Obamacare: One Year Later
By Megy Karydes
The Affordable Care Act (ACA), the landmark law popularly known as Obamacare, took effect last January. One year later, despite positive changes to the healthcare system, the ACA is still marred in controversy.
The idea of government-sponsored healthcare has always been a lightning rod in the political theater. It’s been one in the public theater, too. And while the topic in general is nothing new, it has never been as polarizing as it has been since the ACA was signed into law in 2010.
The opposition worried that it would cause premiums to skyrocket, create unstable insurance marketplaces and give rise to a socialist state that would do families more harm than good. Proponents welcomed the much-needed access to healthcare for the uninsured and underinsured, and they reveled in the opportunity to amend a convoluted and expensive healthcare system.
An October 2014 Gallup poll showed that the view of the ACA is still unfavorable. The reason? “The negative tilt toward the law is largely attributed to Republicans being much more negative about the law’s effects than Democrats are positive about them,” the poll says. “Sixty-six percent of Democrats say the law will make the U.S. healthcare situation better, while 80 percent of Republicans believe it will make things worse.”
It’s important to keep in mind that the views the Gallup poll are reporting are those based on opinion fueled by partisan emotion. According to a study published by Robert Blendon, ScD, and John Benson, MA, in The New England Journal of Medicine in November, the public’s negative perception of the law is less about what it does and more about what it means. Since 2007, Americans have turned away from the favored opinion that the federal government has a responsibility to provide all its citizens with health insurance. According to a 2007 Gallup poll cited in the study, 64 percent of those polled were in favor of government-sponsored healthcare that year. By this time last year, support was down to 47 percent.
This is due, in part, to the “decline in overall public trust in the federal government to handle domestic problems such as healthcare,” the study says. A September 2014 Gallup poll shows that faith in the feds dropped from 51 percent in 2012 to 40 percent in 2014.
But when we look at how the actual mechanics of Obamacare have influenced the healthcare system over the last 12 months, the results aren’t so dreary.
“Most people have this vision of the ACA as this law that transforms people who are uninsured to insured. They know a little about Medicaid expansion and healthcare.gov. That’s where most of what people know stops,” says Elbert Huang, MD, associate professor of medicine at the University of Chicago Medical Center (UCMC). “In many ways, it did much more. The way that costs were rising in 2008 and 2009 were unsustainable. The law helped stimulate the experimentation going on in new contracts and new ways of paying for healthcare.”
Huang has a unique view of the ACA. In 2010, he was a senior advisor in the office of the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services.
“The movement of systems from traditional (fee-for-service) to one that is more population oriented is going to continue happening,” Huang says. “[The law] had modest effects in terms of treating newly insured people at UCMC. What UCMC has done is expand its number of doctors [who] are thinking about population health management.”
He says that we’ll eventually have a completely managed care system in which hospitals, doctors, patients and insurance companies will all be part of the same system, rather than each one being segmented and essentially advocating for itself instead of advocating for the collective, as has been the case.
“This has been a positive disruption in our business model,” says Stephen Ondra, MD, senior vice president and enterprise chief medical officer with Health Care Services Corporation (HCSC), the country’s largest customer-owned health insurance company. “The fee-for-service model has not always met the customer’s needs. It added to the inefficiencies of the systems. The ACA has catalyzed new ways to align incentives for the stakeholders in ways that will give the patient a more high-value system.”
Chicagoan Jenni Prokopy—who suffers from many chronic illnesses, including fibromyalgia, asthma, depression, anxiety, thyroid issues, Raynaud’s phenomenon and others—feels that now, a year into Obamacare, is the first time she can breathe a sigh of relief.
Every day she’s thankful that the ACA took effect, she says, since the law has had a major positive impact in her life. Without her medication, which is covered by her new health insurance, she says she wouldn’t be able to work and function.
Prokopy, a writer and health activist who founded and edits ChronicBabe.com, was not one of the estimated half million Chicagoans who lacked health insurance. She had been covered by state-administered health insurance. Nonetheless, in 2013, her out-of-pocket healthcare expenses were north of $14,000. She was paying as much for her healthcare coverage as she was for rent.
With her new health insurance, thanks to the options provided through the ACA marketplace, she’s paying less and receiving more much-needed services.
