Why have I not heard about this before? Medicaid expansion problems

[passiveporcupine]

I recently found out that the new Medicaid expansion program under ACA is useless for a lot of people. Why? Because there are not enough providers (or any) who will take medicaid.

This may not be the same in all states. I was looking into it for someone in the Northern Illinois area, and I actually found the web site to search for a provider by zip or county, and by specialty (I cannot find it today). I used the link to search for a family practioner in Illinois, outside the Chicago area and I kept coming up with zero found. You can select within 25 miles, within 50 miles and within 100 miles.

I checked a lot of different zips in Northern Illinois, and unless I selected within 100 miles, I came up with zilch. And even within 100 miles often came up with zilch. How is anyone supposed to use this new health care they have if they have to drive more than 100 miles to see a doctor? And even if they drive 100 miles or more...there are so few to choose from and they are so full already, they can't take any more patients.

I have a friend whose daughter recently qualified for Medicaid under the new ACA expansion, and she cannot find a provider for herself, except for her prenatal needs. For anything else, she will have to use the ER, as walk-in clinics won't take Medicaid either.

So what good is this medicaid expansion?

This can't be the only state with this problem. How could the ACA implement a program that does no good even if you qualify for it?

I am not against the ACA (although I prefer single payer), but I was not aware of this problem until yesterday and this is a huge glaring hole in the ACA. People who are too poor to sign up for en exchange, are eligbile for Medicaid, but Medicaid can't serve them because of lack of doctors who accept it. So they still have to go to the ER anyway.

Why isn't everyone screaming about this?

[yeoman6987]

1. Doctors do not have to pick Medicaid, Medicare

Or tricare for that matter. A lot of doctors opt out because of the time it takes to process their billing or they don't get what they requested. I don't think we want to force doctors to take government insurance do we? Or maybe that could be proposed.

[SheilaT]

2. One of the arguements I heard raised many times

back during the debate about the ACA, was that there are not enough doctors already, so covering more people was a bad idea. It never seemed to occur to those objectors that maybe training more doctors could happen.

added on edit:
The fact that some doctors do not take Medicare or Medicaid or any other specific coverage is not breaking news. This has been around for a very long time, especially doctors not taking Medicare. I have also at times in my life lived in places where there was a sufficient shortage of doctors that almost no doctors were taking new patients.

[Igel]

6. Training more doctors is a problem.

In the end, they each have to do a residency at a teaching hospital.

There are a limited number of spaces at teaching hospitals. Residency slots lose money for their hospitals. They are subsidized by the government. And still many hospitals periodically consider axing their residency slots. We won't even talk about fellows, specialist trainees.

The last time I checked--last year--they'd set plans for the number of residencies a few years ago, before the ACA. It will take a couple of years to plan and budget for new residencies. Then it will take a year or two to staff and graduate the first doctors.

The number of medical school graduates has increased. But with that residency bottleneck, they will not become doctors in this country. It may be possible to export them and import additional doctors--we've survived by doing that for decades.

The best and fastest way to increase the number of doctors is conservation: A lot quit the field every year, a hemorrhage that should be stanched but never is.

[Brickbat]

9. You've hit on the double-edged sword.

That bottleneck -- which is set by Congress -- is a key part of the problem, coupled with trained, experienced doctors who are disengaging and retiring.

[enlightenment]

24. I'm confused.

Could you explain a bit more?

I thought that the hospitals set the number of residencies. How is Congress involved in telling hospitals how many residents they can accept?

I know in my state (and city) we have a very big problem with this, but my understanding was that it is because there is only one county/public hospital in the city - and about seventeen for-profit facilities. The for-profits are loath to take on many residents' and as a result the students graduating from the med school leave the state.

[Brickbat]

25. Residencies are funded with Medicare funds, and as such, are set by the federal government.

Here's a statement from the AMA last year:

http://www.ama-assn.org/ama/pub/news/news/2013-02-03-urge-congress-retain-funding-for-residency-programs.page

WASHINGTON – Physicians and medical students from across the country are urging Congress to retain Medicare funding for graduate medical education (GME) programs, known as residencies, and to lift the cap on the number of available residency slots. As the nation deals with a physician shortage, it is importantPDF FIle that all medical students can complete their training and care for patients.

"Residency training gives new physicians hands-on experience and provides high-quality care to patients," said AMA President Jeremy Lazarus, M.D. "Limiting the slots available to train physicians as they leave medical school creates a bottleneck in the system and prevents the physician workforce from growing to meet the needs of our nation’s patients."

