No Access to Care

So this is totally off topic for what I’m usually writing but I just needed to express the immense frustration, anger, and helplessness I’ve been made to feel this week regarding health care. My husband has a very good job, with expensive and supposedly very good benefits, including health and dental. We pay a significant amount of money every month in insurance premiums, and expected that because of that we would be able to get the medical and dental care that we need (and that we were getting under my university insurance in Iowa).

Yesterday I had an appointment to see a specialist about chronic pain, stemming from a repetitive stress injury that I’ve had and been dealing with for years. I went through the proper channels, found a new primary care last month, made an appointment, met with them, got the referral. Only to find after the appointment that my insurance, Blue Cross of MA, won’t allow me to see that particular provider, though that provider does take my insurance. What? So I spent an hour on the phone with the insurance company, which didn’t exactly help clarify things, and left me anticipating a large bill and a lengthy appeal process if I choose to try to get them to cover my routine, preventative care that they claim to cover.

They never mentioned the referral was invalid because of this. Oh, but it is. The day of the appointment I called to make sure they had the referral in the system (because without it I’m charged $250 + 20% of the service, and with it it’s fully covered, according to their website). They did not. Not only that, because my primary care physician wasn’t one the insurance company recognized, I didn’t have a primary care physician to make the referral. I spent two and a half hours calling every primary care physician listed on the insurance company’s website in my area, a 25 mile radius from where I live. Out of the 40 or so providers, many of the numbers were out of service (the providers having moved years ago, according to other health websites), another handful were not in fact primary care physicians and said they’d been trying to get themselves off that list for years, and the majority were not in fact accepting new patients (though the list indicated they were). Of the 40 only 2 were primary care physicians accepting new patients, and neither of them had appointments available until May. And neither would make a referral without a visit first.

So the fact that I’ve been seeking care for this for years, in every area I’ve lived in, with many doctors, and that I want to continue the care that has been helping me manage my pain, all that is utterly irrelevant. The fact that I have insurance that should—and under some very particular set of circumstances does—cover this care is irrelevant. I called the insurance company again, to find out what my options were, and they said that it wasn’t their problem that none of the providers had availability, and if it was really an urgent care matter I could go to the emergency room. What?

I wasted 4 hours of my morning on this, had to cancel my specialist appointment, and have to put off getting care even longer while I wait for someone to cancel an appointment so I can get a referral. This is privatized medicine.

Today, in anticipation of my husband’s upcoming dental procedure, I called his dentist to make sure they’d submitted the pre-procedure paperwork to our insurance company, Delta Dental, as we’d discussed in early November. They had, though they’d forgotten to call me when they got it back, while I still would have time to resolve this before his appointment. Unsurprisingly, our insurance is declining to cover the procedure. The medically necessary, dentist-recommended (by two separate dentists) procedure. Their reason was that one of their ‘consultants’—a dentist who saw only my husband’s x-rays and has never seen his mouth, and knows nothing about him, his life, or his teeth—thinks that one of the teeth adjacent to the one that needs the work might, someday, need a crown. Someday. Might. Something neither of our very good dentists have suggested. Something, I would argue, that is true for all teeth everywhere. And, something that would not be affected in the slightest, according to our dentist and the insurance company as well, by the procedure my husband is scheduled to have. Again, a long appeal process is possible, but unlikely to result in coverage.

So in privatized medicine, a person who’s never met my husband, who’s never seen his teeth, and who’s salary is paid for by the insurance company (and who’s job it is to decline a certain number of claims in order to reduce expenses for the company) is making medical decisions that override the informed medical decisions made by my husband’s doctors, who he’s been seeing for years. And despite paying extremely high insurance premiums, we will still have to pay out of pocket (in advance) for the entirety of the dental surgery.

My question is what are we paying our premiums for, then? Also, what is the great fear of some anonymous making medical decisions for you under socialized health care. That’s already the case, and at least under universal health care that bureaucrat is someone impartial whose job it is not to second-guess the medical advice of the doctors treating the patients. Someone who wouldn’t have bonus incentives and job security tied to how many claims they decline. These people now do not have our best interests in mind, they have their bottom line in mind.


  1. Rachel

    Oh my sister. I sympathize. Oh, how I sympathize. My husband works for a hospital that carries its own insurance, and they won’t cover certain routine care exams or some exams that screen for cancer and other possibly fatal things similar to cancers. Had to pay those out of my own pocket, plus the full price of certain prescription medications, because someone who has never met me decided I didn’t really need them, EVEN THOUGH a physician was recommending that I did in order to prevent something extremely seriously bad from happening in the future, potentially.


  2. Mari

    There should be a course for medical professionals on how to write patient notes to ensure patients are covered for their care. Doesn’t the specialist who you cancelled your appointment with miss out on revenue because you were not allowed to see them? I think this is also why I have a vested interest in pursuing some form of primary care. How can you say we’re increasing access to care when we are denying it!?

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