Monday, December 30, 2013

Things that get worse in the night

A few weeks ago, my perpetually runny-nosed three-year-old had an earache. A horrible earache. So terrible, in fact, that I found myself literally attached to his ear for the entire night.

Picture the scene: It's 10pm. Mother is peacefully climbing into bed after shutting down her work computer, laying out her clothes for the morning, and checking to be sure her alarm is set for 6am. Previously sleeping child wanders into parents' room, crawls into bed saying his ear burns, and requests ice. Dad gets the ice. Child positions himself to "share" his mother's pillow, an act that translates into a restless 37-inch body occupying at least three-thirds of the 26-inch pillow. And then for the rest of the night, this: exhausted-mama's-left-hand-holds-green-shamrock-sock-covering-ice-filled-baggy-placed-over-child's-right-ear.  Just about every time mother dozes off to sleep, mother's hand (and the ice) slip off the right ear, and the achy child wakes to plead for the ice again.

Torture. For all involved.

And, "Quel relief!" when the alarm finally does go off at 6am.

I suspect that many a fellow human has lived such a night. And putting aside the debate about whether and when to treat an ear infection with antibiotics (fodder for a future post) and whether co-sleeping is a good idea (another excellent topic), this particularly painful night prompted me to consider how much worse things feel at night.

For you too, right?
Have you ever been short of breath in the darkness? Or had middle-of-the-night back pain that you were certain was about to kill you? Or felt a panic at 3am that literally wouldn't get up off your chest? Or sat in the predawn with a vomitous friend worried she might lose her very soul with each recurrent heave? Have you ever begged for the sun to rise and the darkness to lift?

It's freaking scary.

I personally know the darkness from my own pregnancy-induced heartburn years ago, from long nights in the hospital with sick sick patients, from my toddler's battles with croup in the most unfortunate of locations, from listening to the the night-time tales of the physicians-in-training I teach in early morning sign-out, and, most recurring, from patients' midnight calls about non-emergencies.

At midnight, you know, everything feels like an emergency-- even slow bowels and itchy ears.

And doctors are not exempt. If you eavesdrop on a bunch of doctors taking call (you know, the voices on the other end of the line when you call because your kid has been crying uncontrollably since 2am or your mother's feeling dizzy and her blood pressure is through the roof), they will complain of one of two related occurrences: either 1) "I couldn't sleep, I was up all night worried about such-and-such patient" (yes, those same scary night-time fantasies that keep you up keep up us too) or 2) I couldn't sleep, the patients kept calling."

Are things actually worse at night? Or is it all in our heads?

Accessing my rational (daytime) mind, there is definite evidence that many illnesses (or at least symptoms) are worse at night. Some common examples include the following:
  • Over fifty percent of uncontrolled asthmatics report night-time cough and wheeze
  • Fevers tend to go up later in the day
  • Night sweats are some of the most disruptive and frustrating symptoms of menopause
  • Bronchitis coughs tend to be more bothersome at night
  • Carpal tunnel symptoms (irritating numbness in the fingers) often wake people in the middle of the night
  • People with bad gastroesophogeal reflux (aka heartburn) tend to have worse symptoms when lying down, which happens for most of us at night
  • The same is true for earaches too (This is probably why my little guy acted fine upright and as though he was going to die when lying down)

But it's the irrational (night time) mind that inevitably exacerbates the discomforts.

As I see it, night feeds illness, and illness brings along her good friend, vulnerability. Darkness feeds fear. With fear and vulnerability runs imagination. And the untetherable imagination inevitably breaks free precisely as the temperature and pain peak.

And so, the next time you are up in the middle of the night worried that the mole on your shoulder is a flesh-eating cancer or that your coughing child might stop breathing any second, consider the context. Turn on the light. Take a little walk around the house, maybe even have a snack. Make the scene feel a little bit more like day than like night. And then re-evaluate.
If after a few minutes of daytime glee it becomes clear your imagination has gone overboard, stay up a little longer, have a cup of chamomile tea and do the crossword puzzle. Then, go to sleep.

