ObamaCare Clusterfuck: “Medical Homelessness” in California

By Lambert Strether of Corrente.

KPIX (CBS local) in San Francisco:

While open enrollment for coverage under the Affordable Care Act is closed, many of the newly insured are finding they can’t find doctors, landing them into a state described as “medical homelessness.”

Rotacare, a free clinic for the uninsured in Mountain View, is dealing with the problem firsthand.

Mirella Nguyen works at the clinic said staffers dutifully helped uninsured clients sign up for Obamacare[1] so they would no longer need the free clinic.

But months later, the clinic’s former patients are coming back to the clinic begging for help. “They’re coming back to us now and saying I can’t find a doctor, “said Nguyen.

Thinn Ong was thrilled to qualify for a subsidy on the health care exchange. She is paying $200 a month in premiums. But the single mother of two is asking, what for?

“Yeah, I sign it. I got it. But where’s my doctor? Who’s my doctor? I don’t know,” said a frustrated Ong.

Nguyen said the newly insured patients checked the physicians’ lists they were provided and were told they weren’t accepting new patients or they did not participate in the plan.

Now, to be fair, “many” is not a number. But since when have we gotten good numbers on ObamaCare from the administration? And since California is a Democratic state, top to bottom, we’re not likely to get any good numbers from Covered California, either.

Dr. Kevin Grumbach of UCSF called the phenomenon “medical homelessness,” where patients are caught adrift in a system woefully short of primary care doctors.

“Insurance coverage is a necessary but not a sufficient condition to assure that people get access to care when they need it,” Grumbach said.

Those who can’t find a doctor are supposed to lodge a complaint with state regulators, who have been denying the existence of a doctor shortage for months.

Meanwhile, the sick and insured can’t get appointments.

“What good is coverage if you can’t use it?” Nguyen said.

Experts said the magnitude of the problem is growing, and will soon be felt by all Californians. But those on the front lines, like the free clinic, are feeling it first.

More than 3 million Californians are newly insured. At the same time, a third of our primary care doctors are set to retire.

Well, of course they’re going to retire. ObamaCare’s ACOs are just HMOs all over again. And who wants to go in debt for an M.D. to end up as an employee in a hospital, with some administrative drone making all the medical decisions? I don’t think so.

NOTE [1] The latest category of good-hearted people Obama has betrayed.

NOTE Now that the “ZOMG!!! 8 million kinda sorta!!!” euphoria is over, we are coming to find out how ObamaCare actually delivers care. This story will be the first of many.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.

91 comments

  1. CB

    Brass tacks: health care insurance is not health care. There, isn’t that simple? 2,000 plus pages to legislate yet another (mandatory) rent extraction scheme. Leave no stone unturned.

    1. Jim Haygood

      “What good is coverage if you can’t use it?” Nguyen said.

      Good for whom? Obamacare is good for the health insurance providers who wrote it.

      And Max Baucus, whose Senate committee took the lead in drafting it, got hisself a nice sinecure as ambassador to China … not to mention his free health care.

      ‘I feel good …’

      1. kmurp

        Our local non profit insurer lost 45 million last year so they aren’t doing so well under this.

      2. jrs

        Even then if you are actually paying for insurance and can’t actually use it anywhere, it seems inevitable more people will opt to take the penalty rather than keep flushing money down the tiolet (so watch those numbers of insured drop). Of course Medicaid and the like are different as it’s a full subsidy.

    2. Jagger

      Couldn’t have said it any better and you even managed to get in the rent extraction aspect. Just 3 sentences and you summed up Obamacare beautifully.

  2. Middle Seaman

    This post may point to a serious problem, but it doesn’t provide sufficient information to show that. What does it mean “can’t find a doc?” There are many possibilities: – not enough docs in a give geographical location. – docs don’t accept low level Obamacare plans. – Plan allows insufficient number of docs.

    Without numbers and details, the point made by the post doesn’t hit the target.

    1. Yves Smith

      With all due respect, I beg to differ.

      Yes, I agree the lack of numbers is a problem, but Lambert concedes that this is an issue, and frankly, no one is ever going to have good numbers. This isn’t something that will ever be tracked in a systematic way.

      But I don’t agree with your “not enough doctors” issue, save in rural locations, which is not what the underlying news story is discussing. If there was a doctor shortage, you’d see it in long waiting times to see a doctor, which is not what is being reported. “I can’t find a doctor” says narrow networks, as in no one with a reasonable driving/public transportation distance.

      1. CB

        And docs are very mal-distributed. Too many in some populous and monied areas, not enough in the contrary. More market distributions gone disastrous.

      2. Eric Sabety

        You hit it on the head. The funds are being channeled through health care organizations that contract with doctors with abysmally low payment rates, extensive and expensive requirements, and restriction of networks so they can negotiate rates downward. They exclude most doctors so the few they contract with will figure they will make up in volume what they are losing on the contract……meaning the patient gets less attention. The rent collectors triumph and many doctors just can’t deal with it…..especially solo or small group practitioners. It is a total waste of time and effort from the doctor standpoint. You mentioned EMRs in another piece…..another piece of the puzzle…….doctors generally, not all, but most went into medicine to help people, not insurance or HMO executives. There are plenty of doctors willing to take patients at a fair rate with fair support.

