MISSOULA, Mont. - One of the strongest selling points for the Affordable Care Act is the promise to increase quality care for all Americans -- but quality means something different to one person than it means to another.
The law tried to guarantee improved quality through increased preventive care and performance-based pay, but the practice of medicine boils down to one thing -- taking care of people and the additional 23 million Americans expected to now have insurance by 2014.
Hamilton, Montana, has a population of 4,500 people. The day we visited Marcus Daly Hospital, 18 of its 25 beds were full. A new baby was on the way.
Down a hallway bustling with nurses and staff members, Respiratory Therapist Duane Abbott checked on surgery patient Esther Brown. Tubes and monitors were connected to her body. Esther's daughter Donna can only wait and watch and hope her mother recovers and comes home.
The same mornings play out in hospitals around the country. The responsibility within their walls is preserving life itself. There is little wonder that the largest, most comprehensive overhaul of the country's health system starts with this promise: "…quality, affordable health care for all Americans."
John Updike of Mineral Community Hospital says, "For the people who don't have insurance, the quality of their care will go up."
Updike is paid to worry about the bottom line and the patients in the small western Montana town of Superior.
The building is along Interstate 90, not far from a major mountain pass connecting Montana and Idaho. Many of the patients come in from accidents on the busy interstate.
Mineral Community Hospital is what's known as a frontier hospital, the first and last for 60 miles.
Updike can rattle off the statistics for small towns like Superior across whole country: 50 million Americans in rural areas, higher poverty, faster job loss, more uninsured people, fewer doctors.
When we visited Mineral County, we came across resident Tommy Ireland, whose biggest concern is the extra money a patient will have to put out. He fears the quality of care may be going down and the possibility of having to drive a long way away to get care in bigger cities.
"I may have to go out of town to see another doctor, like a specialist or something. That's a care because it's more driving -- and again, it brings it down to expenses," Ireland says.
Much like a restaurant that suddenly has to increase its production by 25 percent, doctors and hospital administrators worry a nationwide glut of close to 20 million newly eligible Americans means people will end up waiting in line for health care.
"Some doctors could become too busy to see patients," says Marcus Daly Emergency Room Doctor Brian Kelleher.
"I think we will see a lot of patients in emergency care because now the issue isn't financial, the problem will become what's available," he adds. Kelleher sees it all -- the injured and ill without insurance. They end up in his emergency room. It's an expensive line of defense.
While the Affordable Care Act is meant to stop that, the fallout has Kelleher worried. "The ACA is a big octopus and the tentacles extend far and deep," Kelleher explains.
It's like a physics law. For every action, there is an equal and opposite reaction. Studies from Harvard to the 2012 Annals of Family Medicine all predict roughly the same things -- the total number of office visits will climb from 462 million in 2008 to 565 million by 2025. Add in baby boomers and millions more insured Americans and estimates are an additional 39,000 family physicians will be needed by 2020.
In 2006, the Association of American Medical Colleges recommended a 30 percent increase in U.S. medical school enrollment but the study concludes the 30 percent expansion still would not eliminate the projected shortage.
Hospital officials say with millions more coming into the system, you will likely be seen by nurse practitioners, physician assistants or residents coming from out of the country.
We asked Updike if people would be able to keep their own doctors. He responded, "It's probable, but it is possible you may not be able to. It depends on how many patients there are and whether primary care and specialists can still see the same number of patients."
In Massachusetts, the state that started the rough model of the ACA, a 2011 study concluded that, despite an increase of patients, the wait time to get in remained flat. Massachusetts is just one state. The ACA covers the entire country.
Most medical professionals we talked to could not answer whether you will be able to keep your doctor. If you stay on your company's insurance, that answer depends on your company's policy. For those shopping on the new insurance exchanges, the answer will be buried in the paperwork.
Steve Carlson, CEO of Community Medical Center in Missoula says, "Patients who buy through the exchange may not have as many choices as if they had bought through other products, other insurance plans."
Carlson will tell you quality is tied to access. If you can't get in, you can't get care. That's why he predicts a tremendous need for mid-level professionals -- nurse practitioners, physician assistants, trained specialists with master's degrees. The Affordable Care Act itself supports this theory.
Kim Mansch works with the uninsured. She supports the act's mandate for increased preventive care. After all, a problem is easier to stop than to solve. The ACA mandates top preventive tests like pap smears, yearly screenings for children, even flu shots be free -- no co-pay. It's not cheap. The average price of a colonoscopy is $1,100.
"Individuals will have the ability to access care and access their physician prior to their health care situation or problem becoming a crisis. So that is going to directly lead to more positive outcomes, as well as a positive reduction in the overall health care costs for the entire system," Mansch explains.
Some patients are optimistic. Phillip Stauffer of Missoula says, "I think it will bring better health care."
Some disagree. Neurologist Carter Beck is not a fan of the Affordable Care Act.
Beck insists the act supports a cookie-cutter approach to medicine that has been growing across the country already. "It's sort of an ‘all of us are in it together' philosophy. That means the individual's particular needs might be neglected. What we end up doing is treating populations based on statistics, based on averages. I don't think that's what a patient expects when they come to the office," Beck explains.
He points to his patient Leann Schaf to make his case. Schaf says that cookie-cutter approach has cost her a procedure that was right for the type of pain she is experiencing.
"It just kind of puts an end to my life almost, and the activities that I want to do," says Schaf.
Beck wanted to do two procedures in one surgery to help Leann. Her insurance said no way. Instead, she'll have two separate procedures.
For Beck, that shows a non-individualized approach to health care. He tells us, "So instead of the old model of a doctor who came to town and was the quintessential small businessman in town, who spent his life and his career in a particular location, we're going to have doctors provided by a big company. Imagine AT&T or Verizon deciding who the doctor is going to be that day. I think that is the direction we are headed -- the corporatization of America."
Beck would rather be the employer than the boss. He's negotiating with a hospital to join its staff. That would close his office that has been open for 40-plus years.
From private offices to hospitals, health care is in for massive change. Remember Donna and her mother Esther? Esther is home now. Their story is at the heart of the most basic ACA claim -- increase the quality of care.
Only it's not so clear whether that will happen.
We reviewed several studies from the Massachusetts Medical Society, as that state has a model similar to the ACA. The most recent study has some interesting facts in it. In summary, the Massachusetts Medical Society's 9th Annual Access to Care Study (http://www.massmed.org/News-and-Publications/Research-and-Studies/2013-MMS-Patient-Access-to-Care-Study/#.UmA_IL7nZ-Y) shows that wait times for new patient appointments with primary care physicians remain long and that half or more of primary care practices remain closed to new patients.