In the past, all we could do for many of these patients was offer them a quick fix: bandage them, take away their pain, and send them on their way. Most of these patients were low-income but didn’t qualify for Medi-Cal, the federal-state program for needy Californians. They usually ended up back in the emergency department sooner or later.

As the benefits resource manager for O’Connor Hospital in San Jose, I oversee the uninsured population and provide my staff with resources for the community we serve to assist patients with their medical needs. My job has changed a lot since the Affordable Care Act (ACA) took effect on January 1, 2013.

Now, we are able to talk to every uninsured patient who visits the emergency department—either in the Health Benefits Resource Center right down the hall or at bedside. We ask them a few basic questions to determine their eligibility and provide them the information they need to get enrolled in either Covered California or Medi-Cal.

Before ACA, we saw a lot of patients whose incomes qualified them for Medi-Cal, but who didn’t meet the other requirements. Back then, Medi-Cal was limited to people between the ages of 21 and 64 who had a child or a disability. This left a lot of low-income people uninsured.

For example, if a middle-aged, low-income woman came into the emergency department in diabetic shock, all we could do was offer her a charity application to cover that visit. If she didn’t have children or a disability, she didn’t qualify for Medi-Cal. We’d refer her to a clinic to see a specialist and write a prescription—but she couldn’t afford either that visit or the insulin.

If that same woman visited the emergency department tomorrow, I’d enroll her in a new program we implemented this year called “hospital presumptive eligibility,” which is temporary coverage for two months. We would then offer her an appointment to get step-by-step assistance with the application, as well as a list of clinics where she could see a specialist.

For some patients, it comes as a surprise to learn that they have these options now. Though there’s been extensive media coverage and information about the Affordable Care Act, many people think they’ll have to pay for it. They don’t know about the subsidies for people who buy plans in the Covered California exchange—or about the expansion of Medi-Cal. They also don’t know what steps they need to take to get signed up. That’s where we come in.

In the first open enrollment period in July 2013, we certified all of our enrollment counselors and saw 75 to 100 patients in a month. At that time, the counselor worked with patients to go through the entire application, which could take up to two hours for a family of four.

Since implementing this fast track to enrolling in Medi-Cal here at O’Connor Hospital in July 2014, we’ve been able to help 300 to 400 patients get temporary coverage and a start on their Medi-Cal application until they are able to apply for their full coverage.

When we first approach people, we try not to overwhelm them with too much information. People who come into the emergency department without insurance are worried about how to pay the hospital bills. We tell them,“If you’re willing to answer a few questions and you qualify, we have a program that might help pay your bill today and get the medication you need.” We’ve received many hugs from grateful patients!

I find my job extremely fulfilling. I enjoy being able to help people and think it’s wonderful that because of the Health Benefits Resource Center and the programs we have implemented, we can do more for patients today than ever before.

The post How Obamacare Is Changing the ER appeared first on Zócalo Public Square.

This year, the Affordable Care Act (ACA) had a profound and rapid change on my professional life as a physician who works in an institution that forms part of California’s safety net for those in need. I’m the chief medical officer for San Mateo Medical Center, the county hospital and affiliated clinics in San Mateo County. I also provide primary care in one of our outpatient clinics.

As a result of the ACA, many patients we serve in our county became newly eligible for Medi-Cal, California’s Medicaid program. With this transition, they were offered far more choices: They had access to services that were previously unavailable, such as dental services and expanded mental health services. And, instead of having to travel to our specialty clinic in the middle of the county, they could be referred to “private” specialists in their own communities. Far from luxuries, these new choices will help promote preventative care and early disease intervention; patients who in the past might have delayed a gallbladder or hernia surgery (and ended up in the emergency department with pain) can get prompt treatment with their new Medi-Cal coverage.

Before the ACA, most of our patients were either uninsured or were enrolled in a county program that only covered services at our institution; they could not seek care elsewhere. So more choice for patients means more pressure on us; as patients become eligible for Medi-Cal, they may now choose to leave our organization to seek care elsewhere. I will try to avoid clichés as I write this, but there is one that is especially appropriate here: “pressure makes diamonds.” I am seeing a spectacular gem being built around me here in San Mateo, far from flawless, but beautiful nonetheless.

Competition has forced us to confront some difficult questions, such as: What is the role of the safety net in this new era when many more people are insured? Why should we, as an institution, continue to exist? Thankfully the answers to these questions came fairly easily.

As an integrated health system, we offer a range of services from outpatient to emergency services to inpatient to long-term care; we offer a distinct advantage over the traditional fragmented health care system. Embedded in the San Mateo County Health System, we can work with our colleagues in Adult and Aging Services, Family Health Services, and Public Health to better meet all the psychosocial needs of our patients. For example, our partnership with the county’s Behavioral Health and Recovery Services has allowed us to embed behavioral health experts in our primary care clinics so that they can better address the mental health needs of our patients; this partnership also expands our ability to refer patients with drug and alcohol problems.

