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The Affordable Care Act has ushered in “a time of change and a time of challenge,” Dr. Nick Rajacich told his colleagues last year after being elected president of the Washington State Medical Association (WSMA), and it has definitely prompted lively debates.

Not since the 1960s, when President Johnson signed the Medicare law, have doctors experienced such “turmoil and change” in the health-care delivery system, said Rajacich, a Tacoma pediatric orthopedic surgeon.

“This debate continues to test our nation’s beliefs in how we physicians deliver care, which patients receive our care, and what decider controls our compensation … ,” he told the doctors gathered at the association’s annual meeting in Tacoma last year.

And from a doctor’s perspective, he said, it is good news and bad:

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“It makes medical care more accessible, coverage more reliable, insurance companies more accountable, and it strengthens, hopefully, through wellness and prevention, a healthier nation” — all good things, he said, and not small things.

But it has left unfixed problems many doctors feel strongly about, he said, including reforming medical law so that compensating patients for medical errors is more fair and predictable both for patients and doctors. It also has not solved the problems in Medicare reimbursement, and may have worsened access issues.

Rajacich told his colleagues he was proud that they had supported expanding Medicaid, the federal-state insurance plan for low-income residents.

Doctors in some states did not.

“I am proud that WSMA is not among those ranks,” he said. “WSMA physicians know that we do not live in a Goldilocks world. Things are never going to be juuuuust right.”

In a recent interview, Rajacich said he would have voted against the ACA had it been up to him.

But now that it is the law of the land, “undoing it is not a good thing,” he said. “We need to go with what we’ve got — not destroy it and start over.”

He continues to worry about patient access, he said. “Giving them an insurance card on Jan. 1 doesn’t mean they automatically get access.”

Although there’s capacity in many suburban and urban areas, in areas of Central Washington there is not, he said. “Even if [doctors] are willing, you can only see so many people in a day.”

The tension between the insurers and state Insurance Commissioner Mike Kreidler, who initially turned down some companies because the office determined their provider networkers were not adequate, shows the complexity of this equation, he said.

“I had a kid in the clinic a week out from the injury — his mom called and said they couldn’t get in,” he said. “That’s a concern.”

As for costs, he believes the ACA will eventually reduce them through getting people insured so there’s less cost shifting than now — that is, uninsured people showing up in emergency rooms and having the costs of their care added to other people’s insurance plans through higher premiums.

He thinks everyone is more cost-conscious, including patients, who often have a considerable co-payment for services. Five years ago, he said, if a patient had a sore back, they would demand an MRI.

“I would try to argue [why an MRI was not needed], but people would say, ‘I deserve that.’ ”

By contrast, these days, when he makes his argument against unnecessary tests, people say, “I get that.”

“It’s shocking, but it really makes me feel good,” Rajacich said.

When doctors complain about pressure to hold down costs, he said, he has a ready answer: “We don’t have a choice,” he tells them. “If we don’t, ultimately we will be completely unaffordable for anybody.”

Carol M. Ostrom: or 206-464-2249. On Twitter @costrom

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