To listen to Episode 4, visit the show page.

The transcript below supplements the United States of Debt, a Slate Academy. To learn more and enroll, visit Slate.com/debt.

Leigh Lehman: The strange thing was as long as I wasn’t moving, I still felt great …

Very few of us want to go to the doctor. It’s uncomfortable. It’s time consuming. We might get bad news. And then there are the bills we receive after the visit. And they’re not insignificant.

Mayleen: We are afraid of debt. He’s the sole breadwinner in the family.

I’m Helaine Olen, a columnist here at Slate. And this is the United States of Debt, our ongoing look at how our bills impact our lives.

And in this episode, we’re investigating medical debt. In 2014, Americans spent about $3 trillion on medical services: for hospital stays and emergency room visits, X-rays and blood works—everything.

And, increasingly, more of that money is coming out of our own pockets.

But that doesn’t mean paying for a trip to the doctor, or getting prescriptions, has been getting any cheaper.

So we’re going to ask a few big questions about medical debt.

Why is deciding to go to the doctor such an expensive, tricky proposition for so many of us? Why are individual costs increasing? Why, if you have good insurance, do you still get hit with out-of-pocket expenses? And why, despite the affordable care act, does this continue to happen to so many of us?

Chapter 1: “No One Asks to Get Sick”

A lot of people like to think that we can control our health.

“Stay healthy. If you’re healthy, you can choose a high deductible health insurance plan.”

“Yeah, superfoods—food that we buy. That, to me, that’s taking care of my health. And I feel good.”

“Your food is your health insurance.”

“If you’re not somebody that is vegan, eating organic food, doing self-massage, then it’s a lot more likely that you need to go to a medical doctor.”

Do people really ask to go to the emergency room? Get cancer? Have heart attacks? That’s just another way to blame the victim.

Lehman: Every time the mail’s delivered, it’s a surprise.

Leigh Lehman’s given up on guessing what how much he will owe when yet another medical bill arrives.

Lehman: This one came in, then six months later, this came in and it’s like, “What’s this for?”

You just never know. You think you’re done and then more stuff comes in. And, maybe it’s only $50, maybe it’s $20, maybe it’s $2,000. You just don’t know.

Leigh’s 64 and lives in suburban New Jersey with his wife, daughter, and their dog named Toddie.

He’s a computer consultant, and he and his wife earn a six-figure income combined. His daughter’s done with college. He should be coasting financially. But there are medical bills—and lots of them.

Lehman: Unfortunately, what I inherited was not money but a lot of high cholesterol and ... and just problems.

Leigh has a 20-year history of heart issues. They run in the family.

Lehman: My dad passed away at the age of 46 of a massive heart attack. So, that’s something that you grow up thinking about, and as I got older, unfortunately I had a heart attack at the age of 43, you know, I’ve been maintaining, exercising, doing all the things they tell you you’re supposed to do, but things happen.

It’s been a scary time for him. The worst was in August of 2015.

Lehman: I was walking outside and—you know, it was a really nice day and all of a sudden I couldn’t—I couldn’t breathe and I had to sit down. I was actually with a friend and he’s going, “Do you want me to call?” Oh, nah, nah, that’s fine, it’ll go away.

But it didn’t go away. When Leigh’s wife finally forced him to go to the doctor, they found out some terrifying news.

Lehman: They call it the “widow-maker.” It’s basically the left main artery and once that gets blocked, you have like five minutes before you die ...

As it turns out, Leigh had a blockage, and had to be rushed into surgery immediately. He got a quintuple-bypass surgery, and he was stuck in the cardiac intensive care unit for two days.

But that’s just the latest procedure for Leigh. Since that first heart attack at 43, he’s gone through 10 surgeries and at least 12 overnight stays, not to mention loads of doctors’ appointments.

At the moment Leigh owes $2,000 in medical bills. In the past, the bills have been as high as $17,000 out-of-pocket. And that’s with medical insurance through his job. Not everything is paid for, and over time, everything adds up.

So how does he get the money to pay for all of this?

