For most of us, health insurance is part of our employer benefits package. The costs are built into the business’s cost structure, and the company pays a large portion of the premium. If our per-paycheck cost is relatively low, and we don’t have a huge bill at the doctor’s office or pharmacy, we generally don’t give the true costs much thought.
What happens when you don’t have group coverage available? If you are self-employed – as a contractor, small business owner, etc. – you don’t have the luxury of a predefined benefits package. You must make some difficult choices. Do you go with an individual qualified health plan on the federal marketplace? Off the marketplace? Do you go with a non-qualified plan? Health share ministry? Short-term plan? Do you go online and explore the options that operate in a legally grey area? Association plans, member plans, etc.? If you choose wrong, you can end up with catastrophic out-of-pocket costs.
That could have been John, a 52-year-old male, active, no major medical conditions, with a standard bronze marketplace plan. One Friday night in May of 2025, John experienced gross hematuria in his urine for the first time (bright red color in his urine). On Saturday, John had increasing bouts of blood clots and blood in his urine. By Sunday, John was worried, but the blood was clearing up, and by Sunday night he was back to normal.
This was the start of John’s journey with bladder cancer. A visit to his primary care physician led to a referral for a CT scan and a Urologist visit. This led to a cystoscopy (a camera view of the inside of the bladder), which confirmed a tumor. The next step was a TURBT, a procedure to remove the tumor and surrounding tissues to send off for biopsy. That pathology came back confirmed as high-grade stage 1 urothelial cancer, and the unfortunate revelation that the doctor did not get deep enough into the margins to determine if the cancer was muscle-invasive or not. A second TURBT was scheduled, and John began the search for a second opinion. The second biopsy raised more questions than the first, and the unclear prognosis led the original urologist to say, “I don’t think it’s in the muscle.” On that doctor’s recommendation, John began treatments of BCG – a targeted immunotherapy for non-muscle invasive bladder cancer.
Midway through the initial cycle of BCG treatments, John took the most important step in any major health journey; John went to a different doctor for a second opinion. This doctor suggested completing the initial BCG cycle and scheduled the follow-up cystoscopy to coincide with a more thorough TURBT. On Halloween, John went for the third and final TURBT, which confirmed the cancer was stage 2 – muscle invasive. This drastically changed the course of John’s treatment – BCG was ineffective, and the gold standard treatment for muscle-invasive bladder cancer is pre-surgical chemo and immunotherapy infusions, followed by a radical cystectomy – removal of the bladder and surrounding tissue.
Just to arrive at a correct diagnosis and treatment plan, here are the costs from the hospital system:
CT Scan – $8,600; TURBT – $25,000 each ($75,000 total); BCG – $745 each ($4470 total).
If John hadn’t had insurance, he would’ve paid $88,070 out of pocket without receiving meaningful treatment. Because he was on a marketplace plan for 2025, John’s out-of-pocket expenses were capped at $9,200 for the year.
John elected a bronze plan again for 2026 with nationwide network coverage and a $10,600 max out-of-pocket. He reached that maximum on January 2nd this year after one chemotherapy treatment.
If John had chosen a coverage option other than a qualified health plan, he could be looking at hospital bills of $1,000,000 and counting. Having the right health coverage is critical to avoid financial catastrophes.
The time to sign up for health coverage is now – Open Enrollment for individuals starts November 1st and runs through January 15th, 2027. If you miss this annual enrollment window, you may not have another opportunity to sign up for qualified health insurance coverage unless you have a qualifying life event (move to a new zip code, birth, adoption, etc.). Getting a major health diagnosis isn’t a qualifying event.
John has a great independent agent in his corner; do you?
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