When Darius Settles died from COVID-19 on the Fourth of July, his family and the city of Nashville were shocked. Even the mayor noted the passing of a 30-year-old without any underlying conditions. However, he was uninsured and had just been sent home from the emergency room for the second time.
A WPLN News investigation into his death finds that uninsured COVID-19 patients are rarely being told that cost shouldn’t be a concern.
In their Antioch apartment, Darius and his wife, Angela Settles, both had been feeling ill with fevers and body aches. Then Darius took a turn — bad enough that he asked his wife to call an ambulance.
“My husband is having issues breathing and he’s weak, so we’re probably going to need a paramedic over here to rush him to the hospital,” she told the operator, according to the recordings obtained by WPLN News.
Darius was stabilized and tested for COVID-19 at the hospital, according to his medical records. The doctor sent him home with antibiotics and instructions to come back if things got worse.
Three days later, they did. And now he also knew it was COVID.
But Darius was also between full-time jobs, playing the organ at a church as he launched a career as a suit designer. So he had no health insurance. His wife, who works for Tennessee State University’s extension office, says he was worried about going back to the hospital a second time.
“He said, ‘I bet this hospital bill is going to be high.’ And I said, ‘Babe, it’s going to be OK.’ And we left it alone, just like that,” she says.
Upon his return to TriStar Southern Hills, they tested his blood oxygen levels, which are usually a first sign that a COVID patient is in trouble. They had dropped but not dramatically. An X-ray of his lungs “appears worse,” the physician wrote.
But the doctor also noted that he no longer needed oxygen and had otherwise stabilized in his few hours at the ER. The records show they discussed why he might not want to be admitted to the hospital, since he was otherwise young and healthy, at low risk for complications.
And when Angela called to check in, he seemed to be OK with leaving, despite his persistent struggle to breathe.
“Him being a COVID patient, I could not go up there to see him,” she says. “He was saying that I might as well go home.”
Angela was surprised since he was the one who wanted to go to the hospital in the first place. But now she considers what was left unsaid.
At first, she thought perhaps the hospital just didn’t want to treat a man without insurance who would have trouble paying the full bill. But Southern Hills admits hundreds of patients a year without insurance — more than 500 in 2019, according to a spokesperson. And in this case, the federal government would have paid the bill.
Message never makes it to patients
Tristar, like most major health systems, is part of a program through the Centers for Medicare and Medicaid Services in which uninsured patients with COVID-19 have their bills covered. But Tristar doesn’t tell its patients that upfront. And neither do other local hospitals or national health systems, despite cost always being top of mind.
“This is obviously a great concern to most uninsured patients,” Jennifer Tolbert of the Kaiser Family Foundation who studies uninsured patients. She says her research finds that people without insurance often avoid care because of the bill or the threat of the bill, even though they might qualify for any number of programs if they ask enough questions.
Tolbert says the problem with the COVID uninsured program is that even doctors don’t always know how it works or that the program exists.
“At the point when the patient shows up at the hospital or at another provider site, it’s at that point when those questions need to be answered,” she says. “And it’s not always clear that that is happening.”
Among clinicians, there’s a reluctance to raise the issue of cost in any way and run afoul of federal laws. ERs have to at least stabilize everyone, regardless of their ability to pay. Asking questions about insurance coverage is often referred to as a “wallet biopsy,” and breaking this federal law can result in fines or even being banned from receiving Medicare payments.
Physicians also don’t want to make a guarantee, knowing a patient still could end up having to fight a bill.
“The thing is, I don’t want to absolutely promise anything,” says Dr. Ryan Stanton, an ER physician in Lexington, Ky., and a board member of the American College of Emergency Physicians.
“There should not be a false sense that it will be an absolute smooth path when we’re dealing with government services and complexities of the healthcare system.”
But Stanton acknowledges that emergency physicians should be able to get away with a discussion about cost if it promotes free care.
‘Could I have done more?’
For Darius Settles, he knew he was in bad shape. But he didn’t attempt to make a third trip to the hospital. Instead of 911, he called his father, pastor David Settles of Murfreesboro.
“He said, ‘I need you pray for me.’ I said, ‘Son, I’m praying for you.’ He said, ‘No, I really need you to pray for me. I need you to get the oil, lay hands on me and pray,'” David Settles recalls, and so he went, despite concern for his own health.
He sat by his son’s side. Darius’s wife made some peppermint tea, but when they put it to his lips, he didn’t sip. They thought he had fallen asleep. But he was unconscious.
At that point, they called 911 and the operator instructed them to get Darius on the floor and perform chest compressions until paramedics arrived. Eleven minutes later, they entered the apartment, but Darius never revived.
Pastor Settles was back in the pulpit just a few weeks later, preaching on suffering and grief after the death of his son, “whom I watched as the breath left his body,” he told his congregation. “”The Lord gives, and the Lord takes away.”
Darius left behind his own son, who is 6. And his widow’s head is still spinning. She says she can’t shake a sense of personal guilt.
“Could I have done more?” Angela Settles asks. “That’s hard, and I know that he would not want me to feel like that.”
She doesn’t want to blame the hospital, even though after failing to explain its no-billing policy for uninsured COVID patients, it did send her a bill for part of her husband’s care. Asked why, the hospital tells WPLN News it was sent in error and doesn’t have to be paid.