Healthcare Crisis Part II: The "Benefits" of Health Insurance

On Thursday, St. Vincent’s who “accepts” both insurances requested Juliette bring the films as soon as possible. Since I work from home I volunteered. The UMDNJ is a typical hospital, white floors, white walls and white ceilings, however friendly medical staff dressed in blue pajamas smile at you and ask, “can I help you find something?” This is the same hospital I attended Physical and Occupational therapy for my hip and elbow. Memories. I picked up Juliette’s films from UMDNJ, paid a bored cashier and waited for the films. Directed to a waiting room, I sat and watched Rachel Ray as she made eggplant balls for Thanksgiving. “Do people actually watch this?” I said out loud. Seven pairs of eyes stared at me as my name was called. Clemency.

I arrived in the city at St. Vincent’s, a beautiful facility on the west side not far from the structure on Seventh Avenue. The first thing I noticed as I walked in was a cappuccino maker, various teas and thousands of magazines. Not bad I thought. I can wait here in peace. The walls were bright, the office neat, it felt like a children’s hospital. A beautiful young looking Chinese American woman, nervous stood before me, Juliette’s age, waiting to speak to a Secretary. We both hemmed and hawed for 10 minutes as they stood just outside our vision talking. Not a good sign, I thought. Though, quickly after we caught their attention, they attended to us and I was on my way back to Jersey City. They gave me a date of November 17^th for an appointment. Everything we could possibly do done, we took a sigh of relief and settled in for the week’s wait.

Juliette and I spoke about the procedure, what this means. Everyone we spoke to seemed to know some relative, aunt, mother, sister who had a similar procedure. “It will be fine” we were told. Except sometimes it wasn’t fine, which scared us a bit and our luck ran with the Irish. Non-existent. We decided to not discuss it and muddle through until the 17th, after all this is something thousands of Americans are experiencing at the same time, right? We need to wait and see and breathe.

On the Saturday before the procedure we received a letter in the mail from St. Vincent’s. “No need to come in for an appointment.” Juliette continued to read. “Wait six months. Probably benign, come back for a new mammogram in six months,” with a bill for $50 tucked in for all the work the medical staff perfromed. “We’re still going to the appointment I announced to Juliette.” “What are you talking about? They just cancelled the appointment!” “They can’t do that” I argued. “Well, they just fucking did!” Juliette said angrily. We pumped ourselves up for the appointment and now it is not to be. “Fuck!” I yelled. “What do we do?” I asked. “Is this reliable? Is this a good thing?”

The fifty dollars was a bill for their services. Juliette called them and said her insurance should cover it. “Well, you didn’t meet your deductible.” “What deductible? I have insurance.” “Right, but this is 'an out of network' claim.” Perplexed Juliette asked them “what the fuck are you talking about. I thought you said you accept healthnet?” “Technically we do “accept” healthnet, but only out of network benefits.” She connivingly said. In "out of network benefits" she explained, “You pay.” So, basically as long as they get their money? No need to tell the patient they will be paying the first $500 or $1000 in deductible instead of simply a “co-pay,” or “in network benefits.” Thank god, we didn't have them perform the procedure, I said.

We weighed our options. Some told us to wait the six months. Juliette would receive another mammogram, and eventually have the biopsy anyway” was the advice. What is the point of that? Juliette asked her personal physician, “what should I do?” “If it were me,” she said. “I just don’t know.” Helpful. Juliette did not want to have her boobs shoved in a machine again, just to be told you need to have a biopsy, “what is the point of that?” she repeated. I agreed and encouraged her to seek a second opinion, though she was not happy about it.

Like controversy was made for us, new mammogram guidelines were released on November 17^th, the day we were supposed to be attending an appointment with St. Vincent’s. These new guidelines sparked immediate controversy. A government advisory board made up of medical professionals said women should not be receiving mammograms until the age of 50. Our eyes perked. The guidelines written by a government panel essentially said that getting screened for breast cancer “so early and so often leads to too many false alarms and unneeded biopsies without substantially improving women's odds of survival.” That sounds about right actually. They sparked outrageous controversy and fear, the media talked about them for a while especially the Rethuglicans who thought it was a good way to derail healthcare reform.

