This year I have been working as a health counselor in Newark, New Jersey at Covenant House, a shelter for homeless youth ages 18-21. One of my main roles is to assist our youth in accessing healthcare resources in the community. Since many of the young people who stay with us have not seen a doctor in years, the needs that we address are often extensive. We are fortunate to have our own mental health care team on-site, as well as a physician and nurse practitioner who visit us twice a week to provide health screenings and basic primary care. Everything else—from dental care to eye exams, prenatal visits to specialist care—is found in the community. That’s where I come in.

 

As I work to help people meet their wellness goals, some days I get to feel like a superhero. But the reality is I am not sweeping into this need-gap with anything novel. I connect people to resources that already exist; it’s as simple and as complex as that. Integrating advocacy knowledge and linking people to the right care in a dynamic urban environment is a great social and intellectual challenge. The phone is my superpower of choice, but being physically present in the community is just as important. Newark has some of the best resources for everything from HIV care to emergency dental services. Every youth’s needs are different and there is always more to do. I like to think of myself as a medical matchmaker—and when my job works, it is extremely gratifying.

 

 

The youth at Covenant House don’t necessarily need my help to sign up for insurance or find a doctor. They are independent adults and many have had to take care of themselves from a young age. Still, I risk providing a glamorized picture of this healthcare landscape. What I have learned in the process of stretching out my arms between providers and patients has only confirmed the universal lamentation that I myself had never experienced at such a profound daily dose: our healthcare system is the very embodiment of inefficiency, and to a rather insufferable degree. Navigating this system is one of the most daunting tasks a person can face, as well as potentially dehumanizing and frightening during an already difficult time of illness. I have seen the effects of healthcare failure time and again. Every time a client has returned with a broken bone and no cast, a script for vital $600 medication not covered by insurance, or paperwork that traces a confusing trajectory from doctor to doctor with no continuity of care, I have begun to sense the crisis of a future medical student delving into this circus-like arena: how am I going to treat my future patients?

 

This year, I’ve been collecting euphemisms for why a doctor’s office is unable to see my clients. In the language of medicine, they have been “too many too count.” I discovered there is formalized, proper language for turning away a patient. “We no longer accept… err, we don’t participate in Medicaid,” the receptionist often stammers, catching himself. Based on my experience, I was not surprised to find that New Jersey is the state with the fewest doctors who accept Medicaid. In that moment, like a chivalrous Don Quixote, I vowed, “When I am a doctor, no patient will be turned away!” Could this someday be the case?

This year, I found myself surprised if I sent a youth off to a specialist appointment and they came back treated. I began trying to cover all my bases with insurance companies and I kept my expectations cautiously low. The number of things that can go wrong in the process of getting someone past a doctor’s reception desk would appear endless: the patient’s straight Medicaid plan just switched over to an HMO and needs a referral processed; the doctor providing the referral is not the primary care doctor listed on the plan; the referring doctor can’t be found in the system; the specialist doesn’t accept the new HMO; the doctor is in New York but the Medicaid plan is in New Jersey. All of this is just for the consultation.

We play a similar game for medication, imaging, and medical equipment coverage. For example, some HMOs won’t cover certain birth control medications. Others need preauthorization for splints or nebulizers. It’s one thing to read about health care failure in articles, but it’s another to witness it play out over and over on the ground level and encounter the human impact of such barriers to care. If practice makes perfect, we have perfected the art of doing a lot of extra work (necessitating mountains of paperwork and circuitous phone calls) with little benefit to show for it, aside from a rise in healthcare worker stress. All along the way, people get sicker, give up on seeing that doctor, and even die waiting for care.

After jumping through hoops with insurance companies for a couple of months, one of my clients asked the right question—the simple question: “What if someone has a brain tumor but doesn’t have insurance?” The young people I work with get it, and that lessens my fear that we will become complacent and begin to think a lack of access to care is normal.

The Affordable Care Act has been crucial in increasing insurance coverage to those who would otherwise fall through the cracks. But when many of our youth receive their Medicaid cards, it comes in the mail with a user manual the size of a dictionary. They don’t often know what to do with their coverage, and they don’t have access to phone and internet to research and call providers, much less the time to go doctor-shopping. Lists of accepting providers are not well-updated, and their numbers are becoming fewer while patient loads are increasing.

Medicaid-accepting offices in Newark are often run-down, overcrowded, and located in areas that are not safe. Accessing care simply becomes too much of a nuisance. But even when one gets past these barriers to make an appointment, they still risk being turned away from the office due to an insurance technicality. Being sent away from the doctor when you are sick–this is what pains me the most. As a future physician, I don’t want to just treat patients who can afford to see me. That’s not what my classmates and I have studied and sacrificed for.

 

 

Still, there is hope here, because exciting change is on the horizon. Recognizing that our current system can’t get much worse should become our launching-pad to the calculated risk-taking we need to make changes–and indeed it has. Doctors are not waiting for a top-down approach to change; we are seeing new models of care pop up all over the country, such as the Ideal Medical Practice. A sense of urgency frees ourselves up for innovation, and selling a novel idea to society about what care can look like becomes easier in the face of a system that is fully agreed upon to be unsustainable. As science changes, medical care will follow suit, and we will need a model that is flexible enough to grow with us and our evolving concept of health. Understanding where our current system fails is key to forming the ideas for structures that work. That is why I am grateful for the fumbles and failures amidst the successes of my case management work. And in this way, I have hope that we will someday be able to throw the exam room door wide open to all who need to see the doctor.

 

Leave a Reply