It was an emergency. It was Sunday, two days before Christmas. She was in excruciating pain. My son took her to urgent/emergency room care. The urgent care doctors said she needed to have her gall bladder removed right away, because they were afraid infection was setting in. As a Type 1 brittle diabetic, she cannot handle this kind of disruption to her system. The Urgent Care doctor made arrangements for her to be seen at the nearest hospital and sent my son and her there immediately.
She did not have time to think about the network, nor had the insurance company provide her a list of network providers. The hospital accepted her insurance, which she believed meant they were ok. It wasn’t as if she had a choice. She did not have the option of getting it approved by her insurance in advance. She needed surgery now. Within a few hours, she was home, missing a gall bladder. She did not even spend the night at the hospital.
Days and weeks went by. She got the urgent care bills, that were paid for by the insurance, so she owed nothing. Emergency care covered. Certain other bills, covered. Then, a full month after her surgery, she got a bill from the hospital. The insurance company, Anthem, denied her claim. The person who denied her claim is not a doctor, does not realize that diabetics do not take surgery of any kind lightly. Amount due – $21,000. Payable immediately.
She doesn’t make that much money in a year. She is in school. She has monthly insulin costs. She has to take other medications to make her body accept the insulin. She has costs associated with making her pump work. She has to have regular doctor visits to check her numbers, to check her body, to check her pump. There are visits to her GP, to her diabetes doctor, to her eye doctor, and so on and so on. To cover all these costs, she would have to make $4,000 a month after taxes before buying a mouthful of food or paying a nickel for a place to live.
Anthem claimed the surgery was elective. As if she woke up two days before Christmas on a Sunday and decided, hey, I think I’ll get my gall bladder removed today. Except that serious diabetics don’t do elective surgery on a whim. They have to spend days ensuring their numbers are stable enough to have the kind of jolt to the system that surgery causes. And then, after the surgery is scheduled, they check again. If the numbers are off, the surgery is postponed until the numbers are acceptable.
She will have to appeal the denial. This will require more time and expense, and may even require a lawyer. She is working with the patient advocate at the hospital, but there are no guarantees. The last thing she needs is to be fighting this claim while she is going to school.
They say that diabetes is a manageable disease, and that is true. But that doesn’t mean management is easy or inexpensive. Diabetes doesn’t just mean you take a couple shots a day, management is expensive, in terms of both time and money. Time is expended to make regular trips to the doctor to get the body checked, to recalibrate pumps, to recalculate the right doses of insulin to keep the body under control. Money is expended in ways I never imagined before I had a diabetic in my home. The pump costs money (thankfully, because of ACA, it was paid for) to the tune of $44,000. Then there is the insulin. There are drugs needed to help the insulin. The pump requires new sensors every few months. There are copays to the doctor every visit (without ACA, those copays are really high). And the diabetic still has to carry insurance (without ACA, that insurance is really expensive).
The management of the disease does not mean that it is not taking a toll on the body. She needs to check on that body a few times a year. Currently she is taking shots in her eyes to keep diabetes from stealing her sight. Diabetes is also causing neuropathy in her feet. The constant ups and downs in her sugar levels has cost her her gall bladder and her pancreas. It impacts the functioning of the kidneys, to the point where it can shut down the kidneys and put the diabetic on dialysis(thus another expensive drug and a machine to keep the kidneys working). It also causes fits with her teeth, which then get infected and cause problems with her sugars, and becomes a vicious cycle. Yes, the disease is manageable, but it is a full time job that requires hours and dollars.
Here is the thing: she is a smart woman with a lot to offer our society. Keeping her healthy is difficult and expensive, but her contribution will be worth every penny. She is a prime example of why we need regular, complete medical care for every citizen – because the only untapped resource left in this world is the human potential. I talk about diabetes because that is what I know, but there are many diseases that are “manageable,” but require access to health care. And we can’t allow a lack of medical care to prevent us from tapping the human potential.