National Public Radio ran an article Tuesday about a family’s struggle with a lack of affordable health care. The protagonist, Amber Cooper, was employed as an accountant in a firm and a change in insurance left her with significant ($20,000 annually) out-of-pocket expense in order for her to continue her life sustaining treatment plan. The story was one of how the family made do with that much less over several years and is now doing better thanks to another change in coverage that her employer made. Paul Fronstein, of the Employer Benefits Research Council outlines the reasoning of the company as follows:

“Employers are trying to manage those costs. They’re trying to keep those cost increases as close to inflation as possible. And they’re doing everything they can to get their workers so that they think twice about the health care that they are using,”

Ms Cooper had the misfortune of having a liver transplant when she was 10 years old. Her medical expenses are anti-rejection drugs (the lack of which will lead to acute rejection, prolonged hospitalization, and potentially a second transplant) and lab work to monitor the levels of those drugs (the lack of which would, well, see above).

So, what should Ms Cooper think twice about? Perhaps she was engaged in risky behavior prior to her transplant such as drinking or promiscuous sexual behavior and should have thought twice about that, though that is doubtful. Perhaps at the age of 10 she should have anticipated this as a potential problem and chosen an early death as preferable to a life of serfdom to the medical-industrial complex, though I suspect the decisions were those of her parents and not hers. Perhaps she should have chosen less expensive care, searching for the Dr Nick of post-transplant care, though this would likely have the same effect as not taking drugs at all (see above). What she chose to do was to pay what she could, seek out charity for some care, and defer other needed care to be able to continue to afford food and shelter for her family. All necessary but risky decisions.

Ultimately, Ms Cooper’s company selected another insurance and she is back on her medication and being monitored appropriately. This speaks to the need to provide a seamless, affordable package of benefits regardless of who is paying the bills, including individuals.

What the reporter describes mirrors what I see as a primary care physician. Patients have reduced access to less expensive, primary and ambulatory specialty care as a result of increasing deductibles, co-pays, and arbitrary denials of coverage. Those that are unfortunate enough not to lose their job and move onto Medicaid become sicker and sicker, leading to heroic hospital based rescue care (subsidized in part by the community or the federal government). Each hospitalization leaves these patient  just a little weaker and that much closer to being on disability instead of holding down a job. Unless repealed, replaced or nullified, access and quality of primary and ambulatory specialty care will improve as a result of the ACA. Some of the  improvements in care delivery are happening now and some (near universal access and standardized benefits) will take effect in 2014. It will make my job, keeping people healthy and out of the hospital, that much easier.

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