One Swallow Doth Not a Summer Make

by Dave Schuler on April 2, 2014

The editors of Bloomberg enter the lists on reforming the PPACA:

Now that the rush of enrollment has passed, the challenge is to identify and respond to at least three kinds of concerns. The first involves relatively narrow problems with the law itself. For example, many state-run exchanges are poorly run; states such as Maryland and Massachusetts need help to fix them in time for the next open enrollment period, which starts in November. The law’s programs to cushion insurers from excess risk may also need reinforcement — if not enough young people sign up for insurance — to lessen any shocks to premiums next year.

That leads to the second kind of problem — with the health-care system generally. This includes persuading still more young people to sign up next time; getting more doctors and hospitals to coordinate care, making good on the promise to make medicine more affordable; and smoothing the transition from employer-based coverage for people who lose it.

I’ve mentioned before the stated objectives of the PPACA:

The Patient Protection and Affordable Care Act will ensure that all Americans have access to quality, affordable health care and will create the transformation within the health care system necessary to contain costs.

It’s just about four years since the PPACA was enacted into law and neither of those objectives has been effected. Some say that other worthwhile objectives have been acconmplished and those were, in fact, the real objectives. To believe that you must believe that the president and Democratic Congressmen have been lying. I prefer to believe that they genuinely believed that insurance reform would effect the changes that were the stated objectives.

But that can only be true if care and insurance are identical. Not just congruent. Identical. And they most definitely aren’t. Care is limited by the resources available for care and those resources are limited by design. Roughly a third of doctors won’t accept new Medicaid patients. About 10% of doctors (and 57% of psychiatrists) don’t accept insurance at all and that trend is increasing rather than decreasing. Among primary care providers more than 30% plan to stop practicing within five years (more than 50% among physicians over 50). There is already a critical shortage and that’s before you factor in an increased number of people seeking care.

We’d better all hope that excessive care-seeking by the insured is a figment of our imaginations.

I think the prospects for reforming the PPACA in any substantial way are very slim for the foreseeable future. They’ll fight it out on this line if it takes all summer.

{ 11 comments… read them below or add one }

PD Shaw April 2, 2014 at 10:30 am

There will be no legislative reform while Obama is in office. Obama has opposed legislative changes like delays that he himself had ordered.

Humorous story I read recently in my newspaper (perhaps A.P.) in which emergency room staff trying to get people to sign up for the Affordable Care Act found that patients were more willing to do so when told it was “Obamacare.” Don’t want any of that Affordable Care, I want the good stuff.

steve April 2, 2014 at 11:10 am

“A final point: ACA enrollment was always going to be weakest in year one. CBO set the expectation that 6 million would enroll in the exchanges by the end of 2014—that’s the end of the calendar year (including people who enroll during special enrollment periods), not by March 31. But projections get much bigger over the next few years: Medicaid enrollment is expected to jump 50% between 2014 and 2015.CBO expects enrollment in exchanges to double in 2015, then reach 24- 25 million by 2017.”

http://theincidentaleconomist.com/wordpress/some-quick-thoughts-on-enrollment-to-date/

Steve

Dave Schuler April 2, 2014 at 1:46 pm

I’m not certain why you cited that, steve, since it’s not really germane to the post. However this

Medicaid enrollment is expected to jump 50% between 2014 and 2015

is not good news. In a few years most of the spending that represents will fall on the states. I can’t imagine economic growth producing the jack to pay for it. I don’t know about your state but Illinois is just in no position to absorb a 50% growth in Medicaid spending.

jan April 2, 2014 at 3:45 pm

Yesterday I had to go to our family orthopedic doctor to x-ray both of my ankles, after missing a stair last Saturday night and falling awkwardly with a basket of laundry in tow. I was taken by surprise as he always participated in insurance plans before. But, yesterday, a financial form conveyed that he no longer honored any health insurance, including medicare. He would supply a super bill to be submitted to a patient’s insurance company. But, private payment was due promptly after his medical services were rendered.