That’s good news, especially for those with chronic conditions, for whom receiving ongoing care is crucial. Nearly half of all Americans have at least one chronic health condition, according to the Centers for Disease Control and Prevention. Prior to the ACA, many went without insurance coverage because they couldn’t secure private insurance due to preexisting conditions. And those who did have insurance, like Prokopy, were paying a hefty premium.
But getting here wasn’t easy. Prokopy admits to feeling terrified that she wouldn’t be able to enroll by 2013’s deadline, since the healthcare.gov enrollment website was constantly down.
“The stakes were high,” says Prokopy, who spent hours at the library trying to sign up to no avail. “I posted a rant on Facebook, [and] a friend reminded me that he was an insurance broker and could help me.”
After meeting with her friend, who helped her find the right plan, Prokopy secured insurance that covered her needs for considerably less per month than she had been paying.
But not everyone has a friend who’s an insurance agent, so the city of Chicago created the Enroll Chicago! plan to reach out to uninsured Chicago residents. The effort enabled people to step forward to identify and reach eligible residents, especially groups with historically higher rates of uninsured members in their communities, such as artists and taxi drivers. Among other ways, artists were met at cultural and special events, while taxi drivers were asked about their insurance coverage when they renewed their driver’s licenses.
“Of the estimated 506,340 Chicagoans who lacked health insurance, approximately 215,000 residents signed up through the marketplace,” says Bechara Choucair, MD, commissioner with the Chicago Department of Public Health. “Over 167,000 have signed up for expanded Medicaid.”
The numbers don’t include more than 100,000 undocumented residents who were not eligible for ACA coverage.
Expanded Medicaid covers individuals with incomes up to $16,105 (up to $32,913 for a family of four) with or without a disability. Above that limit, ACA marketplace plans provide coverage with federal tax credits for individuals with incomes of up to $46,680 (up to $95,400 for families of four). Those whose incomes exceed the limit still can purchase insurance through the marketplace, but they will not receive a tax credit.
Choucair was happy to see so many eligible residents secure insurance during open enrollment but knows that 2015 will be just as important. “These are our friends and relatives,” he says. “They deserve the opportunity to receive healthcare.”
While widely touted for providing a pathway for healthcare coverage for millions of uninsured Americans, the ACA has also provided numerous opportunities for public health and prevention services, making access easier and more affordable.
“There are tangible benefits to residents including [preventive] care and access to mental health services because they now have access to insurance,” notes Choucair.
He’s quick to point out that the city reaps other benefits, too, including federally funded investments into long-standing public health efforts such as health screenings and vaccinations, as well as creating jobs in communities.
Having healthcare coverage isn’t just a financial cost; it’s a human cost, Prokopy says. “We’re all impacted by chronic illness whether we have [insurance] or not,” she notes. “If I couldn’t work and didn’t have a boyfriend and friends to help me, I’d be homeless. Then I would be a cost to society because I would need social services in another way: for food and housing.”
She’s thankful for an insurance plan that is more financially manageable and includes most of her preferred healthcare providers. It’s not comprehensive, but it’s still better than nothing, she says. “I have dental now, but eye coverage is not included,” she says. To care for her eyes, she looks for special deals. “I’ve learned to become a very conscious healthcare consumer.”
For many, with and without insurance, healthcare costs have been a bit of a black box. But given the general direction of healthcare payment, that’s changing.
“This is a chance to change the relationship between payer and provider,” HCSC’s Ondra says.
“People are being asked to be more financially responsible for themselves,” Huang says. “People being more aware of expensive healthcare may help bring transparency, and that will help the healthcare industry reduce [its] costs.”
Choucair says his goal is to make sure that everyone who qualifies for healthcare coverage gets enrolled, regardless of income level or preexisting conditions.
“Our healthcare system is stronger, a year later,” says Choucair.
Huang agrees, especially as it relates to receiving care. He says that the system is moving away from fewer strings attached to more strings attached. “That’s generally a good thing,” he says. “Organizations will be incentivized to know more about the patient. It’s the injection of having an interest in the overall health of the people.”
“The ACA allows for a collaborative relationship rather than one that’s adversarial,” says Ondra. “It’s hard to see that in the midst of change.”
Originally published in the Winter/Spring 2015 print edition
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