Thanks Obamacare No Thanks

Policy changes have all good intentions, but they have good and bad results. The value is not about innovation. The value is about implementation. Denial and distraction only work temporarily to hide poor implementation.

At the very start of ACA there have been massive promotions and massive protests - but both sets of claims were quite uninformed and politically motivated. In many ways, CMS seems to move rapidly to new innovations perhaps to cover up problems with the past innovations.

Sadly the claims of benefit continue in the face of known adverse consequences. In Think Progress the headline screams that Obamacare helps the sickest to gain insurance. This author is taking some liberty with his reporting (like so many others). A more detailed examination reviews those sickest, the role of insurance access, true access barriers, and what is going on where care is compromised by design.

Who Are the Sickest in America?

The sickest in the United States are the oldest people with the least resources who live in poverty and have Medicaid and Medicare due to disability or age. These have two forms of insurance - Medicare and Medicaid. In some ways they have lesser health outcomes because of their insurance plans do not pay sufficiently for their care - shutting doors, erecting barriers, and changing the types of providers that they can access who can provide less because they care for more Medicaid and Medicare and other disadvantaged patients. 

Do the Sickest Have Insurance Access?

Dual Eligibles, Medicare plus Medicaid, have been granted insurance since 1965. The sickest patients have long had ways to get Medicare (disability) as well as Medicaid  insurance have been present for those discussed. 

Do the Sickest Have Access to Care?

Multiple blog posts have dealt with the flawed reasoning that insurance coverage equates to access to care. Basic health access workforce is required, something poorly supported by payment for decades. New ACA wrinkles in implementation include narrow networks. GAO criticized CMS for lack of sufficient supervision of innovative programs such as Medicare Advantage and expressed concerns about access for those with chronic conditions. 

This summer a Dual Eligible patient suffered delay and eventual death as he was shipped to different hospitals. His neighborhood reels from the worry that the same will happen to them. Some patients must travel 50 - 100 miles and fill out paperwork for practices - that are likely to reject them as patients because of their situation. Word gets around helping to suppress access to care to an even lower level. The good news is the insurance coverage. The bad news is the continued access barrier.

What Has ACA Done to Hospitals and Practices Serving Disadvantaged Patients?

Providers serving a disproportionate share of Medicare, Medicaid, low pay, and no pay patients once had significant special funding - before ACA killed it. Hospital boards for small hospitals and the few remaining small practice owners have to look realistically at the future - a future of declining payments, increasing regulation, and across the board cuts. The writing on the wall has closed dozens of facilities with dozens more closing each year. 

Sadly, many still point to the lack of Medicaid expansion as a reason for small practice and small hospital decline. Insufficient payments for Medicare, Medicaid, and ACA generated plans still result in small practice and small hospital decline.

Who Is Worst in Cherry-Picking - the Media, insurance corporations, biggest practices?

Cherry-picking works well for research studies and for insurance plans. Cherry picking works best for hospitals and practices that care for the most advantaged. Not only do they get the best paying insurance, they will get paid even more by value-based CMS payment designs. Forbes had an article today pointing out the value of "cherry picking" by cultivating the favor of all of the elite patients that they can get. 

God help the plans, practices, and hospitals serving those disadvantaged as they will be paid even less and deteriorate more - under ACA/CMS design.

You cannot overcome access to care barriers by health insurance expansio

because the plans and the payers fail to pay enough to primary care, mental health, and other office payment dependent (cognitive services) providers. 

ACA as implemented by CMS is killing off small practices and small hospitals - the ones where care is most needed. Where care is most needed is where Medicaid, Medicare, low pay, high deductible, and veteran populations are concentrated together in lower cost (poor quality) housing. 

The payers create the shortages, barriers to care, higher costs of delivery, and higher costs while impairing access.
When infrastructure falls apart, it is time to invest in infrastructure - not innovation, rearrangement, cost cutting, reorganization, consultation, and more research.

Recent Posts and References  

The Consequences of Innovation Procrastination - Delays in indicated care result in harm to patients. Distractions due to innovation result in harm to millions who need care delivery, not rearrangements, confusion, reorganization, and rapid change.
Feeling Bad About CMS Feeling Good
It takes more than a feeling to lead in health care. Health care design must work for Do No Harm rather than I Feel Good - especially when it comes to constant changes.

The Massive Failure that is Primary Care Payment
Like past policies, ACA did not address cognitive vs procedural to balance workforce but it did take on quality payment with costs and questionable benefit.

Lack of Accountability for Accountable Care
Health Care Who Is it Good For? Count the billions in corporate earnings and the millions in CEO salaries to see who wins and who loses 2010 to 2016 and beyond

Innovation Incapacitation
We are so focused on innovation that we cannot even take care of the basics - Commonwealth Foundation is supposed to be about access. A foundation truly focused upon the access to care foundation could be powerful in shaping needed change. But why does it promote innovations that cost more and divert front line workforce from being able to deliver health access? Why does Commonwealth consider access to insurance to be access to care?

Safety Net Must Sunset and Front Line Health Access Should Rise

Experimental Innovation or Basic Infrastructure? Wouldn't it be nice if we actually funded infrastructure and basics instead of trying to substitute innovation or other distractions?

For Better or For Worse in Quality - More for fewer and less for more - thus continues the new innovative designs - same as the old designs

Are We Moving Away from Achieving Value in Primary Care? - Quality is over 60% about the patient, situations, relationships and has very little to do with clinical intervention - but this does not prevent serious exaggerations of "so-called value."

Time for Quality in Quality Studies - The Best Studies from the best institutions and journals have led the nation astray in quality studies and we continue down this pathway.

Pressures Mount for ACA Reforms or Revisions - It has taken too long for critical voices to be heard about the consequences of experimentation plus change that is too quick, too costly, and impairs access to care. Compromise may be most specific to small practice and small hospital settings and those that they attempt to serve.

IOM Should Learn About Social Determinants Not Preach Them - Too many IOM studies fail basic research design tests and often for failing to understand important influences of health care outcomes - like social determinants and patient situations and relationships.

The Federal Cause of Shortage Areas and Access Barriers - It is the Federal Design for payment that shapes the breadth, depth, and locations of shortage areas. It is about concentrations of Medicaid and Medicare patients with lowest payment for health access by federal design.


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