While I was doing book signings for my book Surviving American Medicine at the Los Angeles Times Festival of Books on the University of Southern California (USC) Campus, I had the opportunity to hear a wide range of views of patients, doctors and nurses about the Affordable Care Act (ACA). Since the Festival was being held in the middle of an academic center USC where I am a professor of clinical medicine, and where the focus each year is on what grades you earned, I just knew it was time for the first semester report card on ObamaCare.
Why is it the first semester? Because March 31 was the lawful deadline for applying for an individual healthcare policy through the healthcare exchanges, and the last time to avoid a federal tax for failing to have insurance. But the second semester has started, when we all will find out if out healthcare premiums will increase or hopefully decrease, and if our benefits will decrease or hopefully increase. Probably around October 1, we will all find out (and I am sure the media will not let us overlook) if there will be any changes for 2015. So how are we all doing and feeling about this law? In contrast to prior articles on the ACA than emphasize how we should celebrate, or modify, or repeal this law, I want these grades that I will describe to solely reflect the context of our own individual medical care. I want to grade what the ACA is doing for me now. Because that's where healthcare reform hits the road, in the care that each of us pays lots of dollars to receive.
Here are the courses that the Affordable Care Act are changing, and let me give you my grades, those of the people I asked at the Festival, and those of the patients and doctors I work with daily. Here is the ABC.
Access: The first goal of healthcare reform is to increase access of patients to doctors and hospitals and medical centers in order to improve patients' care. Some people who have only been able to get health insurance because of the ACA feel the grade should be A, like patients who had pre-existing cancer. But others who have lost their old policies, and only been able to replace them with more expensive and higher deductible plans, feel it's a D or F. The most important personal principle is to have affordable insurance that enables you to have a doctor and hospital care as needed. Because the uninsured rate has decreased from 18.0 percent to 15.6 percent, I give the ACA a grade of C. There has been some progress, but not enough to be great. Yet. Come back after the second semester to see where we have gone.
Benefits: The second goal of healthcare is to be certain that prevention, diagnostic tests, and appropriate treatments are covered by the health plan. In the past, many benefits were not covered. But with the ACA and the mandated minimal benefits package, prevention and maternal health and mental health benefits are included. And the law includes coverage of care services when a patient participates in a clinical trial, which can make promising treatments available to people. Still lacking are some forms of disease prevention, coverage of many drugs, and even some benefits within the state-regulated Medicaid programs. So, I give the grade of B to the ACA reforms at present. And we will have to monitor our own care to be sure that our doctors pay attention to prevention, prompt diagnosis of our symptoms, and getting insurance authorization of all our needed treatments.
Confidence: The third goal of reform is to instill confidence in our own care. For those of us with conditions or illnesses, the ACA now makes certain that insurance companies do not deny coverage because of pre-existing conditions, or rescind coverage because of developing an illness requiring expensive tests or treatments. Those should give us all more confidence. But changing regulations and uncertainty (about what benefits, deductibles and costs will occur going into 2015) make employer based insurance unpredictable and lead most people to have anxiety and concerns about what will personally happen to us and our family members within the next 12 months. So I give the ACA the grade of D (although many people at the Festival said just give it an incomplete).
Now for some other important issues, that I describe as PQR.
Price: The ACA is supposed to make insurance and care affordable, and for some of my patients and friends the costs of their insurance has been reduced by 70 percent. For older individuals, the donut hole in medication coverage is smaller. And the rate of increase in health care costs is slowing (maybe because of or maybe despite the ACA). But for many other patients, costs of policies have risen by 16-25 percent and deductibles are now many thousands of dollars. In other markets, increases in policy premiums have been less. Overall rising premiums (despite promises of reducing premiums) lead me to give ACA a grade of C at present. But next semester, that may change depending on how insurance companies change each of our own costs.
Quality: The ongoing development of integrated clinical care systems (with coordinators and navigators that reduce needs for hospitalization when we have chronic conditions) and medical homes (that place more responsibility on primary care offices to coordinate care) may increase favorable outcomes for each of us. However, using our insurance is often more difficult (smaller doctor networks, doctors retiring or selling their practices, hospitals no longer within our insurance approved network, and the regrettably poor performance of healthcare exchanges and poor information available at some insurance companies) have led to extraordinary frustration in many of my patients and individuals at the Festival. These experiences force me to give a grade of D so far, but I hope improvements will come with ACA modifications.
Records: Since the ACA strongly promotes use of electronic health records (by increasing physician payments for computerization), we can now read our doctors' records and prescriptions. Communication between doctor offices and hospitals is empowered by these improvements. Although we still have diverse software systems that do not YET communicate with each other, I give the enhanced record systems a grade of B. And remember, just as I stress in my medical tips in my book Surviving American Medicine, you should ask for and receive a copy of your tests, doctor's notes, list of medications and record of your diagnoses so you can keep copies of these at your home. You can take important ones with you when you travel, and have them available when you see a new doctor or consultant, facilitating your efficient care. I always emphasize you should read your records, understand every thing that the doctor has written, and tell the office to correct any mistakes.
Overall: I give the ACA a GPA of 2.0 (this average is a letter grade of C). So each of us should be sure we have the best insurance we can afford (even use a private health insurance agent to understand all your choices), make certain we discuss our health, symptoms, preventive care and comprehensive coordination of our treatments by our own doctors. And keep our records.
And for the health care system in America, what do I recommend? A GPA of 2.0 needs improvement by modification of the ACA and its regulations, or replacement.
Perhaps just as we have platinum health plans for patients who anticipate lots of healthcare needs, so too we should have Dr. Cary's plastic health plan for reasonably healthy individuals who now are not buying insurance because of cost. This would be a very inexpensive catastrophic plan with high deductible that has good coverage of catastrophic conditions or injuries, but reduced benefits which cover few of the day to day smaller expenses that the individual pays for with plastic (of course, a credit card or debit card) which leads to comparative shopping for the best price. Just sayin'!
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