Health Care Reform

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Commentary — October 2013  

By Esteban López, MD  

Starting in 2014, key provisions of the Affordable Care Act (ACA) will be implemented, and doctors across the United States will experience the biggest change the health care industry has seen. As physicians, we have a responsibility to be well informed of the new law's impact on our practices — both as doctors and as employers. And with this great challenge comes great opportunity — to make the most of what the doctor ordered.  

Understanding the Changes

As you know, some health care changes have already taken place. Children may now continue on a parent's insurance until age 26, and preventive care services are fully covered (including screening labs, immunizations, and cancer screening). To ensure premium dollars are spent primarily on health care, ACA generally requires insurance companies to spend at least 80 percent of all premium dollars on health care services and health care quality improvement (85 percent for large employer plans).

In 2014, we'll see more transformation. Though there are some exceptions, most Americans will be required to have insurance coverage. Those without insurance will be subject to a minimum penalty of $95 — an amount that will increase over the coming years. All Americans required to have insurance will qualify regardless of preexisting conditions. Plus, Americans will have a new and easier way to shop for insurance.   

Buying Insurance

Your patients may continue to buy insurance directly from an insurer, but now they have other options. Under ACA, two new types of insurance exchanges or marketplaces have been created to sell insurance online. The first exchange, sometimes referred to as the Health Insurance Marketplace, is for individuals. This exchange is scheduled to open this month and will allow individuals to purchase insurance to be effective Jan. 1, 2014. On the exchange, consumers can view and compare health insurance plans offered by all insurers participating on the exchange, consider the various benefits and premiums, and enroll in a plan.

 This also is where approximately 2.5 million Texans will discover they are eligible for various levels of premium tax credits and financial assistance to help lower their cost of coverage. It's important to note that there is no publicly sponsored plan; all insurance coverage provided on the exchanges will be through participating insurance companies.

The other exchange is for small businesses (those with fewer than 50 employees) — including many health care practices. If you fall into this category, you could benefit from searching for insurance on this exchange, known as the Small Business Health Options Program (SHOP). As a small business owner, you will want to consider all your options when selecting a health insurance plan for your employees. Keep in mind that on the SHOP exchange, small employers may be eligible for two years of tax credits.  

Providing the Essentials

As your practice starts to adjust to the new changes, you'll also want to keep in mind that starting in 2014, all health plans will cover 10 categories of benefits considered essential to good health. These are called essential health benefits — with no dollar caps on this type of coverage.            

These services are: 

  1. Hospitalization,
  2. Emergency,
  3. Laboratory,
  4. Maternity/newborn,
  5. Mental health and substance use disorders (including behavioral health),
  6. Prescription drugs,
  7. Rehabilitative/habilitative,
  8. Preventive/wellness and chronic disease,
  9. Ambulatory care, and
  10. Pediatric (including oral and vision care).

Recognizing the Impact

Several major changes will affect providers financially. Some of the charity care you may have provided in the past will become compensated care. This change will allow those low-income patients to be better able to contribute to their care in the future. As Medicaid programs and providers prepare to cover more patients, ACA will require states to pay primary care physicians (who apply for Medicare parity) no less than 100 percent of Medicare payment rates on primary care services provided to Medicaid patients in 2013 and 2014. Search for "Medicaid fee increase" on the TMA website ( to learn more.

There will be a notable difference in the number of patients seeking primary care physicians. Currently, more than 6 million Texans are uninsured. As these people gain health insurance coverage, they will become much more likely to schedule appointments with you. This is an opportunity for you to increase your patient pool and grow your practice. These patients may have avoided or delayed their medical services, which means they may require more of your medical attention. They may also be good candidates for disease/care management services available through their insurer.  

Educating Others

I come from a background of serving patients in the emergency department. From this clinical standpoint, I look forward to knowing that more individuals will have access to insurance and therefore be able to obtain the appropriate follow-up care after they leave the emergency department or hospital. I know many of you share my same desire to see that everyone receives continuation of care and maintenance of health problems.

As you prepare for the changes ahead, it's equally important to prepare your patients on this complex topic. According to a health tracking poll conducted by Kaiser Family Foundation in April, only 11 percent of people had received health care reform information from their doctor in the preceding month.

I challenge you to increase this percentage by proactively communicating with your patients. You will be one of their most trusted sources for information. Information is available through various sources, including a grassroots educational initiative called "Be Covered Texas" funded by my employer, Blue Cross and Blue Shield of Texas. By partnering with community organizations in the communities we serve, the Be Covered Texas campaign is working to reach and inform the state's uninsured population about the changes coming through ACA. The campaign's educational materials, available in both English and Spanish, can help people learn how the new health care law impacts them and what steps to take to get access to individual health insurance.

I invite you to visit and consider directing your uninsured and underinsured patients to this nonbranded, educational resource. As physicians, we have an opportunity and an obligation to take a leadership role with our patients. Let's take on this challenge and make the most of this opportunity to improve health care access for all Texans.  

Dr. López is president of the San Antonio Region for Blue Cross and Blue Shield of Texas. He is board certified in internal medicine and pediatrics and has practiced in various emergency departments in San Antonio and South Texas.  

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