The demand for physicians will grow as the US population continues to age, 30 million newly-insured Americans have increased access to health care services from the Affordable Care Act and life expectancies become longer.

Medical schools are expanding enrollment and making changes to prepare students for the future practice of medicine, and the AMA has announced a $10 million initiative to further accelerate change in undergraduate medical education. But that is just part of the continuum of medical education essential to produce physicians ready to meet future demands. The number of GME slots has been frozen by the federal government since 1997. As a result, U.S. medical school graduates will exceed the number of available slots as soon as 2015.

[SheilaT]

28. I also seem to recall that a very long time ago,

perhaps back in the '70's, the AMA made a very considered decision about limiting the number of medical students in the first place. I wish I could remember more details, but I remember reading that this wasn't a very good idea, because the population was growing, and over time more doctors would be needed. I also recall that the decision to limit the number of doctors was to insure that the doctors' income would stay high enough.

We are now reaping what was sowed nearly more than a generation ago.

[passiveporcupine]

35. Sure sounds right.

So frustrating. Middle class wages are stagnant, but not doctor's fees.

[enlightenment]

30. I had no idea. Thank you for

responding to my question. It doesn't seem like a very logical way of doing things (speaking purely from my uninformed perspective). Obviously I need to do some more research.

Thanks again.

[Doctor_J]

3. The private insurers pay more than Medicaid, so the doctors probably prefer

treating their patients. Also a lot of doctors where I live actually work for an insurance company now

[dixiegrrrrl]

4. Google "free medical clinics"

There used to be lists online, I know I have posted them before.
These are Gov't sponsored clinics, on sliding scale, the docs are often doing a stint in the clinics as part of their med school fees,
or other gov't programs.
I have been to ours in the past, found the docs were good.
If you have no money, they still take you.

[passiveporcupine]

5. The point is this young woman now has Medicaid,

and she is very low income, and even if she could get low cost care at a clinic (if she could even find one in her area), she will go to the ER, because there she is 100% covered by Medicaid.

Before I found out about this, I read an article that showed that most states had a 50% or higher participation in Medicaid, and for Illinois, it showed 64% of doctors in Ill accepted Medicaid. That was an "estimate". But when I searched specifically I discovered that maybe only 1% of doctors in Illinois accept Medicaid.

So what the hell good is it to expand Medicaid and put more people on it. They should have been accepted into the exchanges and given a full discount so it's free.

This is going to leave a lot of people out (for states that don't expand Medicaid) which I'd already heard about, but now it also leaves out a lot of people in states that did expand Medicaid, but don't have the doctor's to service them.

Medicaid pays the lowest of all, which is why doctor's don't want to accept it. ACA offers a higher payment (double I think) for one year if they accept the expansion, but at the end of the year (2014) it goes back to the original compensation.

What good is Medicaid if it doesn't pay enough for doctor's to accept it?

This needs to be fixed, or the ACA is a waste of effort for poor people. They are not allowed on the exchanges, so they are left competely out of the system, unless they use the ER...and the point of the ACA was to get people to stop using the ER for non-emergency issues.

I can't believe how complicated this stuff all is. We really really just need to switch to a single payer system where you pay through taxes on a sliding scale and there is no deductible or copay for your needs. And any doctor can serve you. If not for non medical needs, like plastic surgery.

[Curmudgeoness]

7. I agree that this is a huge problem,

but I don't agree that accepting very low income people into the exchanges and having a full discount would help people who have no money. The co-pays and deductibles are all high on the exchanges. I believe that too many people will still not be able to go to a doctor with the insurance because of the expenses that they have to pay.

Although one of the points of the ACA was to get more people to use doctors' offices for non-emergency care and to keep them from the most expensive ER visits, at least that option is still available with the Medicaid. A shitty way to solve the problem, but if that is all there is, that is the way it has to be for now.

You and I are in complete agreement on the single payer system.....that is the only way that any of this will work for all of us.

[dixiegrrrrl]

14. Sorry, I was not clear. The clinics accept Medicaid.

It is the private practice docs who are mostly declining Medicaid.
And some are refusing Medicare.
Gov't sponsored medical clinics take Medicaid...that is usually what the term "sliding scale" means....you pay according to your ability.

