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ACA and Beyond | Lisa McNeil BS, CFSS (M)
THE FUTURE OF HEALTH CARE IN AMERICA

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©2014 Lisa McNeil
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Summary
Since 1965 America hasn't seen radical changes in health care until the 2010 house and
senate passage of Patient Protection and Affordable Care Act. With the greater access to health
policies and new health care legislation, America is beginning to see a strain on health resources.
Physician and nursing burnout has been on the rise due to larger workloads, increased paperwork
and decreased reimbursement schedules. While wait times for appointments and therapies are
increasing, referral restrictions being placed on policies and physicians, and deductibles and co-
pays increasing, sometimes doubling, for consumers are just a few negative results of the ACA.
This paper will give a brief summary of the ACA, discuss the pros and cons, and examine the 20-
year trend in the UK and other countries with a similar health care structure. Also attempting, a
look at what America will be facing in the next 10-15 years and the solutions being offered to
consumers who desire to take more control over their health dollar.
Introduction
The Patient Protection and Affordable Care Act (PPACA), commonly called the
Affordable Care Act (ACA) or "ObamaCare", is a United States federal statute signed into law
by President Barack Obama on March 23, 2010. This statute was a historic milestone in our fight
for a more equitable and cost-effective health care system. As has been noted by many
authorities, both scholarly and popular, the US pays about twice what the next most expensive
country pays for health care per capita and has worse results in terms of life expectancy. Limited
access to medical services and reactive approaches to disease and dysfunction have played a role
with out of control expense rates.
It is important to look at the pros and cons of the ACA and the European model the US
adapted. While looking at the European model it is important to forecast what America needs to
be bracing for over the next ten years and explore some innovative ideas that will once again
change the landscape of health care.

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(Economist.com, 2013)
There is an enormous range of the health care costs individuals bear as a result of illness, a fact
of which the general public is unaware and health policymakers have had little success in taking
into account.
The Affordable Care Act
The ACA was intended to provide near-universal coverage through a set of individual
and employer mandates, create a universal marketplace for health care plans while requiring
minimal requirements on those plans, and an expansion of Medicaid. As of April 6, 2015, the
Supreme Court decision which found that the ACA's requirements for Medicaid expansion were
unconstitutionally coercive of the states, led to 16 states to not expand the Medicaid program,
leaving tens of millions of people without coverage. Even so, the ACA has dramatically reduced
the number and percent of people without health insurance.
The Post-ACA Structure of the Health Care Marketplace
To talk about the health care "marketplace" is misleading. With per capita insurance costs
now around $8,000, with the average family premiums in the range of $14,000 a year, while the
median family income of around $64,000 per year, very few can afford to pay for health care.
That market, prior to the ACA, primarily provided affordable insurance only to the very young
and the very healthy. (Health Research Institute, 2015) Those with pre-existing conditions were
excluded entirely or had their pre-existing conditions excluded. (Hamel, 2014) Today's
marketplace is intended to give individuals and businesses the opportunity to choose from
qualified plans, plans that meet the minimal federal requirements and offer subsidies for low
income applicants.
Employer-Provided Insurance
In addition to requiring individuals to carry health insurance if they do not have any other
source of coverage (e.g., Medicare, Medicaid, employer-provided coverage, coverage under a
parent's plan, etc.), the ACA mandates that employers above a certain size provide health
insurance or pay a penalty. There are some indications that the combination of pay levels,
premium subsidies under the ACA, and hours of work are reducing the amount of employer-