If it's something you're still worried about (and I mean really worried about), call your primary care provider. That way she can stay up and worry about you--perhaps long after you've dozed off again.

Thursday, November 7, 2013

Gambling, you in?

The big news this week in Sonoma County was the grand opening of the long-anticipated Graton Resort & Casino, located in Rohnert Park, six miles south of my home in Santa Rosa. To quote The Press Democrat, our local paper, "Thousands of people from around the Bay Area descended on the Graton Resort & Casino for its debut Tuesday, clogging surrounding roads and forcing the casino to temporarily close its doors to long lines of gamblers waiting outside."
Graton Resort & Casino in Rohnert Park. (CBS)
Graton Resort and Casino (CBS)

Per the same PD report, people were crazy excited: some arrived to the casino before 4:30am to be the first ones in, almost all 5,700 parking spaces were full of cars, Highway 101 was backed up for miles, 3,000 slot machines were occupied by 11am, and people were so anxious to see the new digs that they even parked on nearby streets and walked to the casino. Imagine that, walking to the casino?! Hooray for outdoor exercise!

Reading the article literally made me want to vomit, and I had to pause a moment to evaluate why something that drew thousands of people in wonderment was so automatically distasteful to me. After a little bit of research (yes, I am a geek) and some reflection, my nausea is not any better: it may even be worse.

Warning, this is a self-righteous post. Both my doctor self and my public health self are threatened by this place and what it represents to individual patients and to my community at large.

Doctor me: Gambling may be bad for your health.

The act of gambling--"placing something of value at risk for the opportunity to get something of even higher value"-- is not, in and of itself, a bad thing. Let's face it, lots of people gamble. Eighty-six percent of US adults report having gambled at least once in their life, 60% in the last year.  And, similar to other enjoyable aspects of human existence, for most people, gambling is fun and not at all dangerous. In fact, research shows that less than 10% of adults gamblers develop a gambling disorder. That means that more than 90% don't.

But it also means that somewhere between 15 and 20 million adults in this country have a gambling problem. That's a lot of people. To put the number in perspective, in the US, the equivalent of half of all Californians (there are 38 million of us) have a gambling disorder. And that doesn't include the rest of the world!

To be honest, until I delved into my research on gambling and casinos this week, I didn't remember from medical school that "pathological gambling" was actually  a psychiatric diagnosis. It's not a diagnosis I have ever made--though I've certainly worried about a friend or two.

According to the bible of psychiatric medicine, the Diagnostic and Statistical Manual of Mental Disorders (DSMIV), in order to be diagnosed with "pathological gambling" a person has to meet five or more of the following criteria. "Problematic gamblers" meet thee or four criteria.
  • Preoccupied with gambling (e.g. preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble)
  • Needs to gamble with increasing amounts of money in order to achieve the desired excitement
  • Has repeated unsuccessful efforts to control, cut back, or stop gambling
  • Is restless or irritable when attempting to cut down or stop gambling
  • Gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g, feelings of helplessness, guilt, anxiety, depression)
  • After losing money gambling, often returns another day to get even ("chasing" after one's losses)
  • Lies to family members, therapist, or others to conceal the extent of involvement with gambling
  • Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling
  • Relies on others to provide money to relieve a desperate financial situation caused by gambling

Pathological gambling used to be found right alongside trillotrichomania (compulsive hair-pulling), kleptomania (recurrent urge to steal), and pyromania (obsessive desire to set fire to things). However, interestingly, in the newest version of the bible (aka DSMV), gambling disorder has been moved to the section on Addiction.

