A Case Example Supporting the ACA

Two Mondays ago a patient came into the clinic with complaints of upper right abdominal pain that hurt most when he would take a deep breath in. He had this pain a week ago and it resolved with ibuprofen. Sunday night he became uncomfortable with feeling feverish and nauseous. Monday the pain itself returned and was unrelieved by ibuprofen. The pain radiates to his mid-back and up to his neck. He thought it might be worse with eating, but couldn't affirm it definitively. He is a non-smoker, non-drinker, full-time worker, morbidly obese uncontrolled diabetic on metformin and on blood pressure medications. He cannot afford health insurance and so wanted to keep costs as low as possible. Exam showed tenderness to touch mid-upper abdomen, the rest of the exam was unremarkable but it was difficult to assess some things due to size. My differential diagnosis list included gall stones, hepatitis or pancreatitis. My money was on gallstones and I strutted around telling everyone else it was so. I had labs ordered and sent him for an abdominal ultrasound. (I was so proud of my diagnosis!)

Well, the labs showed elevated liver enzymes, inflammatory markers, and elevated pancreatic enzymes. His ultrasound came back negative for gallstones. It put us back to the beginning with no diagnosis. The other providers at the clinic did not know what was wrong either. We decided to take the watchful waiting approach to see if this would resolve on its own as the patient could not afford even what we had already done.

The next day the patient called after spiking a 102* fever. He was sent to the emergency room. My preceptor kept in close communication with him. She text me last Wednesday to tell me "He has gallstones after all." He was admitted to the hospital due to its severity and the impact it was having on the pancreas and liver. (Admittedly, I was proud my original diagnosis was correct.)

I touched based with my preceptor today to find out how he was doing. He had to have his gallbladder removed. He continues to run fevers so they are concerned that he has pericarditis (inflammation of the heart, probably infectious causes). He is now under the care of a specialist and may need hospitalization.

It makes me sad that he ended up having this experience. The cost of labs, ultrasound, the office visit, the emergency room visit, the hospital stay, surgery, specialists=$$$. He didn't have insurance previously because he couldn't afford it. His job didn't provide it. Because he has a pre-existing condition his premiums would have been unreasonable. Guess what he really can't afford now?

And how many people are like him, walking around not taking appropriate care of their health because of cost? We all will lose to patients in this similar situation. He simply will not be able to pay his medical bills. He will probably make monthly payments of $50 until the hospital writes off the debt. Or he will need to file bankruptcy. Ultimately, it’s the whole population that will shoulder this debt. Had he had affordable insurance and was able to take care of his health under the supervision of a capable provider, maybe none of this would have happened to begin with.

With that, I encourage everyone without insurance to visit their state’s health care exchanges. Find out about the various plans, see if you qualify for subsidies. ENROLL and begin the process of taking care of your health.

Republicans are Missing Out on the ACA

Republicans are missing out on a golden opportunity to make meaningful changes to health care in the United States. I originally was not a supporter of the Affordable Care Act (ACA)—I wanted to go all in with full national coverage—but I have caved to the inevitable. Since the Supreme Court has upheld the legality of the bill I think it is unwise to keep fighting it so zealously.

We know that our current health care system does not work. Health care is provided to those who can pay. The more you are able to pay, the better your “benefits.” While we have Medicare, Medicaid, and state-provided insurances, these programs is only for the poorest of poor and is mired in bureaucracy and restricted treatment options. Studies show that when people have access to affordable health care they will be healthier, when they are healthier they are more productive. Productivity creates a thriving economy with less people draining the welfare systems. (Oh, and providing health care in any civilized society might be the humane thing to do.)

Anyway, the argument for health care reform has been made. Both reigning parties presented ideas to fix it and the Democrats/ACA won. (Although it's technically not a leftist idea since it’s modeled after Romneycare… but I digress.) With the implementation on its way there are currently two schools of thought:

1. Obamacare is doomed to be a failure. Doomed. And we must do everything possible to stop it, to sabotage it. It is our obligation to keep things the way they are (as in broken).

2.Those darn Republicans. If this thing fails, it will be because it never stood a chance with the Repubs kicking and screaming the whole way. All of our energy and resources were spent fighting the opposition instead of focusing on the implementation of the ACA.

