Evaluating the realities of the Affordable Care Act

There are no valid reasons, in my opinion, that everyone should not have access to high quality healthcare. Sadly, due to corrupt governments, geographic isolation, religious and ethnic conflicts, poor economies, inadequate education, ineffective leadership or a simple lack of will, much of the world’s population - especially those in Third World countries - has little or no access to healthcare. This is a gigantic problem with global implications that has no simple solution.

As a result, this lack of access to healthcare will continue to shorten life expectancies, cause high maternal and childhood death rates to persist and result in pain, suffering, disability and even death from some of the most common and readily treated diseases.

If one chooses to focus attention only on the industrialized countries of the world, however, where most of these limitations to receiving healthcare do not exist, we find that the United States is a very long way from the top in providing high quality healthcare to all its citizens. The reasons for this are numerous, but all are ultimately unacceptable.

To try and give access to healthcare to millions of uninsured Americans, Congress and the president have recently passed legislation that has resulted in the creation of the Affordable Care Act (ACA). Though highly debated and controversial from the outset, ACA has now been enacted into law. While it is still being implemented and certain to continue evolving over time, I believe it is fair to evaluate the early successes and shortcomings of the ACA.

Next: More people with coverage

Number of people receiving care - Despite a less than officious start manifested by an extraordinary number of technical difficulties in getting people signed up during the six-month enrollment period, it does appear that more Americans now have health insurance coverage than before ACA was enacted. This is certainly an improvement, but despite all the promotions and advertisements, more than 13 percent of Americans still remain without health insurance coverage. With a lot more work still needing to be done to provide healthcare coverage for these individuals, in my arbitrary grading system, this category would only receive a grade of “incomplete.”

Quality of care - Merely having increased access to healthcare doesn’t necessarily imply anything about the quality of that care or the quality, training and number of physicians available to provide it. In fact, there are disturbing reports of a huge looming problem for both patients and specialty physicians alike. This comes in the form of a concerted effort by both the government and some insurance companies, especially the Medicare Advantage Plans, to reduce the cost of treating patients by limiting access to certain specialties, including cardiology, nephrology and dermatology.

This is being accomplished by “narrowing the scope of the provider networks” and “delisting” physicians without providing any explanation or reason. In a broadcast fax to its members dated June 23, 2014, the American College of Mohs Surgeons released a letter stating that “to date, there are 20 states in which either Humana or United Healthcare have terminated physicians to create a narrower network of physicians.”

Furthermore, it seems apparent that those “delisted” physicians were never accused of having provided low quality care or had bad outcomes. Rather, these actions appear to be based entirely on reducing costs. If increasing access to healthcare comes at the cost of not being able to see certain specialists, then I believe this creates a two-tiered system of healthcare, something I’ve always personally found reprehensible.

Those individuals who can afford it will purchase a more costly but higher quality plan and maintain their access to the physicians of their choosing, including specialists who may be better qualified by training to take care of their particular personal healthcare needs. Those individuals of lower economic means with less expensive healthcare plans will likely lose out on the option of seeing specialists in a timely fashion.

When National Health Insurance was adopted in England years ago, long waiting periods developed for patients with certain chronic diseases or disorders. As a result, those with the necessary financial means purchased their own private health insurance so they could be seen more rapidly by the physician or specialist of their choosing.

This is just the type of two-tiered system I’d like not to see repeated in the United States. If “delisting” of physicians to narrow the scope of the provider network continues, my grade for this component of ACA would be a “D.”

Next: High deductibles, more bureaucracy

Higher deductibles - In order to avoid the tax penalty of $95 or 1 percent of an individual’s total taxable income for not having enrolled in a health insurance plan under ACA, some patients opted for a lower cost plan having a high deductible. Many of these patients failed to realize this and were subsequently shocked to learn when an unexpected injury or illness occurs that they are responsible for perhaps a sizeable portion of their care. In some cases, the deductible may range from $3,000-$5,000. While this problem may have been driven by the terms of the ACA (since uninsured people had to get insurance or pay a penalty), it should not really be blamed on this program since it truly was one of those unintended consequences of this legislation. The grade for this section would therefore appropriately be “non-credit” or no grade.

Increased bureaucracy - If you thought HIPAA (Health Insurance Portability and Accountability Act) and EHR (electronic health records) were difficult and expensive to implement, wait until you or your practice have to decide which ACO (accountable care organization) to become affiliated with and how to prove that your practice provides efficient, effective, high-quality care at appropriate cost.

It seems inevitable with the push toward value-based incentives that more effort will be required to prove to your ACO the value of a patient seeing you for dermatologic care than someone else. If all those weren’t enough new bureaucratic hurdles to have to clear, wait for the creation and implementation of the new IPAB (Independent Payment Advisory Board) that will determine how to reduce Medicare costs without impacting quality of care. So, my grade for increased bureaucracy under ACA would be a “D.”

In summary, providing healthcare of high quality at a reasonable cost is not only incredibly difficult but also extremely complex. Having partially accomplished the goal of increasing the number of Americans with health insurance coverage, it is now time to take substantial, thoughtful corrective action to eliminate the errors described above that were made with its implementation of ACA. Otherwise, these goals will never be met our patients will continue to suffer the consequences.