Question to those who are in favor of ACA

[whoisjohngalt]

What do you think of this article

www.forbes.com/sites/johngoodman/2014/11/04/a-two-tiered-health-care-system-is-coming-faster-than-you-think/

[Shooby]

I used to live in Buffalo. People from Canada came to Buffalo to get their gallbladders out and assorted other things because they wait time was so long there.

[zibazinski]

It's been here forever anyway. Heard of concierge medicine? It's only going to get worse.

[Shooby]

Doctors aren't wards of the State. They didn't go to medical school for years and take on big debt to get $25 from Medical Assistance for their skill and knowledge. And, people think 'Oh, I've got health CARE". No, you don't. You might have a health INSURANCE card under the exchange or state but that doesn't mean you then have all the CARE you need.

[Deleted]

It's been that way for a very long time. Years ago (late 1980s) I paid more for a "Major Medical" plan that didn't require you to use a network because DS' pediatricians weren't in the network. They were conveniently located,  I liked all the docs in the practice, and they had a nurse you could call 24/7 at no charge.  I didn't care if the copays were higher.  I now have a private policy through Coventry and, while my doc accepts that, he doesn't accept the Coventry policy bought on the Insurance Exchange.

Medicare scares the crap outta me because over my career, my employers and I paid $160K for "coverage".  If I had that amount plus 6% interest it would be about $250K.  There are areas now where docs won't take Medicare patients because the reimbursement rate is so measly.  That will only get worse and I can't get that money back.  Even though my health is good and I don't need a doctor very often, I'll probably end up with some sort of concierge care so I can see a doctor on less than one months' notice and not have to wait an hour past the purported appointment time to get 5 minutes of face time.

BTW, in England, supposedly a mecca for "free" healthcare, my former employer provided a supplemental plan for our executives.  My boss found that if you had that coverage, same-day appointments were suddenly available.

[milee]

Here's the article referred to in the Forbes article:

www.usatoday.com/story/news/nation/2014/10/27/insurers-aca-exchange-plans-lower-reimbursements-doctors/17747839/?utm_campaign=KHN%3A+First+Edition&utm_source=hs_email&utm_medium=email&utm_content=14667741&_hsenc=p2ANqtz-_Aeoj1JV-Vg_64SYmNB15BNOgJh8mFk_uuFCTm_xReKdCAAR5xaSmVk6PQaccuHXwa48sBikfuIBB0YjjzxcJvvvJ6bw&_hsmi=14667741

[whoisjohngalt]

I've never had govt insurance, but are you guys saying that it's been for years that a patient A with insurance A would get an immediate appt vs patient B with insurance B would have to wait?

[Deleted]

Going to the actual source material from the article: 

"While more than 8 million consumers have enrolled in health insurance coverage through the ACA exchanges, 56% of respondents reported no change in their practice’s patient population size through April and 24% reported a slight increase. Practices expect a small shift in this trend through the end of the year. Thirty percent of respondents projected no change to their practice population size by the end of 2014 and 44% predicted a slight increase. These figures illustrate that most practices are not being inundated by new ACA exchange patients but do expect to treat somewhat more of these patients as the year progresses."

And what does this mean? "• 62% of respondents reported moderate to extreme difficulty with identifying a patient that has ACA exchange coverage as opposed to traditional commercial health insurance."

.... They can't even tell the difference? 

[chiver78]

Nov 5, 2014 8:42:25 GMT -5 whoisjohngalt said:

I've never had govt insurance, but are you guys saying that it's been for years that a patient A with insurance A would get an immediate appt vs patient B with insurance B would have to wait?

absolutely!

a hockey teammate and I sustained similar knee injuries, both requiring an MRI. I saw my PCP on a Friday, had the MRI on Saturday, and went to the orthopedic surgeon the following Friday with MRI results in hand. my teammate, after waiting a few months for her insurance to eventually approve the MRI, opted to start PT activities without dr supervision in the hopes of minimizing damage while she waited to be seen.

both of us have insurance through our employers.

ETA: this happened before the ACA, but we're in MA and we were already under the "Romneycare" mandate. I don't know if that will impact how you read my post, but I feel like I should put it out there as a disclaimer of sorts.

[Deleted]

I don't have "government insurance"... I have a Blue Cross plan I bought on the exchange.

The source material for wait times... Is for new patients for routine care... Please don't compare that with existing patient or acute care info. I've actually had shorter wait times this year for well child and pap appointments than in prior years. 

[milee]

Lena, people who support the ACA without reservation appear to have difficulty discussing, much less admitting, some of the flaws in the system.

