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A new year with insurance.

January 1, 2014

Well, the day is finally here.  I am officially insured by Blue Cross Blue Shield of Texas.  I was never able to sign up for coverage through the federal exchange, healthcare.gov.  My application got caught in an endless loop right at the step where you confirm the policy you want to buy.  Several phone calls to the healthcare.gov phone line (800-318-2596) did not solve the problem though I must say the customer service representatives tried their best.  They’ve all become quite adept at saying, “Thank you for your patience” and “I’m very sorry you have had this experience.”  All told, I think I visited the website well over 100 times and called the phone line perhaps 20 times.  I did not count, though I wish I had.

Since I was unable to obtain my insurance through the exchange, I had to buy my policy directly from the insurer.  My agent tells me I will not be eligible for the $97/month tax credit because I did not go through the exchange.  This seems patently unfair to me since the exchange didn’t work.  I couldn’t afford to wait for coverage until the government could fix the problem.  Fortunately, I only need insurance for three more months.  I will be covered by Medicare April 1st.

It is unfortunate that actually signing up for insurance has been this hard for so many people.  It casts a pall over what should have been a joyous occasion.  Millions of people have the opportunity to get much cheaper coverage or coverage they can finally afford.  Some people in the upper middle class will pay more than they did before, but in all fairness they can generally afford it even though they will bitch about it.  I probably would too in their position.  Too bad I don’t have that disposable income to be in their position.  Like so many others, I have slipped from what I thought was a firmly ensconced position in the middle class to what I suppose must be called the lower class.

Well, tomorrow I have an appointment to go to.  I could not have made it without insurance.

Why healthcare reform matters.

December 13, 2013

I have heard grumblings from people here and there about how they aren’t getting anything out of Obamacare and so they think it is a bad thing for everybody.  Or maybe they don’t care that much who benefits if they don’t.  I don’t know.  It is disheartening to here these things from friends and relatives.  These are people I have tended to think of as reasonably good and generous.  I don’t like thinking I was wrong.

I think one problem is that many in our country just don’t get how fortunate they are.  My cousin who says, “I am not Obamacare,” is solidly middle class with a wife who also works and three children.  I don’t know how much they make, but knowing their professions, I suspect their household income is solidly in the top 25% in this country.  Another  person I know from a heart disease support site complained about having to pay more for insurance next year.  She and her husband are not eligible for the tax credit which means they have a household income over $62,040 for the two of them.  As you can see on the chart below, this places the couple well above the median US household income of $50,000.  I have a hard time feeling it is that much of an inconvenience for their premiums to increase from $600/month to $1,200/month with their deductible decreasing from $12,000/year to $6,000/year.  When you break it down, it’s not as bad as it sounds.  When you carry a deductible of $12,000, I assume that means you are budgeting to be able to pay that deductible.  With annual premiums of $7,200 plus the deductible of $12,000, that is $19,200 of annual health care cost plus your copays and/or coinsurance.  With the $6,000 deductible and $14,400 of premiums, you are budgeting $20,400.  That is a difference of $1,200/year or $100 per month which may well be made up for by offering better coverage.  Sounds kind of whiny to me since I’ve been unable to even contemplate buying individual insurance until this year.

Distribution of Annual Household Income in the United States in 2009. Based on US Census/Bureau of Labor Statistics data from the March supplement of the CPS: http://www.census.gov/hhes/www/cpstables/032011/hhinc/new06_000.htm

Distribution of Annual Household Income in the United States in 2009. Based on US Census/Bureau of Labor Statistics data from the March supplement of the CPS: http://www.census.gov/hhes/www/cpstables/032011/hhinc/new06_000.htm

Why is it that our society is so stuck on “What’s in it for me?”?  Why do we revel in our charitable donations at Christmastime, but don’t want to do much as a country to help our own people.  Is it because we think the people who couldn’t afford insurance before were somehow inferior?  That they somehow deserve to suffer and go without care? Besides that, these complainers are ignoring the other benefits of the Affordable Care Act, such as free preventive care, no penalty for pre-existing conditions, the ability to keep adult children on family policies a bit longer.

