I work in a state that elected to provide medicaid expansion as part of the ACA. We were closed yesterday for New Year's, so today was when "obamacare" implementation really took effect for my clinic.
Instead of seeing
My schedule for the next 3 weeks is booked entirely with established patients who need new referrals placed to the medicaid system. I am trying to clear a 2-year backlog of orders for echo's, ultrasounds, CTs, MRIs, physical therapy, and any specialty referral to rheumatology, urology, sports medicine, orthopedics, pain management, etc.
.... Yes, our patients previously waited, on average, more than 12 months for any of the above referrals. Without insurance we can only refer to the horrendously overbooked safety net county system. It was hopeless. Usually they never got any appointment at all. The alternative is a 24+ hour ER wait which rarely gets them the evaluation needed (an angry resident once returned a patient to me with WE DONT DO MRIs IN THE ER scrawled on the referral I gave her.)
I was finally able to order diabetic shoes and a wheelchair. Tomorrow I will see 2 asthmatics who need prescriptions for neb machines.
I will complete prior auth's for cellcept (SLE) and rebif (MS). Both patients are currently off meds due to cost and not doing well.
For patients with no insurance we have a very small dispensary with limited stock of meds. With medicaid coverage, I can now prescribe:
combined BP pills, januvia, finasteride, flomax, epipens, advair, imitrex, fioricet, insulin pens, namenda, aricept, lexapro, lipitor, lovenox, verapamil, zyrtec, olmesartan, atropine nasal, levaquin, and valtrex to name a few. I have missed lexapro and verapamil the most.
My experience with obamacare is that it has made me feel like SUPER NP!!! because I can finally deliver care to high-risk patients. These are not bad people, or freeloaders, or "welfare queens." The majority of my patients are the working poor, who put in more hours/week than I do, feed more mouths, have more chronic diseases, and make a fraction of my salary. They keep my city running.
Has anyone else seen a dramatic change in their practice with ACA implementation?
I feel the need to add another perspective to "obamacare." My youngest son has a severe disability through no wrong doing on my part. He has lots of health problems, general health issues, has had lots of surgeries etc... Obamacare will help my son, we make too much money for Medicaid and I know his healthcare is into millions of dollars at this point, yet we no longer will have to worry about being denied insurance due to his pre-existing condition or meeting the lifetime cap of benefits many ins companies have. My son is on several medications but his Growth hormone alone is over $1400 for a 28 day supply! That's the generic brand... As I said, his surgeries are countless, he has scoliosis and wears a boston brace. I could go on and on... For my family obamacare is a good thing, for those it's not I'm very sorry but I am great flu to know no ins company can say they have paid enough money out for my son and that they will not pay anymore! If you think this does not really happen, it does... Talk to parents of special needs kids and you'll be surprised what ins companies have been putting us through. I did not post this to start a debate, it's just a look into the life of someone obamacare has helped.
Should a Type One diabetic be allowed to die because of inability to pay for insulin? Should a cancer patient die because of inability to pay for treatment? No human should die because they can't aide in the profit of a pharmaceutical company. Lifesaving medication and treatment should be a human right. Nobody should die from a treatable condition. Nobody.
Well...where do we factor in the element of self-responsibility? I treat pts with diabetes in the hospital. Yes, we try to provide care and do not deny meds for any diabetic. However, there is only so much we can do and then the rest is up to the patient. It is discouraging to see people with healthcare coverage who come in as readmits over and over with one complication after another...repeated episodes of DKA...revascularizations followed by CVAs, followed by infection, followed by deridements, followed by gradual amputations. One thing I hear over and over from patients is, "I know what I'm supposed to do, I just don't do it."
Specializes in Clinical Research, Outpt Women's Health.
Healthcare provided by the government isn't really a constitutional, or God-given right. That doesn't mean that we shouldn't, as a nation, decide that we want to provide it.
Having people die in the street, having children go without care, letting people starve, I don't really think that's where we want our society to go. We are a civilized nation and an ethical one, for all our flaws. We elect people to represent us, to organize society, to protect the helpless, to provide infrastructure to allow us to work, and recreate. Why can't we also try to improve our healthcare system? It wasn't working well previously.
Having said that, I am still skeptical about Obamacare. I think there are superior systems out there, that it was put together poorly, and has many many flaws. But, the goals are valid ones.
I agree with this 100% You really articulated what I wanted to say.
Re:patient self responsibilityI would vote for mandatory counseling. Help people take an interest in themselves and help them with their choices. Staff could also use support with their feelings about patients who don't follow up properly.