This issue was discussed a few months ago. notmsnmoney.proboards.com/thread/39538/obamacare-insurance-hack?page=1 

The problem of lack of network access was brought up on page 1-2 and the prediction that there would be a two-tiered system came up on page 4.  It was difficult to have any discussion on those topics because people who wholeheartedly support the ACA either do not believe the issues are real or believe it's OK to have those problems because the entire package is for the greater good. 

[973beachbum]

Nov 5, 2014 8:42:25 GMT -5 whoisjohngalt said:

I've never had govt insurance, but are you guys saying that it's been for years that a patient A with insurance A would get an immediate appt vs patient B with insurance B would have to wait?

No I don't know any Dr's offices that manipulate their wait times for appointments.  I do know that every Dr's office around here will only have a certain percentage of patients from plans like medicaid, chip and medicare.  If the payments are the same on the exchanges as medicaid I would think they would also limit them as well. 

It is all a numbers game for the Dr's.   They need X amount of revenue coming in every month.  They also need X number of patients to be fully booked.  The Dr's I know also genuinely like helping people.  The key is to keep a patient mix in the practice that allows them to both make enough money every month while helping people.


I have heard people recently who were VERY upset about being booted off medicaid/chip plans and onto the exchanges. They said the coverage wasn't even close to the same and they had less choices of Dr's.  I thought from what they were saying the lack of choice was because the exchange HMO's weren't as good as the medicaid ones.  Why a Dr would choose to be on the medicaid HMO but not the exchange one is a good question.  My first thought is they think the person with medicaid/chip is more needy.  My experience says that is sometimes true but in many cases the person working a job for low wages can often times be even more vulnerable.

[973beachbum]

Nov 5, 2014 9:03:30 GMT -5 milee said:

Lena, people who support the ACA without reservation appear to have difficulty discussing, much less admitting, some of the flaws in the system.

This issue was discussed a few months ago. notmsnmoney.proboards.com/thread/39538/obamacare-insurance-hack?page=1 

The problem of lack of network access was brought up on page 1-2 and the prediction that there would be a two-tiered system came up on page 4.  It was difficult to have any discussion on those topics because people who wholeheartedly support the ACA either do not believe the issues are real or believe it's OK to have those problems because the entire package is for the greater good. 

And the exact same thing can be said of people who hate the ACA without reservation.

[milee]

Nov 5, 2014 9:03:49 GMT -5 973beachbum said:

Nov 5, 2014 8:42:25 GMT -5 whoisjohngalt said:

I have heard people recently who were VERY upset about being booted off medicaid/chip plans and onto the exchanges. They said the coverage wasn't even close to the same and they had less choices of Dr's.  I thought from what they were saying the lack of choice was because the exchange HMO's weren't as good as the medicaid ones.  Why a Dr would choose to be on the medicaid HMO but not the exchange one is a good question. 

With most Medicaid plans, the patient has either $0 to pay as their share or some very nominal amount.

With the new exchange plans, most of the least expensive plans have low monthly insurance premiums, but there is a large deductible.  So the patient has to pay 100% of the doc visits until the deductible is reached.  For a doc's office, that means instead of collecting their payment from the state Medicaid plan, they're trying to collect from hundreds of individuals who don't really understand how their insurance works and don't have the money to pay the doc even if they do.

[Deleted]

Nov 5, 2014 9:03:49 GMT -5 973beachbum said:

Nov 5, 2014 8:42:25 GMT -5 whoisjohngalt said:

I've never had govt insurance, but are you guys saying that it's been for years that a patient A with insurance A would get an immediate appt vs patient B with insurance B would have to wait?

No I don't know any Dr's offices that manipulate their wait times for appointments.  I do know that every Dr's office around here will only have a certain percentage of patients from plans like medicaid, chip and medicare.  If the payments are the same on the exchanges as medicaid I would think they would also limit them as well. 

It is all a numbers game for the Dr's.   They need X amount of revenue coming in every month.  They also need X number of patients to be fully booked.  The Dr's I know also genuinely like helping people.  The key is to keep a patient mix in the practice that allows them to both make enough money every month while helping people.


I have heard people recently who were VERY upset about being booted off medicaid/chip plans and onto the exchanges. They said the coverage wasn't even close to the same and they had less choices of Dr's.  I thought from what they were saying the lack of choice was because the exchange HMO's weren't as good as the medicaid ones.  Why a Dr would choose to be on the medicaid HMO but not the exchange one is a good question.  My first thought is they think the person with medicaid/chip is more needy.  My experience says that is sometimes true but in many cases the person working a job for low wages can often times be even more vulnerable.

I don't think it's the wait to see a doctor but the wait for the insurance company to approve an MRI or physical therapy or if you need a referral for an orthopedist getting your PCP to give you one.