        1. Eric Sabety

          It is kind of like the lettuce growers with their horror stories of rotting crops because no American will do the work. Yup no American is going to pick lettuce for slave wages. Now we have the doctor horror story……Yup no doctor is going to treat patients with all the liabilities and issues for dirt wages. The only doctors that prosper are the ones cheating the system…….a great incentive for better medical behavior.

    2. diptherio

      “Nguyen said the newly insured patients checked the physicians’ lists they were provided and were told they weren’t accepting new patients or they did not participate in the plan.”

      That’s the problem. You sign up for insurance and are provided with a list of doctors. You call them and find out that they’re already full up, or they’re not actually on the plan. The problem here is that the ACA is a POS, poorly thought out bit of legislation. Seeing as how we’re all required to participate, don’t you think they should have had this figured out before they started signing people up?

      Face it, the Administration doesn’t give two sh*ts about providing health care to the poor. All this was ever about was finding an excuse to hand a bunch of gubmint money to the health insurers. If some of us po’ folk get crushed in the process–oh well.

      1. kmurp

        The ACA did provide for a huge Medicaid expansion, which is how most poor are getting health insurance now.

        1. jrs

          Or not getting it, I suspect (ok I guess they are getting health insurance just not health care).

          1. kmurp

            In my community there are quite a few resources for Medicaid patients, especially primary care. As numbers increase though, I imagine access to private practice specialists could be a problem.

        2. marym

          Medicaid is extensively provided through managed care organizations, so the issues of handing money to insurance companies, and narrow networks are applicable to Medicaid as well.

        3. Lambert Strether Post author

          To me, the essence of ObamaCare is the marketplace (since IMNSHO that’s the template for future “market state” rollouts of the delivery of public services).

          So, why not unbundle Medicaid expansion from the rest of ObamaCare?

    3. Cocomaan

      As Lambert says, numbers aren’t being provided accurately, but the legislation is still being called a success. At the same time, any criticism is met with “we need numbers”.

      See the problem there?

      1. OpenThePodBayDoorsHAL

        We could use a lot fewer “successes”: Iraq, Afghanistan, Libya, Egypt, Ukraine, Dodd-Frank, War on Drugs, ACA, Asia pivot/TPP,..
        Incompetence all around. Question needs to be asked: what if ANY of the above had succeeded? Were we on the right policy track in the first place? I guess it depends who “we” is, clearly that term applies to just the tiniest percentage of the population anymore in America. There’s the real problem: “We” should be defined as at least 51% of the citizens of the nation, from whom the government derives its power in the first place. N’est-ce pas?

  3. LAS

    America has been under-producing primary care physicians for many years prior to ACA. The ACA actually has additional titles/sections in it designed to encourage more primary care physicians and to mitigate the long-standing shortage in primary care and these began to be implemented several years ago for just this kind of projected issue. Is the ACA a fully adequate solution? No, but it is a step in the right direction. Our greatest threat is Congress refusing to fund these parts of the ACA as time advances.

    BTW, medical literature shows that public health is not improved one wit by proliferation of specialist physicians per unit population, but it is positively impacted by number of primary care physicians. Be that as it may, the US medical market produces too many specialists –because that is how doctors maximize their profit (and increase your medical costs).

    BTW, Grumbach has written some excellent papers/books on healthcare policy. He’s an advocate of government intervention with a fine sense of all the many-sided arguments various stakeholders make.

    1. diptherio

      Yes, it’s long been known that we have a shortage of GPs. Maybe that’s a problem that should have been dealt with before mandating that everyone sign up for narrow-network health insurance. Whatever encouragements to GPs they’ve been providing have obviously not been effective enough to ensure that we have enough to go around. Did they (the Administration, the insurance companies) not know this before they started taking people’s money, or did they just not care? Methinks its the latter.

      The ACA is not a step in the right direction (unless you’re a pharmaceutical company), it’s a way of making people pay for a service that is not available. That’s a great deal, if you’re the one receiving the payment.

      “Oh, oh, but we’re working on making the service available. If only those evil republicans don’t get in the way, maybe in X years will have enough GPs so that everyone can find a doctor.” Meanwhile, we’re all required to pay up now. Puh-leez.

      1. jrs

        Of course it doesn’t help (probably greatly inflates demands for GPs) that you have to see a GP even if you really need a specialist, as you have to get past the HMO gatekeepers, which forbid seeing a specialist until the GP oks it. PPOs avoid this of course, but HMOs are being pushed on us.

        1. Yves Smith

          Agreed completely. The old policies (indemnity plans, and there are still some legacy policies around) don’t have that feature. Why should you see a GP if you have back pain? You should go directly to an orthopedist.

          And even sillier here, GPs don’t do certain routine procedures that ARE done in other countries. For instance, in Oz, a GP can do a Pap smear. Here, women have to see a gynecologist for that, so you pay for a big ticket specialist visit when all you wanted was one test.

            1. Yves Smith

              I’ve never had a primary care physician in NYC willing to do one. May be a regional difference.

