Can You Say Anything Good About Your Health Insurance?

Cuz if so I'd really like to hear it.

While this shit has made and may continue to make me cry, mine isn't a sob story. Because in the grand scheme of things I have a lot of privilege. (Just to have health insurance in the first place for example and to be able to pay for out-of-pocket costs is a privilege.) Still, I can't seem to get my health insurance company to cover my actual medical needs. And if it's hard for me, well I can only imagine what it's like for folks who are less privileged than me. And that breaks my heart.

_____

One example came a few years back. Without going into the gory details, I'll just say that something was not right with my body. Note, in those years, I was still reluctant to see a physician for anything, really, because of a traumatic experience I had with a campus doctor decades earlier (which you can read about here). So, I would only go see someone when I was in a pretty good deal of discomfort.

Also, in those years, I was fully supporting my family as a self-employed author and speaker and so instead of having employer-provided health insurance we had to buy our own to the tune of $30,000 annually. (Further privilege to be able to afford that.)

So, here I am at the doctor to see about this thing. He orders tests then refers me to a specialist. The specialist orders more tests, then tells me my options which include taking a drug or having surgery. I opt for the drug, stop by my pharmacy hours later to pick it up, and begin taking it that very night. I quickly experience very uncomfortable side effects in the form of my tongue feeling dry, bloated, and thick, and my speech sounding slurred or like I have a lisp.

Now, I imagine such side effects would be problematic for anyone. But since I give speeches for a living, I find it untenable. So, the next day I call the specialist's office. I'm on hold for twenty minutes. When someone finally answers I tell the person what's up and ask is there a different drug? She says I need another appointment. I go back to the specialist. He listens to my concerns. He prescribes a different drug that apparently doesn't have this side effect. Yay!

Hours after leaving the specialist's office, I call the pharmacy to see if my prescription is in? No, they tell me, Blue Shield denied coverage. I get on the phone with Blue Shield. After many minutes on hold I learn that they want "prior authorization" from the specialist. (I'll admit that I don't even understand the concept because, well, hasn't the specialist implicitly authorized it by prescribing it, but whatever.) I call the specialist's office and am on hold for quite some time until someone answers. I ask them to fax "prior authorization." They say they will.

A week later I call the pharmacy. They tell me that my prescription is still not available because the insurance company has not approved it. I call the specialist's office. More time on hold. They tell me that they faxed it a week ago. I call Blue Shield. More time on hold. (Having the flexibility in my day and the sheer time to spend hours on the phone with doctor's offices, the pharmacist, and the insurance company is another privilege.)

Finally, the Blue Shield representative says that they received the prior authorization form, but nevertheless are declining to cover the medication. I lay into this representative unlucky enough to have ended up with me on the phone that day.

I pay you $30,000 a year out of pocket, after taxes, for our family of four, and we have a $12,000 deductible. What exactly DO you cover?

He is silent. Then my tears come. Through sniffles I tell him about the medical issue I'm having and how the first drug had awful side effects and that this second drug is supposed to be better. He tells me he understands and he'll talk to someone and he puts me on hold.

After awhile someone else comes on the phone and tell me they're denying coverage until my doctor can prove why I need this. Like everything I've just told them is of no import. I began to bawl. Yes, while on the phone with them. I'm frustrated and dismayed, and what's also going through my mind is If the barriers are this high for a person like me who is highly educated person and has access to resources, how do people with less time, flexibility, and wherewithal even cope?

I am on the phone with Blue Shield at least three times. Each time I speak with them I operate with the conviction that I will somehow convince them. Each time I scrawl notes on the back of an envelope in pencil. Each new piece of key information is scribbled down. Words go off to the side, up and over each other. I still have that envelope somewhere. But at some point in my battle with Blue Shield, I give up. I can't even remember why. I guess other problems in my life grew bigger, or work got busy, or the pandemic started, who knows? I gave up on a medical solution for my discomfort. Obviously this particular health problem is not killing me.

_____

Fast forward to today. My blood sugar numbers are in the pre-diabetic range, and have been for about three years. I have a new doctor and she and I have been working to address and monitor this issue. I've been doing all the right things in terms of what I eat and how, in order to ameliorate this condition (I won't go into the details of what I mean by that, because what is right for my body isn't necessarily what your body needs, but if you're interested you can message me). And, I'm a bit of a nerd, so I track and monitor all that I'm doing with a spreadsheet which I've named A Votre Sante which is French for "to your health." However, my blood sugar numbers still aren't moving in the right direction, so because of that my doctor diagnoses me as insulin resistant, a condition newly understood by the medical community. (Learn more about insulin resistance in this TED Talk.)

So the good news – and this is REALLY good news – is that there are drugs coming available that counteract insulin resistance. Which means my blood sugar should go down and I can go back to enjoying food instead of dreading what it will do to me. I practically scream with joy when my doctor tells me about this class of drugs. Now, mind you, they have to be injected into your body - no fun - in fact, who am I kidding: yikes. But I can see that an end to my pre-diabetes woes just might be within reach. I feel like I've got the winningest hand in poker: I'm ALL IN.

My doctor prescribes the drug. I call the pharmacy to see if it's ready for pickup. They tell me that my insurance company (CIGNA, now, through my partner's employer-provided health insurance) won't cover it. I call CIGNA. They say they need "prior authorization" from my doctor. Ok, I know this drill. I know it's a whole back and forth and they're just going to deny it anyway. I message my doctor and ask what she thinks we can do to unstick this.

