Americans Understand Their Health Care Differently?

Last week, I replied to a physician whom I knew from college after he posted a long commentary on Facebook about healthcare funding.

After reading and replying to various posts in this thread about Obamacare, I thought " we all understand our healthcare system in different ways"?

We are experiencing very different realities.

Watching the discussion unfold, reminded me of experiencing healthcare before, during, and after the implementation of the Affordable Care Act (ACA) in Indiana. Indiana is valuable to understand for many reasons: it improved access to care before 2008, it is a red state with a penchant for balancing its budget, and it eventually expanded access leveraging Obamacare funding. When I posted to the thread that the Healthy Indiana Plan (HIP 2.0) was funded using federal dollars during the Obama administration, under Governor Pence I suspected many would be surprised. Hard to say, as only one friend acknowledged this and the remainder continued to lament how much worse things have gotten. Perhaps healthcare in the US or anywhere is just too complex for most to understand the context of others' experiences. Also, healthcare just keeps getting more expensive.

In my mind, there are 3 buckets of experience in the US

1. Americans who are fortunate to work larger employers (thousands of employees) who have continuously provided insurance and even improved access to innovative services. Employers like this include Boeing, Lilly, Cummins Engine to name a few. My older brothers fit into this category.
2. Americans who work for small employers or are self-insured. This included me from 2004 to 2014 when I worked as a health care systems consultant and physician. The experience in this group has been rough with many losing insurance or changing plans multiple times. Many employers opted out of providing insurance directly after ACA, encouraging their employees to obtain insurance via the marketplace including gold, silver, and bronze Obamacare options.
3. Americans who were uninsured (or dangerously underinsured) prior to 2008 -- estimated by the Obama administration to be 48 million Americans. This group clearly benefited from financial subsidies which made insurance affordable for those close to poverty. I saw many patients who fit in this category who had the Healthy Indiana Plan 1.0 insurance and at a clinic that provides free care. I suspect some of my extended family fit in this category, but I don't know them well enough to be sure.

During the remainder of the article, I will share stories from my personal and professional life about each bucket.

My 2 older brothers have worked for one of the largest companies in the world for the past 20 years, Boeing. Over the last decade, I have asked them several times if they are happy with their insurance from Boeing -- the answer is always YES. I have seen many presentations and spoken with executives at Boeing about their innovations including wellness programs and centers for excellence which my brothers both accessed.

Hearing about the successes of Boeing, inspired me to better understand what Indiana companies were doing with their employee health care programs. Both Cook Medical and Lilly are life sciences companies that created their own primary care clinics over 30 years ago. Both companies have quietly innovated to deliver access to care and coordination which is now being modeled by giants Apple and Amazon. Cummins Engine, a $17 billion-dollar company based in Columbus, Indiana also created its own primary care clinic in the past decade. In addition, Cummins Engine hired a chief medical officer who helped them establish centers of excellence and integrate lifestyle (cooking, fitness) classes into their benefit structure. These large companies live in the first bucket where employees have not experienced significant interruptions in insurance coverage. They have been able to continually innovate before and after the ACA.

From 1998 to 2014, I worked for a series of small businesses that were challenged to provide affordable insurance coverage. For ten of these years, I was self-employed and purchased my family's insurance on the open market -- during that ten-year span, my total costs doubled. Some of this was driven by changes in my family's health, but during that time no one in the family had a catastrophic illness such as cancer or major trauma. Prior to Obamacare, employees of small companies were losing access to care. It would be logical to attribute some of this to regulations imposed by the ACA. I attribute many problems to the dramatically inflating the cost of care in the US. Our country is more than twice as expensive as Japan, which is the 2nd most expensive care per capita in the world. Many articles have written on this topic. If ACA were not in place, I believe one of the members of my immediate family would be uninsurable due to preexisting conditions.

This leaves us with the third, massive bucket of Americans who were uninsured before Obamacare. I do not know anyone in this large group on a personal level outside of my work as a physician. However, I have taken care of hundreds of patients who were newly insured after Obamacare and I was paid for my services at a reasonable rate by the Healthy Indiana Plan 2.0. This group appears to have greatly benefited from the affordable expansion in insurance coverage. Ideally, having insurance will encourage patients to avoid expensive and unnecessary care at emergency departments by establishing primary care relationships. Like any significant culture and behavior change, we are not likely to see individuals who have not had insurance for many years proactively seek preventative care. This article provides a comprehensive summary of HIP 1.0 and 2.0 history.

If nothing else, writing this article forced me to think about others' experiences with the US healthcare system. Going forward, I hope we can maintain insurance coverage for as many Americans as possible in a manner that encourages regional and state-level innovation. The ACA is an enormous federal program that has created a number of unintended consequences.