I am a family physician and professor of public health, and an expert on the ACA aka Obamacare, ask me anything!

What do you wish more people understood about Obamacare, positive or negative?

Well at 906 pages, the Patient Protection and Affordable Care Act (aka the ACA or Obamacare) it's a little hard for individuals to sort through what's positive and negative. For example, there's almost $1 billion funded via an ACA provision for Prevention and Public Health. This allows funding through federal agencies like the Centers for Disease Control and Prevention (CDC) to grant funds to states for public health preparedness (for example to deal with Zika virus outbreaks), to education prescribing providers, individuals and families about the appropriate use of prescription opioids for acute and chronic pain, and for education programs to deal with our epidemic of overweight and obesity.

Could you give me a layman's definition of "single-payer"? I keep hearing that we didn't do it with ACA and that's the problem. If you could give your thoughts on the subject, it would be appreciated.

There are many countries with 'single payer' systems - though the universal coverage in one developed country can be quite different than another (e.g., Canada's might be described as along the lines of Medicare for all [not just for those age >65 as it is in the US], versus the system in Germany). Compared to other developed countries, the US spends far more (almost twice as much as other developed countries), yet in some important population health outcomes doesn't do as well (such as neonatal mortality, life expectancy). For what we spend (almost $10,000 per person in the US), we should be achieving better health outcomes.

Would a true "single-payer" system achieve better outcomes (wouldn't one entity have stronger bargaining power than dozens or hundreds of smaller entities?)?

Many of the developed countries with single payer do better in terms of lower per capital costs and better population health outcomes.As the ACA was being drafted in 2007-2010, the single-payer and Medicare for all proponents pushed very hard for this. There weren't enough votes to get that through the House and the Senate back then. Doesn't seem likely in this Congress either.

In economics, one of the ways to lower costs and make a market more competitive is to ensure that customers have the best information in regards to the product they're buying. Healthcare seems to be this incredibly unique market where the customers seem to just accept an asymmetric information problem. In addition, hospitals in particular seem very reticent to tell a patient, prior to a service, what their service will cost.

What are your thoughts on requiring published price lists for services for hospitals, doctors' office, etc.?

Cost opacity is a real problem, it's so hard to apply economic and marketplace strategies when so little information is available to consumers. Arizona passed a interesting bill making cost transparency more available to the public!

Simply put, how optimistic are you that the Trump Administration can, and will, produce a better solution?

I see no upside to pessimism, so I remain hopeful that we can build on the gains made in coverage (i.e., reducing the uninsured to a record low of 8.6%), and focus on reducing the volatility of the individual health insurance marketplace. That won't be easy - but one thing that could be done is allowing insurers to sell plans across state lines, and making it so that the insurers can count on multi-year agreements to offer affordable plans on the state and federally facilitated individual marketplaces.

A follow-up on selling plans across state lines: how do you weigh the benefits of high coverage rate vs. the potential "race to the bottom" that would be caused by removing individual state regulation? In other words, is having some coverage for a lot of people worth it being flimsy coverage?

The downside of selling across state lines is that it could reduce local department of insurance control and regulation.

Aren't they already able to sell plans across state lines? And how would that increase coverage for poor/sick folks (whom the insurance companies "compete" to not cover)?

There is indeed a provision in the ACA, giving states the option to allow this. While three states have allowed it, no insurer has done so to date. So it might be a useful way to keep insurers or to expand insurer options, it hasn't panned out so far - at least in terms of insurers jumping on board.

A lot of people have seen their premiums go up.

I live in Washington State and always paid for private insurance until finally getting employer health care, and I feel like I must be living in a parallel universe.

Why are some people seeing a view going from $50/mo premiums and $1000/mo deductible to like $700/mo with a $6k deductible, whereas someone like me, healthy, young, and employed, nonsmoker, always seemed to be paying between at least $400/mo slowly rising to $500/mo over a period of 15 years?

Can you speak to why this law (and previous legislation) appears to be affecting people so differently?

