Paul Spaude is the Chief Executive Officer of Borgess Health, and has been a part of their team since 2005. Paul jumped right into the discussion and explained that Borgess and Borgess’ parent organization, Ascension Health, are committed to three main themes with health care: “1) health care that is safe, 2) health care that works, and 3) health care that leaves no one behind.” Accordingly, Paul said, “So when the concept of the ACA developed momentum, Ascension Health was strongly behind it.” Personally, Paul has held a number of public forums in which he has discussed the principal concepts listed above, even before the ACA was enacted.

Paul stated that once the ACA was enacted there was a change within the hospital: “You have to understand that the most expensive site of care are hospitals and therefore, the biggest challenge to reduce the cost of health care in the US is going to fall on hospitals. Yet, there is still a lot of pressure on the hospitals to be high quality and as effective as they can be.” He explained that over time, the reduction in their Medicare reimbursement at Borgess would be over 100 million dollars.

He noted that before the ACA, the majority of people were getting their primary care through the ER because “… the payment levels for physicians to see those patients in their offices was very suboptimal.” To address that in Kalamazoo, Borgess and Bronson embraced the Family Health Center and their $10 million addition to expand ambulatory capacity and more “slots” available for immediate care for patients.

Paul believes the ACA is fundamentally good. For instance, “The preventive care has no out of pocket cost, and the act is starting to standardize health insurance plans… It is an internet-based service. Based on your income level, you’ll either qualify for Medicaid or Medicaid expansion, or you’ll get a tax credit if you go purchase your health insurance policy as an individual, if your employer doesn’t have one for you.” He went on to explain further by means of comparison, “You basically have catastrophic coverage. In the past, you would see some health insurance policies that would have a 1 million dollar maximum coverage for life. So if you are a cancer patient, trust me, and you’ve been diagnosed early in your life and you need the follow up care, you can go over a million dollars in your lifetime. So health insurance in the past would stop at a million, and the rest would be your responsibility, out of pocket. Those issues have been taken away now.”

However, Paul said that there are some “ironic speed bumps” with the ACA. For example, it is “not unusual to have a $5000 out of pocket deductible. That means that the first $5000 you are personally accountable for and then your insurance will kick in.” Furthermore, he explained that at Borgess it seems that people don’t really understand their insurance plan, as they will come in to hospital “seeking elective procedures, and that’s when they find out they have high deductibles… Then we have people that come in urgently, but have a large out of pocket, cannot pay for it, and so that has become a new level of charity for us.”

Borgess itself has enrolled 60 patients that had qualified for coverage that entered their ER office. “What I find amazing… given all the media attention, [is] that everyone would know there is Medicaid expansion. But there is a huge population, that, unfortunately, tends to be the at risk population, that has no idea and so, it’s incumbent on us to get them applied for medical assistance. I think, in Kalamazoo County, there are about 14,000 people who are potentially eligible to be enrolled, that aren’t enrolled yet.”

In the end, he explained that “[Borgess] is getting coverage for people who before had no coverage and [Borgess] get[s] the Medicaid reimbursement for them. We are also seeing another group of people who have high out of pockets, who in the past their employers covered most of that, but now they don’t have the means to cover it so we have to provide them care. So it is kind of a ying and a yang. That’s the way I would describe the ACA in terms of our experiences: ying and yang.”

With all the good the ACA has done, Paul is nevertheless concerned with the one issue that has not been addressed in the ACA: physician payments. Currently, the ACA “would require a 22% physician payment reduction in Medicare, which would be absolutely devastating to the Medicare program and primary care physicians.” He believes that Congress has been “kicking the can down the road” on this issue. Paul explained that the reason why it was not in the ACA originally was because the budget for the act would have been over a trillion dollars. Furthermore, Paul explained that there is so much rancor around the ACA, which tells him “it is turning into more of a political process than public policy and that’s what hurts this country. There’s no health care public policy. There are financial schemes, but no health care public policy.”

Overall, Paul is aligned with the underlying principles of the ACA, as he believes, “that every US citizen should have a core set of coverage, a safety net that they should fall underneath, and that because of your personal genetics you shouldn’t not have coverage.” Paul believes that “obviously the ACA was not a consensus in terms of how it was created… It will be [among] the most politically contentious issues in the fall election, without a doubt. It’s going to take a long time because of the political turmoil, I think, to improve the ACA as we go forth. Because it has some nuances that are not really intended but it is a political process to remove them.”

Furthermore, he expects in the long run that, “There will be potential for more failures in hospitals.  By that I mean, that you’ll see hospitals going out of business. We may shrink well below the 5,500 [nationwide hospitals] that are out there. I think the victims will be many times in the rural areas and maybe potentially inner city hospitals, because of the dynamics of their economic profile, it just isn’t sustainable no matter how well they manage it.”