          1. hunkerdown

            Cash prices, acyclovir cream for cold sores:

            Costco Pharmacy: 5g tube $633 Rx required
            Random foreign web pharmacy, representative: 2 x 2g tube $50 OTC incl. air mail
            Random Amazon seller in Canada who might or might not ship to the US: 5g tube $10 +s/h

            The Permission Economy is creating a terrible world.

            1. direction

              Truly! I over worked my shoulder. Need physical therapy. Why do I have to go to a doctor for permission? I am a reasonably intelligent person and I self diagnose my body more accurately than, say, my car. I waste time and spend twice as much going to sit in a sterilized office to ask someone for a damn prescription. Pharmacists go to exhaustive training, why can’t I go directly to them? and if I kill myself it’s my own damn problem, obviously. Let me sign a liability waiver for that.

          2. Eric Sabety

            Why do you need to see an orthopedist for generic back pain? The problem with GPs is simple…..they get paid crappy wages and patients, as well, are not satisfied with a GP telling them there is no magic treatment for back ache.

          3. H. Alexander Ivey

            Ok, here I am, piling on, commenting on something that is not related to the post – but I’m director of a chiropractic clinic so I have some economic interest here (it IS an economics blog!). Why not see a chiropractor for generic back pain and let them recommend a specialist if need be.

              1. direction

                Chiropractors and dentists seem to see patients without the need for GP referrals. PTs and other specialist won’t give you the time of day without a doctor’s order, but chiropractors do. and planned parenthood for a good dose of socialized medicine. They’re often pretty hip, and the pap smear is free.

              1. Yves Smith

                Wow, in the Communist state of NY, all insurance plans must cover 15 chiropractic visits in a year.

          4. John Yard

            Suggestion : Initial screening be done by a nurse practitioner. He/she will be able to take care of the great majority of medical issues. Next escalation to a GP. Final escalation of care to a specialist. The initial NP/GP triage can be done the same visit.
            I recently spoke with a NP who worked for GPs who adamantly opposed adding NPs lest it cut into their workload and billing.

    2. tongorad

      A half-assed, incremental “step in the right direction” is also by definition a step in the wrong direction. A misdirection in other words, designed and intended to block real problem solving.
      Gamesmanship, and nothing more. Except they’re playing with people’s very lives.

    3. NotTimothyGeithner

      For the Obots, this is “fixing later” promises were stupid. People affected negatively by this will be voting against the Democrats because you put branding ahead of quality. Congratulation.

    4. Thor's Hammer

      The USA has 1/7 as many doctors per capita as Cuba. That is all you really need to know about what the political/economic system values—-.

        1. kmurp

          Nevermind, I found a Kaiser site that lists physicians/10,000. Looks like the US is similar to England, Canada and Japan but less than many western European nations.

  4. Tim Olesnicky

    All I know is this — I have just completed using “ObamaCare” for vision, dental and a health check up and everything worked like a charm. And I could not be happier with the system — although I am sure improvements can and will be made.

    Stats:
    51 year old male
    Good health
    Umemployed (with BSME and MBA)
    Location=NJ
    ___________________________

    Story:
    I enrolled via the NJ Medicaid website back in November 2013, as I tried the ACA site and it was such a mess I knew there would be problems.

    Had to to several back and forths with the State on documentation. Some would probably complain and find this annoying. As for me — for free healthcare — I hardly found it annoying at all.

    Finally received all my docs, cards, enrollment info, etc etc etc for a April 1st start date (although coverage was back dated to Jan 1, 2014).

    Made appoints with optometrist (I had never been to get one my entire life), dentist (it’s been 6 years since I had dental coverage), and doctor PCP (primary care phys, that I was assigned, although I am free to change my PCP).

    All were in walking distance from my house!

    Result
    _____________________

    Everything went batter than I could have ever imagined!

    Got my eyes checked. They were “a weak” 20/20, but I needed a pair of reading glasses. Received them in 2 weeks FREE!

    Went to the dentist. Checked out OK, but he recommended a nightguard to prevent teeth grinding (probably due to reading ACA bashing garbage like this all day). Nightguard ordered — FREE!

    Went to PCP for full healthcheck. Everything looks good — see ya in a year. FREE!

    So enough with the whining and complaining already — and this is in NJ for crying out loud!

    1. Lambert Strether Post author

      In general, ObamaCare plans do not cover dental. So your experience is, ipso facto, not representative of the ObamaCare experience. So I, and NJ readers, would be interested in hearing more detail about exactly which plan you have.

      However, I’m pleased at your good luck. Why do you characterize a wish for all, equally, to have luck as good as yours as “whining and complaining”?

      1. kmurp

        I think the biggest success in Obamacare has been the increase in medicaid enrollment (at least in states like NY). I don’t know how it’s all going to be paid for though and it’s unknown how low medicaid reimbursement will affect hospital solvency.

      2. CB

        “I enrolled via the NJ Medicaid website back in November 2013, as I tried the ACA site and it was such a mess I knew there would be problems.”

        Tim Olesnicky is not in an ACA private insurance plan, he’s on Medicaid. Different animal, altho he seems to assume it’s all the same thing.