Lehman: Basically, I can tell you where you get it. Life savings. You go against your 401K. You crank up your credit cards and you kind of don’t pay certain bills. You know, you prioritize and you try not to get too many late fees.

All of those bills affected his daughter’s college savings too.

Lehman: Unfortunately, my medical expenses ate up the money we’ve set aside for her college, so … I used my credit cards to pay the tuition.

Leigh and his wife had originally saved about $60,000 for her education. But some of that money ultimately went to paying his medical bills.

Lehman: I have all sorts of debt. I would say, probably ... close to $80,000. Some of it is credit card, student loans, all sorts of things. I had to borrow $8,000 against my 401K to pay the bills ... Debt seems to be like a domino effect and one thing leads to another.

Leigh’s right. That’s something that you’ve probably realized over the course of this series: that debt leads to more debt.

The largest driver of bankruptcy in the United States? A medical crisis.

Even though the vast majority of households reporting medical debt cut back on things ranging from vacations and clothing and—yes—even food, it’s still not enough. Almost forty percent of health-insured households with medical debt either took on credit card debt, or borrowed money from friends and family to get by.

That’s from a survey from the Kaiser Family Foundation conducted earlier this year.

Trudy Lieberman: When you go to the doctor, you don’t know whether you want to bring your wallet, a loan application or bankruptcy proceeding papers. I mean, and that kind of captures it. I think people know that the price of this stuff is really high. And they also know that they can’t pay it, even with insurance.

That’s Trudy Lieberman, a legendary consumer affairs reporter and longtime expert on health care and medical insurance.

The mountain of debt is so overwhelming, so awful, that Leigh—like many people—has even tried avoiding going to the doctor.

Lehman: I had pain, chest pain ... and couldn’t focus, couldn’t concentrate. Was very disoriented. I just knew that this wasn’t right.

Once again, trying to save money, Leigh didn’t call 911. How did we get here?

Chapter 2: “Skin in the Game”

Medical costs have been soaring for a while.

Let’s take a look at the facts. Out of pocket costs for someone who gets insurance from their employer has increased by more than half since 2010, according to human resources consultant Aon Hewitt. Part of the surge? Deductibles are also on the rise—today, almost  under the age of 65 with workplace supplied health insurance have a four figure deductible.

Many people thought the Affordable Care Act, better known as “Obamacare,” was going to change all that.

First and foremost, the ACA was all about getting people insured. And it did that—the percentage of uninsured Americans fell from 17.5 percent to 10.7 percent (from 2010 to 2015). Not bad.

But, to many Americans, the ACA was also about making health coverage more affordable. For all of us.

And it’s worked, somewhat. One recent survey found that the number of people who said they had trouble paying medical bills fell—from 41 percent to 35 percent in two years. That’s a drop, but it’s not exactly anything to write home about.

But many experts, like Trudy, believe that’s not enough. Not even close.

Lieberman: The ACA did not really solve the cost problem for many, many families, although it was premised that it would do that. And for some families, it has. But for many families, it has not.

When it comes to actually reducing the cost of medical bills that millions of Americans need to pay every day … There’s still a lot of work to do. Part of the issue? There’s a concept called “skin in the game.”

Lieberman: Shoving of the cost onto the patient is called “skin in the game”. And the idea behind this, it’s the cost control method of choice now in America. The feeling goes like this, that, over the last 40, 50 years or so, or maybe even longer, we have been too generous in our health insurance arrangements. And we’ve given people too much care, because somebody else has been paying for the care, mostly employers through the insurance mechanism and so forth. So, in order to stop people from getting so much care, we have to give them more skin in the game. If they have more skin in the game, that means they pay more of the bill. And the theory goes that they will use fewer services.

And when it came to shoving more costs onto the patients? Many politicians eat this up.

Chris Christie: “There were hundreds of thousands of public workers who were paying nothing for health care. We then moved to 1.5 percent of salary and now, to what I believe is a more logical system, which is a percentage of the premiums on the health insurance side. So everybody has skin in the game.”

