Applying for coverage under the Affordable Care Act

I’ve started the process of seeking coverage under the Affordable Care Act on the website.

I ran into a few snags with the registration process last week, and the eligibility application process kept hanging, but this week, I was able to successfully submit the eligibility application.

I was less frustrated with the technical glitches than with just being confused about some of the questions.  The process felt similar, in terms of flow through a web process, confusion and frustration to filing my income taxes.  Here are the things that I found most confusing:

  • I work as a freelance developer, so my income can vary by a few hundred to a thousand dollars each month depending on which projects I’m working on and the number of hours I put in.  The eligibility web form asks me for my monthly income.  What should I put?  The system then calculates a yearly income from the monthly value that I entered (minus any deductions). Why doesn’t it just ask for a yearly amount.  I could more easily input my adjusted gross income from last year’s tax return than estimating a monthly value.
  • You can get exemptions for student loan interest. How do I figure out how much I pay in interest every month or year? I ended up looking at my monthly loan payment statement and using the amount of my payment applied to the loan interest.
  • My eligibility report said that I wasn’t eligible for any tax rebate or subsidy.  I’m a little surprised by this. Are there any lists of estimated costs/subsidies to make sure my options match what others with similar incomes are seeing?

What seems to get overlooked in the supreme court’s review of the individual mandate …

What seems to get overlooked in the supreme court’s review of the individual mandate is that though young, healthy people may not need health insurance, health insurance is, sadly, a gatekeeper to getting access to even (relatively) cheap and easy healthcare services.  The expense, difficulty and stigma of accessing health care without insurance, and often even with insurance, keeps people from getting into habits of self-care that can lead to better health or earlier detection when someone’s health changes.  Young, healthy people may not need health insurance in the same way as other healthcare users, but they need to take care of themselves, which should include accessing different kinds of healthcare.

I’m deeply ambivalent about an individual mandate as a solution, but I do think it exposes the shortcomings of a market-based health care system that puts the market and the system above human needs.

Bump Remover

The stiches after my cyst has been removed.
The stiches after my cyst has been removed.

“What’s CR10?” my surgeon asked as he pointed to the t-shirt I had gotten from my volunteer shift at the conference.  “It’s a conference that I went to about prisons,” I replied.  I have this problem where I either explain things too verbosely, or to simply.  This was one of the times where I should have been more specific.  “I think that we should deal with prisoners by putting two people in a cell together and giving them one gun,” offered the surgeon.  Stunned, isn’t exactly the right word, because the surgeon’s response was both a shock and totally expected.  I hate these moments when someone says something that is completely offensive, largely ignorant, representative of so many things that are troubling, but when one also has this overwhelming sense that, in the grand scheme of things, what was said, and any possible response, really don’t matter.  There was a lengthy, awkward silence, an expression of terror on the face of the surgeon, and then he quickly sputtered, “I’m joking, I’m joking.”  I don’t think that he would actually advocate for this kind of plan to reduce prison overcrowding, or that he really thought much at all about such things.   Sadly, his best guess at a joke about prisons said a lot about his reading of what the average person would probably think about incarceration and incarcerated people.  I didn’t want to think about this at the moment and didn’t want to add another item to my queue of hopeless things for humanity, I just wanted him to do a good job of cutting the bump out of the back of my neck.

In general, bedside manner and small talk didn’t seem to be his strong suit. This was fine with me as I’d come to expect perfunctory treatment from healthcare professionals.  I’ve started to expect doctors to be like tech support.  I just want them to get the job done quickly and correctly and to answer my questions and to make me feel like they’re not messing up.  I want a feeling of competence and not neccessarily warm and fuziness.  He started explaining the procedure of removing the cyst, and again, his tone indicated that such explainations were something you learned was important to do in medical school, but not something that he felt was important.  It all sounded reasonable enough to me anyway.  As he had explained, he injected the area around the cyst with a local anesthetic.  I had been offered the choice of this option, or general anesthetic, but chose the shots because it was cheaper and meant that the procedure could be done in his office instead of the hospital.  It was pretty painful, but momentary.  I was surprised at how quickly the drugs took affect and how there wasn’t so much a sense of numbing, but of complete absence of feeling.  As he made his first incisions, it was really strange to anticipate pain and feel nothing, to feel outside of just one part of my body.  All I ever felt was the strange, gentle tugging at my neck.  It was to physical sensation what dream is to memory and at least the feeling was something to focus on.  At one point, I felt a sharp pain as the anesthetic wore of, but after a few more shots, it was back to feelings of gentle tugs.  He said that in many cases, one could just peel the cyst from the surrounding flesh, but in this case, he would have to scrape it.  What did it look like, the inside of the mass that had been slowly growing for the past year or so?  With his description of the extraction, all I could muster was the image of removing the flesh of an avocado from the skin.  This was medically inaccurate, I know, but I couldn’t find a better relation for scraping and peeling.

