Have you ever heard the saying by Ghandi, “Be the change you want to see in the world”? If we apply this idea to the need for change in our country’s healthcare system as it relates to how people who work in the healthcare industry are insured, we have an interesting set of issues that are readily visible. Many healthcare institutions bemoan the effects of uninsured or under insured patients that flow through their doors because of the money they lose. There is an opportunity for these institutions to examine the effect of their insurance plans on their employees to understand how their policies may contribute to the numbers of uninsured, under insured, and insured but still in debt.

The following examples are food for thought.

When I worked for a nonprofit children’s hospital in New Orleans, our health insurance covered no well visits. Most children only see their pediatricians for well visits which include immunizations. These visits were not covered by insurance. Can you believe that a hospital whose mission is to serve the health needs of children did not provide a health insurance policy to its employees that covered well visits? Imagine how the employees who worked there and did not earn a living wage fared with this insurance policy. For immunizations, employees were encouraged to visit a free immunization bus that traveled around the city. While this would allow everyone to have their children immunized, it did not provide for well visits with a pediatrician to screen children and provide anticipatory guidance to parents.

Many businesses are now encouraging their employees to open Health Savings Accounts for their health insurance. I understand the idea behind such accounts, but I think they are a potential disaster for people with lower incomes. I am concerned about how employers are encouraging people to enroll in these plans as if they are less expensive for everyone. The system is complicated enough that we all need to carefully weigh the costs and benefits associated with various plans, the propaganda about these plans is misleading, in my opinion. If I were to change to this type of plan, I would not have sufficient cash to start the account such that if I had a catastrophic illness before I had put several thousand dollars in the account, I would have a serious financial problem.

Similar problems can occur with PPO plans. These were also touted as better than HMO plans because they have lower premiums and you have more choices. You also have a much higher deductible. I had this type of plan at one time. When I needed a minor surgical procedure, I ended up paying about $800 between my deductible and some other fees not covered by the plan. It was very difficult for me to pay this much cash, even though I have a very good income. Imagine what happens to people who make less than I do.

I do not believe that it is fair for the housekeepers upon whom we depend to keep our facilities clean pay the same premiums for healthcare that we do when those premiums will constitute a significantly higher proportion of their incomes. If I made minimum wage, I do not believe that I would enroll in the health insurance plan my employer provides because it would be financially implausible for me to have health insurance and pay my bills. This phenomenon has been noticed by forward thinking living wage advocates who have advocated for a living wage ordinance in Los Angeles. This is a description of the rationale for their efforts to include health insurance premiums in their living wage calculations.

If we want more Americans to have the befit of health insurance, we may look to the practices of our own employers and start the dialogue about how we are insured. Contact your Human Resources Department and ask them to investigate how many of their employees are uninsured and why. Also ask them to investigate what proportion of their employees require public assistance to be insured. Remind them if we want to change the flood of uninsured that come into our facilities, we need to look at how their own practices contribute to the numbers of uninsured in their area. I would advocate researching the costs and benefits of instituting a sliding scale of insurance premiums for employees that would set the cost of the premium at a proportion of your income.

In the meantime I devoutly enroll in my HMO plan during benefits renewal every year, until my employer or the insurance company decides that it costs them too much money. I may need a referral or a PCP, but I choose not to pay 10% of my hospital bill.

If you haven’t seen this movie by Michael Moore yet, I highly recommend it. This movie does an excellent job of showing the state of healthcare today in human terms. I mentioned that I had watched the movie to some fellow nurses. Many people commented that “socialized” medicine had terrible consequences. I found these comments interesting given the terrible cost of capitalist medicine in this country for the average insured person. As a nurse, patients often express their anxiety about getting their bill or comment that their insurance company has denied their claim. We are all aware that some of the people we care for will simply not be able to pay their bill. I think we sometimes forget that these are not people who are among the uninsured. There are many people WITH insurance who will be financially destroyed because of their medical bills. These are the people Michael Moore chronicles in this film.