Surprising to myself, as I have flipped through all the radio stations and all the news articles, I think the second thought has quite a bit of validity. But I want to introduce one school of thought that I have not heard yet and want others to consider:

3. Switch gears, Republicans. The Supreme Court has said it is legal, stop fighting it. Join the Democrats with its implementation. Find solutions within the goals of the ACA to all the faults you are so quick to point out. Make something work for America for a change. We have clearly stated that we want a working health care system now. Instead of being the guy that “opposed Obamacare from the beginning,” be the guy that said “You know what? I didn’t agree in the beginning and I still have my doubts, but the people have made their choice. I am going to stop thinking about my next campaign talking points and instead try everything I can to make the ACA work because that’s what we need.”

That’s what needs to happen now. If we can accept that the ACA is coming, we can move on to the next step of becoming involved in its success. Right now, the ACA is a strictly “liberal” phenomenon. The Republicans are missing out on some fantastic opportunities. How great would it be if one of the Republicans were able to balance the ACA to meet the needs of the US?

As I have said before, the ACA is great in theory, even Republicans have admitted to it. The only way to prove a theory is to test it and to test under optimal circumstance. I want to encourage everyone to write your representatives and insist that they not only support the ACA, but also become involved in its implementation so that it will represent the health of all Americans.

Join us on Facebook

This blog gets little activity and methinks it's because my acquaintances don't really blog. They often come here when a new post is shared on my FB page and then return to FB to leave commentary on my "share." OK, fine. So Jadon and I set up a page you can easily "like" and follow posts: facebook.com/recliningsociety.

I don't know how I feel about the change. While I am hoping for more activity, FB makes it too easy to become carried away with posting every thought and interesting article that comes around... And then it becomes overkill and loses its value. I'm really hoping that it doesn't turn into that.

We are also planning to do an actual live podcast, which was actually the main ambition when starting this little endeavor. We hope to have a show up soon.

I still plan to post actual blogs here for those that want to anonymously read without having to "like" anything, but please feel welcomed to join us on the dark side.

Healthcare CO-OPs

I had to write a paper for my course Professional Aspects of Advanced Nursing and "take a position" on a current healthcare issue. I had to limit it to two pages using APA format. This is what I came up with. Let me know what you think:

  The Patient Protection and Affordable Care Act (PPACA) passed in 2010 is an ambitious attempt to make healthcare a reality for every citizen, mandating that employers provide health insurance to its employees and that every individual has health insurance. This might become problematic for small businesses and the self-employed or unemployed individuals. As it currently stands, small businesses and the individual have more expensive plans than large employers and coverage is often minimal within these plans. Small businesses and individuals are relatively too insignificant to create favorable change within the current market. Healthcare providers, including nurse practitioners, often feel the strain of their patient’s financial burdens when they are compelled to stray from the standards of practice due to the patient’s lack of coverage or inability to meet high deductibles and co-pays.

  To offset the burden of the mandate and avoid forcing people onto government-run healthcare, section 1322 of the ACA created the Consumer Operated and Oriented Plan (CO-OP) and provided each prospective CO-OP the potential to borrow up to $56.4 million in federal funds to cover the expenses of start-up. CO-OPs that take out a loan have several contingencies they must follow: the health insurance issuer must offer plans on a statewide basis, it must be governed by its own members, and it must be recognized as a nonprofit organization as defined by the state while reinvesting its profits to improve benefits or lower the premiums.

  There is some opposition to the implementation of CO-OPs. Since the CO-OPs are using federal dollars and there isn’t a guarantee that they will be viable, some think that it’s too much of a risk for taxpayers to invest in. Initially, the goal was for all states to implement CO-OPs but because of pressure to decrease federal spending, only 24 states received these funds before budget cuts were made.

  Oregon is one of the 24 states that received federal loans and is the only state to attempt two co-ops—Freelancers CO-OPs of Oregon and Oregon’s Health CO-OP. A major appeal of a healthcare CO-OP is that with each member being a part-owner, the individual will have more autonomy within the healthcare system. Focus groups within Oregon found that consumers are interested in established flat rates for their appointments, being able to contact providers through email, having alternative medicine as part of the plans, and affordable premiums. Enrollment for these two CO-OPs begins in October 2013 and coverage will start in January 2014.

