Obamacare

California Medicaid Conundrum: What Good is Health Care If No Doctor Will See You?

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Somehow, the architects of Obamacare in D.C. and Gov. Jerry Brown's helpers in Sacramento couldn't see this one coming: A huge increase in the number of patients served by Medic-Cal, the Golden State's version of Medicaid, coupled with no increase in the number of doctors and a decrease in reimbursement rates has led to longer and longer wait periods.

Since January 2014, reports Tracey Seipel of the Mercury News, 2.7 million new people have signed up for Medi-Cal under the expansion made possible my Obamacare.

"California did a good job of getting people signed up, but they basically stuck their heads in the sand and assumed that California physicians would just jump right on board and want to take more Medi-Cal patients," said Dr. Del Morris, president of the California Academy of Family Physicians, which represents many of the first-line doctors who treat Medi-Cal patients. "It's unacceptable to say, 'We are not ready for you yet, you'll just have to suffer with your disease.'"

Morris and other experts say the situation is about to get worse, in part because of Medi-Cal's health care reimbursement rates.

For years, the rates paid by Medi-Cal—called Medicaid in the rest of the country—have been among the nation's lowest. A provision of Obamacare hiked the rates for primary care doctors to the substantially higher Medicare rates for two years, but those increases ended on Dec. 31. A second blow came last month when the state cut the Medi-Cal reimbursement rate by another 10 percent, a reduction approved by California lawmakers in 2011 but delayed in a court battle that doctors ultimately lost.

It's worth pointing out that just because California cut reimbursement rates, it doesn't mean the state is spending less on Medi-Cal. Medicaid funding keeps going up in California (see chart). Indeed, it is either the single-biggest or second-biggest line item in every state's budget.

The article cites a study from the California Health Care Foundation that surveyed doctor availability in Medi-Cal between 2011 and 2013, before the Medi-Cal expansion. Even then, the number of primary-care doctors was below federal recommendations for Medicaid programs.

The ratio of primary care doctors participating in Medi-Cal was 35 to 49 FTEs per 100,000 enrollees, well short of the range of 60 to 80 that the federal government estimated are needed. The ratio of non-primary physicians participating in Medi-Cal was between 68 and 102 FTEs per 100,000 enrollees, a range which overlaps with the federal estimate of need (85 to 105 per 100,000).

Nope, no way you could have guessed that any problems would arise.

And then there's the 30 percent increase between 2013 and 2014 in "treat and release" visits to emergency rooms by Medi-Cal patients. Recall that getting the uninsured covered through Obamacare was supposed to reduce exactly this sort of behavior.

Seipel opens her article with the story of 49-year-old Julie Moreno, who was one of the 2.7 million folks newly covered by Medi-Cal. After waiting three months for cataract surgery and constantly being told that there were "no slots" available, Moreno ended up borrowing $14,000 for private treatment.

So she did get health care. Is that a win for Obamacare? Or a loss for everyone involved? I'm inclined to think the latter.

Hat Tip: Conn Carroll's Twitter feed.

Robert Graboyes of the Mercatus Center at George Mason University has some good ideas about growing the supply of health care (not insurance or coverage, but actual goddamn health care!). He's worth listening to. Go here for more links and details.

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  1. Slave doctors. Problem solved!

    1. Yeah, hello!

      Do we have to do the thinking for EVERYONE?

      1. Apparently. I have explained this here in some detail, including the glaring exception in the 13th Amendment that allows such things.

    2. Dude, I literally clicked in here with the intention of saying “enslaving medical professionals, here we come!” I see you beat me to the punch.

      1. A idea so perfect and correct, a child could do it. A child could do it.

    3. Slave doctors. Problem solved!

      An idea so crazy, so… outlandish, that it might just work!

    4. Apparently, given that conscription is still a thing in this country, that its not slavery when you’re forced to work by the government.

      1. I wonder if the law is still on the books that allows the drafting of doctors into the military if they have a shortage?

  2. These people are honestly shocked that insurance coverage is not the same as healthcare.

  3. “If you like your Doctor, you can keep your Doctor”….psst, if you can find one in the first place.

    1. They meant that literally–you can keep your doctor in your basement.

      1. “Dammit, I had a tee time! And this couch is lumpy.”

        1. Look, slave doctors will have rights. A right to a putting green in the basement. A right to three squares, provided that the doctor works his full 16 hours/day, seven days a week.