As our patients have moved to Medi-Cal, the ACA has brought our institution some new funding. But we realize that this will be short-lived; many of the new programs of the ACA are funded by reductions to other parts of the safety net. Such pressure is not new; safety net programs are often short of resources, forcing adjustments and redesigns. But the ACA ramps up this pressure on us to innovate, to find ways to do things cheaper and more efficiently.

Fortunately, we had a head start. We began almost a decade ago by redesigning our primary care services and establishing team based care. The county implemented an electronic health record in our clinics long before there was a mandate to do so. The ACA, through its resetting of priorities and funding mechanisms, offers us an opportunity to build on this foundation. We have repurposed some staff roles and brought in new staff members with new skill sets. For example, we have staffers who are specially trained to extract information from electronic records to better manage chronic disease, and pharmacists have been added to some primary care teams to assist with medication management.

The ACA has facilitated new partnerships with other community providers, allowing us to focus on those services that we provide well while partnering to provide services that are best delivered by others. This is a transition from the past, when we were the provider of last resort, forced to provide as much as we could and living, without the services we could not provide by ourselves.

One of our biggest investments has been in what we call our Lean transformation. Lean, based on the Toyota Production System, is a proven performance improvement methodology. Lean healthcare principles focus on increasing value by constantly improving quality and reducing defects and other wastes. Within the San Mateo County Health System, this transformation is being organized through our LEAP Institute. LEAP stands for Learn, Engage, Aspire, and Perfect (as a verb). As part of LEAP, we bring together teams that include line staff to observe and analyze our core processes–and then design new improved approaches that reduce waste and improve outcomes.

There is much work ahead, but much has already been accomplished. So far in 2014, we have brought almost 7,500 new patients into primary care facilitating better preventative health and chronic disease management. The majority of these patients are newly eligible for Medi-Cal. We have also seen a reduction of more than 20 percent in the number of patients leaving our emergency department without being seen due to long waits. We have seen an improvement in our performance on patient satisfaction surveys in a variety of areas including the Emergency and Inpatient Departments. And our pharmacy has reduced the time patients must wait for their prescriptions by about 75 percent. These are just a few of the gains. We look forward to many more.

The post Obamacare Is Turning Us Into a Better Hospital appeared first on Zócalo Public Square.

Costa Rica is healthier because its government spends more money than ours does on prevention and wellness.

In our country, we have left vast segments of the population without affordable care and we do not focus on wellness or chronic disease management. We don’t consistently control the glucose levels in diabetics and, consequently, too many go blind or lose a limb. Too often, hypertension goes untreated until the patient has a stroke or kidney disease. Then, all too often, these individuals go on medical disability with far more societal expense than the cost of the original health management.

Sadly, it has become the American way to leave many chronic diseases untreated until they become emergency situations at exorbitant cost to the U.S. healthcare system. For many patients, this care is too late to prevent life-changing disabilities and an early death.

When people ask me why we started the UC Riverside School of Medicine last year–the first new public medical school on the West Coast in more than four decades–I talk about the need for well-trained doctors here in inland Southern California. But we also wanted to demonstrate that a healthcare system that rewards keeping people healthy is better than one which rewards not treating people until they become terribly ill.

As we build this school, we have a focus on wellness, prevention, chronic disease management, and finding ways to deliver healthcare in the most cost-effective setting, which is what American healthcare needs.

We also teach a team approach to medicine—another necessary direction for our healthcare system. If you have a relatively minor problem, your doctor might refer you to a nurse practitioner or physician assistant for follow-up. This kind of team care makes financial and clinical sense, particularly since we have such a national shortage of primary care doctors. The good news: Even among physicians, the team approach, or medical home model, is gaining ground, with the Affordable Care Act accelerating change.

For all the talk about the lack of health insurance in this country, we don’t often discuss the other side of the problem–the fact that many Americans get more care than they need. You may have heard advertisements that you should have your wife or mother get a total body scan for Mother’s Day, because it will find cancer or heart disease. There is no evidence that this screening is a good idea. But in the U.S., we often encourage people to do things that have no proven benefit, and our churches or community centers sponsor these activities.

For all these reasons, we must shift the focus of healthcare to prevention. Two of the most profitable prescription drugs in the U.S., according to some sources, are those that reduce blood cholesterol and prevent blood clots—both symptoms of coronary heart disease, a largely preventable condition. Shouldn’t we be spending at least as much on prevention as we do on prescriptions? Closely connected to prevention is wellness. So many of our health problems in the United States are self-inflicted, because we smoke, eat too much, and don’t exercise. Doctors need to “prescribe” effective smoking cessation programs, proper diets and exercise as an integral part of care.

One way to accomplish this shift is to teach it to future doctors. At UC Riverside, we are supplementing the traditional medical school curriculum with training in the delivery of preventive care and in outpatient settings. Our approach is three-pronged.

First, we work with local schools and students to increase access to medical school through programs that stimulate an interest in medicine and help disadvantaged students become competitive applicants for admission to medical school or other professional health education programs. These activities start with students at even younger than middle school age, because that is when students begin to formulate ideas about what they want to be when they grow up. We focus on students from Inland Southern California because students who live here now will be among those best equipped to provide medical care to our increasingly diverse patient population. Doctors who share their patients’ cultural and economic backgrounds are better at influencing their health behaviors.

