Reports Show More People Insured But No Increase In New Patient Volume For Physicians Since January Under Affordable Care Act

The New England Journal of Medicine has reviewed the increase in coverage under the Affordable Care Act and concluded:

Taking all existing coverage expansions together, we estimate that 20 million Americans have gained coverage as of May 1 under the ACA (Figure 3Figure 3Categories of Expanded Health Insurance Coverage under the Affordable Care Act (ACA).). We do not know yet exactly how many of these people were previously uninsured, but it seems certain that many were. Recent national surveys seem to confirm this presumption. The CBO projects that the law will decrease the number of uninsured people by 12 million this year and by 26 million by 2017. Early polling data from Gallup, RAND, and the Urban Institute indicate that the number of uninsured people may have already declined by 5 million to 9 million and that the proportion of U.S. adults lacking insurance has fallen from 18% in the third quarter of 2013 to 13.4% in May 2014.

However, these surveys may underestimate total gains, since some were fielded before the late March enrollment surge and do not include children. With continuing enrollment through individual marketplaces, Medicaid, and SHOP, the numbers of Americans gaining insurance for the first time — or insurance that is better in quality or more affordable than their previous policy — will total in the many tens of millions.

As we look to the future of the coverage provisions of the ACA and their effect on the U.S. health care system, several observations seem justified. First, as the number of individuals benefiting from the law grows, its wholesale repeal will grow less likely, although the law could still be importantly modified in the future.

Second, experience with the ACA will vary enormously among states. Those deciding not to expand Medicaid will benefit far less from the law, and since many of these states have high rates of uninsured residents and lower health status, the ACA may have the paradoxical effect of increasing disparities across regions, even as it reduces disparities between previously insured and uninsured Americans as a whole.17

Third, the sustainability of the coverage expansions will depend to a great extent on the ability to control the overall costs of care in the United States. Otherwise, premiums will become increasingly unaffordable for consumers, employers, and the federal government. Insurers who seek to control those costs through increasingly narrow provider networks across all U.S. insurance markets may ultimately leave Americans less satisfied with their health care. Developing and spreading innovative approaches to health care delivery that provide greater quality at lower cost is the next great challenge facing the nation.

The full article is available to non-subscribers and there is also further discussion at Talking Points Memo.

There has been concern that the increase in number of insured might lead to an increase in number of people seeing physicians despite predictions and early evidence that this would not be a significant problem in most areas. I have seen several reports indicating that doctors generally are not seeing more patients as a result of the Affordable Care Act. The most recent came from Athena Health and the Robert Wood Johnson Foundation. Here is a summary of their findings:

  • Influx in New Patient Volume Not Detected: In the first five months of 2014, a national sample of 14,300 health care providers across the athenahealth network did not see an increase in new patient volume.* Instead, the percentage of total visits with new patients actually dropped slightly compared to the same period in 2013. These findings suggest that an increase in newly insured patients, resulting from the ACA, has yet to have an impact on new patient volume at medical practices.
  • Health Care Reform Widening the Medicaid Gap: In states that are expanding Medicaid coverage under the ACA, the data shows an overall increase in adult (18-64) Medicaid beneficiary patient visits. In expansion states, on average, the percentage of Medicaid-covered patients who are being seen by primary care physicians is rising, with Medicaid patients accounting for 12.3% of care in December of 2013 compared with an increased rate of 15.6% in May 2014. Surgeons and other specialists also show increases. Conversely, states that are not expanding Medicaid coverage have seen Medicaid visits remaining flat. These findings indicate that the implementation of the ACA is widening the gap of the total share of Medicaid patients that doctors in expansion vs. non-expansion states are caring for.
  • No Increase in Chronic Disease Diagnoses Among New Patients: Findings from the first five months of 2014 indicate that established patients have a higher rate of chronic diseases compared with new patients seeking care. When comparing diagnosis rates of chronic conditions from the first five months of 2013 to the first five months of 2014, across both new and established patients, no increase in diagnosis rates of chronic conditions is detected for either population.

It is possible that some of the newly insured are initially going to the Emergency Room and therefore are not picked up as an increase in visits by primary care physicians. In May I reported on a study by the American College of Emergency Physicians which found that 37 percent of ER physicians reported that patient volume had increased slightly, 9 percent reported that it had increased greatly, and 27 percent reported that the number of ER visits had remained the same.

It is also a good finding that the newly insured are not turning out to be sicker than the previously insured. Many insurance companies held off on entering the exchanges last year out of fear that they might wind up with sicker patients, costing them more money. Those which sold coverage have wound up doing well with more insurance companies planning to enter the exchanges to sell coverage for next year. This should help reduce anticipated increases in premiums and give consumers more choice.

Forbes has further discussion of the differences in states which are offering the expanded Medicaid program compared to those which do not.

What’s The Matter With Thomas Frank?

Obama Green Lantern

Thomas Frank has fallen for the Green Lantern view of the presidency, thinking that the president has the power to do anything he wishes. His criticism of Obama:

Why did he do nothing, or next to nothing, about the crazy high price of a college education, the Great Good Thing that he has said, time and again, determines our personal as well as national success? Why didn’t he propose a proper healthcare program instead of the confusing jumble we got? Why not a proper stimulus package? Why didn’t he break up the banks? Or the agribusiness giants, for that matter?

