Will Doctors Treat All These New Medicaid Patients?

Long lines in waiting rooms of hospital emergency rooms are often misinterpreted as solely due to demand from the uninsured.  Certainly some of the people are there because they have no insurance and they know hospitals have to provide them care.  But many of the people in that waiting room do have insurance through Medicare.  But they cannot find a doctor who will treat them at Medicare's combination of low reimbursement rates and onerous paperwork requirements.

JD Tuccille has more

Five minutes with using supply and demand curves and the most basic lessons of microeconomics would have predicted this.  In fact I did, about a year ago.



  1. mogden:

    Yes, but if we just believe hard enough, a magical mandate fairy will make sure all those doctors work twice as hard for less money.

  2. Pinebluff:

    Believe you mean Medicaid not Medicare

  3. Matthew Slyfield:

    over half of all doctors are within around 10 years of being eligible for full retirement. Good luck with getting them to work past that for significantly less money than they are used to making.

  4. kidmugsy:

    "Five minutes with using supply and demand curves and the most basic lessons of microeconomics …" Oh come now. One minute reflecting on what you've seen in life, and recalling what your father told you when you were fourteen, takes you more directly to the same conclusion.

  5. Earl Wertheimer:

    In Canada, we have had this for years. The long lines in the hospitals are only the tip of the iceberg.
    You don't see the millions of people who can't find a Family Doctor.
    If you want to see a Dermatologist, no problem. They are taking appointments for 6 months from now.
    People are dying as they wait for operations that keep getting postponed.
    Newly graduating doctors can't find jobs because the government has limited the number of available jobs.
    In Quebec, new doctors are forced to take a 30% pay cut if they work in the city.
    Private clinics are not allowed to charge for procedures that are covered by the government, thus enforcing their monopoly.

    Welcome to our nightmare.

  6. MingoV:

    Medicaid is more of a hassle for doctors than Medicare. Medicaid is a joint federal-state program, so there are more regulations. Medicaid reimbursement is lower than Medicare. Many physicians refuse to see Medicaid patients, which is one reason why so many Medicaid patients go to ERs for minor problems. That problem caused many hospitals to close their ERs. The ACA-related expansion of Medicaid will worsen the ER situation since it is likely that more doctors will opt-out of Medicaid.

  7. mesaeconoguy:

    Will they treat them?


    Will they be forced to treat them, eventually?


    That is the course of events.

  8. mesaeconoguy:

    PS, we predicted this, and other problems, more than 3 years ago


  9. Rick C:

    This is why I laugh in the face of people who tell me the US needs to make our medical system more like Canada's, or England's, etc.
    When Canadians come to the US for procedures, but you don't really hear about Americans going north, you know who's got a more accessible system. (This isn't intended to be bashing Canada's system, btw.)

  10. HenryBowman419:

    I just read Avik Roy's thin tome How Medicaid fails the Poor, and I recommend it, partly for the brief historical synopsis. His conclusions are the same as yours, of course, though he has some recommendations for improvements -- which would mean scrapping the current system.

  11. FelineCannonball:

    Under the ACA doctors see 30 percent increase in reimbursement for two years. States that are flailing, like NJ, are out sourcing their Medicaid system to private insurance. Many states are doing fine, like AZ with 80 percent plus participation. I guess we'll see but your eyes aren't the only ones on this.

  12. Rick C:

    Remember, one Democrat (a House rep, I think) was willing to publicly say she thought doctors should be forced to take Medica{id,re}.

  13. Methinks1776:

    Mesa, I doubt it.

    Even the Soviets could not force doctors to treat anybody. I don't think that it'll be possible to make that happen. The doctors are a pretty powerful special interest as well with their own lobbyists.

    As Obullshitcare increases wait times and decreases quality of care, demand for out of pocket care will grow. Killing concierge service would mean killing a way around the miserable wait lists and it would be political cryptonite. I realize they have such a system in Canada (although, I think that's changing), but in Canada it was possible because their system took hold around the time European single-payer systems were implemented and at that time medicine could do little for the sick. If you think Obullshitcare is unpopular, just wait to see what happens if they threaten concierge services.