        1. Lambert Strether Post author

          Thanks, missed this on my hasty first reading.

          Again, then, why not unbundle the Medicaid expansion from ObamaCare? (Not advocating this, I just don’t see the logic of the bundling, not being Rube Goldberg.)

          1. NotTimothyGeithner

            I don’t believe Rube Goldberg would either, but I imagine he could have retired working on nothing but ACA cartoons.

          2. CB

            This discussion misses another point: what congress giveth congress can taketh away, as anyone who was cut off from UI or has reduced SNAP and LIHEAP knows. In future, when Tim Olesnicky wants appointments, he may find fewer providers and reduced benefits. It’s been known to happen. In fact, if the current congressional trajectory continues, I’ll bet on it.

            We’ll live, we’ll see, but I’m not changing my opinion of ACA, and forced Medicaid. Too easy to label it welfare and cut the subsidies and the benefits. A program for the poor soon becomes a poor program.

            My guess is ACA has delayed single payer by at least 20 yrs. Evil to them who do evil.

        2. human

          His “free” care will be paid for by his estate, if there is anything to claw back, ignoring the fact that nothing is free.

          1. CB

            Actually, back when I was buying treasuries, there was a free lunch for small but worthy potatoes like me: the big buyers paid the costs of the auctions, I rode free on their fees. Don’t know about now, haven’t bought treasuries in yrs. Maybe Yves knows?

      3. Carla

        I think Medicaid includes some routine dental care, because of course dental problems can cause systemic infections that sometimes are fatal. It would be really great if Medicare covered dental. And if we can get New, Improved Medicare for All before the existing Medicare program is completely privatized and destroyed, then that could cover at least routine dental also. Whoopee!!! That would be fabulous!

        1. cripes

          Unfortunately, any dental care once covered under Medicaid (minimal, cleaning, filling, pulling) is gone now, at least in Illinois, and probably elsewhere, too. Kidcare still covers some ghetto dental work if you can find a dentist, and only for children 19-under, from families meeting low-low-low income criteria. Think TANF/welfare.

          In the meantime, much is happening to privatize medicaid altogether, selling it off wholesale to “health” insurance companies, eager to cash in on a projected 900 billion (over ten years) dollar market and jack up share prices! Usual administrative fees applicable, past performance (none) is no indication of future performance.

    2. kareninca

      So Tim, Ms. Nuguyen, who cannot actually obtain medical care for herself or her children, despite paying Obamacare premiums, should stop “whining and complaining.” Your response is just disgusting. YOU are getting great care for free (or so you say), and so others who suffer should just shut up.

      You say that you enrolled “through the NJ Medicaid website”, but you imply that you have Obamacare. No, you have Medicaid. People who have low/no income (you say you are unemployed) are NOT ALLOWED to buy ACA policies; they are forced onto Medicaid.

      So, you are a 51 y.o. on Medicaid in NJ. Congrats; if you stay on past age 55 you can kiss your estate goodbye.

      1. jrs

        The estate clawback is a scam, but I suspect a lot of people just don’t care. They may own little to begin with (and can it be used for debts? how many people have positive net worth afterall?), and even if they do if one actually lives to a ripe old age the chances of anything not being taken for end of life care aren’t good. End of life care decimates “estates” And of course not everyone has anyone to will an estate to anyway.

        So while it’s a scam to gut some of the inheritence of the 99%, estates are mostly rich people talk anyway. There are already a dozen other scams for the 99s to die broke including nursing homes/end of life care.

        1. kareninca

          Boy, jrs, you sure sound like a hopeless, dispirited peasant. I am guessing that you don’t have kids. I don’t either, but I can tell you that people who do have kids, care very much indeed that if they are on Medicaid past age 55, their estate will be clawed back. It is a huge issue to them, no matter how measly their estate is.

          I have a relative in Indiana right now who is frantically trying to get back home from the rehab facility, so that she won’t lose her house in an estate clawback. It is her only asset; it is worth about 100k. Yes, she is in her 70s; yes she will probably lose it and have no estate to pass on to her kids; this upsets her enormously. I cannot even imagine how berserk someone who is 55 who has kids in their late teens would be, realizing that they could never leave them anything!!! That no matter what job they got, or what small business they started, they could never leave their kids a penny.

  5. LAS

    On April 9 or thereabouts, there was a Senate committee hearing on healthcare workforce issues and testimony from various primary care physicians and community health providers. These persons paint a picture of primary care and community health services being underfunded and under-supported considered their role. The Congressional gov. accounting office also reports in this hearing and (erroneously IMO) criticizes another federal agency as not being timely in its estimates of physician workforce, but actually the figures are on their website in “charts” – which is why I’m puzzled by the accusation. I’m wondering if the GAO is being infected by political pressure.

    The hearing and prepared papers are accessible at the link below.

    http://www.help.senate.gov/hearings/hearing/?id=5ab814ee-5056-a032-5231-08baebc7c8cf&utm_source=Master+List&utm_campaign=62f8c9f402-NP_Residency_Testimony&utm_medium=email&utm_term=0_e80a08c624-62f8c9f402-214724265

  6. jjmacjohnson

    Hopefully this will help make wealthy doctors understand the plight the rest of working america is in and perhaps join the fight rather than country club.

