Since my husband entered graduate school, our insurance situation has been a bit dicey. It changes every year, every pregnancy, and every new massive-healthcare-law-and-associated-regulations-passed.
With my first pregnancy, I was on my employer's insurance plan. There was a deductible, there was a co-pay, and I'm certain we achieved out-of-pocket maximums that year, but they weren't especially high.
With my second pregnancy, I carried my husband's student insurance plan as my primary and held Medicaid as secondary. Little did I know, but carrying two insurance plans is apparently a *major* pain for your doctors. Also, little did I know, but Medicaid is apparently a major pain for doctors, too. In fact, it's such a major pain that I called 22 doctor's offices and only one of them would accept Medicaid patients. I drive 45 minutes each way for my appointments.
In 2011, at the end of the first year of my husband's Ph.D. program, the school dropped dependent coverage for their Ph.D. students. This was a bit of a crisis for us. I signed up for an "open enrollment plan" through Blue Cross Blue Shield. It cost us $500 per month, and the premium increased by about $50 per year each year I was on it. The deductible was high and the out-of-pocket maximums were high, but fortunately most doctors accepted this plan. Unfortunately, the plan did not cover maternity costs.
So when we conceived our third child in the fall of 2011, I went back on Medicaid. My OB's office administrator confessed to me that it had been such a disaster to bill Medicaid as secondary insurance the last time they had me as a patient that they were no longer willing to do so. Medicaid would have to be primary, or they wouldn't accept it. I had difficulty explaining to the Office of Family Services why my private insurance couldn't really be considered primary for the pregnancy (since it didn't cover maternity). And although I never followed up on all this, it seems to have been resolved satisfactorily to all parties. In the process, I also learned that private insurance pays about $3,000 for a vaginal delivery. Medicaid pays only $900.
When I became pregnant this time, we were expecting that the roll-out of the healthcare law would give us more options. My private insurance premiums had increased yet again, and I was paying $600 per month. I also learned that Blue Cross Blue Shield in Virginia had decided to voluntarily cover all abortions, for any reason, under their new plans. The new plans also all covered maternity expenses, but they were going to cost us more per year than we were currently paying (the difference of about $1,000-$1,500 per year). Given our income level, I would have certainly qualified for a subsidy, but I applied and never heard back. I went on the website twice and got kicked off twice. I've had so many bad experiences trying to get answers from the Office of Family Services about anything that I decided it was not worth the anxiety of waiting months and months and months to finally be told, "Please send us more information about your income," in spite of the fact that I submitted all the information they asked for (and more) the first time.
We finally decided to make the jump to Christian Healthcare Ministries. This means that I will be paying only $150 per month for "coverage," but all my routine diabetes expenses will be out of pocket. This includes prescriptions, doctor's visits, and bloodwork. Unless it is an unexpected complication of my diabetes, hospitalization, or new diagnosis, my medical bills will not be eligible for "sharing" through the program.
This sounds frightening, but when I calculated the actual costs of my routine diabetes care without insurance, it came to about $7,500 per year. If you add $1,600 for the Christian Healthcare Ministries program to that, it's about $9,100. The insurance premium plus deductible for the plan that I was on already cost about $9,000 per year, and the new insurance plans I was looking at (without subsidy) cost about $10,000 to $10,500. So I will now be paying roughly the same, or perhaps a little bit less. I know that some healthcare providers (pharmacies, etc.) will also charge a little less for people who are paying out of pocket, because then they don't have to deal with crazy insurance company billing rules. I'm hoping that, between these two things, I will at least break even. I also won't be paying for abortions, nor supporting an insurance company which is taking upon itself the task of making abortions seem like routine health care, rather than the intentional killing of another very small human being.
My husband and I recently decided to switch to Christian Healthcare Ministries, rather than signing up for a new insurance plan. This affects the way I seek medical care, because all preventive and/or maintenance care for pre-existing conditions is not covered. (Medical emergencies related to the pre-existing conditions are). This means that trips to the endocrinologist, prescriptions, and routine bloodwork are not covered, and I have to be careful about the way I spend my dollars on these expenses.
Since my endocrinologist has asked me to come in to see him every month ($190), and also have blood drawn each time (not sure how much this total is, but at least $55 or more) for an A1C, this will be a significant burden. I've never thought it was necessary, though I played along as long as someone else was picking up the bill. But that is no longer true.