  14. Methinks1776:

    I agree with you. An aunt and an Uncle of mine who were both surgeons in the decrepit Soviet health care system now live in Canada and it's so bad it's managed to horrify even them.

    Britain is better, however. Not the NHS, of course (an ad for private insurance in London finishes with the tag line "because we can be bothered!"), but the U.K. does not restrict private practices from performing procedures the NHS performs. So, if are willing to pay out of pocket, you can find a private practice which is worlds better.

  15. mesaeconoguy:

    The AMA is extremely powerful. But they hold the union compensation cards, if you will. If they don't like it, and they won't (even though they endorsed Obamascare initially), they will pull the plug. Game over.

    But that would be after il duce mandates Medicare/Medicaid treatment coverage. He will be forced to do this, because of the mechanics of Obamascare.

  16. mesaeconoguy:

    All the hoser snowbirds are here right now, getting their medical things taken care of.

    Every third license plate is Alberta, BC, or Ontario.

    Canadians are, however, strictly forbidden from spending longer than 6 months in the US. This will become a major issue when wait lines become much, much longer than that in the US.

  17. Methinks1776:

    I don't know how you think you can get away with the line of hooey that docs are getting an increase in reimbursement because what the insurance companies are telling them is that their reimbursements are dropping to as much as 70% below preferred provider networks. You should always do the smell test before making such assertions. Why would such a large percentage of doctors and health care facilities refuse to accept Obamacare if reimbursements are slated to be 30% HIGHER? Do you believe nobody wants to make more money? You'd think doctors would be elbowing each other out of the way to sign up to the big Obamacare raise. Yet, even in your "doing fine" scenario, only 80% are taking what you claim is a raise!

  18. FelineCannonball:

    Read a little: https://www.advisory.com/Research/Physician-Practice-Roundtable/Members/Expert-Insights/Medicaid-payment-increase-for-PCPs

    I imagine the non-Medicaid doctors are ones in specialties that serve the wealthy. I don't think there are a lot of Medicaid breast implants.

  19. Methinks1776:

    Oh. So, first of all, it's not "doctors" who will see a reimbursement increase but the shrinking number of physicians willing to accept medicaid patients who may receive a temporary bump in already exceptionally below-market reimbursement rates. Those rates are so low that a temporary bump isn't going to make any difference to them. Over half the doctors in this country won't accept new Medicaid patients. And while your little breast implant quip sounded good to you, it makes you look ridiculous. I can't believe I have to explain elementary math to you, but here goes: there aren't enough wealthy people (the people you're soaking to pay for the people on medicaid) in this country for half the doctors to be occupied with breast implants and other plastic surgery. Never mind the stupidity of saying that seeing as women living in trailer parks (and who are often on medicaid) are get
    ting breast implants. Funny how money materializes when it's important to you, isn't it?

    As for the doctors that do accept medicaid, they limit the number of patients they'll see because reimbursement is so low and the regulatory headache so immense and costly that practices will go out of business if too many of their patients are paid for by medicaid. My cousin is one such doctor. Her choice is to go out of business or limit medicaid patients. She's not going out of business. As a result, the wait for a medicaid patient to see her stretches to six months (already. And that's before more medicaid patients materialize as a result of OBullshitcare). There is no wait for those insured through private providers or paying out of pocket. She may agree to see new medicaid patients, but it's virtually meaningless to the the patient if the wait list stretches out to 12 months. She will still limit the number she sees per day. And that's the thing about those numbers. The programs vary by regions, but in general, medicaid patients wait longer to see a doctor. They also have much worse health care outcomes.

    Anyway, back to your original...um..."misrepresentation". You were wrong. Doctors are not going to see an increase. Only medicaid will bump reimbursement for a couple of years. Likely that's designed to trick doctors into signing up for that hot mess and then drop the reimbursements again. Something tells me docs aren't that stupid. Most Obullshitcare exchange policies will cut reimbursements drastically - and that's why the network of providers in those plans is so very very narrow.