Ben Carson: “You know the other thing is we need to create a situation that has everybody involved. Everybody has to have skin in the game in order to make this work.”

The whole point of “skin in the game” is to put more of a burden on patients. The theory goes, that if they need to pay more out of pocket, they’ll shop more efficiently, comparing prices for medical providers and other services. So, copays go up and deductibles go up.

Obviously, if you get sick, “skin in the game” can get real expensive real fast. But ultimately, there’s an even bigger problem with the whole concept. Customers can’t really shop for medical care like they can bargain shop for clothes, or cars, or even their dog’s health care.

Let’s say Lassie needs a hip replacement. Chances are that your vet’ll give you a fairly accurate estimate, right from the get-go. In fact, we found that many places will even post costs on their websites. But if you’re a human? Good luck.

In 2013, the Journal of the American Medical Association revealed something pretty shocking. When someone attempted to get price quotes on a hip replacement for a 62-year-old women lacking health insurance, less than one out of five hospitals questioned could even give a number. And those that did? That ranged from a little over $12,000 to over $126,000.

So why is it so easy to get numbers for your pet and not for yourself? Well, you’re not required to spend money on your pet. That’s considered a discretionary expense. As a result, they need to convince you to spend the money. And, they’re upfront with the cost as part of that.

But obviously, treating humans is not discretionary. Medical providers know that, in many cases, you’re scared and stuck. You need care, you need it fast, and you want it from the best doctor or hospital you can find. Joseph Cohen, a professor at Queens College at the City University of New York, explains this.

Joseph Cohen: It’s a captive market. We can’t shop around for health care services as easily. You know, we’re likely to yes to health care regardless of what it costs.

But not so far. There is some evidence shows that “skin in the game” does get people to reduce their spending. But there’s a hitch.

Lieberman: There’s some very new research that has just come from Berkeley this fall showing that people, very educated people in an employer group, a very high income employer group, that people in that group can’t even distinguish what they need and what they don’t need.

In other words, it comes at the expense of their health. People don’t necessarily know what to stop spending on. So they cut willy-nilly, eliminating needed care along with unnecessary care, cutting back equally on scans and check-ups.

Ester Bloom knows this all too well. She’s an editor at the Billfold, a website devoted to the subject of money. She’s also a contributing writer for the Atlantic online. She lives in Brooklyn with her two kids. And she had to deal with lots of medical bills from when she gave birth to her son this March.

Helaine Olen: How long was your labor?

Ester Bloom: It was long, you know. Everyone told me with the second child, that everything would be speedy and smooth, and I’d barely even feel it. And that was not the case. With the first child, I gave myself two black eyes pushing, because labor was so hard.

The second child was still awful—not quite that bad. I didn’t look like I had been in a car crash when I was done. But it was still, by far, the most painful and exhausting experience of my life.

So you’re probably thinking—like most women, she must’ve decided to get pain relief at some point right?

Bloom: I didn’t have an epidural with my first baby, and I remember wondering whether I should consider having one with the second baby—and thinking, no, I have no idea how much that will cost. I know anesthesiologists are expensive. I’m going to try to do without if I possibly can, purely in order to save money. And that’s what I did. So, I ended up doing it unmedicated just so that I didn’t have to pay for an anesthesiologist and an epidural.

She didn’t get an epidural, not because she wanted a natural childbirth. She chose a natural childbirth, mostly because it would save money.

Bloom: I did regret it a little bit. The next day, I had kind of a—I don’t want to say posttraumatic stress, because I don’t know if that’s disrespectful, but I really kept having flashbacks. It felt like I had been through a trauma. And to some degree, I wondered, if I’d had the epidural, whether it would have felt less traumatic - and whether I would’ve felt, you know, better that next day, and less like I had somehow wasted an opportunity to do this in a cleaner and less painful way.

Arguably, Ester really did need that epidural.

Olen: OK. And so do you know how much the epidural would have cost?

Bloom: No. I’m really curious, actually. I would like to know exactly how much I saved on the epidural by just, you know, screaming my head off instead.

Olen: Would your insurance have covered the epidural?

