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A patient caught between doctors and health insurers

Frank Esposito of Lindenhurst received $650,000 in medical

Frank Esposito of Lindenhurst received $650,000 in medical bills for back surgery after his insurance company initially denied the coverage. Credit: Newsday / Lane Filler

When Frank Esposito's lower body began shrieking with pain last year, his ability to handle the medical bills was the last thing on his mind. Esposito, a 59-year-old tool and die maker  from Lindenhurst, knew he had good health insurance from Oxford United Health Care through his employer.

But once his spinal fusion surgery was over and his mailbox was brimming with bills, Esposito faced an issue he thought his insurance would protect him from: demands for $650,000 from medical providers that Oxford refused to pay.

"I thought it was muscle spasms," Esposito said. "But it gradually got worse, with nothing seeming to help, and then boom, one day at work, the pain was suddenly so intense that I went to the bathroom and I couldn't stand up. I had to go home, leave work, and the pain was so intense I can't walk, I can't get in my truck, I can barely drive. When I got home, I laid in bed two weeks, practically delirious."

An MRI revealed a bone spur and herniation in his spine. His vertebrae needed to be fused. And it was an emergency, his surgeon said, because waiting could sever a nerve. He went for surgery at St. Catherine of Siena Medical Center in Smithtown, which is in his insurance network. His surgeon was the same one who had operated on his back successfully 13 years ago. And he ended up with $650,000 in bills. 

First, Oxford claimed the surgery wasn't medically necessary. Then, the company said it was needed, but not an emergency, and tried to deny payment of a bill of more than $200,000 from Esposito's surgeon. Esposito enlisted the help of Susan Null, whose Rockland County-based company, Systemedic, does medical billing and advocacy. Null got the surgeon's bill covered, but made little progress on the neurologist's $220,000 charge.

Then CBS called.

The network, doing a series on situations like Esposito's, featured his grim tale on national broadcasts. And Gov. Andrew M. Cuomo stepped in to make sure Esposito's bill got covered via a 2015 state law that is supposed to remove patients from wars over huge bills for emergency and surprise out-of-network services, and let the insurance companies and medical providers duke it out.

Esposito got caught between two bad practices: doctors sending out colossal bills as a starting point in negotiations and insurance companies that avoid paying those bills. It's a common predicament, and most such patients don't get a broadcast network or governor to help.

When insurance companies and care providers argue that suddenly banning private health insurance and creating "Medicare for All" would devastate health care, they're right. Medicare reimbursement rates are not enough to fund the system, and the increase in demand for services would be staggering. But the impetus for going to a single-payer system isn't just worries over the 30 million people who have no insurance. It's also the fear and anger of nearly 200 million Americans who have private coverage and know they could still go bankrupt if they can't get insurers to pay the wildly inflated bills the providers send.

Esposito is neither a communist nor a socialist, but he definitely feels this system is broken "if I have to worry that I'm going to lose this house that I built, this life that I built for my family," over medical bills. Most people would agree.

So if they don't want to see their industry model destroyed, it's on health insurers and care providers to stop doing business in a manner so predatory and incomprehensible that normal people want to tear it all down.

Lane Filler is a member of Newsday's editorial board.