The whole procedure, or the surgical part, at least, took only 15 minutes.  By then, he had stitched me up and I was out the door, my surgeon scribbling a prescription for antibiotics and hurredly giving me care instructions as we walked down the hall.  Do you have any questions?  No?  Good.  I walked out of the office, murky with its faded carpet and wood paneling, and into the pale midafternoon sun.  I felt off, maybe more for lack of side effects that are so common now (for example, in this case here, one can get worse taking pills to get better!), than for any lingering effects of the surgeons incisions.  It seemed strange for my body to keep going, seemingly undettered by the extraction.

Recently, a few months from having the cyst removed, then the stitches, and the end of the no-swimming period (the cyst’s absence left a hole, the surgeon explained, and with permeable skin you don’t want the hole to fill with water), I’ve gone twice with my friend to visit her grandfather in his nursing home.  Her grandfather, whose exploits as a young man have become family legends that transfix his great-grandchildren with wide eyes and jaws agape when they are retold, is now mostly heavily sedated.  This, I am told, doesn’t have a particular medical purpose, but is instead to make it easier for the staff to deal with the residents, to make them pliable and to soften any emotional outbursts or expressions of discontent.  He swallows akwardly and I wonder if, through his entire body, he feels the disconnection that I felt in the square inch or so of my neck.  I realize that my expectations for my healthcare provider, my pragmatically constricted settling on the doctor as competant technician, are the expectations of a relatively young, relatively healthy person.  For someone facing greater uncertainty with their health, whether because of age or serious illness, I can understand the desire for care that is actually caring and not just fast and relatively error free.  The healthcare needs of different people are very different and healthcare systems, in general, and attempts to address the needs of the uninsured such as the Healthy Indiana Plan in particular, struggle to address this.  At the very least, they can aknowledge these differences with some empathy, but far more is going to be needed.

Becoming a health care consumer, after a few years of being uninsured, I’ve become part of a larger dynamic.  I’m going to the doctor with all the health issues that I had previously ignored.  In states like Massachusetts with healthcare systems that attempt to insure large numbers of the previously uninsured, this has put a heavy load on primary care physicians.  In addition to my cyst, I wanted to try to get rid of a wart on my finger.  I got referred to a dermatologist, but there weren’t any who accepted the Healthy Indiana Plan in Bloomington, so I had to go to Indianapolis and wait for a few months for an appointment.  My appointment ended up being a few days before leaving Indiana for a few weeks for the holidays so time was short and I ended up driving to Indy, having my appointment, and then heading straight back.  The appointment was at the university hospital’s outpatient center and navigating the campus and then the labirynth of the hospital was pretty frustrating.  I liked the doctors though.  I’ll chalk it up to the hosptital being a teaching hospital of the university because they had that laid-back, almost jovial quality that I’ve come to find through the halls of many universities.  It was in stark contrast to the crazy bustle of the hospital and the university.  The doctors were also very happy to take time to answer my questions in some depth, and I wonder if this can also be attributed to the frequent questions that come with being a student or teacher.  It took maybe half an hour to get the wart frozen and to answer my questions and for me to answer theirs and more than three-times that to make the drive up and back.  I’m happy to have been able to see the doctor, but I can’t help but feel like things could have worked more smoothly.