Bloom: I think, like everything else, it would’ve come out of my deductible. And, you know, counted toward my out-of-pocket maximum.

Olen: OK. And so there’s no way for me to determine what it would’ve been, because I would have to call the hospital, and say what your insurance was, and—

Bloom: And even then, they keep everything as opaque as possible. It’s part of how they maintain control.

Ester’s deductible is $1,000. No that’s not $6,000, like some plans, but it’s not nothing either. No wonder she was trying to save money. But even an expert on money matters like Ester can’t really navigate the system—or decide what is or isn’t a necessary medical service. And maybe most important—Ester is healthy.

But it’s different when you or a loved one suddenly gets sick.

Chapter 3: “Being A ‘Smart’ Patient”

A lot of experts say that you can keep medical bills in check and avoid unpleasant surprises by doing one simple thing: making sure your doctor’s in your insurer’s network. That certainly sounds reasonable.

But all too often, it’s easier said than done.

Let’s go back to Leigh. Leigh was a smart patient. Even as he was lying on his hospital bed, getting ready for heart surgery, he was—unbelievably—thinking about money. He was worried about how much that life-saving surgery would cost him. He already had more medical bills than he could pay. So he checked. He made his wife check to make sure the surgeon was in-network.

Lehman: I mean, I was happy, at least I found the surgeon was in network. But, the anesthesiologist, I didn’t know who they were. You can’t check that. You know, it’s difficult, anyway. Because, you don’t know who they’re going to bring in. You had the angiogram, you had the stress test, you had the cardiologists discussing things. The surgeon discussing things. All these things were kind of separate bills.

The surgeon was OK. And as it turns out, the anesthesiologist was OK too. But there were so many doctors. And, no surprise, Leigh missed one.

The critical care doctor assigned to the ICU wasn’t covered by Leigh’s insurance. Leigh says he had no way of knowing that and even if he did, what could he have done?

He only found out, a few weeks later, when he got a $2,200 bill. And that was on top of all of his other bills for the surgery.

When we asked Valley Hospital in Ridgefield, New Jersey, how this could have happened to Leigh, they told us, “Unfortunately, we cannot anticipate every provider who may be called in to care for our patients. To the extent that the patient in question did make every effort to seek care from in-network providers, we find it dismaying that his insurance company would reimburse a consultant physician as out-of-network for care the insurance company authorized.”

Since then, they went on to add, the doctor in question is now employed by the hospital and “fully participates in all the plans in which the hospital participates.”

And what about the insurance company, Aetna? They said Leigh didn’t appeal the out-of-network doctor’s bill and that they agreed to cover the extra cost after Leigh contacted PBS, and PBS called Aetna about it, several months later. When we reached out to Aetna, they wrote to us and said, “In Leigh’s specific situation, there was confusion with the provider that we worked with, who was out of network at the time.

What a mess. What happened to Leigh is called balance billing. And it’s a growing problem.

You visit a doctor, or receive a medical service. But that provider—often through no fault of your own—isn’t in your insurer’s network. The doctor bills. Your insurance pays them what they think the service is worth. But the doctor can still charge you the difference—and that can be a substantial sum.

OK, OK. So you’re thinking that people who choose to go out-of-network should know they can get hit with a large bill. But often people don’t make the choice.

Mayleen: We just automatically assumed, “Hey, this is covered. It’s emergency.” But, no, it wasn’t.

That’s Mayleen. She’s 46 years old and lives in the suburbs of Sacramento with her husband and her two small children.

Mayleen: I’m a stay-at-home mom. My husband is an executive chef.

Things are a bit rocky for Mayleen and her family. They’ve racked up $10,000 in debt from a whole bunch of medical issues …

Mayleen: It comes from the birth of my son and the expenses from that. It comes from my husband having a chronic illness. He has Crohn’s disease. So, there’s maintenance on that, you know, yearly colonoscopies, medications, checkups. It comes from my daughter getting extremely ill with scarlet fever with severe complications two weeks after the birth of my son.

But on top of that, there was an emergency situation, back in March of last year.

