Impact on Access to Care

 VII. Key Issues: Regulation & Reform >> C. Health Reform >> Affordable Care Act (ACA) >> ACA Impact Analysis >>ACA Impact on Access >> Impact on Access to Care (last updated 4.24.17)

Access to General Medical Care

Overview

  • CMS, Office of the Actuary. The Medicare actuary has issued a series of reports suggesting that access to health facilities and health professionals for Medicare beneficiaries may be severely compromised if the ACA Medicare payment provisions are fully implemented.
  • Athenahealth. “ACAView is a joint effort between the Robert Wood Johnson Foundation and athenahealth, a cloud-based health care technology and services company. Because athenahealth uses a cloud-based network, we can analyze and report rapidly on the effects of the ACA. Issues reports on the impact of ACA on access to care using physician survey data. ACAView tracks provider activity among practice locations on athenahealth’s network since December 31, 2010. By comparing data over time with a single practice cohort, we are able to capture shifts in patient demographics, payer policies, and practice patterns. The athena sample is broadly representative of the nation’s physicians and is very similar in most measures to the national benchmark provided by the National Ambulatory Medical Care Survey.”
  • Heritage Foundation. The Impact of the Affordable Care Act on the Health Care Workforce (3.18.14). “The health care workforce is already facing a critical shortfall of health professionals over the next decade. The ACA breaks the promises of access and quality of care for all Americans by escalating the shortage and increasing the burden and stress on the already fragile system. The ACA’s attempts to address the shortage are unproven and limited in scope, and the significant financial investment will not produce results for years due to the training pipeline. With the ACA’s estimated 190 million hours of paperwork annually imposed on businesses and the health care industry, combined with shortages of workers, patients will be facing increasing wait times, limited access to providers, shortened time with caregivers, and decreased satisfaction. The health care workforce is facing increased stress and instability, and a major redesign of the workforce is needed to extend care to millions of Americans.”

ACA and Physician Shortage

Access to Health Facilities

The Affordable Care Act requires permanent annual productivity adjustments to price updates for most providers (such as hospitals, skilled nursing facilities, and home health agencies), using a 10-year moving average of economy-wide private, non-farm productivity gains. According to the Medicare actuary: “While such payment update reductions will create a strong incentive for providers to maximize efficiency, it is doubtful that many will be able to improve their own productivity to the degree achieved by the economy at large… The Office of the Actuary’s most recent analysis of hospital productivity highlights the difficulties in measurement but suggests that such productivity has been small or negligible during 1981 to 2005.” The actuary has explicitly warned: “providers for whom Medicare constitutes a substantive portion of their business could find it difficult to remain profitable and, absent legislative intervention, might end their participation in the program, possibly jeopardizing access to care for beneficiaries.”

