Our Bodies, Ourselves (140 page)
Read Our Bodies, Ourselves Online
Authors: Boston Women's Health Book Collective
In early 2010, national comprehensive health care reform became law. While far from perfect, this law takes critically important steps to remedy some of the many challenges that women face dealing with the current health care system. Under the health reform law, which will be phased in over several years, millions of people will have greater access to more affordable and comprehensive health care and insurance. Unfortunately, health care reform includes burdensome restrictions on insurance coverage of abortion care and unacceptable limits on access to coverage for certain immigrant women. For a more detailed discussion, see “Health Care Reform and the Politics of
Women's Health.”
The website healthcare.gov explains how health care reform affects individuals, families, children, and employers. By answering a few simple questions, you'll learn about the different insurance plans available and where you might be able to find low-cost health care if you are currently uninsured. Starting in 2014, insurance “exchanges” will be available to individuals who do not have access to other coverage through their employers and to small businesses.
Under the law, health plans must cover a broad range of health services that are particularly important for women, including certain preventive care and screenings, such as mammograms and Pap tests, without any cost-sharing (such as a co-payment). Starting in 2014, insurance plans must include coverage of “essential benefits,” which will include maternity care, prescription drugs (which should include contraceptive drugs and devices),
*
and mental health care.
The new reform law has many components, only some of which have received media attention. Here are a few other provisions that are important to women:
⢠Women will have direct access to obstetrical and gynecological care, meaning you won't have to obtain prior approval from your health plan when seeking care from these providers.
⢠Pregnant women will gain insurance coverage of additional options for labor and birth:
⢠Medicaid will now cover births at freestanding birth centers.
⢠Nurse-midwives will receive more equitable reimbursement under Medicare.
⢠Young peopleâwho are more likely to be uninsured than any other age groupâwill be able to remain on their parents' health insurance policy until age twenty-six.
⢠Older women on Medicare will benefit from a provision that will eliminate the Medicare “donut hole”âa gap in prescription drug coverage that requires seniors to spend a considerable amount out of pocket. (For more information, see
“Medicare Basics.”
)
There are a number of troubling restrictions that many women's health care advocates are seeking to remedy:
⢠Immigrants must wait five years before being eligible for Medicaid; however, once eligible, immigrants are eligible for sliding scale insurance subsidies.
⢠Immigrants who lack documentation of their legal status will be ineligible to buy insurance through the exchanges or to enroll in Medicaid.
⢠Insurance coverage of abortion is treated differently from any other health care service. Anyone who purchases a subsidized health plan with abortion coverage through an exchange is required to make two separate payments for this health insurance: one for abortion coverage and another for the remainder of the premium. This unfair and burdensome requirement could deter women from purchasing plans that cover abortion and deter health plans from offering it.
Several groups offer information and advocacy about the reform law and track its implementation with respect to women, including:
⢠National Women's law Center (nwlc.org)
⢠Equal health network (equalhealth.info)
⢠Raising Women's voices (raisingwomens voices.net)
TRACKING YOUR OWN HEALTH
It can be helpful to keep a log of symptoms, triggers, or behaviors relevant to your health condition and to track the effectiveness and side effects of treatments. Bringing this information with you is one way to get the most out of visits to a health care provider.
There are many ways to monitor your health. Tracking your menstrual cycle and signs of ovulation can help you manage problems related to menstruation, achieve a wanted pregnancy, or avoid an unwanted pregnancy. (for more information, see
“Charting Your Menstrual Cycles.”
) A pain diary can help you notice what triggers your pain or makes it better or worse. If you have started a new medication, keeping a journal of your symptoms and side effects can help you determine if the treatment is working and identify possible adverse effects. Tracking your nutritional habits or physical activity may make it easier to succeed at making long-term changes.
A simple paper or online journal often works fine. There are also many mobile phone applications and online health sites designed specifically for this purpose.
One benefit of online health management tools is that people with similar health concerns can track their data together and support one another in finding and sticking to the best treatment plans. Websites like FertilityFriend (fertilityfriend.com) allow you to chart
your ovulation cycle and, if you want, share charts with friends, your care provider, or online contacts. Sites such as PatientslikeMe (patientslikeme.com) and CureTogether (curetogether.com) allow registered users to track their symptoms and treatments and pool the data from multiple users so that people can see what worked and what didn't for others with the same symptoms or diseases. Several sites sell health data (without personal identifying information) to pharmaceutical companies, who typically use the data to track drug safety and look for new uses for drugs. Carefully review each privacy policy to make sure your personal health information is secure.
I could not take the excruciating burn in my vulva (vulvodynia) a single moment more. It not only completely inhibited my sex life, it eventually took over my life when I could barely walk. As traditional health care and medicine failed (often making the pain even worse), I found an abundance of information online and people at CureTogether and other communities with my same unlikely condition. Tracking every symptom out of desperation and using the sites to compare my symptoms and triggers with other women's, I was finally able to uncover underlying hormonal causes and find treatments that worked
.
Some sites run ads for medications or other health products and many accept funding from drug and device companies. When websites accept funding from pharmaceutical or medical device companies, it can influence the content available on the site or make it more difficult to identify reliable information. For more information, see
“evaluating health Information in the Media.”