One Saturday night, Dan and I are streaming a show and my phone lights up with a call from my doctor. She reiterates that she is sure that this drug will help me. She sounds hopeful and excited by the prospect. She then goes over her frustration with my insurance company and her strategy for fighting this with them. She explains that CIGNA want me to take Metformin instead of the drug she prescribed. She says she told them that Metformin is for diabetes and that I don't have diabetes. But they won't budge. They tell her they won't approve the drug she prescribed until I have diabetes. "I told them you need this drug precisely so you don't get diabetes."

When I had the problem four years ago, which took me to a doctor and then to a specialist and ultimately went nowhere, I didn't feel like I had an advocate. My new doctor is an advocate and I love having her fight for me.

Days go by. I pick up our mail one afternoon and see a letter addressed to me from CIGNA. I open it. I read that they're formally telling me that they are denying coverage for the drug. I already know that without CIGNA's approval the drug will cost me around $1600 per month.

You get that?

They want me to get diabetes so that then they can medicate me. They don't give a shit about what my doctor knows to be true about my body. To them, I'm a number. A diagnosis code.

My doctor makes a Telehealth appointment with me simply to talk me through this, to tell me she's still fighting for me, and to walk me through the process of obtaining a coupon for the drug directly from the pharmaceutical company that will allow me to obtain the drug for $25/month. She walks me through how this will happen. That she will prescribe it, CIGNA will deny it, and then I am to walk into the pharmacy with the coupon.

Yesterday, I do this. I walk into Walgreens to make this happen.

"I'm here to pick up a prescription."

"There's nothing under your name."

"Hmm there should be, it's called..."

"Oh. It's been denied. Doctor needs to prior auth. We faxed them."

"Ok well I have a coupon from the manufacturer."

The Walgreens clerk takes a look at the coupon and starts typing into her system. She types more things. More things. Doesn't speak. It's like five minutes. Finally:

"You can't use the coupon if your health insurance is denying coverage."

I'm acting as fucking nice as I possibly can even though I'm about to lose it. I point to the fine print on the coupon which directs pharmacists on what to do if the insurance company is denying coverage. The clerk goes to her supervisor, a guy named Allen.

Five more minutes go by. Allen comes over to the window where I'm standing and holding up the line.

"I got it to go through," he says with a smile. "We don't have the drug here but I can order it. It'll be here in 1-2 business days."

Allen is the end of the chain and I pour all of my gratitude into him.

Yep, I have a great doctor. And Allen at Walgreens was clutch. But health insurance? Man, I'm done.

_____

I would love to hear how you've fought the system, whether you've lost or won? Any success stories? Any sob stories? How did it all make you feel? Maybe you work in health insurance and can shed light on what the heck is going on. Share below. NOTE: Please take good care not to disclose any more information than you're comfortable sharing. (I'm modeling that in this piece, if you notice.) But please also know that when you share, it might help someone else! Strike the balance that works best for YOU.

🏚You've been in Julie's Pod, an online community of over 11,000 subscribers. If you aren't already one of them (it's free) you can take care of that here. We're made up of folks who know that by opening up and getting vulnerable about what's up with us, we grow and help others do the same. The community has grown the most over time by readers simply sharing any particular piece with a friend. So if you know someone who should read this post, please share it by clicking here.

📝 If you left a comment on any post before today, here or on social media, I've probably responded, and I always appreciate what you have to say even if I may feel differently. Please feel welcome to join the conversation. I want you to. We need to get MUCH better at being cordial and thoughtful in response to what other people have to say, while also articulating our own truths. This is a good place to practice.

☎️ For those who can't comment publicly, no worries. I've set up the hotline 1-877-HI-JULIE where you can leave an anonymous voicemail to let me know what's on your mind. I respond to these calls most Mondays live on my Facebook page at noon Pacific Time (while keeping the caller's identity private).

📓 I'm trying to help humans have an easier time of life, and one aspect of my efforts is a new online asynchronous course I've created with TED on how to become your best adult self, which is based on my book, Your Turn: How to Be an Adult. If you have a young adult in your life who needs help getting unstuck, or you know an adult of any age who is eager to re-tool things, consider getting them the course as well as the book.

🧐 If you missed my post at the end of June about how I was estranged from a neighbor and I thought it was their fault but came to realize it was maybe kinda also mine, check it out here. Other popular posts in Julie's Pod include one on the day COVID got me which is here, the impact of the return of grown children on the sex life of empty nesters which is here, on the trauma and tragedy of youth suicide which is here, and the role parents can play in turning normal childhood fears into outright anxieties which is here.

🎁 If you've read this far, you are definitely entitled to a free "Julie's Pod" sticker for your laptop, phone, or water bottle courtesy of me and the U.S. Postal Service. Just DM me your snail mail address (or if you don't know how to DM a person, just email me@lythcott-haims.com). I promise to toss your snail mail address in the trash as soon as I pop the sticker in the mail to you!

🪢 Next week I'll be publicly announcing that I'm trying to address the dismay and hopelessness I feel in response to national events by doing something at the LOCAL level in the form of running for City Council in my city of Palo Alto. Consider this a sneak peek. If you dig the idea, and want to contribute to my campaign click here. 😊 Sadly, it costs a lot to mount a successful campaign and every small donation will help me get there.

👋🏽 If you're interested in learning more about me and my work, please follow me @jlythcotthaims on Facebook, Instagram, Twitter, and/or TikTok and check out my website.

📸 Cover Photo Credit: Getty Images/Carol Yepes/Moment

@ 2022 Love Over Time LLC All Rights Reserved