31 Days into the Affordable Care Act: A Midwife's Perspective

Screenshot of the website healthcare.gov

I am a Certified Nurse Midwife in urban America, practicing full-scope women's healthcare at two clinics and one hospital. At my busiest, I may see up to 30 patients daily for outpatient care, and have attended as many as five births in one 12-hour shift of inpatient care. All three of my practice sites are part of a system called "Federally Qualified Health Centers (FQHC)", which "serve an underserved area or population." This designation is largely based on sheer size of patient population, but also utilizes numbers of people who are uninsured, low-income, and live in areas with minimal surrounding clinic and hospital sites.When I first started working as a midwife in 2012, most of my patients were uninsured. Our community health centers offer many lower cost options for those without insurance: sliding scale visit fees, enrollment in a free screening program for breast and cervical cancer, lower cost prescriptions through 340B collaboration, and community-donated funds to cover costs of cancer treatments and life saving medical interventions. Notably, all of these are available regardless of immigration or citizenship status. For the uninsured patient, visits often focus on providing the most care possible at one time, to minimize the need for return visits and additional costs. Lack of prior consistent care commonly led to abnormal results mandating prompt call-backs, subsequent referrals, and loss-to-follow up due to inability to pay for repeat visits or treatments. In summary, a broken system.Uninsured pregnant women in our state receive full coverage for healthcare services related to the pregnancy, again regardless of citizenship status. This insurance covers all prenatal visits, birth, and postpartum care, as well as chiropractic, emergency medicine, prescriptions, breast pump, maternity support belts, compression stockings, and any high risk care needs. For most, this insurance coverage stops 6-8 weeks postpartum.In the fall of 2013, our county began roll-out of an additional free healthcare program for those who do not qualify for Medicaid. Healthcare navigators, or individuals whose sole responsibility it is to assist patients in applying for health insurance, started their work immediately. This opportunity brought not only insurance, but healthcare, to many for the first time. Since last fall, I have seen many individuals with insurance, and organized healthcare, for first time in their lives.Since January 1, 2014, the Affordable Care Act is in full effect, and all uninsured individuals must apply for health insurance, or are subject to pay a penalty for remaining uninsured. Today marks 31 days of full roll-out of these requirements, and what a time it has been.Logistically, as a clinician I would sum up the ACA roll-out as burdensome. With a busy clinic schedule, I have 15 minutes per patient, and often those time slots are double-booked. The women and families I serve usually have more pressing issues to discuss than health insurance: secure housing, restraining orders, employment, partner infection notification, medication cost, as well as their health and well-being. Our front desk is the front line in discussing our support system for signing up for insurance, and many patients are late to see me because they are caught at the front desk discussing healthcare coverage. For those who are uninsured, I make a point of discussing the ACA during the visit, and many are surprised to learn of the requirements. When this becomes a longer topic of discussion, logistically two things happen: I will run late for other scheduled appointments, and we are sidetracked off topic from the original questions for the visit. "Running a bit behind" in the outpatient settings never feels like a problem at the beginning of the day, but its cumulative effects may lead afternoon patients to waiting an hour or more for their visits. Time-wise, the ACA has me both running late and distracted from tasks at hand.A first visit with newly-acquired health insurance can be overwhelming: patients desire to address all needs at once, and it is a challenge as a clinician to triage needs and compartmentalize tasks into referral systems, without making the person feel dismissed about issues that have been chronic in their lives. There is no 15-30 minute visit that will allow time for a full health history, medication review and refill needs, complete physical exam with chest/breasts and gynecologic screening, as well as leave time to address hypertension, diabetes, cholesterol, asthma, back pain, nutrition and exercise counseling, sexual health, smoking cessation, mental health assessment, and every appropriate screening or diagnostic test to go with each issue. And even with that list, a patient with each of these issues will have more questions beyond that: deservedly so. Logistically, there's an impending rush to do everything, when not everything can realistically be done at once. While it sounds easy as a provider to ask someone to come back to continue discussing other issues, for that person to take off work or arrange for family care or transportation, it isn't always so easy. So just because someone has insurance, it does not mean their life rearranged to more easily schedule self care. Again, the issue is time, and the limited time we have is already burdened as it is.With all that being said, I love the ACA.Holistically, as