Perchance to Dream?

“Doc, I finally got insurance!” She danced a little jig with her cane right there in the hallway as my staff was getting her weight and vitals. The medical assistant had to catch her as she lost her balance.

“Really? Woohoo! Off the exchange site?”

“Yep.” She beamed. It had been a tough three years of treating her psychiatric issues, severe osteoarthritis, and diabetes without medical coverage. “I want you to do the works, Doc. Whatever I need, let’s do it.”

Eagerly, I set about ordering her colonoscopy, mammogram, PAP, immunizations, diabetic eye exam, lab work…

I was very excited for her.

I was also a little bit excited for me. Finally, she would stop bringing down my preventive care numbers.

Two weeks later, I got the note requesting a diagnostic mammogram. Her screening mammo had found a suspicious mass in her right breast.

I dialed her number to give her the bad news.

There was the expected silence on the other end of the line.

“Look. Don’t worry about this. Most of the time it ends up as nothing.”

More silence.

“Are you OK?”

“Doc, how much is this going to cost? I have one of those high deductible plans. It was the only one I could afford. I don’t have the money.”

It was my turn for silence.

Finally, I said, “This needs to be done, I’m afraid.”

“I just can’t do it.”

“Look, this might be cancer. You should not ignore it.”

“I just can’t do it.” She hung up.

Several months later, she sold her house and finally got that diagnostic mammogram and then the biopsy and mastectomy and radiation and chemo….

Was this a win for the ACA? Maybe. We found a cancer that we did not know existed. But what good is screening coverage for patients that cannot afford that diagnostic mammo or colon resection? If this is supposed to help people who cannot afford insurance or healthcare, it seems that it actually falls rather short of that goal. Her treatment, in the end, cost her tens of thousands of dollars. Her entire life savings at age sixty-two.

My post, “Bridging the Gap With Silk Draperies” illustrates further what can happen with high deductible plans. Do they decrease costs by making patients bear more of the weight of cost? Sure. But at what larger expense, I wonder? Is anyone even studying that?

I ask because this is not an isolated incident in my practice and there are many of the ACA plans that I do not take.

Does this mean we should trash the whole thing? No, not necessarily. Perhaps I am naive, though, because I expected more…


108 thoughts on “Perchance to Dream?

  1. It seems like the health care system you have in place is not standing up to the test. (more ways than one) Canada may have gotten a lot of those things right. You may have a little wait but things do get done here.

    Liked by 5 people

  2. Sigh. It just astounds me that Americans will allow insurance companies to have any involvement in medical care. Some things are too vital, too sacred, to allow a for profit corperation to have control over. When you think about all the infrastructure and services that are paid for collectively likes roads and schools and defence budgets, it is so obvious that medical care should be on the top of that list.

    Liked by 10 people

  3. You and a lot of us expected more and we should have gotten it but instead of innovative and clean sweep we got a mish-mash of bureaucratic, designed by committee (never good), so-called compromise. The high deductibles was part of the bait and switch.

    Working for the ACA/ I got to see several views of the system. The effed up computer system got all the buzz but it was only part of the nightmare. States that didn’t expand Medicaid? They created a no-man’s land where you still couldn’t get insurance. Those were horrible calls. In other instances, other states, you’d get people who qualified for some insurance but yes, often the deductible was ridiculous. A $2000 deductible for a single person making $18K isn’t considered to be catastrophic coverage (where the deductibles start at $4000) but c’mon? Really?

    Some people were so much fun to help because they had a combination of the right numbers and the right states. How nice to tell someone they had a $0 deductible and a $21/month premium?!

    It was BS that some states got to back out of the Medicaid expansion. We weren’t allowed to get political, and that was very difficult as people started screaming about Obama when actually the fault was firmly with the state legislature or governors. (And yep, I let the consumers know that. I can tightrope!)

    The ACA did open up some good doors but, um, my comment is getting longer than your post. 😀

    Liked by 6 people

      • The worst calls were from Florida, Texas, Georgia, North Carolina and Tennessee. There were many more states that also didn’t expand, but for our call center, those were the top calls no one wanted to take. It probably varied from call center to call center. The two biggest horrors, for me, personally were Florida and Texas and those two states also had the most people yelling about lousy Obama. :::shakes my head:::

        Liked by 2 people

  4. The ACA was never going to be the perfect solution. It is a Republican-conceived plan, but it was all that was going to get through Congress. It needs serious work. But it is a start.

