Illustrations by John Gara.
With the law upheld, I will see fewer patients who lose their insurance, don’t get birth control, and then come to me with unplanned pregnancies. And a planned pregnancy is a healthier pregnancy, so fewer unplanned pregnancies would also mean fewer infant deaths.
I don’t take any insurance. I have a fee for service practice. In the past, a patient would be reimbursed about 80 percent of the bill by their insurance carrier. Now they will only get 140 percent of what Medicare pays. Since that is very little, I believe many of my patients will be forced to switch to an in-network provider. As a result, I could lose a huge patient base. While I truly believe that health care is too expensive, it is still unclear how mandating that everyone is covered will decrease the cost of healthcare.
My practice treats largely geriatric patients and is almost 100 percent Medicare. We have already seen some benefit from Obamacare. Specifically, our patients have better coverage for their prescription drugs, and they are very happy about it, especially our significant percentage of limited-income patients. From our side, as primary care doctors, we have seen a bonus to our pay which was enacted with this law. If it had been struck down completely, that would have affected our patients because of their drugs, and us because of our bonus. It is urgent to get more doctors attracted to primary care, and keeping this bonus is a help.
We are still seeing a lot of people who still can’t find insurance and even if they do it is so costly that people cannot afford it, because the provisions for uninsured people will not be effective until 2014.
We need to get the insurance companies to lose total control of healthcare in this country, but whether increasing government control is the answer remains to be seen! The Canadian system would be a good model if we could afford it.
The Hospital Resident
From my perspective as a resident right now, this bill doesn’t affect me because doctors, hospital residents — we don’t care where the money comes from. Someone else worries about how our patients pay for it. So this is not going to affect us in the near term. We’re going to practice medicine exactly the same way.
The people who pay for the care, it affects them. The bill is going to affect the billing department at the hospital — it’s going to affect the way they do business. At the clinics the nice thing is if everyone has insurance they might go see a doctor regularly for check up before they come into the hospital. So they might know about problems like high blood pressure well in advance of them becoming so bad they have to come see us. The hope is that $10,000 in health care for the lifetime of a patient doesn’t turn into $250,000 because they found out they didn’t get treated and later found out they needed some expensive surgery.
I really think patients would take advantage of the opportunity to get regular checkups. People don’t go to the doctor because they say, I don’t want to spend money on going to the doctor. If maintenance is financially available to them, they can go in to the doctor because insurance covers it. With Obamacare, it’ll be affordable if they need an operation. And if you catch things early, it’s always less expensive to fix the problem than if you catch it late. So we could save money but that’s a very small part of the total picture and the bill certainly doesn’t address the whole picture and wasn’t designed to address the whole picture. No legislation and no rhetoric coming out of Washington has really addressed the whole picture. The law doesn’t really address how to reduce cost of health care. It just unified the payment stream.
My fellow residents and I don’t even talk about this bill even a little bit. Everyone’s made up their mind long before the ruling, and it splits according to what kind of specialty they are in. The surgeons and cardiologists tend to be against Obamacare but the primary care and family doctors tend to be for it. They’re really made up along politically ideologies and not related to substance. If they make a lot of money they want to keep on making a lot of money, and if they don’t they’d like to give better patient care.
The Public Policy Professor at a Pharmacy School and Former Pharmacist
With the law upheld, you might see an influx of people obtaining treatment. It will increase the number of people who have health insurance, which would increase their ability to get medicine. To respond to that influx, we wouldn’t need to train more pharmacists. (Ten years ago, we had one pharmacy school in North Carolina. Now there are three, and one more on the way.) We would need to continue this shift that’s already happening in the industry — pharmacists are moving away from just dispensing medicine and becoming more involved in clinical care. If the law goes into effect, there’s going to be a greater need to help people understand their prescriptions since so much more medicine will be prescribed.
A a psychiatrist, I have a different relationship to the insurance industry than most doctors because of mental health carveouts. Basically, people’s regular insurance doesn’t handle mental health — the insurance company contracts with a behavioral health management company to manage behavioral health benefits. The companies have a separate set of requirements for patients and doctors — some of them require that you meet a separate deductible for behavior health, some require doctors to submit a different and more detailed treatment plan for mental health treatment than they would for physical health. Mental health parity laws say you can’t have different lifetime limits or visit limits for mental and physical health, but they don’t say you have to have the same standards or requirements.
I’ve opted out of taking direct insurance payments in my practice because insurance companies haven’t made it possible for me to provide care. In 2000, behavioral health management companies moved in and undercut the health plan I worked for. For two to three years my colleagues and I tried very hard to work with these companies, but we basically discovered that they stole from us. They didn’t have consistent standards, they wouldn’t tell us what their standards were, and even if we did what we were supposed to do, they would bundle and drop 10 percent of claims without even reviewing them. They also valued our services at a level that didn’t let us pay our electric bill. We lost money on every insured patient.
With the Affordable Care Act upheld, I’m hoping health insurance coverage becomes genuinely widespread and I’ll be able to see a full range of patients again. We will have to revisit whether we accept insured patients again. If there are provisions in the law to remove the perverse incentives for behavioral health companies to deny claims, that could really help. But some of these things await implementation, and since implementation is delayed until 2014, it’s hard to know for sure what will happen.
The Marital/Family Therapist
The healthcare law is going to mean an end to what is called “preauthorization” for mental health, and that’s absolutely fantastic for young doctors who are just starting out, and who are affiliated with HMOs or PPOs. With those plans, in some cases mental health visits are doled out 5 at a time or 10 at a time, and that’s extremely annoying for us, because we have to document what is wrong with the patient and why the patient needs therapy. And frankly, it’s nobody’s business. Who the heck knows who’s reading these things? They’re on file, who knows for how long? The forms have to be perfect, because otherwise when we share information like this, we’re breaking patient confidentiality.
Of course not having to deal with preauthorization for therapy is going to be a huge, huge thing for millions of people with this new law. That said, I have no idea how that will affect those who don’t use insurance, or whether or not the law is going to indicate that we have to lower our fees. People like myself sometimes can see poorer people because we have a sprinkling of wealthy people who pay out of pocket, or they have private insurance that is often much better than HMOs or PPOs. We may not be able to charge those people $150 a visit anymore, that may go down to $73 or $83, I don’t know. How will it affect us ultimately? In the big scheme of things, it’s anybody’s guess. In the little scheme of things, it’s going to make everybody’s life easier, and hopefully impact in an incredibly positive way the mental health of our country.
—With reporting by Anna North, Amy Odell, Hillary Reinsberg, and Jessica Testa.