Still, what if? What if Juliette is in that category of women that have no warning signs, could she afford to wait until she was 50? We decided that because she was already screened we would receive a second opinion. We wanted to see what an actual surgeon who examined her would indicate.

We arrived at the doctor’s office at 5:00 PM, right on time. We needed to be buzzed in, "come on this is Hoboken, are we afraid of robberies now?" I said. Not a seat in the house as Juliette checked in with the receptionist. Also, not a white face in the room, all low-income, primarily Latino clientèle. “What is this guy doing,” I thought to myself and intimated to Juliette. "Scheduling everyone he can before healthcare reform passes?" Juliette rolled her eyes with abandon and scoffed the first seat available. After about an hour of waiting and several chapters read in “the Last of her kind” I looked at Juliette and said, “what the fuck?” He comes recommended Juliette said. Dr. B, her personal physician that operates as a community clinic recommended him.

We were called in, he was young, our age actually, he just turned 40. Is that still young? He was Latino, good looking and competent, and calming. He immediately told us “you should have the procedure done.” He explained the procedure and why he thought Juliette might benefit. "Most likely, in six months you will be right back here anyway." he said. "Plus, it is probably benign, but there is no way of telling unless the procedure is actually done." Juliette felt comfortable with him, so we scheduled the procedure for December 23^rd. Done. The scheduler seemed nice, but she told us “I can’t schedule you at Hoboken Medical Center. I am having problems there and the Radiologist there is not on the schedule.” So, she scheduled us for an "ambulatory center" in North Bergen. Only two weeks to wait.

A week flashed by and we still hadn’t heard from the office, she informed us she would call to approve the procedure with Oxford, Juliette’s insurance company and then call us back. We started to worry. Five days before the procedure we started to panic. Juliette called her insurance company. “You are not covered at the ambulatory facility” she was told. "You will pay upwards of 2,000 dollars if the procedure is performed there." "You have not been approved, nor will you be approved.” "No one has called you from Dr. Costa’s office?” Nicole asked. “Nope.” And she intimated, "It sounds like they want you to use "out of network benefits."

The Healthcare Crisis: Part I, Healthscare

Below is a true story of healthcare. Names have been changed for purposes of anonymity.

Sifting through the Guatemala travel guide, I thought I might visit Tikal, the ancient ruins in the northeast part of the country, though the book alleged the trip might take eight hours by bus. Do I have that kind of stamina in a “chicken bus?” Copan, in Honduras appeared closer via the map and Dominga and I were investigating that possibility. Though, Honduras held symbolic and very real danger to Juliette, her best friend murdered there in 2001, just before September 11^th, so I lightly peddled that with a whisper only hinting it might be a possibility. I left for Guatemala in three days, nearly frantic to learn Spanish, sit at the foothills of volcanoes in Antigua, and sip dark roasted coffee in the cool, sunny air from a Guatemalan roaster. My former colleague and good friend Dominga volunteered her time in “Guaty” and helped me find housing, she was the reason I decided on Guatemala instead of Peru or Chile or even Argentina. Guatemala is also cheap by any standard used in the Spanish speaking world, excited and desperate to leave the states I was walking on air to leave Jersey City. That was until Tuesday night.

Juliette, happy for me to finally abscond on a trip out of the country to improve my Spanish kept to herself and did not let on that something might be afoot, until fright, and insurance malfeasance brought it to the forefront. Tuesday night, November 3^rd she looked nervous and angry and needed to vent. “I can’t do this.” she screamed. “What” I said as I shut-off Keith Olbermann. “Nothing, forget it.” “Tell me!” I said. “I am worried about the procedure.” Both of us uneasy, trying not to discuss this subject I said, “Why?” “Because it is surgery and it is scary! I don’t know where to go for the surgery or if insurance is even going to pay. I am overwhelmed!”

In early October Juliette entered UMDNJ, Jersey's premier medical center for her the first mammogram of her life. The pleasantries of aging and turning 40, she took these measures seriously. Only one year before Juliette travelled deep within New Jersey, near her hometown, for a routine eye check-up and found herself on a gurney undergoing emergency eye surgery. We thought she might go blind in the only eye in which she had vision. Thankfully, the eye stabilized, but it was scary and I thought Juliette might be experiencing PTSD and I needed to help.

