Personal Injury Protection, or PIP, as a Backup

Another interesting strategy we found was to up the coverage on our car insurance with something in Texas called "PIP," or Personal Injury Protection. I know it's available in other states under a different name (possibly MedPay), but it is a coverage that will kick in if you are injured in some sort of accident that involves an automobile. It covers expenses regardless of who was at fault in an accident, and in some cases will cover lost wages.

Check out this article by CoverHound. Here's another good article from ValuePenguin.

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We have firsthand knowledge of this one. My husband was hit while cycling back in 2009 or so here in Austin by some chick driving her boyfriend's truck. She was cutting in and out of traffic, then sped up and turned right to go down a street, clipping him on his bike in the process.

It did real damage; he had torn the lining of his hip joint and we were facing about $54,000 in medical bills. Long story short, it required surgery, and even though we had health insurance through our company, we had to pay copays and out-of-pocket expenses that weren't covered by his deductible. We were forced to sue Progressive, the insurer of the vehicle, because they refused to pay, saying that he had run into her and therefore something called "comparative negligence" was at play. It was a lie...she ran into him, and Progressive was just playing hardball. (Progressive can be great if they're YOUR insurer, but if you're ever fighting against them with a legitimate claim, they are BRUTAL and very unfair and will do everything in their power not to pay a claim).

Back to the PIP. We didn't even know we had this coverage...the default was $5,000 and we had just accepted it, with a cost of something like FIVE DOLLARS a month added to our premium. And even though my husband (then fiancée) was on a bicycle, he was involved in an accident that involved a car, so therefore it kicked in.

Anyway, after the economy tanked around 2010, we found ourselves without health insurance again. So we looked into upping our PIP coverage, betting that any major health issues might be related to an auto accident or cycling. We raised the PIP coverage to $25,000, and when I was involved in a hit-and-run in 2011, the PIP kicked in again. 

So if you find yourself without health insurance, you might check out the options associated with your home or auto insurance to see if there is any coverage that might close the gap! It's not a bad idea to have even when you have other insurance...the cost is relatively low and can bring peace of mind.

SURGERY with No Insurance

So it was the thing I feared most...not the surgery, but surgery without insurance. I asked what kind of timeframe we were looking at, and the rep at TFMS said he didn't know yet, but that it's usually within 1-2 weeks because they pay the surgeon promptly and more quickly than insurance companies, so "they like to get our patients in quickly."

The first step was getting an actual estimate. Within a couple of days, I had the numbers from Texas Free Market Surgery. They said that the cost should be accurate, and even if they got in there and it was less, I would be issued a refund.


The amount seems high, but at $8,000 out the door, that's less than four months of the $2,400 insurance premium quoted to us by Humana. An amount most folks could get a loan for, or put all or part on a credit card, or borrow from a family member.

And I realized something really important...they said it was "$8,000 out the door." That covers the facility, the surgeon, and the anesthesiologist. One of my biggest frustrations about traditional insurance programs is not having a clue what your cost is, and being inundated by multiple bills for months. Could it be true that TFMS was going to eliminate this?

They told me that I'd get a call this next week for payment, and they put me on the schedule for April 27th, with a pre-op appointment on April 26th (included in price). Oh, and I also learned that my initial $200 consultation goes toward the price of the surgery.

So I'm hanging in there for the moment, counting the days. Eleven days and counting. I'm hurting pretty badly, so I look forward to the surgery. After all, the unknowns of the price are not as scary.


Physical Therapy

So my shoulder looks okay, and nothing really jumps out, so my doctor writes me a referral to a physical therapist. Again, with no insurance, she refers me to a direct provider, Carter Physiotherapy. I go for about six weeks, and although my upper shoulder feels a little better, my range of motion is still an issue, I have a shooting pain in my upper arm. 

I even tried "dry needling," an Americanized version of acupuncture.  It actually felt pretty good.

The cost of the physical therapy was comparable to an hour-and-a-half massage, but was definitely more intense. I paid out of pocket and never saw another bill, which was nice.

We realized that something more significant is going on, so my doctor gave me a recommendation to Texas Free Market Surgery. We were hoping to avoid that option, but it's time to look into it.

I called Texas Free Market Surgery, and paid for my consultation over the phone, which cost $200 (April 2018). I was a little unfamiliar with the process, but I was given the address of a well-known orthopedic practice in Austin, and had my first appointment with the same doctor who performed my direct primary care physician's shoulder surgery in 2010.

