Ouch. That ‘Free’ Annual Checkup Might Cost You. Here’s Why.
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When Kristy Uddin, 49, went in for her annual mammogram in Washington state last year, she assumed she would not incur a bill because the test is one of the many preventive measures guaranteed to be free to patients under the 2010 Affordable Care Act. The ACA’s provision made medical and economic sense, encouraging Americans to use screening tools that could nip medical problems in the bud and keep patients healthy.
So when a bill for $236 arrived, Uddin — an occupational therapist familiar with the health care industry’s workings — complained to her insurer and the hospital. She even requested an independent review.
“I’m like, ‘Tell me why am I getting this bill?’” Uddin recalled in an interview. The unsatisfying explanation: The mammogram itself was covered, per the ACA’s rules, but the fee for the equipment and the facility was not.
That answer was particularly galling, she said, because, a year earlier, her “free” mammogram at the same health system had generated a bill of about $1,000 for the radiologist’s reading. Though she fought that charge (and won), this time she threw in the towel and wrote the $236 check. But then she dashed off a submission to the KFF Health News-NPR “Bill of the Month” project:
“I was really mad — it’s ridiculous,” she later recalled. “This is not how the law is supposed to work.”
The ACA’s designers might have assumed that they had spelled out with sufficient clarity that millions of Americans would no longer have to pay for certain types of preventive care, including mammograms, colonoscopies, and recommended vaccines, in addition to doctor visits to screen for disease. But the law’s authors didn’t reckon with America’s ever-creative medical billing juggernaut.
Over the past several years, the medical industry has eroded the ACA’s guarantees, finding ways to bill patients in gray zones of the law. Patients going in for preventive care, expecting that it will be fully covered by insurance, are being blindsided by bills, big and small.
The problem comes down to deciding exactly what components of a medical encounter are covered by the ACA guarantee. For example, when do conversations between doctor and patient during an annual visit for preventive services veer into the treatment sphere? What screenings are needed for a patient’s annual visit?
A healthy 30-year-old visiting a primary care provider might get a few basic blood tests, while a 50-year-old who is overweight would merit additional screening for Type 2 diabetes.
Making matters more confusing, the annual checkup itself is guaranteed to be “no cost” for women and people age 65 and older, but the guarantee doesn’t apply for men in the 18-64 age range — though many preventive services that require a medical visit (such as checks of blood pressure or cholesterol and screens for substance abuse) are covered.
No wonder what’s covered under the umbrella of prevention can look very different to medical providers (trying to be thorough) and billers (intent on squeezing more dollars out of every medical encounter) than it does to insurers (who profit from narrower definitions).
For patients, the gray zone has become a billing minefield. Here are a few more examples, gleaned from the Bill of the Month project in just the past six months:
Peter Opaskar, 46, of Texas, went to his primary care doctor last year for his preventive care visit — as he’d done before, at no cost. This time, his insurer paid $130.81 for the visit, but he also received a perplexing bill for $111.81. Opaskar learned that he had incurred the additional charge because when his doctor asked if he had any health concerns, he mentioned that he was having digestive problems but had already made an appointment with his gastroenterologist. So, the office explained, his visit was billed as both a preventive physical and a consultation. “Next year,” Opasker said in an interview, if he’s asked about health concerns, “I’ll say ‘no,’ even if I have a gunshot wound.”
Kevin Lin, a technology specialist in Virginia in his 30s, went to a new primary care provider to take advantage of the preventive care benefit when he got insurance; he had no physical complaints. He said he was assured at check-in that he wouldn’t be charged. His insurer paid $174 for the checkup, but he was billed an additional $132.29 for a “new patient visit.” He said he has made many calls to fight the bill, so far with no luck.
Finally, there’s Yoori Lee, 46, of Minnesota, herself a colorectal surgeon, who was shocked when her first screening colonoscopy yielded a bill for $450 for a biopsy of a polyp — a bill she knew was illegal. Federal regulations issued in 2022 to clarify the matter are very clear that biopsies during screening colonoscopies are included in the no-cost promise. “I mean, the whole point of screening is to find things,” she said, stating, perhaps, the obvious.
