ACCESS DENIED: Our medical system is a maze, so patients need navigators — people like Maria Lee
This story was produced as part of a larger project for USC Annenberg Center for Health Journalism’s 2021 National Fellowship.
Other stories in Laura Garcia's series include:
Josie Norris / San Antonio Express-News
SAN ANTONIO — Maria Lee, an independent insurance broker and Medicare adviser, is used to saving her clients money on monthly premiums, but one day at the office she saved a woman’s leg.
She recalled seeing a new client at the small office building she rents on the South Side of San Antonio.
The woman told her that she was having trouble paying her $45 copay twice a week for a slow-healing cut, a situation that had worsened with her husband’s stage 4 cancer diagnosis. Their combined monthly income was less than $2,000.
Then the woman raised her pant leg to reveal an oozing wound. Lee, 47, who was a family practice nurse before she became health care navigator, knew the woman was in danger of losing the limb.
“I literally wanted to walk her across the street to the clinic,” Lee said, referring to the San Antonio Vascular and Endovascular Clinic, “because if that gets down into her bloodstream, it can become an amputation.”
Lee called the clinic, known as SAVE, to see whether vascular surgeon Dr. Lyssa Ochoa could see her client immediately. Fortunately for the woman, Lee already had a partnership with Ochoa — the SAVE clinic’s CEO and founder and one of the few vascular medicine specialists in the city’s medically underserved South Side.
While Lee worked on switching the woman to a more affordable health plan, the SAVE clinic was able to save her leg.
Lee and Ochoa are part of an informal network of health care navigators in San Antonio who speak Spanish and understand the cultural complexities and socioeconomic barriers that prevent many residents from getting the care they need.
The idea, they say, is to keep patients from falling through the cracks in the country’s profit-driven health care system — cracks that can be wider and more dangerous for many on the South Side, particularly Latinos.
An opaque system
Over the past several years, Lee has become skilled at finding ways to help people.
Mastering the nuances of the health care system is not easy, even for those who work in the industry. The deals worked out between private insurers, pharmaceutical companies and medical providers change constantly.
Each health coverage option that Lee tells her clients about has its own eligibility requirements and limitations, so she starts by getting to know them.
If her clients are 65 or older or if they have a disability, she helps them apply for Medicare and ensures their doctors and nearby medical facilities are in-network.
For younger clients without access to employer-sponsored plans, she checks to see whether they are eligible for a subsidized health plan through the Affordable Care Act. If they’re approved for a plan on healthcare.gov, she helps them find an independent doctor who accepts ACA insurance.
But when those plans are not an option, she finds out if they qualify for local safety-net programs through CommuniCare or CentroMed, a federally qualified health center that offers affordable medical, dental, obstetric and behavioral health care.
Lee also directs South Side residents to the nearby Wesley Health & Wellness Center or Dixon Health & Wellness Center, operated by the nonprofit Methodist Healthcare Ministries of South Texas Inc.
But if they live in Bexar County and may need hospitalization, she directs them to CareLink, a financial assistance program that gives people access to University Health via the publicly funded Bexar County Hospital District. That program requires proof of residency and household income.
After Lee left medicine, she trained as a certified application counselor with CentroMed during the initial Obamacare enrollment period and eventually earned a master’s degree in health care administration.
She later became a licensed insurance broker so she could help people weigh their options and learn to navigate the health care system.
Lee has had clients wait weeks for callbacks and months for medical appointments, and some have told her they are considering cashing out their 401(k) plans early to stay afloat.
She’s seen people taken advantage of by predators: those who sell so-called “skinny” insurance plans that don’t cover regular medical care or brokers who sell costly plans bundled with life insurance, dental and vision coverage.
Because she is independent, she is not required to direct clients to certain plans and she doesn’t charge for her sessions.
She said some clients bring their teenagers to help them understand the details of their health coverage such as copays, deductibles and which hospitals are in-network. She tells them about rebates and ways to save on prescriptions.
