Obamacare check-up

First the good news: The Affordable Care Act, aka Obamacare, has added millions of Americans to the health insurance rolls in the past year and a half.

Now the bad news: The program is dauntingly complex, unpopular with much of the citizenry, and vulnerable to political obstructionism. That last bit is a large part of why 30 million people remain uninsured.

This was the evident consensus of a panel of three experts who offered a “report card” on the ACA to an audience in the Enloe Conference Center on Thursday (April 16). The event was moderated by Enloe CEO Mike Wiltermood.

The panelists were Amber Kemp, vice president for health care coverage for the California Hospital Association; Dr. Richard Thorp, a Paradise internist and past president of the California Medical Association; and Dr. Bill Skeen, executive director of the California chapter of Physicians for a National Health Program (PNHP). Each gave a PowerPoint presentation.

Kemp’s was a statistics-heavy overview of the ACA’s implementation. It showed that, in the 13 states and District of Columbia that embraced the ACA by expanding Medicaid and setting up their own health insurance exchanges, the program is working reasonably well in qualifying more people for Medicaid or subsidized insurance purchased on the exchanges.

For political reasons, the governors of 37 states, most of them Republican, chose not to set up exchanges, forcing residents to use the federal exchange instead. They also refused to expand Medicaid, even though the federal government would have paid nearly all of the cost. Many poor people in those states continue to go without coverage.

California, which got on the ACA bandwagon early, has been especially successful, Kemp said. Now all but 3 million to 4 million Californians have health insurance, and half of them are undocumented foreign residents ineligible for benefits (a bill now in the state Legislature would end that prohibition). Nearly 2 million people have purchased subsidized private insurance through the state’s health exchange, Covered California, while 12 million Californians—nearly one-third of the population—now receive Medi-Cal.

The ACA is characterized by uncertainty, however. There are many reasons for that, Kemp noted. For example, the U.S. Supreme Court has yet to rule on King v. Burwell, a lawsuit that, if upheld, would prohibit subsidies in the 37 states using the federal exchange, causing some 5 million people to lose their insurance and effectively creating a second, pricier health insurance system for residents of those states.

Approval of King v. Burwell also would reverberate in states with their own exchanges, inasmuch as most of their insurance companies also operate in states served by the federal exchange.

The ACA is having a huge impact on physicians as well as patients, Thorp told the audience.

It’s the largest insurance expansion since Medicare was approved in 1965, he said, and is flooding doctors’ offices with new patients. But having an insurance card is meaningless unless a person can find a provider, and today there is a grave shortage of providers, especially in rural areas.

These days, young doctors tend to have spouses who are themselves professionals, and finding jobs for both of them in a small town can be difficult, if not impossible. Also, Medi-Cal doesn’t pay sustainable amounts, and some of the Covered California plans pay less than Medicare, Thorp said, so some doctors aren’t enrolling on the exchange.

On the positive side, he said, the ACA encourages innovative ways of engaging with physicians (texting, Skype, etc.), is pushing providers to develop smooth methods of transferring patients’ electronic medical records, and is fostering a move away from fee-for-service care toward outcome-based payments.

“The Affordable Care Act is not going away,” Thorp insisted. “Doctors and hospitals are adjusting to it, and patients are becoming more knowledgeable” and skillful at navigating the health care system as they learn to use the online services provided by Covered California.

From Skeen’s perspective, as one of the 20,000 members of PNHP, the country has taken the wrong path on health care.

In 2009, when Congress and the president set about drafting health insurance legislation, they had a choice. They could have expanded Medicare, a proven system that is a model of simplicity and effectiveness, to cover everyone, Skeen said, or they could develop a program based on the existing private-insurance model.

They chose the latter, and the result was the ACA.

The problem is that private insurance is profit-driven and primarily serves shareholders, not patients. Companies can increase their profits in only two ways—by increasing costs or cutting services. Neither is good for patients.

The ACA has placed a limit on profits, and more people are covered, all of which is good, Skeen said. “But coverage is not the same as access, and access is not the same as care.”

Besides, Covered California insurance isn’t cheap, Skeen said. He personally has a neighbor who had major surgery, and her deductible, copays and other costs forced her to declare bankruptcy. In his own case, Skeen added, he and his spouse pay more than $27,000 annually for health care, just for the two of them.

Yes, taxes would have to go up to finance an expanded Medicare, but individuals would pay less than they’re paying now for health insurance, and they would enjoy a service that would make life much easier for patients, doctors and hospital administrators alike.

The 50th anniversary of the signing of the bill creating Medicare is coming up, on July 30. It will be a good time to reflect on the differences between the two approaches, Skeen suggested, adding, “There are those of us who still dare to dream.”