S8 E8: 100 Seconds to Midnight: To Live or Die Part 2

To Live or Die Part 2: Having Insurance Isn’t the Same as Getting Care

The cancer is gone. The nose is reconstructed. The bills? Still here.

In Part 1, I told you how getting cancer surgery became a scramble to raise money—even though I had health insurance. This time, I’m finishing that story. Reconstruction and recovery went well, my plastic surgeon promised me the sexiest nose in Springfield, and I’m still waiting on that last part.

I also still owe about $600 on the surgery. Further treatment for the scar is considered cosmetic under my coverage, so my insurance won’t pay for it.

Then we pick up the history: Medicare and Medicaid, managed care, employer health plans, the Affordable Care Act and the rules shaping access today. We look at deductibles, upfront payment demands, coverage decisions and the companies handling healthcare money.

The point is simple: a service can be covered by a policy and still be financially out of reach for the patient.

I’m advocating for universal access to healthcare in the US. I’m open to different ways of getting there. We’ll examine public financing, regulated insurance systems and a public option—and ask whether each approach actually gets people the care they need without financial hardship.

And our “What if?”: what happens to the next person who needs surgery but doesn’t have an audience, a fundraiser or friends who can afford to help?

Research note: medical expenses and illness-related income loss can contribute to bankruptcy. Studies use different definitions and methods; this episode does not claim that healthcare is definitively the leading cause. Policy details reflect September 30, 2026.

American Academy of Dermatology — Mohs surgery

https://www.aad.org/public/diseases/skin-cancer/types/common/melanoma/mohs-surgery

National Archives — Medicare and Medicaid Act (1965)

https://www.archives.gov/milestone-documents/medicare-and-medicaid-act

CMS — Medicare and Medicaid milestones (1937–2015)

https://www.cms.gov/About-CMS/Agency-Information/History/Downloads/Medicare-and-Medicaid-Milestones-1937-2015.pdf

US Department of Labor — ERISA

https://www.dol.gov/general/topic/health-plans/erisa

US Department of Labor — Self-insured health plans (2026 report)

https://beta.dol.gov/research-data/surveys-reports-publications/2026-report-congress-annual-report-self-insured-group-health-plans

US Department of Labor — COBRA continuation coverage

https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/publications/workers-guide-health-benefits-cobra

HHS — HIPAA Privacy Rule and the 1996 law

https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html

HealthCare.gov — ACA rights and protections

https://www.healthcare.gov/health-care-law-protections/rights-and-protections/

HealthCare.gov — Annual and lifetime coverage limits

https://www.healthcare.gov/health-care-law-protections/lifetime-and-yearly-limits/

IRS — Employer coverage provisions and the 50-employee threshold

https://www.irs.gov/affordable-care-act/employers/employer-shared-responsibility-provisions

HealthCare.gov — Cost-sharing reductions

https://www.healthcare.gov/lower-costs/save-on-out-of-pocket-costs/index.html

CMS — No Surprises Act protections

https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/know-your-medical-bill-rights/know-your-rights-insurance

IRS — Premium tax credits and changes for 2026

https://www.irs.gov/affordable-care-act/individuals-and-families/questions-and-answers-on-the-premium-tax-credit

CMS — Medicaid community-engagement requirements (2026 rule)

https://www.cms.gov/newsroom/fact-sheets/medicaid-community-engagement-requirement-certain-individuals-interim-final-rule-comment-period-cms

HealthCare.gov — Premiums, deductibles and total costs

https://www.healthcare.gov/choose-a-plan/your-total-costs/

HealthCare.gov — What an out-of-pocket maximum excludes

https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/

HHS OIG — Medicare Advantage denials (2022; sampled 2019 requests)

https://www.oig.hhs.gov/reports/all/2022/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/

FTC — Prescription drug middlemen (2025 interim staff report)

https://www.ftc.gov/news-events/news/press-releases/2025/01/ftc-releases-second-interim-staff-report-prescription-drug-middlemen

FTC — Hospital mergers and prices: New Hanover–Cape Fear

https://www.ftc.gov/reports/effect-hospital-mergers-inpatient-prices-case-study-new-hanover-cape-fear-transaction

CMS — Historical US health spending (2024 actual totals)

https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/historical

Himmelstein et al. — Medical Bankruptcy (AJPH, 2019; survey contributors)

https://doi.org/10.2105/AJPH.2018.304901

Dobkin et al. — Economic Consequences of Hospital Admissions (AER, 2018)

https://doi.org/10.1257/aer.20161038

WHO — What is universal health coverage?

https://www.who.int/news-room/questions-and-answers/item/what-is-universal-health-coverage

European Observatory — Canada’s health system

https://eurohealthobservatory.who.int/countries/canada

European Observatory — Germany’s health system (2024)

https://eurohealthobservatory.who.int/publications/i/germany-health-system-summary-2024

CBO — Single-payer design choices (2019)

https://www.cbo.gov/publication/55150

CBO — Public option design choices (2021)

https://www.cbo.gov/publication/57125

Medicaid.gov — State choice following the Supreme Court ruling

https://www.medicaid.gov/faq/2020-04-14/93246

CMS — Part D established in 2003; coverage began in 2006

https://www.cms.gov/Medicare/Eligibility-and-Enrollment/LowIncSubMedicarePresCov/Downloads/StateLISGuidance021009.pdf

Cause of Death – 100 Seconds to Midnight explores threats that could bring civilization to the brink—and the science, people and solutions that might keep us from getting there. Everything is connected. Even your nose and a federal statute, apparently.

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“Time Off” by Damma Beatz

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If this episode made you think, pass it along. Necessary healthcare shouldn’t depend on how good you are at asking strangers for money.

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