Sometimes, she learns that the teenagers want to attend college, so she helps them apply for financial assistance.
Her regular clients often show their gratitude during the holidays, she said, with baked goods, fresh-picked chiles and homemade tamales.
‘Bad for your insides’
For many people, especially those living on the South Side, accessing health care can be financially crippling, said Dr. Carlos Roberto Jaén, chair of the department of family and community medicine at the Long School of Medicine at UT Health San Antonio.
Depending on the rates that insurance providers negotiate with medical providers, consumers can easily fall into debt. The process is not transparent: The price for a routine blood test in San Antonio ranges from $57 to $443, according to a report by the Health Care Cost Institute using data from 2017.
Jaén, a family practitioner, treats some of the city’s poorest and sickest patients at the publicly subsidized Family Health Center, located downtown on University Health’s Robert B. Green campus.
A study by Jaén and four other researchers found that providing free transportation to medical appointments for economically disadvantaged patients led to fewer no-shows and cancellations, saving the county health center more than $15,000 a month.
Offering rides also helped patients avoid unnecessary emergency room visits or hospital stays, which the study said can cost 141 times more than a nonemergency medical appointment.
Still, health disparities cannot be solved simply by paying for Uber rides or building more clinics.
Research shows that enduring hardships can have a deleterious effect on mental and physical health, eventually increasing the chance of developing chronic medical conditions such as type 2 diabetes and heart disease.
“We know that constant stress is bad for your insides,” he said. “It raises all the stress hormones that push your blood pressure up, that push your blood sugar up and tend to make your body more apple shaped because of the way your body deposits fat. Those things over a lifetime take a toll.”
‘Just completely unaffordable’
When Lee was a nurse, she often saw the same diabetic patients visit the clinic without seeming to get better. She’d ask them whether they were taking their medication and learned that many never went to the pharmacy to get their prescriptions filled. It was too expensive.
“They were coming back to us in two or three weeks exactly the same, if not worse, because we’re forgetting that outside of this visit that might’ve cost them a $25 or $40 copay, they don’t have access to the rest,” she said. “What normally should have been healed in a month sometimes took three months.”
Lee saw such heart-wrenching scenarios every day on the job, but she didn’t fully understand them until her mother was diagnosed with type 2 diabetes at age 40.
Lee’s mother, Maria Jimenez, worked 12-hour shifts every day at a restaurant, while her father worked in pool construction. He often worked nights at the same restaurant. Neither had health insurance through their employers. This was before the Affordable Care Act, which provides subsidies to offset monthly insurance premiums.
Her mother was prescribed an oral medication called Actos to control her blood sugar. Without intervention, she was at risk of serious complications, including stroke and vision loss.
She recalls driving to her mom’s house and shaving off pieces of an aloe vera plant, applying them to a sore on her mother’s leg, and praying it would heal. They would bandage it because her mom had to go to work, and there was always the fear that she’d get an infection and lose the limb.
For a while, Lee was able to get the brand-name drug through pharmaceutical assistance programs or obtain samples by calling people she knew, but once those resources were depleted, the family faced paying up to $250 a month.
“It was just completely unaffordable,” Lee said.
Lee had just had her first child, and her parents were sending money to their parents in Mexico. So with the pills financially out of reach and Lee’s mother needing to lower her blood glucose, a doctor prescribed insulin.
Lee’s eyes welled with tears as she spoke about her mother’s fear of injecting herself with insulin.
“I had to help her inject in the evenings and show her again and again,” Lee said. “At least I had a car and I was clinically trained, but I would tell her, ‘Mom, you have to take this. I know you don’t want to.’”
Lee’s mother repeatedly asked why she couldn’t continue taking the pills.
“I’d say, ‘Mom, we can’t afford the pills.’ … So insulin became a normal way of life for her. Pricking her fingers two, three times a day became a normal way of life for her,” she said. “There was no other option.”
[This article was originally published by San Antonio Express-News.]
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