"Sometimes we can’t get the medication we need until a patient has already failed one or two drugs that are covered," Dr. Zecavati said. "So we have to put them on those drugs and just watch them have seizures over and over, because that’s the only way we can get the drug they need."
The ACA "at least attempts to reduce the amount of uncompensated care we provide," she said. "Ultimately, though, we won’t be able to take care of patients like we need to until they have more comprehensive insurance."
A new report by the North Carolina Budget and Tax Center suggests that Medicaid expansion via the ACA will reduce race-related health disparities in the state. The expansion is expected to increase insurance coverage through Medicaid and the Children’s Health Insurance Program by more than 8% among blacks and by 6% in whites and Latinos.
The report assumes that the new plan will dramatically increase access to physicians. What it doesn’t address is the issue of provider availability. Having the resources to connect with a physician is not the same as being able to connect – especially if thousands more patients are all trying to connect with a shrinking provider pool.
Effect on Access to Stroke Rehab
Dr. Lesli Skolarus, a stroke specialist at the University of Michigan in Ann Arbor, said that the ACA may pack a double whammy for younger stroke survivors: Medicaid recipients are already less likely to get the immediate, intense poststroke rehabilitation they need, and expansion of health care access could tip that problem into crisis mode.
Dr. Lesli Skolarus
She recently published a retrospective study of nearly 34,000 stroke survivors who were still of working age when they took ill. About 19% were uninsured and 20% were on Medicaid. A quarter of the patients were discharged to a long-term care facility for subacute rehabilitation. The rest went home and got regular acute rehabilitation, which is generally considered the more effective method of improving long-term stroke outcomes.
Compared with insured patients, uninsured patients were 52% less likely and Medicaid patients were 73% less likely to get the intense rehab, and significantly more likely to be discharged to long-term care facilities (Neurology 2012;78:1590-5).
"This may explain differences in poststroke outcomes among uninsured and Medicaid stroke survivors compared to the privately insured," she concluded.
Health care reform could affect patient outcomes in this area as well. "Our data suggest that the supply of neurologists is not increasing proportionally to demand with stroke patients. There will be an insufficient number to care for adults with chronic neurologic problems resulting from stroke," Dr. Skolarus said.
Dr. Richard Benson
Increased demand also could limit the availability of physical and occupational therapists, compounding the situation, she added.
In the long run, however, the ACA’s overarching goal of preventing health problems before they arise may balance this potentially off-kilter equation, said Dr. Richard Benson, associate medical director of the Washington (D.C.) Hospital Center Stroke Center.
"By the time a stroke occurs, most patients have had years of poorly addressed risk factors, some of which – like hypertension – can be well controlled with relatively inexpensive medications. When I see them, the horse is already out of the barn," he said. "We need to get back to basic preventive care. Our health care system is definitely broken, and one fix will be to concentrate on wellness instead of illness."