Every Woman Counts

Maria is a very quiet woman. Una mujer muy tranquila.

I have never heard her complain. Not once. Not when I examined the drain left in the place where her left breast had once been, not when her eyebrows disappeared, not when her skin sloughed off in layers under the blistering burn of radiation. Never.

Most questions I ask her, even open-ended ones, are answered with a shy nod or a few soft-spoken words. She has a pursed smile and an awkward shrug of both her shoulders when she is uncomfortable. When I ask her how she is doing, she always has the same response, "Bien, doctora".  To call her understated is an understatement itself.

The day I met her--almost five years ago now--is an indelible memory-- one that will be part of my physician-consciousness forever. Maria walked into the residency training clinic where I was literally pretending to be a doctor and told one of the front office workers she needed an appointment. She was having "a breast problem". An astute receptionist picked up on the understated urgency in her face and stuck her in an opening in my schedule that afternoon. Maria waited for a couple of hours before she was finally roomed, and when I knocked on the door, I had little idea of what was on the other side.

After I introduced myself, Maria told me that she had un problema with her breast that she had been ignoring. She needed help. Her Spanish was a little challenging to understand, and as such, I wasn't quite certain exactly what she was trying to tell me. But when Maria lifted her shirt, it was clear to me that the "breast problem" was not something minor. The Spanish no longer mattered.

Breast cancer. Visible breast cancer. A terrible oozing mess of abnormal tissue, red and dimpled and irritated and just about the ugliest site you can imagine. Cancer that had grown from a seed much deeper in her left breast, enlarged slowly over time (probably years), and eventually eaten from its origins up through her skin-- until she could ignore it no longer. Cancer looks just like you might imagine cancer would look like-- hideous. Undeniably gross.

These are the reasons I imagine Maria ignored her breast cancer.

Initially, she didn't know what it could be.
After all, most of us haven't been to medical school. We can convince ourselves in the middle of the night that we have foot cancer only to discover with the sunrise that it's just a blister on our foot. Most of us also delay seeking treatment-- I am going on eight weeks of a tooth ache and still have managed to avoid making myself a dentist appointment to evaluate that ache.

She was taking care of her family and ignored her own needs in the context of her family's needs
After all, that's what plenty of mothers do on most days of the week-- you know who you are: you're the mama that should really work today out but instead you go to the grocery store to stock up on lunch materials for your kids. You should go get your pap smear but it's lower down on the priority list than taking Junior to soccer practice or to library reading time. You have been meaning to pick yourself up a few new pair of undies but always find yourself in the kids section of the store checking out the clearance items rather than in the hot mama sexy lingerie section.

Once it started to become more clear, she got scared.
Fear is a huge barrier for all of us. It's hard to understand the immense power of fear. I was speaking to a local breast surgeon last week, and she actually said "I liken women with open breast cancer tumors to situations where people need to drop children off in safe drop zones, no questions asked. It just seems to get harder and harder for women to access care as the cancer gets grosser and more obvious. I dream of having a sign on my door that says, 'Please bring your horrible tumor here. I promise I won't ask why you didn't come sooner."

She didn't speak any English. 
When is the last time you got on the phone with some bureaucratic agency (think DMV or your own dear health insurance company) to try to make yourself an appointment or clarify an oblique notice you got in the mail? You were probably on hold forever or stuck in some crazy bramble of phone-tree hell. Just imagine doing that in another language. Virtually impossible.

She had no health insurance
Fear of a diagnosis is one thing, fear of a medical bill is an entirely other beast. As Covered California continues to take hold here, I am happy to see some people having access to insurance for the first time in years (or even ever), but undocumented immigrants are completely ignored in our new legislation. Hopefully, there will be political will in the coming years to change that (see more here). Thankfully, in California, we have a wonderful state-based program called "Every Woman Counts", also known as the Cancer Detection Program (CDP) and its sister program Cancer Treatment Program (CTP). Both of these wonderful safety net programs were essential in getting Maria expedited diagnosis and care. Thank goodness for our safety net! I really hope everyone knows how important it is that there are programs in place. Please don't disregard the power of the safety net.
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I am happy to report that it has been over four years since Maria's diagnosis, and though she went through a lot during that first year, she is currently cancer free. She continues to do well physically and emotionally. She still never complains.

Our health care system is pretty ridiculous, even for well-educated, English-speaking, documented citizens with excellent top-of-the-mark health insurance coverage. It's scary, often overwhelming, difficult to navigate, and generally not user-friendly. And yet, there are some amazing gems that enable providers like myself to continue doing the work we do. Every Woman Counts is one of those gems-- designed to offer appropriate screening AND treatment for vulnerable populations. It is funded by a combination of federal funds and augmented California tobacco taxes. Woo hoo!

It's awesome for me to discover that there are similar such cancer detection and treatment programs available in all 50 states (see link here). It's administered differently in every state, but the CDC provides matching funds and support for these programs. Thank goodness they exist! But, unfortunately, this program are limited to specific diseases, namely breast and cervical cancer.

Now with our new health care legislation, more gaps are being closed, but there is still much work to be done. Don't you think the next best step is to figure out a way to provide similarly excellent care for all people in our country? And not just for their breasts and their cervices, but perhaps also for their migraines, diabetes, depression, heart disease, and even ingrown toenails.

I do.



Additional references:
http://www.cancer.org/healthy/findcancerearly/womenshealth/earlydetectionofspecificcancers/nbccedp
http://healthpolicy.ucla.edu/publications/Documents/PDF/undocumentedreport-aug2013.pdf
http://www.huffingtonpost.com/2014/01/28/undocumented-immigrants-health-care_n_4679348.html

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 "Kayak.com 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.

http://www.concept-w.com/works/2012/04/gold-egg-silver-egg-and-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 www.coveredca.com. 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 www.healthcare.gov. 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.