Is it working?
By SUSAN E. SAGARRA
When the Patient Protection and Affordable Care Act (ACA) was signed into law in 2010, the aim was to provide everyone in the United States better access to affordable health care. Six years later, it appears that “affordable” is a misnomer for the law that is commonly referred to as Obamacare.
For a St. Louis County woman who has been battling cancer and did not want to be identified, the challenge of working within the new health care model is “a pain and confusing.”
After losing her job due to her illness, she said she was forced to scramble to find new coverage.
“I had a very short time to arrange insurance that would cover most or all of my doctors,” she said. “I now have to get referrals for everything. For every office visit, I have to have it approved, even for something as simple as getting my regular blood draws. I never had to do that before.”
There are numerous other grievances about the law. Some patients have been forced to change doctors and/or their medications because their existing or new plans no longer cover what previously was covered; some patients are forced to make more frequent visits to the doctor in order to have prescriptions refilled, which results in more co-pays.
One of the biggest concerns is that because insurance premiums continue to increase, patients need higher deductibles to offset the costs. As a result, it takes longer for the patient to pay down the deductible before insurance pays anything. Additionally, physicians are seeing lower reimbursements for the services they provide. Thus, patients and health care providers feel insurance companies are the only ones benefiting from the implementation of the ACA.
Experts say spending has increased
Several recent articles and studies verify that spending on health care has increased, most of it in the government-funded [taxpayer-funded] segment. For example:
• The January/February 2016 issue of Integrated Healthcare Executive magazine reports that health care spending under the ACA increased 5.3 percent in 2014 to a total of more than $3 trillion. According to the magazine, that is the highest increase since before the 2008 recession.
• According to the Centers for Medicare and Medicaid Services [CMS] Office of the Actuary, the 2014 total worked out to $9,523 per capita, up 4.5 percent from 2013, and the percentage of GDP devoted to health care spending was 17.5 percent, up from 17.3 percent. The increase in spending was attributed to the expansion of people being covered and more people seeking services.
• According to the CMS, health care spending by the federal government grew at a faster rate in 2014 than spending by other sponsors of health care, leading to a 2 percent increase in its share of total health care spending between 2013 and 2014. That is attributed to the expansion of Medicaid, the government-funded program.
• According to a December 2015 report in Investors Business Daily, overhead costs for administering the ACA also have increased. Annual spending growth was on a steady downward trend, going from 9.6 percent in 2002 to just 2.9 percent in 2013, according to the CMS. After Obamacare was implemented, national spending increased by 5.3 percent. The report attributes the increase to Medicaid spending. According to the article, Obama officials say “all this spending is justified because millions gained coverage under Obamacare.” However, according to the CMS, the rate of uninsured Americans in 2014 – 11.2 percent – was the same as the number of uninsured in 1987.
• Also according to CMS, the number of uninsured dropped by 8.7 million in 2014. But Medicaid enrollment increased by 7.7 million. Total private coverage climbed just 2.2 million. Employer coverage dropped by 1.7 million, more than three times the Congressional Budget Office forecast for that year.
• According to the U.S. Department of Health and Human Services, the most recent data regarding enrollment in the Obamacare exchanges shows that 84 percent of exchange enrollees qualify for tax credits, and 67 percent of that subset also are enrolled in reduced-cost-sharing plans.
Access appears to be dwindling
According to an October 2015 study by the Show-Me Institute, a Missouri-based public policy think tank, access to primary care physicians has declined.
The study “Where Obamacare Leaves Questions, Direct Primary Care May Offer Answers” is authored by Patrick Ishmael, director of government accountability at the Show-Me Institute. In it, Ishmael cites statistics from the Center for Studying Health System Change, which said that in 2008, “only about 42 percent of primary care physicians were accepting new Medicaid patients, compared to just more than 84 percent for privately insured patients.”
Ishmael writes that the service disparity is due to low Medicaid reimbursement rates and other potential earnings trends that were already driving doctors away from primary care.
“Under the ACA, reimbursement rates for Medicaid patients rose in 2013 and 2014, boosting doctor acceptance of new Medicaid enrollees into the upper 60 percent range nationally; however, as reimbursement rates fall back to their historical levels, it is likely that doctor interest in taking new Medicaid patients will recede as well,” Ishmael wrote.
Ishmael further noted that last summer, HealthPocket, a company that analyzes insurance prices, reported that ACA insurance rate increases would reach 12 percent, with higher rates exceeding 20 percent, in 2016.
“While the increased cost of employer-sponsored plans has not accelerated at the same rate as the cost of plans in the exchange, employees’ shares of the cost of care in employer-sponsored plans are still on the rise,” Ishmael wrote. “Medicaid spending will continue to grow at a whopping 7 percent pace at least through 2022. By that time, federal and state Medicaid spending will approach $900 billion – a nearly twofold increase over 2010 spending and a four-fold increase over Medicaid spending in 2000 …. In both private plans and in the government program that sponsors coverage for tens of millions of needy Americans, spending consistently outpaces inflation. Rather than bend the cost curve down, the ACA may in fact be cementing in place an upward spending curve that will cost patients dearly, through their own plans and through their taxes, in the years ahead.”
