As the House Republican legislation to reform health care moves through Congress, doctors in Fresno are watching carefully. Because whatever happens – a total repeal or a partial replacement of the Affordable Care Act – physicians will be seeing patients insured under the new law.
And doctor acceptance of a new federal plan will be crucial to its success.
So far, the American Medical Association and the California Medical Association have voiced concerns about the American Health Care Act, also called Trumpcare, and how it could affect access to doctors.
But doctors have long complained about Obamacare, as many call the Affordable Care Act. Finding physicians who accept the insurance has been difficult in the central San Joaquin Valley for lower-income patients under the expanded Medicaid (Medi-Cal in California) portion of the law, and also for people buying private health plans through Covered California, the state’s health insurance exchange.
Last week, four Fresno doctors talked with The Bee about the Affordable Care Act – and what they say has worked and what has failed. They also voiced concern that Congress will rush the American Health Care Act into law, as they said happened to the Affordable Care Act, to less-than-perfect result.
They are Alan Birnbaum, a neurologist; Don Gaede, an internist and vascular specialist; Gene Kallsen, a hospital emergency physician; and Alan Kelton, an internist and current president of the Fresno-Madera Medical Society.
Comments have been edited for clarity and brevity.
Q: Do you see patients who have insurance through the Affordable Care Act?
Gaede – I don’t see a whole lot of people with the ACA, but the ones I do appear to be ones that probably would not have purchased insurance and who would have gone without medication, without medical treatment.
Kelton – In my teaching clinic, where I have medical students and residents, most of the patients who did not have insurance before are now covered by the Medi-Cal expansion and some by Covered California. In my other office, where we see traditionally insured patients, it is difficult for us (to accept the Affordable Care Act). We have to do some workaround, having them pay a cash rate in order to still be able to see us.
Birnbaum – The area where my office was unable to see ACA (patients) was in a group of patients who had what we thought was going to be insurance reasonably equivalent to group health insurance but then when the plans came out the actual reimbursement was anywhere from 10 to maybe 15 percent less – one plan was at least 30 percent less.
Q: What have been patient reactions to the Affordable Care Act?
Kelton – It’s a mixed bag. Some when we’re ordering certain tests and doing screening exams, our patients are surprised that we’re doing so and are happy that we’re doing so. On the other hand I still have patients in my practice who refuse to buy care because they didn’t want to be forced into a very narrow network and have almost no access to certain types of care. They were used to having a good private insurance … and they find themselves funneled into essentially the same kind of care that someone with Medi-Cal would have.
Gaede – I was speaking with a patient and his wife just recently. He’s one of the ones who did not have care up until the ACA and now he does. And he’s got medications that he’s taking regularly.
His wife, especially is concerned that if that goes away he’s going to stop taking his medications, which is going to impact their whole family.
Q: What worked and did not work with the Affordable Care Act? What could have improved it?
Gaede – The premiums have been going up, that was not addressed, not very well. That was a gap … that it did not control the escalating cost of medical care. Pharmaceuticals were not controlled and that’s been skyrocketing as well.
Q: Hundreds of thousands of people in the Valley have been insured through the expansion of Medi-Cal in California. Should federal funding, which could be dismantled under the American Health Care Act, continue to maintain the expansion?
Gaede – If you take that away there are going to be a lot of people who are uninsured, and that does concern me.
Kelton – The Medi-Cal expansion gave people insurance cards but not care.
They may have been able to find an urgent care where they could go if they are sick and get treated, but they really could not find a physician to take them on an ongoing basis and provide good adequate screening and ongoing care throughout their lifetime.
Kallsen – It’s not quite as bleak as (Kelton) says, that nothing has changed except they have a card. They sometimes are getting care with that card. New care that they did not get. Preventive maintenance that they didn’t use to get. But it’s not 100 percent of them and it’s not every day.
It didn’t cut down on the total number of emergency visits. Getting in to see their doctor urgently, when they get sick, is very difficult. So I see patients all the time who come in acutely ill and they say, ‘I called my doctor and they said they will see me next month.’ Well next month doesn’t work if you’re acutely ill.
But that’s not a new problem. Medi-Cal has been underfunded for a long time. All of Medi-Cal patients have trouble finding specialty care.
Q: What do you like and dislike about the proposed American Health Care Act?
Birnbaum – I am frankly disappointed.
Unfortunately the Congressional Budget Office has calculated if AHCA went through, we would see 14 million people lose coverage, by 2024 we’d see 24 million lose coverage. Five million would probably be lost out of the exchange plans, 6 million would be people lost out of Medi-Cal plans, 2 million would be people somehow bumped out of group plans. And that is just unacceptable
I had hoped for enrollments to stay about the same – make it more efficient, improve access a little bit better. But that just doesn’t seem to be the case.
Kallsen – I wish that the worst thing that this bill could do is take us back to where we were before the Affordable Care Act, but unfortunately it takes us way past that point.
Q: What could Congress do to improve access to doctors under a new health law?
Birnbaum – What we need to do is in counties where the Medi-Cal rate is greater than 35 percent of the patients, the fee provided should be equivalent to Medicare on an ongoing basis.
At the current Medi-Cal rate, they are providing charity care.
Q: What should stay from the Affordable Care Act, and what should go?
Kallsen – Everybody likes the fact that pre-existing illnesses are covered, but they don’t like mandatory insurance. Well, the two go together. If you don’t have one you can’t afford the other. If you set it up so that only the sickest people buy insurance and the healthiest people don’t buy insurance, it’s going to lose every time.
It’s kind of like saying, how about if we have the Beatles but we don’t have Paul McCartney … and we just do it with the other three. It doesn’t work.
Q: How do we make a new health plan better than the Affordable Care Act?
Gaede – I think the ACA was pushed through in a partisan manner and now the same thing is being done here. And so they need to get a lot more input. The Congressional Budget Report is a wake-up call that they need to do some tweaking, major tweaking and not just ram something through like we did a few years ago with the ACA.
Kelton – We need to figure out what are we going to do to support people who cannot support themselves or cannot obtain insurance. And at the same time, free markets actually work … that’s what makes things inexpensive. So we need to be able to let the free market do what it’s supposed to do.
Kallsen – A single-payer system – with a pretty basic plan and then the ability to buy up from it – is where we’re most likely, eventually going to end up. But it’s probably going to take a long time to get there.
Most of the civilized world has ended up with something like that. Something pretty basic that everybody has and then the richer you are, the more you can buy up above that.
Birnbaum – Unfortunately we got caught up in campaign rhetoric for repeal and replace. Repeal and replace – the two Rs. And really what we needed was the three Rs – review, revise and rewrite.
If there’s any unanimity among the four of us, that’s what it is. What we need is review, revise and rewrite and try and move into an era where we have health care which maintains American quality and starts to move our costs back to where the rest of the world has them.