  Oregon nurse practitioners should consider supporting healthcare CO-OPs for several reasons. First, the nature of a CO-OP not only respects the patient’s autonomy but it promotes it. As part-owners of their healthcare policy, patients will be able to vote on the type of care they want covered and the rates that are willing to pay. Second, it is also a form of social justice. As the healthcare system stands today, access to care is limited by the ability to pay. By providing healthcare insurance with predictable costs, patients will be more likely to seek early treatment for both acute and chronic diseases and injuries from their primary provider and reduce emergency room visits. Patients will also be more able to afford medications and procedures that they previously could not.

  Since healthcare CO-OPs that received federal loans are unable to advertise and solicit membership, nurse practitioners should draw attention to these healthcare plans by working within their communities and informing small businesses and self-employed individuals about this option. Having a large enough membership is crucial as it will determine the CO-OP’s viability.

Edding toward a Den of Snow

Edward Snowden has had his passport revoked, and is stuck in Moscow, according to Time.

http://world.time.com/2013/07/02/snowdens-worst-case-scenario-what-if-no-countries-take-him/?hpt=hp_t2

The list of countries willing to take Snowden is shrinking as more say either "no" or "apply in person."

Whistle blowing keeps getting more dangerous.  While Assange is holed up in an Ecuadoran Embassy, Bradley Manning is still facing a whole host of charges for having a greater allegiance to exposing the truth to the masses then protecting them by...what exactly?  Withholding that information?

We are moving to an open source information age.  Secrets are getting harder to keep.  It is up to us to demand open access to information.  We children of the 80's 90's and 00's are the next generation of policy makers.  Our apathy is the only thing stopping us from greater knowledge, and secrets are like water slipping between the fingers of those that would keep it from us.

By my count, Snowden is a patriot.  So is Manning.  Dissent is patriotic.

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Obama said something about protecting whistle blowers once...

http://www.techdirt.com/articles/20130726/01200123954/obama-promise-to-protect-whistleblowers-just-disappeared-changegov.shtml

"Work-place Violence"?! A Government Cop-out is More Accurate

November 5, 2009

Where were you on that day? I distinctly remember wearing my navy blue nursing scrubs, the pocket embroidered with my nursing school's logo, my white tennis shoes. I was assisting a patient to sit-up in bed when a breaking news announcement on the patient's television buzzed in the background. I turned my head to see headlines about a shooting at Fort Hood. There has been an attack on soldiers preparing to deploy, the newscaster said.

You know how during a climatic scene of a movie the world slows down, you can hear your heart beat and you lose your peripheral vision? That's how that moment felt. Two names flashed into my head: Bergmeier and Burnett.

I gracefully excused myself from the patient's room and retreated to the breakroom, my squeaking shoes echoing off the walls and shiny linoleum. A fellow student found me propped up against the lockers, furiously texting everyone and anyone who might know about the two soldiers from my unit that were at Fort Hood preparing to deploy to Iraq. She tried to comfort me, insisting that it's a large Army and my friends were probably fine, probably at a different location all together.

I nodded half-heartedly, dropped the phone into my pocket and returned to the patient's room. I mindlessly fluffed pillows and checked IV lines, all the while having my ears tuned into the reports as they became available. My patient did not mind my obvious distracted demeanor as he was incredibly focused on the television as well. He called it a terrorist attack. I swallowed and nodded as initial death tolls and suspected injured ran across the scrolling banners.

Terrorist Attack.
13 dead. 32 injured.

That day, before all the details and investigations were known, we knew in our guts that it was an act of terrorism. My extra sense also told me that the soldiers from my unit were there.
While not close to either Bergmeier or Burnett, it was hard for me to comprehend how someone I played poker with or spent drunken nights at the local karaoke club with a few months ago could be victims of terrorists attacks.

Bergmeier was not physically harmed during the incident. In fact, he carried on with the mission he set out to do and finished a tour in Iraq. He could've stayed home, but didn't. He is a HERO.

Burnett was shot three times and has been trying to physically and mentally recover for 3+ years. Burnett fought back against the terrorist. He is a HERO--I can only hope that if I ever encounter the same situation that I can be just as brave.

These men were expecting to encounter danger in Iraq, not at home while doing routine paperwork, not by an officer in the same uniform with weapons of war.
BUT:
Our government has refused to recognize it as an act of terrorism. They call it "work-place violence" and our soldiers have not been compensated for wearing their uniforms that day and coming under fire for being soldiers. I follow SPC Burnett on Facebook. The whole time he was being treated for his injuries, he was also being treated as a no-good bum unworthy of respect while being compensated very little for his war injuries.

