Affordable Care Act ‘mixed bag’ for Cape Codders

Aug. 07--This is the first part of a series looking at the effect President Obama's policies have had on our region.

For Cape Codders, the legacy of the Affordable Care Act signed by President Obama in 2010 is a mixed bag.

Millions of dollars in federal funding have flowed to the Cape's four nonprofit community health centers since the act's passage, allowing them to hire more physicians, add space and expand services such as mental health and dental care for their patients, many of whom are on subsidized care plans.

Stephen Place of Marstons Mills said he was pleasantly surprised when he became a patient at the Community Health Center of Cape Cod in Mashpee, which completed a major addition in 2012.

He said he was impressed by the modernity of the facility as well as its expanded hours, caring staff and knowledge of different types of insurance.

"They're terrific," said Place, a professional handyman.

Also under the ACA, eligibility for subsidized MassHealth plans expanded, and more than 11,000 people from the Cape and Islands now qualify for federal tax credits or state subsidies to help lower the cost of insurance plans.

But many Cape Codders are struggling under the weight of rising health insurance costs despite the expectation that premiums and other costs would decline as million more Americans signed up for health coverage.

While nearly everybody in Massachusetts has insurance coverage, many people are paying for health insurance they are too afraid to use.

"Deductibles go up every year," said Gwen Jones of Marstons Mills. "Because of the deductible, we put off a lot of stuff we need to do."

The cost of coverage for the year comes to $8,000 for herself, her husband and their younger daughter, said Jones, who said she increased her work hours to full time to qualify for insurance.

But with a $10,000 deductible, Jones said she feels apprehensive every time she goes to the doctor in case she is advised to have a test or take a medicine that falls under her deductible.

A survey by the Kaiser Family Foundation and the New York Times early this year found that rising premiums, climbing deductibles and surprise out-of-network costs are taking huge chunks out of the already-beleaguered middle class' retirement accounts and college funds.

And an annual survey released in December 2015 by the Center for Health Information and Analysis showed that 21 percent of nonelderly adults in the Bay State decided to forgo some type of medical care last year because of cost.

That means patients are eschewing EKGs, walking away from tests to determine the cause of lymphedemas and even going without medications prescribed by their physicians, according to doctors and patients on the Cape.

One woman said she went to a specialist appointment but left once she was told the cost of the test would be applied toward her deductible.

"Co-pays and deductibles are so high it's really like having no care," said Dr. Timothy Biliouris of Dennis. "One thousand dollars is a huge amount of money" for most Cape Codders to have on hand, he said.

Medical noncompliance because of financial hardship among patients was a hot topic among doctors meeting last week at Cape Cod Hospital, Biliouris said.

"There is a lot of fear out there. People are afraid they are going to get a large bill. So they are are forgoing care," Biliouris said. "Unless they are getting the care, the coverage doesn't matter."

Nearly everybody in Massachusetts is covered by health insurance -- 96.4 percent of the population compared with 90.8 percent nationally -- said Jason Lefferts of the Massachusetts Health Connector.

While the Bay State already had high coverage rates compared with other states because of health reforms of "Romneycare" in 2006, the ACA further expanded the pool of people eligible for some types of subsidized care.

Federal health reform increased the cap for eligibility for MassHealth -- also known as Medicaid -- from 100 percent of the federal poverty level to 133 percent in 2014, or $32,319 for a family of four, up from $24,300.

In addition, the health connector provides subsidies in the form of state subsidies or federal tax credits to those who are under 400 percent of the federal poverty level, Lefferts said. For a family of four, $97,200 is 400 percent of the federal poverty level.

One Cape Codder who did not want to be named said insurance wasn't a concern when he worked a municipal job, which provided low-cost coverage, or even when he was laid off, when he qualified for MassHealth.

But medical insurance costs -- not counting dental -- eat up more 60 percent of his income at his current job, the man said.

He said his employer assumes the entire cost of individual plans, but he elected for family coverage to insure his wife and two children.

It's nice that the ACA allows children to remain on their parents' plans up to age 26, but many plans make it cost-prohibitive, the man said. "I appreciate what Obama tried to do. It's the families that are suffering."

To add to the woes for families, an ACA initiative designed to help people qualify for subsidized insurance when plans offered by their employers are too expensive -- meaning they cost 9.66 percent or more of household income -- applies only to the amount the employee would pay individually.

It's known as the "family glitch," and according to healthinsurance.org affects about 2 million Americans.

Donald Berwick, the Massachusetts physician whom Obama charged with leading the implementation of the ACA, said the health insurance cost burden would be even worse without federal health care reform.

"People blame the ACA" for issues that don't come under the reform legislation's bailiwick, such as pharmaceutical pricing practices, he said.

"Costs are unacceptably high and can be lowered and need to be lowered," Berwick said.

Berwick, former head of the Centers for Medicare and Medicaid Services, called the control of health costs "a social policy issue for America."

Michael Lauf, president and CEO of Cape Cod Healthcare -- the parent company of Falmouth and Cape Cod hospitals -- wrote in an email that the ACA could have involved more "stakeholders at the table" including patients, doctors, hospitals, pharmaceutical companies, retail clinics and IT companies.

"While the ACA isn't perfect, it was a decent start for a very complex issue," Lauf wrote.

Restaurateur William Zammer, chairman of the board of Cape Cod Healthcare, said real health reform will come when the government recognizes it's time for employers to bow out of the insurance game.

"It should be Medicare for all and get it over with," he said.

-- Follow Cynthia McCormick on Twitter: @Cmccormickcct.

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