Why should healthcare be a God given right? That's the problem with America, everyone thinks they are entitled to everything. No, your not. You need to work for what you have. People think that they are entitled to everything and only the people who are rich should pay for it. Unless you physically cannot work (which healthcare is provided for those people), get up off your butt and get a job. But it's a recession and there are no jobs, people proclaim. There are plenty of jobs out there for people who want them. It may not be your dream job, but do it until a better one comes along.
We are being clobbered with extra taxes, now subpar healthcare, among many other things because people feel a sense of entitlement. They feel the rest of us should pay for their existence. And everything I have worked so hard for is going down the tubes.
People who feel this way need to move to a communist nation where everything is provided for but they have no human rights. You can't have both. Ask the people in China or North Korea what they would rather have freedom or free healthcare. I bet most of them say freedom.
Specializes in ER and family advanced nursing practice.
Freedom or free health care? What? No one said healthcare was free, but if you are talking about universal coverage, then yes you can have both. How silly to suggest other wise. Did you actually say something to the effect of get a job? You do realize that many of the people who benefit from the ACA are the WORKING poor? And no, not everyone in America thinks they are entitled to everything. Absolutist thinking like that is not productive. And wow, a 1950s rant about communism. Priceless.
Why should healthcare be a God given right? That's the problem with America, everyone thinks they are entitled to everything. No, your not. You need to work for what you have. People think that they are entitled to everything and only the people who are rich should pay for it. Unless you physically cannot work (which healthcare is provided for those people), get up off your butt and get a job. But it's a recession and there are no jobs, people proclaim. There are plenty of jobs out there for people who want them. It may not be your dream job, but do it until a better one comes along.
We are being clobbered with extra taxes, now subpar healthcare, among many other things because people feel a sense of entitlement. They feel the rest of us should pay for their existence. And everything I have worked so hard for is going down the tubes.
People who feel this way need to move to a communist nation where everything is provided for but they have no human rights. You can't have both. Ask the people in China or North Korea what they would rather have freedom or free healthcare. I bet most of them say freedom.
I have an "Obamacare" success story of my own now. I work on the psych C&L service of a large academic medical center. We are currently following a young woman with a life-threatening eating disorder. She's being treated medically since some time last Fall. She desperately needs inpatient psychiatric treatment (once medically stable), but has not had any insurance because of her (extremely expensive) pre-existing condition. The psychiatric hospital that is part of our medical center has a nationally-known eating disorder program, and is willing to take her and end up eating the bill, but she and her family definitely do not want to go there because she feels she had a bad experience there in the past. Her parents have desperately been trying to find another ED program willing to take her, anywhere in the country, but no one would because of they were self-pay. Hey presto, thanks to the ACA, as of Jan. 1 she has good coverage that her parents were able to purchase for her on the federal exchange (my state is one of the GOP-run states that refuses to do its own exchange), and they have found another ED program that will take her, that she wants to go to.
During my previous degree (before nursing), I studied healthcare policy and insurance. I think the biggest issue with healthcare and insurance in the United States is NOT Obamacare, but the Medicaid program. Medicaid has HORRIBLE reimbursement for services, to the point that many offices do not accept it. When a Medicaid patient FINALLY finds someone that does take it, they usually have longer waits, poor customer service, and inferior healthcare outcomes. Offices that take Medicaid patients are never the nice, high end places in the affluent area of town, but rather the dirty, older offices. In addition, there is the stigma that a Medicaid user is poor and uneducated that they have to constantly deal with.
Having said that, Obamacare allows low income people to get all the benefits of private insurance while also taking some responsibility and paying premiums and copays. I think the best way to improve Obamacare would be to extend to even LOWER incomes. For some reason the government thinks those below the poverty line actually prefer Medicaid and thus automatically sign them up for it without the option to buy a marketplace plan, yet that is not always true. Give the lowest income people a choice - Medicaid or private insurance plus government subsidy. It would actually be cheaper for the government to pay part of the yearly premiums vs the cost of Medicaid, so a win-win for everyone involved:
low income patient: Gets private insurance and all benefits rather than having to deal with the horrible Medicaid program, in exchange for a modest premium after government assistance.
Providers: more patients with private insurance = more reimbursement
Government: It is cheaper to pay part of a yearly premium than to administer the Medicaid program.