  7. Chromex

    I think the studies that talk about or show things about “public health” are of little interest to individuals. For individuals , the question is , can I find a doctor that my policy will pay enough for so that I am not bankrupted by an appendectomy. This means individuals must take into account, under the current “for profit”system, premiums, copays and deductibles for covered “services’ and actual bills for “uncovered” services, and a judgment involving the percentage of each that they are likely to face in a given year.
    IF “public education” is a right, and offered “free’ to individuals, how much more critical is health care? The insurance model just offers rent extraction coded as narrow networks, premiums, copays, deductibles and the ever growing “not covered” category. More doctors solves exactly none of this. ( Before an ACA defender can reply with the canard that the ACA expanded services, I wish to point out that it left untouched “drug formularies”- another code for rent extraction- and other balkanized services and that the public had no input in what was expanded. I submit that “pediatric dental” to give one example is less useful than expanded drug formularies for mental health to give another),
    In order for “healthcare ” to work in this country, the insurance model has to be abandoned. “Stakeholders” who wish to resist this may eventually be looking at a different sort of stake.
    I think we can all agree that it is not in the public interest for citizens to face financial ruin due to a cancer diagnosis or a bad appendix. The ACA, which I find an abomination, cannot be salvaged by arguments talking in glib generalities. This does not mean that I wish the US would go to a “market” solution or that I found the previous system to be in the public interest. But the ACA is a step in the wrong direction. As an attorney and a business CEO, I am seeing the beginnings of great human wreckage due to the ACA that will not redound to the Democrats benefit in coming years, regardless of sign up targets. I have abandoned both parties as i suspect most of us will be doing in the coming decades.
    Hearings and papers are meaningless to individuals caught in the spiders web of “health insurance”. The sooner the concept that insurers can provide care or should control its distribution is scrapped, the better.

    1. mellon

      California was the birthplace in the US of capitation, and its almost entirely capitated. Capitation leads to low quality health care, IMO. It is basically a system where the medical group practices get a fixed amount of money a month for each patient. They then can bank the whole amount, or deliver some care, but that care comes right out of their income. Obviously, its in the doctors interest to take only healthy patients and to encourage patients who get sick to go elsewhere. Also, I think they get some kind of penalty if they diagnose a sick patient because in California, sick people in the past often had to pretend they were uninsured and go to a different doctor in a different city (or Mexico) and pay cash to get a diagnosis. Then they can get treated early for a disease like cancer and survive, when before it would only be treated when it became undeniable, leading to the insurer only having to pay for palliative care (painkillers and hospice for the final days)

      Stopping these out of network honest diagnoses is the real reason they want more EMRs.

    2. Jimmy

      Accurate thinking on Obama’s gift to the insurance companies. I note the new attack on the VA System and suspect it’s motivated by the same folks. The VA System works pretty well, deals with an aging and beat up clientele, and does it better than most private hospitals at about 1/3 the cost. The same folks who wrote Obama Care are very interested in getting rid of the VA system, when it should be a baseline for all healthcare.

  8. Katniss Everdeen

    Lots of interesting stuff here, of the “OK, what’s next?” kind.

    “Thinn Ong was thrilled to qualify for a subsidy on the health care exchange. She is paying $200 a month in premiums. But the single mother of two is asking, what for?”

    So, unable to find a doctor, does Ong keep paying monthly? I’d say no.

    But the insurance company is being paid a subsidy on her behalf. What do they do? Do they cancel her policy, report it to the feds and return/refuse any further subsidy money paid on her behalf? Again, I’d say no.

    Does her policy remain “in force” as long as partial payment is being made? I’d imagine Ong wouldn’t think so, and would probably not be making any appointments for her “free” colonoscopy. So, the insurance company wouldn’t be handling any “claims” on her behalf. Do they just keep accepting the government payments and sending her monthly statements that go unpaid, having a pretty good idea that they’ll never be called to account?

    Under these circumstances, could she be sent to collections for the unpaid premiums?

    And what happens at tax time? Is she fined? Is she responsible for any subsidies paid on her behalf? Supposedly the “bulk payment” for subsidies is an accounting nightmare. If she is deemed “liable,” would it even be possible to compel the insurance company to return any money erroneously accepted on her behalf?

    These are just a few of the things that popped into my head when I read the post. Poor Ong. She never should have let herself get conned into entering “the system.”

    1. Jody

      If Ong is having her premiums automatically deducted from her checking account, she’s probably still paying.

      How do you cancel an insurance policy like that? The only way it seems to me is to close that checking account and open up a new one. THEN, when the debit hits the closed account, she’ll probably be turned over to collections.

