Where Will the New Covered Patients Find Doctors and How Can One Expect the System to Change?


Since President’s Affordable Care Act insurance began in 2014 about 14 million Americans have gained health coverage but those new enrollees haven’t swamped the nation’s doctors’ offices, new research shows.

When the health-care law started, there was concern that an influx of new patients could overwhelm doctors. It’s already hard enough to get an appointment with a primary care provider — wouldn’t millions of newly insured Americans just exacerbate the problem?

New data from 16,000 providers across the country, pulled by the medical records firm AthenaHealth, shows that requests for new appointments just barely edged upward in 2014. The proportion of new patient visits to primary care doctors increased from 22.6 percent in 2013 to 22.9 percent in 2014.

New patient visits barely increased under Obamacare

Researchers know people do tend to go to the doctor more when they have insurance. That point, proved most famously in the RAND Health Insurance Experiment of the 1970s, is pretty much undisputed.


And Obamacare has helped millions of Americans gain insurance coverage. Federal data released earlier this month shows that the uninsured rate has fallen 35 percent since the coverage expansion began in 2014. Obamacare has expanded medical insurance faster than any new policy since Medicare and Medicaid were created in 1965.

In that way, the health law’s insurance expansion was big. But put another way, it’s also small: 14 million people gaining coverage in a country of more than 300 million residents is kind of a drop in the bucket. We’re talking about 4 percent of the country going from uninsured to covered.

Another Obamacare concern a few years ago was that these newly insured patients, who may have gone without care for years, may have more complex medical conditions that had gone unmanaged.


The AthenaHealth data suggests, somewhat surprisingly, that this isn’t the case: doctors didn’t start seeing sicker patients after the insurance expansion started.

“We found no evidence that patient complexity increased in 2014,” the report finds. “Physician work intensity per visit remained flat, diagnoses per visit increased slightly, and the percentage of visits with high-complexity evaluation and management codes actually decreased slightly.”

This is what happened under Romneycare — and, five decades ago, with Medicare

One reason the Obamacare news isn’t a surprise: it looks similar to what’s happened with previous insurance expansion. Since Massachusetts expanded coverage in 2006, annual surveys by the Massachusetts Medical Society haven’t shown any clear pattern in changes to care access.

There was definitely been a big drop in primary care doctors accepting patients, from 66 percent in 2005 to 45 percent in 2013. The wait time to see an internist has bounced around a lot — 47 days in 2005, 44 days in 2012, and then up to 50 in 2013 — showing no clear pattern related to the state’s insurance expansion.

And if you go even further back in history, you see the same thing happened with Medicare. Back then, there was a lot of worry that an influx of newly insured seniors would swamp the American health-care system.

Sarah Kliff, when she worked at the Washington Post, looked through newspaper archives for coverage of the Medicare launch to get a sense of expectations. Questions like these — raised by a New York Times writer in April 1966, a few months before Medicare launched — were pretty typical:

What will happen then, on that summer day when the federally insured system of paying hospital bills becomes reality? Will there be lines of old folks at hospital doors, with no rooms to put them in, too few doctors and nurses and technicians to care for them?”

But when Medicare launched on July 1, 1966, it went pretty smoothly — the long lines didn’t materialize. This is what the Washington Post wrote about the program’s launch:

“It was a smooth transfusion, undramatic as a bed change. At 12:01 a.m. June 30, Uncle Sam began paying the bills of close to 1,000 patients over 65 in area hospitals.

The transition to Medicare, the federally financed health plan, was as uneventful as it was historic. The influx of card-carrying Medicare patients was a trickle, not the storm that had been predicted by some.”

What all these programs have in common: they are big ideas that fundamentally change the health insurance system in the United States. The Affordable Care Act opened the insurance market to everybody; Medicare guaranteed coverage to Americans over 65.

But in practice, these programs are relatively small: each only insured a small chunk of the population. Even though they’re remaking American health care, they’re doing so in a small, slow progression. That helps explain why none of these coverage expansions have overwhelmed doctors, despite our expectations.

Nina Totenberg reported on a decision that the U.S. Supreme Court ruled last Tuesday that private Medicaid providers cannot sue to force states to raise reimbursement rates in the face of rising medical costs. The 5-to-4 decision is a blow to many doctors and health care companies and their complaint that state Medicaid reimbursement rates are so low that health care providers often lose money on Medicaid patients.

In 2009, Idaho centers that provided care for some 6,200 mentally disabled children and adults went to court to challenge the state’s Medicaid reimbursement rates. They contended the state had adopted a Medicaid plan with reimbursement rates set at 2006 levels, despite the fact that costs had gone up significantly over the three intervening years. The lower courts agreed and raised the state’s reimbursement rates. But the Supreme Court reversed that ruling, declaring that private Medicaid providers have no right to sue under the Medicaid law. If a state is not providing fair reimbursement rates, the court said, the only recourse Medicaid providers have is to ask the federal Department of Health and Human Services to withhold all Medicaid funds from the state — a step so punitive that it has never happened.

The 5-to-4 vote crossed the court’s usual ideological lines, with the liberal Justice Stephen Breyer joining four of the court’s conservatives to provide the fifth and decisive vote against such provider lawsuits and the conservative Justice Anthony Kennedy joining three of the court’s liberals in dissent.

The majority opinion, written by Justice Antonin Scalia, said that Congress, in creating the Medicaid rate-setting scheme, did not explicitly authorize private suits like the one at issue here. Instead, he said, the law mandates that state reimbursement plans are “consistent with efficiency, economy, and quality of care,” all the while “safeguarding against unnecessary utilization of … care and services.”

“It is difficult to imagine a requirement broader and less specific” than that, wrote Scalia. “Explicitly conferring enforcement of this judgment-laden standard upon the Secretary [of Health and Human Services] alone establishes, we think,” that Congress wanted to make the agency cutoff of funds the “exclusive” remedy. With such a big financial club, Scalia said, “we doubt that the Secretary’s notice to a state that its compensation scheme is inadequate will be ignored.”

Joining Scalia in the majority were Chief Justice John Roberts and Justices Clarence Thomas, Samuel Alito and Breyer.

In dissent, Justice Sonia Sotomayor said the ruling would have “very real consequences.” Previously, she said, “a state that set reimbursement rates so low that providers were unwilling to furnish a covered service” could be ordered by the courts to provide adequate resources to meet federal requirements. But now, said Sotomayor, “it must suffice that a federal agency, with many programs to oversee, has the authority to address such violations through the drastic and often counterproductive measure of withholding the funds that pay for such services.” Joining the dissent were Justices Anthony Kennedy, Ruth Bader Ginsburg and Elena Kagan.

Since the Affordable Care Act exchange programs are basically Medicaid programs don’t expect physicians to open their doors to these additional patients. Then even if these patients have healthcare insurance coverage, where are they going to find providers to care for these patients? The expected result as seen on the Oregon study is that there will be no change. Patients will continue to use their emergency rooms for health care, continuing the expensive care already seen in the past. It is even worse in the rural areas in certain states, such as Maryland, where the physicians are paid at lower reimbursement rates than in the urban and suburban areas. The potential patients in these areas are at more risk of poor or no health care.

It really seems that the administration, the politicians and the courts take 6 steps forward and 3 to 6 steps backward or more. With the upcoming Supreme Court decision regarding the ACA, what is next and what will happen when Hillary takes over the reins? I will also be taking on the task of comparing the Hillary healthcare plan with Obamacare. Is there any difference and will we be getting anything better in healthcare?



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