Well, duh, his museum will answer: he couldn’t do any of those things because of the crazy right-wingers running wild in the land. He couldn’t reason with them—their brains don’t work like ours! He couldn’t defeat them at the polls—they’d gerrymandered so many states that they couldn’t be dislodged! What can a high-minded man of principle do when confronted with such a vast span of bigotry and close-mindedness? The answer toward which the Obama museum will steer the visitor is: Nothing.

In point of fact, there were plenty of things Obama’s Democrats could have done that might have put the right out of business once and for all—for example, by responding more aggressively to the Great Recession or by pounding relentlessly on the theme of middle-class economic distress. Acknowledging this possibility, however, has always been difficult for consensus-minded Democrats, and I suspect that in the official recounting of the Obama era, this troublesome possibility will disappear entirely. Instead, the terrifying Right-Wing Other will be cast in bronze at twice life-size, and made the excuse for the Administration’s every last failure of nerve, imagination and foresight. Demonizing the right will also allow the Obama legacy team to present his two electoral victories as ends in themselves, since they kept the White House out of the monster’s grasp—heroic triumphs that were truly worthy of the Nobel Peace Prize. (Which will be dusted off and prominently displayed.)

But bipartisanship as an ideal must also be kept sacred, of course. And so, after visitors to the Obama Library have passed through the Gallery of Drones and the Big Data Command Center, they will be ushered into a maze-like exhibit designed to represent the president’s long, lonely, and ultimately fruitless search for consensus. The Labyrinth of the Grand Bargain, it might be called, and it will teach how the president bravely put the fundamental achievements of his party—Social Security and Medicare—on the bargaining table in exchange for higher taxes and a smaller deficit. This will be described not as a sellout of liberal principle but as a sacred quest for the Holy Grail of Washington: a bipartisan coming-together on “entitlement reform,” which every responsible D.C. professional knows to be the correct way forward.

Frank both ignores the real obstacles which Obama faced and is not very accurate in describing Obama’s record. He forgets that the there was a very good reason that Obama never had a chance to reason with the Republicans–they decided right off the bat that they would oppose anything Obama supported for political reasons. Frank might check out the work of  centrists Norman Ornstein and Thomas Mann on how Republicans are responsible for the current gridlock along with  this Frontline documentary:

On the night of Barack Obama’s inauguration, a group of top GOP luminaries quietly gathered in a Washington steakhouse to lick their wounds and ultimately create the outline of a plan for how to deal with the incoming administration.

“The room was filled. It was a who’s who of ranking members who had at one point been committee chairmen, or in the majority, who now wondered out loud whether they were in the permanent minority,” Frank Luntz, who organized the event, told FRONTLINE.

Among them were Senate power brokers Jim DeMint, Jon Kyl and Tom Coburn, and conservative congressmen Eric Cantor, Kevin McCarthy and Paul Ryan.

After three hours of strategizing, they decided they needed to fight Obama on everything. The new president had no idea what the Republicans were planning.

There were clear institutional limits on Obama in a system where forty Senators could block the majority on anything. The Democrats had sixty votes for a very brief time due to the delays in swearing in Al Franken and later Ted Kennedy’s death.  Even when Obama technically had sixty Senators voting with the Democrats, this included Joe Lieberman and Ben Nelson who would never go for the type of leftist agenda Frank favored.

Obama chose to use his limited political political capital to concentrate on health care reform, passing a comprehensive health reform package after previous presidents from Harry Truman to Bill Clinton were unsuccessful. Ted Kennedy once expressed regret at working with Richard Nixon and instead insisting upon a single-payer system at the time. Similarly Hillary Clinton convinced Bill to threaten to veto anything other than her plan, rejecting a Republican proposal which was very similar to the Affordable Care Act. It would be far better to accept what can be passed and then work to improve it over time.

Sure the Affordable Care Act is a confusing jumble, but that is because it built upon our current system. It would have been better if the system was even more complex and perhaps confusing, including either the public option or Medicare buy-in. Neither could pass because both Lieberman and Nelson opposed them. Obama certainly could have never received sixty votes for a single-payer plan, breaking up the banks, or a bigger stimulus.

Beyond Congress, Obama was limited by conservative media bias on economic matters. Obviously Fox was out there spreading lies and attacking anything Obama wanted to do, but the problems weren’t limited to Fox and its viewers. Most of the media is owned by the wealthy, and much of the news, especially on television, is reported by wealthy television stars. They might not share the Republican views on social issues or their opposition to science and reason (leading to the conservative view of  a liberal media) but many of them are quite conservative on economic issues. They were biased towards tax cuts and cutting spending. Media reports on the economy typically stressed the size of the deficit and included the assumption that a reduction in government spending was necessary. Few pointed out the degree to which Republican spending and tax cuts in the Bush years contributed far more to the deficit than Obama’s stimulus spending. The atmosphere was hardly conducive to pushing an even bigger stimulus, regardless of how much more this would have helped the economy recover. He also ignores the degree to which Obama’s stimulus did help bring about economic recovery.

Just as Frank ignores the benefits of Obama’s policies, including the Affordable Care Act and the stimulus, he exaggerates what Obama did not do. No, Obama did not destroy Social Security and Medicare. It is the other party which has been seeking to do that. Offering  Chained CPI in exchange for a grand bargain on the deficit might never have been a good idea, but we can’t blame Obama for making a bad deal when such a deal was never made and we don’t know what he would have held out for before making such an agreement.

Obama’s record has much in it to displease the far left. It is doubtful that any other president would have achieved more than he actually did.