Why the preservation of the Affordable Care Act should matter to you [PODCAST]

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“Is the ACA perfect? Not by a long shot. In Kentucky, where I live, there are only 2 insurers selling individual policies on the exchange. A Silver plan for my husband and myself costs $1,800 per month in premiums, with a $13,600 deductible and an out-of-pocket maximum of $14,600.  Therefore, the total exposure every year is over $36,000! Furthermore, there are no alternatives for individual coverage other than the exchange. However, without the ACA protections, we might not be able to buy health insurance at all. The best solution? The U.S. must join all the other developed countries around the globe and implement universal health coverage. Make health care affordable and accessible for everyone. It should be the American way.”

Susan G. Bornstein is an obstetrician-gynecologist.

She shares her story and discusses her KevinMD article, “Why the preservation of the Affordable Care Act should matter to you.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Susan Bornstein. She is an obstetrician-gynecologist, and she wrote the KevinMD article “Why the preservation of the Affordable Care Act should matter to you.” Susan, welcome to the show.

Susan G. Bornstein: Thank you very much. Thank you for having me and for the service you do trying to get education out.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Susan G. Bornstein: Sure. As you mentioned, I’m an OB/GYN by training. I was in solo practice for about 20 years in Louisville, Kentucky, and I really enjoyed it, and I valued the bond that I had with my patients. We answered the phone; we didn’t use voicemail. We got the patients in when they needed to be seen. It was a very personalized relationship that I had. But over time, that business model became less and less economically sustainable, and so I ultimately had to leave solo practice, and I went to work for a large hospital organization, which was nice. I got rid of all the administrative responsibilities, and I didn’t mind letting those go so that I could focus on patient care.

But I started getting more and more concerned with the issues that my patients were having with regard to cost and access to care, and it actually prompted me to go back to school to get a master’s in public health, and I finished that degree. About two weeks after finishing my degree, I tripped and broke two bones in my lower right arm, which was a really poor idea for a surgeon. But while I was on some forced time off, it gave me time to reflect, and I realized I couldn’t work until 11 o’clock every night and do the health care delivery system reform advocacy that I really wanted to do. So I left clinical practice just about a year and a half ago, and I’ve been focusing on education around health care and the need for health care delivery system reform, hence my blog post. So that’s kind of how I got to where I am.

Kevin Pho: Excellent. What would you say was the biggest challenge for you, transitioning from a clinical role to one that is more in advocacy and policy?

Susan G. Bornstein: That’s a good question. I would say that I really miss my patients. I took care of many of them for decades, and it was extremely hard for me to leave. A friend who had left clinical medicine before I did said that I needed to double the patient appointment time as I was leaving, because I would spend a lot of time commiserating with the patients regarding their feelings about me leaving, and that was indeed true. But I consoled myself with the thought that while I was no longer going to be able to provide direct patient care on an individual basis, I was going to devote the rest of my working life to trying to help them in a more systemic fashion. So that provided some consolation for both of us.

Kevin Pho: On my podcast and on my blog, I always advocate that physicians go into policy and try to change a health care system from a physician’s standpoint, and some of them do that, like yourself. But a lot of physicians don’t have quite the right skill set. So I guess you’ve seen the world from both sides, both from a policy side and a clinical side. What are some of the skills that physicians are missing to be effective advocates in our policy system?

Susan G. Bornstein: In the run-up to the 2018 election, and with the threat of the loss of the Affordable Care Act imminent, I talked to all of my patients at nearly every visit about what the loss of the Affordable Care Act would mean to them. I think that as physicians, we not only have responsibility for the medical care of our patients, but also for sort of the societal care of our patients. And if they can’t access the care that they need, if they can’t get to our office because of one obstacle or another, then that is partly our responsibility to try to help and make that be different. So I think one of the most important things, and one of the things that’s really getting lost as we’ve sort of devolved into this “let’s see as many patients as you can in a given time block” situation, is to really take the time to talk to your patients and to get to know your patients. And I would say that’s probably one of the most important things, one of the things that I cared the most about when I was practicing.