Another striking point of the film is that the American people have been fed a steady stream of propaganda about the terrible state of healthcare in countries with universal health care. As I watched this sequence I had the sinking feeling that our politicians are not representing their constituents (the people), rather the constituents they represent are those corporations able to write checks large enough to fund their reelection campaigns. My $50 or $500 dollar contribution to the campaign of a politician I support pales in comparison the $500, 000 check someone with deep pockets can contribute. Do we honestly think that we will be equally represented by that politician?

We have to confront the reality that our system is designed for businesses (read: insurance companies) to make a profit. It is in the best interests of these businesses to spend as little on us as possible. Healthcare in other countries that provide coverage to everyone probably is not perfect, but the system is not set up so that a business will profit from your illness by denying your claim. I cannot tell you how many times I have had an insurance company refuse to authorize the treatment prescribed by one of the physicians I work with.

The process goes something life this: 1) Dr. X writes a prescription to treat Johnny’s chronic illness. 2) The insurance company denies the claim when Johnny tries to pick up the medication. 3) Johnny calls the physician’s office to tell them what happened. 4) The nurse calls the insurance company to find out why the medication is not covered. 5) The insurance company has some reasons that makes no sense, medically. 6) the physician submits a letter of medical necessity. 7) the insurance company still denies it. The physician or nurse talks to a physician for the insurance company to explain why the treatment is necessary. 9) Hopefully, it gets approved eventually.

This process takes days or weeks. Think Johnny’s health is improving in this time period? See how that your insurance company has a lot to do with how your physician determines your treatment plan?

We have to change our healthcare system. We have to find a way to make it impossible for anyone in this industry to make money off keeping people from getting well in the best way possible. Look at the healthcare plans the current presidential candidates are proposing and ask yourself if these plans take the profit for private corporations out of the equation.

Nurses have a responsibility to participate in advocating for this change along with other medical providers. We are on the front lines of healthcare and have the ability to convey the impact of the current system on the health of our patients. We can tell these stories, write letters to our representatives, think when we vote, and be sure to tell our friends and families what we know. See Sicko and start talking about what you know.

Most nurses are female. Given that women have babies it is reasonable to think that many nurses will have a baby or two at some point in their career. It would seem to make sense that the Nursing profession would be very supportive of women and the challenges of being a working mother, right?

Before I had my baby, I always supported the mothers I worked with by covering their patients while they pumped if they were breastfeeding or by letting them leave if they had a sick child or some other childcare issue. Since I had my first child, I have been supported by my colleagues in turn, but realized just how systematically unfriendly the nursing profession can be to working mothers.

When it came to pumping breastmilk while at work, I found that we were often so short staffed that pumping had to be delayed to the point that my milk supply and ability to provide milk for my baby was compromised. As supportive as my colleagues were, they had to assume care of lll my patients for 15 minutes every three hours so I could do this.

Furthermore, there was no physical place for me to pump. I had to search for an empty hospital room, occupy the bathroom, or hope some administrator with an office was not at work that day. When I did pump in a patient room, I prayed no one would ignore the sign on the door and come in.

When it came to juggling childcare, as a part-time employee it was not practical or economically feasible for me to have full time day care, as a result I needed a basically set schedule in order to be able to work and have child care. My manager told me that I needed to have complete availability and she was not able to accommodate my child care schedule. In the preceding 6 months I was one of the highest rated nurses in the department by this same manager. In addition, several working mother had vacated their positions because their child care needs limited their availability on certain days of the week. This was very difficult for all of us because we all loved our jobs and had been as flexible as humanly possible. At the same time, we were replaced by younger models with no children and a lot less experience.

