Opinion: What can you expect from health-care reform?

By Marc Sedwitz, MD

Nearly one year ago, the Affordable Care Act — more commonly known as the health care reform bill — became law. As its provisions begin to take effect this year, what changes can consumers expect in terms of medical care, insurance and other health-related issues?

One of the fundamental tenets of the Affordable Care Act is that it makes health care a right to which every American is entitled, rather than a privilege available to those who can afford it. Its key provisions are to provide access to quality, affordable care for all, as well as enabling patents to choose their doctors. Over the past few years, we have seen health insurance premiums more than double, and many people simply cannot afford to keep paying them; as a result, they may lose access to quality care.

Moreover, current insurance guidelines often deny coverage to people with certain pre-existing conditions, making them uninsurable regardless of whether they can afford the premiums. On the other side of the fence, insurers cannot afford to keep paying increasing medical costs without raising rates or excluding the riskiest patients. The Affordable Care Act is really more about insurance reform, not health care reform.

Physicians and hospitals need to work together to determine how we can restructure our current health care expenditures and still provide high-quality care. One of the keys to achieving this goal will be to standardize how we provide care across the health spectrum. Currently, we have many different models of physician reimbursement. Fee-for-service physicians and specialists are compensated differently than primary care physicians, which is leading to a shortage of primary care physicians that will have a major impact in the years ahead. We also have wide variances in how we treat patients. Across the country, we see significant discrepancies in how the same conditions are treated. Procedures and costs vary greatly, and redundancy creates even more expense. We need to analyze outcomes and determine the “right” way to treat an illness—the “best practices” of health care that deliver quality, effective care at a reasonable cost. Several of the country’s leading health care systems are now sharing their outcome data for major procedures with the goal of identifying “best practices” that deliver high-quality, effective care at an optimal cost.

We also need to prioritize preventive care to help keep people well, rather than wait to care for them when they are sick. Hospital care is responsible for an enormous amount of medical costs; we need to keep people healthy and treat them on an outpatient basis as much as possible to get them through their illnesses quickly and effectively.

What about health insurance? Clearly, the system needs to change. The new law will require that 80 percent of premiums are used to cover health care costs, not administrative expenses. Instead of individual health insurance plans, we will see the formation of health care “co-ops” where people can apply for some of the best insurance available at an affordable rate and give patients choice in which physicians they see. Businesses, too, will be able to participate in these co-ops to help them cover the costs of insuring employees.

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