I should wrap up this blog with this post. This was to be the last entry. I said at the beginning, two and a half years ago, that I would chronicle the first two years of progress for health-care reform and the Affordable Care Act (ACA) in Iowa. Now, at the end of the second year of the ACA, we are able — to some extent — to count the successes, some sad outcomes, and end the blog.

There are certainly successes: Millions of Americans now have health-care coverage. In Iowa, we are one of seven states with an uninsured rate of less than 5 percent. I have seen so many of my patients with new health coverage. They can now not only receive primary health care and medical specialists when needed, but preventive services that have included mammograms, pap smears, colonoscopies, and flu and pneumonia vaccines, and some patients now have coverage for medications.

The 2,200 patients who are in my family-medicine practice have always been my divining rod for pointing to health-care trends, both positive trends and those less than positive. Those less-than-positive trends are now exposing another side of health reform. One of my patients whom I have written about in a previous post is just one example. An independent contractor with diabetes, he now has health insurance but has seen his insurance deductible go up by $1,500 to $6,900, and, even with the increase in his deductible, his monthly insurance premium went up $60. Several of my patients are worried about for-profit managed-care companies taking over their Medicaid coverage on March 1. They fear this drastic change will negatively impact them; I am equally concerned. Recently, one of my Medicare Advantage patients was not allowed an MRI of her knee despite limping for three months and having previously been approved for the MRI when she was released from the hospital in September. I have heard story after story from my patients about the obscene increases of the costs of medicines, preventing some patients from using certain medicines I have prescribed because they simply cannot afford them.

Additionally, Iowa still does not have a state health-insurance Exchange, and, come March 1, when Medicaid managed care takes over the care of 500,000 of our most vulnerable citizens, Iowa will have a woefully inadequate system of state oversight. The current oversight includes a legislative oversight committee, which, when it met last month, was not told by the Iowa Department of Health and Human Services that 49 percent of calls to the Medicaid telephone hotline went unanswered. When the committee was asked to provide guidance to Medicaid on failures such as these, the effort was stymied by partisan voting. A second oversight vehicle is a committee on which I sit and which I blogged about last month, the Medical Assistance Advisory Committee (MAAC). Finally, the Center for Medicaid and Medicare Services (CMS), when delaying the start of Medicaid managed care from January 1 to March 1, decreed the creation of an Iowa ombudsman for Medicaid. The position description, details, and advertising for the position have yet to be developed.

Because of these serious and ongoing concerns, I plan to continue this blog. In part, I will use the experiences of the 150 patients in my practice who will enter Medicaid managed care as an opportunity to research and evaluate how the managed-care process is working. For the next year, I will use the experiences of my patients to inform my position on the oversight committee and to advise Iowa about the performance of these managed-care companies. This blog will outline these efforts.

Along the way, I will continue to discuss the major impediment — affordability — to the advancement of health-care coverage, specifically discussing how the current trends of accountable-care organizations (ACOs) and patient-centered medical homes (PCMHs) positively or negatively affect affordability. And, in case you might have missed it, we have both presidential and congressional elections this year. The outcomes of these elections will affect health reform for many years to come. When you vote, vote in the best interest of care reform because it affects us all. Health-care reform is and has always been incremental in Iowa and across the country. In 2016, and for years to come, we will see how the incremental success or failure of health reform unfolds.

In the end, this is not the end. I am not yet ready to wrap this blog and say it’s over. There is still too much that needs to be said about health-care reform in Iowa.