The Thread · Underinsurance & Delayed Care
The Bill Comes Anyway
Underinsurance doesn't remove a cost. It moves it later and makes it bigger. A skipped visit becomes an ER trip. A denied stent becomes an amputation. A denied knee becomes a fall, then a hospital stay. The bill comes anyway — paid by the patient's body, by hospitals' uncompensated care, and eventually by everyone's premiums and taxes.
I · The Gap
A Card in the Wallet Isn't Care
"Underinsured" means you have coverage all year, but your out-of-pocket costs and deductibles are so high relative to your income that using it is out of reach. They had a card in their wallet. They still couldn't afford to use it.
23%
of insured adults 18–64 were underinsured in 2023 — about 1 in 4
57%
of underinsured adults skipped or delayed needed care because of cost
44%
of underinsured adults were paying off medical or dental debt
Source: Commonwealth Fund, State of Health Insurance Coverage in the U.S.: 2024 Biennial Survey (national survey).
II · The Toll
Not Just a Dollar Cost
~29,600
deaths a year among people who already have insurance that full coverage could prevent, according to a Yale School of Public Health model. Nearly 30,000 people a year, dying with insurance they couldn't afford to use.
The same model estimates about 33,200 deaths a year among the uninsured, and 51,311 more from coverage reductions enacted since 2025 — 114,174 in all.
How to Read This Number
It's a modeled estimate from a preprint posted July 2026 that has not yet been peer-reviewed. The authors note there are no direct counts of excess deaths among the underinsured, so they modeled that risk. It's a study about coverage — not about denials — and AbilityForge cites it only for coverage.
III · Stories
What Waiting Does
The first story is the founder's own. This section is built to hold more.
Michael Kissling · May-Thurner Syndrome
The $55,000 Stent
What May-Thurner Syndrome Is
In the pelvis, the right iliac artery crosses over the left iliac vein and presses it against the spine. That squeeze slows the blood returning from the left leg — and slow blood behind a pinch point is where clots form. It's often missed until a deep vein thrombosis (DVT) or chronic vein problems appear.
The fix is a venous stent: a self-expanding metal tube placed through a small puncture in the groin to hold the vein open. It's a catheter procedure, not open surgery.
Michael's first clot came at 15. Doctors found the May-Thurner compression behind it but wouldn't stent a patient so young. At 24, the specialists lined up: in November 2017 a hematologist wrote that he met the criteria for intervention — "He has both"; in December a vascular surgeon referred him to an interventional cardiologist "with experience in this pathology and intervention for this"; in January 2018 an MRA showed the vein narrowed "to an appearance of occlusion." He had already paid the out-of-pocket maximum, across two benefit years, for the imaging that proved he needed it.
On April 16, 2018, the plan changed to compression stockings, exercise and leg elevation. Michael and his wife say they were told in that visit that UnitedHealthcare had denied the stent and would require non-healing wounds before it would consider approving it.
The stent was finally placed in May 2020 — two years later, after an open ulcer had formed. A treating hematologist's 2021 note describes it that way: "he had unhealed open ulcer in his left lower extremity for which he underwent left iliac venous stent placement." By August 2020 it had clotted. A 2022 attempt to reopen it failed.
Wound care, hyperbaric oxygen and months of delayed Apligraf followed. In February 2023 the leg was amputated above the knee. The costs that followed — amputation, revisions, wound care, prosthetics — passed $1.1 million. A stent placed in time could have prevented it.
"They saved $55,000. The system paid $1.1 million, and I paid with a leg."
Why Timing Matters: Every Clot Makes the Fix Worse
A 2024 study followed 83 patients for three years after iliac vein stenting — 55 stented before any clot, 28 after one. Technical success was 100% in both groups. How many stents were still open:
Stents placed after a clot were about 2.6 times as likely to fail. Fix the pinch before the clot and the fix holds about 9 times in 10 at three years. Wait for the clot, and it's 2 in 3.
It's a single-center observational study, and patients who'd had clots also differ in vein damage and scarring — so it shows association, not proof that delay alone caused the failures. Michael's stent went in only after years of clots and an open ulcer — the later, harder end of this curve — and it clotted within about three months. Every year of waiting added damage the stent then had to work against.
More stories of insured patients priced out of care will be added here — see the Reason Room.
IV · The Math of Prevention
The Safer Knee Is the Better Deal
Microprocessor-controlled prosthetic knees (MPKs) adjust in real time to keep an amputee from falling. Insurers often deny them as too expensive. Two independent economic analyses say the opposite: denying the knee doesn't save money — it schedules the fall.
United States · RAND (2017)
- About 26% of MPK users fall in a year, vs. about 82% with mechanical knees.
- MPK users had about $4,220 lower healthcare costs per year.
- Net added cost over 10 years: about $10,604 per person — roughly $11,606 per quality-adjusted life year, far below common U.S. thresholds.
Germany · Kuhlmann et al. (2020)
- Fall-related hospitalizations dropped from 134 to 20 per 1,000 person-years (146 to 23 for people with diabetes).
- About 14–15 fall-related deaths prevented per 1,000 person-years.
- 97–99% probability of being cost-effective at a €40,000-per-QALY threshold, over 25 years.
Read It Straight
MPKs cost more than they save in direct dollars — so "pays for itself" goes too far. "Very likely cost-effective" is what the evidence supports. Both studies have industry ties: RAND's was commissioned by the American Orthotic & Prosthetic Association, and two of the four German authors work for Ottobock, which makes the C-Leg. Their findings point the same way.
Two Routes, Same Delay
Underinsurance and wrongful denial are two routes to the same delayed care. One prices the patient out; the other says no. Either way, the cost doesn't disappear — it waits, and grows.
Sources