Mayleen: He would just be writhing in pain, like bent over. He’d wake up in the middle of the night and it’d was last maybe two hours. I don’t know, he was just living through it, and finally that morning I said, “You know what? You need to go to the hospital.” And I had to call a friend over to come over at 4 o’clock in the morning to stay with the kids so I could drive him over to the emergency room.

And finally, at 7 in the morning, after a ton of tests and scans, the doctors finally dropped the news: Mayleen’s husband Eric needed emergency gallbladder surgery.

Mayleen felt pretty confident things would be OK, on the financial side, at least. They were insured through his employer. They’d used that hospital many times in the past—in fact, both her son and daughter were born in that very hospital. They knew that hospital was in network. But there was one little thing.

Mayleen: Although the emergency room was in-network, the attending surgeon was considered out-of-network.

We were in the emergency room, and it was an emergency situation. We didn’t have time to shop around for a different surgeon, nor did we think we had to. No. I mean, we didn’t even think about it. It wasn’t even offered to us. You know, they just said, “OK. You’re scheduled, you know, for surgery at 11.”

Mayleen didn’t find this all out, until she opened her mailbox weeks later and was slapped with a bunch of medical bills. One from the surgeon’s medical group. It was all very confusing.

We reached out to Sutter Roseville Medical Center—that’s the hospital that Mayleen’s husband went to—and asked them how this could have happened. A spokeswoman responded, saying that there are laws that:

“... preclude Sutter as a provider from even inquiring from a patient what their insurance is until the emergency condition is stabilized and treated. So in many cases, we do not know what the patient’s insurance is, or even if they have insurance until we have provided the necessary treatment.”

In the end, Mayleen says it was over $3,000 from the hospital bills, and more than $1,200 for the surgeon’s bills. Together, it came to almost $5,000.

Mayleen: So I called Cigna. And I said I wanted to appeal it.

Mayleen says a phone rep told her that she would get a phone call or letter when her appeal was decided. She never heard back. Several months later, she called Cigna again. That representative said they had no record of her previous call, and that it was now past the time limit for an appeal.

Mayleen: They basically said that this is what your insurance covers and we cannot do any more than that even though, you know, I argued in appeal that, look, we had no choice.

The law in California is a bit murky on balance billing in emergency situations. It’s possible the surgeon should have accepted the initial insurance payment, since it was an emergency situation and most likely should have been viewed as such under state regulations.

But the surgeon disagreed. When we reached out to his practice, a spokeswoman told us their policy is to appeal the insurance payments in situations like this. If the insurance company then doesn’t readjust the payment, they turn around and bill the patient for the difference.

In other words, patients like Mayleen’s husband are caught in the middle. They’re it—responsible for the bill. And unless they are lucky and committed enough to get an advocate like Slate or PBS on their side, they’re likely stuck with it.

On that note, we reached out to Cigna. They said they would investigate immediately, and they wrote us back within a day, to say it was all a misunderstanding. And that they would pay the surgeon’s bill as soon as possible.

Lieberman: There seems to be a reluctance to deal with the consumer problems that are arising from what we see right now. And I think that as long as we have this system and we keep this, then there has to be some kind of regulation.

Right now, we are in an anti-regulation mode in this country. And perhaps that will shift, depending on what happens to the election. People are clearly saying they’re unhappy. And they’re feeling it in a lot of different ways.

Only a small minority of states have taken balance billing on. In New Jersey, where Leigh lives, legislation to address the issue have gone nowhere.

Chapter 4: “The Snowball Effect”

That hospital stay? That was only one of a bunch of medical bills Mayleen’s family has acquired over the past two years. Remember that her husband has Crohn’s disease.

Mayleen: He has to see the doctor like I think every three months. And he has to get medications every month.

And then there were some complications when Mayleen gave birth to her son last year.

Mayleen: OK. Well, before my son was born, like a few days before he was due I started not feeling him so much. So, my OB advised that I should go to the birthing center and get a stress test.