After an orthopedic radiologist looked at the MRI, they determined that I had a bone spur in my shoulder and an inflamed "bursa." The doctor said that they could inject it with something to bring down the inflammation, and I asked if I should schedule an appointment. He said that he could do it "right now." I was a little unprepared, and since I'm afraid of needles, that was a little intimidating. But I had my iPhone and some headphones, so I just jammed on some German heavy metal (it's my dental playlist!) and he used something to freeze the injection site and then it was done!

Through the whole thing, I was a little worried about the cost. I knew someone who got a shot like this and paid $1400 out of pocket. I was surprised at the end of my visit that I didn't owe anything more and that it was included in my office visit! I scheduled a followup in a month.

The surgeon said that I would probably feel sore the following day or so, then by Monday I should start to feel relief. It was Thursday. The relief came on the second day, on Saturday, and I literally felt NO PAIN. It was glorious! But then the relief started to wane. I waited a week, and it got worse, so I contacted Texas Free Market Surgery and asked what the next steps would be.

At first, they suggested that physical therapy and another injection would be the most "conservative" approach, but in light of the fact that it was a bone spur, the most appropriate course of action is the thing I dreaded most.

SURGERY. Here we go.

The First Big Test...Shoulder Problem

Around April of 2017, my shoulder started to hurt. It was annoying but nothing terrible. I figured I'd just been sleeping on it wrong. My husband likes his firm bed, but mine has always been more plush. For awhile, I'd felt like I couldn't get comfortable, and I'd wake up in the middle of the night with my arm above my head.

I'd been seeking relief from massage, but that would work for a few days, then it would start getting worse again.

I figured it would just go away, and was nothing to worry about. Wrong.

So after about four months, I finally mentioned it to my doctor. I told her that my biggest fear of anything being wrong was the cost, and told her that I was ready to fly to Thailand or Dubai to get affordable surgery if needed. Hey, I'm open-minded, even if my dad kept joking about coming back with missing organs!

I showed her Bumrungrad Hospital in Thailand's website, which allowed me to look up different surgeries, and they showed the price range UP-FRONT (I can't find the prices anymore, though). When I lamented the fact that there was nothing like it in the States, she then told me about something called Texas Free Market Surgery. What was amazing was that the prices were listed on the page, and they were LOCAL.

 An example from Texas Free Market Surgery's website (April 2018, prices subject to change)

An example from Texas Free Market Surgery's website (April 2018, prices subject to change)

So this is a screenshot from April of 2018 that shows the estimate of arthroscopic shoulder surgery. The price seems expensive, but a quick search on the internet will reveal that this procedure can run $25,000 to $50,000 through insurance. Of course, you don't pay that much if you have insurance, but if you have a high deductible, many hospitals are now requiring that you pay your deductible up front before they will operate, in order to make sure they are paid first.

REAL WORLD SCENARIO: In fact, a quick search on their site of hip replacement shows a price of $23,000. I had priced this procedure a few years ago for a friend. I was told Seton Northwest Hospital here in Austin would charge $112,000 for JUST THE FACILITY. The doctor and anesthesiologist was another $30,000 or so, making the total around $145,000. Something's definitely wrong with our healthcare system.

Peace of Mind

So the end result was that I was armed (no pun intended!) with knowledge. I still didn't know what was wrong with my arm, but at least I knew the worst-case scenario. So Dr. Ikbal recommended an MRI, and she referred me to Longhorn Radiology here in Austin, where an MRI out-of-pocket cost $450, which although expensive, is a fair price.

Interestingly, my stepdaughter recently had an MRI with really good insurance. Her copay? $400.

I arranged the appointment, got in quickly, and within days had the results.

Direct Primary Care...What is That?

While at lunch one day with my friend Jill, a nurse, I mentioned how the fact that I had no insurance or healthcare was really making me anxious. 

She told me that she had a "subscription" with a doctor in something called a Direct Primary Care model. She paid a monthly fee for unlimited access to a licensed doctor, and could even text the doctor with questions or issues, and the doctor could even call in medications to the pharmacy.

I was a little apprehensive, but curious. So my better half (now husband) and I made an appointment with Dr. Katriny Ikbal of DirectMed here in the Lakeway area of Austin. We got in within a week, and sat down for our introductory meeting. She spent an hour talking with us about our needs and concerns, and we decided to sign up. For under $200 a month (as of March 2018), we were both covered. This also covered an annual physical with bloodwork, well woman care, and unlimited access. For an extra fee that was very reasonable, she makes house calls.