There are pretty obvious similarities between gambling and substance abuse; these similarities go beyond the financial problems and destruction of relationships that are so often untoward consequences of addictive behaviors. Just like in alcohol and drug addiction, brain imaging studies done while people are gambling actually show activation of the reward areas of the brain (aha, so the reward is more than just the money).  Problematic gamblers report cravings and highs-- just like substance abusers. And, like alcoholism, gambling issues tend to run in families.
Benzodiazepine Addiction Treatment | benzodiazepine treatment | benzodiazepines addiction treatment
Dopamine (our brain's happy juice-- levels go up during sex, drug use, exercise, and chocolate chip cookie eating) and imbalance in the regulation of dopamine probably also play into gambling disorders.  There have actually been case reports of patients with Parkinson disease developing pathological gambling after being started on medicine that messed with their dopamine; and there are similar reports about patients with restless leg syndrome taking dopamine-related medications developing new problematic gambling habits.

Gambling is also associated with other mental health problems. In one study,  people with pathological or problem gambling were compared with  non-gamblers and were 3 times as likely to report ever having experienced major depression, 2 times more likely to report phobias, 6 times more likely to report antisocial personality, 3 times more likely to report current or past alcohol abuse or dependence, and 2 times more likely to report current or past nicotine dependence.

Problematic gambling disproportionately affects young people--people over 65 are much less likely to have a problem (so it's probably okay to let grandma gamble when she wants)--and men, who are three times more likely to have issues than women. Pathological and problem gamblers are more likely than other gamblers or non gamblers to have been on welfare, declared bankruptcy, and to have been arrested or incarcerated.

If you are worried you or someone you know may have a gambling disorder, check out this link , it can help you decide if your worry is warranted.

Public health advocate me: Gambling is bad for our community's health.
Gambling has increased markedly over the last fifty years. In 1960, 61% of Americans reported gambling, in 1999 the number was up to 86%.  In 1978, there were only two states with legalized gambling, and today only two states have not legalized gambling (those prudish holdouts are Utah and Hawaii). Thirteen states allow casinos on non-Indian land.

Casino advocates argue that casinos do good for the wealth and health of communities: casinos create much appreciated new jobs (the new RP casino is expected to generate 2,000 jobs), tax revenue, and local retail income. In doing all this, they increase a community's per capita income, increase individuals' buying power, and directly lead to more people having health insurance. These are all potentially good things. Casinos also draw tourists and other outside visitors, which also increase the income of the community. The wealthier the community, the healthier, right? And don't forget, casinos provide entertainment, which is. . .well. . .fun.

But the negative impact of casinos on the health of communities is not to be minimized. For individuals employed in casinos, the shift work and sleep disturbances are substantial. Casinos also increase second-hand smoke exposure. Casinos  have been shown to increase traffic volume as well as property and violent crimes in a community. And increased gambling has been associated with increased child abuse and domestic violence, unsafe sex practices, alcohol abuse, alcohol related MVAs, and increased suicides.

And the closer the casino, the more likely we will become problematic gamblers. In fact, the availability of a casino within fifty miles is associated with double the prevalence of problem and pathological gamblers, compared to a casino located 50-250 miles away.

If we had a choice, would we really want more problematic gamblers in Sonoma County? Would we want more lung cancer? More road rage? More pollution? More violence toward our children? More alcoholism? More violence?  Is it worth the fun? Or even the jobs?

I will be awaiting the PD reporting of the opening of the next Sonoma County Regional Park or new Santa Rosa City school, which I am sure will draw a similarly eager crowd at 4:30am on opening day, anxious to be the first ones to be let in "the doors". In the meantime, head on down to the new Graton Resort & Casino, not exactly what the doctor ordered. Please take note, the least you can do is park your car across town and walk there-- at least then you will be getting some exercise.

Additional References: pathologic gambling

Wednesday, October 9, 2013

5 things people say when they don't want a flu shot. . .and why they might be both right and wrong.

 Ah, 'tis the season. That time of year when leaves begin to fall, jackets come out of hiding, noses start running, and patients either beg for a flu vaccine or literally sprint out of the office in a mad hurry when offered one.

Such a bizarre dichotomy in the land of the seasonal flu vaccine: people are either vehement defenders or adamant disbelievers. (It reminds me of the Divine and Santa Claus). Which category do you fall into? Is one group more right? Should healthy people get the flu shot?

