Proponents of the Affordable Care Act (ACA) insist that the law will extend health insurance to millions, expand access to health care, and improve Americans’ overall health. But, as the New York Times recently reported, at least 20 percent of the new enrollees have not paid their premiums. They therefore do not really have insurance. But even for those enrollees paying premiums, having health insurance is not the same thing as getting good health care, or any health care. In fact, it doesn’t matter how many Americans obtain insurance under the ACA. Most will have difficulty finding a physician.
Many Americans could lose their employer-provided insurance if firms decide that paying the ACA penalty—and maybe giving small raises to their employees—is cheaper than offering health insurance as a benefit of employment or reduce workers’ hours (the ACA does not mandate coverage for part-time employees). These newly uninsured workers will either have to enroll in Medicaid, if their income is low enough, or purchase a plan on one of the state and federal insurance exchanges. Those eligible for exchange subsidies may end up better off economically as their premiums will be so low, but both the exchange and Medicaid options are fraught with problems.
States are already struggling under huge budget deficits from their existing Medicaid programs. Since states lose federal funding if they adjust their Medicaid eligibility guidelines, their only option for reducing deficits is to cut already-low Medicaid reimbursement rates. Physicians are already reluctant to treat Medicaid patients under current rates that are a fraction of private and Medicare rates. Cutting reimbursements will exacerbate the physician-access problem and could lead to closures of so-called “safety-net” hospitals that care for many of the poor and uninsured. These hospitals have long depended on federal Disproportionate Share (DSH) payments to offset the cost of caring for the uninsured. But the ACA severely cuts DSH payments on the assumption that the uninsured will gain either Medicaid or private insurance. If large numbers of patients remain uninsured, safety net hospitals’ financial difficulties will be compounded by their obligation to provide uncompensated care.
Those who do get coverage through the exchanges and pay their premiums will also struggle to get medical care. The ACA requires insurers to accept every patient regardless of risk, provide expansive benefits packages, and eliminate caps on lifetime benefits. Looking to control costs, most insurers are offering exchange plans that severely limit the number of doctors and hospitals patients can visit. Some state exchanges—including New York’s—don’t offer a single plan that covers visits to out-of-network doctors or hospitals. Many people will not be able to see the physicians who have treated them for years, use facilities providing the most appropriate treatment, or access care within a reasonable time and distance from their homes. Some specialty hospitals have been excluded from all exchange plans.
If this scenario sounds familiar, it’s because we’ve seen it before, during the failed managed-care experiment of the 1990s. Patients and physicians quickly became disenchanted with the restrictions and bureaucratic complexity of Health Maintenance Organizations (HMOs). At least patients had options then. They could avoid HMO restrictions by buying broader, more expensive insurance plans. Many plans available now on the state exchanges are highly restrictive, HMO-like networks.
Patient choice has been further compromised by the haphazard implementation of the exchanges. Patients have reported trouble determining which physicians will participate in which plans. Doctors, too, are often unaware whether they’re listed in particular insurance networks and what the reimbursement rates are. Many find themselves arbitrarily excluded from plans in which they had previously participated; others are getting listed on plans without their knowledge.
Worst of all, insurance coverage under the ACA is unlikely to improve health outcomes. The much-noted Oregon Medicaid-expansion study found that new Medicaid enrollees showed no improvement in health outcomes compared with the uninsured. Other studies have shown that Medicaid patients have worse outcomes compared with privately insured patients (though why this happens is not well understood). The health outcomes of many exchange patients will suffer as a result of not being able to see their regular physicians or access the most appropriate specialists and hospitals.
The drafters of the ACA presumably had noble intentions, but the law is failing in all of its intended goals. Unless the ACA is redrafted to provide insurance coverage that most physicians and hospitals will accept, many patients will find that when they need medical care, the doctor is not in.