Obamacare

The Doctor is Not In (for Medicaid Patients)

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Olga

With pressure from the federal government to expand enrollment, Medicaid costs represent a rising chunk of state budgets around the country—one that's crowding out other priorities. State officials desperate to control costs are stiffing health care providers and turning to managed care. Low reimbursement (which is about to get worse) already discourages doctors from accepting Medicaid patients. And last month, the Office of the Inspector General for the Department of Health and Human Services found that managed care isn't magically closing the gap. Medicaid may be signing up new customers, but there's a shortage of doctors willing and able to care for them.

Specifically, Access to Care: Provider Availability in Medicaid Managed Care (PDF) says:

We found that slightly more than half of providers could not offer appointments to enrollees. Notably, 35 percent could not be found at the location listed by the plan, and another 8 percent were at the location but said that they were not participating in the plan. An additional 8 percent were not accepting new patients. Among the providers who offered appointments, the median wait time was 2 weeks. However, over a quarter had wait times of more than 1 month, and 10 percent had wait times longer than 2 months. Finally, primary care providers were less likely to offer an appointment than specialists; however, specialists tended to have longer wait times.

Read that again. More than a third of the providers listed as available to patients aren't even at the address listed. They may be down the street or in another state, but the contact information provided for them is worthless.

Another 16 percent aren't taking Medicaid patients—whether that means "at all" or just that they've closed their practices to new ones doesn't matter to new enrollees who are shut out either way.

And the OIG report was prepared before temporarily hiked reimbursements to providers, intended to encourage Medicaid expansion, expired at the end of 2014. As of January 1, 2015, physicians are seeing "an average 42.8 percent reduction in fees for primary care services," according to the Urban Institute (actual percentages vary by state, and a few states are maintaining part or all of the "fee bump" out of their own funds).

That just might make it even harder to find providers willing and able to offer appointments to Medicaid enrollees.

Note: My wife is a pediatrician who sees many Medicaid patients as part of her practice in rural Arizona. She anticipates a roughly 30 percent drop in reimbursement for them.

NEXT: What Do You Call it When 14 Fla. Counties Stop Having Courthouse Weddings Entirely? Perhaps a Good Start.

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  1. Remember, even progressives have openly admitted: Giving coverage is easy, actually providing it? Well, that’s something else entirely.

    1. I remember being called all sorts of hateful things by progs when I noted that giving someone a card doesn’t mean they get care.

    2. Just wait. They’ll pass a law requiring doctors to accept Medicaid

      1. They’ve already got that covered. The industry is becoming more and more cartelized thanks to government regulatory requirements, ensuring that independent providers continue to be gobbled up by large providers and hospitals who are subject to EMTALA.

        1. EMTALA doesn’t apply to physicians, especially primary care docs.

          1. But don’t most states legally require MD’s to provide care via duty to attend laws?

        2. It just pushes back the pushback so that fewer and fewer kids will go to medical school.

          Eventually they’ll have to conscript doctors. The usual prog solution, subsidies, won’t be acceptable when it comes to subsidizing rich doctors.

          Or maybe they’ll loosen the distinction between nurses and doctors for specific ICD-10 categories.

          But whatever the proggies do, it will all boil down to trying to simulate market simplicity with thousands and thousands of new regulations.

      2. I don’t see how you could. The States have to pay for Medicaid, so that would effectively be an additional burden on the States’ budget (unfunded mandate, if you will).

        1. Oh that’s easy – simply make accepting Medicare a pre-condition for state licensing, then simply don’t pay.

          Send out IOU’s instead – CA did a few years back for tax returns.

          Worst case scenario (for the state) is you allow doctor’s to use owed payments as a tax credit against their tax bill.

          Then, while you don’t collect taxes from doctors, its still a net savings by not paying out on bills.

  2. When Medicare and Medicaid were first proposed, the idea was to spare the elderly the “indignity” of depending on charity for care they couldn’t afford.

    Nothing makes someone feel dignified quite so much as having door after door slammed in one’s face. Thanks government! Thanks for nuking private insurance for the elderly and replacing it with a golem that provides shittty care and shitty prices.