Having not had health insurance for a few years, and having not really used healthcare before that, it’s hard for me to tell whether my experiences are representative of some of the struggles that everyone is having with healthcare or if they’re the result of having only the sparsest health coverage.  In either case, I feel like I need to be more constructive in defining what I would like to have:

  • I want to be able to see doctors in my own community
  • I want to be able to pick from a variety of doctors and I want to have resources available to make informed choices about my doctors.  When most of the people you know don’t have health coverage, it’s hard to get good information through word of mouth.
  • I want a stable set of doctors who accept my health coverage
  • I want to be able to see a doctor within a few weeks, not a few months
  • I want dental coverage in addition to other types of health coverage

Perfunctory Healthcare

Since getting some semblance of health insurance, I’ve felt like the doctors I’ve dealt with have been competent, but curt, and I felt like my primary physician is just a dispatcher to a specialist.  Last night, I heard a story on All Things Considered that suggested that I wasn’t alone in my experience and that there are reasons (of course) why the care I get is the way that it is.

“You have someone on your hands with five separate medical problems, 15 minutes to see them. If you spend the extra half hour, you don’t get paid for it, so the pressure is to refer them to a subspecialist,” Levy explains. “It takes a lot of the pleasure and fun out of doing medicine.”

Check out the rest of Mass. Health Care Reform Reveals Doctor Shortage.

Healthcare and the state update

Healthcare and the State continued

There are few feelings better than knowing that someone’s got your back, or at least is looking out for you, or at the very, very least is holding up their end of being accountable to you.  So, I was really excited when my primary medical provider’s office called me and told me that, while the surgeon I had originally been scheduled to see didn’t accept the Healthy Indiana Plan insurance, they had scheduled an appointment with another surgeon.  They couldn’t find a dermatologist who accepted the HIP in Bloomington, but I could see one about the wart on my hand in Indy, in December.

Today I went to see the surgeon.  I had to wait an long time, or what seemed like a long time, but the receptionist was friendly and clear.  Being fairly healthy, and fairly irresponsible, I haven’t used healthcare services in a long time.  So, I feel like I have few points of reference to evaluate the quality of care that I’m receiving.  I think this is a common problem with folks who haven’t been able to see healthcare providers in a long time – you don’t know what to expect, so it’s hard to hold doctors, insurance providers, and paramedical staff accountable.  The surgeon was to the point, but moved through what he wanted to tell me really fast.  He was glad I didn’t smoke (it saved him a lecture), I had a sebacious cyst which was the result of a natural glogging of the sebacious glands, since it seemed inflamed and was on my neck where infection could easily spread to dangerous places like the spine it should be removed, I could choose to have it removed under local anesthetic at the office or by going under at the hospital.  The first option would be faster and cheaper, but bad if I had a low pain tolerance or an aversion to shots.  The doctor paused only briefly to allow me to make my decision. I chose the local anasthetic because I didn’t want to spend my day at the hospital, and, as I understand it, I am only covered for up to $1100 in healthcare expenses, so I need to watch costs.  The doctor prescribed some generic antibiotics (covered by the HIP, but they would have only cost me $4 out-of-pocket) to get rid of any infection of the cyst and scheduled a date for the surgery.
All in all, I’m happy with how things are going so far, but would be really nervous if I had to deal with more serious or complex medical issues.  I get this sense that I’m being herded through a big system, as efficiently as possible, and that I’d have to really struggle to make my concerns known and have my questions answered.

A tail of different healthcare experiences

I went to my first doctor’s appointment under the Healthy Indiana Plan yesterday, and went to the Volunteers in Medicine (VIM) clinic to get my records from the checkup I had there a year ago.  I wanted to write about these experiences and it seemed convenient to frame it in the metaphors of ‘a tale of two cities’ or of ‘hell and purgatory’ (sadly, there’s no healthcare heaven to be found in either of these places).  I realized though, that this such framings don’t do justice to the many different experiences that people can have with healthcare, all of which need to be improved.  A race to the bottom or a game of “who’s got it worse” isn’t very productive.  Having no experience is a kind of healthcare hell.  So is working a job with inadequate wages to maintain health coverage.  So is having state subsidised healthcare for your kids, but no support for keeping you as a parent healthy.  So is having insurance, but it not covering important and neccessary procedures.  So is not being able to select health providers that respect your experience and values.  Sitting in the VIM clinic, I realize that even though I’m subject to many of the same shortcomings of a volunteer-run community clinic that everyone else in the waiting room is facing, the simple reality that my job doesn’t particulary care when I come into work that day makes my health care experience dramatically different than others.  It also reveals that giving people mobility with their health and care is inseperable from mobility with employment, childcare, and a bunch of other things.

