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ACA Fail Fractal
Under the ACA, the Doctor Won't See You Now

Getting access to a preferred, in-network doctor is getting harder all the time. Three big stories about access blocks under the Affordable Care Act came out this week. First, the NYT profiles the troubling rise of contract ER doctors. The emergency medicine departments in many hospitals now employ doctors who are out-of-network for a given insurer, even when the ER itself is listed as “in-network” for that same insurer. The result is that even patients who have the ability to choose an ER in an in-network hospital often wind up with out-of-network doctors treating them—and large, unanticipated, out-of-pocket bills as a result:

When legislators in Texas demanded some data from insurers last year, they learned that up to half of the hospitals that participated with UnitedHealthcare, Humana and Blue Cross-Blue Shield — Texas’s three biggest insurers — had no in-network emergency room doctors. Out-of-network payments to emergency room physicians accounted for 40 to 70 percent of the money spent on emergency care at in-network hospitals, researchers with the Center for Public Policy Priorities in Austin found. […]

When emergency medicine emerged as a specialty in the 1980s, almost all E.R. doctors were hospital employees who typically did not bill separately for their services. Today, 65 percent of hospitals contract out that function. And some emergency medicine staffing groups — many serve a large number of hospitals, either nationally or locally — opt out of all insurance plans.

The ACA does nothing to address this trend, which is just one example of the barriers to access popping up all across the U.S. health care system. The LA Times reports that, despite several lawsuits challenging it, California intends to stick with its narrow doctor networks for ACA plans next year. Even worse, some insurance companies are planning to cut the number of in-network providers even further. There is still no registry that would allow people to make a comprehensive assessment of which doctors will be covered under their ACA plans, a gap which caused a lot of confusion for patients in the last year.

Nor are those insured through the exchanges the only ones facing access problems. A Department of Health and Human services report on the ACA’s Medicaid expansion finds that many Americans newly insured through the program often have to “wait for months or travel long distances” to get care, according to the NYT. Though the federal government requires states to ensure “adequate access to all services covered,” the definition of “adequate access” is left to the states.  This access problem for Medicaid recipients is not new, as Avik Roy repeatedly points out in How Medicaid Fails the Poor, and has been exacerbated as large numbers of people have joined the program.

In all three of these reports, we see under the ACA a declining level of access to a covered care provider. This is not what progress in health reform looks like.

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  • Andrew Allison

    Had you read the LA Times report more closely, you would have seen that there is, at least in California, a registry ( The declining level of access is inevitable given that insurer’s costs have increased dramatically as a result of ACA’s blanket coverage. What will likely emerge is supplemental coverage providing broader access for a price. The only difference between this and single payer is that basic healthcare costs more. The sad fact is that there’s no such thing as affordable blanket coverage with broad access. Nobody, incidentally, seems to be asking what sort of care one can expect from a practitioner prepared to settle for the low reimbursement rates which have resulted in the narrow networks.

  • f1b0nacc1

    Wow, who would have guessed that this might happen? After all, we were promised that service would get better and costs would go down….we had top men, TOP men working on it….

    • Andrew Allison

      Actually, as should have been expected, we had idiots approving and working on implementing it. A word about a so-called “success story”. The Covered California sign-up website asks for, but is incapable of incorporating, income paid annually (dividends, RMDs, etc., etc.); the compare plans pages demands that annual income be entered but responds with “enter in numeric format” for any conceivable numeric format; and, surprise, surprise, the wait time for chat help is well over an hour. And that’s a couple of months before the next open enrollment period. The morons who voted for this POS sight unseen and the idiots implementing it should all be fired and be required to actually attempt to utilize the monster which they have created.

      • Corlyss

        “we had idiots approving and working on implementing it.”

        Look, I don’t want to knock my former fellow government employees, but they are not smart enough to make silk purses out of the pigs’ ears constraints that federal laws place on them when doing government business with ANYBODY. So here’s a hint: If you (the voters) turn something into a government responsibility/obligation/job, you are only looking for poorer service at high cost and everyone touched by the system gets screwed. SO DO NOT RELY ON GOVERNMENT IN LIEU OF THE MARKET PLACE. Until very recently, the market place was very agile at working around federal and state laws to provide services, but lately the reg pipeline has become so constipated with restrictions and compulsive behaviors that are inimical to good results at a reasonable price, that there needs to be a whole lot of undoing to get functioning services again. The first step is to get government out of the biz of providing services that are better provided by a market . . . any market.
        I never dreamed that the collapse of the Soviet model meant that we, the winners (the West), would end up adopting many or most of the systems proven by the Communists to be such absolute losers.

        • FriendlyGoat

          You have had a career as a government employee and now caucus with conservatives? The citizens hired you and now you laugh at them for doing so. Crappy.

