As a college professor, I have been committed to giving accurate grades to patients. As a physician and hematologist-oncologist, I have been following closely how the Affordable Care Act (ObamaCare) has been impacting care of my patients and medical care in America.
Starting in April 2014, I have periodically given grades to the Affordable Care Act. By dividing aspects of medical care into 6 categories, I have been able to score each of these aspects of care and then averaged them for a “grade”. The categories are ABC: access, benefits and patient confidence; and PQR: price, quality of medical care, and records.
The grade point average for ObamaCare was 2.0 (C) in 4-2014, 2.2 (C+) in 8-2014, and 2.53 (B-) in 4-2016. How good are the grades now? And now that a new administration has been elected, where are changes needed? My evaluation is oriented mostly to patient care, not to political considerations.
Access: Patients have improved access to physicians because pre-existing condition exclusions are prohibited and children can remain on their parents’ insurance policies until age 26. The uninsured rate has dropped from 18% to 10.5% among nonelderly people, and the number of uninsured patients has fallen from 41 million to 28.5 million as of the end of 2015. However, access to care has still been limited for insured patients due to increased deductibles (patients are reluctant to go for expensive treatments or visits), high cost of insurance premiums and medications, fewer participating insurance companies (less choice) and fewer networks of doctors and hospitals (less choice) in many communities. Currently, I give Access a grade of B.
Benefits: Patients have coverage for prevention, mental health, maternal health, and care on clinical trials. Also, there is no lifetime cap on insurance payments and no limitations due to pre-existing conditions. Benefits have improved, and I give this area a grade B.
Confidence: Patients are now more worried than last year, particularly because the incoming republican administration and even democrats have indicated changes are needed. With higher deductibles and premiums, reduced insurer participation and resulting reduced numbers of networks, patients are not sure if they will be able to keep their existing doctors, or have to switch again. In the communities I serve, there has been a reduction in the number of physicians participating in Medicare or accepting Medicaid-insured patients. The IPAB (Independent Payment Advisory Board) is still in place by statute, risking future coverage of some services under Medicare if costs are not reduced. I grade Confidence D.
Price: Premiums are increasing, and costs of drugs are increasing. Since deductibles are also higher, out of pocket costs for my patients are higher. Patients are asking, how much will that test, scan, or treatment cost me? Among uninsured people, 46% say they do not have insurance because of high cost. Worse, there is a non-transparency of cost of care and tests, so patients cannot compare where they can reduce their personal costs. Price deserves a grade of D.
Quality: Evaluating quality is difficult. There has been a 17% improvement in hospital acquired infections, and a 19% reduction in hospital readmissions, but overall quality improvements have been difficult to identify. Blood pressure control and diabetes control are not measurably improving and there continues to be poor physician and patient compliance with many national care guidelines. This area should have a grade of C minus.
Records: There has been a rapid increase in use of electronic health records by physicians. Among physicians, 83% use electronic records, including 87% of primary care providers, 80% of medical specialists and 78% of surgical specialists. Unfortunately, only 64% of solo practice doctors use computerized records. This should improve further as MACRA (Medicare Access and CHIP Reauthorization Act of 2015) is implemented since it reduces payments to doctors is meaningful use of electronic health records is no performed. Electronic records are more understandable by medical staff and by patients themselves, provide better communications with consultants, allow insurers to be certain doctors are complying with national guidelines, but do reduce the amount of time a doctor spends face to face with a patient. Nothing is more frustrating for a patient than staring at the back of the physician while she/he types. But Records gets a B plus.
So as 2016 ends and as President-elect Trump appoints his healthcare team, the Affordable Care Act earns a grade point average of 2.46, or a C plus. Improvements in medical care have occurred, but more improvements are still needed by amendment or replacement of the act. But popular and important advances in ObamaCare should continue.
Here are Dr. Cary’s tips for you and your care under the current Affordable Care Act:
· Always carry health insurance., even if you choose a lower cost plan. This gives you discounts at the doctor, for tests, and at the hospital. Without insurance, any emergency could bankrupt you and your family.
· If you are an employee, you can discuss available plans with the Human Resources department or with your union. If you are a senior, you can get advice from a Medicare adviser at the social security office. If you do not have employer based insurance, you can get advice from a private health insurance agent, or state Medicaid office. See my book and website Surviving American Medicine for a discussion of health insurance plans.
· Once you have insurance, be sure to use your doctor for staying healthy by prevention and screening, not just for evaluating symptoms. If you have any symptoms, get them evaluated promptly so a simple problem does not get worse or incurable.
· If you have a chronic condition, discuss coordination of your care with your doctor, who may be able to improve your care and keep you out of the hospital by using a care coordinator and/or nurse through the hospital or health plan. Also use websites such as NIH, CDC, or Surviving American Medicine to get more complete information about your conditions, or about health maintenance which you can discuss with your healthcare team.