21 days on the road

Sanibonani from Arusha, Tanzania!

Our internet access on this bus tour hasn't been good enough to really commit to blog posting. (I say this knowing that one of our fellow travelers has blogged consistently, even posting photos. Perhaps it's more about us than the internet connection.) But I've been taking good notes, so eventually you'll have more information.

We started at Victoria Falls, which was stunning, and traveled through Zambia. It was interesting to see the differences among the countries we visited. Lake Malawi was absolutely gorgeous, and the Great Rift Valley is unparalleled.

Tanzania has been fascinating. The Serengeti was great at times — we saw 45 lions, including about a dozen cubs — and not so great at other times. We've camped almost every night, which has presented challenges of its own.

Overall, I'm very glad to have done this trip. The whole bus tour part is interesting and merits more discussion later. But we're alive, well and headed for Kilimanjaro!

Salani kahle!

Signing off from Swaziland

Sanibonani.

So, this is it. We leave on the first khumbi for Johannesburg in the morning, and we'll say goodbye to Swaziland for now.

I can't explain how I feel. These weeks have been full of goodbyes and tears (mostly mine). They've been full of gifts and dancing and singing and eating meat. They've been full of packing and planning and printing and playing. I have a brand-new niece to meet when I get home, so these weeks have been full of excitement for that as well.

It's all just too much.

Two years ago, Jack and I embarked on what we knew would be an amazing adventure. He had no idea what his immediate future would hold (get his eloquent final thoughts here). I was more aware of what I was getting into, but Peace Corps Swaziland was still more abstract concept than concrete reality.

Now I'm walking away. I leave a kind and welcoming family behind, as well as a core group of amazing friends in my community. I leave a club of great girls who I know will become strong women. I leave a support group with at least the beginnings of a community garden. And I leave a piece of myself.

I take a piece of Swaziland with me.

I hope that when I'm stressed out about life or sad about a loss, I remember my host dad's favorite words: "Life is just like that."

I hope that when I'm feeling sorry for myself, I remember the astonishing women I've met who bear up under the challenges of difficult marriages, abuse, HIV and oppression. I smiled, screamed and danced alongside them. Together they were stronger than any one alone.

I hope that when I'm struggling to reintegrate into the fast pace of American life, I remember to walk slowly when it's hot and nap under a tree in the afternoon.

And I hope that when I'm frustrated with Americans and the way we talk about and treat this continent and its people, I have compassion and patience.

I'm so very, very glad I served here. I'm so happy and lucky (SO lucky) that Jack was willing to move half a world away to share this experience. I am thrilled to enter our future together.

Thank you to everyone for your support and kind words. I'll see you in America on Sept. 28.

Salani kahle (stay well).

Quick hit

Sanibonani, team. My ACA blog has started up over here: http://blythereadstheaca.blogspot.com/. I think we're looking at a potentially different audience.

I'll try to give you a real update here this week on my final days. It's been hectic. I did sign Sakhile up for the TOEFL exam, so I'm thinking we can move ahead there. Thanks so much to those of you who have already donated!

I'm saying my goodbyes this week, as well as introducing the next volunteer to my village. Whirl. Wind.

Salani kahle!

Reading the ACA, part 2

Another ACA post, brought to you while we borrow internet so my host sister can work on TOEFL prep. If this doesn't interest you, please ignore!

July 14, 2014

Day Two. I actually kind of enjoyed my efforts of Day One, so I’m feeling positive going into an amendment to the Public Health Service Act. Let’s get to it!

This is part of that section that prohibits insurers from refusing to provide coverage for pre-existing conditions. From my recollection, this was a huge deal. This part also talks about how insurance eligibility can’t be affected by:

-       health status

-       medical condition (physical and mental)

-       claims experience

-       receipt of health care

-       medical history

-       genetic information

-       evidence of insurability (including conditions arising out of acts of domestic violence)

-        disability

-       anything else the secretary says

These factors also apply to continued eligibility. So if I’m eligible one year and am diagnosed with a chronic condition, my insurer can’t boot me the next year.

