By Debra Rich Gettleman
What works with the ACA?
No pre-existing conditions: This means that even if you have a debilitating illness you cannot be denied insurance coverage. In the past, people with a history of cancer, diabetes, or a number of other diseases were often denied coverage for that particular disease and had to pay huge out-of-pocket funds to cover costly treatment programs. Obamacare insists that no one can be denied coverage for any preexisting condition.
Insurance Exchanges that allows consumers to effectively analyze a variety of insurance plans in a single locale and compare plans on an even playing field. Comparing various plans with premium costs and clearly defined benefits, co-pays and deductibles does empower patients when choosing their best health care options.
Bundled payments through the ACOs for hospitalization. Patients pay one bill to their insurance company and are not subject to individual charges from anesthesiologists, lab technicians, and radiologists. Payment schedules are more clear and patients are not met with a myriad of unexpected surprise charges.
Covered well checks: If you go to a doctor within your ACO network.
Covered preventative procedures: Again if done within your ACO network.
What isn’t working with the ACA?
Deductibles continue to rise rapidly and dramatically putting costs directly on consumers until annual deductibles are met.
Quality of medicine decreasing as doctors are forced to meet patient satisfaction metrics that demand unnecessary testing and overuse of medications.
Low enrollment in young healthy cohort which was originally meant to pay for the older, sicker population thus creating an unsustainable business model for the long-term.
Low income families receive significant subsidies and are able to choose from higher coverage plans than working middle class families who are being slapped with higher premiums, increasing co-pays and rising deductibles.
Medical care suffers when patient satisfaction metrics become the norm and good medicine becomes secondary.
Preventative medicine visits can only include preventative medicine issues. If acute sick issues like asthma, back-aches, head-aches or other chronic disease topics are brought up, it becomes illegal to code the visit as a preventative visit and requires new coding and subsequent out-of-pocket patient payment.
On a recent visit to the dermatologist I was shocked by my bill. As a melanoma survivor, I go to the dermatologist for preventive skin checks three times each year. But this visit I’d noticed a slight rash on my neck and chest. I pointed it out and my doctor said it was nothing to worry about, just an allergy. She handed me a sample of hydrocortisone cream and advised that the rash would fade within a day or two. When I went to check out, I was charged for two separate office visits—my usual $85 scan, and another $85 for the diagnosis of my rash. When I inquired, I was told that because I had brought up the issue of the rash, they could not simply code the visit as a preventive care visit and were obligated under the new laws to also charge me for a sick visit.
I thought that was rather odd. Then a few weeks later I was scheduling a routine preventive colonoscopy, as my family has a history of colon and pancreatic cancers. I got a call from the hospital the day prior to my procedure to let me know that the entire procedure would be covered under my Affordable Care Act (ACA) insurance plan as a preventive medical procedure. Unless of course the surgeon found anything questionable and needed to send tissue samples to a lab for further analysis. So, as long as I was healthy, I would not have to pay anything for the procedure. But if even the slightest polyp was found, I was suddenly going to be fully responsible for the costs until I met my $6,000 deductible.
These two situations perplexed me, as I had been hearing from the media and my president that the sole purpose of the ACA, which had been signed into law on March 23, 2010, was to make health care more accessible and affordable while also giving consumers more control over their health and wellness. I was feeling anything but in control and was personally aware that saving me money did not seem to be part of anyone’s health care equation. As I began to research the ACA, also known as Obamacare, I learned that while some aspects of the ACA do empower patients, there are a lot of issues that fail to conserve costs, protect patients or provide superior medical care.
Obamacare set out to create groups of health care providers known as Accountable Care Organizations (ACOs) in which the providers work together to offer patients coordinated care and simplified billing options. The ACOs are regularly monitored and provider performance is graded based on a variety of newly designed metrics. Unfortunately, the ACOs demand that primary care physicians choose to belong to only one ACO, and once a patient selects an ACO, he or she can only see physicians affiliated with that ACO as in-network, covered providers. The metrics used to measure and grade physicians are often random and arbitrary and have little to nothing to do with physicians providing excellent patient care. These patient satisfaction surveys, which are often tied to physician reimbursements, reward doctors for running unnecessary tests that can lead to false positives, prescribing superfluous medications and even performing uncalled-for surgeries. The current grading system positively reinforces doctors for excess and penalizes them for inactivity, even when they believe time is the best course for restoring wellness. In a recent online survey of 700-plus emergency room doctors by Emergency Physicians Monthly, 59 percent of the respondents admitted that they had increased the number of tests they performed because of patient satisfaction surveys.
