I’m in line with my friend Liz to get a flu shot at the CVS pharmacy counter. The man in front of us is told that the prescription cream he needs is not covered by his insurer.
“Can I pay for it myself?”
“It’s very expensive.”
“For a tube of cream?”
“Is there something less expensive I can use?”
He walked away, and I felt bad. After the fact I thought of helpful suggestions, but I didn’t want to intrude on the privacy of a man who required a $750 cream.
It was our turn. Without being asked, I handed over my insurance card. The clerk found my file, entered a bunch of data, and told me, “It’s not covered under your pharmacy benefit. Maybe it’s on the medical portion. You could go over to Urgent Care (which had at least an hour wait) and see.”
The same happened to Liz, although we have different policies and carriers. Rather than waste more time, we paid out of pocket — $41 each. Prior to this, Liz had called her carrier and been told it was covered at some CVS pharmacies. They were to email her a list, but after an hour on hold and a two-hour wait for their message — which never came— we took our chances. It was all a reminder of how fractured and difficult healthcare has become.
I travel the country to give seminars on opioids and other things, and when we discuss case studies and real people, one of our first questions is “What’s the card in your wallet?”
Your health insurance (Medicaid, Medicare, private, or self-pay) makes all the difference. It’s a killer.
Imagine a person with a severe opioid problem. They’re in the agonies of withdrawal but finally ready and willing to get help. They —or possibly their mother or spouse— call their carrier in search of a treatment provider. They’re put on hold. Barrier after barrier is presented while music plays — no available openings, $4,000 deductibles, high co-pays, pharmacy benefits that will cover this but not that.
“I’ll need to refer this to our medical director.” “Please hold, all available agents are currently busy. Your call is very important to us.”
No, it’s not.
The truth is ugly. Barriers and denied care boost the bottom line. A patient who foregoes a costly course of chemo or winds up dead from an overdose because they can’t get into treatment benefits the corporation and the shareholder. Even when things are covered, the hurdles that have become such a part of our healthcare reality delay access and make the experience so frustrating that many of us would rather do without or pay out of pocket… if we can.
Healthcare in the United States is financially driven and morally corrupt. No amount of political or corporate gloss can conceal that.
We’re also unique among first world nations as we restrict, ration, and deny access to healthcare far more than countries with national health plans. And while the Affordable Care Act was a valiant step toward coverage for all, because of special interest groups, it never made it across the finish line with the single most important piece — a public option to divorce profit from the delivery of healthcare. In plainspeak this would have translated to basic Medicare or Medicaid for all.
In 2018 who gets what is all over the map. If you’re near or below the poverty line, you get Medicaid and have decent options. These include everything from federally qualified healthcare clinics to a generous pharmacy benefit that covers both the $750 cream and the flu shot without hesitation.
If you’re rich and can pay out of pocket or have top-tier—and pricey—coverage, such as is afforded to our politicians, government employees, and the lucky few with employers able to absorb the massive premiums, this article won’t resonate. You’re good.
As a healthcare observer, participant, and consumer, I’ve watched our system deteriorate. The central problems worsen, costs spiral, access and quality of care decline (America’s statistics, from life expectancy to infant mortality, are not good despite the costliest system in the world), and we are unable to find the political will to make real change.
The answer has always been clear to me and to an army of economists, healthcare experts, and many other physicians —a single payer system with universal coverage. Ditch the for-profit and non-profit insurers, the kickbacks to shareholders, and the redundant administrative costs.
Eliminate the need and expense for every hospital, physician’s office, pharmacy, and clinic to have specialists employed to battle for authorization and payment, negotiate drug prices with the pharmaceutical companies, and make medical and nursing schools free. If we took those steps, we’d wind up with something that’s equitable and affordable.
It won’t happen, although we deserve better and I continue to hope. But for now, and until we elect the right mix of public servants, this is what we get. So pour a hot beverage, get out your card, put the phone on speaker, start a Sudoku, and wait.
Charles Atkins, M.D. is a psychiatrist, author, chief medical officer for Community Mental Health Affiliates (CMHA) in New Britain, Waterbury, and Torrington, and member of the Yale volunteer faculty. His web site is www.charlesatkins.com