Ishmael proposes an alternative to try to keep costs down: direct primary care [DPC]. Also known as concierge health care, these arrangements allow patients to pay providers directly via a set fee.
“Primary care physicians are instrumental in promoting and maintaining the good health of the patients they see,” Ishmael said. “By cutting out the frequent participation of an insurer, DPC doctors are able to reduce administrative costs by a third or more.”
Restoring patient-physician relationships
At least two local doctors share Ishmael’s perspective.
Helen Kornblum, a longtime local physician, reiterated that everyone has access to care; it’s where they receive care that is troubling.
Kornblum has worked in the ER, with the elderly, in private practice, and currently does medical mission trips to the Honduras and works with some of the region’s poorest patients.
“There is nobody in this country who doesn’t have access to health care,” Kornblum said. “No doctor can deny care. That is different from the rest of the world. Is it good, efficient health care? Absolutely not. People go to the ER for minor problems that could be taken care of through primary care physicians. It is a complete waste of resources.”
She believes universal health care and socialized medicine will not address the root of the problem.
“If you have an overgrown oak tree in your yard and the roots are eating into the foundation of your house, just cutting some branches doesn’t solve the problem,” Kornblum said. “The answer is certainly not universal health care. Obamacare did nothing to fix the root of the problem. It [ACA] put a Band-Aid on an arterial bleeder.”
She said the majority of the patients she sees still do not have insurance.
“About 90 percent do not have insurance so Obamacare did not take care of them,” Kornblum said. “All of our care is charity care, which means the hospital or you and I pay for their care. These are complicated patients with multiple health issues. It’s a microcosm of the bigger issue in health care.
“Obamacare is counterintuitive. I have a patient who works, and wants to work, but he makes too much money so he can’t get Medicaid, but he also can’t afford regular insurance. It’s a disincentive to work.”
Kornblum said primary care and education are key.
“We need more primary care physicians who are reimbursed at reasonable rates,” Kornblum said. “Additionally, every patient needs to be held accountable. If you don’t take care of yourself, you will get sick. We also need more patient education. We need to get back to patient-physician relationships so the doctor can have a personal relationship and be able to ask, ‘what’s going on in your life?’ It takes time, though, and time is not reimbursed.
Tobin Lingafelter, a chiropractic physician from Ballwin, said many Americans are taking notice about the costs of their health care.
“One incentive for working somewhere always has been the benefits,” Lingafelter said. “A lot of people never paid attention to health care costs because the employer always paid.”
He said he has been preaching healthy options and has offered a concierge-type service for his patients for several years.
“Guys like me can put plans together for people that they can afford,” Lingafelter said. “And other than major, catastrophic things, little things can be handled between just the patient and the doctor.”
Is there a government fix?
In December, the U.S. Senate passed the Restoring Americans’ Healthcare Freedom Reconciliation Act to repeal the president’s health care law; the U.S. House passed the legislation in January. However, as most predicted, President Obama vetoed the bill.
Among other things, the bill would have repealed numerous mandates, including the one requiring Americans to acquire insurance or pay a tax.
U.S. Sen. Roy Blunt [R-MO] was among those who voted in favor of repealing Obamacare.
“Premiums are increasing by double digits and the average deductible has reached $2,000,” Blunt said in a statement at the time. “Those who cannot afford coverage face up to a $2,085 penalty. Small businesses are holding down hours to comply with the law’s burdensome employer mandate. Insurance companies are fleeing the state and federal exchanges, narrowing health care options.”
Blunt highlighted several solutions to help lower costs and improve access, including:
• Expanding access to Health Savings Accounts and allowing qualified participants to use HSAs to pay for premiums
• Allowing small businesses to pool together to offer affordable insurance options to employees
• Enacting meaningful medical liability reform to reduce malpractice insurance costs, leading to increased access for patients
• Allowing consumers to buy insurance across state lines
• Expanding and reforming high-risk pools to provide insurance options for people with pre-existing conditions
• Promoting prevention and wellness programs by giving employers greater flexibility to reward employees who adopt healthier lifestyles
• Prohibiting insurers from canceling a policy unless a person commits fraud or conceals material facts about a health condition
• Implementing fair tax treatment for people who don’t receive their insurance at work
He also predicted that “the law will impose a job-killing, trillion-dollar tax hike over the next 10 years.”
With the 2016 presidential election on the horizon, the fate of the ACA hangs in the balance. Perhaps the most pressing question of 2017 will be whether a new administration will be able to repeal or reform a health care system that has already cost the American taxpayer and medical community billions to implement.