Health policy changes result in winners and losers. Any statements that imply universal benefit via a health policy change are misguided at best and deceptive at worst. An optimal health reform should result in improvements for populations that have been marginalized under previous designs. Obamacare has little chance of helping populations left behind and should set back care where needed for some time to come.

LoConc40 Demographics and Distributions or Lack Thereof

An examination of lowest physician concentration counties can help to understand why ACA did not help and why it hurts access in the 2621 counties with lowest physician concentrations (LowConc40 counties) that have 40 percent of the population, the 32% of the urban population and the 75% of the population most behind for decades of health policy designs. These are counties with 40% of the population but with deficits indicated by just 21% of active physicians, 23.5% of mental health providers, and 26% of nurse practitioners and physician assistants. Higher proportions of lowest paying insurance plans suppresse workforce and access. ACA did not improve plan payments or payments for the generalist and general specialty services most prevalent. ACA made regulation costs much worst instead of helping with productivity, efficiency, and gains in access. ACA to MACRA changes have marginalized team member support, distracted them from care, and decreased their productivity - by design.

Health Insurance Expansion Was a Poor Fit

From the start, the ACA reform result was questionable for these counties. These are counties with higher concentrations of Medicaid and Medicare patients, those with dual eligible plans, those in poverty including children, fixed income populations, disabled populations, older and oldest populations, Veterans, and those on Social Security and Food Stamps. There are more people with obesity, diabetes, smoking, lower health status and other markers of poor health and health outcomes.

The people clamoring for ACA claimed that health insurance access was associated with better outcomes. In actual fact, hundreds of variables indicating populations better off or left behind correlate with better insurance and better outcomes including the major factors shaping health outcomes - environments, situations, behaviors, and social determinants.

From the very start, the research was wrong, the assumptions were wrong, and the interventions were wrong. The designers were willing to overlook the potential damage to experiment on the American people. Since they are unwilling to accept the fact that people factors shape 60 - 70% of outcomes and clinical interventions shape only 10%, they chose the means to the end of clinical interventions via insurance expansion and digitalization. Not surprisingly they did not accomplish much. Even worse, there have been consequences where care is needed.

Why is it so hard to critically examine policies or research? Why do the positive studies continue to gain press and exaggeration? Why do access foundations continue to push policies and programs that impair access? Why do family medicine organizations promote Pay for Performance discriminations when these hurt family physicians, primary care, health access, and care where needed? Why do medical associations profit off of MACRA modules rather than fight the lack of evidence basis and the discrimation that is MACRA, or readmissions penalties? Why do family medicine leaders fail to support the 50% of members who are small and solo?

The failures of ACA have had numerous consequences and perhaps none as serious as those impacting care where needed. Examination reveals that ACA did not take on the most important reforms, the opportunity for reform was lost for a generation of workforce (30 - 35 class years), and health access has been worsened in the 2621 counties with lowest physician concentrations before, during, and after ACA design.

Cognitive/Office/Basic Services vs Procedural/Technical/Subspecialized

Reforms only come around every 20 years or so. When the few years of health reform time come around, it is important to choose the right reforms to address. If this is missed, an entire generation of physician workforce (30 - 35 class years) will be shaped in ways that have consequences - such as inadequate access to basic services.

There is one payment reform most necessary for every single population and place with deficits of workforce. Deficits of workforce do not exist in a vacuum. Deficits are shaped by the health policy design such as

A design that concentrates the most lines of revenue and the highest reimbursements in each line in just a few places and populations creates deficits for most people - such as 45% of physicians in 1% of the land area in 1100 zip codes with just 10% of the population (and shrinking).
A design that shapes deficits where Medicaid, Medicare, Veteran, and high deductible patients are concentrated
A design that pays the least where patients most need care and the most where patients have the most access to care.
A design that pays the least for the most prevalent services such as primary care with 55% of encounters and that pays the most for the few services of highest cost delivered in just a few locations.
Medicaid As Savior or Betrayer of Access

These populations and places of lowest concentrations depend entirely upon the most prevalent services such as primary care, office, and basic services. These are the services provided by generalists and general surgical specialties - the workforce that is over 70% of the physicians in 2621 Low40 counties. Every place of need has the greatest needs for generalists and general types of specialties. These are, of course, the specialties most denied by current payment design.

