A Social Worker's Health Care Stories

A Social Worker's Health Care Stories

--Holly Sorensen, CHW
One 63-year-old woman whom I assisted last May considered herself fortunate to have friends who allow her to live in a house of their's while she takes care of it, since she has no income and no one else.  When I was assisting her, her Oregon Health Plan had lapsed and she was in desperate need of reinstating her benefits as quickly as possible because her Humira prescription would not be shipped without active coverage that could be billed.  I would assume this is because the pen costs anywhere between $1800-$2400 per month for just a couple of pens.  She went a few weeks without her Humira shot, but because she so desperately needs the medication, she was so relieved once her benefits finally kicked back in because the carrier could then ship her Humira to her. 

I have also worked with a mother in a family of four, who has an 11-year-old son who has such severe psychiatric conditions that his mental health and behavior solely rely upon medications to help him avoid institutionalization, as any instance of him having a gap in coverage (due to state processing delays) typically results in his ending up in psychiatric care or institutionalization, because she cannot afford all of his scripts out of pocket and he is that severe.  When he ends up in an institution, I can only imagine the additional costs that could have been avoided had he had ongoing access to coverage without gaps.  What would they do without any access?

Another similar story to the last: I worked with a gentleman whose domestic partner passed away, leaving behind a 13-year-old boy who also struggles with severe mental health issues and depression.  The gentleman who was dating his mother while she died, took him in as if he were his own son and went through waiting to get approval and relies a great deal on Oregon Health Plan to cover anti-depressants and whatever other types of medications the boy needs to just be okay.  This is also a situation where, the man caring for this young boy does not have the means to pay for the prescriptions out of pocket, and without OHP coverage for the boy, he would be left with other additional costs of treating even worse problems when he is not on his meds.  Whenever it comes time for this household to renew, this man gets really stressed out, because his hands are full caring for a boy he took in, and there are usually problems whenever medication discontinues for any amount of time. 

Other than that, I would also like to state that I have a high number of urgent applications for Oregon Health Plan folks who rely on OHP to cover their seizure meds, insulin, heart meds and mental health prescriptions.  At least half or more of the folks we assist have one or more of these type of prescriptions and have frantic interactions with us while desperately seeking resolution through re-instatement. 

To add, I also work with a majority of the justice involved population in our county as they transition from inmate status back into the community or simply carry out probation requirements.  We encounter at least two or three per week in Union County alone.  These folks also depend a great deal upon the Medicaid system to ensure they successfully meet requirements placed upon them as part of their transition back into the community.  Obviously, this encompasses all of your most severe mental health, drug and alcohol treatment and assessments.  Without access to Medicaid coverage, we would essentially see most of these individuals failing to comply with requirements as they make attempts to get re-established or better their lives, thus bringing them back as repeat offenders.  We are told by law enforcement officials about the high risk of these individuals turning back to use of street drugs and criminal activity if they miss the follow up to re-instating their coverage and as a result, cannot manage behavior with prescriptions or even function to show up to required classes and assessments.  A majority of these individuals also lack job income and resources upon release due to their criminal background, so when they are released and regardless of cost of drugs prescribed to them, they have no other means to afford them at all.  The safety and well-being of our community relies a great deal on one of our highest-risk populations having access to affordable care and medication coverage.  Although I am not providing specific stories about these folks, it is clear that we really benefit from having our justice-involved folks enrolled in these programs while they are available.

The other less specific example would be insulin strips and equipment for diabetic patients.  Or any "durable medical billing" supplies really.  OHP only covers four test strips per day, or 100 every 25 days, and this is just a set quantity limit.  Any additional would require prior authorization, which is a complicated process for most OHP folks. This alone is bizarre since there is such a wide variety of types of diabetes severity and a range of needs for testing frequency for any given patient based on the severity of the diabetic condition.  The other thing about "durable medical billing" supplies is that most retail pharmacies don't have the capability to bill Medicaid for those particular things, so if patients want to get strips from a retail pharmacy, they usually have to pay out of pocket, or they can buy in bulk via mail order pharmacy, but again, those quantity limits apply.  What most diabetic patients end up doing is getting what they can of their test strip supply covered by OHP through the mail order pharmacy, and then purchasing back up strips out of pocket at their local retail pharmacy.  This seems like it could be a real hassle for folks who have to test more frequently just to access and afford their supplies.  This only focuses on the strips, while you have lancets, needles, pens, etc.

Other than that, I would also like to state that I have a high number of urgent applications for OHP folks who rely on OHP to cover their seizure meds, insulin, heart meds and mental health prescriptions. At least half or more of the folks we assist have one or more of these type of prescriptions and have frantic interactions with us while desperately seeking resolution through re-instatement. 

I hope these stories are helpful.  We appreciate your efforts in collecting this information for the sake of saving people their health care!
--Holly Sorensen, Outreach and Enrollment Specialist, CHW
Northeast Oregon Network
541-624-5101 Ext. 6
541-910-5286