Second, we recruit our medical students specifically with a focus on increasing the number of physicians in Inland Southern California in primary care and short-supply specialties. Our region has just 40 primary care physicians per 100,000 people—far below the 60 to 80 recommended—and a shortage in nearly every kind of medical specialty. Students who have been heavily involved in service such as the Peace Corps, or who are engaged in community-based causes, are more likely to go into primary care specialties and practice in their hometowns.

Then, we teach our medical students an innovative curriculum. For instance, the Longitudinal Ambulatory Care Experience, called LACE for short, replaces the traditional “shadowing” preceptorship, where students follow around different physicians. Instead, our students participate in a three-year continuity-of-care primary care experience that includes a sustained mentor-mentee relationship with a single community-based primary care physician. In this experience, they “follow” a panel of patients and gain an in-depth understanding of the importance of primary care, prevention, and wellness. Our approach also includes community-based research that grounds medical students in public health issues such as the social determinants of health, smoking cessation, early identification of pre-diabetic patients, weight loss management, and the use of mammograms to detect breast cancer.

We try to remove the powerful financial incentive for medical students to choose the highest paying specialties in order to pay off educational loans. We do this with “mission” scholarships that cover tuition in all four years of our medical school. This type of scholarship provides an incentive for students to go into primary care and the shortest-supply specialties and to remain in Inland Southern California for at least five years following medical school education and residency training. If the recipients practice outside of the region or go into another field of practice before the end of those five years, the scholarships become repayable loans.

Third, we are creating new residency training opportunities in our region to capitalize on the strong propensity for physicians to practice in the geographic location where they finish their post-M.D. training. Responding to our region’s most critical shortages, we are concentrating the programs on primary care specialties like family medicine, general internal medicine, and general pediatrics, as well as the short-supply specialties of general surgery, psychiatry, and OB/GYN. We are also developing a loan-repayment program for residents linked to practice in our region.

Ultimately, we hope our ideas for how to change healthcare will succeed and be adopted by others. It might take 30 years, but we believe what we are doing at the UCR School of Medicine will change the face of medical education in the U.S.

The post It Took 40 Years for California to Build a New Public Medical School appeared first on Zócalo Public Square.

Yes, it’s way too early for any verdicts about the Affordable Care Act and its implementation, even in California, which has embraced this messy mash-up of a law more rapidly and firmly than almost any other state. It may be that we’ll never be able to evaluate Obamacare coherently—it’s simply too complex and contradictory, a wave slowly remaking one-fifth of the economy via regulatory jargon and codes that test the limits of human understanding.

But if Obamacare is ever to fulfill its core promises—of bringing health coverage to those without, of driving health innovation, and of improving community health—I’d bet those promises will get fulfilled in San Diego first.

Why does place matter in how a big federal law plays out? Because the heart of Obamacare is the creation of healthy, competitive regional markets for health coverage and, eventually, for healthcare itself. When you buy a health insurance plan in one of these markets—the so-called exchanges like Covered California—you are not buying into a national plan or a state plan but into a regional plan. Your age and where you live are the only two factors that insurance companies are supposed to consider when they give you a price on health insurance.

California is divided into 19 such Obamacare regions. And in building its regional market, San Diego already holds a lead, as no other market in California has more insurance carriers offering plans. While some parts of Southern California—sections of the Inland Empire and Los Angeles—have lagged in health coverage enrollment, San Diego nearly tripled projections.

Those enrolling in San Diego can choose from among a broader, more diverse mix of high-quality health providers than are available in less populous regions of California. And the fact that San Diego County is all in one Obamacare region (Region 19) may make Obamacare less confusing than in greater L.A. and the Bay Area, which are divided up into multiple regional markets.

San Diego also is distinguished by how its providers have embraced Obamacare. One of its two dominant local health providers, Scripps Health, will be in more insurance networks next year than it was this year. And the other, Sharp—an intensely local company (it’s San Diego’s largest private employer) that is both a healthcare provider and an insurer—set a tone in San Diego by seizing on the Affordable Care Act with more focus and fervor than any other company in California. Most strikingly, Sharp decided to enter the individual market for health insurance plans with the advent of Obamacare. In its first year, it secured more than 10 percent of the Covered California plans sold in the San Diego market.

Such success reflects not only on Sharp but also on the advantage that Southern California health organizations have had in adapting to Obamacare. “Managed care”—the management of cost, care, and patient populations most closely associated in California with Kaiser (another strong competitor in the San Diego market)—has been a fact of life here for two decades, making Obamacare’s emphasis on managed care less of an adjustment.

And when it comes to building a new, more technologically advanced health system in the future, San Diego is extraordinarily well positioned. Its regional economy combines strong research institutions with strong life science, pharmaceutical, software, and communication industries, making it a potential leader in the emerging “mobile health” industry. It doesn’t hurt that San Diego is home to leading thinkers of so-called “personalized healthcare,” like Dr. Eric Topol, a cardiologist and chief academic officer at Scripps Health.