Do flu shots cause the flu? 12 influenza vaccine myths busted
As usual, in medicine, there is no perfectly perfect answer to these questions, so I thought I would address the top 5 reasons my patients give me for declining the flu vaccine. Hopefully, you will learn something from the process. I definitely did.

1) "The flu is no big deal."
There are two problems with this argument: semantics and reality.

Semantics.  People are often confusing common colds (a slew of  mild to moderate upper respiratory illnesses that feature runny nose, cough, fevers, and more) and the real deal flu (a super serious upper respiratory infection caused by a specific virus that circulates seasonally).

And how we talk about them is a big part of the problem. After all, "the flu" is a phrase that we use in quotidian conversation with some frequency and, often,  inaccuracy. We call winter "cold and flu season"; over-the counter medicines advertise themselves "for symptoms of cold and flu", people say things like, "gosh, I just got over a horrible flu";  and  in many languages and cultures, there is little vocabulary distinction between the words for "a cold" and the words for the real "flu".   Personally, I trip over my words with my Spanish-speaking patients, never quite sure I should actually be using the Spanish word "gripe" when talking about a common cold, though my patients often do.

But, please hear this: "the real deal flu" is not the same as "a cold".

People get colds all the time. My 3-year-old is on his third this month, having lovingly shared his most recent virus with my husband, mother-in-law, and our dear neighbor. (Thankfully and unbelievably he did not share with me, in spite of the large bucketfuls of snot I have wiped from his nose). And, though colds are pesky and annoying,  most of us would probably agree that they are hardly serious.

There are over 200 viruses that cause the common cold, including the rhinovirus, adenovirus, coronavirus, parainfluenza virus, respiratory synctial virus, and 195 more. That's one of the reason you can get cold after cold. In contrast, the real deal, "the flu" (aka influenza) is caused by a specific set of viruses called-- drum roll please-- the influenza viruses (I know, I know, we doctors are clever). These are totally different viruses than the viruses that cause the common cold, and they are much meaner.

Reality. Putting common colds aside, the flu is actually a pretty big deal. In fact, the influenza pandemic of 1918-19 killed between 20 and 40 million people, more people than World War I-- perhaps the most devastating epidemic in recorded world history. Thankfully, we have not had a flu epidemic as serious since then; however, there is still no cure for influenza, and plenty of  people do die from the flu each year.

The Centers for Disease Control (CDC) estimate that between 1976 and 2007, between 3,000 and 49,000 people each year died of the flu. The range is crazy big for two reasons: first, it's hard to figure out how many actually people die of the flu and second, each flu season varies intrinsically. Some years are bad years, others are good.

On average each year in the US, 200,000 people are hospitalized as a direct result of the flu. People 85 and older are at the highest risk of being hospitalized. The other high risk groups are children younger than 5 (especially those younger than 2), adults over 65, pregnant women, and American Indians and Alaskan Natives. Also at risk are people with asthma, chronic lung and heart disease and a whole list of other chronic health conditions.

For those of us who don't die, getting the flu still knocks us down. Big time. A study published in 2007, estimated that seasonal flu epidemic results in 3.1 million hospitalized days, and 31.4 million clinic visits (that's a lot of business for me and a lot of sick-time, co-pays, and stress for you all). Direct medical costs average $10.4 billion annually, and projected lost earnings due to illness and loss of life was $16.3 billion per year. In this study, the total economic burden of seasonal flu epidemics amounted to $87.1 billion.

No big deal?

2) "That flu shot does nothing to protect me, I still always get sick all winter long. I don't think it works."
You are right.

Winter is a germy time of year and, as alluded to above, the flu shot does absolutely squat (i.e. nothing) to protect you from the common cold. That is not its job.

The average preschooler gets 9 colds per year, the average kindergartner 12, and the average teenager and adult 7. Most of these occur between November and March. Yuck! And though colds and the flu are two different entities entirely, the flu and the common cold have a lot in common: both are spread by droplets, both are caused by viruses, both are present during this time of year, and people with colds often have "flu-like" symptoms.

So, how are you supposed to know the difference?

