Reform creates new incentives in health care

I advocated for the Affordable Care Act, and celebrated when it was passed.

It’s good to have everyone covered, I thought.

Insurance for everyone is the first step to health care for all.

Alas, access to health insurance isn’t the same as access to health care.

First there is the niggling detail of providers. We already have a primary care provider shortage.  Internists, pediatricians, family physicians are already working at full capacity in caring for the general health needs of a community. The poorest neighborhoods with the worse reimbursements already have a severe shortage of providers. More people with health care coverage, means more people will be seeking routine care, and we don’t have more providers ready to see them all.

For patients, this will mean longer waits to see a provider.  Or for providers, it will mean longer hours at work to see more patients.

Second, the ability to buy subsidized health insurance doesn’t automatically mean the ability to pay for health care.

I just learned that patients who are unable to pay their co-pays within 90 days may then need to face the entire medical bill on their own. How bad can a co-pay be, you may ask?

“When I say I have zero income, that means I have no money. None,” said one of my patients from the community health center where I work as a family physician on the South Side of Chicago, when I was encouraging him to buy generic medications at Walmart or Target. “$4 is too much for me,” he said.  “I’d need to steal to buy it. “

Zero income means an enormous challenge to pay anything, borrowing from a network of friends and relatives and searching out social programs for medical assistance. In some states, Medicaid will be expanded to cover everyone who is near the federal poverty line.  Other states are choosing not to expand coverage to young men.  Private insurance plans may effectively leave them unable to afford health care, even if they are able to afford subsidized health insurance on the state exchanges.

When patients who live on the financial edge, who currently don’t have health insurance miss their co-payments, they will become liable to pay the entire cost of the doctor’s visit.  After 90 days with no co-pay, then insurance companies would owe nothing.  The people who are poorest , who have the toughest time scraping together the money to cover their co-pays, may ultimately be responsible for paying not only their co-pay, but the entire medical bill, while also paying insurance premiums.

This would be unfortunate.

I wish we could turn back the clock and create a simpler system where everyone had access to care without needing to worry about who pays what.  Instead we have recreated pricing mechanisms that in effect result in tiered payments where the poorest patients continue to pay the most.

People are poised to buy into a broken system at the stroke of midnight announcing January 1, 2014.

The health insurance exchanges are coming—faciliating the buying and selling of imperfect products that promise access they can’t fully deliver, while potentially leaving vulnerable patients without full access to health care.

And still this is better than the alternative, where patients had no coverage at all, and the system wasn’t incentivized to find ways to become more efficient and more effective.

There will be new incentives in healthcare.  We’ll see what happens. The American healthcare system will need to continue to adjust to the needs of patients, to be responsive to the most vulnerable, in order to ensure a healthier America.

Kohar Jones is a family physician who blogs at Progress Notes.

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  • mmer

    We have to couple insurance for all with price controls. Yes, price controls. Simply having insurance, as you noted, is not enough:

    According to the Harvard study, Medical Bankruptcy in the United States, 2007: Results of a National Study, “62.1% of all personal bankruptcies in 2007 were medical; 92% of these medical debtors had medical debts over $5000, or 10% of pretax family income…Most debtors were middle aged, middle class, and had gone to college..three quarters had health insurance”

    We have to confront the cost of medicine, not just allowing people to have insured access to it. In most developed countries, personal bankruptcy due to medical bills in unheard of, in the US, it’s the leading cause of personal bankruptcy. This is morally perturbing.

    We have to get over the philosophy that medical care ought to be considered like any other commodity, like a large screen TV or a new car. Unlike these consumer goods (the medical terminology is sounding increasingly market-based, which is troublesome, ie. “health care consumer”), access to healthcare allows people to reach their full potential in life, like education. We consider education a right, a public good, why not healthcare? Look at the social determinants of health; the health of and individual and a population cannot merely be reduced to our personal choices – much of it is determined by factors completely outside of our control.

    Proper structural changes to medicine and treating it as a social good will help reduce economic inequality, will do wonders for the doctor-patient relationship, and can play a large part in creating a more just society.

    • Filo

      Most people argue over what course of action is best for the health care problem. Yet very few fail to address, or ask for that matter, what the source of the problem is. I can’t imagine anyone anyone disagreeing with increasing costs and reduced access as being a problem. But I have seldom seen or heard an honest assessment of what is causing the United State’s astronomical health care costs (beyond obtuse philosophical/ideological positions).

      I was with you, for the most part, until your 4th paragraph. You essentially went down that same proverbial road.

      Maybe heath care shouldn’t be seen as a commodity, but it still needs to be an input equal to (or more) than its output. This is basic energetics.

