Obamacare, As Seen from the Diabetes Trenches

Longtime type 1 Jacob Padilla could be a case study on how healthcare reform is a two-sided coin with pros and cons, but how I think it's more of a benefit to people with diabetes.

This 38-year-old in New Mexico had his wallet out and was ready to buy. Diagnosed at age 12, he's lived his entire adult life without health insurance... until now.

Thanks to the Affordable Care Act (aka Obamacare) and the abolishment of the practice of pre-existing conditions historically leading to automatic coverage denials, Jacob is now able to purchase his first health insurance plan.

While the plans he could choose from were breathtakingly more expensive than he was led to believe they'd be, he was philosophical about it. He was not only willing and able to pay the steep premium, he was eager to do so. "I was just happy there was going to be options, you know, regardless of cost. I was happy to be able to have something, just to have the opportunity to have health coverage changed my whole perspective."

The very day he got his brand-spanking-new insurance card, he called his local clinic in Pecos, NM, to schedule an annual physical with lab work -- his first in two decades. That visit the following week seemed to go well, but the next morning his phone rang. It was a nurse at the clinic.

Her message was terse: "Jacob, you need to go to the hospital. Right now."

The labs from his first physical as an adult had come back with "critical high" values. Jacob spent the next four days in intensive care where he was diagnosed with stage 4 chronic kidney failure, the most severe form short of total kidney failure. He also had hypertension, retinopathy, and diabetic cataracts. Not to mention his TSH levels soaring at more than 14 times the normal level, indicating hypothyroidism.

On one hand, Jacob's story is a victory for healthcare reform. Thanks to his new insurance, his life was likely saved.

But on the other hand, it seemed like it was too little, too late. While his life was saved, the same may not be true of his kidneys. Years of scrimping to pay out-of-pocket for insulin and test strips (much less doctor visits) had caught up with Jacob. He had done his best flying blind, but realistically type 1 diabetes can't be managed in a vacuum.

How does Jacob feel about what happened?

"I could very easily be angry," he said, "but anger will get me nowhere. I'm just glad I can do something about it now."

I guess Jacob is a better man than I, because while he isn't feeling any anger, and remains grateful to have any kind of health insurance, I'm angry. In fact, I'm outraged.

I'm outraged that he didn't have health insurance five years ago. Or ten. Or 20 years ago, when he lost his childhood insurance. Because I believe that had our society stood with its citizens, and put the health of our people before corporate profits in the first place, Jacob, and all the other Jacobs out there, wouldn't have failing kidneys, shot eyes, whacked-out blood pressure, and all the rest. Access to routine care could have prevented all of that. Still, Jacob remains positive, saying, "It could have been worse. I could have died."

But that makes me wonder: In the past 20 years, just how many Jacobs did die?

Now that we finally have health insurance reform, my view from the diabetes clinic trenches is that one arm of Obamacare has fallen flat on its face, and the other arm has succeeded beyond anyone's wildest expectations. The surprise: the part of Obamacare that everyone involved in providing healthcare thought would be great is a disaster, and the part we didn't think much about is the part that's working.

Of course, I'm talking about the exchange programs and the expansion of Medicaid.

Health Exchanges (Not the Food Counts)

First, there's no need to re-hash the botched roll-out because that's old news. And it's also pretty well-known that our D-Community benefits from the abolishment of standard rejection of pre-existing conditions, and lifetime caps. A happy nugget is also that at least seven and a half million Americans, like Jacob, now have insurance for the first time.

But that insurance, although finally available, can be breathtakingly expensive. The cost of premiums on an Exchange, after the various subsidies, ranges from a low of 4% of your income to a high of 9.5%, depending on how much you earn. That's a percentage of your gross income, not your take-home pay, which for most Americans is about 25% less. The truth on the ground is that to purchase an Exchange plan costs between 6-12% of your take-home pay. Frankly, many people living paycheck-to-paycheck simply can't afford the extra expense.

