Consumers Need to Meet Reform Halfway

A Conversation with Sen. Irene Aguilar, MD
Photography by
James Chance

Balancing State Control with Consumer Empowerment

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Sen. Irene Aguilar, MD

EDITOR'S NOTE: One of the consistent voices in state politics for the average person's health experience is Sen. Irene Aguilar, a Denver Democrat and physician who has long championed easier access and a better health care experience for all patients. Aguilar, who has worked at Denver Health and seen where the patient "rubber" meets the rough "road" of health bureaucracy, often pushes the biggest health changes at the state level. We talked at her state Capitol office between meetings on health bills.

Have we made it simple enough to find health insurance, and then health care itself, in Colorado?

I have had the chance to go on the Connect for Health Colorado website because I have some care providers for my daughter who do not have insurance. I think that for people who are comfortable with technology, the manual part of it is accessible. I was surprised because the women I work with qualified for some premium tax credits, and perhaps because we waited until later in November and December, the Medicaid application was not nearly as complex as I remembered. Even for me, it was very hard to tell what coinsurance was vs. copays. I know that before my children were born, because my employer paid so much of my plan, I just picked the highest price plan and had no idea what the details of it were. Once I had a daughter who was disabled, and I started looking at the details, I realized how complex the plans were. You pick based on what you have right now, and what you think might happen, and then life pitches a curveball.

Can the private sector do a better job connecting people with insurance? What role can it play?

It would be great for small businesses in particular. There are people at Connect for Health who will talk just with them. My husband is actually part of a small business, and they had just Humana for a long time, and I encouraged his business manager to talk to Connect for Health because they had employees with different needs. Year 1, a lot of people just wanted to stay with what they had and knew; I would hope that in Year 2 more businesses would make the connections to Connect for Health and find out what more is offered to the small employer.

The consumer plays a role. What would you encourage consumers to learn to achieve better health care for themselves?

I don't know that it's intuitive to people. There are people who have learned that getting care means you are sick, so you go in. I think most people might think preventive care is something for children. Probably all of us need to do a better job educating consumers to go in at least one time and become familiar with a general care provider, and make sure you don't have any silent diseases, and what you should do to stay healthy.

Are there problems with the roles of emergency rooms at the moment, and the ways people use them?

I don't mean to be mean to primary care, but I think the problem with emergency rooms is really the problem with primary care. Primary care tends to be open 8 to 5, and they tend to have a wait. Those become barriers to people accessing the right care at the right place. Realistically, if you're healthy, getting care doesn't have to be right now. But most of us are like, "I finally have this, I have an hour, I'll get it done!" So I think the easy availability of emergency rooms gives some people the misperception that even though my life is not in danger, I can go here and at least get seen. I don't think people realize emergency rooms cost 10 to 100 times more than a regular visit to the doctor, and even though your copay may only be two or three times more, it's going to cost the system 100 times more money; and that will be reflected when your rates come up for next year. It's because you didn't seek the most cost-effective care.

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Are there things Medicaid should do to make sure patients are getting the right care?

I wouldn't target just Medicaid. It's something all of us as a society need to think about doing this together. I think what we can tell people is that at least when they come to the ER, they're going to get a screening no matter what. And that screening will rate how sick you are, with 1 being very sick and 5 not being very sick at all. And I think most providers would agree that if you are not a 1, 2 or 3, you don't need to be seen at an ER. It's OK to find out that you're a 4 or 5, and we're not going to see you here, and we're going to help you find a provider who will see you.

You've been involved in legislation that looks at the growth in emergency beds in Colorado and suggests there's a lot of growth in the areas with the most expensive care. What role does the private sector have in making more sense of the system?

I had someone come in the other day and wanted to talk about their new idea for four new micro-hospitals. They came in unfortunately on a day when I was thinking about how to contain costs, so I went on a rant about why we don't need more hospitals. At the end the business manager said, "But that's what we're paid to do. That's what you're incentivizing us to do right now." I said, "You're absolutely right. How do I change the incentive to make sure the primary clinics are open from 6 in the morning to 11 at night?" What can society do to make that happen? If most people get access when they need it by the right provider, they wouldn't care if it was labeled emergency or not. That would be my request to the medical system. People want care when they don't feel well, and if you're not available to them, they're going to go where they can get care.

One reason people may seek emergency rooms is the lack of a doctor taking Medicaid, for example. Have you come across incentives that will draw providers to places that are underserved?

Medical schools have expanded capacity, but Medicare put a freeze on graduate medical education. So in 2013, there were 500 doctor (MD) graduates and 600 Doctor of Osteopathic Medicine (DO) graduates who could not find a training program. Period. Eleven hundred people who went through all that cost and brain damage of graduating medical school and had to go find something else to do for a year while they waited to get licensed. Colorado has huge numbers of applicants for a program that gives them a year in rural residency; research shows 70 to 76 percent of doctors who train in a rural residence end up practicing in a rural setting. Part of the problem with training in family practice is the billing loses money. So we're going to ask the programs what they bill, and see if we can help make up the difference. We'll provide the safety net to make sure these training programs remain fiscally sustainable in rural areas.

You've fought hard in the Legislature for transparency, especially billing transparency and fairness. Is there more to do on that when we may be headed for deductible shock and other issues?

There's a lot more to be done on that. One way to do that is to create a commission around health care costs. Come to agreement and bring forward legislation together; otherwise it's too easy for one side to take the other side out. Everybody wants to know how you control costs, but nobody wants to do what it takes to control costs. If we really want to control costs, there are going to be winners and losers.

You've also been interested in some form of a universal or single-payer system in Colorado and nationally. Do you feel as consumers realize more about high-deductible plans and other issues that haven't been solved, it will push more people toward some form of a single-payer system?

I would hope so. What people don't realize is what having a single-risk pool does for prices for everybody. The classic example is what's happening in our mountain communities with prices. People ask, "Can't you just rate the state as a whole?" If we do that, the mountain communities' prices would go down dramatically, but everybody else's would go up. There's enough money in the system. I don't think people realize that with the premium tax credits, we're subsidizing money from here to there. We're just doing it in a different way. It's not as transparent. We're helping people to pay for the same thing you get. They're just not paying the full price.

 

This article was originally published in the Spring 2014 issue of Health Elevations.

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