  20. Johnnyreb:

    The States that signed on with Obamacare exchanges will see a 30% increase in reimbursement rates form the Fed for two years, not the Doctors.

  21. FelineCannonball:

    An orthopedist reimbursed by Medicaid would get 400k take home as opposed to 500+ from private insurers. Refusal of service has nothing to do with bankruptcy or the poor house. The real problem here is non-free market practices. Cartel type behavior in self-controlling doctor training numbers, and lack of transparency in cost. Doctors and patients have no idea what a surgery costs and there is virtually no possibility to shop around or discuss cost options. Doctor training is nearly 100 percent paid by the federal government across specialties (why?) and the number of GPs per capita has dropped off dramatically over the decades.

    So I'm not going to cry for the random doctor turning down medicaid till I see the details on his practice, and I'll continue to laugh at pro-free market conservatives defending the cartels and the opaque status quo. If nothing else standardization in health exchanges force insurers to compete over similar services and information transparency on the cost of procedures is embarrassing hospitals into revamping their cost breakdown. There's a long way to go but I think we've moved toward enough of a public spotlight to solve some of these problems in the long term.

  22. Methinks1776:

    I see you're getting your crazy numbers (400 vs. 500 and the percentage paid by government) from the same dark pit of nonsense that produced the 30% raise for doctors you claimed in your first comment, but if you're looking for a conservative or a defense of cartels from me, you'll die waiting. Third party-payers and licensing are at the very heart of the problems with the healthcare system - problems Obama, supported by a band of useful idiots like you just amplified.

    I don't really know what you looking at a doctor's practice has to do with anything and neither do you. The point is, they're unwilling to take medicaid patients and to patients that's all that matters. Period. Insurers are now forced to limit their offering to four very bad and expensive products that provide limited access to a tiny network. The insurers are prevented from innovating and from responding the needs of the market. Dynamism, key to fulfilling the demands of the market rather than the whims of politicians, is throttled by the state. You celebrate that. This you call "moving in the right direction". If Obama embarked on purges you'd celebrate that too.

    Your magical thinking about embarrassed hospitals and moving in the right direction by socializing healthcare (a thing that has never served the population anywhere) should embarrass you. If it did, though, you wouldn't be a useful idiot.

  23. FelineCannonball:

    Compensation: http://www.mgma.com/WorkArea/mgma_downloadasset.aspx?id=1366514

    I'm not going to read all your stuff, but ACA required reporting on hospital specific procedures means someone has to answer for having the same hip replacement parts and the same surgery varying 5x in the same city. If nothing else, people will stop paying 150k for a hip surgery they can get for 30K. Just like they don't pay 20 bucks a gallon for gas. Even if your copay is 10% you care enough to avoid the rip off.

  24. Quincy:

    "I'll continue to laugh at pro-free market conservatives defending the cartels and the opaque status quo."

    Yet you laud a system that keeps the worst of the status quo while further stripping away the remaining vestiges of the free market. Curious.

    As to refusal of service to Medicaid patients, citing take home pay numbers for doctors as proof that "Refusal of service has nothing to do with bankruptcy or the poor house" is literally citing no proof at all. Here's an equation for you:

    Income - Costs = Take Home Pay

    Pretty simple, right? Let's make it a little more true to life:

    ( Number of Services * ( Income per Service - Costs per Service ) ) - Staff - Durable Equipment - Facilities - Insurance = Take Home Pay

    Notice that the income from services has to cover staff, durable equipment, facilities, and insurance for the practice (and a bunch more that I'm probably missing). Now, without details as to what these various costs are, it is not possible to conclude that changing a doctor's average income per service would not cause them problems.

    "If nothing else standardization in health exchanges force insurers to compete over similar services"

    Competition in markets takes place with three variables in play: price, quality, convenience. The standardization you claim is forcing insurers to compete is taking away any avenue to gain competitive advantages on quality and convenience, so the only differentiator remaining is price.