Even with my tax credit of $97 per month, the policy that makes the most sense for me to buy is going to cost me $290.70.  It’s not quite what I’d call affordable, but is infinitely better than the $500/month COBRA would have been costing me or the undoubtably much higher risk pool premium I might have been offered with my pre-existing conditions.  I’m just happy I can manage to pay for some coverage for the three months next year before I qualify for Medicare.

So, back to my original question, why does any of this matter?  In my 30+ years of experience working in the health care field, I have had ample opportunity to observe the inner workings of our system and the consequences of our failure to care for our own people.  Who do you think pays for the emergency surgeries or hospitalizations for uninsured people?  The vast majority of these people will never be able to pay these medical bills.  Do you think the hospitals and doctors just eat the cost themselves?  No, they get tax deductions for these losses and they raise their prices to make up for them.  Then who pays?  You do, all of you.  All of us.

So, it’s not just about you and your slightly higher premium.  There is a whole society out there and this law is just a step toward taking care of our own.  A step hampered and complicated by a bunch of selfish people who don’t even want to try to help their neighbors and fellow citizens.  As a Buddhist, I strive to cultivate compassion for all, even those who cry out so loudly at being asked to make a small sacrifice for the good of all society.  It’s really hard sometimes, but I mean to keep trying.

 

 

 

Younger, Female Heart Attack Survivors Face Higher Risk Of Mental Stress-Induced Myocardial Ischemia

November 30, 2013

Younger, Female Heart Attack Survivors Face Higher Risk Of Mental Stress-Induced Myocardial Ischemia.

I found this article on Huffington Post today.  It describes a recent study done at Emory University exploring differences between men and women heart attack survivors between the ages of 39 and 59.  It’s a small study, less than 100 participants total, but it is an important step in elucidating what the important differences between men and women recovering from heart attacks are.  Up until recent years research focused on middle aged men almost exclusively, perhaps explaining why my first cardiologist tried to tell me chest pain associated with anxiety or emotion probably wasn’t cardiac related.  I wish I could send him this article.

For the record, I am 47 years old.  I survived a heart attack shortly after I turned 44.  Mental stress still causes a significant portion of my angina pain and definitely causes worse angina than exertional stress in my case.

A couple of articles telling the truth about Obamacare.

November 26, 2013

I ran into a couple of articles today that echoed what I was trying to say in my post yesterday about my experience with Obamacare.  I’d like to share them to expand upon the points I already made.

First, my friend Beverly sent the link to Paul Krugman’s article from the New York Times, California Here We Come?, in which the columnist points out the fallacies inherent in declaring Obamacare a failure based on the faulty performance of the federal insurance marketplace, Healthcare.gov.  He offers California’s successful marketplace as an example of what this program will be in the future.

This morning I encountered this story by Michael Hiltzic of the LA Times, The Obamacare Success Stories You Haven’t Been Hearing About.  Hiltzic talks to people around the country who have signed up for the new policies available for 2014.  People who were uninsurable now have reasonably priced policies and many people are finding cheaper policies that offer much more comprehensive coverage.

This is exactly what I was hoping for back in 2009 when the Obama administration was trying to get started on health care reform.  At that time, I changed from a full time employee to per diem in the hospital ICU where I was working.  The stress of night shift was harming my health and my manager would not allow me to go to day shift.  Changing to per diem allowed me to sign up for open day shifts and work fewer days per week, but made me ineligible for the employer sponsored health coverage.  COBRA for myself and my husband cost over $1000 per month.  I took a second job as adjunct faculty at a community college teaching nursing.  I enjoyed teaching very much, but my chances of securing a position that offered benefits were slim.  If my husband and I had been able to sign up for the kind of coverage now available at that time, I would likely have continued teaching instead of returning to hospital work full time.  Would that have saved me my heart attack?  Impossible to say, but it would have reduced my stress tremendously.

Signing up for insurance through the federal marketplace.