  • CMS, Office of the ActuaryProjected Medicare Expenditures under Illustrative Scenarios with Alternative Payment Updates to Medicare Providers (August 5, 2012). The Medicare actuary estimates that due to the cuts in Medicare payments to health facilities required by the ACA, 15% of Part A facilities (hospitals, nursing homes, home health agencies) will have negative total facility margins by 2019, 25% will be operating in the red by 2030 and 40% by 2050.
  • Nation’s Elite Cancer Hospitals Off-limits Under Obamacare. AP: “Cancer patients relieved that they can get insurance coverage because of the new health care law may be disappointed to learn that some of the nation’s best cancer hospitals are off-limits… In all, only four of 19 nationally recognized comprehensive cancer centers that responded to AP’s survey said patients have access through all the insurance companies in their state exchange. Not too long ago, insurance companies would have been vying to offer access to renowned cancer centers, said Dan Mendelson, CEO of the market research firm Avalere Health. Now the focus is on costs. ‘This is a marked deterioration of access to the premier cancer centers for people who are signing up for these plans,’ Mendelson said.” (New York Post, 3.19.14)
  • Obamacare is a ‘Haves and Have Nots’ Health System. “The rich have always been able to pay for the best doctors and medical care. But until now, that advantage had not been institutionalized by the federal government… If you have insurance through Obamacare, your odds of being accepted by one of the nation’s top hospitals or having access to top doctors is seriously diminished… The result, of course, is that the nation’s high-end teaching hospitals — where the best research facilities and some of the best doctors in the world practice — will be mostly available to rich people.” (The Fiscal Times, 3.28.14)
  • Ready or Not? How Community Health Centers View Their Preparedness to Care for Newly Insured Patients. “By expanding access to affordable insurance coverage for millions of Americans, the Affordable Care Act will likely increase demand for the services provided by federally qualified health centers (FQHCs), an important source of care in low-income communities. A Commonwealth Fund survey asked health center leaders in 2013 about current and anticipated workforce challenges, as well as efforts under way to prepare for the increase in patients. The majority of FQHCs reported shortages of primary care doctors (56%), especially bilingual physicians (60%). Health centers are engaged in activities to meet the needs of new patients, with 53 percent pursuing integration of behavioral health and 31 percent hiring additional clinical staff. To help them provide quality care to more patients, FQHCs will require assistance to recruit additional personnel, particularly bilingual staff and mental health professionals, and to expand access to care through telehealth and other strategies.” (Commonwealth Fund, May, 2014)
  • Health Centers Try to Expand Without Losing Roots. “When Clare Ross couldn’t afford her $300 health insurance premium on top of her student loan payments, she turned to the Santa Cruz Women’s Health Center. The safety-net clinic was founded in 1974 to serve only women, many of whom, like Ross, couldn’t get care elsewhere. But the center is now expanding its services in order to serve a wider demographic and receive federal funding under the Affordable Care Act… A combination of federal funding for health centers through the Affordable Care Act, more patients becoming insured and support from hospitals and donors is helping to grow the network of health centers that primarily serve low-income people… Federally qualified centers receive higher reimbursement rates than other California providers when they treat low-income patients. However, the clinics must also abide by federal laws that prohibit discrimination, which means they must be open to all. And with the federal funding comes more regulation and oversight.” (California Health Report, 7.3.14
  • The Cleveland Clinic: Coming to a Kiosk Near You? Health System to Offer New Telehealth Options. “The Cleveland Clinic has signed a letter of intent to partner with HealthSpot, a provider of telehealth services based in Ohio, to provide care to patients via walk-in kiosks located in non-traditional health care settings, like workplaces, universities, and retail stories. The kiosks are private, eight-by-five foot spaces outfitted with medical devices, videoconferencing capabilities, and medical devices. They allow Cleveland Clinic providers to see patients through the kiosks, and each kiosk is staffed by a medical assistant.The clinic will integrate patient data from the kiosks into its electronic health record system.” (The Advisory Board Company, 5.22.14)

