Five years after the passage of the Affordable Care Act (ACA), more famously known as Obamacare, open season has come around again. As our mailboxes fill with offers and reminders from insurance companies, and ads appear encouraging us to sign up, I thought it would be a good time to look at how this momentous and highly controversial change in the medical system is playing out on the ground along Park Heights and Greenspring Avenues. Do more people have access to health insurance? Have the costs gone down? Who has been helped by the law and who not – and why? And how have doctors been affected?
Insured, Yes: Covered, No
Internist Dr. Elliot Rothschild sums up the effects of the law like this: “The ACA has made it much easier for some and much worse for others. As a result of the law, people’s out-of-pocket expenses went up significantly, so whereas nearly everyone now has health insurance, many don’t, in effect, have coverage.”
This is one of the ironies of Obamacare. The purpose of the law was to enable everyone to get healthcare, particularly those with low income who do not receive insurance through an employer and who do not qualify for Medicaid, as well as those with preexisting health conditions. According to insurance broker Ari Gross, of The Columbia Group, this goal has to some extent been realized. “The people who benefit the most from the ACA,” he says, “are those with large families whose income is not very high. Many of these families – including a large segment of our community – can now get regular individual insurance plans with substantial government subsidies, and are doing better than they otherwise would have been.”
For the vast majority of Americans, however, insurance rates have gone up tremendously, forcing many people to choose less expensive plans with very high deductibles. The resulting out-of-pocket costs have discouraged many from getting treatment they need but cannot afford. Indeed, a report released by FamiliesUSA.org states that, among Americans with private insurance, one in four didn’t get needed care last year because they couldn’t afford it. “Not getting recommended follow-up care to treat an illness or not taking needed medications can result in people facing avoidable, more serious health problems and more expensive health care costs down the road.” the report concludes.
Tehilla, who does billing in an internist’s office, reports confused patients, some of whom are paying triple what they paid previously with changed coverage. Tehilla agrees that the people in the middle income brackets have been hit the hardest. “For those who now qualify for free or very low cost health insurance, it has been great. But for everyone else, it has become much harder.”
Through the Eyes of the Insurance Brokers
Ari Gross says that his insurance broker business, The Columbia Group, has seen an increase in volume due to the confusion of many consumers when they try to sign up for new health plans. The brokerage is compensated by the insurance companies for this kind of help, so there is no charge to the consumer, and Ari sees his group as free and impartial advocates for its clients.
One reason for the confusion is that, with the advent of Obamacare, every insurance plan has changed. The changes may be less noticeable for those on group insurance. But this article mostly applies to individual policies, which have changed dramatically, causing more people than ever before to seek out Columbia’s services. His group spent a lot of time and money to train their staff to be ready for this new system.
“Many of the same plans are offered both on and off the exchange, with the only difference being the premium cost, which is either subsidized or not,” says Ari. Although it might appear that the insurance companies are making more money with their high-cost plans, Ari says this is not the case. “Their costs have gone up significantly. They are highly watched and regulated by the government. By law, they now need to offer free well-care, free preventative medicine, coverage for children up to age 26, no lifetime maximum care, and they need to accept everyone, including those with pre-existing conditions.”
(The ACA also requires coverage for bariatric surgery, weight-loss programs, colonoscopies, preventative health issues, some immunizations, and routine visits and physicals.)
Ari points out one of the ironies he sees in the new law: Although everyone is mandated to have health insurance to avoid being penalized, a person may only enroll during the open enrollment period. And if 60 days pass, for whatever reason, and you did not sign up for health insurance, you are forced to wait until the following year!
“In the past anyone could sign up for insurance at any time,” says Ari. “Open enrollment begins this year on November 1, and in order to have coverage by January 1, you must be signed up by December 15. The latest date one can sign up for 2016 coverage is January 31, but that means your coverage would not begin until March 1, which is when the 60-day, non-covered period would run out[a1] .”