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provided insurance. The percentage of employers providing health insurance was shrinking
before the ACA, currently there isn't enough data to disentangle the ACA effects from that long-
term trend. (Blahouse, 2012) As of this writing 89% of employers planned to offer health
insurance in 2014, that number dropped to 66% in 2015. Organizations are controlling health
costs were by changing prescription coverage, passing on the costs to employees through higher
copays and premiums and offering more high-deductible health plans with health savings
accounts. Employers also have begun to alter business practices by decreasing future hirings and
decreasing the hours of part-time workers.
Costs
There are early indications that the ACA will cost much more than was initially expected.
The system is in the first year of penalties for not having insurance and influx of individuals
seeking care, so it will take several more years of evolution before the cost impact is clearly
understood.
The Future of US Health Care: Upside
The ACA has dramatically reduced the number of uninsured and is on track to achieve
one of its goals: bending the cost curve by reducing the annual rate of increase in health care
premiums. While there will be some Americans benefitting more than others, all Americans will
benefit from the new rights and protections of the ACA, guaranteed coverage of pre-existing
conditions and the elimination of gender discrimination are just a few. The ACA ensures that a
person cannot be dropped from coverage when sick or making an honest mistake on an
application. Additionally, women can no longer be charged a higher premium just because of
their gender. Health insurance companies cannot make unjustified rate hikes, and that these
companies must spend the majority of premium dollars on care. All major medical coverage
must now count as minimum essential coverage, which means more preventive care is available
to policyholders. While electronic medical records (EMRs) are controversial, the ACA's
requirements and substantial penalties and rewards for not using them, or for using them, mean a
faster transition from the era of paper charts. Most experts feel that this is long overdue.
The Future of US Health Care: Downside

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With the benefits come a few trade-ins Americans may not realize, to get funding to help
insure tens of millions, there will be new taxes primarily on high-earners and the healthcare
industry.
As noted, the ACA has probably accelerated an already existing trend of employers
dropping health insurance or decreasing benefits for their employees. In anticipation of the
employer mandate, some businesses have begun to cut employee hours. Many lower wage
employees will find health insurance premiums too unaffordable and be forced with no
affordable options due to having been offered health coverage through work.
Many policyholders whose plans were impacted by the ACA's minimal coverage
requirements have seen their premiums go up, co-pays increase and deductibles, in some cases,
doubled. This simply reflects that the non-standardized plans sold before the ACA were a crazy
quilt that often had coverage gaps that made only economic, not medical, sense.
Due to decreased reimbursement schedules, we also see a greater influx of fraud. "Almost
every estimate is that 30% of US medical spending is unnecessary, including fraud," says Elliot
Fisher, a Dartmouth College medical professor and director of the Dartmouth Atlas on medical
disparities. And a federal report published and reported in the claims that hundreds of nursing
homes had billed the taxpayer for skilled services that were not performed. "They're billing for
therapy they don't provide or which the patient doesn't need," says Jodi Nudelman, a New York
state official.(US Health, 2014)
Perhaps the darkest cloud on the horizon concerns the supply of medical personnel.
(Rabin, 2014) Between the start of Medicare/Medicaid in 1965 and now, doctors have gradually
lost power in the field of health care and patient management. With the increase of paperwork,
web of bureaucracy, and decreased reimbursement schedules physicians are being treated as
"units of production" and given productivity targets. Burnout is becoming common. In particular,
with the amount of standardization imposed by the ACA, insurers' requirements for payment
approval and pre-authorization are a crazy quilt that has everything to do with money and little to
do with health care.
Many physicians are seeing about one-sixth of their day consumed with new paperwork
requirements, impinging the ability to spend time with patients. A study led by Harvard Medical
School researchers found the average doctor spends 16.6 percent of their working hours on non-

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patient-related paperwork. In a report on the study, published in the International Journal of
Health Services, the researcher stated the trend is likely to continue, increases of doctors'
paperwork burdens, cutting into time spent with patients, and decreasing career satisfaction
among those in the medical profession.
Among the researchers’ key findings:
 The average doctor spent 8.7 hours per week, or 16.6 percent of their working time, on
administration. This excludes patient-related tasks such as writing chart notes,
communicating with other doctors, and ordering lab tests. It includes tasks such as
billing, obtaining insurance approvals, financial and personnel management, and
negotiating contracts.
 In total, patient-care physicians spent 168.4 million hours on such administrative tasks in
2008. The authors estimate that the total cost of physician time spent on administration in
2014 will amount to $102 billion.
 Physicians who used electronic health records spent more time (17.2 percent for those
using entirely electronic records, 18 percent for those using a mix of paper and
electronic) on administration than those who used only paper records (15.5 percent).
 "Although proponents of electronic medical records have long promised a reduction in
doctors' paperwork," they write, "we found the reverse is true."
As the population ages, physicians have more and more to deal with patients who have
multiple chronic conditions that can only be managed, not cured. The reward of a cure is thus
denied them, and replaced by a treadmill of decline and frustration. Only geriatricians and
palliative care specialists are trained to deal with this and to seek, and accept, maintaining the
status quo or engineering a slow decline as a triumph of medicine. Only a tiny minority of
physicians enter the specialties of palliative or geriatric care. Some 62% of physicians are
considering early retirement or changing careers. (The Physicians Foundation, 2010) The use of
physician extenders such as nurse practitioners and physicians' assistants is a partial solution, but
not a complete one. (De Milt, 2009) Assistants and practitioners can handle perhaps 90% of