“If intelligent people work hard to take advantage of the distinctive combination of industries that are already thriving in San Diego,” said a recent article in the journal of UC San Diego’s Rady School of Management, “we can create relationships that will result in the technology innovation that the health care market needs.”

That may sound overly optimistic this weekend, as phone lines jam and websites crash with Californians trying to secure Obamacare plans before the December 15 deadline. The San Diego-based insurance agent Craig Gussin, who sells policies all around California, warned me that in this moment, one shouldn’t make too much of any San Diego strengths in healthcare. “It’s all a mess right now, everywhere.” And, as they did throughout the country, rates in San Diego rose in the first Obamacare year—up by nearly 6 percent.

The good news is that it’s hard to go very far in San Diego without bumping into people who want to help you figure out your healthcare options. On one rainy weekday afternoon last week, I found a half-dozen different places with special seminars or services to help me with existing or new coverage.

In the lobby of Thornton Hospital, part of the UC San Diego Health System, Covered California had a pop-up service for enrollment and questions. When I told them I was covered, the staff offered me strategies for convincing family members, neighbors, and even my accountant and gardener to sign up.

In the evening, at a Sharp Health Plan office just off the 163, I dropped by a free hour-long seminar that offered a crystal-clear, warts-and-all explanation of the Affordable Care Act and the choices facing insurance-seeking San Diegans. Maybe it’s because it is the Christmas season, but the Sharp people—in a style reminiscent of Miracle on 34th Street, when the department store Santas send customers to competing stores—talked up the virtues of competitors’ health plans as well as their own.

If I needed to enroll, I was invited to attend a future “enrollment lab” where Sharp staffers with iPads would help me get online and navigate the website maze. If I needed to call Covered California, I was advised to avoid business hours (we can’t get through ourselves during the day, one staffer explained) and call either between 6 and 7:30 p.m. on weeknights, or on Saturdays. After the seminar, staffers stayed on for a half hour to answer questions from 14 people who attended, many of them freelancers or contractors who have variable income and are struggling with how to calculate subsidies they might earn for buying plans.

Navigating Obamacare is an unpleasant chore, but it might be a little less unpleasant in America’s Finest City.

The post If You Want to Make Sense of Obamacare, Go to San Diego appeared first on Zócalo Public Square.

Desert Healthcare District ACA campaign manager Samantha Prior, who works on enrollment in the Coachella Valley, said that in the first open enrollment period, large community events did not work well. So this time around, they’re going out to apartment complexes, community centers, mobile home parks, and hospitals to inform people of their options.

A lack of public transportation was an issue in the Desert Healthcare District, but other parts of the Inland Empire had other problems to contend with. Inland Empire Economic Partnership president and CEO Paul Granillo said it’s important to remember that Riverside and San Bernardino counties have a combined population of 4.3 million people. If the Inland Empire were a state, it would be the 26th largest in the country (just 70,000 people shy of Kentucky). It’s a mix of urban centers (Ontario, San Bernardino, Riverside) and more rural areas like Temecula and the High Desert. “If you’re going to paint your house, you’ve got to measure it and figure out how much paint you need,” said Granillo. “With the ACA and other initiatives, there’s always a failure to take into account the size and complexity of the region.”

Julie Marquis, senior editor at Kaiser Health News and the panel’s moderator, said the region’s diversity is part of this complexity: The Inland Empire’s population is close to 50 percent Latino, 7 percent African-American, and has a growing Asian population as well. What, she asked, is the healthcare literacy of these groups?

Granillo said that it’s impossible to lump these groups together. There are 2 million Latinos in the region (the fourth-largest concentration in the nation) for instance, and just 18 percent of them are newly arrived. There are also generational divides. An older generation went to work at the steel mill and received insurance on their first day on the job. “You didn’t have to worry about it,” he said. “It was part of the package. That has changed.”

Marci Aguirre, director of community outreach for the Inland Empire Health Plan, which serves low-income patients on Medi-Cal, said the region’s undocumented and newly arrived immigrants have faced a particular set of challenges. Language was a barrier—particularly because Spanish-speaking enrollers were extremely scarce in the first open enrollment period. Another barrier was fear and confusion over who was eligible in mixed-status families with documented children and undocumented parents. She said that a number of people who lacked green cards or even documentation (under deferred action, for instance) were eligible to enroll but didn’t know it.

Marquis asked the panelists if the region’s healthcare infrastructure is keeping up with the growing insured population.

Granillo said that keeping up with the region’s growth—as well as the growing poverty rate—is a challenge, period. “We are under-doctored and under-nursed and under-hospitaled,” he said.

Aguirre said that the Inland Empire Health Plan has been growing its network of doctors and healthcare providers since before the ACA was implemented. “We don’t turn doctors away who want to be part of the network,” she said. The plan recruits, too: They’re offering grants to doctors to move their practices, or a portion of their practices, to the region.

Medi-Cal, said Marquis, is not popular among physicians because it doesn’t pay very much. How do you entice doctors to serve low-income patients?