Since my endocrinologist fired me at the end of last pregnancy when I wouldn't come in on his monthly schedule, I decided to be up-front this time, and explain my situation. I'm not sure how he'll feel about it, but the diabetes educator I met with at his office today said, "I don't think he'll budge." So here's the note I sent to her explaining our situation, which she said she would discuss with him:
"We signed up for a health insurance alternative called 'Christian Healthcare Ministries.' They don't cover maintenance or preventive care for chronic or pre-existing conditions. If I were only coming 4 times a year, like normal, we calculated the cost and figured this might actually save us money, but coming once a month will cost too much.
"As my doctor knows, I feel very comfortable managing my blood sugars, since I've learned a lot in my last three pregnancies. I would be happy to come every other month (or, perhaps I could come every month, we could do bloodwork every other month, and he could cut the charge of the office visit in half). My OB could also order whatever bloodwork is required, and I imagine Medicaid would likely cover the charges submitted from my OB's office.
"Alternatively, I could see him on an as-needed basis, with whatever waiver/disclaimer he needs me to sign for legal purposes so that he is not on the hook for a bad outcome with my health or the baby's. He knows me well, the office staff is friendly and competent, and kindly accommodates the strangely high number of toddlers who accompany me to my visits. It's always nice to have someone to call when you have strange symptoms or need some diabetes advice.
"I understand that both of these situations might leave your staff inadequately compensated for the time spent reviewing my blood sugar readings every week, so I am content to forego that service.
"Hope to see you again soon! If neither of these situations works, I'll probably try to find another doctor just during the duration of the pregnancy. But if he'll have me as a client again in July, I'd happily come back."
I tried to understand where they were coming from, but also give a reasonable explanation for how I think things could go during this pregnancy. I really hope he doesn't drop me again, but I finally decided that it would be better for me to be dropped and have to find someone else than continue to pay for services where seem rather unnecessary to me.
UPDATE: They did not drop me, but they did make me sign a waiver releasing them from all liability regarding my outcome or the baby's.
I am finally learning to release the anxiety I have about my blood sugars. I am learning that anxiety does no one any good. Every time I have a high or a low one, I take the most reasonable course of action (correction, up or down), and then I wait. I don't immediately start changing my basal and bolus rates to prevent the problem in the future. I try to reflect on what I could have done differently. I observe whether it's a pattern over a few days, or just an isolated incident. And then I trust that whatever will be, will be...and know that the One who cares for us now will not abandon us in trouble. I pray almost every time I feel the anxiety creep up on me, and this has helped.
It is freeing to be able to approach the matter this way. It's still true that I will strive to spare nothing of myself. I will avoid eating those things which I have identified as problematic, and I will avoid eating at times when eating may be problematic, and I will push myself to go out on walks with the kids, and so forth. But I will not worry when all my best efforts fail me, or even at those times when I do fail to exert my best (God's mercy is great!). This way is best.
This week marks the first time I felt the baby move this pregnancy. What a relief! I have recently heard two stories of women who miscarried late - at 15 weeks - and was sincerely hoping that my child hadn't passed from life to death inside my womb and was waiting to also pass out of my body. In my first three pregnancies, I felt movement absurdly early: 9 weeks with my first, 10 or 11 with my second, and 10 with my third. So this was normal given the pattern of most pregnancies, but atypical for me. The midwife at my doctor's office suggested that it might reflect a different placement of the placenta (anterior instead of posterior).
I also went on retreat with the Sisters of Life this week. Their work is to promote the sanctity of human life through prayer, but they also run a few mission houses where they serve women with crisis pregnancies and women who have had abortions. Women may come and stay with them during their pregnancies, up to a few months after the baby is born. It's a beautiful work, and you should check it out!
In any case, a lot of mostly hidden anxiety came out about this pregnancy while I was reflecting on my life. There's something about silence during a retreat that really helps to focus your attention on the fears within your heart. That certainly happened for me this week, and my greatest fears these days seem to be about my blood sugars (especially the low ones).