The VIM clinic is clean and pleasant, but a sense of stress permeates the reception and waiting area.  I think the VIM clinic is a necessary community resource and respect all the physicians and other volunteers who make the place go, but it is a band-aid and not a cure for the health care needs of Monroe county.   The times that I have been in there have always seemed hectic.  Patients become quickly frustrated when their records are lost, information about appointments was ambiguous, or expectations about timelines and procedures weren’t clearly communicated.  People working the counter try to respond politely and empathetically, but seem on the verge of cracking after being faced with the constant questions and demands that seem beyond the clinic’s available resources to coordinate all the records, appointments, and volunteer providers.  The woman in line in front of me is asking about what seems to be three different appointments.  She was supposed to get a call back about one last week, but never got the call.  She is told that a doctor can see her today, but that since she is a walk-in, she will have to wait.  The woman periodically returns to the counter asking if they can give her any idea of what time a doctor will be able to see her.  She is told she will just have to wait and she returns to the seats, looking nervously at her watch.

I once heard a cocky critic of universal healthcare say that it was totally unreasonable for Americans to expect both the same quality of healthcare they had been receiving and that it be available to everyone.  He also said that the quality of healthcare in the U.S. is so much better than that in countries with nationalized healthcare.  What little I have seen of foreign nationalized healthcare systems seems similar, in some ways, to what I see at the VIM clinic.  Doctors have strange hours, and you might have to get bounced around a few times before finally getting to see the correct doctor.  It seems amazing sometims that such a system works.  And, despite high taxes (and attempts to evade them), and some inadequacies with the care, people do get healthcare, and it’s free.  I think the biggest difference with with more universal care, though, is that the experience is more universal.  When there are problems with the system, there is a collective knowledge about how to navigate around them.  It seems more likely, too, that problems are recognized as systemic and there is more posibility of a socio-political push to remedy them.  In the U.S., with the “beggars can’t be choosers” ideology that underlies so many of our systems, health care consumers are too often blamed for the quality of their healthcare.  We struggle to find a better health care situation for ourselves and our families, and in doing so, have little time or energy left to learn how to be health care advocates for ourselves and others, or to understand exactly why the system is so broken and what we need to push for to improve it.  The frustration experience of dealing with disorganization or waiting to see a doctors at free clinics or the total lack of accountability and run-around that one gets dealing with institutions like Indiana’s now-privatized Family and Social Service Administration is one more way that our culture punishes those whose lives do not match up with the equation of “hard work equals prosperity” that underlies our American mythology.  Sadly, more and more people in America are finding that they’re left out of this rosy picture.

The complex that houses the offices of my primary medical provider that I chose (with a lot of effort) seems more like a hospital.  It is a large and sprawling and awash with muted pastels, potted plants, and out-of-date sports magazines.  I get lost trying to find my backpack before I realize that the reception desk and waiting room where I’m looking is identical to the one just down the hall where I left my backpack.  It doesn’t feel particularly friendly, but it also seems like it just works in a way that the VIM clinic doesn’t.  At least, I don’t feel the same sense of stress here.  The woman that takes my information at the counter seems busy, but collected and she greets me pleasantly enough.  I’m at the right place, they’re expecting me, and despite the trouble I had getting assigned to this doctor, they take my insurance card without complaint.  This is a relief because, for the past two weeks I’ve been more and more worried about the cyst on the back of my neck that managed to double in size and become inexplicably tender at the end of August.  It surely must be infected and its time to have it removed.  I go to see the nurse and then the doctor and both seem competant enough but spend more time entering information into a database on their laptop than examining me.  The doctor takes a quick look at my neck and says that I’ll have to see a surgeon.  She warns that many providers in town don’t accept the Healthy Indiana Plan insurance, so finding one might be tricky.  With that, the exam is over.  It seemed prefunctory, but I can understand that in today’s healthcare system, the role of many doctors is just to redirect patients to other specialists.  An appointment is made with a surgeon and I’m happy that things are finally moving along. It’s nice to just not feel a sense of collective nervousness in this place.  However, when the person scheduling my appointment calls the surgeon, she finds that they don’t accept the HIP.  She says she’ll call the HIP and find out what to do an call back if the surgery needs to be rescheduled. I’m relieved that I don’t have to try to negotiate this myself, but I’m still nervous that she might not call back.  If I want one thing from the healthcare that I receive, I want to feel like others are looking out for my well-being and that I don’t always have to be suspicious or my own constant advocate.  I guess I’ll continue and wait and see if I’m any closer to that reality.