This isn't just happening in the state of Washington! In Arizona, where I live, we had at least 7 insurers offering over 70 plans on our federally facilitated ACA marketplace two years ago - and this year we only have one insurer offering plans in each of our 15 AZ counties. Two years ago, we had the second lowest premiums for silver marketplace (healthcare.gov) plans - and from last year to this year, some of our counties saw a doubling of premiums. Those less than 250% of the federal poverty level were largely shielded due to the way the advanced premium tax credits work in the ACA - but those without subsidies certainly felt that jump. Congress can address this volatility in several ways - one important one would be allowing them to offer plans across state lines, another would be to allow multiyear contracts. This individual health insurance market needs stabilization - and the insurers are nervous, and the consumers unhappy with the jumps in premiums and that insurers are jumping in and out of the market each year.

Sorry, that was not clear.

In Washington, the ACA has been overwhelmingly positive for people who were previously paying for insurance. Only those who were depending on ER care but who are not exempt are suffering.

Whereas in places like AZ, I keep hearing about doubling of premiums. I don't get it. That is not happening here.

Here, the only premiums that doubled were those that workplaces chose to stop subsidizing. Or many people would not pay, file medical bankruptcy, and now have to pay in month by month and that bothers them. Well, paying for their medical bankruptcy bothers me if they can pay in, so I view that as a different question.

My premiums have not gone up. At all. They were always high.

Sorry, misread your note. For the low income, those over 100% FPL but less than 250% federal poverty level and many others - the plans remain affordable (i.e., $100 or less per month).

Do you have a professional opinion on TRICARE?

In full disclosure, I served on the TriWest board of directors some years ago - that was the Tricare entity for the western third of the US. From that experience - the beneficiaries (military active duty and dependents in the CHAMPUS triple option plan called Tricare) really seemed to like their options, access and coverage. I think we could learn a lot from Tricare - for example - allowing an insurer like United to bid on a multiyear contract, and then creating a contractual network, held accountable by standard access metrics- such as how long it takes to schedule a routine appointment, how many days until a specialty appointment can be scheduled.

I did a lot of calling for OFA in the run-up to ACA, and everybody I talked to LOVED Tricare. Even if they were against ACA (in which case their reasoning was, "I don't care, I have Tricare.")

The consumer satisfaction survey responses would validate that comment - in general those on Tricare are as satisfied, or more satisfied than those covered by other types of health insurance.

What do you make of the change in rhetoric among Republicans from "Repeal and Replace" to "Repair"? Does this shift indicate that we may have more time before elements of the ACA are dismantled?

On the front page of the New York Times today, the headline was "Reality Chills Heated Words on Health Law: G.O.P. Ambitions Shift from Quick Repeal." The US health system is unduly complicated and fragmented between public and private coverage. Taking the time necessary to build on the progress, and make coverage and access to care better - means a thoughtful - and hopefully, bipartisan approach. We can do better for the $3.2 Trillion we are spending on health care in our country.

I'm a walking preexisting condition and am a grad student, so I don't make any money to potentially save in an HSA to prepare myself for the inevitable repeal of my healthcare. I have endometriosis, Hashimoto's and POTS. Is there anything that I can do to prepare myself for no longer having health insurance?

Yes, good point - health savings accounts may work well for the young and healthy, but few save enough to deal with a truly catastrophic event (developing cancer, or being in a serious motor vehicle accident). And HSA's don't help for those with a pre-existing condition. Some have proposed high risk pools for those with chronic disease, pre-existing conditions - but those don't have a very good track record to date. It's just hard to make health insurance (or automobile insurance) work when people only pay premiums when they become ill (or in the case of car insurance - get in an accident). That was the idea behind a tax mandate, a penalty to encourage people to get insurance.

As someone observing from outside the US, my understanding of Obamacare is that it is similar to the german and japanese systems in that it forces insurance companies to cover everyone. However unlike the two systems in question, doesn't legislate the prices of medical interventions and insurance premiums/terms leading to abberations like overpriced medical services and deductibles that basically make your medical insurance unusable.