“No One Is Happy”
Like nearly everyone I interviewed, insurance broker Leah says the ACA has made insurance more difficult to afford for nearly everyone who does not qualify for a government subsidy. “But consumers are not getting less as far as what’s covered,” she says. “In some ways, there is actually more coverage, because some services that were once capped at a specific number of visits or dollar amounts are now unlimited. However, the total out-of-pocket expenses are much higher than they used to be. And insurance plans with low deductibles have such astronomical premiums that they are prohibitive. It’s harder to please my clients now,” says Leah. “No one walks away happy.”
Although many consumers complain about rising and/or changing medication costs, Leah says that the cost of brand name and generic drugs is always changing, depending on what kind of deals a particular insurance company can make with the pharmaceutical company. She feels the ACA might not have any direct bearing on this problem.
(One unexpected yet interesting result of the high out-of-pocket expenses is that businesses and websites have sprung up advising patients how to shop for the most affordable services – for anything from simple blood tests to diagnostic imaging, surgery, and many types of treatments. Many insurance companies post their own lists on their websites. It is well worth contacting your insurance company or shopping around the next time you need a test or treatment.)
The higher insurance rates are a consequence of the insurance companies’ inability to project their expenses under the new terms of the ACA, says Leah. “They prepared for the worst, as many services became unlimited and they were forced to include a much less healthy, previously uninsured, population into the insurance pool. Another reason for the skyrocketing rates is that many of the younger, healthier members of society are not signing up for health insurance. “The premise was that young people signing up would make the insurance pool more even. However, even though they face a penalty, many of the young feel that is preferable to paying such high rates when they are still young and healthy.”
Like many others, Leah feels that a change to the health care system was needed, but she does not believe it was done properly with the current ACA law. “Likely, the original idea was to make all health insurance more streamlined and uncomplicated like the Medicare system, where only a few plans are available and the premium is affordable.” It took many years for Medicare to work properly, and Leah assumes it will also take many years for the ACA to work properly. “Currently, insurance companies don’t have a clear idea how to price everything,” says Leah. She believes that “in a few years things may equalize and the plans will become more affordable – although it may get worse before it gets better.”
Doctors Change their Ways
The ACA has also affected the way doctors practice medicine as well as their quality of life. Dr. Rothschild says that, mostly due to insurance company demands – though partially because of the ACA – there is an increased demand for documentation. This means a greater work load for the office, and has caused Dr. Rothschild to get home later than he formerly was able to do.
Another change, which he believes is related to the ACA, is a policy adopted by the hospital where Dr. Rothschild has privileges (though not in all area hospitals) that has led to some patient dissatisfaction. It used to be that his hospitalized patients were cared for by a healthcare practitioner – whether a resident doctor, intern, or physician’s assistant – who followed the patient’s care 24 hours a day. If the patient had some difficulty, the hospital practitioner would urgently evaluate him and get in touch with Dr. Rothschild. They would then discuss the patient’s condition and carry out any needed actions. Dr. Rothschild was comfortable with this level of care; he was kept informed during the day and then visited his patients at the end of office hours. For 16 of his 17 years practicing medicine, Dr. Rothschild went to the hospital every day.
Due to changes to the reimbursement system, however, some hospitals have become less interested in having private physicians come in. Hospitals have not overtly forbidden community doctors, but it has become more difficult for the doctors to come. Last year, for example, changes were made at Dr. Rothschild’s hospital, for economic reasons, and residents and physician’s assistants may no longer work with private physicians. They are only permitted to work with the hospitalists (doctors employed by the hospital). This has created a situation in which, if a hospitalized patient has an acute change in his condition, Dr. Rothschild has no way of evaluating him. The only possibilities would be for him to leave his office patients and run over to the hospital, which is impractical, or let the patient stay in that condition until he can get there, after hours. Dr. Rothschild says, “From my viewpoint, it has become unsafe to follow my patients in the hospital, and I felt forced to let the hospitalists take over the care.”
