The bill came to $51,148.73. It left them reeling.

"I really don't know how we would pay that," Honre said. "My wife isn't making enough money for us to pay this."

It's not just a money problem. The Ladson couple are in a jam because when Dawn lost her job, the pair lost their health insurance coverage, leaving them responsible for the entire bill.

Had they been insured by a private carrier or covered under the government's Medicaid or Medicare program for the poor, the cost of Honre's hospital stay might have been about 40 percent lower, thanks to discounts negotiated between hospitals and insurers.

The couple's story is not unique. It is an everyday fact of life in the American health care system, one that advocates for change say may finally be getting the attention it deserves.

The problem: The nation's estimated 41 million uninsured are expected to pay for health care at prices that are far higher than what private insurers or the federal government pay for the same procedures.

"Those who have the least, pay the most," said Sue Berkowitz, director of the South Carolina Appleseed Legal Justice Center, an advocate for the poor.

That's not exactly right. The very poorest are covered by the government's Medicaid or Medicare programs. It's those who lack insurance altogether who are penalized the most by the system.

Oftentimes, hospitals aggressively collect these debts, referring bills to lawyers and collection agencies, filing lawsuits and placing liens on homes.

That hasn't happened to Deveaux and his wife. Instead, they have filed for bankruptcy protection to safeguard their home from being seized.

Now, hospital companies across the country are coming under fire to change things, and the pressure The American Hospital Association itself sent a notice to its 4,800 member hospitals in June urging them to start providing discounts to the uninsured, to be more up front about charges and to ease up on some of their collection practices.

Congress is responding, too. The House Energy and Commerce Committee has launched an investigation into consumer complaints of hospital billing practices. This summer, it asked 20 of the largest hospital companies to provide billing information for the past five years.

Health industry officials say it's not a problem created by the hospitals. In their view, the blame lies with the federal government because its rules don't leave room for negotiated discounts with the uninsured.

Officially, the government requires that hospitals charge everybody the same amount for every procedure. Yet Medicare and Medicaid can pay much lower amounts than what hospitals charge because of the markdowns the government negotiates. Private insurers, meantime, negotiate their own deals with hospitals under which they, too, pay a smaller percentage of the bill.

Donna Thorne, a spokeswoman for BlueCross BlueShield of South Carolina, likened it to the group rates companies of all sorts provide their largest customers. An insurer like BlueCross BlueShield represents tens of thousands of members, so hospitals are willing to provide discounts to get access to those prospective patients, she said.
Lynn Bailey, a health care economist in Columbia, said the general rule of thumb in South Carolina is that insurers get a 40 percent discount on charges.

Thus, if an insured patient were to undergo the same procedure that Honre Deveaux did, the bill may come to about $20,000 less, or roughly $31,000.

When they're not trying to collect outstanding debts, hospitals will often write off as charity any care provided to the poorest of patients. Those who do get charged the full amount tend to be those who have no health insurance but still work and have some assets. Some call them the working poor.

"There is a very real problem for people who are not poor enough to qualify for charity care but not rich enough to afford" insurance, said Carmela Coyle, senior vice president for policy at the American Hospital Association. "There is a real problem and a real dilemma for the working poor."

In many cases, hospitals will designate the debts of the uninsured as charity care, or they simply write them off their books as uncollectible debt.

Yet some hospital companies around the country appear to make money off this population. According to the House committee's letter asking for information from hospital companies, one chain -- Tenet Healthcare -- attributed 35 percent of its profit to self-pay, uninsured and walk-in patients.

Under increasing pressure to make changes, some big hospital companies have made efforts to offer the uninsured discounts. Tenet, which earlier this year settled a price-gouging lawsuit brought by 10 Hispanic patients, has just such a plan awaiting regulatory approval. Tenet owns East Cooper Regional Medical Center in Mount Pleasant.
Another big hospital company, HCA, which owns Trident Medical Center in North Charleston, also has a plan awaiting approval.

Some hospitals already offer discounts to their uninsured patients. The Medical University of South Carolina, for instance, allows uninsured patients to pay off their bill on a sliding scale.

And uninsured or underinsured patients can oftentimes negotiate a reduced bills.

Gene Harris did that. A Mount Pleasant small business owner, Harris has insurance that covers only catastrophic illness. When he, his wife and children need to see a doctor, Harris pays cash.

Two years ago, Harris had surgery at East Cooper hospital on his left elbow. He expected a bill of a few thousand dollars. Instead, he was floored when the bill exceeded $14,000.

Harris was angry at the size of the bill, but he paid $1,000 immediately and wanted to make payments. The bill was sent to a collection agency, which hounded Harris for months. Eventually, Harris got the agency to accept less than $7,000.

"I had to negotiate with them," Harris said. "I got it down to a reasonable level, but I don't know why they didn't do that in the first place."

The uninsured have other resources, most notably Project Care, a local effort to provide health care to the working poor who make between 125 and 200 percent of the federal poverty level, or between $18,287 and $29,260 annually for a family of three.

Honre Deveaux didn't know about Project Care until after he had the heart attack.

But even a discount from the hospital on his $51,000 bill probably wouldn't have kept the couple financially afloat. They had other debts and so sought bankruptcy court protection. Big health care bills are the second leading cause of bankruptcies in the United States, studies say. "We got so behind on our bills," Honre said, "it was all these things coming together at one time."

Today, Honre works part time with his wife as a Market Street vendor. She is thinking of returning to her old job in hotel management. He had one heart-related scare on Father's Day but says he's fine for the most part.

"I'm paranoid all the time," Honre said. "It makes me think I'm having another attack every time I have problems."