    I feel sad for the patients and doctors like you who have to deal with the repercussions of a system that just gives a little, when a lot is needed. By the same token, I have limited sympathy for the folks in this mess who continually vote for politicians who do not work FOR the things that we all need.

    Liked by 2 people

  5. Isn’t the “requirement” of a screening test be that it is meant to detect a condition in its early stages, that has an effective treatment or prevention strategy, which can significantly reduce the morbidity and mortality associated with the condition… oh, and that it be affordable? I only bring this up because it seems to me that insurance companies (at least the ones you describe) go directly against this notion: They cover the cost of the screening test, thereby making it affordable and accessible, but then they restrict/deny/hinder access to effective treatments by having high deductibles when there needs to be medical action taken based on the results of that screening test. It would almost be better if they didn’t cover the cost of screening if they aren’t going to do anything else. As the definition of a “screening test” suggests, it shouldn’t be available or offered to people if there is no “acceptable” way to treat the disease. I realize that what I’m saying would only increase the disparity and accessibility of services to people who can’t afford them. However, it’s like the insurance companies are just making more money off these “at risk” populations:
    “Here, we’ll be nice and give you all that screening for free, but if you’re really sick, then we’ll take your huge deductible and still not cover the complete cost of your treatments.”
    I completely agree with what John Callaghan had to say above…

    Liked by 4 people

  6. I don’t understand most of this. And that’s not just terms like ACA and high deductible plans, I just don’t get how an advanced society can let vulnerable people go to the wall. I knew you had to pay for healthcare in the US, but I thought if you had no money, you would still get care. Is that not right?

    Liked by 2 people

  7. I agree with Elyse–it’s not a perfect system, but it’s a start. It will take tweaking, no doubt. And those high deductibles are ridiculous. There is no way many families will be able to meet them. Finally getting health insurance should not be a burden like it turned out to be for this poor woman.

    Liked by 3 people

  8. My individual deducible is $5,000 a year, and that’s on top of the $12,000 a year premium, and of course, there are the additional prescription copays. If my company didn’t cover every penny of the deductible and the copays, I would not be able to afford my Remicade treatment. I don’t know about anyone else, but I do not have $5000 a year to pay out of my own pocket, especially since I haven’t had a salary increase in 10 years.

    Liked by 2 people

  9. I am very surprised! Did you expect more? Our drug insurance premiums rose 19.6% in 2015 and copay for generic Ramipril increased 13 times. What else could you expect? This law takes money fron senior citizens who worked many years and live on their SSA and gives it to people who have never worked. It is good for insurance and pharmaceutical companies that supported democrats. .

    Liked by 2 people

      • It’s not about politics. I stopped taking two medicines because our expenses went up drastically. COLA this year only 1.7% but actual inflation for senior citizens is more than 10%.

        Liked by 1 person

      • Seniors have been hit terribly. Seniors and veterans should be top priorities and yet they are not. Medicare ties physician’s hands in red tape. For instance for an insured person, I can just send an electronic prescription for glucometer test strips and say PRN (as needed) refills for one year. For Medicare patients I cannot send it electronically. I have to print it out, physically sign it, fax it. I have to write the diagnosis on it AND the numerical ICD code for the diagnosis, specify an exact quantity of test strips and specify 12 refills (not as needed). This is stupidity. So, yes. I agree seniors are hit harder.

        Liked by 1 person

  10. You and other commentators raise many important points of frustration with the ACA! The good news for your patient is that every plan on the exchange has a maximum that patients have to pay out of pocket before the insurance companies take over (my understanding is $6350 each year for an individual). Your patient may want to talk to a health navigator to review the coverage and make sure the insurance company is covering its obligations.
    I practice in Illinois, where Medicaid expanded (thank god). My patients at the community health center definitely have better access to specialists and needed testing than before. Except the rise in generic drug prices is infuriating–my patients who are still uninsured (undocumented immigrants) are worse off than before! It makes me angry that all the people in all the states who didn’t expand Medicaid now have to pay up to 400% more for the medications that used to be $4 at Walmart or Target! Grrr…