Other Access Issues

  • Cuts Planned for Medicare Providers, May Limit Access. “If you are on Medicare, you and others like you are probably going to be more affected by the new health reform law than any other population group.” (Psychology Today, 2.6.13)
  • Some Find Their Children Are Being Forced into Medicaid Plans. “Families shopping for health insurance through the new federal marketplace are running into trouble getting everyone covered when children are eligible for Medicaid but their parents are not. Children who qualify for Medicaid, the safety-net program for the poor and disabled, can’t be included on subsidized family plans purchased through the federal marketplace. … ‘Based on your income, they’ll separate your kids from your primary policy and they shift them off to Medicaid or Healthy Kids and there’s no way you can bring them back,’ said Clouden.” (Associated Press, 1.26.14)
  • ObamaCare and My Mother’s Cancer Medicine. [Opinion]: “She used to have a policy that covered the drug that kept her alive. Now she’s on her own…On Feb. 12, just before going into (yet another) surgery, she was informed by Humana that it would not, in fact, cover her Sandostatin, or other cancer-related medications. The cost of the Sandostatin alone, since Jan. 1, was $14,000, and the company was refusing to pay. The news was dumbfounding. This is a woman who had an affordable health plan that covered her condition. Our lawmakers weren’t happy with that because . . . they wanted plans that were affordable and covered her condition. So they gave her a new one. It doesn’t cover her condition and it’s completely unaffordable.” Blackwood, Stephen, MD. (Wall Street Journal, 2.23.14)
  • Affordable Care Act Eclipses Low-Cost NJ Program for Middle-Class Kids. “FamilyCare Advantage, an insurance plan created for children from middle-class families who earn too much to qualify for financial assistance, was canceled March 31 because it did not meet the requirements of the Affordable Care Act. ‘Without having that safety net, if an illness arises, we will probably take him to the ER,’ said Miotla.” ( NJ.com, 4.6.14)
  • How ObamaCare More Than Doubled One Family’s Yearly Pharmaceutical Costs (Video). North Carolina resident Pattie Curan describes how pharmaceutical care for her two sons with mitochondrial disease has been impacted by the ACA. (FOX News Videos, 10.5.14)
  • More Patients, Not Fewer, Turn To Health Clinics After Obamacare. “She expected the insurance exchange, or marketplace, established under the Affordable Care Act would reduce the number of uninsured patients the clinic sees. The opposite happened, she says. ‘What we found within our patient population and within the community is that a lot of the advertisement and information about the marketplace brought people [in who] didn’t know anything about free clinics and did not qualify for any of the programs within the ACA marketplace,’ Hudson says… ‘Over half of the people that we see would’ve been eligible for Medicaid expansion had the state elected to exercise that option,’ says Ben Money… Dr. Gary Wiltz, the CEO of 10 community health centers in the southwestern part of Louisiana, says demand has surged. ‘We’ve gone from 10,000 patients to 20,000 in the last six or seven years, so we’ve doubled,’ he says. Wiltz says other things are at play, too. The economic recovery hasn’t reached many of the poorest people, and some who do qualify for Obamacare subsidies say their options are still too expensive.” (Kaiser Health News, 6.3.15)
  • An Aging Nursing Workforce Confronts Rapid Healthcare Industry Change. “Hospital patients typically spend far more time with several nurses over the course of their stay than with the physicians who are in charge of their care. Nurses are an indispensable part of the services delivered in every physician’s office. But, today, nurses are being asked to take on new jobs. As the healthcare payers demand greater value for their healthcare dollars, delivery systems must learn how to care for their patients more safely, with higher quality and in a less costly manner. That’s led health system leaders to ask the nation’s 3.1 million nurses to play a greater role in coordinating care. Are they up to the task? The nation’s nursing workforce is growing older, with the average age approaching 50. About a quarter of current nurses are slated to retire in the next decade. Given the aging of the population — 10,000 baby boomers are retiring every day — the government projects the nation will need to train and employ a million new and replacement nurses between now and the middle of the next decade.” (Modern Healthcare, 1.13.17)
  • Access to Primary Care Appointments Following 2014 Insurance Expansions. “The Patient Protection and Affordable Care Act (ACA) expanded coverage to roughly 12 million individuals by mid-2014 and 20 million by 2016, raising concern about the capacity of the primary care system to absorb these individuals. We sought to determine whether there was an empirical basis for these concerns… we find no evidence of such as of mid-2014, as evidenced by the stability in appointment rates and wait-times for new privately insured patients and an increase in appointment access for new Medicaid patients in our 10 study states. Notably, as of mid-2014, there may indeed have been sufficient capacity within the primary care system to absorb new patients. Alternatively, practices may be increasing the supply of primary care by reorganizing the way they provide care. The Patient-Centered Medical Home (PCMH) model, for example, encourages a team-based approach to care with greater accessibility for patients through extended after-hours or weekend care, although early results concerning the effects of PCMHs have been mixed.[13–16]  It is also possible that electronic medical records and asynchronous communication with patients and specialists are helping primary care clinicians care for more patients. In addition, it is possible that the increase in demand for care from the insurance expansions may have been offset to some extent by decreases in demand following the recession. A less rosy view is that clinicians may simply be seeing more patients in a given day. If this is the case, the added patient load may be contributing to the increasing primary care physician dissatisfaction and burnout that has been widely discussed,[18,19] and that may portend an unsustainable future for primary care. Finally, mid-2014 may have been too early to see sufficient demand pressure resulting from the insurance expansions. Having health insurance is often a prerequisite to seeking care, yet many of the newly insured may not yet have accessed the primary care system to schedule appointments in our study’s time period of May 2014-July 2014.” (Ann Fam Med. 2017;15(2):107-112)

