Most patients come to my primary-care clinic with a specific complaint - such as a stomachache, runny nose or sore throat.
But Mr. R came for a different reason.
“What brings you in today?” I asked.
“Well,” he shifted uncomfortably. “I think my health care will be taken away.”
I was surprised to learn that I was the first doctor he had ever seen to establish care. Mr. R, whom I’m identifying by his initial to protect his privacy, was among the more than 20 million Americans who gained insurance after the Affordable Care Act was passed in March 2010. He was fearful that he would once again join the ranks of the uninsured after the newly elected Congress promised to repeal the landmark health law. Although House leaders have presented a replacement plan that keeps some aspects of the ACA and is far from final, some of the proposed changes could have a profound effect on those with low incomes.
Mr. R is a warm, middle-aged man. He never learned to read and write, and so getting health-care coverage was always a challenge. Previously, he couldn’t afford the insurance that his employer offered. Once the exchanges came online in 2014, he proudly purchased subsidized health insurance for the first time.
“I was so excited to finally get care,” he said.
As the new plan is being developed, it’s worth noting the federal policies that I consider to have worked synergistically to get Mr. R to my office for his inaugural doctor visit.
First, he was redirected to a “navigator” after finding out that he made too much money to qualify for Medicaid. The ACA made this redirection possible because it enabled individuals to apply for coverage using a single application to Medicaid, the Children’s Health Insurance Program and ACA plans. This streamlined application process made sure that a patient like Mr. R was offered ACA plans at the same time that he was told he did not qualify for Medicaid.
Second, Mr. R was helped by a navigator to find insurance coverage. The ACA created navigators, specially trained personnel who help people apply for insurance and select the best coverage. Navigators help steer patients through sometimes unfamiliar terms such as “premium,” “deductible” and “out-of-pocket maximum.” For patients who have language barriers or for those who are illiterate, navigators can help prepare applications to establish eligibility.
Third, Mr. R found a plan and paid less than $50 a month for his coverage. The ACA provides subsidies to purchase insurance, which has made coverage significantly more affordable for millions of Americans. In 2016, 85 percent of insurance plans purchased on exchanges involved subsidies, which covered on average 73 percent of the monthly premiums. Even with large increases in premiums in 2017, lower-income consumers are protected by subsidies - and more than 70 percent of shoppers can still find a plan for less than $75 a month.
Finally, Mr. R was able to afford his appointment with me. The ACA helps those who are low-income actually use their insurance, and subsidizes such care as clinic visits and medications for anyone with an income of less than 250 percent of the poverty rate.
As I sat across from Mr. R, I couldn’t help but reflect on the fact that so many steps had to have worked in concert to get this jovial man insurance. If the ACA didn’t coordinate between Medicaid and private insurance exchanges, he wouldn’t have found out that he qualifies for other affordable options. If navigators didn’t exist, he wouldn’t have filled out the forms to purchase insurance. If the subsidies were less generous, he wouldn’t have been able to afford coverage or his appointments. And now, everything could be in jeopardy.
I wanted to tell Mr. R that everything was going to be okay, but I make it a point of not being overly optimistic when I talk with patients. Indeed, the Urban Institute estimated that repealing the Medicaid expansion, insurance subsidies and the individual mandate would increase the number of uninsured Americans from 29 million to 59 million, creating more uninsured people in this country than before the ACA passed in the first place.
The new House replacement plan doesn’t seem viable for patients like Mr. R. It rearranges how subsidies are calculated, so that low-income people receive less financial help to purchase coverage, while high-income people receive more. Furthermore, the new replacement plan eliminates cost-sharing assistance, meaning that Mr. R would have to pay more for his medications, doctor visits and hospital stays. If these increased costs force Mr. R to have a gap in coverage, the proposed plan forces him to have to pay 30 percent more for his premiums to sign up again.
While it is still unclear whether and how health care will be changed, we need to keep patients like Mr. R in mind as we examine the actual policies being presented. How would each proposal affect those most at risk of losing their insurance?
If Congress repeals integral parts of this law without a viable replacement plan, then Mr. R, along with millions of people just like him, will lose his coverage. If Congress replaces the law with one that disadvantages low-income Americans by altering subsidies for insurance, then Mr. R will still lose his coverage.
It has become clear to me that the ACA was not an amalgamation of random policy ideas ripe for repeal, but a coherent act, with interwoven parts that work synergistically. Just as repealing the ACA’s subsidies would make Mr. R uninsured once again, replacement plans that target other key aspects of the law could be just as devastating.
Some politicians have argued that the ACA gets in the way of the “doctor-patient relationship.” What they do not seem to understand is that without the ACA, I wouldn’t have a relationship with patients like Mr. R at all - because he wouldn’t have health insurance. And without insurance, if Mr. R had chest pain, he would face the terrible choice that nobody should make: stay home and risk permanent disability or death from a heart attack, or go to the emergency room and risk bankruptcy.
Mr. R deserves better. As he sat across from me, I sighed and tried to ask a little bit more about his insurance coverage.
“Mr. R, what kind of insurance do you have?”
“Obamacare,” he stated simply. “And it’s going away.”
Jacobs is a resident physician at Brigham and Women’s Hospital in Boston.