Though these patient bills defy common sense, room for creative exploitation has been provided by the complex regulatory language surrounding the ACA. Consider this from Ellen Montz, deputy administrator and director of the Center for Consumer Information and Insurance Oversight at the Centers for Medicare & Medicaid Services, in an emailed response to queries and an interview request on this subject: “If a preventive service is not billed separately or is not tracked as individual encounter data separately from an office visit and the primary purpose of the office visit is not the delivery of the preventive item or service, then the plan issuer may impose cost sharing for the office visit.”
So, if the doctor decides that a patient’s mention of stomach pain does not fall under the umbrella of preventive care, then that aspect of the visit can be billed separately, and the patient must pay?
And then there’s this, also from Montz: “Whether a facility fee is permitted to be charged to a consumer would depend on whether the facility usage is an integral part of performing the mammogram or an integral part of any other preventive service that is required to be covered without cost sharing under federal law.”
But wait, how can you do a mammogram or colonoscopy without a facility?
Unfortunately, there is no federal enforcement mechanism to catch individual billing abuses. And agencies’ remedies are weak — simply directing insurers to reprocess claims or notifying patients they can resubmit them.
In the absence of stronger enforcement or remedies, CMS could likely curtail these practices and give patients the tools to fight back by offering the sort of clarity the agency provided a few years ago regarding polyp biopsies — spelling out more clearly what comes under the rubric of preventive care, what can be billed, and what cannot.
The stories KFF Health News and NPR receive are likely just the tip of an iceberg. And while each bill might be relatively small compared with the stunning $10,000 hospital bills that have become all too familiar in the United States, the sorry consequences are manifold. Patients pay bills they do not owe, depriving them of cash they could use elsewhere. If they can’t pay, those bills might end up with debt-collection agencies and, ultimately, harm their credit score.
Perhaps most disturbing: These unexpected bills might discourage people from seeking preventive screenings that could be lifesaving, which is why the ACA deemed them “essential health benefits” that should be free.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
Subscribe to KFF Health News’ free Morning Briefing.
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Do We Need Sunscreen In Winter, Really?
10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.
It’s Q&A Day at 10almonds!
Have a question or a request? We love to hear from you!
In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!
As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!
So, no question/request too big or small 😎
❝I keep seeing advice that we shoudl wear sunscreen out in winter even if it’s not hot or sunny, but is there actually any real benefit to this?❞
Short answer: yes (but it’s indeed not as critical as it is during summer’s hot/sunny days)
Longer answer: first, let’s examine the physics of summer vs winter when it comes to the sun…
In summer (assuming we live far enough from the equator to have this kind of seasonal variation), the part of the planet where we live is tilted more towards the sun. This makes it closer, and more importantly, it’s more directly overhead during the day. The difference in distance through space isn’t as big a deal as the difference in distance through the atmosphere. When the sun is more directly overhead, its rays have a shorter path through our atmosphere, and thus less chance of being blocked by cloud cover / refracted elsewhere / bounced back off into space before it even gets that far.
In winter, the opposite of all that is true.
Morning/evening also somewhat replicate this compared to midday, because the sun being lower in the sky has a similar effect to seasonal variation causing it to be less directly overhead.
For this reason, even though visually the sun may be just as bright on a winter morning as it is on a summer midday, the rays have been filtered very differently by the time they get to us.
This is one reason why you’re much less likely to get sunburned in the winter, compared to the summer (others include the actual temperature difference, your likely better hydration, and your likely more modest attire protecting you).
However…
The reason it is advisable to wear sunscreen in winter is not generally about sunburn, and is rather more about long-term cumulative skin damage (ranging from accelerated aging to cancer) caused by the UV rays—specifically, mostly UVA rays, since UVB rays (with their higher energy but shorter wavelength) have nearly all been blocked by the atmosphere.
Here’s a good explainer of that from the American Cancer Society:
UV (Ultraviolet) Radiation and Cancer Risk
👆 this may seem like a no-brainer, but there’s a lot explained here that demystifies a lot of things, covering ionizing vs non-ionizing radiation, x-rays and gamma-rays, the very different kinds of cancer caused by different things, and what things are dangerous vs which there’s no need to worry about (so far as best current science can say, at least).
Consequently: yes, if you value your skin health and avoidance of cancer, wearing sunscreen when out even in the winter is a good idea. Especially if your phone’s weather app says the UV index is “moderate” or above, but even if it’s “low”, it doesn’t hurt to include it as part of your skincare routine.
But what if sunscreens are dangerous?
Firstly, not all sunscreens are created equal:
Learn more: Who Screens The Sunscreens?