  11. It must be so hard to see this happening Victo. It has to twist you up. Sigh. I felt bad when I read your drapes story. I mean you have spent so much money and so much time just in training so that you can help people – surely you should be able to buy a set of drapes without thinking how that money could help someone else. I knwo the insurance companies are hard and unfeeling and yet, as much as they are making pofit, they are still reflecting the cost back. For instance here in Canada if you make, say $50k a year, you are taxed (including all taxes) about $25K. Of that about $13K goes to health care. My own medical problems have made it so that no one wants to employ me which has forced me to go on disability. At least I have medical care. Americans are used to iving in a manner that does not include health care costs which rise very sharply as we age. So, I worked for about 40 tears before I needed serious health care, if we say an average of $50k (some years lower, some higher) – I paid about $520,000 (40 yrs at $13k per year), before I even spent a night in the hospital. I’m sure, in my case, that in the inteveneing years I have used close to a million dollars in health care. I could never have afforded to use a pay as I go system, which is basically what your system is wth the deductibles. How could I ever have told an insurance company that they had a million dollar bill over 5 years? It cannot work and it really isn’t the insurance companies’ fault. Americans are not putting enough aside in their productive years to cover the costs of aging. That’s the bottom line.

    As much as this situation is untenable, you are truly on the front lines Victo and I am sure it is very hard on you. It really is not your fault even though it has become your problem. I wish you the least worry possible. You and your colleagues bring so much care and happiness to this world, it seems unfair for you to shoulder this burden.

    Liked by 2 people

  12. The ACA is big and it was built by Congress steered by lobbyists. Since Congress is incompetent to address almost every subject it tackles, this tells you right away that the act is full of mistakes and bad policy decisions. Before Congress became hyper-partisan, the process was to pass a law, watch its operation to see where the mistakes were, and then address the mistakes. Over a few years, this can lead to convergence on something that will be judged by people in the political center to work reasonably well.

    Today, apparently, the process is to pass something (anything that can get passed), see that it is full of mistakes and bad policy decisions, and then throw it away. It would then be replaced by another big act, full of different mistakes and different bad policy decisions. Sorry, folks, but I’m pretty sure this process will never converge.

    Liked by 2 people

  13. I am very grateful for your writing about a real-life illustration. It’s actually the first, dry reading I’ve had from a practitioner.

    I am getting frustrated about reading about why the law is flawed from those who have a political rather than a medical agenda. However, I do agree that it’s also hard to look at this without viewing through *some* political prism. My own partisan beef is that the GOP is speaking out of both sides of its mouth: On the one hand they want to dismantle and destroy the ACA, but on the other hand they also want to keep the parts of it they like. You can’t do both. The GOP has to make its up its mind whether they even agree that universal coverage is a good thing or not. Until there is any kind of cogent plan from those who oppose, I guess we have a very crippled system — which may be their diabolical plan. Thanks again for writing this.

    Liked by 1 person

  14. ACA is not a panacea. In fact, it is so watered down, which was required to get it passed at all, that it’s a mess. The original idea of a single payor would have been so much better, but between the balking health insurance companies and the Republicans crying “Socialism” — which is apparently one of the dirtiest words in American politics — we ended up with complex, convoluted health care “reform.” And as some have already commented, it is hard to understand why the United States stands alone as the only industrialized country that doesn’t provide every citizen with free or affordable health coverage.

    But at least the woman was able to get the diagnostic care that uncovered the mass, something that might not have happened without ACA.

    Liked by 2 people

  15. This makes me crazy and scared to ever retire. The wondrous drugs they are coming up with and then price them out of the reach of the consumer makes no sense to me. My monthly shot is $1800.00 and yes that many zeros. I am covered by my job. But they look at the high cost end users at work, even though it is confidential and no name is stated, it does not take a lot of smarts to figure out who has MS, PsA and the other immune diseases that use these high cost drugs.
    On a good note, even though the lady had to sell her house, she did live and would have not had you done the tests.
    On a bad note, we all will probably end up penniless if we live long enough.


  16. Personally, I hate what the ACA turned into (vs. what it could have been). But please note that ANY insurance policy drastically reduces the out-of-pocket amount for the individual. When I was in law school (decades before ACA), I had a high-deductible policy from the state insurance pool because I was single, self-employed, and otherwise uninsurable due to a prior condition. The policy had a $15,000 out-of-pocket limit before it kicked in any money.