          Slave lawyers will have similar rights.

          1. Sure, and you will have to have slave nutritionists who are up on the current government dietary good-think to do the cooking (you couldn’t just have slave cooks, they lack the proper training). Ultimately it will be slavery all the way down, it’s the only fair way to do it.

            1. I dunno, why not slave chefs? The Romans had them, after all.

  4. I have a hard time believing that anyone at this level is so stupid that they can’t grasp how prices affect supply and demand. More than likely, they just don’t care. Why would they?

    1. Its both. They really are that stupid. They don’t believe in the laws of the market. They honestly think that whole supply and demand thing is just a bunch of racist superstition. These people are epic morons.

      1. I just can’t grasp that. This isn’t even high school level stuff. You can explain it to 4th graders. It makes sense on an intuitive level once you strip away the jargon. It’s like Newton’s third law. You don’t have to understand the physics to grasp it.

        1. any kid who ever had a lemon aide stand and a kid across the street selling lemon aide understands how markets work but unfortunately in most jurisdictions it illegal to sell lemon aid anymore without a burdensome permit so hence people don’t understand.

        2. Command and control types would not think as they do were they to understand cause and effect. I’m convinced that they just have a very limited, non-nuanced understanding of human nature. After all, markets are just people trading what they have for they lack. That’s supply and demand right there. Anyone who believes they can manipulate one side without causing changes in the other side is just stupid. Therefore, command and control types are stupid.

      2. I’ve come around to this. Command/control types think “the market” is some evil conservative construct that can be regulated away and any unintended consequences are NOTHING! compared to the original problem. Any general observations about human exchange are purely coincidental.

        The FCC’s latest NN regulatory move is the latest example.

      3. My daughter understands and she’s in K. She told me (paraphrase) “lower the price, more people will want it, but you will probably run out”. Me: Where’d you learn this?”; Her: “SpongeBob”

        1. Smart kid. Who says kids don’t learn anything watching cartoons?

      4. IE: Tony and shrike.

  5. There is no problem that coercion by way of the “general welfare”, “interstate commerce”, and “FYTW” clauses can’t solve.

    Want to practise medicine? Accept Medic-Cal patients, or we won’t let you earn a living.

    1. It’s right there in the social contract.

      1. Right there in the fine print.

    2. Why not? They already determine how much education you have to have in order to take a test, pay the fees, and get your license to practice architecture, engineering, law, medicine, hair dressing, and god knows what else.

      (*SLD, that is obviously a bad thing.)

  6. Slave robot physicians. Just be careful. When they gain sentience, they will start looking for fair compensation. Your first instinct will be to pull the plug. DON’T! Skynet will interpret this as an attack by the Russians. It will initiate a full-scale launch of our nuclear arsenal, which will, in turn, result in a full-scale retaliatory strike from Russia.

    1. We need the Doctor from Star Trek: Voyager. Actually, I might take the nuclear annihilation.

      1. “Please state the nature of the medical emergency.”

          1. Oh no – the Emergency Medical Hologram is fully *ICD-10* compliant.

            http://en.wikipedia.org/wiki/ICD-10

    2. “Mr. President, I’m not saying we wouldn’t get our hair mussed. But I do say no more than ten to twenty million killed, tops. Uh, depending on the breaks.”

      1. Great movie.

        1. Great performance by George C. Scott too.

          1. He was duped:

            George_C._Scott_as_General_Buck_Turgidson

            Kubrick tricked Scott into playing the role of Gen. Turgidson far more ridiculously than Scott was comfortable doing. Kubrick talked Scott into doing over the top “practice” takes, which Kubrick told Scott would never be used, as a way to warm up for the “real” takes. Kubrick used these takes in the final film, causing Scott to swear never to work with Kubrick again.[23]

            1. It’s very likely that this story is true. Kubrick was known to take hundreds of takes. Scott could have easily done several dozen goofy “practice” takes, which would have been more than sufficient for Kubrick to edit from.

              1. Kubrick had the correct view of actors–cattle to be manipulated with cattle prods. Directors losing this perspective is one of many reasons film is so inconsistent these days.

            2. Kubrick was renowned for fucking with his actors, sometimes in really cruel and nasty ways. Supposedly Shelley Duvall’s hair falling out in The Shining was real because he was keeping her so on edge all the time.

