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Nearly 9 million Americans gained health coverage last year according to  Census Bureau reports.  The New York Times (9/17 ) reports that the number of Americans without health insurance dropped by 8.8 million last year, to a total of 33 million.

The Census Bureau reported Wednesday n its annual report “on income, poverty and health insurance coverage, and that the percentage of people without insurance was 10.4 percent last year, down from 13.3 percent in 2013.” According to the Times, officials attributed much of the change to the Affordable Care Act.
The Washington Post (9/17,) reports on its front page that the new figures from the Census Bureau “are the most solid evidence to date of the impact that the Affordable Care Act has had since its main coverage provisions took effect in 2014.”
The Washington Times (9/17, ) reports that Medicaid coverage “saw an uptick of 2 percentage points and now covers nearly one in five Americans.”
The Wall Street Journal (9/17)  reports that the findings also reveal the extent of the health law’s impact for some groups that have historically had lower rates of health coverage. In 2014, the insured rate increased by about 4 percentage points for Hispanics, as well as for blacks and Asians.
The Los Angeles Times (9/17, Lee) says analysts “expect the nation’s overall share of the uninsured to drop further as more people become familiar with the mandate and the federal and state marketplaces.”

Blogfinger Medical Commentary. Paul Goldfinger, MD, FACC

One of my former partners had been working part time as a cardiologist at a free clinic in Georgia.  Recently the clinic closed because there weren’t enough patients without health insurance.  I have no doubt but that the increased numbers of insured patients are straining the healthcare system significantly.

Among the indicators:  long waits to get an appointment with a doctor, rushed care at in and out patient settings, stressed /burned out physicians and nurses, especially among ER and primary care doctors, under-staffing in hospitals terrorizes nurses trying to do their jobs correctly, difficulty getting to speak to a doctor on the phone, inappropriate substitutions of nurse practitioners for doctors, assigning clerical people in medical offices to triage medical complaints, inability to get doctors to see patients who are acutely ill,  difficulty finding a primary care doctor, long waits to schedule surgeries and tests, barriers at doctors offices that make it difficult for patients to get care, indifference by some doctors who are frustrated in their rolls as employees of corporate entities,  doctors rushing to get through busy office hours,  a greater risk of sloppy care and mistakes in offices and hospitals, frustration over electronic medical records by doctors and nurses , doctors going bankrupt and/or closing their practices, etc.

This is all anecdotal now, but I predict that this will become a huge story once some data rolls in. The emphasis on the bottom line has become the top priority which supersedes quality care. Too many bureaucrats in the healthcare field are making wrong decisions as physicians and nurses are becoming marginalized.  Watch for an uptick in malpractice cases.

Healthcare professionals:  What do you think?  Comment below:

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Sarah Ferris at The Hill.com reports that “more hospitals will be rewarded with bigger payments from Medicare because of improved patient ratings this year, a sign that incentives under Obamacare are helping to improve treatment.”

A total of 1,714 hospitals will receive extra payments from the Federal government this year, compared to 1,375 hospitals with reduced payments because of poor ratings.

The Centers for Medicare and Medicaid services noted in its announcement on December 18  that this is the first time the number of hospitals receiving higher payments will outnumber those penalized for subpar treatment. “This change indicates that many hospitals are improving the quality of care delivered to patients,” the agency said.

Blogfinger Medical Commentary:  Paul Goldfinger MD, FACC:

Some you BF readers have denied that Obamacare has any influence on quality of care—-ie it’s just about insurance coverage.  Those who say that are fans of the ACA and don’t want any of the quality fallout to land on that law.   But in the instance noted above,  you can see that Obamacare policies helped to improve treatment.

If you have been a hospital patient or provider of care, or if you know someone in those categories, you know that there is plenty of room for improvement in hospital quality.  We have been finding mostly negative impact on overall quality since the ACA regulations are being realized in the trenches of care.

But I  know that there are areas of real and potential improvement to be found in the ACA, and those need to be maintained as a new Congress tries to modify  ACA provisions.  I doubt that efforts to repeal the law will succeed, but changes for the better will be implemented.

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Editor’s Note:  (Paul Goldfinger, MD  Editor @Blogfinger)     The last time I saw Grover Carol Rizzo, she was directing traffic near the Pavilion for the OG Citizens’ Patrol. Carol is a bonafide expert in healthcare, having worked as CTO of Kaiser-Permanante  in California as well as in other high level positions in the financial world, and lately as a consultant for the healthcare industry. Every once in a while she surprises us with one of her knowing insights as to what is going on in healthcare.  She is the sort of expert that appears in the Wall Street Journal rather than in a blog like ours, so we thank her, and all of us should pay careful attention to her opinions.

Carol and I had a little email discussion recently.  She thought I was being a bit too gloomy.

