dr. john noseworthy, it is (202) 748-8002.back to the six anniversary of the affordable care act, what has been the biggest change in the mayo clinic system that you have seen? guest: i think the biggest change we have seen is that pat biggest change in the mayo clinic system that you have seen? guest: i think the biggest change we have seen is that patients with insurance, the typical patient, a working american who has insurance, they are staying away from health care more than they used to because they are uncertain how much their total experience they will have to pay for. many americans have high deductible health care plans. ahich basically gives them crisis traffic coverage but depending on the terms of the insurance, they may be responsible for the first one thousand dollars-$5,000 or $12,000 in high care costs. so patients are staying away. up to 40% of patients in the middle-class are actually delaying and deferring going to the doctor or having procedures concernedse of their that they will pay more out of pocket th