(KPLR) – Dr. Sonny Saggar stopped by the studio to continue talking about the Affordable Care Act.
In the second segment of his three part series, he discussed money and Missouri.
What’s the same in every state?
When it comes to your health care options on the Marketplace, some things are the same in every state such as basic coverage.
The U.S. government sets basic guidelines for what are called ‘essential benefits’. Every health plan sold in the Marketplace has to offer them.
They include emergency care, pediatric care, maternity care, lab testing,and more.
There are upper limits on how much you have to spend before your insurance company starts paying toward your care. No plan can charge more based on your health or whether you’re a man or a woman.
Four levels of coverage
To make it easier to compare plans, every Marketplace will rank the types of plans according to the level of benefits they offer, from platinum (the most) to bronze (the least). There’s also a special plan for young adults.
What decisions can Missouri make?
Aside from those basic requirements, states that set up their own Marketplaces have a lot of control over what to include in their health coverage.
Which insurance companies get to sell on their Marketplace and how many
States can choose insurance companies and can set tougher rules for coverage than the federal guidelines require.
Some states, like California, are limiting the number of insurance companies selling on their Marketplace. They hope it will improve the quality of the plans offered. Other states are taking a different approach. For instance, Colorado will allow any insurance company to sell plans.
Treatments that are covered
States running their own Marketplaces can tell companies that they must make the essential benefits more generous than the federal guidelines.
For example, some plans may pay for weight loss surgery, but others may not. Some plans may cover fertility treatments to get pregnant under maternity care, but others may not.
One plan may only cover a few drugs for your condition, like medicine for high blood pressure, while another plan may cover many brands.
What complementary and alternative treatments count as essential benefits
For instance, some states, like California, Maryland, New Mexico, and Washington, are including acupuncture as an essential health benefit. Many other states probably won’t.
How to promote the Marketplace
States are in charge of advertising for their Marketplaces and encouraging people to use them. That matters. If a state is very successful in getting lots of people to buy plans, the costs of insurance in that state could go down for everyone.
State Marketplaces may offer extra coverage for health problems that are more common in that state. For instance, if a state has high levels of diabetes, its Marketplace might include more plans that have special programs to help people with that condition.
Coverage for more people with low incomes
One way health reform was supposed to help more people get medical care was to expand each state’s Medicaid plan. Medicaid is the free or low-cost health program for people with very low incomes.
However, states can decide whether or not to expand Medicaid. If a state doesn’t expand Medicaid, some low-income people won’t be able to afford coverage. To find out whether you qualify for Medicaid, check out the insurance finder on HealthCare.gov.
Things to know about Missouri’s Marketplace
Plans will vary state-to-state. If you’re trying to help an out-of-state relative buy a plan, remember that their options will be different from yours.
We don’t know all the details yet. What exactly will Missouri offer? Presently, nothing. Missouri has so far decided not to participate in any way in the Affordable Care Act.
The Federally-facilitated Marketplace (FFM) will be offering health coverage in Missouri in 2014. The FFM will make assessments of Medicaid/CHIP eligibility and then transfer the applicant’s account to the state agency for a final eligibility determination. Missouri is not expanding Medicaid coverage to low-income adults effective January 1, 2014.
Physician’s point of view
The healthier our citizens are, the more productive they are. It is as simple as that. You can’t contribute much to society if you are crippled with a foot broken years ago and never repaired properly.
You can’t contribute much if you are burdened by depression or an untreated psychosis or lupus or rheumatoid arthritis. We benefit from the productivity of healthy people.
Furthermore, we benefit from their health itself.
If poor people don’t get checked for tuberculosis, the rest of us are at risk. If poor people don’t get treated for addiction, we all suffer from petty theft to secure them a supply of drugs.
If mental illness isn’t diagnosed and treated early, that burden is for all of us to bear. We pay a lot more to care for the mentally ill in prison than early treatment would cost. And it’s cruel as well as expensive.
Medicaid expansion will benefit those of us who don’t need it, who have health insurance, as well as benefitting those who cannot afford insurance.
But most important as a matter of law, caring for the poorest among us, ensuring that they receive the benefits of good healthcare, is a measure of the quality of our society. Do we harden our hearts and turn our backs? Or do we provide quality care to everyone who needs it?
The important thing to note is that the Affordable Care Act is not as much health care reform as it is insurance reform.