Our first appointments were scheduled separately, and to my surprise we sat and talked for about an hour. We discussed diet, health concerns, and family history. It was very comprehensive, and very personal. I also got a chance to learn about her background, and how part of her goal in getting away from a traditional practice was to be able to spend quality time with her patients. I also later learned that another member of her family is a doctor, and another is a nurse.

It wasn't long before I was feeling like my heart was racing, and I scheduled my first "real-world" appointment. It ends up she has the equipment in the office for an EKG, something for which I was charged $600 at another local facility.about eight months earlier. There was no extra charge, and everything was okay. After talking, we figured out it was most likely caused by general stress.

Since then, I've also had the opportunity to reach out to the doctor via text...they were recurring issues that just required a prescription, which she called into the local pharmacy.

This was all fine and good for regular healthcare, but what about something a little more serious?

Shopping Around for Medications

Did you know that prices vary for medications, and that you can find lower prices by shopping around? I didn't know this until I lost my insurance years ago when I left my traditional job with healthcare.


My first experience was with Flonase, a medication that thankfully is now available over the counter. But in 2010, I was shocked to find that the generic of this medication (fluticasone), for which I had been paying $10 a month (copay), was now $79.99 with no insurance at Walgreens. That made it unaffordable to me. So I decided to shop around, and I was in for a big surprise.

Here in Texas, we have H-E-B as our largest grocery store, and it has a pharmacy. But what I didn't realize is that their prices are lower than chain pharmacies like CVS and Walgreens. When I first checked the price of fluticasone, I was surprised to find that the price—$28—was significantly less than what I'd been paying. I was satisfied with the price, so I never bothered to look further.

H-E-B also offered a discount card, which I think was free. I also learned that other pharmacies linked to retail stores, like Target, did the same.

A year later, H-E-B raised the price $10, to $38, and I decided to shop around again. To my surprise, Sam's Club (like Costco, warehouse-style retail store) came in at $15 for the same generic. But gets better. I was on the way to my parents' house about an hour away, and I forgot my fluticasone. So I stopped at another Sam's Club in a smaller town, and the price was about $9.50! Same chain, lower price. I was blown away.

So if I ever got a prescription, I got in the habit of shopping around. Sure, generics are cheaper, but there are even variations in price between generics, so it can be worth making a few calls. We do it with everything else, why not?


Enter smartphones and helpful apps! A few years ago, an app called GoodRX appeared and showed these variations in price between different outlets.

There is no cost to download the app, and you can search by location. The app shows you a "coupon" price, which may be low, but in some cases it's not. See the images to the right...the Tylenol 3 is pretty cheap, but Breo Ellipta, a prescription I got last year, is NOT. At $346, this is kind of outrageous. I was really sick, so what's a girl to do?

Well, what do you do when shopping online? GOOGLE "ELLIPTA COUPON!"

I had an upper respiratory issue with a serious, exhausting cough, and as if I didn't feel bad enough, that $346 price made me feel worse! But I had a prescription in hand, I just needed to get my hands on some Ellipta.

With a single Google search, I found that the Breo folks had some savings offers on their site. So let's take a look.

The first is an example of a prescription pricing scam that I wish the government would shut down. "Pay no more than $10 a month on your prescription for Breo for 12 months." I simply don't understand these stupid discount cards. Sure, you're only going to pay $10 a month if you have commercial insurance, but if you don't, you'll get $100 off a month's supply, leaving you to pay $246...still, not the bargain I'm looking for. For someone with an ongoing condition like asthma, if you have insurance, this could be big savings.

(Something to note, though...if you're on Medicare, it's a whole 'nother ball o' wax. Check GoodRX's tools to see how being "eligible for Medicare" affects your ability to obtain the medication.)

But where does the rest of that cost go if the customer is only paying $10 a month? Is it a writeoff for the drug company? On some of the coupons, they will actually write "$336 value." I believe that these costs are passed on as higher premiums to insurance customers. (If anyone understands this, please comment below.)

More importantly, over on the right was another coupon for a FREE TRIAL OFFER! This coupon literally saved my life. I was able to print it out and take it to Walgreens to get a free one-month's supply, and I was better within a few days.

Moral of the story? SHOP AROUND!

Texas Healthcare Options...Not Good

So once we got back to Texas, we had to drop Kaiser Permanente because they didn't have offices in the state. By this time, the ACA had plans available, and we went to the exchange to choose one.