Secondly: consider putting on a protective layer of moisturizer first, and then the sunscreen on top. Bear in mind, this is winter we’re talking about, so you’re probably not going out in a bikini, so this is likely a face-neck-hands job and you’re done.
What about vitamin D?
Humans evolved to have more or less melanin in our skin depending on where we lived, and white people evolved to wring the most vitamin D possible out of the meagre sun far from the equator. Black people’s greater melanin, on the other hand, offers some initial protection against the sun (but any resultant skin cancer is then more dangerous than it would be for white people if it does occur, so please do use sunscreen whatever your skintone).
Nowadays many people live in many places which may or may not be the places we evolved for, and so we have to take that into account when it comes to sun exposure.
Here’s a deeper dive into that, for those who want to learn:
Take care!
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Lemon Balm For Stressful Times And More
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Balm For The Mind: In More Ways Than One!
Lemon balm(Melissa officinalis) is quite unrelated to lemons, and is actually a closer relative to mint. It does have a lemony fragrance, though!
You’ll find it in a lot of relaxing/sleepy preparations, so…
What does the science say?
Relaxation
Lemon balm has indeed been found to be a potent anti-stress herb. Laboratories that need to test anything to do with stress generally create that stress in one of two main ways:
- If it’s not humans: a forced swimming test that’s a lot like waterboarding
- If it is humans: cognitive tests completed under time-pressure while multitasking
Consequently, studies that have set out to examine lemon balm’s anti-stress potential in humans, have often ended up also highlighting its potential as a cognitive enhancer, like this one in which…
❝Both active lemon balm treatments were generally associated with improvements in mood and/or cognitive performance❞
~ Dr. Anastasia Ossoukhova et al.
Read in full: Anti-Stress Effects of Lemon Balm-Containing Foods
And this one, which found…
❝The results showed that the 600-mg dose of Melissa ameliorated the negative mood effects of the DISS, with significantly increased self-ratings of calmness and reduced self-ratings of alertness.
In addition, a significant increase in the speed of mathematical processing, with no reduction in accuracy, was observed after ingestion of the 300-mg dose.❞
The appropriately named “DISS” is the Defined Intensity Stress Simulation we talked about.
Sleep
There’s a lot less research for lemon balm’s properties in this regard than for stress/anxiety, and it’s probably because sleep studies are much more expensive than stress studies.
It’s not for a lack of popular academic interest—for example, typing “Melissa officinalis” into PubMed (the vast library of studies we often cite from) autosuggests “Melissa officinalis sleep”. But alas, autosuggestions do not Randomized Controlled Trials make.
There are some, but they’re often small, old, and combined with other things, like this one:
This is interesting, because generally speaking there is little to no evidence that valerian actually helps sleep, so if this mixture worked, we might reasonably assume it was because of the lemon balm—but there’s an outside chance it could be that it only works in the presence of valerian (unlikely, but in science we must consider all possibilities).
Beyond that, we just have meta-reviews to work from, like this one that noted:
❝M. officinalis contains several phytochemicals such as phenolic acids, flavonoids, terpenoids, and many others at the basis of its pharmacological activities. Indeed, the plant can have antioxidant, anti-inflammatory, antispasmodic, antimicrobial, neuroprotective, nephroprotective, antinociceptive effects.
Given its consolidated use, M. officinalis has also been experimented with clinical settings, demonstrating interesting properties against different human diseases, such as anxiety, sleeping difficulties, palpitation, hypertension, depression, dementia, infantile colic, bruxism, metabolic problems, Alzheimer’s disease, and sexual disorders. ❞
You see why we don’t try to cover everything here, by the way!
But if you want to read this one in full, you can, at:
An Updated Review on The Properties of Melissa officinalis L.: Not Exclusively Anti-anxiety
Is it safe?
Lemon balm is generally recognized as safe, and/but please check with your doctor/pharmacist in case of any contraindications due to medicines you may be on or conditions you may have.
Want to try some?
We don’t sell it, but here for your convenience is an example product on Amazon
Want to know your other options?
You might like our previous main features:
What Teas To Drink Before Bed (By Science!)
and
Safe Effective Sleep Aids For Seniors
Enjoy!
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Intermittent Fasting, Intermittently?
10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.
It’s Q&A Day at 10almonds!
Have a question or a request? We love to hear from you!
In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!
