The Washington Post’s Wonk Blog reported on how people on Medicaid expansion felt about the program earlier this week:
Medicaid enrollees are generally happy to have coverage, though many are encountering roadblocks to receiving the care they want, according to new research that provides one of the earliest insights into people’s experiences under the expanded health insurance program for low-income Americans….
Before obtaining new coverage, most people in the focus groups said they delayed medical care while they had been uninsured, and some in the focus group said they’re facing medical debt for care that they couldn’t delay. Preventive care, in particular, had been a challenge for this group – many said they hadn’t received a checkup in years….
The enrollees’ biggest problem has been finding a primary care doctor, which has been a major concern in the health policy community….Some new enrollees in the focus groups said they had to call at least six practices to find a doctor, some had to choose doctors far from where they live
The biggest problem with the Medicaid network is a pricing problem. Providers are paid too little compared to their next best set of alternatives. Therefore, getting providers willing to take on new Medicaid patients is a pain in the ass. Usually providers who take on Medicaid patients are either part of a major academic medical center group, a charity/provider of last resort center, or fairly young and building out a new practice. Mid-career providers in the suburbs with an office in a nice building are unlikely to take new Medicaid patients; they may continue to serve patients who they started to see early in their careers or who had changed insurance to Medicaid, but are unlikley to look to fill their roster with new, low paying, Mediaid patients especially when much higher paying Exchange patients are now insured and available.
PPACA temporarily addressed this problem. For Calendar Year 2013 and 2014, the feds as a 100% pass through to the states raised the Medicaid reimbursement rate for primary care services to be equal to that of Medicare. This is typically a 40% to 70% raise. As expected, panels opened up and more providers have been taking on new Medicaid patients. However, on January 1, 2015, the enhanced payment rates are set to fall back to standard Medicaid rates. Two states have base rates above the enhanced rate, and six states are paying for the extra reimbursement with state money.
There is a proposal to extend the payment enhancement for another two years as well as broaden its applicability to more provider types and services. This bill would cost $11 billion over two years, and it would be a good idea. I don’t think it will pass. The Republican Party is more opposed to anything that benefits poor people and potentially Obama than in sending money to very high income individuals. Spending money would solve a significant chunk of the Medicaid access problem.
OzarkHillbilly
The Achilles heel of the PPACA has always been the Republicans in Congress.
Baud
@OzarkHillbilly:
That’s the Achilles heel of everything.
mb
Just about every physician in this country was trained using public funds. They should be required to accept a certain percentage of their patients with mcaid coverage as a condition of their training. Some debt forgiveness could be part of it too to encourage compliance.
Elmo
Before my wife was able to get on my health insurance, she was uninsurable except through Medicaid. The difference between her treatment through Medicaid and now through my insurance is astonishing, horrifying, heartbreaking. Five medications a month, no matter your condition or treatment plan. Routine three and four hour waits for a three-minute visit with a doctor who couldn’t even recall her name, let alone why she was there. And ye gods, the way she was treated by staff.
Better than nothing, since nothing = dead. But hideous.
OzarkHillbilly
@Baud: Not tax cuts or deregulation or finance or pollution or income inequality or global warming or……
MPAVictoria
It is also worth pointing out that doctors in the US are paid WAY more than anywhere else in the world…..
seabe
Shouldn’t the solution be more geared towards reducing their pay, and towards what Medicaid pays? This is a bandaid to continue an unwanted trend.
Eric U.
@MPAVictoria: while this is true, medicaid payments can be really low. It has been a while since my wife was in private practice, but medicaid paid quite a bit less than her going rate. And in psychiatry, medicaid patients are usually really sick. I think a normal person can only tolerate so many hopeless cases. Furthermore, a really sick patient is likely to have crises in the middle of the night when medicaid doesn’t want to pay. We weren’t getting rich in those years, that’s for sure. I think a better model is to have some kind of public clinic, but of course the republicans wouldn’t hear of such a thing
MomSense
So simple and so helpful, it is a no brainer but then Republicans have given new meaning to the expression no brainer.
jl
I think a part of the problem is the growing split between primary care and specialist reimbursement. I don’t think it is true that all US docs are Wealthy as God Oligarchs in the Mayhew tradition. So, shortage of primary car doctors, and actually all primary care providers form Physician Assistants to pharmacists to higher skill technicians results, and operating with slim margin. (Edit: and note that if healthcare really were a normal market, this could not happen: shortage of important element of supply chain, but relative pay continuing to look crummy. More evidence that US healthcare is not normal standard market setup from supply side as well as demand side. this is too often forgotten)
Recent attempts (maybe even sincere ones) made by ruthless and self-righteous cartels such as AMA to increase primary care doctors have not been successful, because specialists control the decisions that control of the flow of reimbursement. So, even if the attempts are sincere, the natural conflict of interest between the public healthcare mission and reimbursement flows have resulted in policies that lead to medical students strongly favoring going into very highly paid specialist training.
