Affordable Care Act in Kentucky, one year later

After spending a year experiencing severe abdominal pain and other symptoms, Davis finally sought care in the emergency room. The diagnosis? Metastatic colon cancer.

"If we'd found it sooner," Davis said to the physicians, "it would have made a difference. But now I'm just a dead man walking," a phrase so evocative, the physicians chose it as the headline of their article.

Today, however, Stillman and his colleagues are witnessing what another of his patients terms a "sea change in health care" because of the passage and implementation of the Affordable Care Act (ACA) in Kentucky.

Stillman has authored a follow-up "Perspective" article in the New England Journal of Medicine that notes the changes brought about by the ACA and Kentucky Gov. Steve Beshear's decision to accept federal funding for Medicaid expansion that the act brought about.

One year later, the ACA rollout in Kentucky has been a success, he says. "…Our Commonwealth's citizens -- among the poorest and most (medically) underserved in the country -- finally gained broad access to health insurance," he says. "… allowing us to provide data-driven and thorough care without first considering our patients' ability to pay."

Stark contrast between then and now

The contrast between last year and today is stark, writes Stillman. "Before … Medicaid expansion, the 60 percent of my clinic patients and 650,000 Kentuckians who lacked health insurance received disjointed and disastrous care." Many avoided routine and preventative care because of worries over cost.

"But during the past year," Stillman writes, "many of my lowest-income patients have, for the first time as adults, been able to seek non-urgent medical attention." In Kentucky, 413,000 people gained medical coverage who did not have it prior to the ACA implementation.

The ACA has brought about other unexpected benefits as well. Expanded health care coverage has greatly improved residency training in Kentucky, enabling the doctor to spend more time doctoring and less time serving as a financial advisor.

"One year after the law's implementation, residents at my hospital can finally provide guideline- and evidence-based care," without first considering the cost, he writes. "Since 92 percent of our patients are now insured, we no longer receive fretful looks when we recommend laboratory tests; we screen for colorectal cancer with colonoscopies rather than with less sensitive fecal blood cards; and we spend more time examining patients and less time helping them knit together limited public-assistance resources."

Another unanticipated benefit has been an increase in competition for patients. Before the ACA, patients without health insurance had a limited number of facilities in which they could receive care.

Today, however, "with increased enrollment in Medicaid and commercial (health) plans, these same patients are pursued by medical groups and hospitals and can be selective in choosing their sites of care."

Challenges remain

Stillman notes that the ACA remains threatened, both in Kentucky where its success is verified by data, and in other states throughout the country.

"Some Kentuckians question the adequacy of the newly purchased plans and are concerned that despite being 'insured,' people who have bought low-premium, high-deductible plans may (still) wind up accruing substantial medical debt," he writes.

Also, he notes that 21 states have yet to expand Medicaid eligibility despite the example Kentucky shows of the success in doing so. Physicians, however, can help.

"First, we can challenge our elected officials to do a better job of seeing to their constituents' needs," he writes. "Furthermore, we can delineate for our patients the often-subtle links between current affairs and their own health," including asking them if they are registered to vote and reminding them of candidates' support of or opposition to the legislation that has palpably benefited them.

"I hope that an increasing number of state legislatures will help their vulnerable citizens receive the services they need and that the next generation of physicians will be shocked that our current efforts at health care inclusion were ever seriously questioned."