Aguirre said that the Inland Empire Health Plan pays physicians in high-need specialties above the Medi-Cal rate when necessary. And Prior said that the Federally Qualified Health Clinics in her district get reimbursed slightly above Medi-Cal rates as well. This is a statewide issue and not unique to the Inland Empire, said Aguirre.

The region is also trying to create a pipeline of homegrown doctors through UC Riverside’s new medical school. There are a number of new loan forgiveness and tuition reimbursement programs for doctors who stay local for a certain period of time after graduating, said Aguirre.

A key element of the ACA is shifting the burden of healthcare from high-cost emergency room visits to preventative care. Marquis asked the panelists to talk about the demand for such services from people with chronic conditions that are prevalent in the region, like asthma.

Prior and Aguirre both said that educating people on the resources available to them is hugely important. Prior said that homeless people now qualify for free preventative care, and her district has been trying to spread the word about this increased access.

Aguirre said that a new program that offers home visits to families who visit to the emergency room frequently for non-emergencies has been very successful. People don’t realize they have options beyond their primary care physician or the emergency room—from urgent care to a 24-hour nurse care line. Even offering advice as simple as writing down your questions for the doctor before going into an appointment can help people learn more about their health issues.

In the question-and-answer session, an audience member asked the panel how they get past the complexity of the ACA to educate regular people.

Prior said that partnerships with neighborhood groups and nonprofits have been key. These groups are already in schools, in churches, in community centers; they’re holding events in the evenings and putting out information in the newsletters people already receive.

The post The Inland Empire Will Do Just About Anything to Insure You appeared first on Zócalo Public Square.

I was elated—for his survival, for Obama’s victory. I looked forward to one of Obama’s major campaign promises: to provide national healthcare reform so Americans with a pre-existing condition could get insurance. Since his heart diagnosis in 2005, Jim, who probably couldn’t have found a policy as an individual because of his condition, had been covered by small-business group insurance, because his self-storage business in Banning had one other employee. But his work, and his coverage, were always subject to change.

I remained vulnerable as a freelance writer and part-time university professor who had to pay for her own health insurance. I also had had a few recent health hiccups, including a surgery to repair a herniated disk from spinal degeneration, and so I lived with the daily realization that one bit of bad health news could cause my policy to be canceled.

As it happened, the 2008 election was the first time Jim and I were bitterly divided on candidates. Jim foresaw healthcare reform as an addition to the federal deficit more worrisome than any health benefit. When I told my husband about Obama’s victory in the hospital, he grumbled, “I guess I can’t blame Obama for breaking my heart.” But, he worried that he would eventually be able to blame the president “for keeping me from getting better.”

The transition to Obamacare—at least for a 59-year-old man and a 56-year-old woman in south Orange County—wouldn’t be quite that bad. But it would be, in three big ways, far rougher and more frustrating than I’d ever dreamed.

1) Obamacare brought us new health insurance options, but cost us our more affordable plans.

“If you’re one of the more than 250 million Americans who already have health insurance, you will keep your health insurance—this law will only make it more secure and more affordable,” President Obama promised in 2012.

The fact that this wasn’t true would be our biggest disappointment. In November 2013, Jim learned his small-business policy would be cancelled because it didn’t comply with the new mandate to cover pediatric dentistry and maternity care. So Jim went to Covered California, the state’s health insurance exchange, to look for coverage for his employee and himself.

He found that the cost of his employee’s individual “bronze” plan monthly premiums went up 13 percent , and that his own new individual “silver” plan was also more expensive. In 2014, Jim was individually paying $82 more a month in premiums. The deductible (the amount you have to pay before the insurance company starts footing the bill) did go down—from $5,000 to $2,000 for each individual insured. But if you added together 12 months of premiums, the deductible, and the new policy’s out-of-pocket maximums, we were potentially on the hook for $13,260, rather than the $11,024 from 2013, if Jim got very sick. Around this time, Jim was diagnosed with prostate cancer, so the threat of high medical bills was real.

The individual plan I had with Blue Cross was cancelled, too. The bronze plan I got at Covered California raised my monthly premium payment from $301 to $422, with a $5,000 deductible. The maximum I might be responsible for if I got really sick went from $8,612 to $11,314.

2) We learned patience, but we couldn’t keep our doctors.

The only way to decrease the cost of our premiums was to get the subsidy offered by the federal government to lower- and middle-income people. And the only way to get the subsidy was by getting insurance through Covered California. But contacting Covered California, especially by phone, was maddening. The elevator music they played on hold became our winter soundtrack.

We had applied online and sent copies of our passports to California Covered for verification, but we received no bill, no confirmation of our coverage, no insurance cards. Jim spent an hour and a half on hold once before getting disconnected. He tried again the next day, waiting another two hours before getting disconnected.

After a few more calls, Jim drove to a pop-up Covered California shop in the Laguna Hills Mall on January 15, 2014, the deadline for adding coverage. He hoped to avoid website computer glitches and phone hang-ups. All we had were verbal assurances, which were not enough to see the cardiologist and a urologist at the insurance-negotiated rate. Receptionists at the doctors’ offices said we could pay cash: $150 per visit for the urologist, $203 for the cardiologist, plus lab and treatment expenses.