Even if you can re-arrange your budget to purchase a plan, you don't get much bang for the buck as far as coverage quality. Visit copays are high. Drug copays are steep, and the drug formularies are restrictive, in terms of medication choices. On the diabetes front, patients are being forced into low-quality blood glucose meters, and some make copays that are nearly half the cost of strips at retail. And don't even get me started on durable medical equipment (DME), a category that most health plans use to cover insulin pumps, CGMs, and other diabetes gear. On all the Exchange plans in my state, the DME coverage is abysmal, at best covering 50% after the deductible.

So not only are Exchange plans expensive to own, they are expensive to use. It's sort of like being forced to buy a gas-sucking SUV that you have to leave in the garage because you can't afford the gas to drive it anywhere.

From what I'm seeing, the health insurance system is still run by the fat cats.

But of course, I'm not seeing much. At our clinic, by our best guess, only 20 people in the community were able to purchase plans on the Exchange, while perhaps just as many chose to pay the fine and remain uninsured. This year the fine runs about the cost of one month's premium. Many of these folks desperately wanted insurance, but they just can't spare the income.

And when it comes to income, the other side of the Obamacare coin is the politically-controversial Medicaid expansion -- arguably the best health plan in the U.S., and on that front I see just as much success as I see failure in the main body of Obamacare.

Expanding Medicaid

The expansion raised income eligibility limits from 100% of the federal poverty level to 133%, in states that choose to accept the expansion. You wouldn't think that would really be that big a difference. And in cold hard cash, it really isn't. Poverty level is linked to family size, and changes annually, but for a family of four in the pre-Obamacare world, the poverty level would have been $23,500 a year. Under the new Medicaid guidelines, that same family can make up to $31,716 and now get coverage. (The math isn't clean, as the poverty baseline was also raised a hair between 2013 and 2014.) The bottom line on the equation is that you can earn $158 more per week than the old poverty level and qualify for Medicaid. Well, that's assuming you live in a state that has a soul.

So how many people live just above the poverty line? It turns out there are a whole hell of a lot of hard-working people who don't make much money. Our clinic added 292 members of the 16 rural villages we serve to the Medicaid rolls, and in the 27 states that agreed to go along with the raising of income levels to qualify for Medicaid, a stunning 3 million citizens who had no insurance last year now have Medicaid. (You can see if your state is one of them here, scroll to the bottom.)

This not-quite-totally-impoverished population has been much-derided as being the "emergency room care crowd," and many critics felt simply having insurance would not change their habits. They were wrong. In states that expanded Medicaid, ER visits are down and the payment for visits is up.

In fact, what I witnessed was that as soon as their cards arrived, these newly-covered people were calling for physicals, labs, mammograms, getting preventive care, and basically doing all that you would hope they would do to get and stay healthy. They are coming in before they are in dire straights. They want healthcare, they just couldn't afford it before. I find they don't want a handout, so much as a hand-up.

It's still all about the money, but now it's about your money. Before the Affordable Care Act, charity care ran in the billions of dollars. One survey of 5,000 US hospitals reported that nearly $40 billion was written off medical care in 2010. And that doesn't include write-offs from clinics that focus on serving the under-privileged.

Who do you think really ended up covering those written-off expenses?

View from the Trenches

Obamacare turns out to be good for people (and for hospitals), but critics still claim it's bad for the federal budget and for the overall economy. That remains to be seen, but I doubt it. Prevention, although we are not good at it yet as a medical system, is a fraction of the cost of tertiary care, and almost any neglected health condition will get more expensive over time. Stated more crudely: Poor, sick people don't die cheap. That makes keeping people healthy a good investment that benefits the pocketbooks of everyone in the country, from the guy in a shack in a Louisiana swamp to the guy in the glass tower corner office in New York City.

I'm not the only one who feels that way. "What's the bad thing about keeping people healthy?" asks Jacob. "I always believed that a healthy society makes for a productive society."

Exactly, Jacob. That is how it should be. Think about it.

If Jacob's kidneys fail, We The People will by footing the bill for his dialysis. It would have been cheaper for us to just pay for his doctor visits all along. Jacob even says so, acknowledging that if he had the means, he would've gone to the doctor and gotten the preventative care two decades ago that might have prevented his high healthcare costs (and suffering) now.

So while some of us in the D-Community may be getting hit in the pocketbooks now, at least we can look ahead with more optimism that our future costs may be less than they might have been.

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Originally published at DiabetesMine on June 7, 2014