A Two-Tiered Health Care System Is Coming Faster Than You Think

Forbes reports:

“Get ready for two different health care systems. In one, patients will be able to schedule a doctor’s appointment in one or two days. In the other, patients will wait weeks or even months – with access problems similar to those in Canada. Patients who get health insurance in the new (Obamacare) exchanges will be in the lower tier. In fact, they may have even greater access problems than patients on Medicaid.

The American Action Forum estimates that as many as 214,524 US physicians will not be participating in any plans sold in the exchanges. In some cases that is because the doctors are unwilling to see patients with “Obamacare insurance.” In other cases they have been excluded from the narrow networks that exchange plans offer. The estimate is based on a May survey by the Medical Group Management Association (MGMA), a trade group comprised of multi-physician medical practices.

In Massachusetts, patients who obtained subsidized insurance though the (Romney care exchange) are having greater difficulty seeing doctors than Medicaid patients do. The same may be true under Obamacare. Among the problems doctors are experiencing:

  1. Fees paid by the plans sold in the exchanges are often set at Medicaid rates or a little bit above Medicaid (although in some cases the plans pay less than what Medicaid pays).
  2. Because of high deductibles, insurance isn’t paying most of the bills any way; and doctors often have difficulty collecting from the patients because of their low-incomes.
  3. Compared to traditional commercial insurance, doctors have more paper work problems with insurance obtained in the exchanges (verifying eligibility, determining networks, etc.).
  4. Another worry is that patients who quit paying premiums have a 90 day grace period during which they continue to be “insured”– for the first 30 days, the insurer is liable; but for the next 60 days the provider is at risk for the insurer’s share of the bill.

Only 15 percent of the doctors surveyed think that Obamacare will have a “favorable” or “very favorable” impact on their practice.

How is this affecting patients? According to a report in USA Today:

  • Shawn Smith of Seymour, Indiana, spent about five months trying to find a primary care doctor on the network who would take her with a new, subsidized silver-level insurance plan.
  • Jon Fougner, a recent Yale Law School graduate, sued Empire Blue Cross because he couldn’t find a primary care doctor who would see him after calling 30 doctor’s offices.

These are examples of a much broader problem that is going to affect all of us. As I explained previously, Obamacare greatly expands the demand for care, while doing nothing about supply. As patients try to take advantage of newly acquired insurance benefits, they will find that doctors can’t supply all those benefits. As a result, health care will have to be rationed and the most likely way that will happen is rationing by waiting.

Waiting times are going to be especially lengthy for anyone in a health insurance plan that pays providers below-market fees. In addition to those with “Obamacare insurance,” that includes the elderly and the disabled on Medicare and low-income families on Medicaid. Increasingly they will find they are financially less desirable to providers than other patients. That means they will be pushed to the end of the waiting lines.

Those who can afford to will find a way to get to the head of the line. For a little less than $2,000 a year, for example, seniors on Medicare can contract with a concierge doctor. These doctors promise prompt access to care and usually talk with their patients by telephone and email. They serve as an advocate for their patients, in much the same way as an attorney is an advocate for his client.

But every time a doctor becomes a concierge doctor, they leave an old practice serving about 2,500 patients and take only about 500 patients into the concierge practice. That means about 2,000 patients now must find a new physician.

Because the two tiers of health care will compete with each other for resources, the growth of the first tier will make rationing by waiting even more pronounced in the second tier. As a result, waiting times in the second tier may look more and more like those in Canada.