She said, “I am not as gloomy about the future with the ACA though I have seen a few issues and missteps from the current administration. Attention to detail is truly not a strength of American government (federal or state).”  And then she followed with the following:

By Carol Rizzo:

“The reason, I am not so gloomy is because the ACA is primarily focused on payment reform rather than practice reform. The real issue that the ACA is focused on is affordability which I suppose is all well and good but where we need reform is on the cost side which if left untouched, just moves the cost onto taxpayers. After working in healthcare and seeing how health practices, specifically hospitals work, I can tell you they really don’t have a handle on cost. And there is far too little transparency.

“The ACA does not directly address that issue. That’s being addressed more by CMS* and insurers who are focused on capitation** and bundled payments via Accountable Care Organizations—ACO’s), etc. (see the Accountable Care  Organizations dialogue here…. http://www.kaiserhealthnews.org/stories/2011/january/13/aco-accountable-care-organization-faq.aspx )

“Until we have are a real dialogue on why our costs are so much higher than the rest of the worlds, we aren’t solving the problem.

“The rest of the industrialized world negotiates price for their national health systems with pharma and medical devices; we are actually subsidizing those countries.  So when Medtronics bids for the pacemakers business in the UK or India, they have to compete against a host of vendors, but those countries gets them cheaper from Medtronics!  Also regulators move faster in those countries  because it’s in the national interest to get the best drugs and the best devices and avoid health costs.

“In 2000, I was in India on business with an American colleague who was wearing a Holter monitor. When we landed, his doctor at Johns Hopkins paged him to get to a hospital immediately because he needed the newly FDA approved Medtronics pacemaker. We flew down to Chennai where the doctor at Johns Hopkins could not believe that the Indian cardiologist had been using the brand new Medtronics pacemaker for over  two years!  The bill for 7 days of hospitalization, 24 hour nursing, the cardiologist and surgery was about $11,000; at a fraction of the cost here. (Still expensive though for the average Indian)

“What I am more concerned about is that hospitals are buying up practices and they are doing that so they can direct where emergency and surgical care will be given.”

Regards,

Carol

* CMS:  Centers for Medicare and Medicaid Services

** Capitation:  A payment arrangement where a set fee is paid, for example to a medical group, to cover all the care for each patient covered by an insurance company that pays doctors that way.

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By Paul Goldfinger, MD

As predicted, the ACA’s problems will multiply as we get past the website disaster.     To keep you informed of the concerns regarding quality as they evolve, we will periodically do the Obamacare Hotline.

1. It is expected that about 107 million people   (80 million from the business community)  will eventually lose their existing policies so that they will be forced to look for other health insurance, preferably on the ACA exchanges.   But most will find higher premiums and higher deductibles and perhaps crummier policies than before.  Contrast these “losers” with the “winners” who get insurance that they didn’t have before, but they number about 14 million according to current projections.

2. Because of the huge increases  (“explosion”) in Medicaid enrollment, we will evolve a two tiered system, not a system equal for all.  Those at the bottom of the ladder will be on Medicaid and they may have major problems in getting access to care for a variety of reasons, not the least of which has to do with doctors not wanting to participate in Medicaid due to extremely low fees. Clinics will have to be organized to deal with the huge rush and demand for services.  Note that New Jersey has the lowest rate of Medicaid doctor participation in the country.  Then comes California.

California is a model for dealing with the Medicaid  problem. The link below discusses how California is doing it:

NY Times on California Medicaid

3. The mechanisms for passing new customer dollars (premiums)  to insurance companies  are flawed. As a result, patients with ACA acquired policies may find themselves rejected by providers in their networks because the providers are not being paid.  This could leave covered individuals at risk for medical problems. This problem should be fixed quickly.

4.  Doctor networks in ACA policies are smaller than customers would like. In many cases,  doctors have not been contacted to sign up with insurance companies. Or the doctors have refused to sign contracts with some companies.

5.  Applicants have until Dec 23 to buy insurance  on an exchange if they hope to have coverage by Jan. 1.

6. The sign up forms  (called 834 EDI transmission  forms) on the exchanges have been causing confusion. These are the forms that everyone who wants to buy insurance needs to fill out.  They contain all the information that insurance companies need to enroll a customer.  But this “back end” function, which provides data to the ACA website has proven to be difficult for shoppers and prone to errors.

The insurance companies are finding all sorts of errors on those data sheets which cause problems getting people enrolled.  The NY Times says, “This is what everyone’s worried about”   Some people who think they have acquired insurance on their exchange  may find out that they don’t when they check in January.

Sign up for Medicaid has been the most successful part of the process, but that program is free, and the government is pretty good at offering free benefits.

7.  Here is a website called “ObamaCare Facts:  Dispelling the Myths.”   ObamaCare facts web site.   This site is supportive of the plan and tried to provide encouragement and information to those who want to sign up.

But don’t be bamboozled by double talk.  Here is a quote from page one of that website:

“ObamaCare doesn’t regulate your healthcare, it regulates health insurance and some of the worst practices of the for-profit health care industry.”

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