Column: The risks and benefits of the Affordable Care Act

BY EZRIEL KORNEL

The New York state health insurance exchange fared better from the get-go than its federal equivalent under the Affordable Care Act (ACA), known as Obamacare. Getting onto the state website and signing up for a plan was not nearly as problematic as the federal site. There can be no question that making health insurance available to those who previously could not afford a policy has been a good thing. It also has been undeniably a good thing that individuals can no longer be denied a policy because of a pre-existing condition. Allowing children to remain on their parents”™ policies to the age of 26 has been a boon for many. With these substantial positive aspects of the ACA, why are so many health care consumers and health care providers unhappy with this piece of legislation?

Well, there are negatives and they are substantial. To begin with, while there are happy individuals who can now afford health insurance, there are unhappy individuals who found that the policies they had been carrying were no longer available and the ones they now had to choose from were more expensive and more limited. So they are paying more and getting less. Other than insurance company executives and some odd bureaucrats, no one could really say this is a good thing.

What is really distressing is that policies are so confusing that even the brightest consumers may not understand what they are signing up for. One big promise of Obamacare was choice of not only plans but, most importantly, of providers. This has clearly not been the case when it comes to the New York State of Health marketplace. For the vast majority of New Yorkers, whether purchasing insurance as an individual or as part of a group of fifty or fewer employees, real choice of health providers has not been an option. Even with all of the out-of-pocket expenses these plans demand with deductibles, copays and coinsurance, the option of seeing a physician or going to a health care facility that is not a plan participant is nonexistent. If you want to go out-of-network, then you are completely on your own. If you can”™t afford paying the fee, then too bad, you just have to use the health care providers and facilities that your plan has signed up. Furthermore, you may be in for a surprise, thinking your health care provider is in the plan because they are on the plan”™s list, but as so many consumers and providers have discovered in New York, these lists have often been wrong. Many doctors and facilities that had participated with a particular insurance company would not sign up to participate in their market exchange plan because the offered reimbursements are untenably low. Other providers discovered the contracts they had previously signed with insurance companies forced them now to participate in these plans at reduced fees. The result has been confusion and unhappiness, which will certainly amplify as New Yorkers begin to utilize their policies.

In order to accommodate higher numbers of patients at reduced fees, providers will have to further curtail the amount of time spent with a given patient. It will become increasingly difficult to get an appointment with a health care provider, and once in the office or clinic, the patient will find that they have only a few minutes of attention, often by a nurse or physician”™s assistant and perhaps not at all by the physician. Most surgical patients only have the opportunity to see their surgeon once briefly before surgery and perhaps once or twice after. Can there be any doubt that this will affect quality of care? After all, our well-being may require significant thought and attention, not just a brief glance, even with all the sophisticated tests and “guidelines” now being utilized. Physicians don”™t like caring for their patients in this way, and patients (and we are all patients at one time or another) don”™t like receiving this type of care.

The state Legislature has, fortunately, recognized flaws in the system and, with the leadership of an intelligent governor and wise senators and assemblymen, has just passed crucial legislation that will go a long way toward ensuring quality health care in New York. The larger insurance companies have been offering out-of- network policies to large employers and insurance groups but had been trying to peg these payments to very low Medicare rates. Unbeknownst to the consumer until they get the bill, the lion”™s share becomes their responsibility. These policies have been giving the false impression that the policy holder can choose out-of-network health care providers, but from a true practical perspective this has not been the case. Choice becomes a fiction. The new legislation changes this. Insurance companies that offer any out-of-network policy must include in their offerings a policy that reimburses out-of-network fees based on FAIR HEALTH, the fees that have been independently established as the usual and customary fees in New York. Additionally, the insurance companies as well as physicians must provide transparency. The consumer needs to know if the plan they are considering reimburses based on Medicare rates or on usual and customary rates (FAIR HEALTH), and how much of the bill may be left for them to pay. New Yorkers who opt to purchase a plan that reimburses based on usual and customary rates will retain a true choice of health care providers, thus assuring that one of the most important promises of Obamacare is kept.

Ezriel Kornel is a leading New York neurosurgeon specializing in minimally invasive neurosurgery, with offices in White Plains, Fishkill and New York City. He can be reached at ezrielkornel@gmail.com, 914-948-0444 or brainandspinesurgeon.com.