I should probably preface this by mentioning that earlier this week, a few days after Christmas, my blood sugar was very low when I woke up one morning. I became very stubborn when my husband tried to help me. It happened several days in a row, these severe lows, and I was very discouraged by it. It's one of the only reasons my endocrinologist can point to justify why he believes I shouldn't have more children (whichissomethinghesaysalmosteveryvisit). At least I didn't almost drown myself in a bathtub this time, but I think I rather disturbed my spouse!
So lows are a continual challenge. It's interesting to note that it was about the same time of year, same time of pregnancy, when this happened last time around. Most of the time I think that I just need to get better about dealing with the lows (which is true!), and then sometimes I wonder if it really might be wiser not to have more children. I'm not sure the answer is all that clear-cut, given how awesome babies are. But I do know that, at least this time around, I just have to play the hand I've been dealt and manage the lows as safely as I can.
How do you and your family deal with your stubbornness when your blood sugar is low? I told my husband to just keep repeating the same words over and over: "Your blood sugar is 34. Can I help you? Your blood sugar is low. Would you like me to bring you something? Your blood sugar is 34. What can I do for you?"
After the blood sugar management failure of the last couple of weeks, Christmas was actually a surprising reprieve. I have been dialing back my insulin levels, ever so slowly, to combat the overnight lows. I have been able to bring my eating back to a healthy level, and have not gained any more weight. Fighting through the weakness of hunger can successfully get me through the 2-3 hour postprandial slump, and back into a reasonable amount of energy until the next meal time (or low blood sugar).
This was actually part of our plan all along. We wanted Christmas to be a time for low-stress blood sugar management. We often travel across the country with our kiddos to visit my in-laws for Christmas. It is something we usually all look forward to, especially my husband and the boys. I felt bad, but I made the request that we stay home this year, for the sake of my blood sugars. It's hard enough to manage them when you are pregnant, and hard when you are traveling, and hard during the holidays. The hat-trick of hard is all three, and we've done that twice now. And I've learned, the hard way, that my disease really does need special accommodation sometimes.
Midnight mass on Christmas morning also happens to be a great way to check your overnight basal rates (when you wake up, while you're at mass, and after mass)! (Turns out mine were too high).
When we became Catholic, I learned that Advent - approximately four weeks before Christmas day - are supposed to be a time for penance. Almost like Lent, except not that serious. But it's the same liturgical color (purple) and everything! Fasting and almsgiving and preparatory prayers are recommended the same way they are in preparation for Easter.
So this year, I made firm my resolve to abide by the eating habits I laid out a few weeks ago: eat only at regular meal times, normal portions, and when my blood sugar is low. No snacking without a strict need.
Talk about best-laid plans sometimes failing. Or a lot of times failing. I don't know *what* happened, by my lows got really bad over the last few weeks. I have been ping-ponging all over the place. And besides that, I've just been so hungry that I'm eating at all the wrong times. And ugh...all the slow weight gain I was trying to achieve, for the sake of my health and the baby's, exploded from 3 pounds up to 10 pounds when I last stepped on the scale. (I haven't been able to bring myself to do it since).
I have learned a lot about Divine Mercy in the last few years, and God continues to teach me. Failure, in the face of our best efforts, is so painful. Trust in mercy, trust in the Goodness of The Plan, trust in the face of uncertainty and pain is so hard! I am so afraid of and overwhelmed by failure. Each day, the hardest thing I do is resolve to try again, trust in His help, not fear His anger. And so I do. Because caving in to the fear is no way to live.
What do you do when you've failed with your blood sugars and you're afraid to fail again? How do you shore up your resolve to do better next time?
I know it's a little thing, and I probably shouldn't be so bothered by it. A really small thing, and most women probably don't even notice the difference. But I've always been a detail person, and this happens to be a really important detail: the due date.
Very early on in pregnancy, I estimated that my due date was probably June 22. This was based on when I believed ovulation to have occurred (September 28), so it was even more accurate than simply knowing the date of intercourse. Conception, after all, does not often happen on the day of intercourse (unless you have impeccable timing!). Conception occurs when you ovulate. That egg, it's precious. All the sperm are just lying in wait for it to be revealed.
(I don't think I would ever say that out loud to someone that I didn't know. I probably don't know you. This has now become slightly awkward.)