    1. They regarded as an Idea so good it should be manditory, next they’ll make it mandatory to accept such patients as a precondition to practicing medicine. Thenn all the problems will go away (along with all the doctors)

      1. The only solution left will be Single Payer.

        1. So Single Payer is kind of a final solution?

          1. Yes, but it will affect far more than a measly six million people.

        2. Still has the problem of how do you force the Doctors from accepting those working conditions.

          Given that the average Doctor is something like 60 and relatively wealthy there wouldn’t be much if anything stopping them from Going Galt and just retiring

          1. I think the docs will Go Galt and retire.

            The solution will be to pass some new immigration law that allows docs from other countries to come here with the understanding that they will see these Medicare patients.

            A lot of docs from poor countries will be completely willing to work for the low rates the guvt is offering for the right to emigrate here.

            1. And this will benefit their countries of origin because those 3rd world shitholes don’t need doctors, right?

          2. Offshore hospitals. Srsly.

            Sucks for those in the central US, but those of us near coastlines or the Mexican border can avail ourselves of healthcare beyond the reach of US regulations.

            1. I already do this (for minor stuff and dental). Pop over the border to San Luis.

              Many of my friends living here don’t even have American insurance – everything’s set to be covered in Mexico.

          3. Germany has universal health insurance. Plus you can buy a private supplement. Not much different from our Medicare. Are their doctors quitting and jumping ship? No.

        3. Medicaid is single payer.

          Any budget or quality problem you see with Medicaid, you would see with single payer.

          Example: California has budget woes because they pay state employees too much. Instead of fixing that, they cut medi-cal reimbursement rates. Much easier.

          Limit the formulary. Ration care. Find reasons to deny care. (Same as with heartless insurance companies, only now the motive can be budgetary rather than evil profits…LOL)

          And the rich will have private insurance and private care. A two-tier system. I suspect a lot of SJW support for single payer is they imagine Rosa Parks being in line and Steve Jobs would be behind her…so fair! so equal!n real life.

          1. “I suspect a lot of SJW support for single payer is they imagine Rosa Parks being in line and Steve Jobs would be behind her…so fair!”

            I imagine purple unicorns!
            A friend is an expat Canukistani MD. Her mother got sick in Canukistan; she called and presto; Mom didn’t have a wait.
            I’m sure Warren Buffett will stand in line, just like he does at the airport!
            (IOWs, he’ll buy the hospital)

          2. I have been told this by an acquaintance whose first degree was in philosophy (paid for by his parents). When, in his 30s, he was starving to death, they paid for a degree in law. He masturbates to pictures of Karl Marx.

            He bleated about how “It’s wrong that rich people get better care than poor people!”

            I asked him to name a single society on Earth where this is not the case.

            The next day he started talking about his personal trainer.

            I asked if it was fair for him to have that when poor people don’t.

            We haven’t talked since.

            That’s probably a benefit.

      2. No, then you just make it mandatory to be a doctor.

    2. I am really confused by this comment. How did Medicare nuke private insurance for the elderly? I am sure if someone over 65 wanted insurance, they could just buy it.

      1. Actually they couldn’t.

        No private insurer could offer a full insurance program for the elderly at the rates the government can so even though you might get a few curmedgeons who don’t want anything to do with a government program there wouldn’t be enough customers to make it a viable business.

      2. If the government required you to buy a motorcycle with sidecar and a 20cc motor for $10,000 as a requirement to being issued a driver’s license, what do you think the effect would be on used car sales?

        The expense of medicare precludes other spending. Any insurance you purchase is going to be an add on.

        For an insurance company, there is no market for providing old age health insurance. The pool of people with disposable income is too small, and the state is constantly fucking with the medicare rules, meaning that a product that took years to put together and get approved by regulators could be rendered unprofitable by a single stroke of the pen.

        The best thing we could do for the health and welfare of the poor and infirm in this country would be to torch all the Health and Human Services buildings to the ground, and sell their employees as galley slaves to some foreign potentate.

      3. ” How did Medicare nuke private insurance for the elderly?”

        Monopolistic pricing backed up by taxation.

    3. Now they know has Native Americans, and Vets, feel like – if they live.

      1. “know how”

    4. If charity does it, you have to feel beholden — even grateful — to the benefactors. If government does it, you can “keep your dignity” by applying to receive your “entitlement.” Nevermind that the latter process often involves more effort, inconvenience, frustration, embarrassment, and waiving of one’s privacy than would be the case in seeking private charity. Indeed, if the shoe were on the other foot, private charities would be publicly excoriated for demanding that the needy jump through so many hoops to get assistance.

  3. Let no one say that the next stop on this slippery slope is for government to force health care providers to accept Medicare and Medicaid patients. Those who do so say are obviously raving lunatics, Koch-funded libertarians, and tea-bagging ratfuckers.

