As a physician, I often get questions from my patients about the Patient Protection and the Affordable Care Act (ACA), also known as Obama Care, the massive healthcare legislation voted into law in 2009. With the mandated healthcare exchanges scheduled to launch on October 1st, 2013, questions and skepticism are becoming more frequent in the news as well. My response is usually the same: “It is extremely complex, and we will have to wait and see.”
A recent poll published in the Wall Street Journal/NBC News reported that nearly 70% of Americans do not understand the law. It is no surprise that even physicians are having a hard time understanding the basics. The ACA document currently stands at 2,700 pages, including 20,000 regulations and a 21 page exchange application with a 61 page appendix attachment. The massive law requires approximately 159 new agencies just to ensure oversight. Medicare in its current form is required to administer 10,000 prices across 3,000 counties which is an enormous feat with conflicting results and questionable effectiveness. That’s without Obama Care. Now add the implementation of Obama Care which is heavily reliant on accurate communication between a large range of institutions such as the IRS, Medicare, Health Exchanges, private insurers’, HHS and whatever else and it becomes an even larger implementation challenge, more like an ensuing catastrophe.
In order to shed some light on the confusing law, it is helpful to review the timeline of some key provisions that have been implemented to date, as noted in a recent Wall Street Journal article.
July 1, 2010: The federal government set up a temporary exchange for high-risk patients (known as the high risk pool) enticing employers with less than 25 employees to buy insurance for their employees in exchange for tax credits.
September 23, 2010: A mandate to include all dependent children up to their 26th birthday, requiring insurers to cover preventive services without out-of-pocket expenses was implemented.
June 28, 2012: After several changes in 2011, seniors became eligible for discounts for prescription drugs not covered under Medicare Part D and the CLASS Act, or long term insurance program, was eliminated due to its high costs. The Supreme Court upheld the healthcare law and confirmed its constitutionality.
August 1, 2012: All FDA approved contraception drugs were ordered to be dispensed to qualified patients without out of pocket expense causing Catholic groups to challenge this provision.
October 1, 2012: A new payment rate for hospitals came into play using new criteria such as patient-satisfaction scores.
December 14, 2012: Only 18 states say they plan to operate their own exchanges leaving 32 for the federal government to handle. At the current moment there are roughly 34 states with 28 million uninsured and only $54 million in federal funding to share.
Beginning of 2013: A new 2.3% tax on medical device manufacturers took shape and the federal government announced it will not accept any new applications for the high-risk pool to “catch up” with the 100,000 claims that require payment thus far.
October 1st, 2013 is a monumental date for the Affordable Care Act. It marks the launch of open enrollment via the healthcare insurance exchanges. The goal is to target roughly 30 million uninsured Americans allowing them access to coverage through existing Federal/State Medicaid programs or a government subsidized program based on income qualification. Starting in 2014, insurance coverage will be mandatory and individuals and larger employers will be fined if they do not carry or provide insurance for employees.
The intent and goal of the law is two-fold, target 2/3 of the uninsured and get them insured through these exchanges and spread the healthcare cost more evenly across all Americans. According to ex-Senator Daschle’s book on healthcare written in 2008, each uninsured individual will cost the insured an additional $900/year. Americans and the medical profession are asking how the ACA will reach its goal if a majority of the uninsured prefer to pay the fine or not enough enroll? Eighteen million of the uninsured are between the ages of 20-30 years of age and are primarily healthy. Will the fines push them over the edge to comply? Employer sponsored healthcare has been on the decline by roughly 30% since the 1970s and it has been projected to continue even further with the implementation of ACA. According to the CBO, roughly eight million fewer workers will have employer sponsored insurance in the near future which will create greater pressure on the ACA mandated insurance exchanges’ ability to be effective.
Even more pressing is the question of whether there are enough providers to ensure accessibility to care with such a large number of individuals searching for affordable healthcare coverage. A recent survey conducted by the National Center for Health Statistics found that 31% of doctors weren’t taking new patients with Medicaid, 18% weren’t taking new patients with private insurance, and 17% were turning away new patients with Medicare. Doctors are generally not on board and do not believe that the ACA will achieve its goals. In fact, even with enormous physician shortages on the horizon, The 2013 Deloitte Survey of U.S. Physicians found that 60% of physicians are contemplating retirement in the next 2-3 years! This cohort is also notorious for believing that healthcare insurance costs outweigh what individuals will receive in benefits under this plan.
If you are confused, you are in the majority and should not feel alone. When CEOs of major health insurance companies like Aetna state that insurance rates will go up by 20-50% more in 2014, and major companies like UPS drop coverage for 15,000 spouses specifically because of the law, while others such as former President Bill Clinton praise the law, one wonders who to believe. Complexity is a breeding ground for skepticism. If you are highly skeptical or confused or not sure how the ACA will actually be effective in achieving its goals, so am I.
Disclaimer: The views expressed in this article are the personal views of Robert Moghim, M.D. and do not necessarily represent and are not intended to represent the views of the company or its employees.