Kevin Pho: And for those physicians who do want to get more into the policy advocacy space, what would be your number one actionable tip for those doctors?

Susan G. Bornstein: I think that you have to really be aware of what’s going on. I think that the responsibility is incumbent on all of us to understand the ways in which the current health care system is failing, not just the patients. I mean, it’s failing the physicians, too. I’m sure you know, and I’m sure you’ve probably gotten blog posts about high rates of physician burnout and turnover and the number of hours that physicians are spending charting as opposed to providing direct patient care and doing the things that are really meaningful. So I think that they have to try to spend time understanding what some alternatives might be and then talking to their patients.

You know, the health care policy decisions are made by elected officials and by legislators, but they affect all of us. And one of the problems, as I see it, is that those decisions are incentivized by the large special interest groups that keep the politicians in power, and the two large ones that come to mind are insurance companies and pharmaceutical companies. So if a politician wants to stay in power, they need money, and so they take these monies from special interest groups, even though it’s not meeting the needs of the constituents that actually elected them. And so I think that one of the things that’s really important is for trusted individuals, so physicians, nurses, community leaders, to become aware of what’s going on, how the situation can be different, and models for those situations to be different, and help get that information out to their patient base, so that they’ll either help convince their legislators to vote differently or elect people who will actually act in their best interests.

Kevin Pho: Let’s transition now into your KevinMD article, “Why the preservation of the Affordable Care Act should matter to you.” Now, for those who didn’t read that article, can you just walk my audience through it and share the story of why you decided to write it?

Susan G. Bornstein: Sure, sure. As you mentioned, I’m an OB/GYN, and there are a number of patient protections in the Affordable Care Act that were going to directly impact my patients, but the patients weren’t necessarily aware of those things. So I wrote the article to help increase the awareness of some of the very important factors, or protections, that are in the Affordable Care Act.

Some of those things: The one that we talk about the most is protection against pre-existing conditions. Up to a third of Americans have pre-existing conditions, and prior to the passage of the Affordable Care Act, about 20 percent of people were denied health insurance. That means they just couldn’t get health insurance at all, so they had to pay rack rates for whatever they needed if they went to the doctor or they went to the hospital, which led, not surprisingly, to the largest category of bankruptcies being health care costs. And so, keeping the, if we got rid of the Affordable Care Act, we would lose. The Affordable Care Act says that insurance companies cannot discriminate against patients based on pre-existing conditions. So that was a really important protection that was in the Affordable Care Act.

Other important protections include guaranteed coverage for maternity care, guaranteed coverage for well-woman care, so Pap smears and mammograms, and guaranteed coverage for contraception. If you can’t control your fertility, you can’t control your life. You can’t finish your education. You can’t climb the corporate ladder. You might wind up having children that you either can’t afford or are not capable of caring for as those children should be cared for. So the Affordable Care Act mandated that employers that provided health insurance to their employees had to cover contraception as a benefit. There were already exemptions in the law for religious reasons, but unfortunately, in 2017, Mr. Trump and his administration widened those exemptions so that employers could refuse to provide contraceptive coverage for any reason at all.

So keeping those things, which are very important to the lives and welfare of our patients, I thought we needed to be aware of. There are definitely problems with the Affordable Care Act, and it still is leaving 10 percent of the population uninsured, and 29 percent of people with insurance are underinsured. And I don’t want to spout a bunch of statistics, but one that I always keep in mind is that 25 to 50 percent of people forgo medical care because of cost. So we’re still not where we need to be, but the protections that are enshrined in the Affordable Care Act are extremely important.

Kevin Pho: Now, we’re speaking in the second week of January, shortly before the incoming Biden administration. Where do you see the future of the Affordable Care Act going in the next year or so?

Susan G. Bornstein: Where do I see it going, or where do I want it to go?

Kevin Pho: How about both? Where do you see it going, and then where do you want it to go?