    1. See my response to Lynchpin above

  4. The only way to repeal the law of supply and demand is through something called slavery (police state).

  5. The Democrats in my state are still pissed off at the governor for paying the hospitals. That’s right. The state owed millions of dollars to hospitals, some of the more rural ones were threatening to close, and the Democrats were going to let it happen. So the Republican governor paid the bills, and now he’s a terrible person. I really don’t get it. Unless the Democrats want to force doctors to work for free or something.

    1. Unless the Democrats want to force doctors to work for free or something.

      Personally, I’d say let every last one of the bastards (not all Democrats, all Democratic politicians making a fuss about this) only be able to utilize the services of enslaved doctors. Might be a useful lesson in how well you can rely on those you’d oppress.

    2. Those Docs need to pay for their White Privilege.

  6. Apparently health care is a privilege, not a right. But health insurance is not only a right, it’s a requirement.

    1. That’s the problem with positive rights. It ignores scarcity. Because no good has an infinite supply, then that good has a certain value. Entitlements mandate that a person gets something for nothing, so by default someone else is working to produce that good that another is entitled to.

      If people have a right to healthcare, then by default you’re enslaving every doctor, nurse, and anyone else connected to the healthcare industry to the rest of society.

      1. So far nobody forces one to be a doctor or a nurse.

      2. Or you are, at least partially, enslaving the rest of society to pay the health care bill. It’s just a matter of whom you victimize. It’s a lot easier to “enslave” taxpayers for a few dollars per week (or even a few tens or hundreds per week) than to conscript medical professionals. I like the upthread suggestion that we will move immigrant doctors to the front of the line in exchange for a commitment to deal with medicare/medicaid patients. We are already doing something like that now, when we subsidize a medical school education in exchange for the promise to practice in “underserved communities” for the first few years of one’s professional career. Indeed, the immigration-oriented solution is more cost-effective, since a US medical education is expensive, and foreign-born doctors already have education and training, which the US would not be obliged to reimburse. We would only have to guarantee waivers for licensing requirements, so that the foreign education and experience does not count against them.

  7. An additional 8 percent were not accepting new patients.
    New medicaid patients, that is.

    Must be Shreek’s doctor.

  8. Look, the important thing is that people *have health insurance*.

    Once that’s solved then we can work on how to get them actual *health care*.

    1. Most likely, that’s been their thinking all along.

      1. No ‘thinking’ required:
        The Left has a terrible track record in dealing with “unintended consequences” –
        why, they can’t even spell it.

    2. There are a couple silver linings to the ACA.

      One of them is bringing it up to the idiots who KEEP whinging about access to healthcare in America as if people are dying in the streets.

      I have not seen any sob stories yet about people going bankrupt due to the super high deductible plans. I suspect the media feels very uncomfortable about that narrative…for now. Once Obama is out of office, or the ACA gets “fixed” by the GOP, then these stories will pour out.

      Expect Liz Warren to start talking about medical bankruptcies.

  9. Let’s not talk about the Oregon study showing no improved medical outcomes for people enrolled in Medicare compared to the uninsured.

    1. Sorry, Medicaid not Medicare.

    2. I remember reading about that. In a just world the program would have been shut down the day after the study was released.

  10. my friend’s sister makes $68 an hour on the laptop . She has been without work for 10 months but last month her check was $21549 just working on the laptop for a few hours. browse this site……….
    ????? http://www.netjob70.com

    1. Your mother probably makes twice as much giving b-jobs at the back door.

    2. Is it painful having sex on a laptop?

    3. I’ll pay you $68 to kill yourself.

      1. Should take less than ten minutes $6.80 would be fair.

  11. Inequality. That is the boogeyman that the proggies are fighting. We had inequality in healthcare, never mind that even the poor in our country today have better care than anyone in history and better healthcare than many affluent people in the rest of the world. Inequality must be solved, so they take the greatest healthcare system in the world and take a giant shit on it. Then we will all be equal. They are desperately trying to do the same thing to the economy as a whole and for the same reason.

    Proggies are some evil, fucked up sons of bitches.

    1. Funny how the same people who decry capitalism as “a race to the bottom” are so in love with forced equality, which is nothing more than a race to the lowest common denominator.

      1. Forced equality looks like the USSR. One percent living like royalty and everyone else in hopeless, grinding poverty.

        “When they see the reality of their beautiful world of equality and social justice they won’t like it very much.” – Yuri Bezemov

    2. This. Inequality is seen as a problem because people assume that economics is a zero-sum game. If you have more, then it follows that others have less.