          • qet

            He is laughing at us for hiring his successors.

          • f1b0nacc1

            Corlyss is being honest about the state of affairs in the so-called Civil Service. If that hurts, tough…
            Also, note the second-to-last paragraph as an important explanation of exactly HOW we have gotten into this mess. I worked in DC for two decades, and I have seen the very same process in action. Granted, there was never a golden age when all government workers were hard-working competent and dedicated, but it has gotten exponentially worse in the last few decades for reasons that are obvious to the unbiased observer.
            Final note: The citizens didn’t hire anyone. The ELECTED political leaders who have no direct control over who gets hired/fired in the civil service. This is by design, and has been so since the 19th century. Whether or not it should be the case is a subject for debate, but the idea that these worthless drones work for us is nothing more than a pleasant fiction enjoyed by the historically illiterate.

          • FriendlyGoat

            When any person has a job (past or present) that is paid for by what we call the “public sector” (government, agencies, public safety, public schools, military, or government contracts with suppliers), then I believe the citizens HAVE hired that person. That person has usually enjoyed a much higher level of job security AND benefits than many, many others in modern society.

            When such persons then march off to live a political life badmouthing government spending, badmouthing government goals, badmouthing government competence and arguing against everything they got at work, I say it’s crappy.

            If the quality of government employees is going down, we need to lift it back up by any means possible, not rely on guys formerly on the government gravy train to tell us how sweetly the “marketplace” works instead.

          • Anthony

            Friendly Goat, you express your ideas in clear writing and appreciate that objective knowledge is a precious commodity (despite IT and current culture reinforcing echo chamber of shared viewpoints – Black or White no shades of Grey). The ability to distinguish vetted fact from rumor, ideology, and unexamined conventional wisdom comes through in your comments (and that’s not to say I agree with them). But FG, ideologies are (as you well know) idealistic: a conception of a greater good. It renders (generally) opponents infinitely evil and hence deserving of …. If I may take liberty, recognize your audience and remember that groups (liberal, conservative, Muslim, Zorastrian, etc. etc. etc.) can breed a number of pathologies of thought. And yes military pensions, federal pensions, medicare, homeowner mortgage exemptions, social security, and much much more are paid by public sector. But since 80s the mantra has been “Government is the problem” reined it in, cut marginal tax rates, privatize and deregulate, etc. etc. etc. So, my friend here we are with a bold diagnosis useful to any inclined to justify a predilection.

          • FriendlyGoat

            I’m glad you believe I express thoughts in clear writing even though you don’t agree with many (or any) of them. My wife does crossword puzzles for mental exercise, and I write comments mostly as practice to continue thinking. I also happen to believe that liberal values are being swamped by disinformation campaigns, so I practice writing from the liberal side of nearly everything.

            On this particular matter, in my state (New Mexico), we have a retired Colonel, who owns an aviation company flying illegal immigrants back to home countries for Uncle Sam, running for U.S. Senate as a Republican. He is on two kinds of gravy trains at once (the aviation company being the biggest) and he wants to go to Washington to repeal Obamacare and trim those pesky entitlements. He maintains that government cannot create a job WHILE BEING THE BENEFICIARY of government economic demand for his whole life. Joni Ernst is trying to pull a similar trick as a Republican Senate candidate in Iowa. There is something WRONG with this. When Corlyss, above (and elsewhere on TAI) says one thing while admitting to having lived another, then, yeah, it’s time for us “idealists” to complain.

          • Anthony

            FG, obviously quite a wife. Seriously though, I didn’t want to taint response as partisan support. That said, I not only enjoy reading your commentary but also agree with more than you know. As an aside, Freud (I think) looked upon civilization as a process of necessary repression and at different times and places small classes arise and identify themselves with repressive rule while aspiring to utilize system to their ideological advantage. I think you and I can agree that human life is less an affair of institutions and systems (though they both have their place) than of people and an interplay of motivations and abilities – therein we look to rationalize our biases.

          • FriendlyGoat

            Thanks. Perhaps we can entertain each other a bit and maintain our pet biases too.

          • Anthony

            You’re welcome and of course.

