Who will the Affordable Care Act benefit most?

BUFFALO, N.Y. – For months, Nancy Nielsen, MD, has been talking to a variety of audiences about the Affordable Care Act. Since the summer, Nielsen, senior associate dean for health policy at the University at Buffalo School of Medicine and Biomedical Sciences, has made invited presentations on it to the American Medical Association (AMA) student chapter at UB, incoming chief residents at UB and fellow physicians during grand rounds at Buffalo General Medical Center and other venues.

Nielsen, a past president of the AMA, served as senior advisor at the Center for Medicare and Medicaid Innovation (CMMI) in the Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services. The CMMI was established by the Patient Protection and Affordable Care Act (ACA) and is charged with testing innovative approaches to improving health care delivery, payment and quality.

The ACA exchanges open today. What is your gut feeling about what the exchanges will accomplish?

This is a very exciting time. I happen to be very optimistic about the exchanges. For people who already have health insurance through their employers, nothing will change. But it will be a big improvement for those who have no insurance, or who have been buying it on the individual market, since they will have a choice of plans at much more affordable prices and many will probably qualify for tax credits which will lower the prices even further. We are the last developed country in the world to figure out how to insure our citizens, and this is long overdue.

What are some of the most obvious benefits of ACA?

Already, adult children can remain on their parents’ plans until age 26, co-pays are eliminated for many preventive services like mammograms, children with pre-existing conditions can’t be excluded from insurance and the same will go for adults starting in 2014. There also will be no lifetime or annual limits on coverage. These provisions of the ACA are very popular, even among those who declare themselves opposed to the ACA itself.

Who does the Affordable Care Act help the most?

Two categories of individuals will benefit the most from the exchanges: those who don’t have health insurance right now and those who buy insurance on the individual market. Those who have no insurance because they cannot afford it or because they have preexisting conditions which made their premiums too high will now be able to buy affordable health insurance on the exchanges. Premiums on the exchanges are 16 percent lower than the Congressional Budget Office had projected. And not only are the premiums lower, but it is estimated that more than 70 percent of individuals who buy through the exchanges will also qualify for  tax credits, making their premiums lower still.

How many people in Western New York will really benefit from the ACA?

New York State has 2.7 million uninsured people.  Of those 2.7 million, 64,000 uninsured people are in Erie and Niagara counties; that’s a lot of people.

Who qualifies for a tax subsidy on health insurance purchased through the exchanges?

Individuals making under $45,960 and families of four with incomes under $94,200 may be eligible for a subsidy. To find out exactly what may be available to them, folks should go onto New York’s exchange: nystateofhealth.ny.gov.

How much is the penalty if you decide not to get health insurance?

The penalty for not buying health insurance the first year is $95 per person or 1% of your income, whichever is greater. The penalty will grow yearly. But it doesn’t make sense to skip coverage and pay the penalty. Why would someone choose to pay the penalty and put themselves and their family at risk, when just one visit to the emergency room could potentially bankrupt the family? Why do that when affordable health care is now available? The U.S. government estimates that six out of 10 Americans who seek insurance through the exchanges will pay less than $100 a month for individual coverage.

Who will the ACA benefit the least?

The individuals who will benefit the least are the poor and uninsured who are living in states that choose not to expand Medicaid. When the law was written, the assumption was that everybody making up to 138 percent of the poverty level would be eligible for Medicaid under the expansion, but the Supreme Court decision threw a curveball, making it optional for states to expand Medicaid eligibility.

Under ACA, premium subsidies were made available to those who made between 100 percent and 400 percent of the federal poverty level and buy insurance through an exchange. So now, if you’re in one of those states that didn’t expand Medicaid, and there are more than 20 of these states, and if you make less than 100 percent of the poverty level, but don’t qualify for Medicaid, you can still buy coverage offered on the exchange but you aren’t eligible for premium subsidies. Nobody expected that. These are the people who need the help the most and will be hurt the most.  That’s an unintended consequence that needs to be fixed – but Congress is not in a “fixing” mood right now.

How will the ACA change the way physicians practice?

The ACA will absolutely change – and I would say, improve – the way we care for our patients. We know that being uninsured is hazardous to your health. Insured patients seek care in doctor’s offices, not just emergency rooms. The world of medicine is becoming more patient-centered and efficient and the ACA is going to reinforce and support those improvements. If we are to have a sustainable health care system, physicians and patients need to be more aware of the costs and benefits of the things we order. Physicians will be practicing and delivering care as members of teams, and there may be some new members on those teams as care becomes more patient-centered.

How will the ACA change medical education?

It’s critical that we train our medical students to function in this new environment. When I addressed UB’s first and second year students, they were very attuned to the changes that are coming and they’re excited about giving patients better, more efficient care.

The ACA will further promote the move, already underway here at UB and elsewhere, toward interprofessional education, where students in all the health sciences learn to work together on teams. There is a drive to educate physicians so that they fully appreciate what things cost and the economic and medical impacts of the tests and procedures they order. There’s also a nationwide movement right now called “Choosing Wisely” that is providing information on procedures and tests that should not be done routinely; that’s an important national conversation that’s going on right now in medicine. Our students need to be well-prepared to function in this environment and also able to lead the changes that can improve medical care.

How will the government shutdown affect the exchanges that open today?

It won’t.  They will be up and running in every state, but expect glitches due to the large number of people trying to access them and enter their information today. The New York exchange alone received 2 million visits in the first two hours.  It may be easier, due to less cybertraffic, in a few days. This is not a new government “program;” it’s just a new way, a “marketplace,” where insurers compete for your business and consumers can choose plans that are best for themselves and their families.