Even as a Doctor With Decent Insurance, I Had Difficulty Entering the Healthcare System

Why navigators benefit everyone

At two in the morning one Saturday last November, I was pummeled awake by the worst eye pain I have ever felt. I fumbled to the bathroom to look at the culprit eye. It looked a little red, but nothing too concerning. I went back to bed, thinking it would be magically better when I woke up in a few hours. Though I’m a doctor with decent health insurance (and was working in the emergency room later that day, no less), the last thing I wanted to do was to actually interface with our healthcare system as a patient.

As daylight streamed through the window, not only did it feel like an ice scraper was grating across my eyeball as it did all night, now it felt as if I was being repeatedly punched in my right eye. Still hoping maybe it was simple conjunctivitis also known as “pink eye,” I pushed my contacts lenses in my eyes anyway and went to work.

Twenty-four hours later, the pain had exponentiated and I had retreated to a Vampire-esque existence. Examining my eye more closely, I spotted the miniscule white dot at the bottom of my right eye–and knew immediately I had a corneal ulcer. I called up my pharmacy right away for antibiotic eye drops. Then I started committing my number one pet peeve with my own patients: playing a frantic game of Internet medical detective. “Red eye and white spot,” “red eye contact lenses,” “corneal ulcer time to heal.”

As I trolled various discussion boards, with members’ stories warning of blindness and corneal transplants, I panicked and started calling around for an appointment. This must be what drives my patients into that full panic state when they come in the ER at three in the morning.

In 2015, experts estimate that 20 million more non-elderly Americans will be minted into newly-insured patients. But while much of the current debate surrounding the Affordable Care Act has been around the cumbersome website, the controversy of having to trade in one’s current health insurance, the true affordability of monthly premiums, and the potential low ratio of primary care physicians to new patients, there may also be other unforeseen issues. Namely, will these newly-insured patients be able to navigate this complicated—and still expensive—healthcare terrain? Even being a supposed “insider,” I had limited membership.

Many phone calls later, plus several attempts at booking through an online site, as well as an erroneous visit to a laser eye clinic well-concealed as a comprehensive eye center, I was getting nowhere. Surrendering, I finally called the cornea specialists at the academic hospital where I worked and explained how I was a physician there and needed to be seen immediately.

I know how lucky I am to be a patient who happens to also work in the healthcare system. I was able to diagnose myself, start treatment on my own, and get squeezed into an appointment when everywhere was booked. But in many ways, I certainly felt more like an outsider. Even after starting treatment and seeing a top eye specialist, it still wasn’t easy or cheap. Initially, I had to use antibiotic drops every hour. But my insurance would only cover one three-milliliter bottle every three weeks. Each bottle not covered by insurance cost me $130. I was also supposed to see the eye doctor daily in the beginning, then weekly. Each visit cost me $35. Between the appointments and the medication, by the time I was finally labeled “cured,” I had spent nearly $800 in out-of-pocket expenses for a relatively small health issue.

My own experience makes me fear that for many Americans, health insurance may not necessarily equal health care. Access and cost will still remain barriers—and can be difficult to surmount for many. The pioneering Oregon Health Insurance Experiment, which is the first time the impact of Medicaid has been evaluated using the gold standard of a randomized controlled design, may foreshadow many of these hurdles to come once the ACA is fully implemented.

In 2008, by using a lottery system to select nearly 30,000 qualifying people for admission into its Medicaid program, the state of Oregon was able to generate data on the effects of expanding public health insurance to low-income, previously uninsured adults. The latest results are quite revealing. Notably, Medicaid actually increased ER visits classified as "non-emergent," "primary care treatable," and "emergent, preventable." Furthermore, there was no difference between these visits occurring during standard workday hours—times during which doctors’ offices are open—and during weekends and evenings.

The studies did not analyze the “why,” and of course there are many hypotheses on the findings. As an ER doctor—and now having gone through my own little health scare—I have to suspect some of it might be due to the same challenges I faced. The first is not being able to get into the (right) door. This could be due to not having a primary care doctor at all, or the difficulty of seeing one’s doctor unscheduled, or the biggest challenge of all—getting in with an actual specialist.

Another obstacle is the affordability of certain medications even with insurance, a problem I’ve frequently encountered with my patients and now have also experienced myself. After that, follow-up appointments with requirements for payment upfront, particularly with specialists, can accumulate into relatively big costs. Thus, when one is anxiously Googling the heck out of whatever ailment, while simultaneously trying to steer our fragmented healthcare system and calculating one’s budget, it bears no surprise that one ends up in the ER.

As Obama iterated in his State of the Union Address, the ACA will likely give “the peace of mind that if misfortune strikes, you don’t have to lose everything.” But between losing everything and actually having healthcare, there’s still a vast space.