I'm a die hard Republican who has tried super hard to be objective about Obamacare all along. Even before it went fully into effect I saw it benefit our own family when my 25 year old niece who has a Masters degree and THREE part-time jobs (still looking for full time work in her field but none of the part-time gigs offered insurance) was able to get back on her parents insurance benefits to get some much needed surgery.
Last spring my husband was laid off from his long-term mid-management level engineering job and yes, I panicked. We had been in the market years before for individually purchased health insurance and because of a heart condition I have (even though I am considered 100% recovered).. I was denied coverage at least 3 times.
He is again facing a layoff (DARN the manufacturing environment in this country!! but that's another post) and I'm super relieved that we can get coverage. Will it be subsidized and *cheap*? No. We will likely pay $800-1000.00 a month. But that's fine. We do well on my salary...at least we will HAVE health insurance while he looks around.
It has occurred to me over these next few months that it is an insane system to have your health insurance tied to your JOB. Everything else is portable (cable, phone, etc.) and not tied to your employment...why is it your boss's job to subsidize your insurance? I still haven't reconciled the question of why it is the job of our government to subsidize certain parts of the healthcare act and I am sure I won't be able to come up with a good idea there. We still need massive amounts of young healthy adults to sign up or else the whole system is going to be so top heavy with chronically ill people I don't see how it is going to work..but one step at a time.
I completely agree that the ACA is wholly imperfect. It does indeed have valid goals, and I think that is the only reason most of us cling to it- the goals are worthwhile, and for now, the ACA is all we have to offer those in need. Hopefully, in the future, we can offer everyone a single payer government option.
In so far as constitutionality is concerned, I believe that is well covered here (bold mine):
"We hold these truths to be sacred & undeniable; that all men are created equal & independent, that from that equal creation they derive rights inherent & inalienable, among which are the preservation of life, & liberty, & the pursuit of happiness."
One can neither preserve life, obviously, nor arguably pursue happiness without the foundation of basic health care. Frankly, that should be a given.
I have a few more ACA success stories from my practice, and no disasters of consequence of which I am aware. All in all, in this state (we opted in) it is going fine. I am very pleased with the Rx drug coverage that my ACA patients have, as well as the ease of which I can get advanced diagnostics. I am not having to fight or do PAs, which is always a relief to all involved. For my patients with high deductibles, they have been holding off on health care for so long, so far they don't really care. They are used to paying for almost everything out of pocket, so at least now they are paying a chunk up front knowing they are going to get the big ticket items covered: the cholecystectomy someone had needed for 5 years! She isn't going to have to just live with the pain anymore, she is happy to pay $2,500 and have the rest covered, believe me. I have someone else I referred for a laminectomy he'd been putting off for years. That is going to be a heck of a lot more than his deductible. This is the kind of stuff I'm seeing so far. Working people who didn't have insurance through their job and couldn't pay 30K out of pocket for a non-emergent surgery, but can pay $300 a month for insurance and can pay a $3,000 deductible to get a much needed procedure they had been putting off.
No, the problems are more likely to come next year. If too few healthy young people enroll to offset costs, premiums will go up substantially. That is, after all, how shared risk pools work, lol. Thank the scare mongers for a job of sabotage, well done.
Specializes in Med/Surg, International Health, Psych.
With the application deadline concluding for the ACA today, I was wondering for those that work Psych if you've seen any changes in your practice areas? Thanks.
because I can finally deliver care to high-risk patients. These are not bad people, or freeloaders, or "welfare queens." The majority of my patients are the working poor, who put in more hours/week than I do, feed more mouths, have more chronic diseases, and make a fraction of my salary. They keep my city running. 
RN&mom
123 Posts
I feel the need to add another perspective to "obamacare." My youngest son has a severe disability through no wrong doing on my part. He has lots of health problems, general health issues, has had lots of surgeries etc... Obamacare will help my son, we make too much money for Medicaid and I know his healthcare is into millions of dollars at this point, yet we no longer will have to worry about being denied insurance due to his pre-existing condition or meeting the lifetime cap of benefits many ins companies have. My son is on several medications but his Growth hormone alone is over $1400 for a 28 day supply! That's the generic brand... As I said, his surgeries are countless, he has scoliosis and wears a boston brace. I could go on and on... For my family obamacare is a good thing, for those it's not I'm very sorry but I am great flu to know no ins company can say they have paid enough money out for my son and that they will not pay anymore! If you think this does not really happen, it does... Talk to parents of special needs kids and you'll be surprised what ins companies have been putting us through. I did not post this to start a debate, it's just a look into the life of someone obamacare has helped.