    Even though I wound up on the operating table, the insurance never paid anything because I never hit the limit. Why? Because although if I’d had NO insurance, the hospital would have charged me over $25,000, the amount due got reduced to $1,500 by the time they got through slashing their charges to match the amount allowed by their contract with the insurance company. Okay, I didn’t have $1,500 either, but they let me pay that off over time. I would still be paying on it if I’d been hit with the total $25,000.

    Don’t beat yourself up too much over this. You are too nice a doctor and we need all of those we can get. I feel sorry for the lady, and I don’t know what was in her mind, but I do know that patients will sometimes use cost as an excuse to put off “finding out” about a suspicious mass when the real culprit is fear. (Hell, I’ve done it myself.)

    Liked by 1 person

    • Actually, I had felt her boobs and there was nothing palpable. I think she was avoiding the cost of the mammo and not the possibility of something being wrong. What are the odds, right? But she would have never done it in the first place without the ACA so there was that.


      • Just to clarify: I was talking about the diagnostic mammo (not the screening mammo), which is where you said your patient started balking at the cost, even after you brought up the “C” word.

        BTW: my wife, the nurse, just got her regular mammo and came home with a suggestion. She thinks all men above 40 should have a testicular exam using the same procedure. I think she might have some displaced anger. As a doctor, do you think she’s right?

        Liked by 1 person

  17. We tend to sometimes believe the propaganda that all other countries should aspire to be as amazing as your wonderful country. Then we see your crazy legal system and how many are failed by your health system and we think, this isn’t a bad old country after all.

    Liked by 1 person

  18. I wouldn’t know what to say about this even if I did understand all the intricacies, which I don’t, but I do sympathize, both with the people who have to go through all this on top of having health matters to worry about, and with you, because I know that if there was any possible way to just heal them all at no cost to anyone, and still manage to make a living for you and yours, that you would do it in a heartbeat. It really is a messed-up world at times and we all just do the best we can.

    Liked by 1 person

  19. As a native person in Alaska, I get “free” medical care at our native hospital. It’s beautiful and non native people often go on about how lucky we are. I won’t discount the benefit completely however, it’s not all it’s cracked up to be.

    Liked by 1 person

  20. It is not really “affordable” for everyone when they still have to meet high deductibles I was in the administrative/claims side of healthcare for years and nothing seems to work. Yet the ACA has helped many. Texas choose not to cover more with Medicaid. It is hard for physicians, I know.

    Liked by 1 person

  21. Psh, I have “the good” insurance, and I still put off going in unless I’m ill, because it costs too much out of pocket. Our “good” insurance, through my husband’s employer, is our second largest expense each month. More than groceries for 4-6 and almost as much as our mortgage. It’s terrible. Just terrible.

    While I’m glad your patient was able to receive treatment, I’m deeply disturbed at what she had to sacrifice to get it.

    Liked by 1 person

  22. everyone wants care but no one wants to pay for it, especially those that can contribute to the system (the 1%). of course they dont contribute a dime, burden falls on the middle class, while many fall through the cracks using medicaid and abusing the system. its a giant game of jenga they keep adding blocks to…

    Liked by 1 person

  23. I live in Texas and our good ole GOP gov has made a living hell for the peons. My daughter has been it for the past 3 years since beign diagnosed with a weird kind of arthritis. She was a wonderful veterinarian with a mobil practice. Without my help she would have lost her house, SUV and everything she worked for. Medical expenses have chipped at her self esteem. Depression is taking its toll. Blue Cross/Blue Shield deductible is thousands. She is not able to work. But I know that things could be worse. I continue to draw on my savings- I’m lucky to have civil service retirement.

    My daughter’s plight is not unique. There are millions of folks that do not have someone that can help. ACA has been a nightmare from hell. And I’m afraid that it will get much worse before it gets better or completley nixed by the GOP. Frankly it was a disaster waiting to happen. The US is in a sad state of affairs. We are being smothered by insurance and pharmaceutical companies and a government that no longer knows what it is doing. Yes, I am bitter.

    I’m so sorry but this seemed to be a good place to rant.

    Liked by 1 person

  24. $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

    …. the bottom line.