Nevertheless, Dr. Rothschild does not believe that this system is detrimental to patients. He points out that it is used in other countries, including Israel. However, many patients, not used to the new reality, are not happy with it, even if the level of care has not been affected.
No More Private Practice?
Kim is a practice manager at a pediatrician’s office, and sees the challenges for pediatricians and their patients when people sign up on the Maryland Health Exchange. She has seen countless cases where a parent signs up her child online and runs into problems. “Patients sign up – for Amerigroup (a Medicaid program), for example – and get a message that their insurance is activated and in force. However, when our office calls Amerigroup, the patient is not on file immediately.
“It can take between six weeks to three months until patients get assigned to an insurance company and get a card,” says Kim. “This can be a particular problem and a tremendous hardship on the parents of a newborn.” She explains that, since babies are not necessarily born during open season, the three visits that are scheduled before the newborn is six weeks old are not covered. When the family’s insurance for the newborn cannot be validated, the office needs to treat them as self-pay patients. In previous years, before the Maryland Health Exchange was activated, once a parent signed a child up for Medicaid, his insurance was active within 10 days – and Medicaid always had the name in the system.”
Sara, whose children are covered under Amerigroup, says she is constantly stressed because she finds them to be neither organized nor reliable. Sometimes the doctor bills are paid with no problem, and sometimes the charges are denied because Amerigroup seems to think her kids are still covered under her old CareFirst plan. Even though Amerigroup was repeatedly given the information, it seems their system keeps losing it. Sara has to spend hours on the phone with Amerigroup trying to resolve the issues, and with each re-enrollment period, she is nervous that her family won’t be approved and will end up without health insurance.
According to Kim, doctors in her practice are getting reimbursed less. In the past, if they billed the insurance companies for $100, they got around $55 or $60. Nowadays, the sum is usually no more than $35. In order to stay afloat, doctors need to fit more patients into the day.
Kim is not optimistic about the future of private practice medicine. Many practices will be bought out by hospitals or medical centers, she thinks, and many doctors will be retiring earlier. A Physician’s Foundation study done last year supports her belief. Of the physicians surveyed, 39 percent indicated they may retire earlier than planned.
On the Bright Side
Dr. DeeDee Shiller, a local gynecologist, says the ACA has been able to improve some of the services she can offer her patients. She is delighted that her patients have access to a variety of free or very affordable birth control options to choose from. Her patients can now make decisions based on their personal preference rather than only on the basis of affordability, as was true in the past. Dr. Shiller believes the American public views birth control as one of our social freedoms and considers this service critical to women of child-bearing age. But she realizes that others, like internists, may think it unfair that life-saving drugs – such as those for diabetes, high blood pressure or heart disease – can be extremely expensive, while these “elective choice” medications and procedures are fully covered.
More Americans have cheaper access to health care, says Dr. Shiller, who is able to see more patients who might not have had access to her before, since all insurance plans now cover preventive care, a yearly exam, and family planning. But although they have insurance, patients’ deductibles for doctor visits, radiological studies, and medications are significantly higher. “It can be difficult to discuss a special surgical or medical plan with a patient who has high out-of-pocket expenses,” says Dr. Shiller. “This can lead to patients needing emergency services rather than an earlier doctor visit and diagnostic testing.” And if Dr. Shiller needs to prescribe a medicine other than birth control to a patient, the cost can be prohibitive.
An Imperfect Act
Although everyone I spoke with agreed that the health care system we had before 2010 needed to be improved, most believe that the Affordable Care Act has unfortunately made medical care not as affordable as it once was for a large portion of the population. This includes people with job-related insurance plans, since many employers changed the plans they offer to ones with higher deductibles and co-pay amounts. Studies also show that, while physician satisfaction had been declining before the ACA, many physicians now feel their jobs are even worse.
There are no easy answers on how to improve the U.S. health care system. Whenever there is money to be made, combined with the red-tape of government involvement, there is the potential for corruption, greed, and plain old mismanagement. Perhaps in the future, a system can be devised and implemented with more input from doctors and patients.