November 25, 2013

 

 

100_0007Fifteen states plus the District of Columbia have set up their own insurance marketplaces for people seeking coverage under the Affordable Care Act (Obamacare).  You can see a nice interactive map describing what each state has in place here.  My state, Texas, is not one of them.  I, like millions of other people have been trying to sign up for individual health coverage for the new year at Healthcare.gov.  So far the news regarding states with their own marketplaces is a lot better than what we are hearing about the federal marketplace.  Despite the reassurances from the Feds that we can sign up on paper or over the phone, the people on the other end of the phone are dependent on the same dysfunctional website that all of us use online.  I recently spoke to an insurance broker who told me the insurance professionals have to use it too in order to sign you up in a way that allows you to use your tax credit to pay a portion of your premiums.

Anyone can sign up for insurance on the individual market directly with any insurance company that offers coverage in your area.  That is the best option for those on the individual market and not eligible for the tax credit (those with income 400% of poverty level).  Those of us who do qualify for the credit (those with income between 100% and 400% poverty) are better off signing up through a marketplace so the tax credit can be applied directly to premiums.  For example, in my situation (according to the Kaiser Family Foundation calculator) my estimated tax credit would be 67% of my maximum premium (6.81% of my family income) on a Silver plan.  That would cut my monthly premium down to less than $200.

Let me share a bit of my experience attempting to use Healthcare.gov.  Before the open enrollment period started October 1st, the website was easy to use.  I signed up for email updates and signed up for my account.  I was able to log in easily and use the pre-rollout features of the website.  Come October 1st, it all went to hell.  Most times I accessed the website I was placed in a cue to even sign in.  Then when I could sign in, some parts of the application worked and some didn’t.  Everything went extremely slowly.  I had time to go out and putter in the garden while waiting for the opportunity to fill in the next page of the application.  Then it would suddenly stop working.  After trying different times of day, I was finally able to complete my application early on a Sunday morning.  I was informed the next step was to read my eligibility letter which would explain my tax credit situation and premiums.  I clicked on the button to read my letter and a pdf file was downloaded to my computer.  The file was a letter informing me that I had the wrong version of Adobe Reader and telling me to update.  I knew I was already updated, but still went to the Adobe site to download the most current version.  The letter still did not download properly.  I chatted with a customer service person at Healthcare.gov who suggested turning off my pop-up blocker.  That didn’t help.  I was informed the letter would also be mailed.  I never received it.  Then a couple days later I could no longer sign in to Healthcare.gov.  Since around mid-October every time I try to sign in to the website, I am taken back to a blank log in page.  If I purposely use the wrong password, I am taken to a log in page with the message that my user name or password was entered incorrectly.  I waited a few weeks then tried calling the phone number for the marketplace, 800-318-2596.  I spoke to a very nice lady who suggested turning off the pop-up blocker or using Firefox instead of Safari.  Then she attempted to help me with my application but was unable to access the system.  She said I could sign up for insurance directly with an insurance provider, but then I would be unable to apply my tax credit to my premiums.

I only need insurance for 3 months next year.  After that I am eligible for Medicare.  The deadline to sign up for coverage starting January 1st is December 15th which is closing in fast.  I will most likely sign up without my tax credit if the problems with the system are not fixed by the deadline and try to get the credit paid to me when I file my taxes for 2014.  I’ll probably need to get help from family to pay the premiums, but at least I won’t have to go to the CommunityCare Clinic any more.  The deductible is very high for the plan I’m looking at, but the copays for doctor visits and medications are quite reasonable.  I’ll hold off on the stuff that has a deductible until April when I’m on Medicare.  I’ll be able to start catching up on some of my “deferred maintenance.”  That’s the stuff either not covered by the program I’ve been using since March 2012 or that I’ve been unable to deal with because I hate going to their doctor.  I have been doing what no chronically ill person should do, putting off seeing a doctor and saving up lots of little problems.

