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The ACA: Pros, Cons, Public Ire

The Affordable Care Act (ACA) continues to generate strong opinion. Chicago Medicine’s goal has been to accurately report on the law, with balanced and useful information for our 5,000-plus physician-subscribers. The law aims to address rising health care costs and significant coverage gaps in states like Illinois where an estimated 13% of the population, or 1.7 million people, were uninsured.

The disastrous rollout of the ACA on Oct.1, 2013, includes a dysfunctional website and dismal initial enrollment numbers. By the final enrollment date of April 19, 2014, over eight million Americans had selected a marketplace plan, according to the Department of Health and Human Services. But there are important caveats to this enrollment number, since there are likely significant numbers of duplicate enrollments. Moreover, choosing a marketplace plan is not synonymous with paying the premium and having insurance.

The initial rollout was also marred by the phase-out of existing individual plans that did not meet the minimal ACA coverage requirements. Some plans have now been grandfathered in, and some affected individuals have found replacement exchange insurance.

For patients, the ACA offers popular benefits. The law eliminates pre-existing diagnosis exclusions and lifetime limits, sets minimal standards for all insurance products, and allows young people to remain on their parents’ plans until age 26.

On the physician side, several ACA provisions affect office management policies:

Cost-sharing mechanisms. A Chicago Tribune analysis in October of the lowest-price Cook County plans found that 21 out of 22 had annual deductibles of at least $4,000 for individuals and $8,000 for families. With the sharp increase in high-deductible plans, offices must be proactive at collecting co-pays and deductibles at the time of examination.

Coverage gaps. Participating insurers must grant a 90-day grace period to pay delinquent premiums, if the individuals are subsidized and have paid at least one premium. After 90 days of delinquency, the insurer can terminate coverage. The insurer is responsible for charges in the first 30 days. But in the 30-90 day period, physicians are not paid for services by the insurer and must collect from patients.

Narrow networks. Insurers insist that smaller panels with lower reimbursement are a prerequisite for cost control. The industry uses the example of Medicare Advantage, contending that the trend toward smaller panels was already in progress. This is reminiscent of the early 1990s when HMOs pushed to restrict physician panels, raising the public’s ire.

Rise of ACOs. At least 360 Accountable Care Organizations (ACOs) exist nationwide, serving 5.3 million Medicare beneficiaries. Chicago Medicine (May 2014) documented the ACO rollout in Cook County and the programs at Advocate Health Care and Presence Health. Individual physicians need to evaluate the opportunities for their own practices to participate in ACOs.

On a personal note, it has been a privilege to serve this past year as your CMS representative. I was repeatedly amazed at how warmly CMS representatives were greeted in hospital boardrooms, Springfield, and even in Washington, DC. CMS members can be proud that our 164-year-old Society is so highly regarded by the public and elected officials. I am also confident that incoming President Kenneth G. Busch, MD, will continue his tireless service to CMS in the areas of public health, education, and advocacy.

Robert W. Panton, MD
President, Chicago Medical Society

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