Really the best way to know whether or not you have the real flu is by getting tested (it's done by a nasty swab in your nose), but not everyone gets tested. Personally, I favor my mom's classic description of influenza: "When you have the flu, you literally cannot stand up. You literally have to lie down and stay in bed. And it lasts a good long time. A week, usually. Your body aches, your fever is high, and you feel like crap." (Mom doesn't use the word 'crap', that's my addition to her definition).

Most people cannot tell me that they feel that bad (or feel that bad for that long) when they get a cold--even a bad bad cold. 
Courtesy: Artville - Whitney Sherman

3) "I have never had the flu up 'til now. Seems like I just don't need the shot."
It is true, statistically-speaking, that most people will not get the flu in a given year. And though the pro-vaccine propaganda professes that getting a flu shot decreases your risk of the flu by 60%, the number is definitely misleading. The reason is this: this widely quoted percentage doesn't give any information about how likely it is that you will get the flu in the first place; it only tells you how much the flu vaccine will reduce your relative risk of getting the flu. Welcome to absolute versus relative risk reduction, two of the trickiest concepts in medicine.

Unlike the common cold, your risk of actually getting the flu is pretty low-- it's about 7% per year. That's why many of you have never had the flu. The flu vaccine reduces that risk down to 1.9%. This translates statistically into a 60% relative risk reduction but in actual terms is only a 5% reduction. Does 7% risk seem high or low to you? What about 1.9%, does that seem like a reasonable reduction?

Those of you who play the flu lottery and assume you won't get sick will be right 93% of the time, even if you are never vaccinated. Acceptance of risk is tricky and personal. We've hit on that notion before when talking about breast cancer screening, lung cancer screening, and car seats. It's your call to make.

The question to ask yourself is this: on the off chance that you are one of the 7%, who actually gets the flu, how horrible would the flu be (in addition to the inevitable fever, body aches, and general malaise)? Would missing work threaten your job security or make it impossible for you to pay your rent? Are there loved ones under 5 over 65 who could get really sick if you shared your influenza? Do you work with frail seniors who are at the highest risk of dying from the flu? Do you have a young vulnerable niece or nephew? Do you just prefer to be safer than sorry? Or does that flu shot hurt too much to be worth the risk?

4) "I got the flu shot last year and got the flu anyway, so why bother?"
 This is some of the most interesting part of the flu vaccine story. Did you know every year the vaccine is different? Each year there is a statistical modelling done by the World Health Organization (WHO) and scientists around the world to try to guess which will be the dominant influenza strains that year.

More than 100 centers in more than 100 countries do year-round surveillance for influenza. These centers receive and test thousands of influenza virus samples from patients with suspected flu illness. Then, the viruses are sent to five WHO Collaborating Centers located in Atlanta, London, Melbourne, Tokyo, and Beijing.

In February of each year, WHO consults with experts from these labs and other partners to review data generated by the worldwide network of influenza laboratories. Afterward, WHO makes recommendations for the what should go into the seasonal influenza vaccine for the Northern Hemisphere. For the Southern Hemisphere, the same groups meet in September.

Some years, the "match" is better than others. . .
See here  and here for more details from the CDC.

5) "That flu shot gives me the flu every time."
Impossible, mostly.

The injectable flu vaccine is dead vaccine. You cannot, I repeat can NOT, get the flu from the vaccine. You can get a really sore arm (I always do, along with 64% of people). And about 1% of people get fever, malaise, muscle pain and a general sense of feeling yucky (this is more common in kids who've never been exposed). They might interpret this as "getting the flu", but it's not nearly as bad. Believe me.

The caveat is this: the intranasal vaccine (for those of us who don't like needles) is a live attenuated vaccine, which in theory, means there is a risk of actually getting the flu from the vaccine. Big population studies have not shown this to be true. There is evidence that people who get the live vaccine can shed the virus, but these viruses are pretty close to dead and unlikely to make another person sick. We still don't give this vaccine to people who have chronic diseases-- it's licensed for "healthy people" ages 2-49. The advantage? No needle stick, just a weird sensation up your nose.