      People don’t realize that you can increase the size of the pie. Wealth is created, there’s not a set amount. It’s mind boggling that people don’t realize this. If there was a set amount of wealth in the world, then human beings would still be wandering around hunting buffalo and woolly mammoths.

    3. Yep. These people imagine that in their idealized European single payer system, Steve Jobs stands in line behind Rosa Parks for care.

      How fair! How egalitarian!

      In fact, that does not happen anywhere. The rich and powerful get better care and don’t stand in line.

      Single payer always leads to tiered care. I’m sure some single payer supporters understand that but a lot of shallow SJW types don’t.

      1. The Left’s solution:
        They’ll just outlaw private practices and force everyone to use the neighborhood soviet….er…. clinic.
        Then, they’ll confiscate all the private jets so the wealthy can’t fly to wherever to see a private doc.

  12. The state owed millions of dollars to hospitals, some of the more rural ones were threatening to close, and the Democrats were going to let it happen. So the Republican governor paid the bills, and now he’s a terrible person. I really don’t get it. Unless the Democrats want to force doctors to work for free or something.

    My guess is they hate those rural hospitals for being independent. They stand in the path of a glorious new world in which a very few mammoth centralized organizations will be enabled by the federal government to provide rigidly standardized health care solutions to the plebs.

  13. On a very related issue:

    “Thirty-six states that rely on private managed care programs to provide medical services to all or some of their Medicaid recipients are facing an added ObamaCare tax.

    According to a report by Milliman consulting actuaries, states that contract with Medicaid managed care plans face up to $15 billion in added costs over 10 years for their share of the law’s tax on private health insurance.”

    http://www.forbes.com/sites/gr…..new-costs/

    1. “….their share of the law’s tax on private health insurance.”

      The law’s tax. A tax that originated in the Senate, so it is a tax that isn’t a tax but we still call it a tax, cuz if it were a tax the law would be unconstitutional and that would be unacceptable because then the government would be operating outside the constitution and that would mean that this is not a legitimate government.

      The glory of post-Constitutional America.

  14. …And at some point the pitchforks are going to come out. Everyone that thought they were going to get something for free by forcing Scrooge McDuck to pay for their insurance is finding out that they are forced to pay and they aren’t going to get what they pay for. The system will implode before single payer and hopefully some of the evil fucks that orchestrated all this will end up decorating a lamp post.

    1. I also believe that most people assumed they would get state employee style insurance, not super high deductible plans.

      They aren’t imagining $100 to see a doctor. They are imagining $10 co-pays.

      This is why Obama keeps delaying the employer mandate, and tweaking the law to not allow companies to dump to the exchange. or make it less easy.

      Because when enough people get on the exchange who are not getting Medicaid, subsidies, or do not have pre-existing conditions, you will hear major squawking.

      Right now, those 3 groups like it, because they get something for free or very much subsidized.

  15. We have no choice with the POOR. Single Payer (tax payer paid and private providers) is the only way to go in the USA.

    I am a progressive and I supported ONCE government run medical facilities. That opinion went away QUICK once I saw how good the veterans of war were treated by the VIA. If the government won’t help the veterans, can you imagine what they would do with the poor?

    1. We don’t have to imagine, just read the zillion stories about old ladies drinking water from pot plants in NHS run hospitals and bed ridden patients dying of hunger and thirst.

      I used to be acquainted with an ex-NHS nurse. She lost her license to practice because she performed an appendectomy to save a patients life. The docs were just gonna let the guy die rather than perform a simple operation. They didn’t have it in the budget. So, she was kicked out.

      Maybe you should reconsider your association with such an evil political philosophy.

    2. If you think the VA is bad, wait until you visit a clinic/hospital run by the Indian Health Service (IHS)/Bureau of Indian Affairs (shouldn’t that be a dating service?).

  16. Clearly healthcare providers are too important to be left to the whims and vagaries of the market and so must be nationalized. First, re-badge all doctors and nurses with government ids. Second, allocate patients by location. Third, fix provider pay to a government determined scale, adjusted for time in service and specialty. Last, kiss any notion you had that the USA will have quality healthcare goodbye.

  17. And in a lovely bit of schadenfreude,

    http://www.nytimes.com/2015/01…..d=tw-share

    Richard F. Thomas, a Harvard professor of classics and one of the world’s leading authorities on Virgil, called the changes “deplorable, deeply regressive, a sign of the corporatization of the university.”