People often try to call local docs for Medicaid coverage.
Problem is, outside of the bigger cities, most people are not aware of the clinics.
And if really rural, transportation could be a problem.

[passiveporcupine]

16. I agree many of the deductibles and copays are too high

But the government also helps people in exchanges with deductibles and co-pays for lower income folks, so they could have just paid the deductibles and copays and not required it of anyone that poor.

Single Payer NOW! We have to keep screaming this at our congress critters...constantly! We should not leave poor people hanging, or still using ERs for regular care.

[alarimer]

8. The only way ultimately to solve this problem is a single-payer system.

I hope we get there. I feel the current system (even with ACA) will shatter completely sooner or later.

[jwirr]

11. With a single payer system doctors would have to take the patient but only time will solve the

shortage of doctors and other staff.

[SoCalDem]

18. The cure for doctor shortage is an easy one to fix

Single payer system
medical school debt wiped out after 7 years in the system as a general practitioner
Generous pay for doctors

We would soon have plenty of doctors....happy doctors..

[jwirr]

20. Agreed but that still takes the 7 years.

[SoCalDem]

29. a long journey starts with a single step

The longer we wait to start, the longer it will take

[jwirr]

34. Exactly

[passiveporcupine]

15. She tried going to three walk-in clinics in her area

none of them accepted medicaid, so she ended up at the hospital. If there had been a free clinic, I'm sure she would have gone there, but not everywhere has free clinics available. We don't in my town.

[WillowTree]

10. Where in Northern Illinois?

[passiveporcupine]

17. I'm not sure. I checked most of the towns outside of Chicago

And I even checked Chicago. Could not find a family practice that takes Medicaid. There were a few options for kids and dentists for kids, but not adults. She is getting care for her pregnancy, but that is not for family coverage. It might be a gyno or family planning clinic. But they will only treat her for pregnancy related issues.

I think she lives within 100 miles of Chicago.

[WillowTree]

21. Try searching on this site.

You should be able to find some here. Good luck.

http://www.doctor.com/

Edited to add:

And search by city. I found some in the Rockford area to the NW, in or near Ottawa to the West and in the Kankakee area to the South of Chicago. Get an idea of the area where your friend lives and run your search by the town that looks largest in that direction.

[passiveporcupine]

23. I've spent too long searching and not finding anything.

I really don't have time now. I'll let her Mom handle it.

I really just wanted to bring this to everyone's attention, because if no one knows about it, nothing will be done. Something needs to be done to fix this.

[WillowTree]

26. You're welcome.

[MadrasT]

12. We did not even *get* the expansion in PA.

ACA helped a lot of people, but a lot are still fucked.

Single payer. Now.

[Glitterati]

13. And, then, you have states like Georgia

Feel free to look at my old posts.....it's all documented right here on DU.

I applied more than a year ago for my daughter for Medicaid because according to healthcare.gov I had to. Her income made that a necessity. Then, even tho I knew she qualified, we lied about her income and got her on ACA because the state of Georgia was dragging their feet in getting the application processed and the letter we needed to sign up for ACA.

The bottom line?

I got the letters from Medicaid asking for the required information this week.

Almost a year after we completed the application.

Ga. insurance chief brags about sabotage of ObamaCare
Let me tell you what we’re doing (about ObamaCare),” Georgia Insurance Commissioner Ralph Hudgens bragged to a crowd of fellow Republicans in Floyd County earlier this month: “Everything in our power to be an obstructionist.”
http://www.ajc.com/weblogs/jay-bookman/2013/aug/29/ga-insurance-chief-brags-about-sabotage-obamacare/

[passiveporcupine]

19. That is horrible

the ACA has helped a lot of people. I have a number of friends who have benefited from it who would have been bankrupted otherwise...and I'm glad it passed. I just wish it would have covered more of the bases for the really poor.

[daredtowork]

22. The States put more thought into than that

For instance, in California, Medi-Cal (Medi-caid) is actually managed under major existing HMO plans. I had to choose a plan. I actually didn't like this aspect because I thought it over-complicated matters, and I was afraid to choose the "wrong" one, and I might end up cut off from some medication or treatment because of my own choice. As a matter of law, no one could give me advice on the matter.

However, the benefit of that is that I was instantly ensconced in a network of doctors and specialists that covered most of my referrals. Before I was on Medi-Cal, I had access to a local health care program and the county hospital, but I wasn't being referred to crucial specialists for my problems, and that left me disabled. After I got onto Medi-Cal it actually became much easier to see specialists, and my problems began to be addressed. One specialist did gripe that I chose the "wrong" HMO (because it paid slower), but other than that I don't think I've had any problem coming from the doctors themselves.