I think the domestic violence notation is particularly interesting. I suppose this means that if someone experiences intimate partner violence and can’t access her or his home to get insurance information, she or he can’t be determined ineligible. Does that seem right?

Page 91 includes talk about wellness programs. They’re not allowed to be “a subterfuge for discriminating based on a health status factor” or “highly suspect” in their methods. I’m digging the sinister language. SUBTERFUGE.

Some kind of 10-state demonstration of wellness programs should have started by July 1 of this year. Or a demonstration of states applying the provisions to existing health-promotion programs? I’m not entirely clear on what’s being demonstrated on p. 93.

Bronze, silver, gold and platinum plans: These designations refer to how much the health care benefits are worth (compared with the actual cost of services). For bronze it’s 60 percent, for silver it’s 70, gold is 80 and platinum is 90. From what I can tell, catastrophic plans are allowed if you meet certain criteria (younger than 30 and poor, it appears).

Abortions: not paid for by federal funds, ever. It looks like insurance companies aren’t required to pay for them, but I need to verify with section 1303 and the “special rules.” I know the U.S. pays for them for military members in case of rape. I’m not sure what the rest of the rules are. But as always, in general, no abortion funding.

It looks like states can make their own abortion rules for community health insurance plans, as long as no federal funding goes to them.

Something funny is happening on page 124. This is an amendment about optional services, and it says the secretary, when estimating basic costs, can’t take into account “any cost reduction estimated to result from such services, including prenatal care, delivery or postnatal care.” What I’m getting is that the secretary isn’t allowed to look at the future benefits of having insurance coverage for these “extra” services. Right? My brain flagged this because it seems to suggest that even when there’s good scientific evidence about future benefits of investing in care now, the government can’t calculate them in looking at costs of service.

BUT this is referring to actuarial costs (remember how “actuary” is always the No. 1 job on those “best jobs” lists?), so maybe this is more about accounting rules than public health.

As everyone probably knows, these exchanges are called American Health Benefit Exchanges. Another program exists to help small businesses, the Small Business Health Options Program (SHOP, naturally).

Note: insurers aren’t allowed to market their plans in such a way that would discourage people with significant health needs from enrolling. Insurers are also supposed to include providers in their network who serve low-income, medically underserved people. Sounds like a good thing.

Also, the much-talked-about government portal for insurers is supposed to allow us to compare plans based on ratings by those enrolled.

Plans should have annual enrollment periods (with exceptions), as employer-provided insurance typically does. If you’re an American Indian, there are special monthly enrollment periods for you.

Exchanges have to be government agencies or nonprofits established by states. I’m trying to determine whether there are other examples of the latter bit. Is it common? What other nonprofits are established by states?

Dental insurers are allowed to offer their plans through the exchanges, as long as they provide pediatric dental benefits.

Several sections have discussed “child-only plans” for those younger than 21. I think insurers are required to provide these plans, but I’m not sure why. So parents have to get full insurance for their kids even if they themselves qualify for catastrophic? Must investigate.

State power: States can require their insurers to provide additional benefits, but they have to work to defray the cost to the consumer.

The health exchanges are supposed to be self-sustaining as of Jan. 1, 2015.

On p. 144, the measure states that health exchanges “shall not utilize any funds intended for the administrative and operational expenses of the Exchange for staff retreats, promotional giveaways, excessive executive compensation, or promotion of Federal or State legislative and regulatory modifications.”

That’s kind of specific, right? I totally feel like government agencies would justify using their proceeds on “staff retreats.” And I wonder what determines “excessive executive compensation”? I suppose you’d have to be called out on this to get caught. Also, the exchanges are supposed to report “monies lost to waste, fraud and abuse” on their Internet websites.

Health plans must justify premium increases before they’re implemented, and they have to “prominently post” the increases on their websites.

If you’re in jail or in the U.S. illegally, you’re excluded from all of this.