I understand how difficult making a schedule can be when people have limitations, but the nursing shortage will only worsen if attempts to work with the needs of working parents are not included in our strategy for retaining nurses. I had even found a nurse who would job share with me so we could each work set days of the week, but that was not enough for the administrators. I attempted to have complete availability for a while, but I was spending so much time trying to juggle my schedule and have make sure I had childcare. In addition, my manager would release the schedule about a week before it started and coordinating child care at the last minute is near impossible. So I gave up my part-time job in favor of part-time PNP school and working PRN. I have a set schedule and child care but miss my job and they have a job vacancy it will take them months to fill.

On September 17th, 2007 I became a mother. After working as a pediatric nurse for almost 6 years, I had “educated” so many people in the pediatric ER about basic baby care from how to suction a stuffy nose to what to do when fever occurs. I remember being shocked at how little people seemed to know about basic infant care.

Then motherhood happened to me. I forgot everything I had been teaching others and became an insecure, frightened parent when it came to my own child. During those first weeks home I called my pediatrician because my baby had not pooped for 24 hours. If I had triaged that phone call from myself, I knew what I would have said: not something to worry about as long as baby is eating well and having at least 6-8 wet diapers a day. But the new mom in me was terrified that something was wrong. The terrified mommy wins over the rational nurse every time. I remember going to my pediatrician when Molly was 1 month old and asking her not to tell anyone that I was a pediatric nurse.

In my defense I have been doing pediatric hematology oncology for the last three years so even my knowledge of well baby stuff was rusty. But still. I was disgusted with myself and embarrassed at my complete loss of composure over taking care of my own child.

The addition of mommy doubt and anxiety to my life and my new identity as a parent gave me a new understanding of what parents of sick or well children might need from their health care providers.

Parents need to know that we are listening to their concerns first, diagnosing and treating with those anxieties and fears in mind. How often do jaded health care providers dismiss the seemingly overanxious parent and tell them not to worry about something without having actively listened first and then provided basic education. My own experience with this occurred when Molly was 3 months old. She seemed to be sleeping much more than normal. The new mommy in me called my pediatrician and they told me to bring her in. So I did, even though the rational nurse in me knew Molly was OK, anxious mommy alter ego was in the car 5 minutes later. Once there, Molly was fine of course, but I didn’t feel that I had the chance to explain why I was worried. My pediatrician saw the nontoxic looking 3 month old in front of him and we were out the door in 5 minutes. I did not get what I needed because I still did not fully understand why she was acting so differently.

Healthcare providers do not spend enough time providing developmental guidance and assistance with basic childrearing issues. Most pediatric well visits are brief and do not afford parents the chance to really check in with how parenting is going. Most patients will initially say that everything is going well the first time they are asked. But parents need us to provide more support, especially since people are more isolated from each other but are able to Google almost any health topic and educate themselves. There is a great deal of information out there in the internet, but one must be discerning about information. Pediatric healthcare providers have the opportunity to help parents sort through this information.

I have read many books written by medical professionals about pediatric care, but I find the Touchpoints approach by T. Berry Brazelton to be a very holistic and comprehensive approach to how pediatric care providers interact with their patients. http://www.touchpoints.org/

Through my own experiences as a new mother, my ability to serve my patients as a Pediatric Nurse Practitioner has grown significantly. I have a much better understanding of parents. I understood a great deal about the textbook topics of pediatric nursing care, but had never lived the reality of caring for a little human being 24/7.

On the flip side I have to be Molly’s mom first and foremost and let the nurse go take a nap when it comes to my own child. That tired nurse gets some sleep for a change.

When I first went to Nursing School 6 years ago, I remember meeting so many idealistic nurses to be with dreams of taking their education and going to work overseas to make a difference in countries less fortunate than our own. Their experiences as Peace Corp Volunteers and NGO employees sounded so noble and exotic to me and I felt somehow inferior for having chosen to become a nurse without consideration for how my knowledge could benefit those living in areas without access to care at a fundamental level.