Anyway, so this is what I had figured out. When I had my surprise ultrasound at 5 weeks, guess what? She said that, by her measurements, my estimated date of ovulation and due date were right on. RIGHT ON. What I heard was: "you are a natural family planning genius."
So I was a bit dismayed that I could not convince the sonographer who did my 11-week ultrasound that I already knew my due date, and that her date was too early (she came back with June 18, based on her measurements). I explained to them about ovulation (I can't believe they didn't know, I can only assume they thought I didn't understand it well enough). I explained to them about the early transvaginal ultrasound (but I'm certain it was in my chart). I even explained to them that my husband is unusually tall, and all of our children so far have been unusually long at birth (my quack theory about why my due date keeps getting pushed up with each pregnancy). Alas, to no avail. It goes in my chart as June 18.
The reason I care about this so much is because I know that at 37 weeks, they are going to start asking me about induction. It's so predictable that it's almost funny, except not, because I've had one, and induction hurts. My children are not born before 40 weeks. They just aren't. And I have a stronger bargaining position if I simply refuse induction until my due date! Oh well. I'm sticking to my guns on this one, bargaining position be darned.
I had my first ultrasound this week! The sonographer said everything looked great. I had all three boys with me, and they were great, too.
Because I had the boys with me, I asked her not to do ultrasound transvaginally. I thought a transvaginal would a) be awkward with a 4-year-old male child in the room, b) make it more difficult for me to calm the 1-year-old male child in the room with us, and c) not be necessary given the transvaginal I had at 5 weeks and the fact that I was already far enough along to see things clearly on an abdominal ultrasound. I would not have thought this would irritate her, but her demeanor was clearly annoyed by the request. Sonographers of the world, I beg of you: please don't be offended when a pregnant mother of three toddlers asks for a simple favor! We are adults and sometimes even think for ourselves, in advance, about what treatments might be good for us at any particular time!
The other thing I spent a lot of time talking to the doctors about was the genetic testing for Trisomy 18 and Down's Syndrome. I'm very skeptical of prenatal testing, not least of all because of what happened with the Statesman. In the end, he was a very healthy boy who happened to be missing a kidney. So anyway, I guess there's a blood draw they can do between 11-13 weeks that gives them a pretty good risk assessment for those diseases (although it's not a definitive diagnosis). I went back and forth, considering the alternatives, but ultimately decided not to do it. Here's why:
First of all, it's only a risk assessment, not a diagnosis. This means that there could be a false positive or false negative. Even though these rates are not very high, it's a big heartache for nothing if it is.
The ultrasound looked very normal - good, even. If it had not, perhaps there would be a reason to investigate further.
The reason they suggest and push the prenatal testing is so that you have the information, and can be prepared. For some patients, this may be code for, "so you can get an abortion." But I would not kill my child to spare him (or us) pain: that would be an ultimate embrace of the power of death to ruin us. No, not that.
So there is a value to having information before a baby is born, planning for medical needs, etc. But I realized last time that prenatal diagnoses change and develop many times over before they are finalized, so plans cannot really be made until the third trimester anyway. Not to mention, there are so many things that must be revealed about the child's health that cannot be revealed until birth. In short, we will have to be flexible at birth, whether the child has extraordinary medical needs or not. Only birth will tell us definitively what the needs are.
The cost. It was going to be $223 to maybe tell me something that might be true, or not, and might help us plan, or not. Since I'm paying for these things out of pocket until Medicaid kicks in? Not worth it! We're happy to live with the uncertainty for a little while longer, knowing that all is in a kind God's hands.
Did you do early prenatal testing? What did you think? And has anyone ever had a sonographer give them attitude about the transvaginal/abdominal choice? Why does this keep happening to me?
I am proud to report that my plan from last week, not to overeat and to only eat regular meals at meal times or when my blood sugar is low, went swimmingly well over the Thanksgiving weekend. As you all know, this is a tricky time of year.
I also went to visit my endocrinologist this week. He had to think long and hard, and look at me for a few moments, to figure out whether I was joking, when I told him that I was pregnant. After the usual heckling, he asked me seriously:
"Do you all have a number in mind?" (Read: are you ever going to just stop having babies?)
"No, there's no number. We'd like to have as many as we reasonably can. We also recognize that life is highly variable."