    However, there is a natural floor to any insurance company's price: the quality of the company's risk pool. Obamacare made illegal the tools traditionally used to increase risk pool quality. The only tools left to insurance companies to lower prices now are increased deductibles, co-pays, and co-insurance. Even these aren't terribly effective against a flood of poor quality risks (which is what the prohibitions on declining applicants due to pre-existing conditions will cause).

    So, what would the projected outcome of this market standardization be? Higher prices coupled with increased out-of-pocket costs for the insured. Which, by the by, is exactly what we're seeing in the individual market right now. Think the backlash now is bad? Just wait until this hits the employer-purchased insurance market...

  25. Me too:

    "I'm not going to read all your stuff," (because it will prove I don't know my ass from a hole the ground.)

    There, I fixed it for you

  26. c_andrew:

    If nothing else, people will stop paying 150k for a hip surgery they can get for 30K

    This is true. But why use a gov't program for this "hospital shaming?" Right now, medical providers are "dirt beneath our feet" and the bureaucrats are gonna make sure they get it good and proper.

    Have you heard of regulatory capture? What makes you think that when the current political fetish passes that the medical system won't be operating in that realm once again? The cartelization and lack of transparency that you rightfully complain about is the product of gov't interference; specifically 3rd party payer, DRG and gov't licensing. The licensing creates the cartel, the DRG creates arcane rules of reimbursement so that internal transparency is nigh impossible, and 3rd party payer means the people who you hope will "stop paying 150K . . .)" are not the ones paying at all. At best, they're paying at one remove - with higher insurance premiums, So the market mechanism to combat such - advertising - has no impact in a 3rd party payer system. It is a truism of economics that price divergence among similar products falls as the base price increases so long as pricing information is generally available. (This is true even in primitive and barter societies.) Advertising is the means toward this end but it has to speak to the people actually purchasing the product. Compare how closely elective cosmetic surgeries prices run with those in the non-elective market.
    Just to give you one instance of perverse incentives under regulatory capture; shortly after Medicare Part D was passed and signed by a GOP dominated gov't, the price of prescriptions began to rise. In my own case, I use 3 medications that have been off-patent for 40 plus years. One such instance was covered heavily in the media - a particular drug (not one I use) that reduces the chances of premature labor, went from a pregnancy-long course cost of $3500.00 to $35,000.00, a 10 fold increase! Why? Because the FDA granted what was essentially a new monopoly to their pet drug company as a reward for their new clinical trials; as if some new earthshattering insight is to be found in clinical trials when a drug has been in clinical use for 50 plus years!
    The FDA had to back off of that drug because of the political ramifications of screwing pregnant mothers - they no longer tacitly approved the cease and desist orders being issue by their (formerly) pet drug company to the compounding pharmacies that the OB-GYNs had been using. But those of us using medication without the press appeal of expectant mothers are not going to get any such reprieve. My meds went from $14.00, $75.00, and $100.00 a month to $56.00, $496.00, and $1200.00 per month - 4X, 6.5X, and 12X.
    My meds are also made abroad because they are dirt-cheap to manufacture. So I went to the Canadian pharmacies. But even there, I was looking at double and quadruple pricing because the pharmacies had to hire their own pharmacists specifically to re-write US prescriptions, they had to bear the cost of evaluating the quality of the medications without any chance of building reciprocating relationships that would reduce that cost over time (because of the gov't fiat involved) and they had to charge enough to cover the costs of random US Customs seizures of therapeutic drugs shipped into the US. There was a procedural loophole being exploited allowing 3 months supply of meds to be shipped to individuals in the US but there was no recourse if Customs seized the shipment. The FDA has since closed that loophole.
    The point of this extended comment is to give you enough specific instances to point out that the problem here is not the free market which we haven't had in medicine for 50 years. The problems you rightly cite - cartelization, lack of transparency, divergence in pricing, etc., are artifacts of the gov't policies in medicine not the free market. And if you think we have problems with cartelization, lack of transparency, divergence in pricing, etc., then let's drop multiple gov't bureaucracies on top of the current mess. Think Pentagon budget. Because that's the size and configuration we're looking at. I have a brother that works in DC. He says that the Pentagon has yet to submit a rationalized budget from 7 years ago as required by some offshoot of Dodd-Frank.
    I lived in Japan for an extended period 30 years ago. They have socialized medicine installed by MacArthur during the Occupation. I have a congenital defect that comes down the male line that involves a weakness in abdominal muscle fibers along the inguinal ligament. That same problem overtook me while I was in Japan. I knew what the problem was. An indirect inguinal hernia. I went to the University Hospital in Gifu City. I waited for 4 hours in a nearly empty waiting room. When the doctor came in, I told him what the problem was, but he didn't examine me. He took a blood sample. By slicing my right ear lobe and sucking it out with a mouth tube! He then came back to 90 minutes later and told me that I didn't have appendicitis.
    I later went to an American endowed hospital outside of Kariya city. The Japanese MD there had been trained at Harvard Medical. He took 5 minutes to examine me and told me that I had an indirect inguinal hernia. Then he looks me right in the eye - a trait he must have picked up in the US - and said, "Whatever you do, don't get it repaired here in Japan." When I asked why, he said, "Because they will keep you flat on your back for 30 days and that will make it far more likely to recur in the future. Go back to the US. They'll have you out of hospital in 3 days."
    Well, he was wrong. I was out in less than 5 hours.
    The point I'm making here is that the procedure that Japanese health care was going to use, was the same one that was used on my grandfather 60 years before. By the 1930's that procedure had changed to one where - at the Mayo Clinic - the object of the surgery was to get the patient ambulatory as fast as possible in order to avoid muscle atrophy. Japan had been frozen in the 1920's, first by their own fascist regime and then by MacArthur's socialized medicine. In addition to the mess that Obamacare will create on the payment and coverage side, it will destroy innovation.
    The thing is, I don't think that the progressives are blind to these effects. If they were really convinced that Obamacare is the end-all be-all of prime health care for all, they wouldn't be so busy exempting themselves, their cronies, and the currently-in-favor political groups from it. And since, by that behavior, they know how bad it is going to be, the only conclusion possible is that these "complications" in the delivery of health care to the middle class are a feature, not a bug.