So, what do you think? Are you a vehement defender or an adamant disbeliever? 


Additional references:

Sunday, September 29, 2013

Obamacare: Health Care Exchanges Launch

The Countdown is on. . .

Starting October 1st (that's two days from now), the next big component of The Affordable Care Act (aka the ACA aka Obamacare) is being rolled out: enrollment in State-Based Health Insurance Marketplaces or Health Exchanges.

While bizarre commercials bounce around the Internet with creepy Uncle Sam appearing during a woman's speculum exam and Congress bickers its way toward a federal government shutdown, I maintain some optimism that these exchanges-- though imperfect-- are going to increase certain people's access to health insurance and, in turn, health care.

For those of us who have health insurance through large employers, and for those with Medicaid or Medicare, it's likely not much will change. But for individuals, families, and small businesses who buy health insurance on the open market (and particularly for those who haven't been able to afford to do so because it is so freaking expensive), things are about to change. Hopefully for the better.

I think of the exchanges as " for Health Insurance".

If you are not familiar with Kayak, you should be. It has nothing to do with health care. Or health insurance. Or the government. It's a handy, user-friendly website where one can book travel, including flights, hotels, rental cars, and vacation packages. (Disclaimer: I do not work for Kayak, own any stock in Kayak, have any relatives who work for Kayak, or make any money from Kayak. . . I'm just sayin' I like Kayak).

If, for example, you want to fly to Boston to visit your aunt, you input your home city, the city you want to visit, your travel dates, and other parameters, and Kayak searches around the web for the best available flight, ranking the results in order of price. Kayak is quite intuitive, simple to navigate, anticipates some basic twists, allows you to tailor your search  (e.g. would you be willing to leave from a nearby airport? how long of a layover will you tolerate? do you have a preferred carrier?), and makes booking a flight much simpler than booking in the past. I remember, as a child, calling individual airlines one-by-one, keeping detailed notes in the corners of phone books about who flew, when, how much, how long the stopover was, etc. And then calling back again, only to be told the prices were different. Kayak streamlines the process.

To be clear, I'd much rather that Obamacare was rolling out "Kayak for Healthcare" rather than "Kayak for Health Insurance". Or even better, "Kayak for Primary Care". Wouldn't it be super awesome to be able to go online, pick your parameters for a primary care physician and get clear options?

What would your input options be? Gender?  School where he/she studied?
Years since training? Special skills?  Interest in children or obesity or drug addiction or women's health? Funny or serious? Office within 20 miles of your home? Uses integrative medicine? Communicates via email? Office efficiency? Has weekend/evening hours? Delivers babies? Speaks Spanish? Makes good eye contact? Listens?

I would LOVE that. Wouldn't you?

Rather than the mercy of a Google search or a review or two on Yelp or Angie's list, you could have some idea of what you might be getting when you choose a physician. Ah, choice, imagine that?! You may even actually have some idea of what to expect before waiting six weeks to get in to see someone then realizing you cannot stand her bedside manner or her office and having to wait another six weeks to get in with someone else.

Maybe next century.

In the meantime, we are stuck with its predecessor: Kayak for Health Insurance, the Marketplace.

This new Marketplace business means that-- if you are on the search for health insurance-- there is literally a website for you to go to, enter a bit of your family's information (family size, annual income, and zip code) and find out what kind of health insurance plans are available to you.

And the information the exchange spits back at you, like Kayak,  is actually helpful. It includes:
  1. Whether or not, rather than buying on the exchange, you might be eligible for a state-based program like Medicaid, which is expanding under the ACA from minimum 100% of federal poverty level to 133% federal poverty level ($31,321 for a family of four in 2013)
  2. What health plans are actually available in your geographic area
  3. How much the monthly premium will be
  4. What you get for paying that premium, including: your annual deductible, maximum annual out of pocket expenses, co-pays, medication costs, cost for ER visits
  5. AND how much the government will subsidize your payments. Here's the deal: if you make between 138-400% of federal poverty level, you are eligible for a federal subsidy to help you pay your monthly premium (Families who make under 138% of the federal poverty level will now be eligible for Medicaid). 
  6. That means you might actually be able to afford real live health insurance. And you even get to choose if you want that subsidy up front, monthly to help with those payments, or at the end of the year rolled into your tax refund.
gold egg silver egg bronze egg
You can scroll around through "the cheap-o plan" (aka The Bronze) up though the Silver, Gold and as high as the "Cadillac plan" (aka The Platinum) and see what money up front gets you versus money at the time of service.