Is this reasonably accurate or am I missing some information here ?

Yes, these countries have some similarities, though they both do better in certain population health outcomes, and pay far less per capita. The German system has some interesting features that might have appeal in the US population.

This may seem inflammatory but it isn't intended to be.

How does a doctor, who I believe still swear an oath justify bankrupting someone in dire need of medical aid? Is it a case of "i just work here" or are there real viable attempts to change things?

I'm from the UK and I can't understand how an "advanced" culture/society can profit from illness. Our NationalHealthService is sacred.

Many living in the UK like the system they have, as do many of the health providers. In my years as a family doc, my practice included more than half on either Medicaid or uninsured. Some clinics and hospitals get help fiscally for caring for uninsured and underinsured patients (e.g., federally qualified health centers, rural and critical access hospitals). Access to care in rural areas, and for certain populations can be a challenge, but can be overcome with policy interventions to reduce uncompensated care.

First of all I would like to thank you for your valuable time, AMA's are one of my favorite parts of reddit. And this one seems right up my alley. I am a former Army Medic, currently working at a FQHC as a Behavioral Health Care Manager, while going to school hoping to eventually attain a degree in Healthcare Administration. One of the more interesting things I recently learned was how the American Medical Association created propaganda campaigns against universal health care likening it to Nazi socialism, largely hampering America's ability to keep up with other Western Countries healthcare systems. How do you see the AMA currently playing a role in the US health system debate? I understand if you can't answer due to conflict of interest. My second question is what do you think can be done about the huge disparities in Native American health care? Living in Montana and having traveled through many reservations it has not been hard to see they are some of, if not the most, vulnerable patient population in America.

Full disclosure - I've been an AMA member since I graduated from medical school and finished my residency in family medicine. That written, I would say that I don't always agree with official AMA policy. On the issue of covering the uninsured, however, the AMA was solid - and don't want to see an erosion of the 20 million who have gained health insurance since the ACA coverage provisions kicked in Jan of 2014.

Your use of AMA (Ask Me Anything) and AMA (American Medical Association) confused me for a minute.

Always smart to define the acronyms! Sorry about that, but you figured it out!

What are you hoping for with the republicans' replacement plan?

I'd really like to see a commitment to retaining what's worked well and quite popular with Americans - such as being able to cover your kids on a parent's health insurance plan up to age 26 - like I did for my two kids! People also really, really like not being charged more based on gender, or more for a 'pre-existing condition' like a previous diagnosis of having breast or prostate cancer, or living with a chronic disease like hypertension (high blood pressure) or diabetes.

I constantly hear that the medical field is highly understaffed, yet I see a surprising amount of new hospitals and emergency care clinics being built everywhere. Has the provisions under the ACA allowed more health care coverage due to more individuals being insured? Or, has there been an increase in providers because there is more revenue to be made with the stabilization of insurance?

There has been a rapid expansion in medical school capacity over the last 10 years. Once a student finishes medical school with their MD, they must complete graduate medical education (GME = residency training) that takes 3 to 5 years to complete depending on the specialty. The number of residency slots subsidized by the federal government was frozen in 1997 as part of the Balanced Budget Agreement - so that's created a bit of a bottleneck. The more difficult issue, is getting health professionals (nurses, physicians, physician assistants, allied health professionals) to practice in rural and inner city underserved populations. So it's more than the number in the pipeline, its also the distribution of health professional graduates to areas of need.

I live in Pittsburgh. My wife works in healthcare just as so many other people I know. It seems like it is a big employer.

I personally don't see any way to change the system too much without putting a lot of people out of work. Part of the reason that everything is so expensive is because it takes so many people to make it work. How can the system change without a lot of people losing work?

Absolutely right - it's a $3.2 trillion dollar industry, responsible for 17% of our nation's gross domestic product! The National Academies of Science (then the Institute of Medicine) released a report several years ago that estimated that about one-third of spending was 'wasted' spent on duplicative tests, administrative costs, and other items that do not improve health outcomes. Changing where we spend, to improve outcomes, and assure equity across communities and populations are challenges that have to addressed.