So let me tell you what I think of Obamacare.  Sure, the roll-out of this federal market place is a mess.  From what I’ve heard the state marketplaces have worked somewhat better.  Of course most of the states bowed out from that and left the burden entirely on the federal government.  Any new program serving millions of people will have some bugs.  I am disappointed at the severity of the problems with this one.  What people ignore is that this is a tiny part of the entire Affordable Care Act.  People like me with pre-existing conditions can no longer be denied coverage or be charged more than other people for insurance.  Your insurance company can’t dump you because you’re sick.  Your children cannot be denied coverage of pre-existing conditions and they can stay on your policy until age 26.  Preventative care is covered at no cost to you.  Emergency care will be covered out of network.  There is no longer a lifetime limit on coverage.  That’s nothing to sneeze at!  I remember working at a head injury rehab 20 years ago that cost $30,000 to $50,000 per month.  My health insurance had a lifetime maximum of $1,000,000.  I looked around at the severely injured patients I cared for each day and knew a million dollars wouldn’t last long if something like that happened to me.  For more information on the full benefits of the Affordable Care Act, see the Health and Human Services website.

I am overjoyed about all the benefits we will all gain from this law.  Many of the people complaining about how awful all this is have no idea what Obamacare actually is.  This includes my opinionated and talkative mother-in-law.  She’ll bitch about it all, parroting Fox News, but then when my husband and I have problems getting health care she moans about how “terrible” it is that we have these problems and can’t “someone” do something.  Yet when this country tries to do something, she cries out that the world is going to end and Obama is the worst president we’ve ever had.  Well, I have news for her and all the other naysayers:  I am Obamacare!

 

I miss being a nurse.

November 9, 2013

As most of you know, I am a disabled Registered Nurse.  While my cardiac symptoms are now under much better control, I still cannot withstand the normal stresses of work as a nurse.  Three or four hours of activity at the pace of even the most sedentary nursing jobs would leave me exhausted.  That’s because almost all nursing jobs involve a high level of stress due to productivity requirements, time sensitive tasks, and the extreme perfectionism demanded of us.  Fail to document the exact right words and you could face a lawsuit, etc.  I think the litigation threat is somewhat exaggerated, but it hangs over all in the health care field like the sword of Damocles.

I worked in critical care for many years.  I enjoyed the respect given to me as someone working in an elite field.  I liked the excitement of being involved in life and death situations, of trying to figure out what was going on with the patient and what needed to be done.  I was reminded of this yesterday when I faced a critical care situation in my own home.

Mr. Bebe and Miss Bebe in a relaxed moment.

Mr. Bebe and Miss Bebe in a relaxed moment.

My cat Mr. Bebe showed some signs of distress Thursday morning.  My guess was that he might have a bladder stone passing.  This had happened once before and he managed to pass it and was his normal self the next day.  Back when I was working and had much more disposable income, I would have taken him to a vet right away.  Thursday, I had $16 in my purse and maybe $20 left in my checking account that had to last until next week when I receive my Social Security payment.  We hoped that the stone would once again pass and Mr. Bebe would be back to normal.  Thursday night he came inside of his own accord and went to sleep on the couch without eating.  This was an ominous sign.  Friday morning he was still on the couch and showed no interest in going outside when I took the dogs out.  I knew he was seriously ill at this point.

My differential diagnosis included bladder or kidney stones, urinary tract infection, or some infectious disease, or poison (since he hunts and eats mice outside).  My husband noticed blood near the litter box Thursday morning.  That was the sign that made me lean toward a urinary tract problem.  He had become lethargic and weak with some tremor when he moved.  This told me he had a metabolic problem.  I feared renal failure due to bladder obstruction.  This was a life threatening emergency.

Cat bladder obstruction due to stones.

Cat bladder obstruction due to stones. Visit www.vetnext.com for a full explanation of this condition.

I had been researching urinary system problems of cats the day before.  I found that symptomatic stones are more common in male cats because they have a longer, narrower urethra (tube leading from the bladder to the outside of the body) than females.  I also found out that feeding kibble makes cats more prone to stones because cats have evolved to get most of their fluid requirements from their food (prey) and have a low thirst drive.  That means they may not necessarily drink enough water when on a dry food diet.  This causes concentrated urine which can predispose the cat to stones, material which crystalizes out of the urine and accumulates in the bladder.