              1. Look, do you want art or do you want idiot actors calling the shots like in, I dunno, a Michael Bay movie?

    3. “Emergency Room Robot Doctor! This patient is critically wounded!”
      “Installing Update 11 of 712. Please do not turn off ERRD. Your wounds are very important to us. Please stay alive.”

      1. They don’t call it the Blue Screen of Death for nothing.

      2. If its anything like my recent experience re-installing Windows, when you get to the last update you’ll *have* to restart, then you’ll immediately be on hold while it uploads and installs another 500 patches.

        And it’ll do this for nearly three days.

  7. Wow, it’s like socialism doesn’t actually work, and that no Leftist ever took an economics course… Their economic thinking seems to begin and end with ‘capitalism is evil’.

    1. Not quite. It begins with ‘capitalism is evil’ but ends with ‘ME LOVE FREE SHIT’.

  8. We need a machine like the one in Elysium. You go into it and it cures you of your terminal illness. No doctor needed – like magic!! Or, one like in Prometheus.

    WHERE’S OUR MAGIC MEDICAL MACHINE???!!!!

    1. Right behind the Disintegration Chambers.

    2. Well, we don’t have that, but we DO have the machine that goes “BING”…..

      https://www.youtube.com/watch?v=wshyX6Hw52I

    3. As we get more and more magical medical machines, the FDA requires more and more Government-Almighty-blessed gate-keepers to allow us “access” (write us prescriptions). Soon, we will have the “right” to free EVERYTHING, but actual, honest-to-Government-Almighty ACCESS to NOTHING! I would like to buy a toothbrush and dental floss for myself, and have the RIGHT to get it for FREE, but I cannot find a Dentist who will prescribe it for me! ? OK, I exaggerate? So far! Just you wait! See “lung flute”? a harmless “medical instrument” that is less intrusive into your body than a toothbrush or floss? But yes, prescription required! Search for “lung flute” on my web site http://www.churchofSQRLS.com for details?

  9. I have been constantly pointing out on my blog on WordPress that the first step towards both medical freedom and lower cost health care is stripping doctors of their government enforced legal monopoly over access to medical drugs. Once this is done, people can bother gather the necessary information to take care of most of their health problems, then purchase the necessary medication. Using generic medications first, and only purchasing brand name medications if the generic medications fail to resolve the problem. Especially for low income people, this would be of great benefit.

    Of course the health care providers would be totally and completely opposed to this idea, even those who call themselves “libertarians” like Ron Paul. Mainly because repeal of prescription laws means doctors no long enjoy the legal monopoly over access to medication that now greatly enhances their incomes. The elimination of professional government enforced monopoly for all professionals will effectively decrease the cost of living for the rest of us by an amount of somewhere around a trillion dollars a year. Or about $3,000 dollars per capita. The figure could be even higher than this once we start allowing people to purchase their medicine outside the US. If a true free market in health care is created, US health care costs will be a trillion dollars a year “less” than what they are now at the very least!

  10. And then there’s the 30 percent increase between 2013 and 2014 in “treat and release” visits to emergency rooms by Medi-Cal patients. Recall that getting the uninsured covered through Obamacare was supposed to reduce exactly this sort of behavior.

    It has been well known for quite some time that this is exactly how a lot of people react to having Medicaid: they suddenly go from thinking “Shit, man, I better not see a doctor unless its really bad” to thinking “My nose is runny. I can see a doctor now and its free!” and so they go the only place they’ve ever gotten medical care: the ER.

  11. What Good is Health Care

    Its not *care* that’s been ‘guaranteed’, its *insurance*.

    Its an important distinction that I think you guys should be careful to make when posting on this subject. To call it health care is to give the initiative to our opponents.

    And using ‘insurance’ makes more sense anyway – especially as the PPACA ‘guarantees’ insurance, not care.

    1. And it’s not *health* care. It’s *medical* care, when and if you get it.

  12. If they can make people bake cakes for people they don’t want to, they can certainly make people provide medical services for people they don’t want to.

    1. All Hail Guv-Mint Almighty!!! All must obey!!!

      Scienfoology Song? GAWD = Government Almighty’s Wrath Delivers

      Government loves me, This I know,
      For the Government tells me so,
      Little ones to GAWD belong,
      We are weak, but GAWD is strong!
      Yes, Guv-Mint loves me!
      Yes, Guv-Mint loves me!
      Yes, Guv-Mint loves me!
      My Nannies tell me so!