Things turned out OK, but there ended up being some unexpected charges that Mayleen didn’t anticipate or think were really necessary. And then things really turned south when two weeks later, her 3-year old daughter got sick.

Mayleen: First she got strep throat and then she got scarlet fever. Her pediatrician, you know, gave her antibiotics: amoxicillin. She just was not getting better. So, I took her back to the pediatrician and he took a look at her and he said, “I don’t know. She might have meningitis. You know, take her to the emergency room now.”

Luckily, her daughter didn’t have meningitis. And she did get better eventually. But there were a ton of severe complications that lasted eight months. And all of this, well, caused Mayleen a lot of stress.

Remember, she’d just given birth. And with everything happening, her breast milk dried up.

Mayleen: I fed him formula for one year. And it was $11 a canister. And that canister lasted a week. So, $11 a week for 52 weeks.

On top of that, there were other big things: Special mammograms she needed that weren’t covered, the ambulance they had to call after her husband passed out at a wedding, and an emergency room bill from when one of her children cut their chin open on the playground.

Mayleen: Surgeon, colonoscopy, gallbladder ...

And then there are the regular expenses that Mayleen has to keep up with, like her prescriptions.

Mayleen: I have glaucoma now and I have to put eye drops nightly. And I just bought my first prescription of it two weeks ago and when I went to pick it up they said it’s $75.

Leigh is also finding that all of his medications are adding to his credit card bills. Yes, he has insurance, but like Mayleen, it’s not free. He still needs to make co-payments.

Lehman: Since the surgery, I have the Crestor, Xarelto because they discovered that I had atrial fibrillation which I didn’t even know what it was. Metoprolol, which is basically a beta blocker, it slows your heart down. I’m taking Zoloft which is to treat depression but also anxiety and all these other things. So, every month, it’s probably about $70, $80 a month just in prescription medication for myself. That doesn’t include the rest of the family.

And you don’t even think about that. That’s like filling up your tank with gas. You know, that’s your medication and you have to take it.

Shopping for the cheapest drug is often hard for consumers.

For millions of Americans, the cost of pharmaceuticals is on the rise. Take the cost of the common Epi-Pen, used for treating life-threatening allergic reactions. Back in 2004, one Epi-Pen would cost you around $50. Today? It’s around $300. That’s a 450 percent price increase in a little more than 12 years.

Then there are cancer drugs, which many experts agree have gotten more expensive over the last decade as well. A recent survey by CancerCare found that many people turned to cost-cutting strategies to keep their bills in line. Those included not filling prescriptions, skipping doses, and cutting oral meds in half to make them last longer.

None of this, needless to say, is optimal. People aren’t taking care of themselves.

And a study published earlier this year by the Journal of Clinical Oncology found that filing for bankruptcy seems to make it more likely that someone will die of cancer. People with prostate and colon cancer who filed for bankruptcy were two times more likely to die than people whose finances were in better shape. Researchers say they can’t tell if stress compounds the illness, or if people are forgoing needed treatment to save money—or both.

The skin in the game? Here, it can lead to death.

Luckily, most people things aren’t this lethal. But their finances are something else.

Chapter 5: “Impact”

Every month, Mayleen says she receives at least six separate bills that she needs to pay. She estimates they cost her a minimum $450 a month. Many are from the same health care system.

Mayleen: They will not consolidate it even though most of the procedures are done at their medical center. They will not consolidate the bills. So, each department or each time—each time we go and have a problem, we have to pay those separately.

Mayleen’s hospital system told us via email that the law forbids them from combining hospital bills with doctor bills.

Like Leigh, Mayleen has raided retirement accounts, and other savings to pay the bills. Last year, they took $12,000 out of Eric’s 401k.

Mayleen: Well, I just feel like maybe we shouldn’t have borrowed from the 401k because that is, you know, our retirement. But we were just so worried about not making it through last year.

Leigh’s also tried to negotiate with hospitals, but with limited luck. When he had chest pains in 2014, he went to a nearby hospital just five minutes from his home: the Hackensack University Medical Center at Pascack Valley. But it turns out the emergency room was out of network. Leigh got socked with a large bill as a result, he says the establishment was less than forgiving about this finances.