We were fortunate that my sister was able to help us out paying for a vet.  We took him in and the vet said his bladder was the size of a tennis ball.  I’m not sure what size a cat’s bladder is supposed to be, but I suspect it’s closer to the size of a grape.  Mr. Bebe stayed at the animal hospital for emergent catheterization.  The vet called us after a couple hours to let us know he’d been successful in relieving the obstruction and Mr. Bebe now was getting IV fluid and had a catheter to keep the urine flowing.  He was also getting antibiotics and pain medication.

We visited Mr. Bebe this morning at the animal hospital.  He was very drowsy but did wake up for us and was able to rub his head on our hands and knead his claws in the towel under him.  This is an encouraging sign.  His urine is clearing up.  It had been quite bloody at first from the bladder distention.  We feel hopeful he will make a full recovery.

Being involved in this medical stuff this week reminds me how much I miss it.  This blog has been one way I keep a hand in, but I miss actually caring for patients and educating them and their family members.  I miss teaching nursing students.  I just haven’t found a suitable way to care both for myself and for them.

An option we should consider.

October 9, 2013

As I wrote in my last post, I have known three people who killed themselves because of what they undoubtedly considered intolerable suffering.  In this post I am going to discuss some more graphic aspects of these choices and the alternatives we, as a society, should offer.  If this will be too much for you, you might ought to stop here.

I read an article today about a 44 year old Belgian man who chose euthanasia to end his life due to “unbearable psychological suffering.”  Upon doing further research, I found that Belgium, the Netherlands, and Luxembourg are the only countries in the world allowing euthanasia.  Euthanasia is where a doctor actually administers the drugs to end the person’s life.  This differs from physician assisted suicide which is legal in the states of Oregon, Washington, and Vermont.  Physician assisted suicide is when a doctor prescribes a lethal amount of medication to a patient (the laws in these states require that the patient be terminally ill) who wants to end his or her life.  The patient is then free to use the medication to end his or her life.  Montana also allows physician assisted suicide based on a court ruling (Baxter v. Montana).  Belgium’s law is unique in that it allows a patient to choose euthanasia in cases where no terminal illness is present.  A patient who successfully makes the case that his or her psychological suffering is intolerable, with the approval of three doctors, may choose this treatment.

September 13, 2013 my brother’s ex-partner, a man I had known and cared for for over 15 years, shot himself in the head on the side of a road in Pennsylvania.  After his death it became clear from a note found in his car and his actions in the last days of his life that this was an action long planned.  We had watched him become more depressed and remote over the last two years, but he consistently refused to seek medical assistance and isolated himself from almost everyone he knew.  He had told my brother he didn’t want to “start over.”  The meaning of this statement became more clear after his death.  He had suffered from recurrent episodes of major depressive disorder.  He had managed with treatment to pull himself out at least two times in the past.  When the depression returned this time, I think the thought of having to go through it all again was too much.  Having been through episodes of severe depression myself, I can understand his feelings.

The others I knew who killed themselves went through similar recurrent episodes of depression.  They availed themselves of treatment, but were unable to find lasting relief.  They suffered for many  years before making the decision to end it this way.  They did not “take the easy way out” as those hostile to suicide so often call it.  When one seriously considers suicide, it is not an easy decision.  It is one that is absolutely agonizing.  You don’t do this because you don’t care about how it hurts others, you do it because you have to end the terrible suffering.  My brother-in-law’s letter was filled with apology and regret for leaving people he knew would miss him.  He explained that he had pushed people away so they would not feel as much attachment to him.

Why is it that we don’t offer an alternative such as that Belgium offers?  That someone who has suffered for a long time and is unable to endure more has to blow his brains out by the highway or take a bunch of pills and hide behind the bushes in a park is a terrible thing.  Why can’t it be an option to die comfortably, without violence and fear of discovery?  Why don’t we treat this as a choice?  Most arguments against suicide are based in religious beliefs.  But if there is a God, why would God not understand suffering and allow one to end it.  Why would God not forgive?  More importantly, why should we as a country legislate the religious views of some to rule all?  I would have been terribly sad about my friends choosing to die in this way, but so much less than the shock at the violence in the ways they ultimately chose.

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