  27. rst1317:

    When someone else is picking up 70% - 90% of the cost, why would someone shop for cost? For example, if their insurance doesn't cover a procedure at a facility that costs less, their cost is higher, not lower. More importantly, what % of costs for an insurer are due to operations like hip replacement versus everyday servicing like an annual check up?

  28. FelineCannonball:

    Interesting questions. I just know that no one I know gets to make an informed decision about cost before an elective procedure and insurance companies don't seem to have a good way of keeping them down.

    My wife's last elective surgery cost 10x what we were given as an estimate and the anesthesiologist didn't go over options we were later told we had. Our 10% copay was big enough to matter to us.

  29. Quincy:

    Like it or not we have a government, laws,
    rules, and regulations. If they suck we should improve them

    Sometimes the best way to improve them is to get them out of the way. The solution to the pre-ACA status quo that would have addressed the issues you raise about price awareness is the move away from insurance for non-catastrophic occurrences. That would have been possible to try with the removal of some regulations. Instead, those plans have been made largely (if not entirely) illegal by the ACA coverage mandates.

    Instead, we have a law that kept all the transparency impairing features of the status quo and is pushing insurance markets in an unsustainable direction. The ACA is structured in a way to virtually guarantee insurance premiums go up. Way up, in a lot of cases. Insurers no longer have effective tools to limit their exposure to risk and, therefore, keep their premiums down. We're headed for what I'm sure will be billed a "market failure" by the leftists who created it.

    The only way to improve the laws, rules, and regulations right now is wholesale repeal of the ACA. The core structure of the law is irreparably broken. Worse, it precludes innovation by the private sector to attempt to find solutions to the problems you've cited. We need to roll back this monster before we can move forward with real solutions.

  30. rst1317:

    Interesting. Thank you for sharing. It's nice to get an idea of what other people are experiencing. It sounds like the first step needed for being able to compete on price is to be able to get reliable price quotes for procedures.