      Buttle/Tuttle. It’s every bit as bad as anything in the movie “Brazil”

  9. ambrit

    Friends;
    Around here, in the Deep South, at least one doctor I have knowledge of has gone to the Private Network type of practice. You pay him a monthly retainer to keep him as your doctor. Once he comes up with enough “enrollees” he closes the book. That’s the pure Capitalist form of health “care.” The other would be the “Barefoot Doctors” of the late, lamented Emperor Mao. A s— load of basic medical complaints can be handled by RN’s or NP’s. Without the add-ons favoured by Corporatized Medicine. A third possibility, given the expense of a university education today, would be some form of “public service” in exchange for debt forgiveness. Say, you do so many hours a year in designated “medical crisis zones” as your public service. A mixed economy of medical services provision. Wasn’t National Health somewhat like that? (Feedback about how well or ill National Health managed this balancing act is in order. My knowledge is second or third hand about it.)
    Heaven forbid that it get to that, but I fear that most medicos will eventually discover first hand what Pasternaks Dr. Zhivago endured.

    1. Clive

      Yes Ambrit, that’s right. The National Health Service in England does have this “so many hours in public service, so many hours in private practice” split. That’s the basic approach.

      There are some nuances — for specialist clinicians (“consultants”) they can work in this half-and-half (the exact proportion varies with the individual) fashion. In Primary Care, however, (the subject of this topic and Lambert’s — and California’s — lament) 95%+ of Primary Care practices are paid for by the so-called “Clinical Commissioning Groups” which are accountable to the NHS (and by inference the UK Government / the voting public) to provide the minimum standards of Primary Care services in a given geographical location. How they source the provision is the subject of controversy. Traditionally, small-scale General Practice partnerships were the norm, ranging from one-man-band country doctors to a practice with perhaps 10 or even 20 doctors providing Primary Care. But that was the upper limit. Now, corporations are being invited to muscle in on this provision. Time will tell how that works out for us users of the NHS.

      But at least there is some democratic accountability. And if you want metrics, then while it seems to me like Management Information gone mad, there’s more data available — unrestricted and you don’t need FoIs to access it — than you can shake a stick at. The availability of so much data is to me a good sign. It prevents the catch-22 that Lambert refers to (and some comments have critiqued)

      For example, where I live, I can find out if we have the same problems as are being suggested are occurring in California very easily:

      http://practicetool.gp-patient.co.uk/Practice/Search?id2=SP10%202RH&index=0

      And looking broader, all sorts of health outcomes are detailed:

      https://indicators.ic.nhs.uk/webview/

      If the ACA produces this sort of granularity, my own disbelief about its likely effectiveness would be reduced somewhat. I have HUGE reservations about the possibility of fraud and book-cooking in the NHS data, but at least it’s a start. If there’s someone screwing with the data, at least we can see it (or spot tell-tale anomalies). The problem you guys have there is that you’ve no data.

      And then people come along and criticise you for, erm, not having any data. Go figure.

      1. ambrit

        Thank you very much Clive. The details are where the Devil lives, and heaven forbid that Ol’ Nick live in a glass house, (at least here in the States.) {The ending to “Zabriski Point” comes to mind.}

  10. TarheelDem

    “We are not taking new patients” sounds like a provider strike. Providers have pulled this on both Medicare and Medicaid at several points since the 1960s, and a sizeable number of provider will take neither Medicare nor Medicaid because of their political opinions.

    Given the Congressional attempt to force provider prices down through legislation, which they allow themselves to be lobbied to fix (doc-fix), it would not surprise me that this is occurring in high-cost areas like California.

  11. jfleni

    RE: LAS comment “America has been under-producing primary care physicians for many years”

    Absolutely true, and this is deliberate. New docs don’t want to be GPs; the fast bucks (and easier schedules) are in specialist medicine.

    But there is an exception: US Public Health Service – naval uniforms/ranks and all the rest.

    Pretty good pay for well-trained docs (complete Govt-sponsored/paid medical training in return for obligated service of some period of years) for:

    — sailing half-year with the USCG Ice Patrol, to take care of Aleuts, and other aboriginal/native people, fisherman, other seamen, CG personnel, etc.

    — formerly (not now unfortuneately ) delivering medical services to the most impoverished and unfortunate and forgotten people in the US and US territories who have no other option;

    — Many other possibilities.

    After completing their obligation, many retrain as specialists of one kind or another; BUT they paid their dues with prior and sometimes difficult service, and remain some of the most competent and experienced docs around!

    This system could be expanded and re-started at any time!

  12. washunate

    Lambert, I continue to love this series of posts.

    “Dr. Kevin Grumbach of UCSF called the phenomenon “medical homelessness,” where patients are caught adrift in a system woefully short of primary care doctors.”

    That to me is one of the fundamental issues of resource allocation. The US I think is the only healthcare system on the planet that places so much more emphasis on specialists than primary care physicians.

  13. LillithMc

    In Sacramento as a Kaiser member we had large premium increases for ten years while Kaiser expanded their hospitals and system around the area. This control makes life difficult for fee-for-service Doctors. Medicare-for-all, which was the meaning of the “public option” Max Baucus allowed the industry to remove from the bill, has cost-controls. Many seniors were kicked out of HMO’s when they did not show a profit. Bush wanted to end medicare so he created Medicare Advantage to reimburse HMO’s for accepting seniors again. The current medical system is inflated 50% over the rest of the world. Medicare-for-all would have bankrupted the system. Medicare has increased the co-pays and costs that make seniors need a gap plan. Many seniors can not afford even this health care. If they use medicaid in CA their assets a lien is placed on their assets for the amount used.
    The Central Valley of CA is the area where many lack access to health care. It is very Republican with little interest in changing that dynamic. Being homeless is often a result of being sick. SICKO by Michael Moore told the truth.