I do live in a major urban area with a strong commitment to making the ACA work - but it seems to me like other States would also have been planning how to "implement" Medicaid rather than just putting people on it willy-nilly and telling them to go find a doctor.

***********

By the way I think there are some deliberate disinformation campaigns going on even in California. A friend of mine told me her friend in Vacaville (a nearby California city) was up in arms about being "forced" on Medi-Cal because she wouldn't be able to choose her own doctor. This is vastly untrue: I've felt completely free to choose doctors and move around, and I have no complaints with the standard of care I'm receiving now either (well, if I were still on Medi-Cal at the minute, but that's another story). This smells a lot like those Clinton era "Harry and Louise" commercials were "folks just like us" grumbled they couldn't choose their doctor anymore now that the government had gotten involved.

[randys1]

27. ALL american physicians and hospitals and pharmacies should be FORCED to participate in medicaid &

medicare...

Jesus fucking christ, other countries do NOT have this problem...

It all comes back to



CAPITALISM

and the fucked up way we do it and it makes me mad as hell

and we dont have enough primary care docs, why? cuz it doesnt pay enough

again, the problem is our version of CAPITALISM

[YarnAddict]

32. Here's the problem:

Medicaid (and Medicare, I've heard) doesn't reimburse enough to cover the doc's overhead. Would you actually FORCE them to take Medicaid if it would ultimately force them out of their practice????

[randys1]

41. Then their overhead is too high...There is NO reason NOT to require ALL licensed physicians

to do a certain percentage of medicare and medicaid, anything else is absurd.

Get that for profit crap out of your head, there is a limit to the amount of profit you can seek if you are in healthcare, sadly the worst offenders are hospitals.

[jazzimov]

31. Contact the Illinois DHS.

Medicaid is NOT like Medicare, which is a single-payer system. It is a true Socialist system. It is carried out by the State, although it receives Federal Funding. It is not designed to pay private doctors, but to create and utilize "free clinics".

[littlewolf]

33. I have Tricare ... and the area I retired in no one is a provider

meaning they accept what Tricare pays. example: X-ray - Tricare pays 25 dollars. actual cost was 100 dollars. if the Dr is a provider he accepts the 25 dollars and writes the rest off.

if the Dr. accepts Tricare but is not a provider, you pay the difference.

[airplaneman]

36. California is not a good state for ACA expansion.

If you own a house and assets and are in the 50-65 age range. They put a lien on you house and will go after your estate for reimbursement when you die. Its called clawback. Its $611 a month plus any other big expenses you accumulated while on medical. You cant sell your house and your estate will be raided when you and your spouse are gone. Makes you not even want to sigh up.
-Airplane

[Travis_0004]

37. I have worked for Doctors in accounting

Medicaid pays a lot less, often under the actual costs, and they are a hassle to get to pay the claims. Ive seen several doctors have enough claims denied that they drop the program instead of dealing with the hassle.

[passiveporcupine]

38. According to the ACA

the payment rates for Medicaid were doubled for a year. That ends at the end of 2014 IIRC. So why would a doctor sign up for it knowing it was only going to last a year? Maybe they thought they'd find another solution by then. I bet they didn't expect the Gop to still be trying to kill the ACA this long down the road.

Oh, and on Medicare, if the doctor's office makes an error and the claim is denied for any reason, they cannot correct the error and try to file the claim again. They are stuck with it. It's probably the same way with Medicaid.

[Recursion]

39. This was an argument against the public option, also

My guess is that the economies of scale will get there eventually, particularly with Wal-Mart starting health clinics in every store.

[kelliekat44]

40. The answer is a National Physicians Corps. Good paying jobs for young medical professionals trying

to pay off huge college loans and start a practice. The Corps would ensure against malpractice up to certain levels, pay off medical school loans as long as the physician was in a practice 50% Medicare/Medicad adult patients. Bonuses and special pay incentives for practicing in rural and highly low-income areas. Obligated contracts for minimum of 5 years. In this economy this would provide jobs and solve some of the college tuition problems facing the nation. There are a lot ...too many capitalist docs out there whose only interest is in their stock portfolio and the deals they can make with pharmaceutical companies an medical device companies.