The most needed reform for 2010 as in past periods has remained higher payments for the basic services with lower payments for the Procedural/Technical. This has also been the recommendation of physicians and panels of experts. This was not even a consideration for the innovative designers that shaped the 2010 reforms.

Obamacare never took on the most important reform regarding the 100 million people in most need of care. They never understood that insurance expansion of lowest paying plans is incapable of restoring access whereas increases in the basic payments most dominant where care is most needed can expand access to care for those with or without insurance.

Cognitive, basic, office services have remained lowest. This is the least support for over 70% of the workforce for 2621 lowest concentration counties. Generalists and general surgical specialties are prevented by payment design. With increased costs of delivery, workforce where needed is worse off. The design discriminates against those stuck with lowest paying plans and also those with better insurance plans that live where concentrations of Medicaid, Medicare, Veterans, and high deductible plan patients reside. Six Degrees of Payment Discrimination

High Deductible Plans

Rural locations have had decades of experience regarding high deductible/catastrophic care plans. It is interesting that these plans were not exposed from the start as a likely choice of lower income people. Not surprisingly these plans are least supportive for local basic services and primary care. Catastrophic care insurance hurts local care more. Where lower and lowest income people are found, decisions are made by government and by local people help make local care deficits greater.

Even more tragic are the children and adults that present for care too late.

It is interesting to reflect upon the trauma caused by designs and designers. The designers want to micromanaging physicians into preventive behaviors, but the designers exhibit no sense of preventive behavior themselves. Changing physician behavior has been accomplished - the wrong way to lower productivity, burnout, withdrawal, closures, administration, and delivery of services that are better paid by US designs.

Quality Metrics Focus Failure Before and After ACA

Other than insurance expansion, the second major focus of ACA was forcing the nation to better health quality. This attempt was being made while claiming to move toward lower costs. Anyone with common sense or a basic understanding of Deming could predict what has happened - and it has. Quality metrics and health outcomes have not improved.

Even worse, the nation spends massive tens of billions more each year for no change in quality. This is the opposite of value. Those who most promote value have been the ones that have been marginalizing value.

The quality gurus have long had their problems. Rural health has long been marginalized with lower payment and yet has often measured up with same outcomes - and often despite more challenging populations. This is value that the quality gurus have failed to comprehend. This is not surprising given the limitations of their perspective - limited to Medicare and higher concentration areas of the country.

Even worse, there is really not a solid scientific evidence basis for the various pay for performance schemes other than discrimination against the providers attempting to care for the populations and places behind by design.

Basic Health Access: Prevent MACRA to Do No Harm

Robert Wood Johnson demonstrated little improvement despite 300 million invested in quality improvement focus over 10 years

The Quality of Outpatient Care Delivered to Adults in the United States, 2002 to 2013

The Devaluation of The Doctor and Its Effect on The American People by Dr. Alaina George

ACA Compromised Primary Care for Medicaid Patients By Design

Medicaid patients are exactly in the right places to lead to important health, economic, and other reforms. Medicaid patients are concentrated where physician concentrations and health care payments are lowest. Jobs and challenging situations and environments are more prevalent around concentrations of Medicaid. A boost in Medicaid to primary care (especially family practice

ACA failed primary care where needed by failure to address low payments. The places lowest in payment remain too low. The temporary 2 year boost in primary care payments was a questionable design from the start. If primary care was valued, it would have been permanently increased with regular increases in payment to work toward a more equitable payment - one that would have resulted in a balanced workforce (cognitive vs procedural).

There is no chance for a balanced workforce without true payment reform.