On January 22, we finally got our enrollment number and made our first payment to Blue Cross so we could start seeing doctors. Jim finally went to his cardiologist on February 10, only to discover the doctor had left Blue Cross.

Thus began a session of musical chairs as we tried to match our insurance to the doctors we wanted to see before the music stopped. This was one time we had the advantage over an employer-sponsored health plan, which has only one open enrollment period in a year. Due to the start-up problems with state insurance exchanges, the deadline for Affordable Care Act insurance kept being pushed back, allowing us to change coverage twice.

We canceled Blue Cross and enrolled in Blue Shield so Jim could see his urologist. Then, when the urologist’s office said they didn’t accept Blue Shield patients enrolled through the state exchange, we canceled California Covered Blue Shield and bought directly from the insurance company, even though that meant foregoing the subsidies.

But the urologist wouldn’t accept our new Blue Shield plan, even though the Blue Shield website said he did. Jim’s regular dermatologist left Blue Shield, too.

In each case, the doctor’s office said the reimbursements for the insurance we had were too low. In each case, the receptionists chirped, “We’re happy to make you a cash patient.”

Eventually, we requested records and sought new doctors. Although we read frequent reports of patients unable to find physicians willing to take new patients, in our case Jim found a new urologist he liked better than the old.

3) The Affordable Care Act saved us money this year, but it didn’t alleviate our concerns about obtaining affordable medical care.

Jim treated his prostate cancer with radiation, and received his recommended echocardiogram and MRI. So in 2014, we paid the maximum out-of-pocket expense and the insurance company covered the rest. Tallying his medical costs, Jim said, “I take back what I said. Obamacare did help me get better.”

I’m well below my annual deductible. I baby my back, neck, knees, and hip degeneration with regular walking, yoga, and acupuncture. I’ve benefitted from regular $28 acupuncture treatments, something that wasn’t covered in my old plan. But my licensed acupuncturist hasn’t received any reimbursement yet. It’s also harder for her to make a living; the insurance company cut her pay by 25 percent.

What Obamacare hasn’t eliminated is worry: We’re deeply concerned about our ability to get quality medical care from doctors we trust. The day may soon come when we can’t afford the plans our doctors accept, or we’ll have to wait hours to seen. Will the best doctors flock to a cash-only model? How long can a good doctor be satisfied with the $39.75 the insurance company paid her for my annual check up a few months ago?

We had thought that our work and businesses had paid us enough to live on in these older years, but we’re discovering we didn’t account for such dramatic increases in health care costs. Medical expenses already gobble up 20 percent of our income. In 2015, if we keep the same plans, our premiums will rise $95 a month. We have no choice to opt out of the required pediatric dentistry or maternity coverage we’ll never use, so we’ll eventually have to settle for less generous policies, with higher deductibles and out-of-pocket maximums. My husband isn’t required by law to insure his one employee, though he feels it’s the right thing to do. As costs continue to rise, we may have direct him to buy his own health insurance at his own cost.

We’ve already started the dance of enrollment all over again and are having a hard time finding partners. As I write this, the “Find a Provider” link on the Covered California website offers 2014 health providers, but not 2015, even though we’re shopping for 2015 insurance policies. Ditto Blue Shield. Administrators at our medical group won’t say yet if they’ll remain with Blue Shield. At least this year we think we know the steps to the dance. Let the music begin.

The post Dances with Obamacare appeared first on Zócalo Public Square.

There are also new challenges afoot. Organizers will have to go deeper into communities and convince more people who don’t use computers, many whose first language isn’t English, as well as those who were unconvinced by the first round of messaging about subsidized health insurance.

In advance of the Zócalo/The California Wellness Foundation event “How Can Obamacare Reach More People in the Inland Empire?”, we asked health policy experts, community organizers, and patient advocates to tell us about strategies that have worked to get uninsured Californians to buy healthcare coverage.

The post Is There Anything Exciting About Buying Health Insurance? appeared first on Zócalo Public Square.

Fast forward to the present: I have a master’s degree in public health and my weight is under control. I’m the director of programs at Clinicas de Salud del Pueblo, a non-profit community clinic that provides health, dental, behavioral health, and education services to people in Imperial County.

Unfortunately, obesity is much more common here than when I was a kid. Today, 4 in 10 children in Imperial County are considered obese or at a weight that puts them at high risk for serious health problems like Type 2 diabetes, high blood pressure, and complications from asthma. Couple this with the county’s high poverty rate of 22 percent, and you have a recipe for an unhealthy community.

To determine if a child’s weight is a problem, a key measure is body mass index—measuring the child’s weight against a national standard of what’s considered healthy for their height, age, and gender. A child in the 85th percentile or more is considered overweight; at the 95th percentile and above, a child is obese.

One major problem in dealing with childhood obesity is that many parents see it as something their children will outgrow—not a major health concern that requires treatment. The clinic used to take this approach, too. We told parents and children to eat healthy and exercise, and to come back next year for a physical exam. This method didn’t work. Most kids don’t grow out of being overweight or obese and many parents don’t know how to help them make healthy choices around food and exercise.

