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ACA Agonistes
Health Care for Me, But None for Thee

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.

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  • Pete

    Isn’t Medicaid welfare ?

    • Corlyss

      Yes. It never was tarted up to be anything else.

  • Bretzky1

    Eventually the feds are going to make it illegal to refuse services to people solely on the basis of what health insurance they have.

    • Corlyss

      That’s already the law for hospitals that receive federal $$$, which is the vast majority. That’s why over the last 40 years the hospital system in Ca. has experienced so many hospital closures. Another development we can thank the illegals for.

      • Andrew Allison

        Not entirely: Last year “Los Angeles-based Pacific Health Corp. closed all four of its hospitals in California — Anaheim General Hospital, Bellflower Medical Center, Los Angeles Metropolitan Medical Center (and its Hawthorne campus) and Newport Specialty Hospital — after the for-profit chain ran into millions of dollars of legal fines and lawsuits.” Seems there quite a bit of illegality in hospital administration too. Furthermore, the uninsured patients which hospital ERs are required to treat are by no means all immigrants. In fact, the decline in the number of hospitals appears to have bottomed out five years ago, in 2009. I hasten to add that illegal immigration and its effects is a huge problem, but it’s not root cause of the healthcare problem.

        • Corlyss

          A single anecdote does not a trend rebut.

          I take your point that illegals didn’t cause the health care mess but then I never said it did. They tipped the balance in Ca.’s hospital availability (the access issue – what good is the best health care system in the cosmos if you can’t get to it?) as well as playing a meaningful role in the collapse of the k-12 public education system, a separate but related issue in the sense that their numbers and the nature of their demands overwhelm systems. I’ll have a longer post on illegals (the most worrisome kind of immigration I am concerned about) in a reply to free_agent (here:, including links to studies on illegals impact on health care, as soon as I put it together. This is not my first public policy rodeo on the illegal immigration issue. It was too long to construct lying in bed using my iPad.

  • Jim__L

    – Eliminate scope-of-coverage requirements — bring back catastrophic insurance, and stop requiring men to pay for plumbing we don’t have.
    – Eliminate subsidies, we can’t afford them.

    The other option…


  • Corlyss

    All hail the Medicaid/Tri-care model!

    • rheddles

      Then the female doctors can unionize and our health care will be as good as public education.

      • Corlyss


  • Andrew Allison

    Please note that Medicaid is NOT insurance — it’s taxpayer funded welfare, pure and simple. I assume that people on Medicaid do not have to pay anything for their care, the provider getting only what the government decides to reimburse. I’m socked, SHOCKED, that only a third of primary care physicians and a quarter of specialists have closed their doors to Medicaid. Medicare is different in that accepting Medicare reimbursement as payment in full is optional. My primary-care Doc bills me for the difference between his charge and the reimbursement. Perhaps one of the medical professionals who frequent this blog could explain why simply declining to accept Medicare reimbursement as payment in full wouldn’t solve the problem. It would have the additional benefit of exposing patients to the cost of their care and thereby considerably reducing the practitioners workload [/grin]

  • Boritz

    “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. ”

    Translation: Morbidity and mortality will increase under the system.

    Translation of translation: More people will be sick longer and die sooner.

  • Paul Kersey

    The progressives in DC would be concerned about the effects of their signature achievement if they had intended to improve the health care system. But we all know, or at least suspect, that they intended no such thing. They are playing a long game, the result of which will be the collapse of the private health care system in this country. The only option then left will be single payer. If some people get sick and die while this plays out, they will consider it collateral damage and it will be tolerated so that the final goal can be achieved. The only problem, for the progs anyway, is that the coming financial collapse may arrive before the nirvana that the ACA was designed to usher in.

  • Jacksonian_Libertarian

    “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.”

    While getting rid of licensing requirements would be a good thing, American healthcare lacks the “Feedback of Competition” that forces continuous improvements in Quality, Service, and Price in free markets. If the consumer/patient isn’t heavily exposed to the costs of their own health care, then there isn’t any “Feedback of Competition” and Quality, Service, and Price all suffer. As things now stand, Insurance companies and their salespeople are working for the employers who are paying the bill. So patients don’t care what things cost as they heavily insulated, not even knowing how much of their paychecks go to health insurance, or how much medical procedures, equipment, tests, and pharmaceuticals really cost or if they’re even needed. Most people with health insurance go into a healthcare facility not to negotiate the best deal they can get, but to collect on everything their insurance could possibly be made to provide.

    As an example of what would happen if America had a free market for medical care, look to the corrective eye surgery market, that health insurance has never covered. It went from radial keratotomy to Lasik, from hospitalization to in and out, and the price in a recent email is advertised as $298 per eye. At $600 that’s just a little more than an eye exam and a pair of prescription glasses with designer frames for about $500 (which is what I recently paid). Imagine if the entire American medical industry was improving in Quality, Service, and Price as swiftly as Lasik has.

  • Jim__L

    If you say that consumers have to buy more (than they can afford), and you say providers have to provide more (than they can afford), is there any wonder that less transactions are able to occur?

  • AllanDale

    The chosen insurance-model gives the game away. You may have noticed that insurance companies are reluctant to sell fire insurance to a known pyromaniac. In fact, insurers typically are eager to underwrite a policy only if they are convinced you are unlikely to file a claim. That’s because the only way they can make money is to collect more in premiums than they pay out in claims, and, anyway, an insurance company is merely another name for a bank with different deposit and withdrawal arrangements.

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