St. Louis Urgent Cares presently has 4 locations in St. Louis, and all 4 are active participants in Direct Medical Care: Downtown Urgent Care, Eureka Urgent Care and Creve Coeur Urgent Care, and North City Urgent Care. We are planning even more facilities in the near future.
1. Is it worth getting an annual physical?
Most practicing physicians and nurse practitioners believe annual physicals are worth it.
Most primary care physicians and NPs find medical value in annual exams, and continue to perform them.
Other research suggests patients worry less about the state of their health when they’re fully checked once a year, and that peace of mind is valuable to them. So is the relationship between patient and provider, which these annual visits may enhance.
It’s advisable for you to do certain things before going for an annual checkup, to help assure you’ll get the most out of it, such as making lists of medical complaints and all your medications. If the provider is new to you, get your medical records in order, including your family medical history.
Quite a few medical conditions run in families. The more the provider knows about your family’s history, the better chance there is of finding something early, before symptoms even begin.
2. What exactly do you do at an annual physical?
At the annual physical, at Downtown Medical Internal Medicine, we treat every patient as if we’ve never seen them before, even though we may know them quite well. The reason for this is so that we have no preconceptions about their social history, family history and so on. For example, what if someone has started or stopped smoking since you last saw them? What if someone has a close family member who had a serious medical problem a few weeks earlier. The annual physical will pick up all this new data if done correctly.
As well as asking about the patient’s occupation, we also discuss smoking, alcohol, whom they live with, when was their last tetanus, whether they routinely get a flu shot. Are they due for a screening procedure such as a prostate blood test, a mammography or a colonoscopy?
We then go over their past medical history (even if we have it all charted) just to make sure we’ve got it all down correctly, all their medications, whether they are allergic (perhaps newly allergic) to any medications, any procedures or operations (perhaps they had their wisdom teeth out since we last saw them).
The final part of the history is going over a long list of questions covering every bodily function (neurology, cardiology, gastroenterology, endocrinology and so on) to make sure there’s nothing else going on that might alert us to an apparently minor concern that isn’t something worse.
After that we perform a thorough physical examination to make sure everything looks and sounds ok. Then we summarize the entire physical by going over a plan which we give to our patients, so that they know what we are planning and advising as a result of that visit.
3. Why are those steps important?
It’s easy to give a provider a quick rundown of how you’re feeling, then realize when you get home that you forgot something. This is more common with men, whose wives say “I can’t believe you didn’t ask him about X, Y, Z” and so on.
You’ll remember better if you bring a written list with you. By your healthcare provider going through everything systematically, you won’t have to depend on your list as much, although we still love it if you bring it in for us to discuss.
4. What about all the tests that are done on an annual basis? Are they really necessary?
Not every test needs to be run once a year, but because so many people don’t bother to see their healthcare provider (which might be a doctor and it might be a nurse practitioner) unless they have an actual problem, and they don’t focus on preventative medicine (which they would in an ideal world), we do tend to check the full battery of tests in the real world, at the yearly physical.
Detailed medical histories can help a provider decide what tests are most worth doing.
5. How do we keep everything straight when people are on many medications?
Very often, several providers and specialists treating a patient prescribe medications separately, and the only way the providers doing the exam will have the full list is if you physically bring it in with you.
And he or she should also know what over-the-counter medications you are taking.
If you’ve gone to other providers in the past, get your records from them.
6. So the annual physical is really more of a full recap of everything?
That’s correct. There are also things you write down ahead of time, including questions for the provider.
If you’re not sure what certain symptoms or pains or marks on your body might mean, the yearly physical is the perfect time to ask. It is important to note that your physician or nurse practitioner will deliberately have set aside a longer time for your yearly physical than for a regular quick follow-up. This means that he is “all ears” and ready, willing and able to listen to your entire laundry list of questions and concerns. You can discuss the validity of every single medication you’re taking, or that annoying tingling or pain you’ve had for months (or years) but never got round to asking anyone about it. The annual physical is the time for those kinds of questions.
You also should ask if you’re not completely sure how to take your medications, or which medicines might not mix well with one another. And you should be prepared to ask how you will learn the results of the tests you’re given. Some are ready instantly, but others need to be analyzed by a lab. Will the provider send you the results, or should you call the provider?
The physical exam may be the best time all year to ask your provider everything that’s on your mind, all at once.