In 2011, my community clinic saw an opportunity to expand our work and join forces with other agencies in the region to come up with a new strategy for controlling obesity. One focus of our work is to try to identify obesity problems much earlier in children’s lives, and monitor the problem more closely over time.

We desperately wanted an approach that would work. So our coalition included San Diego State University’s Institute for Behavioral and Community Health as the lead agency so that we’d have top researchers. My clinic and the Imperial County Public Health Department provided on-the-ground knowledge. And in order to get real money, we applied for a 4-year research grant from the Childhood Obesity Research Demonstration (or CORD) study of the Centers for Disease Control and Prevention.

The grant program is part of the Affordable Care Act and aims to tackle childhood obesity in impoverished communities. We were fortunate to be one of just three sites funded in the United States—the others are in Massachusetts and Texas. We aren’t scheduled to present the results of our project, which is called Our Choice/Nuestra Opción, until 2016 as CDC is working on a report to Congress first. We have already learned a few things we can share.

The study is focused on three Imperial County communities (Brawley, El Centro, and Calexico). When we launched Our Choice/Nuestra Opción last year, we invited about 600 children who had been diagnosed at our clinic as overweight or obese to participate—and we allow any family that comes through our doors to access the services.

The family wellness program engages the entire family in learning to make healthy choices. Three to four times a year, the overweight or obese child visits the clinic to see a clinician for a weight management and wellness exam. A patient care coordinator also works with the family to connect them with community resources—everything from recreation programs to food stamps.

Finally, community health workers (or promotoras) lead a series of 17 wellness and physical activity workshops over six weeks for both parents and kids. There are workshops just for adults focused on parenting skills like communication, setting rules, and the importance of being a good role model when it comes to healthy living. There are also workshops for the entire family where they set realistic goals and come up with a wellness plan. Finally, families learn to incorporate fun games into physical activities. For example, everyone pretends to be on a ship where a “captain” calls out commands like “drop the anchor” or “swab the deck,” which are different stretching exercises.

When we launched Our Choice/Nuestra Opción, we were not prepared for how challenging this was going to be. For example, only half of the families invited are taking advantage of the new family wellness program. For many families, it’s hard to find the time to participate in the workshops twice a week—or to make the follow-up visits so the child’s weight and wellness plan can be monitored.

One of the first families to participate in Clinicas’ new family wellness program was the Padillas. Their 11-year-old daughter had been struggling with her weight for a few years and her mother knew the family needed help. She was overweight herself.

Nevertheless, it was difficult for the Padillas to be a part of the program. The family doesn’t have a car and needed to find a ride or take the bus, which can be tricky after 8 p.m. when most workshops end. The mother said that she felt guilty when she didn’t follow the healthy life plan she worked on at the clinic. Like many families, she felt reluctant to visit the clinic if the family had lapsed. We stress that the important thing is to stay on track as much as possible.

The Padillas eventually started to figure out how to manage the plan and make changes to their lifestyle. They went out on walks (even when it was 105 degrees), watched less TV, gave up drinking sweet tea, and ate less of their favorite (fattening) Mexican foods.

This year, the 11-year-old girl’s body mass index went down from the 98th percentile to the 95th, a small step in the right direction. Major weight loss takes time, and the Padillas have made real progress by changing their behavior. The family now eats more fruits and vegetables, drinks more water, goes to sleep earlier, and includes more physical activities in their daily routine. The child’s weight is still monitored by a clinician and the family is welcome to attend any physical activity and wellness workshops.

But it’s not just families that need to commit to change. In many cases, social service agencies, including those of us working in the project, also need to model better behavior, like serving healthy food in public meetings. As part of Our Choice/Nuestra Opción, experts conducted training with the staff of clinics, childcare facilities, schools, recreation agencies, and restaurants. We also launched a public outreach campaign focused on healthy behaviors, like drinking water instead of sugary drinks, getting enough sleep and physical activity, and eating more fruits and vegetables. There are Our Choice/Nuestra Opción posters all over Imperial County with these messages.

The magical solution to childhood obesity that I wished for when I was a kid doesn’t exist. Tackling this problem means making a long-term commitment—and understanding that change won’t happen overnight. This is as true for families as it is for all of us.

The post I Can’t Cure Your Child’s Obesity appeared first on Zócalo Public Square.

I grew up in Grand Terrace in San Bernardino County and have been working since I was 16 years old, often in customer service jobs. I’ve had my ups and downs at work and in life, particularly since the big recession hit. I moved back in with my parents, who live in Riverside, in 2010. But I never much worried about health insurance. I’m still young–I’m 30–and I’ve never been seriously ill or injured. I don’t have a wife or kids.

But in the last couple years, my chronic childhood asthma has returned with the vengeance. It’s a terrible feeling. My lungs get inflamed and constricted, and my breathing becomes labored. When I lost that job, I took some solace in the fact that my timing might be good. Obamacare would be starting soon, with sign-ups in the fall of 2013.