Lehman: And, so, I called the hospital and I said, “I can’t afford this.” You know. “Can you reduce it?” First it was like, no, we can’t do anything about it. And, I said, “You don’t negotiate?” No. We don’t have to. And, so, I said, well, “Can I pay this off somehow, you know, in installments?” And, they said, yeah, we’ll give you two years.

I reluctantly agreed to it, and you just try to figure out how you’re going to pay that. And, you know, I did things. I mean, I wrote to the newspaper, an editorial and stuff, but there was really no recourse. And, I talked to my insurance company again and they said, yeah, that’s the way it is.

When we got in touch and asked about their policies, CEO Emily Holliman sent us a statement. Part of the statement read:

The hospital empathizes with patients who are trying to navigate the complexity of the system. Although we don’t comment on individual patient accounts, our billing representatives do work directly with each patient to best accommodate their payments as it relates to the patient’s responsibility under their insurance plan.

Think of it this way: Doctors and other medical providers don’t need to negotiate with patients.

For Mayleen, this makes her petrified about her family’s financial future.

Mayleen: Yeah, if we didn’t have all this debt, we would try to be saving. I mean, we’re kind of running out of time here, you know, to start saving for our retirement.

Leigh’s scared, too.

Lehman: I’m not sure what my health is going to be. I mean, hopefully it’ll be good. But, I don’t see in the foreseeable future that I could retire. My wife and I would like to have more time together for whatever time we have left.

Even if we paid off all the medical stuff ... we wouldn’t have anything. We have nothing left. I just never thought ...

I thought I had made a good living and I thought I was doing all—you know, the right things. And, nothing is there.

And Mayleen blames herself, even though no one asks for bad health.

Mayleen: It just feels like we made a lot of bad choices, you know? And we started having kids late in life, which we love them to death and we wouldn’t change it for the world, but in retrospect it was probably not a good idea.

Trudy Lieberman says this is all too common.

Lieberman: Well, we like to blame the victim, don’t we?

I think that’s part of our psyche. It’s—you know, it’s your own fault. You either ate too much, too many fat things, too much McDonald’s, whatever. Or, you drank too much, or you smoked too much. There’s always kind of a rationale that sort of makes it seem, OK, you know, they did it to themselves. So, why should we have to pay for them?

Leigh: [Sighs.] I mean, honestly, I never expected to be in this kind of a hole.

Chapter 6: “What do you do if you’re faced with all these medical bills?”

As you can guess, there isn’t much in the way of advice we can give you. But there are some ways to make bad situations slightly less bad.

First, if you’re faced with a pile of medical bills, ask questions. One insurance company study found that nine out of 10 hospital bills contained errors.

Second, if you can’t make heads or tails of those bills, consider hiring an outside service to review the charges. These services either charge by the hour or sometimes work for a percentage of the money they save you.

Third, don’t accept an insurance denials as final. Appeal decisions. If they’re still denied and you believe you are in the right, consider filing a complaint with your state’s department of insurance. This sometimes lights a fire under the insurance company, and gets them to reconsider the decision.

Fourth, remember that financial advisers all but beg people to not take money out of retirement accounts to pay for medical bills. Besides endangering their finances in their later years, when they can no longer work, there’s another reason for the advice. Retirement accounts are, for the most part, protected in bankruptcy. If you’re in such financially desperate straits that you’re considering filing, you’ve given up a powerful protection. Save for your retirement.

Finally, take political action, like Leigh did. He’s part of the Consumers Union, a nonprofit advocacy group. And he’s working towards raising awareness about surprise medical bills. Ultimately, the only way to make change happen is to raise awareness of the issue.

Thank you for listening. I’m Helaine Olen and this is the United States of Debt. Jennifer Lai is our producer. Rachael Cusick is our intern. In this episode you heard music from Kai Engel, Chris Zabriskie, and Jingle Punks. And remember, to sign up and hear more stories of debt in America, visit Slate.com/debt.