What can the medical community do to encourage more physicians to choose family practice or pediatrics rather than going into "higher pay" positions? Having had to go to a rural doctor in an emergency situation last year I am a bit disturbed by the lack of proper medical care in under-served areas of the country (whether it be poor or rural).

This is one of my favorite topics! Some states are doing some very innovative education - to help move the health professions training pipeline to areas of need. The federal government, through Medicare graduate medical education, states and feds through Medicaid, the VA and HRSA fund residency education (the big ones are Medicare at over $10 billion/yr and Medicaid at over $4 billion year). One of the provisions I worked on while serving as health staff for Senator Bingaman (retired US Senator from NM), was teaching health centers. This creates training infrastructure for primary care in rural and inner city underserved sites, and its graduates remain in those sites after graduation at 2 to 3 X the rate of other medical school grads (especially when combined with incentives such as loan repayment). States have a lot of flexibility in how Medicaid graduate medical education dollars are allocated to health professions training programs.

How will changes to the ACA affect people's access to Medicaid? Medicaid used to be known as health care for the "poor and..s" -- that is people who are poor and something else, like pregnant, disabled, etc. Expanding Medicaid to childless adults and the working poor has changed lives, saved lives, and given people a change for a better future -- saving our country money in the long view. What can we expect to see for the Medicaid expansion population during the Trump administration?

Since the Medicaid expansion provision of the ACA went into effect in January of 2014, over 16 million have been added to Medicaid in the 31 states that opted to expand Medicaid. That group is at risk, if the Congress eliminates the federal subsidy (the federal subsidy pays for an average of 56% of Medicaid costs, states pay the rest). In Arizona, loss of Medicaid expansion would remove over $1 billion from the state economy, and force over 200,000 off of Medicaid, and increase uncompensated care for hospitals and health providers.

I've read so much muckraking and so much statistics, I have a hard time finding the truth inside mud. Is the ACA going broke? Is it a "failure?" if so, what implementation made it so imperfect? If not, why is it so hard to prove that it is a massive success?

((Please don't hate me as someone "with an agenda." I don't have an agenda. I just keep getting referenced from both liberals and conservatives to segments of the SAME data that seems to show that the ACA is TERRIFIC / TERRIBLE! I struggle to know which is more accurate.))

I think it's hard for individuals to ascertain the "truth" so I try to focus on outcome metrics. The transformation of our health system is in its toddler stage, still a little wobbly on its feet, and unsure of which direction it will stagger when it gets moving. When Medicare and Medicaid were created as amendments to the Social Security Act in 1965 - it was far from perfect, and we're still amending it to do better in terms of health outcomes, and improved cost efficiency.

I see people willing to blame absolutely everything on the ACA. What do you find are pt's most common misconceptions?

Yes, Obamacare has been an easy villain to blame. Partisan rhetoric aside, there's very specific steps that can be taken to improve health insurance coverage, access to high quality health care, and to improve health outcomes. That means taking on some fairly well financed industries including the insurance, pharmaceutical, medical device, hospital and health professions.

Why are so many doctors refusing to accept any of the AMA insurance?

There are some health systems and health providers that only accept certain types of health insurance (for example Blue Cross Blue Shield, but not Aetna or Humana). Medicaid on average pays about 60 to 70 % of what Medicare pays across the country, and Medicare payment isn't as high as what a private health insurer might pay.

For the future of health care in America do you believe a one-payer system is the best option or more of split system like the ACA?

Do you think the ACA was a step towards or away from a single payer system?

For the near future, the realist/pragmatist side of me thinks we will continue with our rather unwieldy, fragmented system that leaves to many without access to affordable health care. So our gains will be incremental - though the substantial gains made in reducing our uninsured, and stabilizing the financing of rural and critical access hospitals (by sharply reducing uncompensated 'charity' care). Even those developed countries with one-payer, often have other options available - such as physicians with both a public practice, and a separate private practice - and countries with a mix of private and public options (though usually with a strong public option that covers anyone who needs it).