      Education is not a right, it it compulsory and is a state function for the good of the state… Definitely a public good, but compulsory. Likewise, health care is not a right. A public good? Absolutely! A service? You bet. Should its ranks be filled by people who have hearts of servants? 100%! Do we have the right to seek health care? Yes. But in no way can I see it as a right. If you see it as a right, you have a fundamental misunderstanding of what rights are.

      When 3/4 of our health care costs are dedicated to obesity, cardiovascular disease, diabetes- all of which are preventable diseases- choice is absolutely a factor.
      But you are welcome to elaborate on what exactly the social determinants that trump lifestyle choices are regarding health.

      • Lisa Corcoran

        Hear, hear!!!

        • pnathanson

          Whether healthcare is a right was recently the subject of a 300-post thread on the LinkedIn Healthcare Executives discussion site. In the discussion, the ayes and the nays just wound themselves ever tighter around their own axles. Large amounts of wisdom, insight, bigotry, ugliness and ignorance were displayed. Nothing was resolved.
          I say that (a) this question isn’t answerable until we agree on the definition of a “right. — which we don’t — and that (b) ultimately, it doesn’t matter what you call it.
          For example, in approximately 151 coutries, access to affordable care is guaranteed and subsidized by the government. Does that make it a “right” in those countries? They think it does. Where do we get off telling them that it isn’t?
          In most developed countries, healthcare is MUCH cheaper than here. Contrary to popular belief, most of them don’t have “socialized medicine.” For instance, France, Germany, the Netherlands, Italy,Japan etc.have combinations of patient, taxpayer, employer and insurance funding, just as we do. But unlike us, they have effective ways of regulating prices. In the developed countries, not only are costs much lower, but health outcomes are better than ours, pretty much across the board. So maybe we can learn something from them? Or are we too parochial, xenophobic and self-interested?

          • Filo

            The topic of this thread was about costs and that is the problem. Rights have become a red herring in this discussion. But I will digress.

            The concept of rights should not be a difficult concept to understand. It only gets confusing when people play convoluting semantical games by conflating a concept with their own values, pre-concepts, ideologies, and agendas (especially). Rights pertain directly to boundaries, not benefits. Those are two distinct concepts.

            You are correct, it doesn’t matter what we call it, it is ultimately the principle that matters. And the principle is about boundaries.

            A person does not have the right to enter into my home without my permission; and if they choose to violate my family’s boundaries, I do have the right to forcibly defend them.

            The boundaries between the government and the citizenry are defined by their own constitution. Consequently, the government has rights (boundaries that should not be violated by its citizens) and its citizens have rights (boundaries that should not be violated by the government they empower).

            Yes, a society has the right to establish its own boundaries and no one has the right to say otherwise. I don’t think anyone here in this country is getting off telling them anything. If that type of benefit is what they choose for their society, that is their right to choose that benefit.

            Once the boundaries (rights) of the citizenry are violated by its government, their sovereignty is lost and they become subjects of an abusive state. If the boundaries (rights) of an individual are violated by another (undoubtedly abusive) individual, they become victims of a crime and have the liberty to take action per the constitution of their society.

            I have the right to not be forced to subsidized other people’s health care. You, Obama, nor anyone else including myself have the right to force anyone to do so; much less purchase a product. I also have the right to subsidize other’s health care. I have the right to pursue medicine and become a health care provider. No one has the right to tell me I have to provide health care for another.

  • NewMexicoRam

    I was in Haiti 33 years ago and volunteered at a rural mission hospital.
    The locals there had to pay SOMETHING for their care. One gourd, about 10 cents, but they had to pay. And they did. I’m talking about the poorest of the poor of the entire Western hemisphere.

    I don’t believe one second that people in Chicago can’t come up with $4 to pay at co-pay.

    Ten years ago I spent my 20th anniversary in Chicago. The guy who walked up to me to clean my shoes in 30 seconds was able to get $8 from me.

    • Margalit Gur-Arie

      Walmart doesn’t take gourds.The days when doctors were independent and hospitals were run by charitable religious orders are gone in this country. It’s not about the $4 per se.
      Under the guise of “Affordable” we are building a health system run by corporations for profit (or revenue), increasingly funded by taxpayer money, that has no heart, no flexibility and no intention of returning our investments.
      They are selling insurance for higher and higher prices, while simultaneously redefining “quality” care to consist of seeing a nurse on TV.
      Those 50% of unfortunate children you mentioned in the other thread are going to grow up and be 50% of the society your children will live in. Is this really what we want? Is the $4 principle so important to us?

      • doc99

        Yes, they keep using that word Quality. I do not think it means what they think it means.

        • mmer

          That’s what happens when the consultants and their “blue sky thinking” and “business synergy” get involved in patient care.

          Be very careful about who is defining these words and what their interests are.