a clinician I would sum-up the ACA roll-out as fantastic. During those visits when I take the time to discuss health insurance, while logistically I may run behind and we get off topic, importantly something else happens: individuals become empowered with the knowledge of opportunities to control their healthcare coverage and become insured. For many, this can mean an opportunity to restructure a family budget and not live in fear of a sudden debilitating hospital bill. It means a minimal or non-existent co-pay to see me, and not delaying essential testing because they don't think they can afford it. It means being able to afford medications when abnormal testing requires treatment. It means that a long-delayed surgery or specialist consult can be realized. Generally, it means less stress, and decreased stress improves health.I have seen many for their very first visit with health insurance. A visit for someone who did not have a co-pay, or who paid an affordable co-pay for them, starts very differently. They are less distracted at the beginning of the visit: with money less of a burden, they can focus on their purpose for making the appointment.  For those visits, I review the idea that having health insurance decreases the need for concerns of doing everything at one go: the first visit especially can be used to create a map of care pathways to address each and every need on their list. As an FQHC, we also offer weekend and early morning / evening hours, to be available for patients on a schedule that might be more amenable to their lives. That first visit is an opportunity to create a patient-provider partnership, and understand how to best navigate a healing healthcare system. It is truly the best opportunity to provide individuals with an empowering experience as they embark on true personal care of their health.Since the roll-out, I have seen what I knew was cervical cancer even before the pap smear result was faxed back to me the next day. Since the roll-out, I have screened countless women for diabetes while treating chronic yeast infections. Since the roll-out, I changed many visits from "well-woman" to "uncontrolled hypertensive" and walked my patient to another clinic room to see another provider for their more pressing issue. Since the roll-out, I have seen more of my rooms filled with families. Since the roll-out, I have seen cousins, and sisters, and best friends, attending visits together for support, when previously they stayed away separately because of cost or fear of needs after not receiving healthcare for so long. Since the roll-out, my inbox is filled with both normal and abnormal results reviews, which become another step in people's pathway to care and well-being. Since the roll-out, my midwife and healthcare provider heart has grown three sizes with the opportunity I have been given to work with people interacting with insured healthcare for the first time. Since the roll-out, I feel proud to be a midwife at this critical and changing time in healthcare.Midwives have an incredible opportunity to introduce people to healthcare. As primary care providers, as well as specialists in normal women's health, we can address initial well-being, take care of most common concerns within our scope of practice, and refer to specialist care when necessary. Midwives are trained to provide holistic care, and consider all components of someone's well-being in conjunction with their specific complaints. Midwives can welcome someone into a healthcare system, into a community health center, and into the world of patient-centered and attentive care. What an opportunity.Nota bene: People who are of immigrant status or have citizenship outside of the United States are not eligible for ACA insurance options. Thus, I continue to have uninsured and self-pay patients, and our fractured healthcare system continues due to a fractured citizenship and immigration system. I hope that our government continues to work toward immigration reform not only for healthcare purposes, but also for individual, social, community, economic, and human rights reasons.Discussing health insurance is my choice during routine visits, and one I continue to choose. Not only do I find ways to make time to support health literacy, but now health insurance literacy as well. I believe that the Affordable Care Act will dramatically improve our healthcare system, and am willing to work through the roll-out and keep on pushing forward, because investing the time now will lead to dramatic investments for the future of my patients and the community as a whole. I have sat in the parking lot outside of my clinics and watched mothers count folded dollars and dropped cents to cover the visit's sliding scale fee, wishing that I could do more. Right now, our healthcare system is working to do more. The ACA may not immediately stop people from counting out their payments, but if they can save money over time due to insurance coverage, those stressful financial moments before visits could become even less.Tomorrow is February 1st. I have a Saturday clinic schedule full to the brim with pap smears and prenatal visits and test results and birth control needs, mostly with people working during the week and only able to attend Saturday appointments. Tomorrow I will continue to find the best ways to discuss why insurance is critical to people's health care. Tomorrow, I will continue discussing the ACA, and running late, and being a midwife. Tomorrow is day 32.