In a recent presentation on the topic of Navigating the Changing Healthcare System, I spoke about how significantly the US healthcare system has evolved over the past 15 years or so.

In particular, I focused on three things, each of which has played a large role in shaping how all of us access healthcare today. 

#1. The Passage of the Affordable Care Act (March 2010)

The Affordable Care Act (ACA) was designed to address the health of Americans in numerous ways. Here are two ways that were especially important…

Expanding Insurance Coverage to Increase Access to Healthcare

This is the foundation. It has made a world of difference to millions of people who previously did not proactively seek healthcare. Instead, they did so only when gravely ill and in the form of emergency care, incurring unaffordable costs that often sent them into bankruptcy.

This provision was designed to expand coverage without limits, offering protections for people with pre-existing conditions.

This is huge!!! To quote the US Department of Health and Human Services:

Health insurance companies cannot refuse coverage or charge you more just because you have a “pre-existing condition” — that is, a health problem you had before the date that new health coverage starts.

Health insurers can no longer charge more or deny coverage to you or your child because of a pre-existing health condition like asthma, diabetes, or cancer, as well as pregnancy. They cannot limit benefits for that condition either. Once you have insurance, they can’t refuse to cover treatment for your pre-existing condition.

As someone who has helped individuals purchase health insurance both prior to and since the passage of the ACA, I cannot overemphasize what a monumental difference this has made to us all. 

And yet, I am still surprised by the number of people who ask me about this topic and who are unaware they can no longer be discriminated against for a previous condition in the world of health insurance. As a healthcare professional, I am a happy warrior about this topic, continuously spreading the word and offering reassurance.

Improving Quality Through Innovation

One innovation of the ACA was the development of a Patient Centered Medical Home model of primary care. This has led to an all-inclusive model that combines physicians, nurse practitioners, and physician assistants who comprise the core of the practice with case managers, social workers, behavioral health professionals, pharmacists, and physical therapists, to create patient-centered and coordinated care.

Overall, this approach has been groundbreaking in preventing hospitalizations and helping vulnerable individuals thrive in the community. 

Some of our clients have complex healthcare conditions. Under these circumstances, our primary focus is to coordinate care through the creation of an inter-disciplinary team that manages the healthcare needs of these individuals. This is invariably challenging due to the lack of coordination in our healthcare system, a system that is comprised of disconnected specialist care.

(I use the term “inter-disciplinary” rather than “multi-disciplinary” because the former analyzes, synthesizes information, and then creates a coordinated and consistent action plan. A multi-disciplinary team tends to draw on individual knowledge but does not cross boundaries.)

But when we encounter a primary care practice that is a Patient Centered Medical Home, it is so much easier to work closely together to coordinate services based on need. Over the years, I believe we have avoided hundreds of hospitalizations from this approach. We welcome all the help we can get from a system with better coordination.

#2. The COVID-19 Pandemic (March 2020 – May 2023)

Our healthcare system demonstrated amazing resilience during the pandemic, especially in the initial 18 months. But there were longer-term implications, including widespread burnout and depression of healthcare workers, leading to an exodus of experienced professionals, resulting in labor shortages, that now manifest in delayed access to care.

One bright spot, however, was the broad adoption of telehealth, something that was in development for years but could never seem to find its footing pre-pandemic. Since then, it has provided opportunities for accessing care more easily. 

Still, telehealth is not perfect — in certain circumstances, laying eyes and hands on a patient is critical to their care. But for follow-up visits and visits where a physical examination is not necessary, telehealth has proven to be a wonderful alternative. 

For older and vulnerable adults in particular, not only does telehealth remove the need to transport these individuals to the center of Boston for appointments, but it is also a much more efficient means of initiating second opinions, especially for cancer care.

#3. The Passage of the Inflation Reduction Act (2022)

The Inflation Reduction Act (IRA) has had and will continue to have a profound impact on how prescription drugs are purchased. Highlights include:

• In 2023, the monthly cost of insulin was capped and recommended vaccines became available to Medicare recipients with no cost sharing.

• In 2024, Medicare recipients who found themselves in the catastrophic phase of their Medicare Part D Prescription drug coverage, a phase in which many had out-of-pocket costs exceeding $10,000/year, had their cost sharing limited to $4000/year.

• In 2025, Medicare will limit out-of-pocket costs for Part D prescriptions to $2000 per calendar year. Further, to avoid potentially paying $2000 the first month on the plan, the IRA includes a Part D “prescription payment plan,” allowing Medicare beneficiaries to break down their prescription drug costs into equal monthly payments. Again, for those clients who had out-of-pocket costs that exceeded $10,000/year, they will have their cost sharing limited even further to $2000/year.

• In 2026, Medicare will begin to negotiate drug prices. The selected drug list for the first round of negotiation is: Eliquis, Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Imbruvica, Stelara, and Fiasp. This will have a major impact for many of our clients.

Recommendations

At Healthassist, our guiding principle is, “Take control over what you can.” That means YOU and how you approach and react to the ever-changing US healthcare system. More specifically…

Focus on your relationships with all your providers. Become the leader of the inter-disciplinary team I described above by partnering in your care, planning for appointments by creating an agenda, and being assertive about the need for a coordinated approach.

Research and fully utilize options for telehealth as a means of improved access and coordination. If you feel limited in your technical skills, seek out others who may be able to coach you in this area.

Identify your care partner(s). For solo agers, please review my suggestions from a previous newsletter. 

Review your Medicare Plans for 2025. Embark on an in-depth analysis to be sure you are availing yourself of the most comprehensive and cost-effective options, taking into account the new provisions of the Inflation Reduction Act.

Summary

I describe myself as a “realistic idealist,” always striving for the ideal and then compromising to accommodate what is possible. In our imperfect US healthcare system, I choose to focus on improvements I have seen over the past several years.

I care deeply about accessibility and affordability of high quality and coordinated healthcare. At the risk of being political, I believe that any politician that wants to take away what we have accomplished in the past 15 years — and who cannot offer a viable alternative — is not serious about our health.

As we find ourselves in this incredibly unsettled election season, I ask that the issue of healthcare be high on your list of issues for consideration.