It’s July, and that means the first provisions of the Affordable Care Act are starting to kick in, and as the reality of the changes slowly sink in, in spite of the massive disinformation campaign the republicans have engaged in for over a year, more people now support the new law than oppose it.

Let’s cut to the chase – the republicans were desperate to stop healthcare reform because they knew that people would like it, and now they are shrieking about repealing it because they know that once it is fully in effect and popular, not only will it be as permanent in our society as Social Security and Medicare, it will expand. What we got was just the starting point of a long journey that will lead, ultimately, to single payer. They know it, and they know that the race is on – they have to do their damage to it now before the people figure out just how venal and craven they have been about the whole thing, and decide to exact a political price on the republicans for their hateful, meanspirited ways.

Good luck with that whole repeal schpiel, repubs. That’s all I’ve got to say.

In about six weeks, the co-pay for preventive services will go away for new policies. The provision will kick in on existing policies on the plan renewal date or January 1, whichever comes first. This means that mammograms, immunizations and routine, yearly exams will be provided free of charge.

This means that more people will get preventive services who couldn’t afford them previously, even though they had insurance. Everyone who has worked in healthcare has stories to tell about patients they provided end-of-life care for who didn’t have to die, but delayed seeking care because they could not afford the deductibles and co-pays.

One particular patient comes to mind when I think about people who fall into that chasm. She was self-employed and, of course, had a high-deductible plan for herself, while her children were covered on her ex-husband’s group policy.

She disovered a lump in her breast in the early summer, but she deliberately waited until the first of the year to have it checked out because she couldn’t even afford the first five hundred dollars that the yearly exams would have cost, let alone the first five thousand dollars out-of-pocket for treatment in one year, let alone two. By January, when she finally saw a doctor, it was a stage 4 cancer and had spread to the bones and lungs. She died within the year, and left two teenagers she had been raising pretty much on her own.

We also know at least one early retiree who became uninsured because they couldn’t afford coverage on the private market, were too well off for Medicaid and too young for Medicare, and who became sick and got wiped out financially getting themselves poor enough to get Medicaid. Of course, that is easy to do. All you have to do is get sick, and then pay your medical bills for a month or two and you’ll be broke soon enough.

To curtail this tragedy and stop the too-familiar cycle from repeating over and over and over again, the ACA establishes a program to help employers cover the cost of providing healthcare to early retirees by reimbursing 80% of medical claims between $15-90,000 for early retirees, their spouses and other dependents. This program is taking applications now, and all services rendered since June 1 of this year are eligible. Think of this program as a bridge to 2014 for these folks, when the health insurance exchanges will be up and running and enrolling patients and the ACA is fully implemented.

By 2014, all states will expand Medicaid, the state/federal program that covers mostly poor children, to include everyone who earns less than 133% of the federal poverty line, including childless adults, and the federal government will pick up the tab. States have the option of moving forward now and receiving partial reimbursement, and Connecticut and the District of Columbia have done so, but I hope they go slowly. Not because I want to deny anyone care, but because I want reform to work. If several states surged to the fore simultaneously, two crippling problems could hinder reform efforts.The first is the number of providers. Currently, there are not nearly enough doctors who take Medicaid assignments to provide for the existing Medicaid patients. We absolutely need a surge of providers – not just doctors but nurse practitioners and PAs as well as registered nurses, LPNs and all of the allied health professionals. The additional healtcare pros we need have to be recruited and trained, and that takes time.

The second problem that will have to be dealt with here is the incompatibility between computer systems. The hodge-podge of health information technology systems in this country is a freakin’ nightmare of systems with minimal compatability. It is a system that has been crying out for standardization and streamlining for three decades, to no avail.

It starts with individual practices. When medical practices started computerizing as desktop computers became widely available in the early eighties, a cottage industry of independent consultants cropped up practically overnight as offices bought computers, apparently thinking they were magic or something, that they would transform their offices instantly simply by taking them out of the box. They looked for help, and those of us on the scientific side of medicine were quick to realize the opportunity in front of us, and we wasted no time cashing in. The only things that had to be standardized were the fields on the HCFA forms that insurance and Medicare reimbursements were filed on, and all claims were filed on paper. This was a good decade before the first claim was submitted electronically.

I know something about this because I got in on it.

My work-week was typically Friday, Saturday and Sunday nights, so picking up extra money defining databases and networking four or five desktop computers in offices where I already knew at least the doc from working with them in the hospital. it was ideal for me. It was also done mostly off-site. With a phone and a fax, I could work from home until it was time to install the software and train the office staff in how to use it. At the time, it was a selling point that each office could have the system they wanted. It was theirs, and since it had to be programmed anyway, they were encouraged to make it however they wanted it. When Microsoft Office replaced dBASE III, WordPerfect and Lotus I-II-III a decade later, we moved them to Office and set them up to file their claims electronically. The opportunity to introduce a standardized system that could be tweaked within certain parameters was missed, and now it is going to be expensive and time consuming to fix it.

There are close to nine million patients, most of them both elderly and poor, who qualify for both Medicare and Medicaid. The rules for dealing with this group of patients is extremely complicated, and it varies from state to state. Bringing the framework across states into some sort of basic allignment will be a good place to start, but it won’t be a cakewalk.

Another change that is coming sooner rather than later is streamlining the process for the FDA granting approval for ‘follow-on biologics.’ These are drugs that are manufactured in living plant or animal cells and are used to treat serious, life-threatening diseases such as cancer and multiple sclerosis. The ACA gives the FDA the power to approve lower-cost generics of these drugs after 12 years. Before the ACA, they had 17 years of patent protection, and that was frequently extended.

And finally, one of the changes that will happen quickly is premiums will be tracked and monitored, and premium increases will have to be approved by the federal government and the insurance commissioners of the states where increases are being sought. Currently the National Association of Insurance Commissioners is in the process of drafting
recommendations for the federal regulators who will be tasked with tracking premiums. While the federal regulators won’t be able to regulate rates, some states already do exercise that authority.

Since the healthcare debate started, people opposed to reform have screamed “it’s a government takeover!” and I have screamed back “you should be so lucky!”

I wish you all had the peace of mind and security I have with my evil, socialist healthcare – but never fear – I will keep fighting for it until you do. That’s just how I roll.