Accurate information about your health and about the full range of health care options available to you is needed to make good health care decisions. To begin with, it is important to listen to and trust what your body tells you. Knowing your symptoms, understanding prior or ongoing health problems, knowing the health status of your sexual and household partner(s), and learning and recording as much information as possible about your family history can help you to more fully understand your current health and improve communication with health care providers.
Discussing medical problems with a health care provider can be enormously satisfying or frustrating, or somewhere in between. When your health care provider has looked thoroughly at your health history and current symptoms and discussed with you your values, priorities, and concerns, she or he can engage with you in shared decision making and help you make the best choice for
you
.
When we couldn't find the heartbeat at my ten-week prenatal appointment, I had an ultrasound and found out that I had miscarried. My doctor offered me medication or a D&C to complete the miscarriage, and also told me that I could wait and see if my body would do it on its own. I asked for a day or two to think about it and she told me to take my time. I read up on the pros and cons of each option and talked to my friend who was a midwife. I had had my son at home naturally and I really felt that I wanted to complete this pregnancy naturally, too, so I decided to wait. But after two more weeks, still nothing had happened. By then the risks seemed to be increasing and I was having a difficult time emotionally being in this state of limbo. I decided on the D&C at that point. I think it would have been the wrong choice for me right after I found out I miscarried, but in the end it was the right one
.
If you receive your care at an academic medical center (hospitals and clinics attached to a medical school), you can use the American Medical Student Association PharmFree Scorecard (amsascorecard.org) to look up information about the center's conflict of interest policies and industry relationships.
While there is much they can provide, doctors and other health care providers may be constrained by such factors as:
⢠Financial incentives built into the system that reward the use of procedures and prescriptions over talk time and preventive care
⢠Pressures or more subtle influence from drug company representatives to recommend certain medications or devices over others that may be more appropriate
⢠“Standards of care” that have been shown to be the most effective for the most people but still may not be appropriate or desirable for certain individuals
⢠Lack of time to keep up with all of the latest research or the skills necessary to evaluate research and tailor treatment to individual patient situations
⢠Inability to recommend certain testing or preventive care if insurance won't cover it
⢠Fear of a lawsuit resulting from a missed diagnosis or a bad outcome, which can drive hospitals and providers to overuse tests and treatments
⢠A mistrust of patients' abilities to understand or make good use of complex information
⢠Sexism, racism, homophobia, and class bias as a result of their training or upbringing
⢠Lack of knowledge or negative attitudes toward prevention, self-care, less invasive procedures, nonmedical alternatives, and Complementary and Alternative Medicine
It is common to want to trust doctors or other health care providers completely and always accept their advice. While this can feel reassuring, you may ultimately receive better care by becoming more informed, asking more questions, and treating the relationship as a partnership with shared decision making. Changing our relationships to care can require courage in the face of uncertainty and may not always be welcomed by providers, but it is a good step in obtaining the care that is most appropriate for each of us.
My son was only seven weeks old and breastfeeding heartily when I developed what I thought was just a really bad clogged duct. After two days of intense pain, my ob-gyn performed an ultrasound and found an abscess. She very sympathetically told me I needed surgery and would have to stop breastfeeding immediately. She prescribed medication to dry up my milk supply and scheduled the surgery for the next day
.
THE TIME CRUNCH
In most settings, the typical office visit for a gynecology exam or prenatal visit is just ten to fifteen minutes. The complexity of care options, the proportion of women with chronic medical problems, and the average number of medications a patient takes have all increased over recent years, but the length of office visits has not. Obstetrician-gynecologists, who provide much of the health care for women's reproductive and sexual health needs, face high malpractice insurance and other overhead costs and recoup those costs by seeing more patients or doing more reimbursable procedures. This takes away from their ability to schedule longer appointments.
You can make the most of your medical appointments by being organized and proactive (see
“Making the Most
of Your Health Care visit”), but we also need to advocate for better access to care models that allow deeper interaction with care providers and better coordination of care. Alternative models of care include the following.
Group Medical Appointments:
In Centering Pregnancy group prenatal care, visits are ninety minutes with no waiting room time and incorporate health assessment, support, and education. The successful model is now being adapted to other areas of health care. For more information, visit centeringhealthcare.org.
Woman and family-centered medical home:
The WFCMH concept is new but is likely to expand in coming years. In this model, each woman has a personal physician or other care provider who knows her and her history and coordinates all care and referrals. The medical home concept also encompasses patient-centered features such as online scheduling and expanded office hours and uses new technologies to measure outcomes and enhance patient education and communication.
Midwives, nurse-practitioners, and physician assistants:
These types of care providers may have lower overhead costs and therefore sometimes offer longer appointments. They also may have more education in preventive care and patient education. However, if you have complex health needs, some of the care you need may be outside the scope of practice of these providers, and you may be referred to specialists.
I was devastated by the idea of stopping breastfeeding. I called my friend, a pediatric nurse practitioner and lactation consultant, for sympathy, and she mentioned that she had heard of instances where a woman continued breastfeeding during and after the surgery. When my ob-gyn called that night to check in, I asked if this was possible. She told me that it's rarely done, because the risk of the incision becoming infected is high, but she listened when I expressed how important it was to me to continue nursing. In the end we agreed to try, because I felt willing to take the risk
.