As it turned out, one ankle was sprained, the other fractured, and our credit card was charged before leaving his office. I thought his bill was fair, and we could pay it, along with the cost of crutches etc. However, the point of this post is that I’m personally seeing more and more private practice physicians withdrawing from insurance altogether, let alone participating in Obamacare exchanges/plans, medicare or the much touted medicaid expansion, structured under the newly implemented PPACA. IMO, this is a growing trend, one that doesn’t bode well for people believing they will receive timely, geographically close, or good medical care when the time comes they should need it.

I also think that much like Bush’s embarrassing, and premature, “Mission Accomplished” banner moment, so too will be Obama’s bullish Rose Garden appearance proclaiming that his mission of nationalized healthcare was accomplished because of being able to scrimp together, via a massive, costly marketing campaign, some 7 million so-called ‘enrollments.’ I actually found his comments obnoxiously conceited, as if he looked at this whole HC roll-out as a game of designing basketball brackets for his own personal win, versus as a desired/desirable HC outcome for a vast majority of people in this country.

michael reynolds April 2, 2014 at 5:19 pm

Jan:

But, private payment was due promptly after his medical services were rendered.

I’ve seen this off and on for years, nothing new. Anyway, dude sounds like your kind of doctor. So pay the man. After all, you didn’t get an Obamacare policy, right? And insurance does not equal health care, right? So what’s your beef?

steve April 2, 2014 at 6:49 pm

Access to docs is more complex than the Kaiser article you cite. First, Medicaid is mostly care for children, pregnant mothers and old people. Many docs dont accept Medicaid, but they dont really treat many of those patients anyway. So, turn it around and look at it the other way. Do Medicaid patients have trouble finding care? It turns out that other than dental care, they have about the same amount of trouble as those with private insurance.

http://www.gao.gov/products/GAO-13-55

Steve

PD Shaw April 2, 2014 at 9:10 pm

@steve, dave was talking about the downside to expanding Medicaid; maybe its “close enough” prior to expansion, but now? From your link:

” 38 states reported experiencing challenges to ensuring enough participating providers for Medicaid beneficiaries. One recent study found that physicians’ acceptance rate of new Medicaid patients varied across the states, ranging from about 40 to 99 percent of physicians accepting new Medicaid patients in 2011. Overall, physicians were less likely to take new Medicaid patients than they were to take patients with Medicare, private insurance, or who self-pay. Ensuring sufficient dental providers was particularly challenging—but states also reported that ensuring sufficient provider participation in specialty care was problematic. Specifically, states most frequently reported having difficulty ensuring sufficient Medicaid providers for psychiatry, obstetrics and gynecology, surgical specialties, and pediatric services.”

Andy April 2, 2014 at 10:11 pm

I think the “critical node” (to use a term in my profession) in health care is providers. Increasingly, I don’t see any likely ways to fix the system without shoving reforms down the throats of providers…one way or another.

jan April 2, 2014 at 10:18 pm

“I’ve seen this off and on for years, nothing new.

It was new for this doctor, which was why I made a point of it. More doctors are bypassing all the obstacles of collecting payment, and simply taking on private pays. I’ve always had catastrophic health insurance, so am used to paying because of rarely meeting my deductibles. However, it still surprised me that this orthopedist was not taking any insurance, as of late 2012. He’s one of the best in his field, including being honest, ethical and good with children’s breaks. Our son went to him for a broken arm and later his wrist. My husband too, and now myself. It’s a shame, because lots of good medical people are opting to circumvent the current complexities of HC.

steve April 3, 2014 at 9:36 am

PD- Read the particulars of the study. 3% of privately insured patients had trouble finding medical care in the time studied. 3.7% for Medicaid. 2.4% of privately insured patients had trouble filling prescriptions. 2.7% for Medicaid. These are pretty trivial differences. Most of the difference is seen with dental care. 3.7% private and 5.4% Medicaid. (Dental care is different in many ways, so not sure it is entirely relevant.) Note that all of these numbers are much different than the 33% of docs who are supposedly not taking new Medicaid patients. If you dont understand that the Medicaid population is different, you wont think to look at this from the other side.

Steve

PD Shaw April 3, 2014 at 10:09 am

@steve, I understand the difference in the Medicaid population — they are usually a more difficult population to treat, for reasons that make me unwilling to give as much significance to the household survey in that report, as to the surveys in that report of the State experience. The States are saying they (pre-ACA) had a variety of shortages that can best be addressed by increasing payments to providers.

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