    Mary D. Lewis, a professor who specializes in the history of modern France and has led opposition to the benefit changes, said they were tantamount to a pay cut. “Moreover,” she said, “this pay cut will be timed to come at precisely the moment when you are sick, stressed or facing the challenges of being a new parent.”

    1. You shouldn’t have ridden that horse in ’08.

  18. “…Medicaid costs represent a rising chunk of state budgets around the country?one that’s crowding out other priorities.”

    This is impossible. We were clearly told by all the Right People that Medicaid expansion is free because the federal government promised to pay for it all.

  19. Up until the 13th century the barbers had pretty much of a lock on the medical business. Today that lucrative racket is just the red stripe on the barbers’ pole, symbol of their old cupping and bleeding business.

    They got too big for their britches, the pharmacists deserted them, the midwives weren’t there for them. In no time at all these newfangled doctor people had taken away their business.

    Today it looks as though the American male medical practitioner has backed himself into the same corner the hair clippers get themselves into eight hundred years ago. They think they’ve got a lock on a very very rich business — and they’re irritating their traditional allies right and left.

    Female doctors, academic MDs, and practitioners in teaching hospitals are solidly against the pretences and exclusivist practices of the free enterprise commercial docs.

    At the same time their monopoly on relevant skills has vanished: nurse practitioners — and more and more the Internet — have a good deal of the prescribing ability that the MDs have claimed — and research is tending by the week to show how hollow that claim has been.

    These poor folks have isolated themselves in a local information pod: American, white, mostly male, and suburban, they operate in an information environment almost totally indistinguishable from raw ignorance.

    The photograph at the top of this page is the last giggle of a bunch of silly, outdated, fratboys.

    -dlj.

    1. So, if you’re a female doctor, or a nurse of either (any?) gender, or an academic doc in a large teaching hospital, you are automatically and without exception pro-ACA? Also, if a patient isn’t privileged enough to live near an academic institution, they can safely rely on the internet to perform their appendectomy or diagnose their glaucoma? I would be comfortable with such a system, as long as all government workers, including the President, Congress, the Supreme Court, and YOU, David Lloyd George, also participate. Do you actually have a working brain, dlj?

      1. a working brain?
        That is not something issued by the government, therefore: No!

      2. poll after poll have shown that healthcare professionals oppose ACA

    2. cutting and pasting nonsense, I see. poll after poll prove that the vast majority of healthcare professionals (insurance companies inherently excluded) oppose Obamacare and Medicaid.

  20. Fundamental Transformation of HealthCare Insurance:
    From a pain in the a$$, to impossible.

    Thanks, President Putz!

  21. The Medicaid system has been unsustainable for years – the new system is going to make it infinitely worse. Doctors who do work with Medicaid are not being reimbursed. Why would they ever want to work with such a system?

  22. This is because of discrimination and will be resolved soon enough. The costs of healthcare is the trouble. Not how healthcare is billed or how healthcare is paid for. Doctors were trained to be wealthy and are accustomed to being overpaid for the work done if required to belong to another “class of Americans”. There will always be enough rich folks dying to keep this economic FRAUD alive.

    “Pay me well enough so I keep you alive while I am a self-made King”

    The system has always been broken and is often dishonorable by default. Trying to adjust a wholly broken system will never repair the natural human drive to dishonorably benefit.

    Making pursuit of the health profession career a wholly government supported goal would make healthcare cost drop precipitously. Use the same process that is used today to keep the fighting forces of the United States wholly voluntary.

    Obamacare only adjusted this broken system and was an honorable attempt. Some coming American President will eventually fix healthcare for the rich AND for people like me. The broken system worked for me but not without outside influences. Few will need the million(s) of dollars of care I already received.

    1. Ah. A government job. So it is going to work like the DMV or the IRS (where 40+% of the information given out is wrong)?

      Excellent!

  23. Most health problems are caused by being overweight. Most people are overweight because of their diet. Stop eating sugar and grains and you won’t need health care.

    1. Except, of course, when some crazy Russian cab driver runs your ass over.

  24. You know they’ll eventually just ban refusal of Medicare/caid patients, on pain of losing their license or not being able to renew it.

    Fighting Leviathan is like having to follow Marquis of Queenbury rules while your opponent’s ruleset is Calvinball.

    I am looking forward to the hilarious irony of doctors going to India to practice, though.

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