A patchwork of experiments across the country are trying to better manage these cases. The Center for Health Care Strategies, a policy center in New Jersey, has documented such efforts in 26 states. Some are run by private insurers and health care providers, while others are part of broader state overhaul efforts. The federal government is supporting some, too, through its $10 billion Innovation Center, set up under the Affordable Care Act.
A physician friend of mine posted a copy of her Medicaid reimbursement on Facebook. Take a look at the charges compared to the actual reimbursement. She is paid between $6.82 and $17.54 for an hour of her time (i.e., on average, she makes less than minimum wage when treating a patient on Medicaid).
The enthusiasm for expanding Medicaid coverage to the previously uninsured seems misplaced. Improved “access” to the health care system via Medicaid programs surely cannot result in lasting coverage. In-network physicians will continue to dwindle as their office overhead exceeds meager reimbursement levels.
In reality, treating Medicaid patients is charity work. The fact that any physicians accept Medicaid is a testament to their generosity of spirit and missionary mindset. Expanding their pro bono workloads is nothing to cheer about. The Affordable Care Act’s “signature accomplishment” is tragically flawed – because offering health insurance to people that physicians cannot afford to accept is not better than being uninsured.
Safety-Net Emergency Departments: A Look at Current Experiences and Challenges | The Henry J. Kaiser Family FoundationFebruary 11, 2015
The ED directors we spoke with in hospitals in Medicaid expansion states reported reductions in the share of ED patients without insurance and corresponding increases in the share with Medicaid. However, uninsured rates remained high in all the safety-net EDs.
The ED directors’ expectations regarding trends in ED visit volume over the next few years varied. Some anticipated increased visits, citing pressures on primary care access, remaining large uninsured populations, or expanded ED capacity. Others anticipated flat or declining ED visits due to expanded coverage and access and the impact of new models of health care delivery and payment.
The ED directors we interviewed were not certain what the net impact of expanded coverage, large remaining uninsured populations, DSH cuts, delivery system reforms, and other ongoing changes will be on ED finances.
The Affordable Care Act has ushered in an era of complex new health insurance products featuring legions of out-of-pocket coinsurance fees, high deductibles and narrow provider networks. Though commercial insurers had already begun to shift toward such policies, the health care law gave them added legitimacy and has vastly accelerated the trend, experts say.
The theory behind the policies is that patients should bear more financial risk so they will be more conscious and cautious about health care spending. But some experts say the new policies have also left many Americans scrambling to track expenses from a multitude of sources — such as separate deductibles for network and non-network care, or payments for drugs on an insurer’s ever-changing list of drugs that require high co-pays or are not covered at all.
Continue reading the main story
Paying Till It HurtsAPRIL 18, 2014
For some, like Ms. Pineman, narrow networks can necessitate footing bills privately. For others, the constant changes in policy guidelines — annual shifts in what’s covered and what’s not, monthly shifts in which doctors are in and out of network — can produce surprise bills for services they assumed would be covered. For still others, the new fees are so confusing and unsupportable that they just avoid seeing doctors.
If you want to understand Medicaid’s problems in New Jersey, just ask the Holstein men.
Justin Holstein, 39, of Ocean Township, spent a year on the government health insurance program when he was starting his own business. Long under treatment for chronic migraines, he lost all his doctors the moment he enrolled.
His new doctor said only a neurologist could renew his medication, but the insurance network’s neurologist couldn’t see him for four months, he said. That meant four months of sleepless nights battered by pain, and four months of getting through the days courtesy of the caffeine in Excedrin.
“You have a card saying you have health insurance, but if no doctors take it, it’s almost like having one of those fake IDs,” he said. “Your medication is all paid for, but if you can’t get the pills, it’s worthless.”
Last month the White House proudly announced that after completing the first year of Affordable Care Act (ACA) implementation the number of uninsured Americans is at historic lows-11.3% in the second quarter of 2014, down from 14.4% the year before. Over 10 million people enrolled for health insurance through Medicaid or an insurance exchange. But signing up for insurance does not equal access. Healthcare has to be available and affordable. The ACA did not achieve these goals in 2014 and 2015 will be worse.
Medicaid recipients have always had trouble finding care primarily because Medicaid pays physicians a fraction of private and Medicare rates. To remedy this the ACA included a federally funded two-year increase in Medicaid fees for primary care physicians up to Medicare levels. $5.6 billion was spent through June 2014. But the Urban Institute reports that it is unclear whether the increase in Medicaid primary care payment had an effect on the number of physicians accepting Medicaid patients, or on the number of Medicaid patients that physicians are willing to see. And increasing the fees of primary care physicians does not improve access to specialists-the Commonwealth Fund found that low Medicaid payment is the main barrier to specialty care. Most importantly, the primary care fee increase expired on December 31, 2014. The Urban Institute estimates this will lead to an average 42.8 % reduction in fees for primary care services. Since most states will not continue fee increases without federal funds, any increased access for Medicaid patients will not last.
For a nonsmoker who earns around $17,000 a year and receives federal premium assistance, for example, annual premiums equal 4 percent of income (about $700); for a similarly situated smoker, the tax credit stays the same, but the price tag for coverage nearly quadruples. Given this calculus, those who might be especially well-served by coverage—and the access to cessation services it provides—may be unable to afford it. Anecdotal reports presented at a recent national meeting of state insurance regulators indicate that, in some areas, the tobacco surcharge poses as big an obstacle to coverage access as the states that have not yet expanded eligibility for Medicaid.