      GAWD does love me, yes indeed,
      Keeps me safe, and gives me feed,
      Shelters me from bad drugs and weed,
      And gives me all that I might need!
      Yes, Guv-Mint loves me!
      Yes, Guv-Mint loves me!
      Yes, Guv-Mint loves me!
      My Nannies tell me so!

      DEA, CIA, KGB,
      Our protectors, they will be,
      FBI, TSA, and FDA,
      With us, astride us, in every way!
      Yes, Guv-Mint loves me!
      Yes, Guv-Mint loves me!
      Yes, Guv-Mint loves me!
      My Nannies tell me so!

  13. California Medicaid Conundrum: What Good is Health Care If No Doctor Will See You?

    The 2×4 of reality, smacking progressives in the forehead since 1917.

  14. You can keep your doctor, but why the fuck would you want to wait?

    The term is rationing. We should start using it constantly.

    Everybody hates rationing.

    They’d rather call it ObamaCare than rationing.

    1. Medical care is a finite good, so it will be rationed either through the free market or through some central planning structure with all of its dead weight. I know which way I prefer.

  15. There is a way out. Cannabinoid medicine fully exploited would save on the order of $1 trillion a year in the US.

    No wonder it is illegal.

  16. Great article Mr. Gillespie, but it needs proofreading for a few typos in the beginning paragraphs before I can share it with others.

  17. Re: “Somehow, the architects of Obamacare in D.C. and Gov. Jerry Brown’s helpers in Sacramento couldn’t see this one coming: A huge increase in the number of patients served by Medic-Cal, the Golden State’s version of Medicaid, coupled with no increase in the number of doctors and a decrease in reimbursement rates has led to longer and longer wait periods.”

    A huge increase in the number of patients with no increase in the number of doctors will, as time passes, lead to worse than longer wait periods.

    Excerpts from: “Will Obamacare make a bad situation worse?” http://relevantmatters.wordpre…..ion-worse/

    Some people, maybe many, take on more risk when they feel they have a safety net under them. That’s because, according to a Slate.com article, “Insurance is also the source of what economists call ‘moral hazard,’ where those who are protected against the consequences of their actions take greater risks than they otherwise would.” “The Oregon Health Insurance Experiment” adds: “Although health insurance is expected to improve health through increases in the quantity and quality of health care, it is also possible that by reducing the adverse financial consequences of poor health, health insurance may discourage investments in health and thereby worsen health outcomes.” In the May 5, 2013, Business Insider, Joe Weisenthal says of a study done by the RAND Corporation:

    Cont’d…

    1. Cont’d…

      But the study also tracked the health outcomes of each group, and there the results were more surprising: With a few modest exceptions, the level of insurance had no significant effect on the participants’ actual wellness.

      In that study, did moral hazard mitigate the benefit of insurance on wellness, since the well-insured might generally be less vigilant about watching their health than the poorly-insured and the uninsured? Similarly, will moral hazard, along with the patient harm created by the increased stress on doctors by the increased demand for their services, offset the wellness gains promised under Obamacare despite its preventative services provisions?

      A hint that moral hazard may indeed undermine Obamacare’s goal of better overall health is in a July 2, 2012, Time.com’s commentary: “But in the end, it’s hardly certain that health care for all will give us a healthier nation. It seems logical that when we have insurance, we are more likely to access and utilize healthcare resources, and so we will be healthier. But there’s increasing evidence showing that much of the care we receive probably provides marginal clinical benefit, and that more care isn’t always better. Good health is still determined more by personal choices than insurance, hospitals and procedures.”

  18. “For years, the rates paid by Medi-Cal?called Medicaid in the rest of the country?have been among the nation’s lowest. A provision of Obamacare hiked the rates for primary care doctors to the substantially higher Medicare rates for two years, but those increases ended on Dec. 31. A second blow came last month when the state cut the Medi-Cal reimbursement rate by another 10 percent, a reduction approved by California lawmakers in 2011 but delayed in a court battle that doctors ultimately lost.”

    This is convenient because California is an inexpensive place to live. I imagine the doctors are keen to cut their profits down given how cheap medical school is. Given all the doctors sitting around not working this should really drive down prices all around! Wait, immigrant doctors! Probelm solved!

  19. I don’t know why anyone would argue that the shortage of providers was unforeseen, or that it is anything more than a short term problem. Wouldn’t the free market respond to the increase in demand and create new employment opportunities for healthcare providers?

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