That didn’t mean I was stoked about the idea. I’m a libertarian, and I’m not a fan of President Obama in general, or his health plan. But I needed the care. So I went to the Covered California website, which I’d learned about from TV ads.

I found the website a little bit confusing, but I eventually figured out how to sign up for a Bronze plan. That is the cheapest kind of plan, though Bronze plans often have high deductibles. I thought I was done, but I wasn’t. Months went by and I never received a confirmation from Covered California. I wondered what had happened.

The answer came in the mail. Covered California sent me a letter saying that I wasn’t eligible to sign up for one of their plans–I didn’t make enough money. That rejection surprised me; I didn’t know that your income could be too low. But it’s true that I didn’t have a lot of money. My unemployment payments, which I hadn’t included on the form, had run out. My only income at that time was from a part-time gig playing guitar at my church.

Instead, the letter (and subsequent rejection letters) would inform me, I was eligible for Medi-Cal, California’s version of Medicaid, the federal program to cover the poor. I wasn’t happy about this, but I had no choice: I needed some coverage because of my potentially life-threatening condition. So I had to go to another website and apply for Medi-Cal, and received a package in return asking me to pick a plan within Medi-Cal. But before I could choose, I was automatically put on the Inland Empire Health Plan.

The hard part was trying to get health care with my Medi-Cal plan. Making an appointment to see a doctor who could renew my prescription for asthma drugs and inhaler was incredibly difficult. The only appointment at first was two months out. Then, the day before, the doctor’s office called to cancel. I rescheduled again for another month or so out—and the clerk called again to cancel.

At that point, I got very persistent and demanded an appointment immediately. I told them I wasn’t taking no for an answer. I knew that if I had nothing to stop an asthma attack, I could die. I had been borrowing the inhalers of a couple of friends to get by and they might not be around the next time an attack came on.

Eventually, after many calls (and after another patient canceled, creating an opening), I got an appointment at the regional health center in Riverside, just off Indiana Avenue, not far from where I live. The doctors there would take my IEHP coverage. It was an eye-opening experience. The place was jammed, and people were waiting for hours for a doctor. It took me three hours to get seen by a doctor, even though I was an easy case. My asthma didn’t need to be diagnosed, and all I really needed was an inhaler.

The outcome, however, was less than optimal. I had previously used a ProAir inhaler, which uses the drug albuterol sulfate, which has been very effective in controlling my asthma. But under the new health plan, they switched me to a different inhaler with a drug, Ventolin, that doesn’t give me the same strong relief. (It doesn’t help that the Ventolin cartridge is twice as big). I only learned about the switch at my local CVS pharmacy when I tried to fill the prescription. When I asked about the switch, I was told that I didn’t have a choice. Ventolin was what IHEP covered.

I’m not sure what I’d do if I had to continue on the Medi-Cal health plan with IHEP. The good news is: I don’t have to. I just got a full-time job and soon will be eligible for benefits again. I’m thankful I won’t have to be one of people in line again, waiting hours to be seen, mired in red tape, and worried about taking my next breath.

The post Breathing on Borrowed Inhalers appeared first on Zócalo Public Square.

This is the office of Crenshaw Health Partners, in the heart of the Crenshaw district.

As the second open enrollment period under Obamacare gets underway, you’ll be seeing pictures of people signing up for new health plans in all kinds of pop-up centers, from farmers markets to storefronts. But you won’t see anything quite like Crenshaw Health Partners.

Officials from Covered California, the state’s health insurance exchange, said this fall that Crenshaw Health Partners is the only full-time enrollment center that is a bricks-and-mortar store.

Sometimes people are confused about the center’s location. You can hear staff members confirming over the phone that yes, indeed, they are in the Baldwin Hills Crenshaw Plaza mall. Crenshaw Health Partners is open every day, including evenings and weekends. Enrollment is not limited to just health plans sold under the Covered California exchange. They’ll enroll you in Medi-Cal, in Medicare plans, in veterans health benefits. If it involves enrollment and healthcare, they offer it.

And if you can’t make it to mall, Crenshaw’s enrollment specialists will come to you. They also roam the city, signing people up at fairs and churches and anyplace that will have them.

On November 15, the first day of this open enrollment period, Zócalo photographer Aaron Salcido arrived at Crenshaw Health Partners just before the store opened for business at 10 a.m. While only about eight people ended up walking through the enrollment center’s doors in the first few hours of the day, there was a concerted attempt to make the experience festive. There’s no escaping the starchiness of a room full of cubicles and taupe carpeting, but the folks who worked there livened up this portal into federal paperwork with fresh irises and blue balloons. And just outside, other organizations had set up booths to take advantage of an audience that was already primed to think about their health. Dentists and dental students from the Hispanic Dental Association and UCLA showed kids how to brush their teeth and floss.

Some people walked away without health insurance that day because they hadn’t brought proper I.D., but most people did end up with a plan. One man even left with a broad smile because it cost less than he expected.

The post Pick Up Some Obamacare, Then Hit the Food Court appeared first on Zócalo Public Square.