      1. LillithMc

        Central valley and rural areas are all poor, highly uninsured with lack of access to health care. Sacramento not as much due to being a large city and state capitol.
        Fresno more due to being heart of valley agriculture much in stress now due to drought.

  14. Ray Phenicie

    I have had several years experience inside the health insurance industry. I would like to share some of my experiences in regards to finding medical providers who are in network with the chosen insurance plan. And by the way, all insurance carriers have provisions in their policies for in and out of network care-mostly out of network care is not covered or is covered with a substantial out of pocket cost tied to it.

    “Nguyen said the newly insured patients checked the physicians’ lists they were provided and were told they weren’t accepting new patients or they did not participate in the plan.”
    The situation here is that any lists of providers may go out of date one minute after it is published either on a web page or in printed form. Usually, it is the responsibility of the provider’s office to notify the insurance carrier of a change in address or a change in status with regard to whether the office is accepting new patients or not. What I saw many times was that the staff at the practitioner’s office involved (I ended up calling many of these on behalf of bedraggled customers) was often (9/10) not aware that they needed to notify the carrier of a change. “We don’t have time to call around to every insurance carrier.” Likewise the carrier could hire a many more folks to constantly call providers except those same offices will then, (and did) complain about too many phone calls and ask they not be called. The carrier I worked for constructed a web based tool provider’s staff could use to update their information on the company web site. Most staff members (9/10) knew nothing of the
    tool or did not know how to use it. On the carrier side of the site, the tool too often (1/5) failed to update the system properly. In addition it seemed like the carrier’s web site was set up to be deliberately pulling out of date information and displaying it as current when in fact deeper in the files of the actual claim processing system (there was a separate, central claims processing database that the web pages were ‘supposed’ to draw down information from) the current information located there was correct. I surmised after dealing with the situation for several years that the marketing end of the carrier’s business wanted to be sure that folks would find lots and lots of providers located near their home because that was good for business.

    This points out a situation that I would like to address. All of the issues inside of health care, involve several segments of our society: consumers, the medical field, medical providers and ancillary service providers, insurance carriers and state and federal government bureaucracies. It is never the situation that one or the other is TOTALLY to blame for a situation. Yes, the AFCA was written to cater to the insurance carriers.many providers as well are benefiting and will in the long run. But we the consumers allowed this to happen. I know, what could we have done -march on mass to DC? Yes!
    Back to my point; I would like to see a more equitable approach to reporting rather than assigning blame to one party or the other; ‘it takes two to tango’ or in this instance four.

    1. francis

      But you just said it was because of the marketing department lying about the amount of providers that was the main culprit. Marketing department=Jay Carney.

    2. Emanuel Goldstein

      You are certainly honing in on an important area, i.e., the fraud, collusion, and overall gross negligence that exists between the “health care providers” and the insurance companies wherein those entities have no incentive whatsoever to ensure the accuracy of the information that they display regarding whether a provider is “in network” or not.

      I had to laugh when I saw this: “it is the responsibility of the provider’s office to notify the insurance carrier of a change in address or a change in status with regard to whether the office is accepting new patients or not.”

      In my own personal experience where an alleged health care provider, who rendered medical services to my wife in an emergency room, made the mistaken assumption that the M.D. was out of network by accident, it led to a lengthy ordeal that involved fraudulent and abusive collection practices by the provider.

      Despite repeated phone calls to the provider, Fremont Emergency Services, they inexcusably failed to seek payment from the health insurance company and continued to insist that I pay the full amount. After I thought I had convinced them to send the bill to the insurance company, they sent that message to their correspondence department which promptly dropped the message into a black hole for approximately 13 months — till just after the period for seeking payment against the insurer expired — and then reactivated the bill and began seeking payment in full from me again.

      In response to my complaints, the provider sent me a form which purported to show that they had properly sought payment from the insurer but had received information from them that we were not insured. Of course, my insurance denied ever receiving a request for payment.

      I later found out that the tax ID number of the MD had changed over two years earlier but that the information was never updated properly, so the provider showed that the M.D. was out of network even though he was actually in network.

      After this entire ordeal, the health care provider never attempted to reconcile their fraudulent and abusive billing practices and their multiple false representations to me: (1) they made false statements showing “proof” that the claim was properly billed, and (2) their office apparently has a computer system which times billing inquiries to drop off and then reactivate after the time for seeking proper payment from the insurance company has expired. Of course, the provider then seeks payment in full as if the person has no insurance at all. The fact that this is occurring with emergency room visits is particularly immoral as the patient has limited ability to “shop around” in such circumstances.

      I keep thinking about my personal situation every time I hear some “industry analyst” talk about the need to narrow up those networks to cut costs. There is a lot of fraud, collusion, and gross negligence hiding in those narrow networks.

