The Patient Protection and Affordable Care Act of 2010 (PPACA) is being touted by its proponents as moving the country to near-universal coverage and a great step ahead in U.S. health care. But what does this really mean? Are the many barriers to care almost a thing of the past?
On the plus side, the PPACA does offer these welcome provisions:
• Extending health insurance to 32 million more people by 2019.
• Allowing parents to keep their children on their policies until age 26.
• Expansion of Medicaid to cover 16 million more lower-income Americans.
• New funding for community health centers that could allow them to double their patient volume.
However, on the other side of the ledger, there are many problems that will render restricted access to care for tens of millions of Americans, an ongoing and even increasing problem. These examples show how far short of the mark the PPACA falls on access to care:
• There will still be 23 million people without any kind of health insurance in 2019.
• Federal support for Medicaid expansion will not kick in until 2014.
• More than 32 million other Americans will be under-insured in 2019, as a result of these kinds of circumstances:
Many people will not be able to afford coverage through either exchanges (which won't be operational until 2014) or high-risk pools.
- Many younger healthier people, the "Young Invincibles," will opt out of coverage until they have an accident or get sick.
The new federal temporary high-risk pool is already underfunded and plagued with many problems; at best, it will be available for up to 7 million uninsured people, but more likely for only about 200,000 or 3 percent of the target population. (Merlis, M. Health coverage for the high-risk uninsured: Policy options for design of the temporary high-risk pool. National Institute for Health Care Reform. May 27, 2010.)
The actuarial value of insurance plans for most of the newly "insured" will be as low as 60 to 70 percent (i.e. insurers leave 30 percent to 40 percent of the bill with patients and their families).
Even those fortunate enough to have employer-sponsored (ESI) coverage will find their plans costing more, covering less, and more difficult to afford; the Congressional Budge Office projects that the average family premium in the ESI market in 2016 will cost more than $20,000, not including deductibles and other out-of-pocket expenses. (Congressional Budget Office. An Analysis of Health Insurance Premiums Under the Patient Protection and Affordable Care Act. Nov. 30, 2009.)
Access to care will further deteriorate as a result of 36 billion in Medicare and Medicaid cuts to safety-net hospitals. We can expect closure of some of these critical facilities that provide a wide range of services that other hospitals find too unprofitable to provide, including kidney dialysis, cancer treatment and mental health care.
Although the PPACA does call for an increase in reimbursement for primary care physicians, that won't happen until 2013, and will then last only two years -- just a small gesture toward the nation's growing crisis in primary care.
The U.S. is facing a shortage of 35,000 to 44,000 primary care physicians for adults by 2025 (Colwill, J, Cultice, JM, Kruse, RL. Will generalist physician supply meet demands of an increasing and aging population? Health Affairs [Millwood] 27: w232-41, 2008.) An increasing number of people with insurance coverage cannot find a primary care physician to take care of them, especially those on Medicare or Medicaid, due to low reimbursement in those programs.
Since the PPACA calls for phased cuts in overpayments to private Medicare Advantage plans over the next few years, enrollees will face cuts in benefits and rising premiums.
As they confront deficits of 127 billion over the next two fiscal years, states are making draconian cuts in Medicaid across the country that will only aggravate current barriers to care. State appeals to the federal government for relief of Medicaid costs are now caught in a political crossfire threatening further unraveling of Medicaid funding. (Solomon, D. States face new pinch as stimulus ebbs. Wall Street Journal, June 23, 2010: A5.)
A majority of states outsource their Medicaid programs to private insurers that frequently create profits by cutting services. A recent report found that 2.7 million children on Medicaid in nine states were not receiving required screenings and immunizations. In Florida, the insurer WellCare paid 40 million in restitution to the state after it acknowledged that it had set up a subsidiary to make it appear that it was spending more on health care than it actually was. (MacGillis, A. Some states say they're not receiving the Medicaid services they're paying for. The Washington Post on line, July 8, 2010.)
Despite the hype we hear about "near-universal" access just down the road with PPACA, the above leads us to believe that access to care will remain inadequate for much of the population. In our next post, we will look at what this year's health care "reform" legislation means for the quality of care Americans receive.
Adapted from "Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Care Reform," 2010, with permission of the publisher Common Courage Press. www.commoncouragepress.com
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