The impact the Affordable Care Act has had on the previously uninsured and low and middle income families cannot be understated as millions of Americans and tens of thousands of Ohioans have gained access to health coverage for the first time through the health insurance marketplace launched last year. But the consumer impact is just one part of the health care law’s overall impact on a complex network of hospitals, insurance companies and other stakeholders, each focused on a critical area of health care. Here are their stories:
Condition kept doctor
from insurance plans
Before the Affordable Care Act became law in 2010, Dr. Tanisha Richmond said she couldn’t buy health insurance — at any price.
“I’m a diabetic, and because of my pre-existing condition I just couldn’t buy a policy,” said Dr. Richmond, who is self-employed and runs a podiatry practice at the Charles R. Drew Health Center on West Third Street. “I was turned down numerous times, so I just paid cash for my medication, doctors visits and lab tests. As a diabetic, you have to have blood work about every three months, so the costs can add up quickly.”
The health care law outlawed discrimination based on pre-existing conditions, opening the door to health coverage for thousands of previously uninsured Ohioans.
“As soon as the law passed (in 2010), I was able to buy a policy,” the 32-year-old foot-and-ankle specialist said. “At the time, I was paying close to $700 a month (in premiums). After the health insurance marketplace opened last year, I cut my premiums in half.”
She now pays $340 a month for a policy from Medical Mutual of Ohio that carries a $5,000 deductible.
Unlike 85 percent of who signed up for marketplace coverage this year, Dr. Richmond’s income was too high to qualify for federal tax credit subsidies that could have reduced her premium and deductible even further.
Still, she said: “I’m very satisfied with my coverage now. I had to change doctors because the doctor I had been seeing wasn’t in my network under my new policy, but I found a doctor right away, so it never interrupted the continuity of my care.”
Studies show that about 70 percent of marketplace plans offer fewer physicians and hospitals than employer-based plans, which cover about 60 percent of Americans under age 65.
But that’s changing, according to Dr. Richmond, who said even doctors who initially rejected the health care law are beginning to join her in accepting marketplace plans because of the financial incentives.
“Physicians are beginning to realize that many of us with marketplace coverage are sick or have undiagnosed conditions because we went without health care for so long,” she said. “We’re patients that are going to need a lot of care. We’re not going to be patients they might see once or twice a year. We’re going to be patients they see at least once a month, if not more, for years.”
‘saved my life’
Sherry Samartini of Englewood lost the health coverage she had through her employer when she was laid off from an engineering job in Cincinnati in 2009.
Samartini, 45, said she remained uninsured while she went back to school to earn a certificate as a medical assistant because she couldn’t afford coverage on her own.
She now works as a medical office manager for a small practice that doesn’t offer insurance, but because of the tax subsidies offered through the health care marketplace she was able to buy a health plan from downtown Dayton-based CareSource for $60 a month.
Signing up for health coverage in the marketplace “basically, saved my life,” Samartini said.
“I went to the doctor in January soon after I got my insurance card, and my doctor told me she heard a heart murmur,” she said. “They sent me for testing and discovered I had a bad heart valve that would have to replace. I had no idea I had this condition because I didn’t have health insurance for so long.”
Samartini’s health plan has a $250 deductible and co-pays for office visits, prescriptions and lab tests are as little as $5.
“There’s just no excuse for people not to have insurance,” she said. “It was something I needed to do, so I just made up my mind to come up with the means to do it. If I can afford, I think most working people can.”
Insurance save man
thousands for healthcare
Charles McClinon of Roselawn — a suburb of Cincinnati — said he hasn’t been able to hold down a job for at least the past five years because of epileptic seizures that had been growing in frequency and intensity until he finally had surgery this past summer.
In July, McClinon, 51, had a vagus nerve stimulator inserted near his collarbone to send mild pulses of electrical energy to his brain to control his seizures. He has visited his doctor every week since undergoing the surgery to gradually increase the stimulation and and monitor his progress.
McClinon estimates his medical bills would be in the hundreds of thousands of dollars if he were not among the more than 300,000 Ohioans deemed newly eligible for Medicaid this year under expanded eligibility requirements established by the Affordable Care Act.
“I’ve already accumulated more than $30,000 in medical bills just from going to the doctor on my own,” he said. “I never would have been able to afford the surgery, much less the follow-up treatments, if I didn’t have Medicaid. I applied for disability and was rejected, so I would have been on my own without the health care law.”
Hospitals deal with
Change, what change?
That’s essentially how Kettering Health Network executives responded when asked whether the Affordable Care Act had fundamentally transformed the way they do business.
The health care law has pushed hospitals away from the traditional fee-for-service payment system, in which doctors and hospitals generally are paid for each test and procedure they perform.
Hospitals are now rewarded for limiting the volume of patients that are re-admitted and avoiding unnecessary tests and procedures. But the approach is nothing new at Kettering hospitals, which are operated by Seventh-day Adventists who believe in a holistic approach to healing.
“Our dedicated focus to comprehensive quality and safety outcomes has really positioned us to be very successful in the new health care environment without really changing our focus because well-being has always been our focus,” said Terri Day, president of Kettering Health Network.
Still, health reform has forced Kettering to deal with decreasing reimbursements as their costs continue to climb.
Medicare payments to hospitals were cut by 2 percent last year as a result of spending reductions — known as sequestration — required by the Budget Control Act.
The Medicare cuts were supposed to be offset by an increased number of patients insured by Medicaid and private health plans under the health reform law.
A new report from the U.S. Department of Health and Human Services projects hospitals nationwide will save $5.7 billion this year from serving fewer uninsured patients.
But the jury is still out in terms of the financial impact on hospitals, said Todd Anderson, chief financial officer at Kettering’s Grandview Medical Center.
“We’ve seen charity care go down, and we’ve seen a little bit of a Medicaid increase,” Anderson said. “But I think it’s a little too early to tell in terms of quantifying that impact.”
Selling health insurance like its chief competitor, Premier Health, would be one way for Kettering to increase patient volume and shore up revenues.
“We know that’s a trend right now,” Day said. But “at this point in time we’ve chosen a path to partner and collaborate with the existing insurance plans in our market.”
But Kettering officials haven’t ruled out the possibility of starting their own health plan.
“I think right now as things continue to develop….you have to continue to be flexible,” Day added.
expected to be easier
A major player in the health insurance marketplaces in the past year has been CareSource and company officials said they are preparing for the next enrollment.
The annual open enrollment period starts again in just two months, and Scott Streator, vice president of CareSource’s health insurance marketplace product line, said CareSource has taken steps to avoid the technical issues that may have curbed enrollment in the early going last year.
“We’ve made a sizable investment in IT,” Streator said. “We have a very sophisticated tool that integrates directly with the federal government website. A consumer can go to our website (caresource.com), start the enrollment process and be redirected to the federal website to find out about their eligibility. Then they come back directly to us, choose a plan and enroll.”
In addition to the IT upgrades, the company is expanding its downtown operations to accommodate the surge of new business from Ohio’s marketplace as well as new markets in Indiana and Kentucky, where CareSource will begin selling marketplace plans next year.
The company is in the process of moving 200 workers from its downtown headquarters to a nearby building at 220 East Monument Ave. to support marketplace enrollment.
The move will free up space for additional hiring downtown, where CareSource plans to grow its payroll to 1,950 from 1,400 as a direct result of opportunities created by the health care reform law.