Right now, my husband and I are really learning to surrender our lives to our children (ages 4, 3, 18 months, and in utero). We are enjoying them more each day, when we used to spend more time being irritated and feeling inconvenienced by them before. But we are also feeling the pinch and the pain of so much responsibility. Our attentions only go around so far, the crying can really disturb everyone's peace, and we are exhausted and physically in pain and grossed out with great regularity. We are also continually uncertain about whether we are addressing the right need at the right time and in the right way.
So we don't make commitments about the number of children we'll have, because we love them so much but life is also more complicated because of them. The only commitment we make is to love each and every one, to the best of our ability, from the moment of conception onward!
Morning sickness drags on, but my blood sugars have (mercifully) been very normal. Somehow, they always seem to be even a bit more even-keel during the first trimester. This is either a special grace of God, or a result of changes in my eating habits. Or perhaps both.
As for changes in my eating habits, this pregnancy, I will basically try to do the same thing I did last time: Eat at regular meal times and only at other times when my blood sugar is low. Low blood sugars happen surprisingly frequently during pregnancy, with tight control over my blood sugars, so this really shouldn't be too much of a problem. And yet, I become like a little baby when I feel the weakness of even mild hunger! This weakness strikes about 2 hours after eating, whether my blood sugars are low or not. If I can push past it to 3 hours past eating, I can usually make it to the next meal time without hearing too much feedback from my body.
When I was pregnant with my first son, I was under the tutelage of people who assumed that, whenever you are pregnant and hungry, you should eat. This might be true, if I were willing to eat carrots or celery at these times. But instead, I would eat rich foods, thinking, "if I can't do it during pregnancy, when can I?"
In reflection, I think this was actually a bad idea. I gained 50+ pounds with my first son. He was a modest size, but it was hard to lose the weight, and I was very uncomfortable by the end of that pregnancy. I gained a similar amount of weight with my second son, and he was not in any danger of being too small at birth. This was all well and good, but then I noticed that babies tend to get bigger with subsequent pregnancies. Since I knew my doctors would not be too keen on my having a 10 pound baby (even though I wasn't especially worried), I decided I needed to rein it in a bit.
Full speed ahead! My pants are fitting a little tighter now, I haven't had any pain or cramping or bleeding or any kind of problem. It's starting to feel more like this one will "stick," even though I know I'm not technically out of miscarriage range. It's also just hard to believe that I will have a miscarriage, since I haven't even had a close call with any of my pregnancies so far.
But this week, for some reason, I am imagining all of things that could go wrong. I think about a woman I heard of who delivered her fourth baby stillborn at 37 weeks. I think of Saint Gianna Beretta Molla and Pamela Sternberg, both afflicted with cancerous tumors during their fourth pregnancies. I think of a friend of mine who lost two babies at 18 and 21 weeks gestation, respectively. I think of the countlessparents I know whose children have been afflicted by disease and suffering from their very birth. I think of my own son, who has only one kidney, a rather minor defect which has made me reflect more deeply on the major problems that can occur with children before, during, and after pregnancy. God, it truly is amazing that everything ever goes right all at the time it's supposed to.
Mostly, I'm trying not to worry about it. Because after all, aside from take care of myself, what can I truly do? Some suggest that I should be allowed to kill the child in my womb if I found out he's sick or 'defective' or disabled or likely to experience a lot of pain in his life. But really? That's no way to live, taking out your fear of suffering and anxiety on other people. That's what I spend my entire day trying to get away from: the anxiety and fear that make me mad at my kids, mad at my husband, and suspicious of the whole world. Far better to embrace what difficult you have, and live the best way you can in response to it.
I wake up every day and pray that God will grant me courage to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.
What I learned this week: raking leaves will make you aware of muscles you didn't know you had, and it will also make your blood sugars wacky! I don't recall blood sugars at this point in pregnancy being too crazy with the last three, so I'm pretty sure it had to do with the way my body was burning fat to keep all the muscles in my core from falling apart.
We shared our news more broadly this week with family first, then friends. My father's reaction to the news of this pregnancy bolstered my confidence in spreading the word. But it also made me sad to tell one woman I know who has had great difficulty conceiving. She said nothing, but I can imagine how the loss might sting her. It also made me nervous to tell one man I know who recently remarked, in my hearing, that five-child families who live in a messy house "probably have too many kids." His reaction to my news was polite.
