BUFFALO, N.Y. – For months, Nancy Nielsen, MD, has been
talking to a variety of audiences about the Affordable Care Act.
Since the summer, Nielsen, senior associate dean for health policy
at the University at Buffalo School of Medicine and Biomedical
Sciences, has made invited presentations on it to the American
Medical Association (AMA) student chapter at UB, incoming chief
residents at UB and fellow physicians during grand rounds at
Buffalo General Medical Center and other venues.
Nielsen, a past president of the AMA, served as senior advisor
at the Center for Medicare and Medicaid Innovation (CMMI) in the
Centers for Medicare and Medicaid Services, U.S. Department of
Health and Human Services. The CMMI was established by the Patient
Protection and Affordable Care Act (ACA) and is charged with
testing innovative approaches to improving health care delivery,
payment and quality.
The ACA exchanges open today. What is your gut feeling about
what the exchanges will accomplish?
This is a very exciting time. I happen to be very optimistic
about the exchanges. For people who already have health insurance
through their employers, nothing will change. But it will be a big
improvement for those who have no insurance, or who have been
buying it on the individual market, since they will have a choice
of plans at much more affordable prices and many will probably
qualify for tax credits which will lower the prices even further.
We are the last developed country in the world to figure out how to
insure our citizens, and this is long overdue.
What are some of the most obvious benefits of ACA?
Already, adult children can remain on their parents’ plans
until age 26, co-pays are eliminated for many preventive services
like mammograms, children with pre-existing conditions can’t
be excluded from insurance and the same will go for adults starting
in 2014. There also will be no lifetime or annual limits on
coverage. These provisions of the ACA are very popular, even among
those who declare themselves opposed to the ACA itself.
Who does the Affordable Care Act help the most?
Two categories of individuals will benefit the most from the
exchanges: those who don’t have health insurance right now
and those who buy insurance on the individual market. Those who
have no insurance because they cannot afford it or because they
have preexisting conditions which made their premiums too high will
now be able to buy affordable health insurance on the exchanges.
Premiums on the exchanges are 16 percent lower than the
Congressional Budget Office had projected. And not only are the
premiums lower, but it is estimated that more than 70 percent of
individuals who buy through the exchanges will also qualify
for tax credits, making their premiums lower still.
How many people in Western New York will really benefit from
New York State has 2.7 million uninsured people. Of those
2.7 million, 64,000 uninsured people are in Erie and Niagara
counties; that’s a lot of people.
Who qualifies for a tax subsidy on health insurance purchased
through the exchanges?
Individuals making under $45,960 and families of four with
incomes under $94,200 may be eligible for a subsidy. To find out
exactly what may be available to them, folks should go onto New
York’s exchange: nystateofhealth.ny.gov.
How much is the penalty if you decide not to get health
The penalty for not buying health insurance the first year is
$95 per person or 1% of your income, whichever is greater. The
penalty will grow yearly. But it doesn’t make sense to skip
coverage and pay the penalty. Why would someone choose to pay the
penalty and put themselves and their family at risk, when just one
visit to the emergency room could potentially bankrupt the family?
Why do that when affordable health care is now available? The U.S.
government estimates that six out of 10 Americans who seek
insurance through the exchanges will pay less than $100 a month for
Who will the ACA benefit the least?
The individuals who will benefit the least are the poor and
uninsured who are living in states that choose not to expand
Medicaid. When the law was written, the assumption was that
everybody making up to 138 percent of the poverty level would be
eligible for Medicaid under the expansion, but the Supreme Court
decision threw a curveball, making it optional for states to expand
Under ACA, premium subsidies were made available to those who
made between 100 percent and 400 percent of the federal poverty
level and buy insurance through an exchange. So now, if
you’re in one of those states that didn’t expand
Medicaid, and there are more than 20 of these states, and if you
make less than 100 percent of the poverty level, but don’t
qualify for Medicaid, you can still buy coverage offered on the
exchange but you aren’t eligible for premium subsidies.
Nobody expected that. These are the people who need the help the
most and will be hurt the most. That’s an unintended
consequence that needs to be fixed – but Congress is not in a
“fixing” mood right now.
How will the ACA change the way physicians practice?
The ACA will absolutely change – and I would say, improve
– the way we care for our patients. We know that being
uninsured is hazardous to your health. Insured patients seek care
in doctor’s offices, not just emergency rooms. The world of
medicine is becoming more patient-centered and efficient and the
ACA is going to reinforce and support those improvements. If we are
to have a sustainable health care system, physicians and patients
need to be more aware of the costs and benefits of the things we
order. Physicians will be practicing and delivering care as members
of teams, and there may be some new members on those teams as care
becomes more patient-centered.
How will the ACA change medical education?
It’s critical that we train our medical students to
function in this new environment. When I addressed UB’s first
and second year students, they were very attuned to the changes
that are coming and they’re excited about giving patients
better, more efficient care.
The ACA will further promote the move, already underway here at
UB and elsewhere, toward interprofessional education, where
students in all the health sciences learn to work together on
teams. There is a drive to educate physicians so that they fully
appreciate what things cost and the economic and medical impacts of
the tests and procedures they order. There’s also a
nationwide movement right now called “Choosing Wisely”
that is providing information on procedures and tests that should
not be done routinely; that’s an important national
conversation that’s going on right now in medicine. Our
students need to be well-prepared to function in this environment
and also able to lead the changes that can improve medical
How will the government shutdown affect the exchanges that
It won’t. They will be up and running in every
state, but expect glitches due to the large number of people trying
to access them and enter their information today. The New York
exchange alone received 2 million visits in the first two hours.
It may be easier, due to less cybertraffic, in a few
days. This is not a new government “program;”
it’s just a new way, a “marketplace,” where
insurers compete for your business and consumers can choose plans
that are best for themselves and their families.