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what a family physician sees, but they too are "units of production", they, too, can be told to treat
patients in eleven minutes, and they, too, can burn out.
Early predictors tell us there will be a shortage of over 89,000 to 200,000 physicians and
with average wait times for most medical specialties likely to increase dramatically beyond the
current range of two to six weeks by the year 2022. Various factors, including the downfall of
managed care, the aging of the population, change with practice patterns, increasing regulation
and paperwork are some of the reasons cited for the impending shortage. In 2013/2014 we see
the beginnings of the forecasted trend with the average wait time to see a physician being 18.5
days.
Locally, Wisconsin faces a 20% physician deficit by 2030. If 100 additional physicians
are not added each year, the state's economy will be as much as $5 billion smaller than it could
be. The report outlines various strategies for reaching the goal and gives time and cost estimates
for each strategy. (Wisconsin, 2011)
Market Failure

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Economists use the term "market failure" to indicate a situation in which a market fails to
produce enough goods and services to meet demand at a price that consumers are willing to pay.
(Morrgan Stanley alphawise, 2014) With the structure of the ACA, we have already begun to see
the medical community struggling to keep up with the demands of the influx of new consumers
of medical services. While, as Americans, we are eager for every citizen to have access to
medical coverage and care, the new climate of health care is creating a strain on medical
facilities and personnel.
Looking to Other Countries
As Americans we see the current health events as 'new', when, in fact, much of our
current policies were adapted from countries like Britain. Most news agencies and government
officials claim we adapted a Swiss form of health care, but further reading and unraveling the
rhetoric reveals a closer replication of England's single-payer system.
When looking to Britain, we see hospital emergency room visits are rising, from 18
million in 2005 to 22 million in 2012. That's an increase of 22 percent in 7 years, above the
population increase of 4 percent.
Higher emergency room use is relevant to America, supporters of the Affordable Care
Act often justify its passage stating it will reduce the number of emergency room/urgent care
visits, thereby lowering the national costs of health care. (RealClear, 2013) Not so in Britain.
Jeremy Hunt, the U.K.'s Health Secretary, warned that the increase in emergency room visits
pose the "biggest operational challenge" to the National Health Service (NHS).
The reality is that with a single-payer, Britain's long waits for non-emergency visits are
common, and even scheduled surgeries, arranged months in advance. Medical procedures are
postponed without warning for lack of medical equipment. It has become increasingly difficult
scheduling a regular visit with a General Practitioner (GP) in Britain. Many GPs are booked
weeks in advance. Patients can manipulate and request to see their doctor more timely if they call
early in the day and say their problem is emergent. This manipulation of the system entitles
patients seen in one of a limited number of emergency appointments on the same day.

