Discussion points on future of the Affordable Care Act

When the Affordable Care Act was passed in 2010, its goal was to improve access to quality health care for all Americans. However, the law has provided the greatest benefit to states with large rural populations like Montana. The reason is that the Affordable Care Act targets the exact factors that lead to poor health outcomes in rural communities: lack of insurance coverage, lack of physicians, lack of access to care, quality of care and geographic barriers.

Rural populations have historically had worse health than those living in urban areas. They are less likely to receive recommended preventive screenings. On average, they receive less aggressive care for diseases such as diabetes and heart disease. They typically have to travel farther to seek care, and have less access to specialists. As a result, they are more likely to report poor or only fair health. They are more likely to be hospitalized for uncontrolled diabetes, and more likely to die from heart disease.

The roots of these health-care disparities are well understood — and there really isn’t any debate here. Rural populations have lower incomes than their urban counterparts. Their jobs are less likely to provide health insurance. And, while 15 percent of the nation’s population lives in rural areas, just 9 percent of physicians practice there. In the end, assuming they can find a provider and can pay for it, rural residents travel farther and, on average, get less care.

—Medicaid expansion and insurance subsidies are one of the cornerstones of the Affordable Care Act. By providing insurance to low-income Montanans — and making care more affordable for others — the ACA helps ensure that patients can afford access to care when they need it. Without insurance, many patients defer essential treatment or forgo important tests. When a family wage earner has their diabetes go undiagnosed, the disease marches on. The complications accumulate: peripheral nerve pain, blindness, kidney failure, loss of limb. It’s not just a loss of function for that patient, we lose a valuable working member of our community — someone who now joins the ranks of the disabled. Medicaid expansion and insurance subsidies help arrest this disease spiral by removing the financial barriers to care.

—The ACA addresses the lack of rural physicians in Montana in a number of important ways. First, increased funding for the National Health Service Corps means more doctors working in rural places. Many of these doctors stay in Montana after their service is complete. Second, additional money to states for loan repayment helps Montana hospitals and health systems recruit physicians to these rural communities. Finally, money for graduate medical education ensures that the pipeline of rural primary care doctors stays open. This is an area of particular success in Montana, where the medical school and residency programs have record levels of primary care graduates, and record proportions of graduate physicians who stay in the state.

—Community health centers are an essential point of access to health care for thousands of patients across Montana. More than $5 million in Affordable Care Act funds has flowed to Montana community health centers since 2010. Health centers in 13 Montana towns — including Kalispell — have used these funds to improve access to medical, dental, behavioral, vision and pharmacy care.

—One of the simple things that the ACA did to improve the quality of care was to require coverage for preventive screening. This ensures that patients have access to the tests we know save lives and prevent disease — screening for depression, diabetes, cholesterol, obesity, various cancers, HIV and sexually transmitted infections (STIs), as well as counseling for drug and tobacco use, and healthy eating. Our ability to treat — and even cure — disease goes up dramatically with early detection and intervention.

The ACA also made fundamental changes in payment structures to enable hospitals to invest in the systematic innovation required to improve care for our patients. This new model gives health systems the resources to care for patients throughout the continuum of care, and holds those systems accountable for health care outcomes. Hospitals and health systems have already spent billions of dollars and many thousands of hours starting to make this transition. Abandoning it now would not only be an inexcusable waste of all those resources, but a lost opportunity to fundamentally improve the health of our patients.

—Even with robust support for community health centers, there are still patients who are geographically isolated and cannot access care. The ACA helps remove this barrier to care by promoting telemedicine. Telemedicine utilizes audio-visual technology to give patients remote access to primary and specialty medical care, as well as behavioral health. For example, a patient on one end of the state can talk to a highly-trained cancer doctor at the other end of the state; or a psychiatrist in one Montana town can provide treatment to patients in a variety of smaller towns throughout the state. While telemedicine was around before the ACA, the law has greatly accelerated the use of this useful and cost-effective technology.

The Affordable Care Act is not perfect — far from it. But, we should recognize that the law is composed of core elements that work well — and work especially well for Montanans. Some sort of repeal or replacement may be inevitable, but we should insist that whatever replaces the ACA is as strong and targeted at promoting health in rural communities. To repeal the law without a detailed alternative plan to replace it, would sacrifice the enormous amount of the progress we have made toward guaranteeing access to high quality care for all Montana families.

Cohen is chief medical officer of North Valley Hospital in Whitefish.