Access to Care: Medicaid Enrollees

  • In 2011 Nearly One-Third Of Physicians Said They Would Not Accept New Medicaid Patients. “Although 96 percent of physicians accepted new patients in 2011, rates varied by payment source: 31 percent of physicians were unwilling to accept any new Medicaid patients. Physicians in smaller practices and those in metropolitan areas were less likely than others to accept new Medicaid patients. Higher state Medicaid-to-Medicare fee ratios were correlated with greater acceptance of new Medicaid patients. The findings serve as a useful baseline from which to measure the anticipated impact of Affordable Care Act provisions that could boost Medicaid payment rates to primary care physicians in some states while increasing the number of people with health care coverage.” (Health Affairs, August 2012 Vol. 31 No. 8).
  • Does Expanding Health Care Coverage Reduce ER Visits? “A few weeks ago, I was asked to write a comment to accompany a study released Thursday in Science, which shows that Medicaid access increases emergency room visits by more than 40 percent… Advocates for health care expansion reason that the newly insured will seek out health care more often, but will choose a primary-care physician over the ER. One reason the uninsured tend to go to the ER when they do finally seek treatment is that it’s their only option… They’re going to the ER not because they’re uninsured, not because they don’t know any better, but because an overstressed primary health care system is sending them there.” (Slate, 1.2.14)
  • When Doctors Slam the Doors on the Newly Insured: One Writer Says Her New Medicaid Card Has Yet to Help Her Find Healthcare. [Opinion]: “As a proud new beneficiary of the Affordable Health Care Act, I’d like to report that I am doctor-less. Ninety-six. Ninety-six is the number of soul crushing rejections that greeted me as I attempted to find one. It’s the number of physicians whose secretaries feigned empathy while rehearsing the ‘I’m so sorry’ line before curtly hanging up. You see, when the rush of the formerly uninsured came knocking, doctors in my New Jersey town began closing their doors and promptly telling insurance companies that they had no room for new patients.” (Ebony, 4.9.14
  • Waiting For Medicaid to Kick In. “Nearly 2 million Californians have gained coverage with the expansion of the Medi-Cal program for poor and disabled people, including those who transitioned from temporary programs like Healthy Way LA. But roughly 800,000 more applications are pending from people presumed to be eligible for the program…’If they don’t have final determination of their eligibility, they are probably not able to get care,’ said Catherine Teare, senior program officer at the California HealthCare Foundation… The delays in confirming eligibility aren’t unique to California. ‘In practically every state, there are backlogs,’ said Matt Salo, executive director of the National Association of Medicaid Directors.” (Kaiser Health News, 4.21.14
  • Can Medicaid Beneficiaries Find a Doctor? CMS Wants to Know. “The CMS is planning to conduct its first nationwide research effort to answer the question of whether adult Medicaid beneficiaries can find providers, and if factors such as being in managed Medicaid versus a fee-for-service offering aid or hurt the search. What it’s likely to find, according to interviews conducted with state Medicaid officials and medical society officials in 20 states, is a mixed picture overshadowed by general concerns that reimbursement rates remain too low to entice many doctors to accept new Medicaid patients.” (Modern Healthcare, 7.8.14)
  • For Many New Medicaid Enrollees, Care Is Hard to Find, Report Says.  “Enrollment in Medicaid is surging as a result of the Affordable Care Act, but the Obama administration and state officials have done little to ensure that new beneficiaries have access to doctors after they get their Medicaid cards, federal investigators say in a new report. The report, to be issued this week by the inspector general at the Department of Health and Human Services, says state standards for access to care vary widely and are rarely enforced. As a result, it says, Medicaid patients often find that they must wait for months or travel long distances to see a doctor.” (New York Times, 9.27.14)
