"However, I have an American friend who is quick to point out that apparently nobody actually pays those bills. They’re just some elaborate dance between insurance companies and hospitals. If you don’t have insurance, the cost is lower or removed entirely. Supposedly."

Partial Truth.

Healthcare providers have negotiated prices for services. These prices are negotiated per insurer.

Blue Cross and Blue shield will pay them X dollars for Deep Sleep anesthesia. United Healthe care will pay them a different amount. Medicare will pay them yet a different amount. Bob's backyard healthcare will pay more because they don't have buying power.

If you walk in without coverage, the provider "can" charge you a reduced rate. They are not required to. They do NOT universally offer that.

If you get the procedure done anyway, agree to pay and cannot pay your health bill, the provider "can" just let you off the hook or reduce your rate. They do NOT usually do that. That's the exception.

If you go to a provider that accepts your insurance (they all do not) and book a procedure, the provider has to get the procedure covered by the insurer. If the insurer decides not to cover the procedure, you can call the provider and try to create a grievance. The back-and-forth is maddening.

My local doctor said I needed a colonoscopy (it's just that time, no emergent issues)

My insurer authorized the procedure but not the anesthesia.

The office offered to pay out of pocket for the anesthesia ($1200), but I declined because I couldn't afford it. They also offered to set up payments if I paid 50% upfront, but I declined because that didn't help me. I can't take on another $100 / month for 12 months.

I spoke with the GI doctor, a second GI doctor, and my General Practitioner. They all said that people here really don't get the procedure without anesthesia, and it was a bad idea for both the doctor performing the procedure and for me.

I contacted the insurer, but they refused. Another GI doctor contacted the insurer, but they refused.

My insurer decided in January that they will not cover anesthesia for a colonoscopy unless someone can prove you're frail enough it might kill you.

We have federal laws that mandate insurers to cover the anesthesia for this procedure, but state-level insurers (hint: they're all state now) don't have to follow their rules.

So here I am, two years late for a colonoscopy, wondering if I have pre-cancer or cancer brewing down there, but can't manage to pay for what is considered by all providers here a necessary part of the procedure.

It's not great here.