And US specialists are very very highly paid by world standards. Last I looked only Netherlands has comparable real reimbursements, though specialists much smaller share of MD supply than in US. IIRC Netherland primary care docs somewhat more highly trained and can do more, but also somewhat more highly paid than in US without comparable medical school debts to pay. So, lower cost share of economy overall is possible with comparable provision of care.
jl
And for some reason the supposed healthcare policy and economic experts that inhabit healthcare professional schools continue to terrify medical and other healthcare students with horror tales of massive oversupply looming around the corner, while older docs like to show off all their lifestyle and complain that they can’t buy all the toys they used to, and their students will probably end up living in a trailer down by the river. OK, that last bit is a slight exaggeration, but I really do not understand what the heck (Edit: many or most of) the healthcare policy people think they are doing. I tend to stay away from them now, better to hang around PhD and engineering people where one hears some logic and actual evidence from time to time.
Ilya
@MPAVictoria: Every type of worker in the US is paid way more than their counterpart elsewhere in the world. Tell you what, if you’re willing to work your job for 1/3 of your pay, I’ll do mine for that as well.
@mb: I was trained using public funds, in that Medicare paid me $8 an hour for the 6 years that I was a resident/fellow, putting in 80 hour weeks consistently. If you think I need to take a vow of poverty because Medicare was kind enough to pay me minimum wage for taking care of some of the sickest and poorest people in the country earlier in my training, you’re even stupider than the insurance industry hack authoring these posts. Also, I assume you went to a public high school / college or got government-subsidized student loans at some point, so I’m sure you’re going to work for the government for free, right? I LOSE money on my Medicaid patients, and barely break even on my Medicare patients. I can’t put food on the table for my family under those conditions, let alone pay my nurses or staff.
MPAVictoria
“Every type of worker in the US is paid way more than their counterpart elsewhere in the world. ”
Know how I know that you don’t know anything about the world outside your country?
/idiot.
Ilya
@MPAVictoria: Try harder.
http://www.oecd-ilibrary.org/education/teachers-salaries_teachsal-table-en
I specifically chose teacher’s salaries because that’s one that most Americans agree is TOO LOW in the US (and I do, too), and most of us expect to be higher in the Le Socialist Paradise Europe. American teachers still get paid more, aside from weird outliers like Luxemburg and Switzerland.
Mnemosyne
@Ilya:
What is the average student loan debt that teachers (education students) in Europe graduate with?
Ilya
@Mnemosyne: Definitely far less than that of their American counterparts, which is, in turn, far less than that of American medical students.
flounder
I live in Norwood, MA, and am covered through my wife’s employment. The nearest PC doc to me that was taking patients when I got coverage was in Millis. It is a 24 min drive according to Google maps. I called well over six providers to find a PC that was taking patients. My children see a doc that is a 30 min drive in the opposite direction because that was the closest network provider at the time.
Isn’t just Medicaid.
Mnemosyne
@Ilya:
Which is my point — salaries are higher because people are graduating with a larger loan burden. I have no problem with figuring out ways to relieve medical students of that burden, but only if they commit to primary specialties and realize that they will have lower salaries to go along with the lower (or zero) debt burden. I see no reason to let, say, orthopedists go to school for free and continue to charge what they do. It’s either ease the debt burden hand-in-hand with lower salaries, or keep things as they are, which is unsustainable for everyone.
Ilya
@Mnemosyne: While the higher loan burden is a reason for doctors here getting paid more than in Europe, it may not be a factor in why medical students choose the specialties they choose – multiple studies on the subject have had mixed results (in other words, students with full rides don’t necessarily head to primary care, and students with major debt don’t necessarily head to the most lucrative fields). The primary reason, in my opinion, why so many medical students avoid primary care is because you simply cannot make a sustainable living in that field in this day and age. Period. $80,000 in NYC, for someone who is earning their first paycheck at age 30, works 60 hours a week, and has 300K of med school and college loans is not a sustainable income. A lot of that is because of Medicare (and the worst offender, Medicaid) reimbursements, which favor procedures over clinic visits (and primary care physicians don’t do many procedures). The only way to get more people into primary care is to prove that it can sustain a livelihood, and the only way to do that is to increase reimbursement for clinic visits, but that will never happen. There are literally hundreds of thousands of people like Richard here whose job all day every day is to deny payment as frequently as possible to providers.
mb
@Ilya: bullshit