OK, that’s all for today! I wanted to hit 80 pages since I could feel my momentum waning. There was some interesting stuff today, though I wouldn’t call any of it surprising.

We’re ending on p. 161, at “Sec. 1313. Financial Integrity.” Are you as excited as I am? (Here’s a preview: exchanges are supposed to do accurate accounting. THE FUN NEVER STOPS.)

Reading the Affordable Care Act

OK, so here's a project I've started. It's not related to Peace Corps. Several weeks ago, I decided I wanted to read the Affordable Care Act. I'm writing as I go, reflecting on what I read and trying to understand it. I'll probably embarrass myself with my lack of understanding, but what the hell?

If anyone reads this, I might give it a blog of its own. 

Here goes nothing. This was Day One:

July 13, 2014

I’m going to read the Patient Protection and Affordable Care Act.

I’m not a doctor, a politician or a policy wonk. I have a master’s of science in public health, but I’m mostly a normal person (and journalist). I’m probably going to misunderstand a lot of it, but I’m going to do my best.

I remember hearing pundits talk about how so many politicians haven’t read the act. It is long. The version I downloaded, with amendments, is 2,409 pages. I imagine the proper way to read it is to read the actual act and then return to the top and read the amendments. I’m not going to do that. I’m just going to read it all the way through. That might muddle my understanding of the document, but I think I’ll manage to get the gist.

Or maybe it makes more sense to read the amendments first, rather than reading a version that was later updated. I haven’t even scrolled through to see whether amended sections are struck through.

Also, I’m in a hut in Swaziland in southern Africa, a month away from finishing a two-year stint as a volunteer. I have a lot of down time. I will use this time to read the Affordable Care Act and to write about it here. I am not speaking on behalf of anyone but myself. Also, I don’t have great Internet access in my hut, so chances are that I won’t always be able to look up things that confuse me. I’d appreciate it if you’d cut me a break if I muse over something I could have just Googled.

If I misinterpret wording or if you disagree with me, please feel free to call me out. This is just an exercise in which a normal American Person tries to read and understand an important document produced by the American Government.

Let’s get started!

---

I’m 11 pages in, and I’m still on the table of contents, with its titles and subtitles.

Stuff I’m interested in learning more about:

-       Public health initiatives such as data collection about health disparities

-       Community transformation grants

-       Medicaid coverage for freestanding birth center services

-       School-based health centers

-       Reasonable break time for nursing mothers

-       Scholarships for health professionals

-       Spending for Federally Qualified Health Centers (FQHCs)

-       Limitation of excessive remuneration paid by certain health insurance providers

-       Additional hospital insurance tax on high-income taxpayers

-       Excise tax on elective cosmetic medical procedures

-       Indian health care improvement

Stuff that gives me pause:

-       Termination of provider participation under Medicaid if terminated under Medicare or other state plan (If a state dumps Planned Parenthood, for example, the federal plan must also do so for Medicaid recipients?)

-       Inclusion of cost of employer-sponsored health coverage on W-2 (My health care costs are considered income, which could mean I’m taxed at a higher rate?)

-       Additional requirements for charitable hospitals (This is under revenue offset provisions. What does it mean?)

Part of the ACA requires summaries of benefits and coverage to be presented in a uniform format that’s four pages or less and printed in at least 12-point font. I assume they talked to insurers about whether this was feasible. I think it’s awesome. I sure as hell can’t remember ever reading more than four pages of a document about my insurance benefits. But I’ve been lucky (read: healthy or lazy) enough to not need to read the fine print.

UCR fees = usual, customary and reasonable fees

The ACA requires every hospital to publicly release the cost of standard charges for items and services. TRANSPARENCY FTW.

Every state has to have an ombudsman. Love me some ombudsmen. This is who I’ll contact if I’m looking to get some health care when we return to America.

There’s a lot of talk of Internet websites. To the Internet website! I require informations!