As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!
So, no question/request too big or small 😎
❝Have you come across any research on alternate-day intermittent fasting—specifically switching between one day of 16:8 fasting and the next day of regular eating patterns? I’m curious if there are any benefits or drawbacks to this alternating approach, or if the benefits mainly come from consistent intermittent fasting?❞
Short and unhelpful answer: no
Longer and hopefully more helpful answer:
As you probably know, usually people going for approaches based on the above terms either
- practise 16:8 fasting (fast for 16 hours each day, eat during an 8-hour window) or
- practise alternate-day fasting (fast for 24 hours, eat whenever for 24 hours, repeat)
…which latter scored the best results in this large meta-analysis of studies:
There is also the (popular) less extreme version of alternate-day fasting, sometimes called “eat stop eat”, which is not a very helpful description because that describes almost any kind of eating/fasting, but it usually refers to “once per week, take a day off from eating”.
You can read more about each of these (and some other variants), here:
Intermittent Fasting: What’s The Truth?
What you are describing (doing 16:8 fasting on alternate days, eating whenever on the other days) is essentially: intermittent fasting, just with one 16-hour fast per 48 hours instead of per the usual 24 hours.
See also: International consensus on fasting terminology ← the section on the terms “STF & PF” covers why this gets nudged back under the regular IF umbrella
Good news: this means there is a lot of literature into the acute (i.e., occurring the same day, not long-term)* benefits of 16:8 IF, and that means that you will be getting those benefits, every second day.
You remember that meta-analysis we posted above? While it isn’t mentioned in the conclusion (which only praised complete alternate-day fasting producing the best outcomes overall), sifting through the results data discovers that time-restricted eating (which is what you are doing, by these classifications) was the only fasting method to significantly reduce fasting blood glucose levels.
(However, no significant differences were observed between any IF form and the reference (continuous energy restriction, CER, i.e. calorie-controlled) diets in fasting insulin and HbA1c levels)
*This is still good news in the long-term though, because getting those benefits every second day is better than getting those benefits on no days, and this will have a long-term impact on your healthy longevity, just like how it is better to exercise every second day than it is to exercise no days, or better to abstain from alcohol every second day than it is to abstain on no days, etc.
In short, by doing IF every second day, you are still giving your organs a break sometimes, and that’s good.
All the same, if it would be convenient and practical for you, we would encourage you to consider either the complete alternate-day fasting (which, according to a lot of data, gives the best results overall),or time-restricted eating (TRE) every day (which, according to a lot of data, gives the best fasting blood sugar levels).
You could also improve the TRE days by shifting to 20:4 (i.e., 20 hours fasting and 4 hours eating), this giving your organs a longer break on those days.
Want to learn more?
For a much more comprehensive discussion of the strengths and weaknesses of different approaches to intermitted fasting, check out:
Enjoy!
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Diet Tips for Crohn’s Disease
10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.
It’s Q&A Day at 10almonds!
Have a question or a request? You can always hit “reply” to any of our emails, or use the feedback widget at the bottom!
In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!
As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!
So, no question/request too big or small
❝Doctors are great at saving lives like mine. I’m a two time survivor of colon cancer and have recently been diagnosed with Chron’s disease at 62. No one is the health system can or is prepared to tell me an appropriate diet to follow or what to avoid. Can you?❞
Congratulations on the survivorship!
As to Crohn’s, that’s indeed quite a pain, isn’t it? In some ways, a good diet for Crohn’s is the same as a good diet for most other people, with one major exception: fiber
…and unfortunately, that changes everything, in terms of a whole-foods majority plant-based diet.
What stays the same:
- You still ideally want to eat a lot of plants
- You definitely want to avoid meat and dairy in general
- Eating fish is still usually* fine, same with eggs
- Get plenty of water
What needs to change:
- Consider swapping grains for potatoes or pasta (at least: avoid grains)
- Peel vegetables that are peelable; discard the peel or use it to make stock
- Consider steaming fruit and veg for easier digestion
- Skip spicy foods (moderate spices, like ginger, turmeric, and black pepper, are usually fine in moderation)
Much of this latter list is opposite to the advice for people without Crohn’s Disease.
*A good practice, by the way, is to keep a food journal. There are apps that you can get for free, or you can do it the old-fashioned way on paper if prefer.
