Family Webicine

By Rod Moser, PA, PhD

Now that the Affordable Care Act has been upheld by the Supreme Court as government mandated “tax” and not just another government social program, up to 30 million more Americans may eventually be able to have (or be forced to buy) health insurance. The real question that comes to my mind is: what will these newly insured people do when they get insurance? Use it, of course.

People who have gone uninsured for many years may show up at medical offices with a laundry list of neglected health issues that they want managed…today. Granted, there may be many unfortunate people that will need a major tune-up or overhaul, but can our already-overburdened (and expensive) heath system handle it? There have been rumblings for years about the lack of primary care providers – the first people who are likely to face this onslaught of the formerly uninsured. Many will be evaluated at the primary care level but then referred for expensive diagnostic tests and/or specialty care, perhaps overburdening that tier as well.

I often encounter patients who demand tests, multiple prescription refills, and office surgeries (like mole removals) all at once. When I inform them that I could not possibly meet all of their requests in one 15-minute appointment they drop the insurance bomb on me.

“I am losing my health insurance at the end of the week, so I want to get as much out of it as I can.”

Similar visits often occur in January, when new insurances typically start, or really at any time of year when people get health coverage. California has millions of people receiving Medicaid (called MediCal in California). Because of unemployment, fractured families, disabilities, and other hardships, more and more people are being qualified. If the Affordable Care Act kicks in, I predict that there will be new waves of people searching for practices that are taking new patients.

Our medical group has a large population of MediCal patients. As a non-profit group, we try to do our share. Not all medical practices are so welcoming, since MediCal pays so poorly for health care services. I suspect the ACA patients may have similar low insurance reimbursements, perhaps so low that they may have problems finding practices that will share the government subsidy. When it costs a practice more to provide care and process claims then it is actually being reimbursed for, many will not accept those patients. If your standard office visit is $75 and a particular insurance pays $15, it does not compute. Many medical providers would rather give away care for FREE than to hassle with certain government-run insurance programs.

The ACA program is going to fine people who don’t get insurance, but according to what I have read, the fine will be about $90 on your income tax return. How in the world is that going to be a deterrent? I wonder if the government will be fining (taxing?) medical practices that choose not to accept ACA patients? They are already giving incentives, but unless those incentives compute and improve the bottom line, they will not work.

A prime example of insurance abuse in my opinion is the use of the Emergency Room for basic care. Currently, many patients on Medicaid will choose to use the ER so they (a) won’t have to find a practice that will take them as new patients, and (b) so they won’t have to wait for an appointment. If they went to a primary care office for the same care, it may cost the government (State and Federal) around $20 or so to provide that non-urgent care. If they show up at the ER that same care may cost a thousand dollars. Is that appropriate utilization of insurance that was provided to you for free?

Hospitals cannot legally turn away any patient because of the lack of insurance or financial resources or immigration status, so they end up giving away billions of dollars of free care every year. Some institutions feel that the ACA program will at least reimburse for some of these unreimbursed dollars. I am not so sure.

As I approach retirement, Social Security, and Medicare age, I wonder how all of this will impact me personally when I am no longer working. Soothsayers have been predicting that Social Security will run out of money. I have been paying into the Social Security system – called a (forced) contribution instead of a tax – for over 50 years and my financial planning is dependent on getting at least some of my “invested contributions” back. Seeing how the Social Security system has expanded since its inception, I am not surprised that the coffers are dwindling.

Medicare is not optional either, unless you are covered by another health insurance. I suspect out-of-pocket costs for that program will dramatically rise, impacting senior citizens on fixed incomes. Even now, though I am gainfully employed and insured by a billion-dollar health organization, my HMO health insurance is terrible. My out-of-pocket expenses for the last year were nearly $5000! Granted, I had a few surgeries during that time, but when I reviewed the charges, they were so inflated that I was shocked.

So, I remain skeptical of and ambivalent about the ACA program as it stands. Half the country is for it; half is against it. Right now, I am sharing the fence.