  • Audit: Medicaid Quality of Care Varies by State. “More than 50 million people receive healthcare through state-managed Medicaid programs, but the quality of that care varies widely and receives little federal scrutiny, a government audit has found. Each state is largely free to set its own standards for care, including the distance a patient travels to see a doctor, the time a patient must wait for an appointment and the patient-to-doctor ratio within certain regions. Those standards vary widely across states and are largely unregulated by the federal government, according to an investigation by the inspector general’s office for the Department of Health and Human Services (HHS). As a result, federal officials say they don’t know whether a state’s standards ‘are adequate to ensure access to care.’” (The Hill, 9.29.14)
  • Reversing the Medicaid Fee Bump: How Much Could Medicaid Physician Fees for Primary Care Fall in 2015? “Overall, primary care fees in the Medicaid program would fall an average of 42.8 percent in 2015 if no extension of the ACA primary care fee increase policy were granted. The fee reduction would be even larger — 47.4 percent on average — in those states that do not plan to extend the fee bump using state funds… Significant drops in primary care reimbursement may lead physicians to see fewer Medicaid patients, potentially leading these patients to have difficulty finding a physician or getting an appointment.” (Urban Institute, December, 2014)
  • Giving Millions More Access to Care, Medicaid Expansion Strains California’s Health System. “Three million more people than expected have enrolled in Medicaid in California. Other states have also seen surges far beyond initial projections, including Kentucky, Michigan, Oregon, and Washington state. As successful as California has been in enrolling millions in Medicaid and building new primary care clinics, patient advocates say the Medicaid expansion has exacerbated longstanding shortages in specialty care. Community clinic directors say it’s often difficult to find cardiologists, orthopedists and other specialists to see their patients and that low-income Californians still face formidable hurdles when they need medical treatment… ‘Why am I seeing all of those people? Because nobody else is available in their communities to see them. Why not? Because the rates are unacceptable, the hassles from the managed care plans, as well as the state, are unacceptable to most offices to deal with.’” (National Public Radio, 9.30.15)
  • Newly Insured Treasure Medicaid, But Growing Pains Felt. “A withering audit by the state of California released this summer found that regulators could not verify if health plans had enough doctors in their Medicaid networks or if the distances patients had to drive were unreasonable. The audit also found that the state’s call centers were overwhelmed, with phone representatives answering just half of incoming calls. And too often, those obstacles have forced patients to seek help in expensive hospital emergency rooms.” (Kaiser Health News, 10.2.15)
  • The ACA Has Improved Access to Care for Low-Income Patients. “The impact of expanded Medicaid coverage on primary care physicians’ (PCPs) practices occurred rapidly. Prior to 2014, PCPs in Medicaid expansion states using athenahealth services saw a Medicaid case-mix – the share of visits from Medicaid patients – of 15 to 16 percent. Within nine months after the coverage expansion provisions of the ACA went into effect, this proportion had increased to 21 percent as doctors increasingly accepted new Medicaid patients. The primary care physicians in our sample saw an average of 33 percent more Medicaid patients in 2014 than in 2013.” (Athena Health, 3.1.16)

