Monroeville-area residents Brian and Marleen Friday have three jobs between them and no health insurance.
So when Brian, 48, a self-employed home repair and maintenance worker, developed a hernia for the second time in 2010, he figured he had only a few choices: Tough it out; schedule an appointment and expect a multiyear payment plan to cover the expected $6,000 to $9,000 cost; or get the procedure done and then tell the hospital he had no way to pay for it.
He chose to tough it out for 18 months, working through the grinding pain that would keep him awake at night or flare up each time he lifted a bag of cement while repairing a sidewalk.
Hernias, which manifest when internal organs bulge through the weakened muscle wall in the lower abdomen, are often caused by heavy lifting, something that's "part of the deal" in Mr. Friday's line at work. He couldn't afford to not work, but work kept him from getting better.
Unable to sleep and constantly in pain, he eventually realized he could no longer wait. The answer to his prayers, it turned out, was a four-hour drive away in Germantown, Md.
The Fridays are among the 50 million or so Americans without health insurance, about 60 percent of whom have at least one full-time worker in their family, according to the Kaiser Family Foundation.
When the Centers for Medicare and Medicaid Services recently released the amounts that hospitals charge for certain procedures, reports -- and the hospitals themselves -- pointed out that almost no one is actually responsible to pay that $45,000 for an appendectomy or $80,000 for a heart bypass because the rates set by Medicare or negotiated with private insurers are much lower.
No one, that is, except the uninsured. Even then, the argument goes, the poor have medical assistance and other government programs, and hospitals have free care funds and often offer steep discounts.
Turns out, the picture looks quite different from the other side.
"It just seems like an insurmountable job, trying to figure your way through the medical process without insurance," Mr. Friday said. "It's scary to know you need surgery and not be able to get it."
The Fridays don't believe they qualify for medical assistance, but they got a taste of the process once when Mrs. Friday applied for a medical study for low-income families.
"No matter how many forms you fill out, there's another one in the mail that has to be done in triplicate," Mr. Friday said.
"By the time you do it, jumping through the hoops, is it worth it? Is it worth it to be humiliated in every fashion? Even if you do apply, they drag it out and make it so complicated. It's like they're saying, 'If we make it hard enough, maybe you will give up.' "
Mrs. Friday, a part-time nanny and teacher's aide, checked Internet websites of hospitals throughout Pennsylvania and found they wanted anywhere from $6,000 to $9,000 to repair a hernia. With incomes from three jobs, the Fridays figured they had little chance at getting a discount that would make the procedure affordable.
Said Mr. Friday: "I knew the financial mountain that was in front of me in this, and there was no way I was going to give it to them."
Then his wife found an intriguing alternative: Alan Kravitz, a general surgeon with two Maryland offices, in Rockville and Germantown, whose practice is almost exclusively repairing hernias for a set cost of $1,900.
The online reviews, many from other families without health insurance, raved about the doctor.
Dr. Kravitz impressed them, too, during an initial phone consultation. "He's very professional and he talks you through the process," Mr. Friday said.
For the appointment the following week, he went to the doctor's Germantown office the afternoon before for an examination. The next day, Dr. Kravitz performed the near-hourlong procedure and a friend drove Mr. Friday home that evening. Since then, the doctor has followed up three times by phone.
The whole process was carried out with assembly line precision, Mr. Friday said, but in a manner "that was very professional and very friendly."
He said it took "a couple of weeks to get up to full steam" after the surgery in February 2012, but Mr. Friday said the repair has worked better than his first one years earlier in Michigan -- which was covered by health insurance. Eighteen months later, he remains healthy and able to work, with no outstanding medical bills hanging over his head.
He gives full credit to Dr. Kravitz. "He could be making way, way more money if he wanted, but he does this because he wants to help people."
And Mr. Friday thinks hospitals everywhere could take a lesson from his experience.
"You can't profit from the pain and suffering of people. If you say you're not making a profit, you'd better be able to back that up," he said. "Do they really care about human life? Or is it just another button on the cash register? Because that's what it seems like to me."
Steve Twedt: firstname.lastname@example.org or 412-263-1963.