It is appalling, disgusting and abhorrent that the government, the Army, the powers-that-be are still dicking around three years later. It was so obvious on the day Hassan became infamous that he is a religious extremist, a terrorist, a traitor and a murderer. Why hasn't UCMJ been swift in trying and convicting him? Why hasn't he been served the death penalty yet? Why is he still alive? WHY IS HE STILL BEING PAID???

Can we please let go of being politically correct? Stop worrying about offending a particular religion? Of being afraid that yes, terrorism really does exist? Can we say it together? "TERRORISM EXISTS, FORT HOOD WAS TERRORISM."

I am embarrassed once again to call myself a freedom-loving, patriotic American while these shenanigans exist. My heart goes out to SPC Burnett and all the other injured and killed soldiers, to their families and loved ones. I apologize for my role as a citizen.

In the meantime, I want to solicit the knowledge of the masses. Who do I write my strongly worded letter to in order to correct this injustice? Who's contact information should I share with others so they can add pressure to the situation, too? How do we fix this?

Defining Health

As I become older, I have become more confused about what "healthy" really means. (A fair warning that there is some rambling in this blog.) Most textbooks would have you believe it's a perfect balance of physical, mental and social well-being, always depicted with an equilateral triangle. If one of the sides becomes disproportionately large or small, then the "triangle of life" is unbalanced and, for reasons unknown, needs correction. 

But I reject the triangle because there's a fourth side of spiritual. Spiritual captures a person's emotional well-being--feelings of self-worth, connectedness to others and their environment, etc. For the religious, it's about a connection with a higher power. Spiritual is separate from mental. Mental is the accumulation and application of knowledge--whether it's book or street smarts. A person can have a high priority for their mental health while have a very low priority on the spiritual. Anyway, please enjoy my diamond--my initial depiction of perfect health when trying to define it myself.

Perfect Health

Except now on reflection, I don't know anyone who is a perfect diamond. More or less, we are all various shapes of quadrilaterals. I looked at my own diamond model and tried to determine what sort of form I would take. Currently with school, I find myself expanding on the side of mental (LOL) and because of the type of  field I'm entering into (advance practice nursing), I find that my spiritual side is also expanding. It's interesting to me that I used the word "currently" in describing my health. I am learning that health is dynamic and in perpetual transition. Anyway, while focusing so much on the mental and spiritual, my already small social side has diminished to nil and the maintenance of my physical health has shifted. 

What health really looks like

Anyway, I want to switch gears and address that nagging "physical health" aspect. Previous to returning to school, the gym was my second home. My mantra of health was the same as the rest of Western society: "Fat Bad, Lean Good." It's a given that too skinny is bad as well.

We know that fat is bad.

We know that anorexia is bad.

But what about this?

Being far removed from going to the gym 5+ days a week, I have gained some new insights. This woman on the right is not the picture of health, either. Sure, she is in pristine physical shape (IMO), but to what cost? (And there are many that would look at this picture and they would not see health, they would see an unattractive "bulky" or "manly" figure, but I digress.)

Even going to the gym as frequently as I did and for the moment in time I "cleaned up" my diet, I was no where close to looking like this. Let's consider, then, what constitutes health--I could argue that she is not the picture of health. She is not a perfect diamond. She totally blows physical health out of the water, no doubt, but what about the other aspects?

While being bombarded with images like these at the grocery checkout line recently, I objectively considered the cost and effort to look like her. There is no way I could be like her and maintain my other priorities; my other priorities are extremely important and rewarding to me. It was an "AHA!" moment a few weeks ago when I recognized that I am not a failure because I am not ready for a magazine cover photo. In fact, spending time in the pursuit of my other priorities have created intense feelings of self-satisfaction. 

Don't misunderstand, this blog entry isn't an attempt to excuse bad health behaviors--without good physical health, the other aspects of health will also suffer. And truthfully, I don't know the exact reason I felt compelled to write about this topic. I think it's because I want to see others being more kind to themselves, to recognize that there isn't a start or end point to health. I hope that we can begin rejecting the notion that there is only one right way to exist and all others are somehow a form of failure.  We are all in motion, our health--physical, spiritual, social and mental--included.

With this explanation, here's my cornball "feel-good" suggestion: Go live your best life on your own terms.