The designers left the usual populations behind in this basic health access area, one of their most important need areas. This is also a route to increased jobs, cash flow, and economics where jobs, cash flow, and economics suffer most.

The cost of switching to higher payment and then back to lower payment is a substantial administrative cost. It also is likely to have stimulated practice closures, retirements, sell outs, physician burnout, and practices not accepting Medicaid and Medicare (no matter what they say). The barriers were increased for patients in most need of care - by design.

Cherry Pickers Rewarded, Providers for Complex Patients Penalized

The announcements of insurance companies bowing out where patients are too costly are appearing on a regular bases. The plans that have the least complex, lowest cost patients are doing very well. It is not a surprise that insurance companies dump the most costly in favor of the least costly and most profitable. In Minnesota the Blues dropped out of individual plans and none of the other insurers wanted them. The state had to step in to avert a crisis. Aetna joined United Health Care in dropping many plans.

ACOs that were paid more and that have had decades to shaped the easiest and most profitable populations are doing well. The models for ACOs such as Kaiser already had the right organization, the right information systems, the right workforce, and the right patients to do well and were paid the most. Those paid less, newest, and caring for the most challenging populations have had greater difficulty.

Practices that are largest, least personal, and least local are doing well. Small practices and hospitals that are most personal, most local, and most essential for care are not doing well. In many ways, ACA forced the move to bigger.

Cherry picking is the only way to address payment policies based on Pay for Performance. Readmission penalties penalize the hospitals where needed as seen in 3% penalty rates for rural, 5% average, 9% rural, and 14% for hospitals in the Low40 counties where the health, health status, workforce, and payments are lowest. Hong and over a dozen others have exposed pay for performance paying less where providers faced more complex patients with lesser resources.

Penalties for those facing the most challenging patient care situations represent the worst possible health policy design. Inequality or errors by providers impact hundreds. Inequality by design impacts tens of millions directly and even more indirectly. It is important to remember

Numerous assumptions have resulted in worsening inequities while the designers cling to their assumptions of cost cutting or quality improvement or medical error - while driving costs higher, worsening quality, distracting those who deliver care, decreasing productivity, and abusing populations in most need of care and those who care for them.

Assumption of Bigger and Higher Volume is better - Studies actually demonstrate variations in the volume to "quality" relationship. Studies have demonstrated that smaller practices and hospitals can perform the same and sometimes better in areas such as preventable admissions and basic services.
Published studies have branded smaller hospitals as lesser in quality but have failed to control for lower payment, greater patient population challenges, deficits of access/workforce, lesser resources, lower social determinants, and numerous other differences.

When designers do not value the providers that continue to provide care despite the challenges, you have to question the values of the designers.Value Failure By Those Who Promote Value

Why Do So Many Claim So Many Benefits from ACA?

Cost cutting - Cost cutting via designs, spreadsheets, copays, denials of services, lower payments may look good in the short term, but pent up demand remains a problem. Even with expansion of insurance, access is about the workforce to deliver care - still suppressed by design. When primary care is suppressed by cost cutting, expansion of insurance coverage can be a big problem for costs as patients go to more costly care. With insufficient primary care and insurance requirements to see primary care for referrals, there are even more consequences.
Lack of Awareness - The ACA focus was on other areas such as insurance reform, new insurance, shifting the risk to providers (ACO), cost cutting, fighting political battles, and state to state Medicaid expansion. Those providing critical reviews of ACA were ignored or were branded as politically motivated. The consequences have been suppressed. Foundations supposedly supportive for access continue to publish and promote positive findings. Journals do much the same, perhaps in reaction to the political situation (as seen now in the news media).
More dollars to Community Health Centers from ACA and MACRA should help - This is not exactly true as ACA and MACRA vastly increased the cost of delivery. Also Primary Care Medical Home has been pushed, a cost of $105,000 more per year for each primary care physician. The route to increased access is more team members in more places, not fewer and less supported team members with dollars sent elsewhere. Also recruitment and retention and locums and turnover costs continue to skyrocket at the local, state, and national level.