first. You find out what's in network and what isn't. Then you get the bill.

That gap is why we built Atlas Direct. It pairs with your direct care membership and pays cash benefits for hospital stays, ER visits, surgery, and childbirth. No deductibles to burn through first. No networks to check. The money goes to you, and you decide how to use it.

Your doctor handles your health. Atlas Direct handles the catastrophe. Neither has to pretend to be the other.

Montie says direct care fits people with nontraditional jobs who don't have insurance, and people who change jobs often and don't want a new doctor every time their coverage changes. That second group should think hardest about the big stuff, because coverage tied to a job leaves when the job does.

Spagnola got her answers in 2 months. The next step is making sure the bill for the worst day of your life doesn't take years to pay off.

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Source:

• CBS6 Albany, "As insurance costs rise, more doctors offer direct primary care as a cheaper option" (Oct 19, 2026): cbs6albany.com/news/wellness-watch/as-insurance-costs-rise-more-doctors-offer-direct-primary-care-as-a-cheaper-option