With the media’s focus on cancelled plans, higher premiums and the website launch, ATQ Poll turns its attention to other ACA issues:  Medicaid expansion, access to doctors and hospitals, and employer sponsored plans.

What benefits and costs (coverage, financial) do states weigh when deciding whether to opt in vs. out of ACA Medicaid expansion?

The goal of this question is to expose the decision making process that states use in determining whether to opt-in or out of Medicaid expansion, and to do so in clear, monetary/human, cost/benefit terms.

At last update, 27 states have opted-in for MC expansion, 21- out, and 2 (PA, TN) are on the fence.  The decision pivots on 2 considerations: the cost of expanding MC vs. not, and additional people covered with the expansion vs. not.

The terms of cost in ACA are:  the government pays 100% for 3 years, 90% thereafter.
Coverage:  CBO estimates 3 million people will be left uncovered in states that opt-out.

With such favorable terms for opting-in, and the high human cost of not, why are so many states choosing to opt-out?  It seems to come down to a cold assessment of whether the 10% saved in states that opt-out (starting year 4), will more than cover the ER expenses incurred by those left uninsured.

Some states claim that additional 10% will strain their budgets. Others (PA, AR) have requested funds for private insurance, leading one to Ask if that is more cost effective for them than MC, and how.  In this NYT article, the reasons against opting-in in Tennesee are left vague: Republicans are against it (why?), and a previous state system failed.  Groups in favor of opting-in include Democrats, the Chamber of Commerce, poverty & health groups, one of which claims 400,000 will remain uninsured and drive costs up with ER visits.

A refrain heard in the news and echoed by TN’s Governor, is that Medicaid does not control costs.  With at least as many claiming otherwise along with a plethora of other hotly contested issues, the media must start invoking Cite The Basis, Ask The Question, and other Rules if we are ever to resolve these disparities and further our knowledge on what specifically is good, and what is not, about Medicaid.

The News Hour provides an example in this discussion which, comprehensive though it is, still hilights such points of disagreement or lack of specifics where an ATQ or CTB could have illuminated so much more.

Why are insurers dropping hospitals & doctors from their plans?

There have been numerous stories on doctors and hospitals being ‘dropped from plans’ but nothing explaining why.  The obvious guess is that it has to do with negotiated payment apportionment between doctors and insurance companies, the assumption being- they are less favorable to doctors under ACA.

In this CNN video, Tom Harris explains that he’ll have to find a replacement for his allergy doctor of 20 years, who is being dropped from his plan, and is too expensive without the coverage.

His doctor, Robert Eitches says he doesn’t know “which, if any, insurance plans he’ll accept”, and “has already stopped taking Medicare” (for which the reimbursement rates to doctors have been lowered).  As for the insurance, his admission that he is considering “not taking any insurance at all” despite regretting the loss of patients he has bonded with, makes no sense whatsoever and is not followed up with additional questions or information from CNN.

Was Dr. Eitches ‘dropped’ from the plan by the insurance company?  Or were the terms changed that caused either Dr. Eitches to drop the insurance, or Mr. Harris to drop the doctor due to higher out-of-pocket expenses for him?  And if Dr. Eitches takes ‘no insurance’, does he not deny other patients his services?

In a CNN debate moderated by Candy Crowley, Sen. (& Dr.) Barrasso, states: “in New Hampshire, Anthem Blue Cross/Blue Shield is excuding 10 of 28 hospitals”.  Howard Dean’s response: “that’s the insurance commissioners fault”, is the only explanation given.  There is no follow up query from Ms. Crowley on what role insurance commissioners have, or what the “fault” of NH’s is.

How many businesses are reducing employee hours to part time levels and how many workers will lose healthcare coverage due to that?

Stories of employers reducing workers hours, or the workforce itself, to avoid having to insure them under ACA have been anecdotal and remain unquantified.  In an economy of high unemployment and where many of the ‘job gains’ have, in fact, been either low wage or part time, this is an important question.

In this CNBC segment, 2 surveys were compared.  One with 400 people participating showed a negative effect, the other with 60,000, showed no effect.

The impact of ACA on small businesses is shown from the business owner’s perspective in this interview of two of them.

Matt Tyler, of Vickers Engineering, employs 175 people and says his insurance cost in 2014 will increase by 50% (11% taxes & fees, the rest ACA changes), and will be shared with employees.  He is further concerned about the lack of flexibility and growth of healthcare in future years.  Beezer Molton, of Half Moon Outfitters, has 120 employees, 90 of which are part time. He says they will adapt by pushing for still more part time employees to mitigate risk going into 2015.

So, the initial impact of ACA is just beginning to be discovered.  One expert says it will take 3 years for ACA to ramp up.  Given the many testbeds in it for cost control, it will take that, and years more, for the system to settle out.  The issue of overall health costs is not dealt with in this poll, but it is one of the most important elements that will ultimately determine the success or failure of ACA. As with many complex issues, the consideration of time and long term thinking is critical in evaluating policy solutions, mandating the incorporation of it into any media discussions deemed honest.