Physician metrics also measure things such as time spent waiting and monitor very specific patient-physician conversation topics. For example, to secure top patient satisfaction ratings physicians must broach topics such as smoking, drug addiction, sexually transmitted diseases and other delicate topics, even when those topics are unrelated to a patient’s symptoms. Also, bringing up questions regarding obesity and behavioral problems can be offensive and insulting to patients. When those patients then provide negative feedback, health care providers risk pay cuts. One emergency room that was consistently receiving low survey scores started offering Vicodin “goody bags” to patients as they were being discharged in order to boost their ratings.
Another challenge of the ACA is to reduce costs by eliminating uninsured patient visits to the emergency room for routine health care. A recent poll released by the American College of Emergency Physicians shows that 75 percent of doctors surveyed saw increases in emergency room visit volume. This is exactly the opposite of what the ACA was intended to accomplish. Experts cite many root causes for the increase in emergency room visits. One of the contributing factors is our nation’s long-standing shortage of primary care doctors—which the federal government estimates will exceed 20,000 doctors by the year 2020. Patients who can’t find a primary care doctor often turn to the emergency room as their only health care option. In addition, many patients can’t take off from work to go to a primary care doctor whose office hours are almost exclusively during standard working hours. Also, with the limited number of primary care physicians, long waits for appointments can force people to go to emergency facilities when they are sick.
Obamacare also vowed to reduce premiums for most Americans. That hasn’t exactly worked out. While most people enrolling in the ACA insurance plans receive subsidies from the government, those who exceed income thresholds ($46,680 for individuals or $95,400 for a family of four) are not eligible for assistance. And, according to a National Bureau of Economic Research study published by the Brookings Institution, from pre-ACA to the first half of 2014, premiums in the individual health insurance market rose nearly 25 percent relative to what they would have been without the ACA.
Part of the problem is that with only low- to mid-income families enrolling in insurance plans offered through the health insurance marketplace established under the ACA, the result is an unsustainable business model, which leads to the need for increased premiums. Further, enrollment among the younger, healthier generation has been low. The initial idea was that enrollment of younger, healthier individuals would offset the health care costs of the sick and aging populations, but without the infusion of younger enrollees, the money is not available to cover the costs of providing care for older and less healthy people. Thus, costs continue to rise for most middle-aged individuals and median income families. So the majority of consumers are seeing significant increases in insurance premiums, co-pays and deductibles.
For people with employer-sponsored coverage, the average deductible (the amount a patient must pay before the insurance company will begin to cover the remaining costs) rose 47 percent from 2009 to 2014, increasing from $826 to $1,217. For people with individual coverage under a Bronze plan through the health insurance marketplace, which are the most commonly selected plans, annual deductibles hover around $5,000. With out-of-pocket costs rising steadily, many people skip doctor visits, put off medical procedures, avoid filling prescriptions and ration pills. Again, we see the opposite result of Obamacare’s intended outcome.
Whether Obamacare is working or not depends largely on your individual perspective. On a macrocosmic level, the number of uninsured has decreased by 16.4 million since the law went into effect. Currently, according to the Department of Health and Human Services, only 13.2 percent of U.S. residents now lack coverage, down from 20.3 percent prior to passage of the ACA. While the number of uninsured is down, though, the cost to acquire and maintain insurance for most middle-class families has risen significantly. With premiums increasing in almost every state and co-pays and deductibles steadily climbing, the cost to those Americans who do not qualify for government subsidies constitutes a hearty blow during a time of low economic prosperity and must be carefully considered when determining the ACA’s overall success and impact.
Regardless, Obamacare won’t be going away any time soon, judging from the Supreme Court’s ruling in June. The court voted 6-3 to uphold the controversial health care law that authorizes federal tax credits for eligible Americans living not only in states that have their own exchanges, but also for those in the 34 states with federally facilitated marketplaces. This decision ensures continued coverage for millions of Americans. After the court victory President Barack Obama said, “We finally declared that in America, health care is not a privilege for a few but a right for all.” He added, “The Affordable Care Act is here to stay.”
