Then vs. Now: How Dire Predictions About Obamacare (Mostly) Didn't Come To Pass

by Dan Diamond, California Healthline Contributing Editor

It may be too soon to know if the Affordable Care Act is making Americans healthier. But there's a smattering of data that suggests the law is making the health care industry healthier, at least.

A tracker indicates that newly insured patients aren't overwhelming doctors.

A batch of anecdotal reports suggests that hospitals' uncompensated care spending is falling.

And a survey of physicians finds that -- while many doctors are upset about the law's added complexity -- they're generally happy with the pay that they're seeing through the ACA's new marketplace plans.

Taken together, the slew of upbeat reports for the industry isn't surprising. (The law was expected to bolster the health care sector by growing the number of insured Americans.) But the positive findings are in contrast to a dire batch of predictions that accompanied the ACA's bumpy rollout across the past year, when the entire law sometimes seemed to be on shaky ground.

Here's a quick look back at several of those predictions, and how early findings are bearing them out -- or not.

How Obamacare Would Affect Patient Demand

    Then: A wave of chronically ill patients would swamp health care providers.

    Now: A trickle of new Medicaid beneficiaries is showing up in some states.

The conventional wisdom around the ACA's newly insured patients: They were going to be older, sicker and overdue for care. And as a result, they'd rush to see doctors as soon as they could.

The reality?

New patients in the first quarter of 2014 tended to be strikingly similar to new patients in 2013 -- and in some cases, the latest crop of patients are actually healthier.

That's taken from ACAview, a tracker from athenahealth and Robert Wood Johnson Foundation that measures data from nearly 13,000 doctors that use athenahealth software.

And based on results from the first quarter of 2014, "we're not seeing notable change in new patients seeking office-based ambulatory care," athenahealth's Josh Gray tells California Healthline. Essentially, demand for doctors in the first three months after the ACA expansion kicked in was roughly the same as the year before. The pool of new patients may have even shrunk.

What gives? It's quite possible that it's too early to see any results manifest, Jason Millman notes in the Washington Post's "Wonkblog." It can take time for patients to make appointments or develop health conditions that prompt them to seek care. And athenahealth acknowledges that the number of newly insured patients may have been relatively small and easily absorbed into the health system.

Gray pointed out that athenahealth is seeing a change in one area: payer mix.

"In the Medicaid expansion states, primary care providers are devoting a higher share of their practice to Medicaid patients," Gray said. "We're not seeing that at all in non-Medicaid expansion states." 

"It looks like poor people who are now eligible for Medicaid are seeing the benefits of coverage expansion," he added.  But "our metrics do not so far support the hypothesis that health care reform will unleash pent-up demand."

How Obamacare Would Affect Hospitals

    Then: Safety-net hospitals warned that the law would leave them grappling with higher uncompensated care costs more than ever.

    Now: Some safety-net hospitals are seeing uncompensated care costs plunge.

After the Supreme Court ruled that the Medicaid expansion was optional, safety-net hospitals began warning that the law's changes to disproportionate share hospital payments would cause serious financial harm. Even in December 2013, more than 100 hospital CEOs warned Congress that safety-net hospitals stood on the brink.

But today ...

"We have seen a steady decline in our uninsured visits," Roxane Townsend, CEO of University of Arkansas Medical Center, told Phil Galewitz of Kaiser Health News. "We did not anticipate this big a drop this quickly."

About 80% of the system's new Medicaid patients had previously been uninsured patients at the hospital. And UAMS saw a 33% annual decline in year-over-year visits by uninsured patients in the first quarter of 2014.

UAMS may be an isolated example. But other safety-net hospitals across the nation are reporting similar gains in revenue and a fall in uncompensated care, Galewitz says.

The fall in uninsured patients seeking care also may coincide with a larger change by hospitals: to cut back on their charity care policies. A small number of organizations are beginning to limit who can qualify for free or discounted care, Abby Goodnough writes at the New York Times. That's partly an effort to push more people to obtain health coverage under the ACA, whether by shopping in the insurance exchanges or getting public coverage when available.

How Obamacare Would Affect Physicians

    Then: Doctors warned that the law would impose new burdens.

    Now: The diagnosis is mixed, but the prognosis is favorable.