Insurers have to submit justifications for “unreasonable premium increases” to the state and feds BEFORE they increase the premium. They also have to post it online (see Internet websites for details). I’m sure the ACA elaborates on “unreasonable” somewhere – in Section 2794. This section is called Ensuring That Consumers Get Value for Their Dollars, which I am all about. It also suggests that insurers who (this is America, so they get to be “who”) have a pattern of increasing premiums “unreasonably” could get booted from the exchange.

Subtitle B is “Immediate Actions to Preserve and Expand Coverage.” I’m going to read it, but since it’s irrelevant – I believe this is all the stopgap measures that were put in place between passage of the act and 2014 – I probably won’t have much to say about it.

Basically, if you were in a high-risk pool, you should have transitioned to coverage from a health exchange by Jan. 1 of this year. Did that happen? I hope so.

By Aug. 1 of this year, the Treasury Secretary should have notified any insurers that have been assessed a penalty (p. 77). I’m sure this is public information. Just, y’know, FYI. I suppose I’m not sure whether the government would update its Internet website to reflect this in real time.

Session one: pp 1 to 80, started with “December 24, 2009” and stopped at amendments to Subtitle C – Quality Health Insurance Coverage for All Americans

Helping Sakhile

Sanibonani!

My host sister, Sakhile, has been selected for a program called Africa's Tomorrow. It helps African girls get through the hurdles involved with applying to and attending college in America. Right now she's preparing for the TOEFL, which she must pass in order to be accepted. It tests how well she comprehends English. If you want to help pay for it, go here and scroll down to Sakhile from Swaziland. Any help you can provide would be greatly appreciated.

She wants to study dentistry. I don't know the statistics, but I know dentists are few and far between in rural Swaziland.

If you can help her out, it would be huge.

Siyabonga kakhulu! (We thank you so much!)

Goodbye, good luck, give me a job

Sanibonani, all.

Sooo, here we are. I have less than a month left here, and it's becoming a whirlwind already. My host sister made it through step one (of a MANY-step program) to go to college in America. That'll mean the TOEFL for her and lots of preparation help from me. There's supposed to be another volunteer replacing me in my village, so I'm hoping that volunteer can help shepherd her the rest of the way. I'll be fundraising to help defray the cost of the exam soon. As of now, I'm paying for it.


I'm preparing to leave and getting ready to say goodbyes. We had one of our last girls empowerment club meetings last week. I had been waiting to talk about reproductive health until I felt that the girls were comfortable with me. This was the time.

We covered the whole female reproductive system, and they asked a few questions. But then I brought out my trump card: the question box. The girls bolted for the scrap paper and started writing the questions they were too embarrassed to ask aloud:

- Will my period hurt?
- How old will I be when I get it?
- What if I have my period, and my mother wants to see my vagina?
- What happens if I have sex while I'm still young?
- Can I get pregnant if I have sex while I'm menstruating?
- What do babies eat inside the womb?
- How does the baby get out of such a small opening?

We had more than 20 questions from our group of 24 girls. As we answered them, girls would run up and put more questions in the box. It was absolutely amazing. These girls are young, 11 to 14, so I didn't expect them to have much information about this yet. But I was thrilled that the other club leaders and I could help explain this confusing process that is adolescence. It was so gratifying.

The next week, my friend and I taught a great HIV and STI session at the high school, where the kids peppered us with questions:

- How long does HIV survive outside the body?
- If a woman is HIV-positive and has an HIV-negative baby, what is she supposed to feed it if there's HIV in her breast milk?
- How can an HIV-positive woman and an HIV-positive man make an HIV-negative baby?
- If one person has HIV, and the other partner doesn't, will they always get infected if they have unprotected sex?

Afterward, the teachers who were present said they'd also learned a lot. And my friend, who had been hesitant before, eagerly took my HIV materials and lesson plan so she could reuse them.

It's been a gratifying couple of weeks.

I've also gotten deep into the job hunt, which is nerve-racking and a little terrifying. But Jack and I know we'll make it through it. Who wants to hire us? Anyone?

Salani kahle, all!