Let's be honest, the Silver plan won't get you tea and massage in the waiting room, but you will get reasonably priced medication co-pays and decent out of pocket expense for things like x-rays (which can get costly quickly). And, probably the most amazing novelty is that at least you actually know what you are getting. Transparency.

The other good news is that all the exchange plans have to have certain (and thankfully decent) minimum requirements, promising evidence-based preventive health care like standard prenatal care, screening mammograms, pap smears, birth control, breastfeeding support, recommended vaccines, colon cancer screening, and more. See here for more details.

Every state is rolling out Marketplaces in slightly different manners. Here in California our exchange is called Covered California. You can find the website at California is one of sixteen states rolling out its own exchange; many other states are working in a state-federal partnership, and nineteen states are using the federally run marketplace, rather than create one for themselves.

Check out this website for detailed state-based info on which states are doing what. If you live in Texas or Arizona or Pennsylvania, or one of the other 19 states that are not creating a state-based system, the federal exchange is available at It's a good start but lacking in specifics so far. More details, per them, will be available on October 1.

In my practice, I take care of plenty of families who are kind of 'in the middle' of the road for a lack of a better label. Some might call them working poor, others live just a bit off the grid. They are literally not poor enough to qualify for MediCal (California's version of Medicaid) and not rich enough to pay out of pocket for health insurance. I think the Exchange is going to be BEST for them.

Here's an example. I just experimented myself with Covered CA:
  • I entered a family size (e.g. 2 adults, 2 children), ages of adults (36 and 37), a mock annual salary ($60,000), and our zip code here in Sonoma County.
  • Covered CA spits out four different plan options for me and my imaginary family, including an explanation of how much I would pay monthly. We would have the choice between: Anthem Blue Shield, Blue Cross, Western Advantage, and Kaiser. 
  • In each of those plans, we can choose between Platinum, Gold, Silver and Bronze plans
  • Cost ranges from $750 (Bronze) to $1408 (Platinum) per month.
  • Platinum obviously costs the most up front per month with less cost when I utilize the service
  • Bronze costs the least but has the highest deductible and highest co-pays
  • For my imaginary family, my monthly premium for the Silver plan would be about $1000 per month. That's a lot! However, based on my imaginary income of $60,000/year,  we would also be eligible to get a monthly tax credit of $601 from the federal government, which brings my monthly premium down to $400/month.
  • I know, I know, still seems like a lot, BUT it's better than anything currently available for a family of four AND comes with guaranteed services and a clear explanation of how much an primary care visit will be ($45 in my example) and an x-ray ($45). 
  • And as far as I know, right now, no family of 4 would be able to find health insurance with guaranteed coverage for this price.

So there you have it. I encourage you to hop on and play with their calculator. You can find it here. If nothing else, it's a great place to toodle around and waste valuable time.

The Marketplace, in my opinion, is not the shining star of Obamacare. Exchanges still leave much to be desired. Namely, we are still at the will of the insurance companies and costs are still spiraling out of control. The true shining stars are the parts of legislation that guarantee people won't be denied care because of pre-existing conditions, the parts allowing children to stay on parents' insurance until age 26, parts of the Medicaid expansion, the inclusion of free preventive health services, and the closing of Medicare's donut hole for senior prescription costs.

Imperfect? Yes.

Health care for all? Definitely not.

But it's an improvement: transparency is always a good thing. And options are nice.

Enrollment in the Exchanges starts 10/1/2013 and coverage starts 1/1/2014. Hop on, check it out, and let me know what happens.