Unanswered Questions of ACA Implementation

In just a week, I start my new position as Medical Director of Near North Health, a network of federally-qualified health centers (FQHCs) with a 40-plus-year track record of providing comprehensive primary care services to historically marginalized communities throughout Chicago.

I’m especially excited to be doing so now, just months before full Affordable Care Act (ACA) implementation, and just days after the third anniversary of its passage. Come January 2014, numerous changes will affect health delivery and payment; innovations in patient centered medical homes (PCMH) and graduate medical education (GME, aka residencies); regulations and quality mandates. A great time to be at the forefront of health care leadership!

Serving on the Board of Directors for one of the largest professional medical organizations in the nation (the American Academy of Family Physicians), in addition to my role with Doctors Council SEIU, I’ve had the privilege to meet with, listen to, and learn from the brightest and most engaged people in health care. And I’m always surprised: whether it’s physician leaders or those at the top of the federal health agencies, no one quite knows what things will look like next year.

Below are just two vital questions, amongst many others, that burn through my mind; that keep me awake at night when I think of the challenges ahead; the unanswered questions of ACA implementation that I don’t hear spoken of enough (or at all). If you have answers (or speculation), please feel free to comment!

What will Medicaid expansion mean in vivo?
Starting next year, many more people will likely be on Medicaid. In most states, individuals making up to 133% of the federal poverty line will be eligible for their state’s Medicaid health coverage, with expansion from current eligibility subsidized by federal monies.

What will actually happen?

Will people sign up? It is going to take a strong effort to educate millions of individuals (especially those with marginal financial and reading comprehension, and those monolingual in a non-English tongue) on their options, help them fill out the paperwork and produce the documents needed to qualify, and direct them to a medical home.

And will there be medical homes for them? What access will the ranks of Medicaid’s newly enrolled have? The primary care physician shortage is a deeper issue that I’m not going to address here, but I ask you a basic question: do you know a lot of primary care providers twirling their thumbs wondering why there aren’t enough patients to see? I sure don’t.

If there are not enough medical homes for the millions of low income individuals receiving health insurance—some of whom have been foregoing health care services for years, if not decades—will emergency rooms be inundated beyond capacity?

This is a prime moment for public systems like Cook County Health and Hospital Systems (my employer the last 4 years) and FQHCs like Near North Health (which I’m joining). These systems thrive in providing primary care services for low-income and historically underserved communities. And while it will be incumbent upon these systems to help meet the demand placed onto primary care by the ACA, they can only expand so fast, and only if financial constraints allow.

How much higher will our private premiums be?
I know it’s frowned upon for those of us on the left to ask this question, but I truly believe that it’s an important issue to address.

I’ve argued before that health “insurance” is a misnomer. Far from simply insuring against health-related disaster, health insurance instead pools our funds together to pay for medical services, which we’ll all need at some point. I’m going to use “Pooled-Payer Company” (PPC) to refer to what we traditional call health insurance companies.

A while back, private PPCs had to decide how to deal with high risk patients seeking health insurance on the open marketplace. They could deny coverage. Or they could charge premiums that, actuarially, it would actually cost to pay for their likely health care service needs based on risk. Imagine someone making around the annual median U.S. income of $50,000 who has uncontrolled diabetes/hypertension with coronary artery disease and progressing congestive health failure, receiving a letter in the mail saying:

“Congratulations, you’ve been accepted for health insurance with Acme Health, with an annual risk-adjusted premium of $60,000. Lucky for you, we have a convenient monthly installment plan. Your first monthly payment of $5000 is due on April 1st.”

Apparently, PPCs decided that the former was more palatable, and that’s the system of denied coverage we’ve been living with. At least until next year when PPCs can no longer use pre-existing conditions to deny coverage (or “discriminate” against high-risk patients, as I often hear it called).

Now, don’t get me wrong. I advocate for health care for all and believe that the way our society would best pool resources for health care payment is through a single payer system run by us (through our elected government).

But that’s not the reality. Instead, my employer pays a private PPC to pay for my family’s health bills. And if each private PPC will now be paying the health bills of the most risky patient populations for the same annual premiums that my low-risk family is paying, well, something’s gotta give, and will it be the premiums of those currently with private coverage? I hope that the argument that enough healthy young people will become customers of these PPCs (with some incentives and nominal fines serving as carrots and sticks) to offset the high risk customers, but I’m not convinced.

A Parting Question
These two questions lead me to a final question. What happens to support for the ACA, already tepid amongst the public, if we fail to implement the ACA well? Will low-income folks turn against the ACA after they’ve moved onto Medicaid roles but don’t have any more access to health care services than they did before? Will those currently with private “insurance” turn against the ACA if their premiums go up significantly to make up for the cost of care for high-risk patients, or if they’re shut out from emergency rooms filled with newly insured unable to get primary care services elsewhere?

Only time will tell what our health care system will look like into 2014 and beyond as the Affordable Care Act becomes a reality. There are great opportunities to expand services to millions of Americans who lack access today if implementation is done right, and so many challenges ahead.


One thought on “Unanswered Questions of ACA Implementation

  1. CongrAtulations Ravi on your new position. Good post and your concerns are generally well placed! But, remember that ACA is not pushing those currently insured into joining the Medicaid rolls! If one is uninsured today, why is getting Medicaid tomorrow so bad? The ACA is far from ideal and I am sure, there will be refinements and improvements going forwards. I respectfully submit: Medicaid, with all skeptism & access problems aside, is still better than having No Insurance! ARVIND

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