[Deleted]

I have no problem discussing limitations, pros and cons. I have a problem with sensationalizing and cherry picking...

CHIP was NOT medicaid. CHIP was Blue Cross for us in PA. But again, many people on CHIP had subsidized coverage, very good coverage! Moving them on to the exchange may mean they are shouldering more of the costs... So how is that MORE government ?

You ou needed earned income for CHIP... I'm not sure I understand your comments about it? 

[Deleted]

Nov 5, 2014 9:07:42 GMT -5 milee said:

Nov 5, 2014 9:03:49 GMT -5 973beachbum said:

I have heard people recently who were VERY upset about being booted off medicaid/chip plans and onto the exchanges. They said the coverage wasn't even close to the same and they had less choices of Dr's.  I thought from what they were saying the lack of choice was because the exchange HMO's weren't as good as the medicaid ones.  Why a Dr would choose to be on the medicaid HMO but not the exchange one is a good question. 

With most Medicaid plans, the patient has either $0 to pay as their share or some very nominal amount.

With the new exchange plans, most of the least expensive plans have low monthly insurance premiums, but there is a large deductible.  So the patient has to pay 100% of the doc visits until the deductible is reached.  For a doc's office, that means instead of collecting their payment from the state Medicaid plan, they're trying to collect from hundreds of individuals who don't really understand how their insurance works and don't have the money to pay the doc even if they do.

Sounds like Single Payer would be better then...

[chiver78]

Nov 5, 2014 9:10:30 GMT -5 @singlemominmd said:

I don't think it's the wait to see a doctor but the wait for the insurance company to approve an MRI or physical therapy or if you need a referral for an orthopedist getting your PCP to give you one.

and there were differences before the ACA as to how individual insurance companies handled stuff like this (see my post above). I'm not sure why people think that all of a sudden the ACA is going to make things like this markedly worse?

[973beachbum]

Nov 5, 2014 9:10:56 GMT -5 oped said:

I have no problem discussing limitations, pros and cons. I have a problem with sensationalizing and cherry picking...

CHIP was NOT medicaid. CHIP was Blue Cross for us in PA. But again, many people on CHIP had subsidized coverage, very good coverage! Moving them on to the exchange may mean they are shouldering more of the costs... So how is that MORE government ?

You ou needed earned income for CHIP... I'm not sure I understand your comments about it? 

If your talking to me, I include chip in with medicaid because it was paid for out of the same pot that the state paid for medicaid.  The states paid the insurance companies to either pay the premiums in full or part.  So while it may not be the full disabled person medicaid it is still a government program.

if anyone thinks they are totally separate just go to the NJ state medicaid page and see how medicaid amd chip, called family care here, are all lumped together.

Welcome to the NJ FamilyCare website.

Beginning January 2014, NJ FamilyCare - New Jersey's publicly funded health insurance program - includes CHIP, Medicaid and Medicaid expansion populations.
www.njfamilycare.org/default.aspx

[The Captain]

Nov 5, 2014 9:03:49 GMT -5 973beachbum said:

Nov 5, 2014 8:42:25 GMT -5 whoisjohngalt said:

I've never had govt insurance, but are you guys saying that it's been for years that a patient A with insurance A would get an immediate appt vs patient B with insurance B would have to wait?

...

I have heard people recently who were VERY upset about being booted off medicaid/chip plans and onto the exchanges. They said the coverage wasn't even close to the same and they had less choices of Dr's.  I thought from what they were saying the lack of choice was because the exchange HMO's weren't as good as the medicaid ones.  Why a Dr would choose to be on the medicaid HMO but not the exchange one is a good question.  My first thought is they think the person with medicaid/chip is more needy.  My experience says that is sometimes true but in many cases the person working a job for low wages can often times be even more vulnerable.

This was actually very well explained in the Forbes article referenced by Lena in the OP.

1.Fees paid by the plans sold in the exchanges are often set at Medicaid rates or a little bit above Medicaid (although in some cases the plans pay less than what Medicaid pays).

2.Because of high deductibles, insurance isn’t paying most of the bills any way; and doctors often have difficulty collecting from the patients because of their low-incomes.

3.Compared to traditional commercial insurance, doctors have more paper work problems with insurance obtained in the exchanges (verifying eligibility, determining networks, etc.).

4.Another worry is that patients who quit paying premiums have a 90 day grace period during which they continue to be “insured”– for the first 30 days, the insurer is liable; but for the next 60 days the provider is at risk for the insurer’s share of the bill.


Under Medicaid you are guaranteed reimbursement (even at much lower rates than average). Under the exchanges the doctors have a lot more risk. 

