A Physician’s View of the Affordable Care Act

I’ve been a physician for 37 years. I’m often asked what my thoughts are on the Affordable Care Act (ACA). First a little history. The Affordable Care Act – The Patient Protection and Affordable Care Act was signed into law by President Obama on March 23, 2010. It is more commonly known as the “ACA” and it’s most commonly referred to by its nickname, Obamacare. The key points were as follows:

• The million time repeated  “If you like your plan, you can keep your plan,” said by Obama over 37 times was part of the “Grandfathered health care plan” portion of the bill. Supposedly any one who had an individually purchased health insurance plan in place had a health insurance plan with “grandfathered status,” which meant that, by-in-large, the plan could stay the same as long as their insurer continued to offer that plan. So what happened? Well LOTS of people COULDN’T keep their plan because insurance companies and physicians didn’t LIKE the ACA and withdrew from ACA plans!! Insurance companies have done that for years – made plan changes that force some people to change their doctors.
• The Individual Mandate. Anyone who bought a health insurance plan after March 23, 2010 would eventually have to enroll in a new plan that met all of the new standards of the Affordable Care Act. The most legally and politically controversial aspect of the ACA, the individual mandate requires Americans to purchase health insurance or face a government penalty, with some exceptions—particularly for low-income individuals who cannot afford to buy insurance.
• Pre-Existing Condition. The ACA was designed to make health insurance available to those that have been denied coverage by private insurance companies because of a pre-existing condition. Something virtually EVERYONE on both sides of the aisle agree on.
• Extension of dependent coverage for young adults.  Young adults can stay on their parents’ insurance until age 26, even if they are not full-time students.
• No lifetime limits on coverage. This eliminated any maximum dollar amount that a health insurance company agrees to pay on behalf of a member for covered services during the course of his or her lifetime. It also eliminated any “annual” cap on coverage.
• A few other items that gave some additional Medicare Part D (medications) coverage, Preventive care and appeals processes.

So how did it go for the ACA? Well here are some of the problems:

• Some people’s costs went through the roof! Those who do not qualify for subsidies found marketplace health insurance plans unaffordable. Many end up paying more for a plan that includes benefits, such as maternity care, that they don’t not need.
• Businesses were unable to absorb the increased costs of providing health insurance for their employees. Many found it more cost-effective to pay the penalty and let their employees purchase their own individual insurance on the exchanges rather than provide employer-sponsored coverage.
• You could face large tax penalties if you were uninsured. This was removed under the Trump Administration in 2019.
• Many insurance companies made their provider networks smaller to cut costs while implementing ACA requirements. This left customers with fewer providers that are “in network.”
• Just TRY buying health insurance in the “marketplace”. Shopping for coverage can be more complicated with limited enrollment periods, difficulties with the websites, and more coverage options.
• Many parts of the country still have only one insurance option because of insurance cancellations, decreasing competition, and increasing costs.

For a VERY detailed analysis of the ACA I suggest reading this article: https://pubmed.ncbi.nlm.nih.gov/28339427/ These are some of the findings summarized:

• “The ACA is applauded for increasing the number of insured, quite appropriately as that has occurred for over 20 million people. Less frequently mentioned are the 6 million who have lost their insurance. “
• “The majority the expansion was based on Medicaid expansion, with an increase of 13 million. Consequently, the ACA hasn’t worked well for the working and middle class who receive much less support, particularly those who earn more than 400% of the federal poverty level, who constitute 40% of the population and don’t receive any help. 
• “exchange enrollment has been a disappointment and the percentage of workers obtaining their health benefits from their employer has decreased steadily.”
• “Those on the exchanges or getting employer benefits have faced high out-of-pocket costs. ” This was the part of the ACA that was SUPPOSED to be about “Cost containment” It didn’t work.
• What did it do to MY PRACTICE? “practice management and regulatory compliance costs have increased. Structurally, solo and independent practices, which lack the capability to manage these new regulatory demands, have declined.” YES……I sold my practice because we were losing money like you wouldn’t believe!!
• “The reduction in costs is an arguable achievement, while quality of care has seemingly not improved.” Actual “reduction of costs doesn’t take into account “factors such as the recession, increased out-of-pocket costs, increasing drug prices, and reduced coverage by insurers.”
• “Quality of care has seemingly not improved. Finally, access seems to have diminished.”

So there you have it. As a physician I actually HAD been optimistic during the legislative phase of the ACA. I TOTALLY support covering pre-existing conditions. I like better access to coverage BUT I am in support of a free market system which is competetive and I believe would result in better products and selection. I currently pay $985/month with a $5000 deductible!! I think government mandates are a slippery slope although I don’t understand requiring car insurance but not health insurance! NO ONE should lose their savings or home because they become ill… so YES, there shouldn’t be “caps” on coverage. I’m not really sure why I should be paying for someone’s 26 year old “child”?? ESPECIALLY when they’re driving a newer car than me and have a $1000 iPhone clutched in their hand!!

Finally…..why re-invent the wheel? Medicare is a fine insurance program with MOST of the money actually going to patient care not executive salaries. Why not let THAT be the “universal coverage” ? Coverage that you can BUY INTO based upon your financial situation. You don’t need BILLIONS for a new “marketplace”. When you are able to afford coverage from an independent plan you can! The ACA was a start….but it’s time to move on sensibly.