Physicians have consistently groused that Obamacare is causing new headaches for them -- so much so that it might prompt some of them to quit the business.

And a new Medical Group Management Association survey of 728 practices -- representing almost 40,000 doctors -- confirms that the law contains its share of headaches. The inability to get key details about patients covered through ACA plans is complicating the insurance verification process. Even now, nearly 60% of practices predicted that the ACA's exchanges would have an unfavorable, or very unfavorable, impact on them.

Yet ...

Physicians acknowledged that the rates paid out by ACA plans were generally equivalent to or surpassed the pay they got from Medicaid and Medicare reimbursement. And given the options, they'd rather take exchange customers than sit out entirely: More than 80% of surveyed practices ended up opting into the exchange.

Around the nation

Here's a look at other stories making news on the road to reform.

Health insurance exchanges are 'like flea markets': The marketplaces may be bringing sellers and buyers together, but they're still a work in progress, Eric Whitney reports for NPR.

Fee on big businesses helps fund Obamacare: In a report for Kaiser Health News, Sarah Jane Tribble notes that the ACA's fees on large self-insured employers like Sherwin-Williams are helping pay for individuals to get coverage on the insurance exchanges.

Robert Forster
Dana, taxes are paying for the subsidies in the exchange--You can't insure millions more and yet the cost goes down--you must reduce access like England or deal with the physicians aND others to let them know less is going to be paid in the future for a service. Yes, efficiencies help, but the drivers are the use times the cost of use. Canada sees there doc on ave. 4X per year, it is 8 times in the USA. Low payment has now created a vigorous private non government system along with the governmental system. We are more obese and demand technology (its all about expectations) in the USA--so expensive services will be delivered at the tax payers expense--cost always returns to the middle class. Open your eyes and deal with facts and not compassionate wishful thinking and words. There are no delivery system savings in the current and ever changing PPACA. I have read it 3X by requirement, Have you? really? Fraud dollars are increasing not decreasing and the bureaucracy grows.
Dana Anderson
Q: "How do we save money by insuring more?" A: The insured are buying their own. The newly insured are getting preventative care, to theoretically reduce future costs for critical care. In my community the crackdown on Medicare fraud, which began even while the ACA was being debated, has led to increased collaboration between the different levels of care providers. Now hospital groups are reaching out to nonmedical care providers to help provide continuity and reduce re-hospitalization. That was a thing they didn't care about in the past, but the threat of being fined is working miracles to make them consider nonmedical options like assisted living. Case management is a vital component. Yes, sometimes a person who needs a hospital bed has to buy their own because it's no longer covered, but the net effect looks like eventually less churning patients in and out of the system and more gentle, less expensive treatment of elderly and indigent.
Dana Anderson
Q: "How do we save money by insuring more?" A: The insured are buying their own. The newly insured are getting preventative care, to theoretically reduce future costs for critical care. In my community the crackdown on Medicare fraud, which began even while the ACA was being debated, has led to increased collaboration between the different levels of care providers. Now hospital groups are reaching out to nonmedical care providers to help provide continuity and reduce re-hospitalization. That was a thing they didn't care about in the past, but the threat of being fined is working miracles to make them consider nonmedical options like assisted living. Case management is a vital component. Yes, sometimes a person who needs a hospital bed has to buy their own because it's no longer covered, but the net effect looks like eventually less churning patients in and out of the system and more gentle, less expensive treatment of elderly and indigent.
John Brown
So much of the law has been postponed it is hard to tell what the real effect will be.
Robert Forster
Tim is correct and we are only at the beginning of the beginning. Any results are tentative at best. Quoting so called experts at this point is showing bias for the program's performance which is premature and will certainly varies geographically. I would just like to know 1. How do we save money by insuring more 2. net/net how many more persons entered the insurance market? 3. How do we insure the remaining 30-40 million uninsured Americans when the piggy bank is empty? Also re: docs signing up--it is like Medi-Cal, 80% there have signed up for the program, but 20% provide nearly 85% of the care. The physicians just are hedging their bet. It in no way reflects how many will be accepted in their practice. Medi-Cal payment rates in California are the primary reason for such a low actual participation by physicians. States who pay (reimbursement) is close to MediCare's have a high participation rate. Like most things, it is about the money. There are notable exceptions.

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