One Year After the ACA, Healthcare That Is Less Affordable and Accessible
Last month the White House proudly announced that after completing the first year of Affordable Care Act (ACA) implementation the number of uninsured Americans is at historic lows-11.3% in the second quarter of 2014, down from 14.4% the year before. Over 10 million people enrolled for health insurance through Medicaid or an insurance exchange. But signing up for insurance does not equal access. Healthcare has to be available and affordable. The ACA did not achieve these goals in 2014 and 2015 will be worse.
Medicaid recipients have always had trouble finding care primarily because Medicaid pays physicians a fraction of private and Medicare rates. To remedy this the ACA included a federally funded two-year increase in Medicaid fees for primary care physicians up to Medicare levels. $5.6 billion was spent through June 2014. But the Urban Institute reports that it is unclear whether the increase in Medicaid primary care payment had an effect on the number of physicians accepting Medicaid patients, or on the number of Medicaid patients that physicians are willing to see. And increasing the fees of primary care physicians does not improve access to specialists-the Commonwealth Fund found that low Medicaid payment is the main barrier to specialty care. Most importantly, the primary care fee increase expired on December 31, 2014. The Urban Institute estimates this will lead to an average 42.8 % reduction in fees for primary care services. Since most states will not continue fee increases without federal funds, any increased access for Medicaid patients will not last.
Access problems are not confined to the fee for service Medicaid plans studied by the Urban Institute. The HSS Inspector General studied the Medicaid managed care plans that cover nearly three-quarters of Medicaid enrollees and found that over half of the plans' putative providers were no longer in practice, not accepting new plan patients or not participating in Medicaid. Among providers offering appointments, over a quarter had wait times of more than one month, and 10 % had wait times longer than two months. Expiration of the ACA fee bump will exacerbate these problems.
Patients who obtained private exchange insurance have also had access problems. The main way exchanges control costs is to limit the number of doctors and hospitals patients can visit. According to McKinsey & Company, 70% of the plans available on the exchanges have narrow or ultra-narrow networks of available local hospitals and well-known academic and specialty centers have been purposely excluded. Most exchanges have few if any plans covering out of network providers. Many exchange enrollees are unable to see the physicians who have treated them for years, use facilities providing the most appropriate treatment, or access care close to home.
A New York Times/CBS national poll indicates that the ACA has made care less affordable and less accessible. "Nearly half of respondents described the affordability of basic medical care as a hardship for them and their family, up 10 points from a year ago." More than half said out of pocket expenses had gone up and a third said expenses had "gone up a lot." A quarter reported care has become so expensive that they are less likely to see a doctor than in the past.
The cost and access issues may explode this spring when King v. Burwell, challenging the provision of ACA subsidies to buy insurance on both the federal and state exchanges, is decided. Only 14 states have established insurance exchanges; 5.4 million citizens of the remaining states obtain insurance through the federal exchange and most receive subsidies. If the Supreme Court finds that the law only allows subsidies on state exchanges, federal exchange enrollees will lose their subsidies and likely their insurance and healthcare access.
By prescribing a generous "essential health benefits" package that many patients neither want nor need, the ACA has increased families' premiums and out of pocket costs and forced them into narrow provider networks. By expanding Medicaid enrollment without measures to increase willing providers, the ACA has only done half the work of improving access. Until ACA requirements are relaxed so that patients have a genuine choice of different benefit packages and affordable plans and the problem of inadequate Medicaid fees is addressed, decreasing the number of uninsured will be a hollow achievement.