I have limited experience dealing with the ACA, so from your perspective and personal experience, would you say that the ACA has harmed or benefited more people overall?

If that question is too binary, then what changes would you make to the ACA to make it more beneficial to its recipients?

For the 20 million Americans who have gained health insurance coverage, I would say that most would say that the new coverage was of benefit. There are many ways that the coverage provisions of the ACA could be enhanced and improved.

If states have their own allotment of money for healthcare, what happens when that money runs out?

For almost every state, the top two state costs are Medicaid and education. The social determinant of health that best predicts good health is educational attainment. These two items in a state budget go hand in hand. Governors are very nervous that the federal government will shift the federal costs of Medicaid to states through block granting, then cut funding in subsequent years - leaving the state to scrape together the revenues to cover the costs of Medicaid and education.

If left completely alone for 10 years, what are the chances the ACA and the larger healthcare system would be operating in a way that worked for most everyone ?

The health system is changing rapidly, with major improvements in medications, surgeries, treatment modalities, testing, electronic health records - so it would not be prudent to leave it completely alone. Legislation and regulation need to more quickly respond to need, and that's not happening right now. We still have 27 million uninsured, and for those - health care is inaccessible. You don't really save money by removing health insurance coverage- you just shift costs to those with health insurance, to hospitals and health providers that continue to care for those without coverage, regardless of their ability to pay. If the uncompensated care burden gets too high - hospitals and practices close, or stop seeing the uninsured, or those with coverage that does not pay as much as other types of coverage.

As a 25 year old with Crohn's disease and who is on my parent's plan, thank you for doing this AMA!

I'm not familiar with the legislation or how quick a full overhaul will be but I am concerned about what will happen if there is a lag between the "repeal" and the "replace" that would leave me uncovered. Is this a real possibility?

I work for the government and would be able to get healthcare despite the pre-existing condition. However, our open season is only once a year in November. If there's even a small chance I could lose coverage even for any amount of time, I would want to try to take action to see if any exceptions could be made.

My mom had Crohn's disease, and it can be very expensive, especially with some of the terrific new medications to keep it under control - but oh so very expensive. The federal employee health benefit plan (FEHBP) is great, I just wish that every American had the kind of health insurance coverage that our Congressional members in the US House of Representatives and US Senate have! Now there's an idea!

Two questions:

What can be done to reduce overall costs of healthcare? I have Spinal Muscular Atrophy type II and am hoping to start Spinraza, the only drug ever approved to treat SMA. It however costs $125,000 per dose (6 doses in the first year then 3 per year ongoing). The insurance industry is already putting strings on who can get it (pay for performance, genetic requirements, type limitations).

What can be done to simplify the Medicaid Waiver system so people with disabilities are forced into nursing homes because of waiting lists to receive care at home. The Community First Choice part of the ACA was a good start but only 8 states have adopted it.

A lot of American don't realize that 75 million are covered by Medicaid and CHIP (Children's Health Insurance Plan), and while 2/3 of the enrollees are women and children - two thirds of the cost is related to the Medicaid eligibility categories that include frail elderly, blind, and disabled. We have not developed integrated approaches to better managing these populations - and many are left out of getting the care they need.

What are your thoughts on repealing the ACA and implementing a new plan that works for everybody?

The discussion has gone beyond provisions to the ACA, to include major changes to the Social Security Act - namely Medicare and Medicaid. Look carefully at Speaker Paul Ryan's "A Better Way" or at the bill Senator Tom Price was able to get passed by the House and Senate (vetoed by President Obama) last year. Sen. Price is the nominee for the US Department of Health and Human Services. Medicaid currently covers 75 million Americans and Medicare 57 million Americans (there are 9 million dual eligibles with Medicaid and Medicare). So there's a LOT more at stake here than the ACA, and that includes Medicare (vouchers are proposed for people to buy their own plan), Medicaid (shifting fiscal risk fro the feds to states through block granting), and the Children's Health Insurance Plan (CHIP).