In March, I gave my first semester grades for the Affordable Care Act (ACA, also known generally as Obamacare), and it received a C grade for a GPA of 2.0. Now, a semester of health care later, how is it doing?
The ACA is an important law, with implementing regulations and executive orders. It governs one of the most vital areas of our lives, our health. Concerns have been raised about its cost, its benefits, its problems and its future. As a practicing physician caring about my patients, and as a patient concerned about my own care and my family's health, I have watched closely the evolution of the program. Here are my grades for second semester.
Access to Care: Although the goal was to have 30 million more American covered with health insurance, recent results show the uninsured rate has decreased by 9.5 million. This is a good accomplishment so far, with in rate of uninsured Americans under 65 falling from 20 percent to 15 percent. If people obtained insurance, 60 percent of them were able to see a physician or get a prescription filled. Of those who became insured under private ACA plans, 59 percent were previously uninsured, while 66 percent of those who became insured under Medicaid had been previously uninsured. However, the uninsured rate is still 18 percent for people between 19 and 34. These results deserve a B grade in my view.
Benefits: Most health care is covered under the new insurance policies. Evidence of this is increased use of emergency rooms and hospitals. Prevention is also covered under the ACA policies. However, I have had my patients who had colonoscopy screenings with assurance they would be 100 percent covered, only to discover that the colonoscopy physician found polyps and that they had to pay additional money for the non-preventive care of the polyps that were found. Despite this, I still give benefits a B grade.
Confidence: Among patients newly insured, 81 percent of them are optimistic that the insurance will improve their healthcare (indeed, even 78% of Republicans were optimistic as well as 88 percent of Democrats!). However, most of my patients and family are worried about the coming notices of premium rates for 2015, and lack confidence that this will be sustainable insurance. This is confirmed in a national poll. These worries warrant a grade of D in this category.
Now for the PQRs:
Price: It gets a little confusing and unpredictable here. Among those who became insured under the ACA exchanges, 90% received a subsidy reducing their monthly premiums from $346 per month to only $82 per month. In 2015 the ACA is expected to see only a 4.2% increase in exchange plan premiums. But premium hikes will vary from state to state in plans without subsidies (higher in most states - up to 16 percent higher - but lower in CO, HI, ID, IN, MA, NH, NJ, NY, OH, RI and WV). To make matters worse, court decisions may eliminate subsidies for plans obtained from the federal exchange (but expect this to be tied up in litigation for a long time). This makes rates for some people unpredictable. So far, with high plan deductibles and high non-subsidized premiums, a D grade seems appropriate.
Quality: Although health care networks have been decreased in size, the quality delivered is still uncertain. With good physicians and nurse practitioners, quality seems to be well preserved. But analyses are still generally lacking. The ACA deserves good marks for expanding mental health and inpatient hospital care. At the moment, quality achieves a C grade.
Records: Having understandable and transmittable records available to all your doctors is important for your care. ACA promotes electronic records for all patients and 78 percent of physicians are now using them. The ACA has also established health information exchanges (HIEs) to share data regionally. Some of these exchanges are beginning to operate and should improve our care and allow us to understand how quality is changing (improving I hope). ACA achieves a B grade here.
Overall, the ACA is a work in progress. Some parts not too great, and some not too bad. But this is to be expected in such a large reformatting of health insurance and health care. My grade point average for this important act is 2.2, making the ACA a C grade program. This is a little better than the first semester.
Here are Dr. Cary's tips:
• Be sure you have health insurance. Get a subsidy if you qualify.
• If you have a health condition, choose a low deductible plan with a large network. If you have no conditions and are under 50 consider a plan with high deductible and lower premium.
• Go to your doctor and get preventive care and screening.
• Take all your medications and follow your doctor's advice to stay healthy.
• Use a health insurance agent or your employer human resources department to help choose the right insurance for you. To help guide you in selecting the best insurance for your situation, see the section on health insurance in my book Surviving American Medicine.
The more that each of us encourages our family and friends to get health insurance and use it to stay healthy or control their illnesses, the better the ACA will help us. And the ACA grade may further improve in the third semester.