A PMP, finally

Working a lot with computers, acronyms have become second nature – lately it’s been SIP and DID and PBX and a slew of other ones.  Somehow though, I’m surprised when I realize that they don’t just exist in the realm of computer technology.  I’m more surprised when, in these other contexts, they no longer seem like par for the course, this arcane language that one can take pride in navigating, but instead a frustrating impediment, a needlessly oblique interface to tasks that should be simple and painless for everyone.

Getting healthcare for the first time on my own and not through school or family health insurance and getting it through the state subsidized Healthy Indiana Plan has introduced me to an entirely new set of acronyms.  A primary medical provider, that is a family doctor, is a PMP, and your recipient ID number is a RID.  And while cold, technical terms for the participants in a network are fine when we’re talking about computers, when I think about it, it’s a little uncomfortable being reduced to a “recipient”.  Even without the acronyms, the language to describe getting healthcare quickly becomes unintuitive.

After having to change my doctor, or should I say PMP, twice because both my assigned doctor and one I picked from a list of doctors with an “active” status in the MDWise system were not accepting new patients, I ended up just calling most of the doctors on the list provided by MDWise and asking if they were accepting new patients.  It was hard to figure out what to say.  I tried using the PMP term, since that is what was used on the MDWise website, but it just seemed to confuse the seceretaries.  More confusing was when I asked if any doctors in their office were accepting patients.  Most of the doctors that are available through the HIP, with MDWise, in Bloomington are part of a large organization called Internal Medical Associates (IMA) that seems to have around 5 locations and, at least according to their on-hold message, around 60 physicians.

So, it was difficult to figure out which doctors were connected with which location and which phone number corresponded to the office of which doctor.  When I was told that a particular set of doctors wasn’t accepting patients, I was often transferred to another location without really knowing where my call was going.  One location asked me if I had to see a doctor, or if a nurse practitioner (a nurse with at least a master’s degree in nursing) would be okay.  I said either and was able to schedule an appointment with a nurse practitioner  only to then find out from MDWise that only appointments with doctors are covered.

Eventually, I found a doctor who was accepting patients, though not until September, and was able to schedule a physical.  I called MDWise and switched to this doctor and was told I would receive a new insurance card in the mail.  When I told the person on the phone that I had never received my original card, she said that there had been some delays, but that I should expect my new card shortly.  This whole process made me feel happy that I have a job that is flexible enough that I can take the time to make a bunch of phone calls during business hours.  It also made me hope that I will never have to fully master all the acronyms associated with getting healthcare in the U.S., particularly state provided healthcare.  It seems that those who have finally figured out how to navigate the system, to whom the acronyms are second nature, have done so only after a dire struggle to get themselves or their loved ones the care that they need.  I hope that I can stay healthy enough that the frustrations of figuring out how to get health care are an occasional occurence and not a constant reality.  Still, it is important to remember that people already facing the challenges of a state of health that requires more consistent care shouldn’t have to have the additional burden of wading through a bog of acronyms, redirected phone calls, and confusing or unknown information.  I can better understand why some people work jobs just for healthcare.  The idea of being able to get the care you want, when you need it, and to be treated with respect and dignity as you work through the process of that care now seems so amazing, almost luxurious.

I don’t think quality health care should be a luxury.  Perhaps I am naive enough about the logistics of providing health care to expect that everyone could have personal attention, respect, and advocacy for working out problems or questions, but I feel strongly that this should at least be the goal, the benchmark by which the heated issue of healthcare is measured.  I don’t think this is the case right now.  A friend recently made the observation, correctly I think, that the Healthy Indiana Plan is, in fact, a rather conservative proposal.  It seems designed, with it’s coverage of preventative medicine, to reduce the costs of the state from uninsured people using the emergency room and not being able to pay for it.  While it’s certainly true that using the emergency room as one’s primary medical care is not in the best interest of the patient either, my experience with the Healthy Indiana Plan suggests an ultimate goal of cost reduction and not of a positive and healthy experience for the patient.