But the important part is: make a note not just of what you ate, but also of how you felt afterwards. That way, you can start to get a picture of patterns, and what’s working (or not) for you, and build up a more personalized set of guidelines than anyone else could give to you.
We hope the above pointers at least help you get going on the right foot, though!
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How Stress Affects Your Body
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Dr. Sharon Bergquist gives us a tour:
Stress, from the inside out
Stress is a natural physical and emotional response to challenges or being overwhelmed. It can be beneficial in short-term situations (e.g. escape from a tiger) but is harmful when prolonged or frequent (e.g. escape the rat-race).
Immediate physiological response: cortisol, adrenaline (epinephrine), and norepinephrine are released by the adrenal glands.
The effects this has (non-exhaustive list; we’re just citing what’s in the video here):
- Cortisol impairs blood vessel function, promoting atherosclerosis.
- Adrenaline increases heart rate and blood pressure, leading to hypertension.
- Stress disrupts the brain-gut connection, causing:
- Digestive issues like irritable bowel syndrome and heartburn.
- Changes in gut bacteria composition, potentially affecting overall health.
- Cortisol increases appetite and cravings for energy-dense “comfort foods”.
- This in turn promotes visceral fat storage, which raises the risk of heart disease and insulin resistance.
- Immune-specific effects:
- Stress hormones initially aid in healing and immune defense.
- Chronic stress weakens immune function (by over-working it constantly), increasing susceptibility to infections and slowing recovery.
- Other systemic effects:
- Chronic stress shortens telomeres, which protect chromosomes. Shortened telomeres accelerate cellular aging.
- Chronic stress can also cause acne, hair loss, sexual dysfunction, headaches, muscle tension, fatigue, irritability, and difficulty concentrating.
So, how to manage this? The video says that viewing stressful situations as controllable challenges, rather than insurmountable threats, leads to better short-term performance and long-term health.
Which would be wonderful, except that usually things are stressful precisely because they are not entirely within the field of our control, and the usual advice is to tend to what we can control, and accept what we can’t.
However… That paradigm still leaves out the very big set of “this might be somewhat within our control or it might not; we really don’t know yet; we can probably impact it but what if we don’t do enough, or take the wrong approach and do the wrong thing? And also we have 17 competing stressors, which ones should we prioritize tending to first, and…” and so on.
To that end, we suggest checking out the “Want to learn more?” link we drop below the video today, as it is about managing stress realistically, in a world that, if we’re honest about it, can sometimes be frankly unmanageable.
Meanwhile, enjoy:
Click Here If The Embedded Video Doesn’t Load Automatically!
Want to learn more?
You might also like to read:
Heart Health vs Systemic Stress ← this is good in and of itself, and also links to other stress-related resources of ours
Take care!
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Habits of a Happy Brain – by Dr. Loretta Graziano Breuning
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There are lots of books on “happy chemicals” and “how to retrain your brain”, so what makes this one different?
Firstly, it focuses on four “happy chemicals”, not just one:
- Serotonin
- Dopamine
- Oxytocin
- Endorphins
It also looks at the role of cortisol, and how it caps off each of those just a little bit, to keep us just a little malcontent.
Behavioral psychology tends to focus most on dopamine, while prescription pharmaceuticals for happiness (i.e., most antidepressants) tend to focus on serotonin. Here, Dr. Breuning helps us understand the complex interplay of all of the aforementioned chemicals.
She also clears up many misconceptions, since a lot of people misattribute the functions of each of these.
Common examples include “I’m doing this for the serotonin!” when the activity is dopaminergic not serotoninergic, or considering dopamine “the love molecule” when oxytocin, or even something else like phenylethylamine would be more appropriate.
The above may seem like academic quibbles and not something of practical use, but if we want to biohack our brains, we need to do better than the equivalent of a chef who doesn’t know the difference between salt and sugar.
Where things are of less practical use, she tends to skip over or at least streamline them. For example, she doesn’t really discuss the role of post-dopamine prolactin in men—but the discussion of post-happiness cortisol covers the same ground anyway, for practical purposes.
Dr. Breuning also looks at where our evolved neurochemical responses go wrong, and lays out guidelines for such challenges as overcoming addiction, or embracing delayed gratification.
Bottom line: this book is a great user-manual for the brain. If you’d like to be happier and more effective with fewer bad habits, this is the book for you.
Click here to check out Habits of a Happy Brain, and get biohacking yours!
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