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GPs are also gatekeepers to specialist services: no GP referral, no specialist appointment.
Last week London's Daily Telegraph published an article about Becky Ryder who was refused a
cervical cancer screening test at age 24 despite showing symptoms of the disease. The NHS only
allows tests for those 25 and older. Ryder died of cervical cancer when she was 26. (RealClear,
2013)
In Britain, some escape the NHS waiting periods through private insurance, private
hospitals, and private practices, with no waiting and a choice of top-quality specialists. Britain's
largest private insurance company is BUPA.
BUPA offers "self-pay" physician services to those whom it does not insure, but who
want to escape the long predictable waits of the NHS. Prices for a "self-pay" GP appointment
range from $105 for a 15-minute consultation to $350 for an hour. (Preview, nd). Concierge
medicine began two decades ago in the UK with a steady increase of physicians leaving the NHS
or legally manipulating the system and operating in both models.
Medical Memberships and Concierge Medicine
In 2010, we saw the rise in the United States of 'medical memberships' and concierge
medical practices, allowing consumers to maximize their health dollars. California, Oregon,
Vermont, Florida, Arizona, Pennsylvania, and Virginia have seen a rapid increase of concierge
medical providers, while Hawaii, Idaho, Iowa, Mississippi, Maine, New Hampshire, South
Dakota, North Dakota, Louisiana, and Alaska have more consumer requests for medical
membership practices than the number of local providers. (Tetreault, 2014)
The lure of direct pay has captivated the medical profession. Mary Pat Whaley, a North
Carolina business consultant who has been helping physicians set up these practices, says
physicians are interested because “they have been getting hammered” in their traditional
practices, and direct pay helps them “get back control” of medical care. A 2012 survey of more
than 13,500 physicians by Merritt Hawkins for the Physicians Foundation found that almost 7%
of physicians that responded planned to switch to the new model in the next three years.
(Physician, 2012) That statistic included 6.4% of specialists, even though, currently, direct pay is
a primary care phenomenon.

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With a clause in the health care law that "allows direct primary-care to count as ACA-
compliant insurance, as long as it is bundled with a ‘wraparound' catastrophic medical policy to
cover emergencies" (Wieczner, 2013, para. 6). Therefore, the emergence of concierge medicine
has encouraged some health insurance plans, such as Cigna, to create employee health plans that
incorporate concierge services (Wieczner, 2013).
Under the medical membership and concierge models, consumers have choices, less wait
times, more control, and better results. The cost of concierge physicians ranges widely depending
on if the patient is paying a monthly recurring fee or annual retainer fee, what services are
included (i.e. if it is a VIP facility), the demand in that area for concierge physicians, and
whether or not the doctor also takes insurance since not taking insurance reduces overhead costs.
For example, a VIP facility may charge as much as $4,000 per year and the physician will
chooses to be limited to 300 patients to have more time per patient. Other physicians may only
charge $660 per year and limit their practice to 800 patients. This is still substantially less than
the 2,000-2,500 patients that a typical primary care physician sees (Carnahan, 2007). The
limitation of patients allows a concierge doctor to see an average of six to eight patients per day
(CMT, 2014a; Press, 2011) compared to the typical primary care physician who sees 20-24
patients per day (Press, 2011).
Conclusion
Just like Britain, our Affordable Care Act will not entirely alleviate the pressure on the
emergency room. Under the Affordable Care Act, visits for preventive care will be free of
charge, which will likely lead to the same kinds of rationing seen in Britain.
Britain's experience suggests that the Affordable Care Act may result in the development
of parallel private initiatives. America already has concierge medical services for those who can
afford it and walk-in clinics in drugstores such as CVS and Walgreen's. Americans are likely to
seek a way out of lengthy waits for doctors, specialists, and services. The free market will come
to the rescue, just as it has in the UK.
While the fate of the ACA is subject to politics and there is at least one more potentially
devastating Supreme Court case to be decided. The best guess right now is that it is here to stay

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substantially in its current form. The big questions are how we will take control of our health
care and providers. Who will dictate care and treatment schedules?
It is likely that the biggest pressure for actual innovation that improves the American
health care "system" will come from frustrated consumers and medical personnel drowning in
paperwork and dissatisfaction with their work environment. Currently there are a number of
solutions suggested and being tested by health professionals pushing boundries and exploring
innovative ideas. Time will tell. Until then, Momentum Movement Clinic has chosen to be
Wisconsin's first concierge, direct access rehabilitation and movement facility. Have we chosen
this path too early to profit, maybe. Have we chosen this path because this model is ultimately
best for patients and clinicans, yes.

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