[Deleted]

I can tell you that CHIP benefits were not the same as medicaid, nor was CHIP treated like medicaid at the doctors office. 

CHIP is a government program, but it is not government 'insurance'. Medicaid is government administered and government sets and pays the reimbursements, CHIP the insurance co sets and pays the reimbursements. 

[973beachbum]

Nov 5, 2014 9:25:59 GMT -5 oped said:

I can tell you that CHIP benefits were not the same as medicaid, nor was CHIP treated like medicaid at the doctors office. 

CHIP is a government program, but it is not government 'insurance'. Medicaid is government administered and government sets and pays the reimbursements, CHIP the insurance co sets and pays the reimbursements.

I actually was a health insurance administrator for years and i promise you the states haven't actually paid the claims or set any of the plans up in decades.  They put out bids for insurance companies to do that part.  One insurance plan from one company may be better than the other but they are all still medicaid.

[Deleted]

So are you saying that CHiP is the same as medicaid and treated by providers the same as medicaid? Because that is soooo not my experience.

[Deleted]

What insurance company card do medicaid enrollees get? Because in PA an Access card is not the same as a Blue Cross card...

[The Captain]

Nov 5, 2014 9:11:54 GMT -5 oped said:

Nov 5, 2014 9:07:42 GMT -5 milee said:

With most Medicaid plans, the patient has either $0 to pay as their share or some very nominal amount.

With the new exchange plans, most of the least expensive plans have low monthly insurance premiums, but there is a large deductible.  So the patient has to pay 100% of the doc visits until the deductible is reached.  For a doc's office, that means instead of collecting their payment from the state Medicaid plan, they're trying to collect from hundreds of individuals who don't really understand how their insurance works and don't have the money to pay the doc even if they do.

Sounds like Single Payer would be better then...

For those who don't have private insurance now?  Of course it would.  For those want something to be provided to them at not cost to themselves?  Of course it would.

Problem is, someone has to pay for it.  If you remove exposure of the true cost of care to people then very few will have an incentive to do all they can to minimize the cost of that care (after all - someone else is paying for it).  This is true even now of private health insurance, but at least there most people have deductibles to make them think twice about where to allocate their dollars.

How many times even on these boards do we advise people to do ALL YOU CAN to save the unborn baby with major defects or treat the 60yo with incurable cancer even if it means bankruptcy.  Thing is, even in those cases someone else will still end up absorbing the cost somehow.

All "single payer" would be is another Ponzi scheme where we demand more than we can afford now and expect to kick the can/bills down the road for our kids and grandkids to deal with.  No thanks.  We've already seen all too well how good (SARCASM) a steward the government is with our tax dollars.

[Deleted]

Ok, but the opinions here seem contradictory. This program moves more people to shared costs, makes them more aware of what things costs... But that is apparently a big negative... 

[billisonboard]

Nov 5, 2014 9:34:36 GMT -5 The Captain said:

...

All "single payer" would be is another Ponzi scheme where we demand more than we can afford ...

I want a Lexus to get me to work but all I can afford is a bus pass.
I want chemo to cure my cancer but all I can afford is an aspirin.

[Shooby]

ACA was ill advised and poor law. I think that the vast majority of people could get on board with some type of catastrophic health insurance or basic plan. But ,in our country, everyone wants everything anytime they want or demand it. And, there are so many nods to special interest groups that it just because another bureaucratic nightmare.

[Deleted]

Nov 5, 2014 9:13:55 GMT -5 chiver78 said:

Nov 5, 2014 9:10:30 GMT -5 @singlemominmd said:

I don't think it's the wait to see a doctor but the wait for the insurance company to approve an MRI or physical therapy or if you need a referral for an orthopedist getting your PCP to give you one.

and there were differences before the ACA as to how individual insurance companies handled stuff like this (see my post above). I'm not sure why people think that all of a sudden the ACA is going to make things like this markedly worse?

sorry, I was talking about before ACA.  I had a plan once where I couldn't actually get a referral to an OB without making an appointment with the PCP to get a pregnancy test, wait for the results and then come back and get the referral.

[Deleted]

Nov 5, 2014 9:52:11 GMT -5 @wxyz said:

Dr's are not dumb and they do not have to treat you.  A lot of people with the new high deductibles are going to find out that they will be required to prepay.  A Dr is not going to take the risk of collecting.

When I had surgery recently I had to prepay for the Dr charges before they would do the surgery.  Those people on their new ACA policies are going to be very shocked when they are asked to pay upfront to get treated.

On my plan (HSA) doctors are not allowed to require prepayment.  I don't pay anything upfront.