  15. Yancey Ward

    I think there are likely to be a lot of these “medically homeless” people. I shopped for ACA plans in Connecticut. One of the very first things I discovered, a problem that persisted from October until at least early March, was that the information available from the exchange plans/insurers did not match the information I got from my old primary physician. To test whether or not I was just a simple anecdote, I actually called some other primary care physicians and specialists, and repeatedly found that the plans claimed those doctors as participants, while the doctors themselves denied such inclusion. Now, I was only shopping for bronze/silver plans, so maybe things were different if one were planning to buy gold/platinum plans, but I can’t escape the notion that the insurers were actively lying in order to make the cheaper plans more palatable than they actually are.

    In the end, I decided to abandon buying a plan this year. I simply don’t trust what I am seeing enough to shell out any premium.

  16. jrs

    I wonder what they attribute the cause too. I suspect it’s doctors not taking Medicaid. I think most doctors still take silver and bronze plans (those plans of course have their own problems with high deductables and narrow networks) The Medicaid problem was already a big problem in CA even before Obamacare with some of the lowest Medicaid payouts of any state (in such an expensive state with such extreme income disparities). But hey Obamcare is working great in some other state why should those people be complaining just because they can’t get any medical care?

    1. kmurp

      It could be medicaid or it could be that the ACA non-medicaid plans are low on physician reimbursement.

  17. Rahul

    Hello,
    I was thinking of this scenario in the near future: Please let me know what you guys think?
    Hypothetically say I own a company and I have few employees who pay for health Insurance. If Its costing me more, Would n’t I suggest that my employees sign up for ACA and say if they are paying me $100.00 now, ACA is costing $120.00, I will pay the difference and leave the rest to the bureaucrats. And eventually ACA will be a default stop for employers to throw employees insurance away. That means less head ache for the companies. What is the motivation for a company down the road say 20 yrs to give employees health insurance?
    Actually I would suggest Obama pitch the IRA a substitute for current 401K’s offered by employers. What would be the ultimate connection between employer and employee after eliminating 401k and Health care. Oh no I forgot vacation. I am thinking of ways where employers can atleast bring back the jobs to america with low over head costs there by pushing those costs to government.
    May be I don’t know. I am naive to think that the government is all good. I hope to optimistic.

    Thanks,
    I

  18. Brooklinite

    Hello,
    Can any one give me insights on how they are going to enforce ACA? May be a step by step break down if you can?I need some one who actually works in the enforcment section of ACA. Please help–
    Waiting for your help —

  19. impermanence

    Although one can spend a great deal of time talking about all of the absurdities that define the present abomination that health care has become, the Tyrannosaurus in the room continues to be the fact that no matter how you slice it, a technology-based health care in simply unaffordable. Those who wish to live forever need to apply to another planet.

    The only long-term solution to this mess is prevention-only.

    1. CB

      May you incur a displacement fracture and spend six wks or so contemplating the folly, and cruelty, of prevention only.

  20. Fair Economist

    Obamacare has produced a phenomenal improvement in care provided. In the first quarter, health expenditures are up almost 10% – driven almost entirely by increased services; prices are up 0.5%. Obamacare has gotten hundreds of thousands, probably millions, healthcare they’ve been putting off for years (far less than 10% got insurance by the first quarter)

      1. CB

        Gosh, Lambert, an intervention, right here in NakedCapitalism City. Wham bam pow phenomenal improvement!

  21. DolleyMadison

    What I wonder is, what is the justification for the fine? if I pay out of pocket, how am I hurting folks who have insurance via (my) tax dollar paid subsidies? I am priced out of the insurance market and will have to pay a fine for the priviledge? If I get care that I can’t pay for due to lack of coverage then there are other legal means for my debtor to collect that debt. This is nothing more than the government basically robbing me at gun point.

  22. DolleyMadison

    While waiting in line for my ClaritanD at Walmart today I watched as one person after another reacted first with surprise, then dismay, then anger, then pleading as their prescriptins were not covered by their “new insurance:”. Of the 5 folks ahead of me only ONE did not have an argument with the pharmacist – the one paying out of pocket. This is extortion with nothing in return.

  23. no one at all

    If a RotaCare clinic is ‘Whistle Blowing’ (Rotary Club clinics, about 7 of them are located in, or next door to, Silicon Valley perimeters) – which clinics I would suspect (and certainly have reason to believe) are notorious for serving up: stunningly punitive ‘messaging’; and ugly, highly sheltered, non-familiar; non-medical; non qualified personal opinions which end up in Patient Profiles attached [permanently] to the medical records of anyone perusing their clinics – my guess is that the Clinic’s ‘expose’ is not at all the empathetic attack (as in: Rotarians are more generally Buck Upsters who lose it when they are actually forced with having to care about other humans whom they generally view as capitalistically unproductive) the Rotary Club, by implication, lays pretense to. Then again that’s a CBS piece, so what can one expect other than a pretense of high morality?

    Nonetheless, in this case, there is certainly quite the grain of truth, despite any disingenuous bean spilling and pretension to empathy.

    As a long time ‘Silicon Valley’ Resident, I know firsthand that it is stunningly ugly here, far, far more ugly than that RotaCare Rep expressed, some would start euthanizing the ‘riff raff’ if they could get away with it.

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