Access to Care: Medically Uninsurables

  • Associated Press. Reporter Tom Murphy reported (8.27.14) that there are three major ways insurers still might steer sick or expensive patients away from their coverage:
    • Narrow Networks. Insurers can lower their chances for covering patients with expensive medical conditions like cancer and autism simply by limiting the number of doctors and hospitals in a coverage network. That would send those patients searching for coverage elsewhere because they don’t want to pay expensive, out-of-network rates. Narrow insurer networks might include only 30 percent or less of a market’s hospitals, as opposed to 70 percent or more for a broader network, according to the consulting firm McKinsey & Co.
    • Prescription Sticker Shock. Some plans are requiring patients to initially pay 30 percent or more of the bill for drugs that can cost several thousand dollars a month. HIV drugs and multiple sclerosis medications are among them. The overhaul caps the annual amounts patients are required to pay for these so-called out-of-pocket expenses. Still, some say the higher cost-sharing requirements can steer patients that need these medications away from enrolling.
    • Enter Markets Cautiously. Another way insurers might land a healthier population is by playing the waiting game. The nation’s largest health insurer, UnitedHealth Group Inc., will dive into the overhaul’s public insurance exchanges with plans to sell 2015 individual coverage in 24 exchanges. That’s up from only four in 2014…. UnitedHealth’s delayed growth could be a savvy way to avoid some of the sickest patients who likely rushed to sign up for insurance in the initial year of the exchanges, said Laszewski, the industry consultant.
  • New England Journal of Medicine. (1.29.15) Using Drugs to Discriminate — Adverse Selection in the Insurance Marketplace. “We found evidence of adverse tiering in 12 of the 48 plans — 7 of the 24 plans in the states with insurers listed in the HHS complaint and 5 of the 24 plans in the other six states (see the Supplementary Appendix for sample formularies). The differences in out-of-pocket HIV drug costs between adverse-tiering plans (ATPs) and other plans were stark (see graph). ATP enrollees had an average annual cost per drug of more than triple that of enrollees in non-ATPs ($4,892 vs. $1,615), with a nearly $2,000 difference even for generic drugs. Fifty percent of ATPs had a drug-specific deductible, as compared with only 19% of other plans. Even after factoring in the lower premiums in ATPs and the ACA’s cap on out-of-pocket spending, we estimate that a person with HIV would pay more than $3,000 for treatment annually in an ATP than in another plan. Our findings suggest that many insurers may be using benefit design to dissuade sicker people from choosing their plans. A recent analysis of insurance coverage for several other high-cost chronic conditions such as mental illness, cancer, diabetes, and rheumatoid arthritis showed similar evidence of adverse tiering, with 52% of marketplace plans requiring at least 30% coinsurance for all covered drugs in at least one class. Thus, this phenomenon is apparently not limited to just a few plans or conditions.”
  • Geruso, Michael, Timothy J. Layton, and Daniel Prinz. (October, 2016). Screening in Contract Design: Evidence from the ACA Health Insurance Exchanges. “By steering patients to cost-effective substitutes, the tiered design of prescription drug formularies can improve the efficiency of healthcare consumption in the presence of moral hazard. However, a long theoretical literature describes how contract design can also be used to screen consumers by profitability. In this paper, we study this type of screening in the ACA Health Insurance Exchanges. We first show that despite large regulatory transfers that neutralize selection incentives for most consumer types, some consumers are unprofitable in a way that is predictable by their prescription drug demand. Then, using a difference-in-differences strategy that compares Exchange formularies where these selection incentives exist to employer plan formularies where they do not, we show that Exchange insurers design formularies as screening devices that are differentially unattractive to unprofitable consumer types. This results in inefficiently low levels of coverage for the corresponding drugs in equilibrium. Although this type of contract distortion has been highlighted in the prior theoretical literature, until now empirical evidence has been rare. The impact on out-of-pocket costs for consumers affected by the distortion is substantial—potentially thousands of dollars per year—and the distortion creates an equilibrium in which contracts that efficiently trade off moral hazard and risk protection cannot exist.”

Access to Care: High-need Patients

  • New Commonwealth Fund Report Profiles The 12 Million Sickest Patients; Finds Health Care System Not Meeting Their Needs. According to the new research, the sickest adults struggle to get the health care they need but still spend more out-of-pocket and have higher medical costs than other adults. Twenty percent of the sickest adults reported going without or delaying needed medical care or prescription medication in the past year, compared to 8 percent of all U.S. adults… Although 96 percent of high-need adults have health insurance, that coverage does not guarantee they are able to get the care they require. High-need adults with private insurance are the most likely to have unmet medical needs (32%), followed by those with Medicaid (28%), Medicare (15%), and both Medicare and Medicaid (14%). In addition, high-need Medicaid beneficiaries have greater difficulties obtaining referrals to specialists compared to high-need Medicare beneficiaries or individuals with private insurance.” (Commonwealth Fund, 8.29.16)
  • Health Law Coverage Has Helped Many Chronically Ill — But Has Still Left Gaps. “New research published Monday in the Annals of Internal Medicine found that the number of chronically ill Americans with insurance increased by about 5 percentage points — around 4 million people — in 2014, the first year the law required Americans to have coverage, set up marketplaces for people to buy coverage and allowed for states to expand eligibility for Medicaid, the federal-state insurance plan for low-income people. If states opted into the Medicaid expansion, people with chronic illnesses such as heart disease, diabetes, depression and asthma were more likely to see those gains. Still, the study suggests, the law fell short in terms of guaranteeing those people could get medical treatment, see a doctor and afford medications.” (Kaiser Health News, 1.23.17)

Access to Care: Exchange Enrollees

Access to Mental Health Care

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