Susan G. Bornstein: So I’m not sure where it will go. As you’re probably aware, the constitutionality of the Affordable Care Act is still under threat. There was a suit brought out of Texas and by the Trump administration challenging the constitutionality of the Affordable Care Act when Congress essentially removed the mandate for individual coverage. They didn’t; they just said that you couldn’t fine people for not having it, which then invalidated the thrust of the individual mandate. There have been some who believe, then, that the rest of the Affordable Care Act is no longer constitutional, and so there’s a challenge that may take down the entire Affordable Care Act. So there is that on one front, and whether that can be halted or not, we don’t know. So the entire Affordable Care Act could be demolished in the next year.

Well, there are a number of problems with the Affordable Care Act, but one of the problems is that it doesn’t make health insurance necessarily affordable for people. The cutoff for qualifying for subsidies to buy a health insurance plan on the exchange, which was created by the Affordable Care Act, is an income of $68,000. And in Kentucky, there are only two insurance companies doing business on the exchange. One of them only allows you to go to one hospital, and neither of them has any out-of-network benefits. So that means if you leave town, you have no coverage at all other than emergency room coverage. The cost is also prohibitive. For example, for anyone that is the ages of my husband and myself, the premiums are roughly $2,000 a month, with a $17,000 out-of-pocket maximum, which means that the annual exposure for anyone the ages of my husband and myself who makes over $68,000 a year and buys one of these plans on the exchange is roughly $41,000 a year. And that’s insane and unaffordable.

What makes a lot more sense is to join the rest of the developed nations and switch over to universal coverage with a tax-based financing plan, which would mean that everyone pays the same according to their income, as opposed to now, where if you have a lower income, you could have the same costs as someone with a much higher income. Therefore, you’re spending a much larger percentage of your income on health care costs. And it would make health care much more affordable and accessible for everyone. No co-pays, no deductibles, so people can get health care. They live healthier and longer lives. They’re more productive in their workplace. It would be a better situation for everyone other than the insurance companies.

Kevin Pho: We’re talking to Susan Bornstein. She is an obstetrician-gynecologist, and she wrote the KevinMD article “Why the preservation of the Affordable Care Act should matter to you.” Susan, you mentioned universal health care, and as you know, there are many different ways of getting there. There are some systems in the world that preserve private health insurers and some that don’t. And of course, there are some people in the country who advocate for a Medicare for All system and want to abolish private insurers. So in your opinion, what is the role of private insurers in the American health care system going forward, and is there a place for them?

Susan G. Bornstein: In models such as Germany, they do still have a private insurance company. Everyone gets universal coverage through their employer, and if they don’t have an employer, they still have access to health care; they still are covered. You have to earn over a certain amount of income in order to be able to buy private insurance, and it does cover some of the costs that the government-based health care does not, so some of the very small co-pays. I think their co-pays for hospital admissions are somewhere on the order of $12 per day. And it may buy access to some of the services that are not covered by the regular insurance companies. But it’s interesting: All of the physicians do participate in the regular care, and it would provide much better access to care than what we have now, where our networks are very restricted by insurance panels. And so I think it would open things up. And in other countries, like England, there is the opportunity to purchase private insurance for access to certain kinds of clinics and stuff like that. So there may be a role for them, but not the 12 to 18 percent overhead that they currently recoup in the U.S. market.

Kevin Pho: And my final question, Susan: What is your take-home message you want to leave with the KevinMD audience?

Susan G. Bornstein: I just want everybody to think about the fact that all we have is now, and if we want there to be a difference, we have to work to make that difference. We don’t get a do-over, and what we’re doing right now isn’t working. It’s leaving too many people behind. I know that a lot of people have many things on their plates, and it’s hard to focus on health care when you’re worried about putting food on the table, when you’re worried about losing your job. But the COVID pandemic has thrust this into the light in ways that we had not been previously appreciating, and it has certainly shown us what stark disparities there are with regard to people of color and minority populations, with regard to outcomes from COVID, but also with other diseases as well. So I just want to raise that on people’s radars and to start thinking about it and find ways that we can catch up with all of the other developed countries to provide better quality of life for all of our citizens. Our life expectancies in the U.S. are falling. That’s going in the wrong direction. So it’s time to try to make a change.

Kevin Pho: Susan, thank you so much for being on the show. Thanks again for your time and insight.

Susan G. Bornstein: Thank you so much. I appreciate it.

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