At the hands of healthcare technicians during the mammogram they shoved her boobs into the machine like an animal. “Please be still” they told her. “Don’t move” as if they were preparing her for the abattoir. She left, somewhat humiliated, but not unlike millions of women in our lagging healthcare system, a system that punishes women frankly, for being women. She received a call, a few days later, the test proved “inconclusive.” “What does that mean?” she asked on the phone to the caller, a technician of some sort. “It means nothing,” she says dismissively, “except you have to come back in the office for another look; we need to do it again.” “Great” Juliette said, at least this time I won’t have my period!” Juliette, back on the train toward Hoboken in late October while I obliviously planned a getaway as far away from health insurance as might possibly be, the poorest country in Latin America the next week.

This time, however they held her in the machine while the radiologist stuffed her boobs back in there, edging closer, focusing a little more intently. They focused on the right breast; clearly called into the office not because the tests were “inconclusive” but instead shades of a “gathering of cells.” “There is a problem area, I see,” the Radiologist indicated. “It makes me curious.” “Well,” Juliette thought to herself, “your language is making me curious.” Juliette anticipated in the waiting room, as she gathered her belongings another “technician” ran after her frenzied before she left.

“We need to do an ultrasound,” she announced to her. “When?” Juliette asked. “Right now! Stay where you are.” Please undo the gown and stick your left boob out please.” she heard not ten minutes later, yet again. This was indeed a cattle call. Instead of being curious, this time he was worried. “You see this area that has a group of cells or in the medical field we call a mass.” As Juliette heard the words ring through her ears the Radiologist said, “You need to see a surgeon right away.” Juliette failed to mention any of this to me when she arrived home.

She left in a dizzying fright. Exactly a year ago she was told she might and likely will go blind until we fought to get the best care money might buy. The diagnosis changed quickly. One year later here we are again. She downplayed the new procedure, in the healthcare field called a “biopsy” as we discussed Antigua and all the fun I will be having in Central America. Juliette didn’t say the word “biopsy” until Tuesday night when she nearly lost her mind.

On Monday her personal physician discussed with her the need to have a stereo tactic needle biopsy all new words in her vocabulary. She recommended a doctor in Hoboken that she thought treated her patients “well.” Juliette called them Tuesday morning. “We don’t take Healthnet,” she said abruptly. Juliette mentioned to her, “Actually we are changing insurance on December 1^st, to Oxford. Does that matter?” “Yes, we do take Oxford,” the rude young lady stated. “But, you may have a pre-existing condition now, so you want to check with your insurance company. You might not be able to get the procedure right away; it could take six to nine months.” She hung up the phone without a response. Juliette now in her own tizzy called her personal physician back.

“Don’t wait until December 1^st, it is better to do this quickly. You want to find a center that takes both health insurances,” her doctor told her somewhat anxious. She called breast centers, in Hackensack, other parts of North Jersey, some of which took one insurance, but not the other, some took no insurance catering to a more “suitable clientele.” I called one myself after the frenzy. “We don’t take insurance,” they told me smugly. "Our clients submit to their own insurance companies. We focus on healthcare.” “Oh.” I said, ready to lay into her with all the fury of every uninsured American, my words worth the 40 million of us. I hung up the phone without a word.

This is where Juliette found herself on Tuesday night as I sifted through the Guatemalan travel guide. She explained to me, “It is a surgery.” The radiologist told her that about 20 percent of these procedures turn up to be cancer. I said, “What?!! Cancer? Who said anything about cancer?” Wednesday morning I decided Central America will wait, we need to find Juliette a place for this procedure. Juliette found it that morning calling every place she “googled.” St. Vincent’s, the hospital of her birth built a brand new Cancer Center in New York City. First, however I called American Airlines and “postponed” the trip. I called Dominga who understood, but we were both a bit disappointed. I told her, “Tomorrow I have to bring Juliette’s films to the St. Vincent’s Cancer Center.” I hung up the phone and whispered the C word to myself letting out a giant sigh, “cancer.”