  31. jimbeaux:

    Long lines in the ER are directly related to three things: the number of patients, the medical problems that prompt the visit, and the determination by the ER staff of who should get treated first. A person who stubbed their toe, then waited overnight to call an ambulance to take them to the hospital, will have a longer wait than the person who is having a heart attack. The patient with the stubbed toe will complain about their long wait, but it has nothing to do with whether or not they have insurance. A heart attack trumps a stubbed toe.

    There is also an ongoing problem of patients returning to the hospital for a problem previously addressed and dealt with by medication. They say they can't afford their $4 a month meds, while admitting to a $10 a day cigarette addiction. Had they purchased their meds and taken them, they would not have to return to the ER.

    Then there are the patients who are trying to scam their way to getting paid meds. They also help clog up the system.

    And the female patients who would rather go to the ER, wait to be seen for two hours, then complain of back pain simply to get a pregnancy test (which is standard practice apparently for female back pain issues). Pregnancy tests can be purchased online for less than fifty cents apiece. They can be purchased at Dollar General for a dollar.

    There are also the patients who are lonely and go to the ER several times a week just for the companionship. At my wife's hospital, they are referred to as "Frequent Flyers". They know my wife by name and have been known to say things like, "You've lost some weight, haven't you?". If you know your ER nurse well enough to recognize slight weight loss, you know her too well.

    None of the examples above are hypothetical - they are situations my wife, an ER nurse, encounters on a regular basis, and relates to me.

    That being said, five years ago the ER would see a hundred or so patients in any given 24-hour period. Now they see the same number in a twelve-hour period. Many of them have no insurance and can't pay their bill - the hospital my wife works at wrote off over $12 million in charity care and unpaid Medicare costs.

  32. pmanner:

    I can confidently say that this is nonsense. How do I know? I'm an orthopaedic surgeon. Here are some numbers for you to consider. We get reimbursed on the basis of RVUs. The average private payer pays about $50/RVU. Medicare pays $34. Medicaid pays $21. The overhead for the average doctor's office is about 50%, and represents about $30/RVU.

    In short, the doctor will take home $20/RVU for the private payer, $4 for a medicare patient, and will pay $9 for a medicaid patient.

    As for your comment down the thread "I'm not going to read all your stuff, but ACA required reporting on hospital specific procedures means someone has to answer for having the same hip replacement parts and the same surgery varying 5x in the same city. If nothing else, people will stop paying 150k for a hip surgery they can get for 30K?" No one pays 150k. Period. The charge is a meaningless fiction.

    Medicare (which sets the price for pretty much every other payer) reimburses the hospital about $15000 for a total joint. If the hospital spends $14000, they make money. If the hospital spends more, they lose money. Very few hospitals break even on Medicare, and therefore make up the loss on the private payer patients.

  33. FelineCannonball:

    Sounds to me like there aren't enough orthopedic surgeons and their overhead is too high. They do the same job in most countries for half the money. I have two Swiss relatives who are physicians and as a lark they went over my dad's bone marrow transplant bills. It was a bit like some Mongolians I knew looking at some job listings in a newspaper I brought to the Gobi. On orthopedic surgeons not being that bad off, this is what I was reading:
    I take it that you argue with his math. Medicaid reimbursement rates aren't national by the way.

    On the cost of a hip replacement, I have a poor memory. It varied from 11k to 126k. Consistent with my experience, 40 percent of hospitals couldn't even provide an estimate. Meaning the cost is opaque to patients, physicians, and insurers. Go free market!


  34. Craig L:

    Do your Swiss relatives have to pay outrageous liability insurance premiums?

  35. FelineCannonball:

    I'm pretty sure that doesn't explain why Swiss specialist physician get paid half as much. Liability insurance for an orthopedist in the US is probably in the 25k to 30k range, and our orthopedist above almost certainly included that in his overhead costs.

    Malpractice insurance is pretty standard in the Switzerland, but the awards are somewhat smaller and the cases are easier for a doctor to win. It's probably the next most privatized system to the US but the law side is more sane. We do have that to learn from them.