We undoubtedly have an incredible wealth of resources within our health care system from beautiful hospitals and clinics with multi million dollar architectural features to state of the art medical equipment, computer services, and highly educated medical personnel compared to health care systems in other countries. For example, it is unheard of in this country for a medical facility to have such a shortage of supplies that medical personnel would have no gloves available to wear when handling blood and body fluids or have to wash out the same pair of gloves repeatedly in between patients. When one considers how vastly privileged we are in this country, it is hard not to feel alternatively grateful for our own fortune and disgusted that we have so much when others have so little.

After 5 years of working as a Registered Nurse in pediatric and adult emergency rooms in New Orleans as well as in Pediatric Hematology Oncology at a nationally ranked pediatric hospital, I have come to understand how social, economic and cultural factors interact with one another in our health care environments that illustrate vast inequalities among patients within our own systems of health care.

The divide between the experience of the wealthy and the poor in this country is well documented. If you asked any medical professional if they treat all their patients the same regardless of their race, class, gender, or cultural background most would answer with conviction that they provide the same care to everyone. As individuals caring for patients, I know how deeply we believe that we treat patient equally. At the same time, if we acknowledge and examine all the ways in which the health care system is designed from corporate insurance policies to how our implementation of particular policies in hospitals and clinics may exclude patients who speak languages other than English, we would be forced to admit how our systems are defined to produce and affirm inequality that is defined by differences in race, class, and cultural background.
Too often we understand the concept equality to mean that everyone is treated exactly the same. This construct itself is what produces and supports inquality. Treating people the same way for the same conditions adheres to this notion of equality but in essence illustrates a failure to understand and address how differences in socio-economic and socio-cultural identities change the way people interface with social institutions such as health care. Imagine a pediatrician who sees two children on the same day in the same office, each wih a complaint of fever. Upon examination, the provider finds that both children have bilateral ear infections. Amoxil is prescribed. Two weeks later, one family returns with the same complaint and the provider examines the chil to find that his ear infections have not improved. The provider is concerned. It would seem that the second family spoke Spanish. The provider used an interpreter to explain the prescription the first time and cannot understand why they did not treat their child as he instructed. As it turns out, this family spoke only a little Spanish, they first language is a tribal Guatemalan dialect. In addition, they could not afford the prescription because they do not have insurance and are not eligible for Medicaid because they are in this country illegally. They did not tell the provider because they feared deportation. Finally, neither parent in this family completed education beyond 6th grade level in their home country.

Of course many providers address these issues successfully on a daily basis, however, there are numerous examples of how our awareness of these issues is not heightened until our attempt to treat patients the same fails. This is a process of trial and error in many provider experiences. If a situation is urgent enough or for cases of complicated management of chronic conditions, however, we may not have the luxury of trial and error. Also the difference economically for a family with access to insurance and without is crucial. Most providers have few options to provide the same treatment to families living below the poverty line who must bear the financial burden of treatment themselves. In effect, the differences between how these families and their upper middle class counterparts with insurance and large disposable incomes access medical care and treatment are astounding. Our health care system is designed to provide them the same treatment in theory, but not in practice.

In my own practice as a nurse, I have come to understand that even my best efforts to provide all children with the same care is severely limited within the health care system at times due in part to my own lac of understanding of the social, cultural or economic realities of my patients. I do believe that our resources are vast enough to decrease many inequalities, though complete elimination of inequality is perhaps unrealistic.

I propose that medical professionals must first define the scope of the problem through research. Let us begin to expand our studies of disease outcomes to include data about insurance status, primary language, family income, and cultural background.

Once such data is collected, we can begin to design interventions that will address the specific needs of families with different backgrounds. No doubt the need for health care policy change will be a highlight of such efforts, but we must also focus our interventions to find the most effective ways to treat, teach, and monitor families on the most basic level of how each provider interacts with each patient. We may find that shifting our thought processes away from notions of equal treatment and towards different treatments for different basic human needs is a philosophical shift that produces profound results.

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