They put a price tag on women’s health

I PULL awkwardly at the sleeve of the overly starched, long, white coat that still feels strange for me to wear. I hate wearing it, as I feel the distance it puts between me and the women I care for. It makes me an authority figure, not a partner, a confidant, a collaborator in my patients' health care.

I glance down at the billing slip for the woman in front of me and see that she's over 40, which means she should be having yearly breast cancer screenings. It also tells me she's uninsured. I hear the crinkling of the paper gown that she's pulling around herself. It's too cold in these rooms, I think to myself.

"When was the last time you had a mammogram?"

"I had one when I found a little lump. It was a few years ago...maybe 2006?"

"Any family history of breast, ovarian or uterine cancer?"

"Yes, my mom and aunt had breast cancer. My aunt was diagnosed when I was still young."

This makes her high risk. And she's unsure about the follow-up she had for the little lump years ago. I tell her that I would encourage her to get a mammogram as soon as she is able. She nods and says she knows she should, but her husband is unemployed. She doesn't get health insurance through her work. She'll go when she can. I nod and move on with the visit.

I think back to my training, feeling overwhelmed and woefully unprepared to be in practice in the real world. I got up in the middle of the night to catch babies. I studied on the on-call couch and compared notes with the family practice residents at 2 a.m.

I memorized hundreds of drugs, their doses, uses and side effects. I learned how to counsel patients, listen to their concerns, and be an empathetic and caring nurse practitioner.

But no amount of studying can prepare you to be a women's health care provider under capitalism. I know what screening tests my patients need and when they need them, but what does that matter if she can't access them?

I WORK for a non-profit reproductive health clinic in a working-class town with a large Navy base. About a quarter of my patients are either active-duty military themselves or are the spouses of Navy corpsmen.

A vast majority of my patients are young women looking for the right birth control method, are in need of a preventative health care visit, or are seeking abortion services.

People trust medical providers, and my patients often tell me about their struggles with finding affordable health care, let alone quality, comprehensive care. These circumstances end up making us witnesses as some of the most vulnerable women must face harsh decisions about their health care.

In school, we learned how to be medical providers, but the ins and outs of insurance companies, billing and coding and the costs of lab tests remained foreign to us. Now that I have entered practice, I have been bombarded with multitudes of insurance plans and different state programs that will cover certain tests and not others, and it drastically alters the quality of care that I can give.

Last week, I offered a woman screening tests for chlamydia, gonorrhea, HIV, syphilis and HSV, the herpes virus, as she had told me she had had new partners and had never been tested. All the evidence shows that when women are tested early and often, it can have positive effects on their long-term health as well as public health in general.

She wanted the tests, and I ordered them. I felt proud of myself. I was doing my due diligence as a clinician and helping someone take charge of their reproductive health.

The phone rings in the office as I sit down to chart the visit. It's the reception desk. The woman who I had just offered these screening tests lists a state-run insurance program as her only coverage.

This means that her ability to get health care is limited to three things: birth control, one chlamydia and gonorrhea test and one "well-woman visit" in a year. No HIV screening. No syphilis testing. No HSV blood work. No treatment if she has other problems.

Forget about primary care, urgent care or abortion services should she need them. I rush up to the front desk and apologize profusely. The woman is being set up with a payment plan and is not angry at me for offering her the tests.

TO ADD insult to injury, I had another patient call the clinic that same afternoon requesting a different drug for her treatment. Her insurance wouldn't pay for it, and she couldn't afford it out of pocket.

I looked at the medical assistant, flustered, "There is no 'other' treatment. I ordered this drug for a reason." I had ordered a generic drug, and the gold standard for her condition. Why wouldn't they cover it?

Luckily, because I am a new graduate, I still have another provider working with me, and she helped me find something else to prescribe, although it was not as effective as the first drug.

As if it isn't enough to be a medical provider, we have to navigate the system in order to make sure our patients can get even some form of care. I find myself wondering if I can "down-code" visits for patients that have to pay out of pocket, but know that I won't because both myself and my clinic would get in trouble.

As providers, to "code" we have to determine the "level" of a visit, on a confusing scale of complexity of issues addressed, number of body systems examined and the treatment prescribed. The difference between one code type and another can be easily hundreds of dollars.

In nurse practitioner (NP) school, they tell us that we, as midwives, are a specialty, that our patients will have a primary care provider (PCP) and half of our jobs will be making sure they are getting appropriate screening, testing and care through their primary doctor or NP.

If you work in private practice, this may be true, but not for those who are uninsured, underinsured or are Medicaid patients. It seems almost cruel to recommend they see a PCP when we both know that isn't an option.

On my third day in clinic, I was instructed to have a patient sign a medical release form for not seeking follow-up care for an abnormal pap smear that she had with us a few years ago.

We referred her for treatment, and when I asked her about it, she said she couldn't afford it. I handed her the form that dissolved the clinic of responsibility for long-term health consequences.

In that moment, the full weight of being an NP under a for-profit medical system sunk deep into me. It means that I will spend my days recommending tests, treatments and drugs that will save people's lives, treat their illnesses and prevent unintended pregnancies, and my patients will not be able to afford them.

It means I will spend valuable time that could be used providing patient care, and instead it will be spent arguing with insurance companies that, no, they actually are required by law to cover that form of birth control.

I AM lucky enough to practice in a state that allows its Medicaid system to cover abortion services. However, my patients who are covered by Tricare, the military insurance, have no such access because of the Hyde Amendment, which prohibits any federal money from being applied to abortion.

The Hyde Amendment is one of the numerous laws passed since Roe v. Wade that have sequestered abortion into my small corner of the health care world, separated from all other services.

My patients come to this clinic to have an abortion because their family practice doctors or their OB/GYNs do not provide abortions. And here, we are an easy target.

Insurance companies often refuse to pay for abortion care, but if a woman has a miscarriage and needs the same treatment we would use to terminate a pregnancy, some insurances will cover it.

I spend my day surrounded by double standards, and I grumble when insurance will cover a woman's birth control pills, but deny an intrauterine device (IUD), which we know through studies is less expensive in the long run and more effective at preventing pregnancy.

We offer medication abortions, which means women take one pill in the office that stops the pregnancy and then another round of pills at home that help expel it from the uterus. It is painful and many women face significant nausea, vomiting and cramping.

We recommend women go through the process on their days off, but this isn't always possible, as most of my patients work on weekends and have other children to care for.

I pull a pad out of the desk to write a patient a medical excuse from work for the next day. She stops me. "I can't afford to take time off. I could barely afford to take the afternoon off to come pick up the pills today."

I tell her she probably can't take the pain medicine we're prescribing her at work and review the warning signs that she's bleeding too much.

I tell her she should rest, but she's already told me it's not an option. The best thing I can offer her is that if she changes her mind and wants a note, she can call me back any time.

I finish charting after everyone else has gone home, and I shrug my long coat off my tensed shoulders. It feels heavy as I hang it on the hook for me to pick right back up tomorrow. I turn the lights out in the office, and realize the separation the coat provides isn't just for the patients; it's for me too.