Keeping up with insurance changes - The Buffalo News

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Keeping up with insurance changes

Dr. Michael J. Edbauer – the Affordable Care Act pointman for the Catholic Health System – wants most of you to understand this about the looming changes in what often is called Obamacare:

They’re unlikely to affect you.

That’s because the new health care system was established for the uninsured, and all but about one in 10 Western New Yorkers already has some form of health insurance.

“Most of us will be spectators,” Edbauer said last week, a few days after the New York State insurance exchange went online at

What’s more, he said, many doctor groups, insurers and health care companies in the region already have goals and philosophies that mesh with the core principles of the ACA: Cover more people, lower costs and put a greater emphasis on preventive care.

“We don’t see the ACA as being the prime mover,” Edbauer said of Catholic Health. “We already were moving in that direction. This probably has accelerated the timeline because now more of the community is moving in a similar way.”

That said, this is health care and government we’re talking about, two gigantic bureaucracies, so some of the details are bound to be devilish.

Edbauer, 51, a Williamsville native, is a pediatrician by training. He’s chief clinical officer for the Catholic Health System and chief medical officer of Catholic Medical Partners, a group of nearly 1,000 independent doctors affiliated with the system’s hospitals and other facilities. Part of his job is to help untangle the ACA.

“It’s going to take awhile to see what happens,” he said. “Right now it’s people struggling to get through the website and all of the logistics of doing that.”

• Q: Do you see more patient responsibility when it comes to the ACA?

A: I think so. In some ways, the huge volume that we’re seeing (on the state exchange website) is a good thing. It shows that people are interested. But after you get through the first wave, one of the unknown questions is how do you bring the people to the exchange, because there are some people who are not terribly interested … especially the ‘young invincibles.’ That’s the mid-20s to 30s population, especially the males, who see very little need to have health insurance and are not real excited about the individual mandate (which requires adults to have health insurance or pay a tax). They probably will be the last to come to the exchange.

• Q: What would you say to these guys? How much would it cost if they had some medical issue?

A: If you have a catastrophic event – let’s say you have a car accident and several fractured bones, and end up having surgery and need to stay in the hospital for a few days – that could be a very large hospital bill, tens of thousands of dollars. … There are catastrophic plans available on the exchange that would cover somebody like that. The premiums are very low.

• Q: You say anyone who signs up for health care really needs to pay attention.

A: I think so. This is a really important decision. I know people are saying it’s taking an hour to enroll. That’s probably a well-spent hour, to understand what’s going on. Historically, people have been accustomed if they’ve had their insurance from their employers that there wasn’t much difference in the plans that were offered, except maybe a co-pay. Now, with the exchange, there may be significant differences in the plans that are available, so it’s going to take diligence and a little bit of ‘buyer beware’ as they walk through the process.

• Q: What have you told your family and your patients about the Affordable Care Act?

A: From the patient side, it’s really seeing which patients are potentially affected by it and helping them to navigate the system moving forward. For family members, begin to start looking at health policies that begin to come before them from their employers with a more critical eye, not just assuming that they’re all the same.

• Q: What’s your favorite part about being a doctor?

A: As a pediatrician, getting to know the patient and their family. I’ll run into people I took care of 20 years ago. They remember you and you remember them. It wasn’t just an incidental contact. It was a true relationship.

• Q: What is the most miraculous recovery you’ve ever seen a patient make?

A: Many years ago, when I was still in my training (at Children’s Hospital), I had a patient who was in the intensive care unit who had a heart ailment. I remember I had to speak to the mom and grandma, because we really didn’t think he was going to make it through the night. I was very young still, and the memory of it is very clear. I remember the grandmother saying to me – and she could tell I was very distressed – ‘Don’t worry, God’s told me everything’s going to be OK.’ It still gives me chills when I think about it. It was amazing faith and an incredible recovery. I can’t tell you I know medically how it all transpired. … He ended up being my patient in an outpatient setting for many years.

You also do remember the events that don’t turn out so well, particularly in pediatrics because the vast majority of your patients are, in fact, healthy.

• Q: In those cases, do you continue to be amazed by the faith those families show?

A: I think the strength, the faith, the ability of people to cope and go through situations, you appreciate what you have when you see what other people have had to go through in those situations, because you sit there and you wonder, ‘Would I be able to cope and handle this as well?’ It’s very humbling when you see what people deal with.


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