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Can you see the same doctor under Obamacare?

By Scott Scanlon – Refresh Editor

Dr. Michael J. Edbauer – the Catholic Health Obamacare guru and a married father of two college-age children – had lots to say about the Affordable Care Act during a recent interview, so much in fact that I couldn’t fit all the good stuff into today’s In the field story in WNY Refresh.

Those looking to learn more about how New York State is rolling out the new insurance program for the uninsured can visit

Meanwhile, here are more excerpts from our recent interview, starting with what many readers may see as a very important one:

Do you anticipate coming up early next year where some people end up signing up for a plan in which they can’t see their current doctor?

It’s certainly possible. One of the things that’s part of the enrollment process is to help patients understand all of the components of the particular plan they’re selecting. That includes the network they signed up for. That might be one of the areas people might not be aware of at this point in time.

Will folks be able to say, ‘Wait a minute, if I can’t see my doctor I want to go back and sign up for something else?’

My understanding is once they enroll, they are locked in for a year. I don’t know if there’s a grace period.

So anyone who signs up for health care really needs to pay attention?

I think so. This is a really important decision. I know people are saying it’s taking an hour to enroll. That’s probably a well-spent hour, to understand what’s going on. Historically, people have been accustomed if they’ve had their insurance from their employers that there wasn’t much difference in the plans that were offered, except maybe a co-pay. Now, with the exchange, there may be significant differences in the plans that are available, so it’s going to take diligence and a little bit of buyer beware as they walk through the process.

How has the Catholic Health System tried to prepare for the provisions that will take effect in January?

We see that as a continuation of the work we’ve been doing. Logistically, probably some of the challenges will be providing education, even now, to patients to help them understand all the components of what they’d signed up for. I think it’s likely many individuals may, even after they sign up, not completely understand their benefits or how to go though the system. That’s not a negative toward the individuals who have insurance through their employers if they really understand their insurance policies when they have to use it.

How are you preparing the doctors and medical staff? Have you hired anyone else or retrained anyone?

We’re doing education and training. We’ve had programs in place that we’ve already made available to the physicians, so they understand the changes better, so they can understand some of the basic questions that patients have, and also direct them to programs that are available on the website, through the government, and some of our folks within the system who have been trained to assist.

What should doctors and patients expect as the new insurance regulations take effect in January? Are there going to be surprises in store?

I don’t think for the physicians. In many ways this is just more people, including some of the people who didn’t have insurance now will have insurance. The part that may still be a little bit of a challenge for patients if they don’t completely understand the policy and it’s one that has a high deductible or a high co-pay. They may not recognize that just because they have a health insurance card now, there still may be significant financial responsibilities.

Is there any misinformation about the act that you think needs to be cleared up?

I’m not sure from the individual patient’s point of view that it’s going to have the big impact people are expecting.

The vast majority of people in Western New York are going to be unaffected by this, as they already have insurance through their employer or other component. They’re going to be spectators to this event.

There’s going to be a much smaller number of those who are affected. To them, I think, it’s a significant event. Hopefully it will be a positive because they’re going to have availability of health care that they may not have had in the past.

It may not be quite as dramatic as the anticipation.

How about employers who say, ‘Here’s some money, you go out and buy insurance on the exchange?’

It won’t change the fact that they have insurance, but it will change the mechanism.

I was at a meeting the other day and one of the speakers said it will be analogous to 401K plans and I thought that was a good way of thinking about it. So, if you used to have a defined benefit plan, your employer said, ‘When you retire, you’re still going to receive this,’ then it changed to a 401K, you still have the employer giving you dollars but now you have to decide how to invest it. You took on more responsibility and you’ve got more control. That’s the same idea with the scenario if the employer says, ‘Here’s $5,000 a year, go to the exchange and buy your insurance.’ Then I as a consumer can decide, ‘I’m going to go with the bronze, lower premium, and I’m not going to have to spend any money out of pocket. A fellow employee might say, ‘I have a lot of medical issues. I’m not sure what costs are involved. I want the platinum. I’ll have to kick in an extra $50 a month out of my own pocket to cover that premium but I’m not going to have as much in co-pays.’ That’s very different in terms of process, but it doesn’t change the coverage per se.

What are the changes those with insurance and those without it need to be aware of as the new year approaches?

Those without need to take advantage of the opportunity if they’re eligible to enroll in an insurance product. Hopefully, they’ll appreciate the benefits of having insurance and be able to establish a relationship with a primary care doctor.

For those with insurance, look very carefully at the policies and plans that are offered to you, and become an educated consumer so that you understand exactly what you’re purchasing, because it is going to be a different model potentially.

Proponents of the act say it focuses more on prevention and patient responsibility for their own health care decisions. How does it do that and how do you see it playing out?

The prevention piece is really through the idea of increasing the relationship with a primary care physician. For these folks who previously did not have insurance, it’s a high probability many of them did not have a primary care doctor, so I believe that will improve the prevention aspect and help people to control the cost on that side.

When you’re looking at which ones your selecting, there’s a much greater level of patient responsibility. You’re really going to have to understand what you’re agreeing to because there’s really quite a difference in the co-pays and deductibles, the metal tiers and the provider networks. The patient is going to really have to be engaged.

Will the act help turn the tide of obesity, Type 2 diabetes and other chronic disease trends?

I think the changes in health care that have already begun and continue have the opportunity to make those changes. I don’t necessarily believe the ACA, in and of itself, is the driver on improving those things.

One piece I think is needed if we’re going to ultimately be successful in those areas is there needs to be greater community involvement. When you look at the history of smoking, when it was simply the doctor telling the patient, ‘You shouldn’t smoke,’ it was not terribly effective. Then came a mass marketing and education and the younger generations knew from an early time the risks of smoking. That was a very different time than the generations that preceded them.

I believe it’s going to be the same need with obesity and nutrition, and the good news is that I’m already seeing that occur.

Do any parts of the act need tweaking?

I’m sure they do, only because when you put together anything this large it’s not going to be perfect in its initial phase. I wouldn’t suggest to you I know where the tweaking needs to be done at this point.

We have to wait to see how it plays out?



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About The Refresh Buffalo Blog

Scott Scanlon

Scott Scanlon

Scott Scanlon is an award-winning reporter and editor who has covered various topics in his quarter-century as a journalist in South Florida, Syracuse and Buffalo. He is aiming to pass along what he is learning these days about health, fitness, nutrition and family life.

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