          • f1b0nacc1

            I don’t doubt that you believe that public sector workers are employed by the people, but your opinion is in complete opposition to the simple facts of the matter. You and I (we are the people, no?) have no input at all in the hiring, promotion, or firing of public sector workers, and we have only the most tenuous connection to those that influence these actions. As I pointed out above, this is by design, and was explicitly intended to remove any public/populist control of the civil service when it was instituted in the 19th century. We might consider this regrettable (or laudable, for that matter), but to pretend that it isn’t the case is simply denying reality.
            As for government alums pointing out the flaws in the system (and they are legion), I believe that there is a principle popular in democratic societies called ‘free expression’, you might want to consider it. Those who have been ‘inside the sausage factory’ are often best suited to comment about how it works (for better or for worse), and thus their observations should be most welcome, particularly for those like yourself who believe that government is often a viable answer to society’s problems.
            If the quality of governmental employees is declining (an observation that is difficult to challenge), of course we should all work to see it improve, but at the same time a discussion of what the proper role of government is and should be is not only welcome, but vital for a free society. You seem to believe that those who enter government service lose the right to participate in that discussion. Would you say the same thing about individuals who accept government assistance (welfare, for instance?, how about social security?) or is their ‘conflict’ of a different nature? How about former military officials who choose to criticize current (or former) administration’s conduct of a war? You seem to be advocating a sort of ‘love it or leave it’ mentality…
            As I pointed out earlier, the quality of governmental competence is awful and growing worse. If you don’t like that, tough….but certainly those who have seen this ‘up close and personal’ are not only well qualified to offer their perspective, they should be expected to do so as a civic obligation. A GS-11 who observes the manifest nonsense that goes on every day in his office is often not in any position to change it, why should he be expected to pretend that it is a good thing?

      • f1b0nacc1

        Of course you are absolutely correct, but given that the idiots who created this mess in the first place weren’t going to have to use it (note that they were careful to exempt themselves from any of its requirements), it really isn’t too much of a surprise….

      • John Galt

        worst legislation ever…
        – limit healthcare options
        – re-distribute wealth
        – impair economy and job market
        – put more bureaucracy, paper work and legal hurdles between the doctor and patient
        – increase long term fiscal risks
        – empower government bureaucracies like the IRS at the expense citizens liberty

  • Suzyqpie

    No one should be the least bit surprised by the debris field created by passing a 2300+ unread page bill that ballooned into a 10,535 unread page bill when “the Secretary” concluded “determining” the foundation of the legislation. You will never convince an 0bama sycophant that medical insurance is not the same as medical care. 0bama and the Democrats blew through all of their political capital to pass a bill that is a burden to all those it was, ostensibly, intended to help. 0bamaCare, aka, DemocratCare did achieve one purpose, it grew government and government control. And it delivered tremendous profit to Wall Street. Share value doubled plus for CI, WLP, HUM UNH, & AET.

    • B-Sabre

      ACA: There Is No ‘Minimum Safe Distance’

  • FriendlyGoat

    There is always a hole to plug with new trends in the business community. (This is why liberals are constantly proposing new legislation to counter the newest scams.)

    But, anyone with half sense knows it should be against the law for a hospital to operate a supposedly-in-network ER with out-of-network doctors. NO ONE can arrive in an emergency and be expected to somehow “choose” something else. This needs to be addressed under a fraud statute, not Obamacare.

    • Boritz

      I think the Cuban system is the endpoint you’re expecting when enough legislation has been passed.  Admittedly it is quite good on paper.

      • JLawson

        And that’s the important thing, isn’t it? As long as it looks good and sounds good, what does it matter whether it actually IS good?

        • FriendlyGoat

          Ask any tail-end Enron shareholder about that. Their private-sector auditors at AA&Co really took good care of them.

      • FriendlyGoat

        You don’t have to live in Cuba to know that an in-network ER with out-of-network doctors—–which you can’t find out about until LATER, when they bill you—-is a scam.

  • creeper

    The problem here is the assumption that Obamacare is about health care. We all know better.

  • Dantes

    This is otherwise known as “rationing”.

    However, your solution sounds even worse. Make doctors belong to networks,,,which means, the networks control the doctors. Of course, that is the idea…easier for the government to control a few networks, rather than tens of thousands of doctors.

  • crabtown

    It depends on what the goal really is. This isn’t a surprise. Wait until the parts which have been delayed to get elected really start taking effect.

  • texan99

    Has anyone here had experience with Assurant Health? They claim that their network has virtually no exclusions: it covers the Mayo Clinics, for instance. I’d love to hear from anyone who’s actually submitted claims to them. Our grandfathered plan was just cancelled, so we’re looking to replace it come 11/15/2014. Last year, Assurant did not offer coverage on any of the exchanges, but this year they opted to participate in 15 states, including my own state of Texas.

  • Fred Chittenden

    Oh, get over it folks. OCare isn’t about providing quality affordable care. OCare is mostly about assimilating as much of the population as possible into the crony health care collective controlled by politicians.

    It’s even better if the quality of OCare provided is crummy and expensive — more stuff for people to complain about means more buying votes at the next election with false promises to fix things. It’s not like anyone will ever be able to escape being part of the crony collective…

    In the process of making crony deals with various players in OCare to (never) ‘fix things’, there will be plenty of campaign donations to make sure the politicians promoting more and more cronyism will get re-elected — the collective “fix is in” for crony lying politicians supporting OCare’s continued existence in one way or another to be re-elected.

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