          • Margalit Gur-Arie

            … as long as we have “value” for “consumers”, it’s all good…
            “value-based” = cheap
            “value instead of volume” = rationing

    • Suzi Q 38

      I agree.
      Can’t they go to a free clinic and get free samples?
      I used to deliver samples to doctor’s offices and clinics.
      I would leave extra if the doctor really needed it for a patient or two. The problem is that the samples are probably rationed now.
      If you write to the pharmaceutical company, you used to be able to get free drugs for needy patients.

  • Anthony D

    You got a problem with ObamaCare? So do I!

    It’s below par healthcare, that’s why certain people like those is
    Washington are exempt and so are illegal immigrants. Insurance companies do not have to cover it either and there are hidden taxes within this bill such as those on medical equipment. 760 billion dollars was taken from Social Security and Medicare to fund ObamaCare and there was NO bi-partisan support for this law. They are not even entirely sure what is in this monstrosity.

    It’s astronomically expensive, [2.6 trillion so far, they need another 800 billion to fund it over 10 years] It will also price over 7 million people out of insurance. It’s crippling small business by demanding that employers pay for their employees health insurance. Employers are either not hiring, cutting back on employees, cutting back on work days and hours. Businesses that have been around for a long time are having to shut their doors because of these costs and regulations. Insurance
    premiums have increased, prescription drug prices have increased, bureaucracy has come to the doctors’ visits.

    The BIGGEST GRIPE I have with this is it’s also UNCONSTITUTIONAL even though it was written up as a “TAX” it’s STILL COMMERCE!!!! You can’t force a product on someone and then fine them for not taking it, especially if they can’t even contest that fine in court. People who don’t have insurance/ObamaCare will be fined $5,000 by the IRS) You
    don’t get to keep the doctor you have, the bureaucrats get to decide or a stupid chart. It violates the 4th, 5th, 7th, 9th and especially the 10th amendment regarding the commerce clause. It doesn’t take into consideration the demographics, budgets and health issues for each individual state.

    • Suzi Q 38

      Businesses will definitely shut their doors or try to employ part-time workers.

    • bradyjohnson

      We’ve determined that mandating car insurance is constitutional. Mandating health insurance is similar, thus it is viewed as constitutional. The Supreme Court made this decision.

      • Guest

        “There was definitely bi-partisan support for this law. How else do you think it passed the Senate and the House?”

        The Democrats had a supermajority – both the House and Senate – at that point.

  • ErnieG

    If a patient really has zero income, then their biggest
    problem is not inability to pay copays or medications, but rather their inability to generate any income. How to treat the financially challenged is a much different question than how to manage the larger working and more fortunate aspect of the population.

    I am strongly against the idea that medical care is a right,
    and that it should be treated like a public good like education. That does not solve a problem- think about it, the US has free public education k-12, but it leaves much to be desired. There is a two or three tiered system and the insistence that schools be paid by property taxes leads to vast inequities.
    The idea of medicine leading to social justice is weird- as long as patients have a choice and right to do with their bodies as
    they wish, and as long as patients remain human, medicine cannot really lead to a “just society” or “reduce economic inequality”. This is different that stating there are unjust ways to practice medicine.

    The problem with health care in this country is that it is
    too expensive, it produces personal medical bankruptcy, relies on employer or government provided coverage, and is now controlled by large players: insurance, gov’t, and pharmaceuticals, and soon large medical accountable care
    organizations. Obamacare proponents chose to see the problem as one of equity, and so they expanded insurance while increasing control over medicine. Large players now control medicine, industrializing medical care. Medical
    care is not like making widgets. Every physician and nurse knows this. In NO WAY will Obamacare help the task of medical providers improve lives of real patients, only “quality” statistics.

    The mechanisms for cost control (cost transparency, less
    third party involvement, stronger patient-physician relationships) as a means to achieving affordable meaningful medical care were never considered as solutions. As expected more of the same will produce more of the same, at the
    same time leading the ship towards national bankruptcy. Obamacare essentially threw out the patient and the physician out the window. That is the legacy Obama has to look for.

    This does not take into account that fact that the biggest
    chronic medical problems facing the US are a result of lifestyle (i.e. diabetes and obesity) and not likely to be improved with medical care.

  • PeterPaul Mary

    Where did you get this fact: “patients who are unable to pay their co-pays within 90 days may then need to face the entire medical bill on their own” ??? Is this part of the new Obamacare coming our way? And this punishes the caregivers: “After 90 days with no co-pay, then insurance companies would owe nothing.” So when I thought that non-insured’s would soon have SOME sort of insurance under Obamacare, they will still basically present as “no-pays” because they can’t pay the copay and the provider/hospital won’t even get paid by the insurance as a result. That stinks. Where does this fact come from? Plz cite your reference.

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