    Liked by 1 person

  25. Very sad, sad story….First, I am reminded of my mother (RIP) mainly because she was sickly and passed away at 64. Second, I am reminded of those cancer survivors that I met when I worked for a magazine — a lot of them didn’t have that much money to use for the needed medication.

    In the Philippines, it’s hard to be poor. There are very little benefits, if at all. There are public hospitals but considering the kind of government we have, health for the poor isn’t really in its priorities. It’s a good thing both my parents were professionals with health benefits that they were able to use up until they passed away. I’m not a sickly person so I’ve never really used mine yet. They were not my dependents because they had their own so there was no need for them to use mine.

    I know in the US, people have complaints about healthcare. But honestly, we do envy what you have already. Much better than we have here.

    Liked by 1 person

  26. I know this is off the point, but how much DOES a diagnostic mammogram cost over there? I’ve had one here and it wasn’t that expensive. Probably not something someone who has no job can easily pay for, but definitely something one can find a way to get done if really necessary. (Borrow money from family, say.) I’m wondering if the reliance on health insurance may actually drive up healthcare costs…?

    In the Philippines, basically, you get the healthcare that you can pay for. The national health insurance system pays for some stuff but only up to a certain amount. It’s awful for the people who have nothing — in the OB wards of some government hospitals here, for example, you can find 3 women and their babies sharing one bed because it’s the only hospital they can afford and all the beds are occupied beyond capacity. A huge number of diseases go undetected, and then a huge portion of those that are detected aren’t treated. (It’s a ripe field for those cure-all supplements touted by the unscrupulous.)

    That said, I have to say, having worked on the fringes of your healthcare system for a while, I don’t envy how complicated it is there, with all the health insurance. Having to get authorization to see a specialist, for example, and having to wait days (or sometimes weeks/months) to see the in-plan specialist. Here, you’d just show up at his/her clinic. You’d have to pay around $10 for the visit, but you CAN see one if you really need one, when you really need one.

    Pros and cons everywhere, I guess; lots of suffering all around.

    Liked by 1 person

  27. In Australia you pay a 2% levy on you taxable income (ie after all allowable deductions) but if your income is low you may not even pay anything. The lady who sold her house would have gone to a govt hospital and been treated for free. But if she was wealthy she may have chosen to go to the hospital next door (private and paid more. Lets say she was a primary school teacher or a shop assistant and was married and had two children and her husband also worked as for eg a truckdriver they would have probably taken out private health insurance and then had the choice. In my town there is a public hospital and next door a private hospital. It is a toss-up as to which is the better of the two. I seriously think we are the luckiest country.

    Liked by 1 person

  28. I really feel for this lady having that kind of worry and stress to cope with coupled with going through such a devastating treatment too. More should be done to help those who can’t pay in life and death situations.

    Liked by 2 people

  29. Not directed towards her, but speaking generally here. One of the issues I encounter, involves those nearing the retirement age not effectively having a plan financially, for unexpected medical expenses. Instead, they say such things as, “I’m all set,” yet when they encounter something like this, a good portion or all of their nest egg becomes wiped out.

    I never do the “I told you so,” because with my understanding of numbers and pride, I calculate when reality will eventually rear its head. Instead, I experience a deep sense of sadness, because there is absolutely nothing I can do to assist.

    In her situation, with a plan that cannot assist due to high deductibles, it is another reason that I question the thought process behind the ACA. Not the entire concept of course, but the actual implementation.

    Liked by 2 people

  30. How sad. Yup, such is the way of this lovely country we live in. A couple of years ago, I suspected I had ovarian cancer (because of issues, plus my previous history of cervical pre-cancer – twice)… And being self-employed, I was uninsured. As I waited for my appointment for which I would pay cash, I looked up my options if cancer was present… I could only qualify for government help IF I either: A) still had children under 18, B) was over 65, or C) was an illegal alien! I was incensed to say the least… not just for myself but for the many people who already were diagnosed with cancer and sent home to die. Luckily for my, I only had a huge ovarian tumor that was benign. But what about those other people that weren’t as lucky? I can’t blame the medical facilities because they do provide a service, so they are in business to make money. But I do blame the government for allowing its citizens to die without even a hope of getting better. I appreciate you getting this out there and for also putting your physician’s spin on things. As ever, you’re awesome, Doc! ❤

    Liked by 2 people

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