I’ll continue to write here about my experience with healthcare, with the hope that others in Indiana can share their experiences and together we can identify problems and propose solutions to the state’s healthcare approach. Perhaps we can help share ways that we’ve been able to better navigate the system.  Finally, I want to express the way in which the idea of healthcare has become real for me and not just a topic of presidential debates or news stories.

finding a doctor continued

After being told that the physician to which I was assigned by MDWise under the HIP was no longer accepting patients, and that the person I switched to after that (being told by MDWise that their system listed them as ‘active’ or accepting patients) was also no longer accepting patients, I called another practice.  I asked if they were accepting patients and they asked if I needed to see a doctor or if a nurse practitioner would be okay.  I told them that it didn’t really matter because I just wanted to establish care with someone, get a general physical, and have the sebacious cyst on the back of my neck re-examined.  They took my information, and were able to look some of it up based on my MDWise RID, and then scheduled me an appointment for next week with a nurse practitioner.

I called MDWise to tell them this and they said that care with a nurse practitioner wouldn’t be covered, it had to be a doctor. I called the office back, canceled my appointment and tried to see if any of the doctors at that office were accepting new patients.  They weren’t accepting new patients, so I continued down the list of results from the MDWise web site.  Of the people on the list that I have called so far, 10 out of 20 are not accepting new patients.  Right now I am stalled at waiting to get a call back from one of the doctor’s offices who I was told was accepting patients.

One of the biggest confusions that I have encountered is the fact that many of the doctors on the list that MDWise provided are part of very large practices (the on-hold message at one of the practices said they had over 60 physicians) at the same location with diffrent offices and phone numbers.    It’s very hard to figure out who I’ve talked to already, especially since I’ve been transferred to different offices via the phone system.  The thing that has cleared things up the best for me has been to ask the seceretary “Which doctors do you schedule appointments for? Are any of them accepting new patients?”

I have been pretty frustrated by this process so far.  Last month, I went to a forum about the FSSA privatization and how it has affected people receiving food stamp beverages.  WFHB covered the event and its worth a listen just to see how messed up the program is and how many people have been treated unfairly or just had to jump through a bunch of needless hoops just to get their benefits.  At least there was a general consensus, even by the FSSA rep there that things needed to change.  A lot of people who did get their situations resolved did so with support from their state representatives or senators.  I would really recommend that if you’re having problems with the HIP, that you contact your Indiana rep. as many actually have social workers working for their office who might be able to help you navigate the crazy HIP system.  You can look up your representatives at the state’s Who’s Your Legistator page.

Switching Doctors Failed!

I tried calling the doctor I selected last week to schedule an appointment.  The receptionist said they were no longer accepting new patients, even though I selected this doctor from a list that an MDWise rep gave me of doctors that, according to their system, were accepting new patients.   The receptionist at the doctor’s office said that they hadn’t had very much luck with the HIP so far and that I should try calling the doctors on the list to see if they are accepting new patients before switching through MDWise.

Healthy Indiana Plan: Scheduling a Physical

I have gotten my information packet from MDWise but I had to call to get my RID number and assigned physician. Today I got my second POWER account bill from MDWise, but it said I didn’t owe anything. I tried to call my physician to schedule a physical and they said that the doctor was no longer accepting additional patients and that I would need to call MDWise to work that out. So far, my experience with the HIP has been one of a lack of communication, clarity, and knowledge by the people I’ve talked to both on the FSSA side and the MDWise side.

Update:  I called MDWise and was able to speak with someone pretty promptly.  She told me that I would have to pick another doctor and pointed me to the list (actually a search) on the MDWise web site.   She had some trouble pronouncing the doctors names which wasn’t a problem because I had the web page in front of me, but would have been really confusing if I was just on the phone.   She had to list the names because not all of the doctors were accepting patients.  She said that I should pick a doctor and call MDWise back.  She said it would take 3-5 business days to make the switch and notify the doctor’s office and that I couldn’t call the doctor I chose to make an appointment until after that.