I can also never figure out how to tell Facebook. Should I be saccharine? Should I express some of the anxiety I feel about welcoming another baby, you know, just to keep it real? Should I quote Jim Gaffigan? Should I make a joke at the expense of my third, who is becoming a middle child? I don't know, all of these just seem inadequate:
"They say middle children are the most well-adjusted adults. I'm sure [the Statesman] will thank us in a few years!" [This makes it sound like, de facto, our son will not be happy to have a little sibling. I don't think that's true.]
"So excited to welcome #4 in June!" [A little devoid of anything but substance.]
"[The Pious One]: If it's a girl baby, we should buy some girl clothes for it.
"Me: What color?
"Me: What pictures should they have on them?
"[TPO]: Trucks and cars.
"If you know where we can find such a clothing item, let me know by June!"
[Cute, but might make it seem like we already know we're having a girl. Not to mention, likely to confuse people who may think they missed a pregnancy announcement several weeks ago.]
"Anyone out there offloading a minivan? Because we're going to need one starting in June! Baby #4 on the way!" [Sounds desperate. Because we are. On second thought, maybe this one's a winner...]
"Do you want to know what it's like to have a fourth child? Just imagine you're drowning, then someone hands you a baby. - Jim Gaffigan
"And I haven't even had the baby yet...!"
[True, but not exactly uplifting. Also makes it seem like I'm not grateful that I have a baby, or that I'm not prepared to have a baby. Both of which are true at some times, but I try my best to make these sentiments the non-dominant ones.]
It's hard to address a massive group of people, all of whom are approaching the question of me having a fourth baby with a different perspective. I can imagine the "Likes" I'll get from some people for some of these, or for others. I guess the news that you're having another baby is almost always bound to go over pretty well, even if you flub up the delivery. I'd just like it to be sweet, perhaps a little humorous, positive, encouraging, and honest.
This week has seen the return of a familiar phenomenon: hunger-inducing fatigue. This kind of fatigue is different than sleep-inducing fatigue, because it leads me in a different direction. Instead of gravitating towards my bed, I gravitate towards chocolate chips and cupcakes...must...resist...
Seriously, though, I do have to avoid continual snacking. My meals are sufficiently high in calories and all the other good stuff (protein, especially) that I don't need to be adding calories in between meals. After dinner is probably the most difficult time. Celebratory the-kids-fell-asleep-without-screaming-bowl of ice cream? I'm in!
But, as I did in my last pregnancy, I'm trying to keep my weight gain to a reasonable level. I am very hopeful that baby's weight will also be less than 10 lbs at birth, since macrosomia and babies that are large for gestational age (LGA) always raise red flags for doctors. They start pushing for induction and c-section much sooner when ultrasounds start to make the baby look big. I don't worry about it excessively, but it makes them tense, and I'd hate to do that to anyone. :) None of my babies have ever been close to small (8 lbs 2 oz, 9 lbs 8 oz, and 8 lbs 5 oz), so I don't expect that a little bit of deprivation will do any damage to either of us.
Seriously? I'm still only on week 6? Oh man, this is going to be one long pregnancy.
So it turns out that I never actually told my husband that we were taking an NFP risk during last month's cycle. Of course we couldn't say for sure whether we would have done things differently, and babies are babies are babies no matter how they come into the world, but it does set a different emotional stage for the parents of said child. I am extremely grateful for a husband who simply shrugs his shoulders and says, "Eh, we'll figure it out." I'm going to be changing diapers and folding laundry for the foreseeable future no matter what happens, but his education plans are hanging in the balance. Every time something big happens, we have to think about moving out, and we have to talk about money, and his income is the only one our family has. If we needed it, he would quit school and find an unrelated job just to make things work. So his flexibility in this regard demonstrates a posture of welcome towards children, and shows that he's a good man.
Speaking of gratitude for someone who shrugs his shoulders and says, "Eh, we'll figure it out," I was pleased to hear my father say the exact same thing. Literally! Here I was, all worried about the conversation that would inevitably need to happen about the space we're living in (theirs!) and whether they think they can handle another small person in it. But he preempted the conversation entirely with these words: "We'll figure it out." What a gracious response from a man whose happy retirement has been taken over by shrieking toddlers.