U.S. health care is increasingly becoming two-tiered, with one zone of relatively easy access and good care for those who can afford it and another of low access and poor care for everyone else. The Hoover Institution at Stanford University recently published an excellent discussion of how the Affordable Care Act will cement and expand this class-based stratification of health care. Those who rely on Medicaid, and those who rely on cheap premiums are both being squeezed out under the new practices imposed by the ACA:
About one-third of primary-care physicians and one-fourth of specialists have already completely closed their practices to Medicaid patients. Over 52% of physicians have already limited the access that Medicare patients have to their practices, or are planning to, according to a 2012 survey by Merritt Hawkins for the Physicians Foundation. More doctors than ever already refuse Medicaid and Medicare due to inadequate payments for care, and that trend will only accelerate as government lowers reimbursements.At the same time, ObamaCare is squeezing out the middle class from affordable private insurance that correlates with far better disease outcomes than government insurance. By bloating coverage requirements and minimizing the consideration of risks fundamental to pricing insurance, the law has already increased premiums by 20%-200% in more than 40 states, according to a 2013 analysis by the Manhattan Institute’s Avik Roy and others.
This piece points to a difficult truth: getting insurance is not the same thing as getting access to health care. Especially if you’re on Medicaid, you can have insurance and still face enormous difficulty in finding a doctor willing to see you. The stratification that the Hoover piece explores is driven in large part by the discrepancies among insurance plans. One solution is to expand the number of providers in the system both by eliminating artificial barriers to entry set up by medical guilds and by allowing nurse practitioners wider scope of practice. With more providers in the system, Americans with lower-grade insurance would have a better chance at real access than the ACA currently allows.