We found it much more difficult than Colorado. Colorado had embraced the new healthcare changes, and the state  had advisors available to help people choose a plan. But back in Texas, which chose not to expand Medicaid, we found ourselves trying to navigate the system on our own. Didn't seem like that big of a deal, because we weren't eligible for Medicaid.


We chose a plan with Humana that was not cheap, but it had some of the things we'd liked with Kaiser Permanente. We realized that we would use our insurance if it had zero deductible, so that was important, even though it cost more. Our plan cost about $1100 a month the first year for two healthy adults. The following year, they increased our monthly rate to over $1300. We weren't happy about it, but didn't have much of a choice.


Until the next year, when Humana announced that they were eliminating our plan altogether. Ends up that because Texas chose not to expand Medicaid, many low income folks who hadn't had healthcare in awhile and were sicker or had untreated health issues were pushed onto the insurance rolls. If Texas had accepted the Medicaid expansion, those folks would have been subsidized.

As a result, our "replacement plan" from Humana was going to be $2400 a month, have a $12,000 deductible, and 30% coinsurance on hospital services. We decided that it wasn't worth it. For almost $30,000 a year, we decided we were better off paying the penalty and saving the money for international healthcare options if something went wrong. We were also not allowed to put money in a pre-tax healthcare savings account like everyone else because we didn't have employer-sponsored insurance.

We refused to pay more for our healthcare than our mortgage. A decision for which I've felt a great deal of anxiety.

In my next post, I'll talk more about our current solution...

The BEGINNING of My Story...

Greetings everyone! I have decided I am going to blog about our experience without healthcare here in the good ol' USA. 

If you're from outside the US, this may be a foreign concept to you, but we don't have universal healthcare in America. My husband and I are self-employed, but used to have employer-sponsored healthcare before the ACA (Affordable Care Act). Although many of my friends will talk about how "Obamacare is the worst," but I can tell you that our healthcare before Obamacare was bad, and the claims about increasing costs only being since the ACA are simply not true. In my old employment, my insurance costs were doubling each year.

But my blog here isn't to complain. It's to talk about what we've been doing since we lost our healthcare options about a year and a half ago. And also about my upcoming surgery on my shoulder. I will, however, give a little background on our healthcare situation prior to going without.

Our "Healthcare" Before the ACA

My then-fiancée worked as a programmer for a large electronics company from 2012 to 2014, and had employee-sponsored healthcare. He contributed about $15,000 a year into the plan, and the employer matched that. So a total of $30,000 went into our healthcare. But two things were wrong with that. Our plan had a very high deductible that we never met, and his health benefits were taxed as income because we were not married. Our benefits were taxed to the tune of about $1800 a year, and additionally his teenage son's benefits were also taxed as income because I was on the plan. Basically the same problem that same-sex couples deal with here in the US.

My husband's son has an ongoing health issue that required a maintenance medication costing about $385 a month, and because we never met the deductible, NONE of that cost was offset. We were required to pay the whole amount until the deductible was met, and it was never met, with the deductible being reset each year. We didn't pay a copay for his overpriced medications...we were required to pay the whole amount. And we didn't qualify to pay a copay at the doctor's office. We were required to pay the entire cost of the visit, which was the same amount BILLED to the insurance company—the overinflated price that is negotiated until the insurance company pays about a third. However, since we had insurance, we were required to pay the pre-negotiated price...not a copay.

We also had a healthcare savings account that we used to save pre-tax dollars to offset some of those costs.

A New Plan That Worked: Kaiser Permanente

Then we switched to Kaiser Permanente, and it was wonderful. We paid about the same amount each month, around $1100-1200, but it was healthcare we could use. We didn't see multiple bills for procedures, we could easily schedule an appointment on our iPhones, the pharmacy was colocated with the doctor's office, and my full-blown surgery on a lipoma cost a copay or $25, and I never saw another bill. 

Compare and contrast that sinus surgery I had in 2010 here in Austin. I had five different bills, and even an overcharge of $850 that I spent hours fighting. I had been careful to select doctors who were "in network," but the pathologist chosen while I was knocked out was not covered on my plan. After months of fighting and hours on the phone, they finally agreed that it was covered and I owed nothing.

We also had some sort of healthcare savings account (HSA) or flexible spending account (FSA), but we learned the hard way that the money was completely LOST when my husband left his job in August of that year. All the money we had put in the account had disappeared.

Back to Texas...

We continued on with Kaiser after he quit his job to become a full-time writer. It worked well, until family issues required that we leave Denver and move back to Texas, a state that had not accepted the Medicaid expansion. In the next post I'll explain why that became a problem.

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