Hail Mary for Healthcare.gov

If you’re selling a dud, will an extra 48 hours make a difference?

Having already strategically downplayed Affordable Care Act enrollment expectations, the federal government again hopes a Hail Mary will save Healthcare.gov enrollment.

{mosads}A similar ploy was trotted out before, and failed.  In February 2014, the Congressional Budget Office had estimated 13 million Americans would be enrolled in health insurance through ACA exchanges in 2015, and 22 million in 2016.

We will not have reached either of those projections through next year.  Instead, the federal government is now projecting it may have 10 million enrollees for 2016.  Why is this underperformance, and especially what is driving it, not a more significant story?

A fine of $695 is not incentive enough to buy insurance with networks so narrow that they may exclude your doctor, or the care found in places such as cancer treatment centers and certain hospitals, and deductibles so high – as much as $6,850 individually in 2016 before even accessing care – they make subsidized premiums meaningless in relation to overall cost.  Many people are making the entirely rational decision to risk paying a fine rather than buy an effectively useless product.

However, the private insurance the more affluent-uninsured are forced to buy on exchanges is not the only disappointing, inaccessible ACA guarantee.

In states where Medicaid expansion is an option for the working poor, atrocious provider rates have created illusory coverage.  For example, although pediatric dental coverage is an essential benefit under the Affordable Care Act, the most recent study by the Health Policy Institute of the American Dental Association shows, again, that the states most supportive of the ACA are among the worst Medicaid payers.

For example, in Washington, Medicaid reimbursement for kids, as a percentage of private dental charges, falls, at 41 percent, far short of the 49 percent national average.  Even ACA-fighting Mississippi, at 48 percent, pays more.  Indeed, Texas, which has also ardently resisted implementing the ACA, including Medicaid expansion, pays Medicaid dental rates for kids at 60 percent of the national average for private charges.

Low reimbursement rates will not attract dentists to serve the Medicaid population.  In Washington, only 29 percent of dentists serve children on Medicaid, compared to a national average of 42 percent.  In such a case, Medicaid expansion merely creates a greater pool of young patients to turn away.

Similarly, according to the Kaiser Family Foundation, Washington ranks 34th in the relation between its primary care Medicaid rates and those higher rates paid by Medicare.  Again, anti-ACA Mississippi eclipses Washington – Mississippi pays primary care Medicaid rates at 90 percent of the Medicare rate, while Washington pays 66 percent.  The two biggest states embracing the ACA pay Medicaid rates even worse in relation to Medicare: California pays 43 percent, and New York 42 percent.  That has made those states’ office-based physicians very reluctant to take on new Medicaid patients – federal data shows such patients would be turned away by 45.8 percent of California doctors and 42.9 percent of their New York counterparts.  It can be very difficult in many places throughout this country for the parents of a child to find a pediatrician who takes Medicaid.

We can reasonably expect Medicaid payment shortfalls to worsen in 2017, as states start paying expansion costs that, to date, have been borne entirely by the federal government.  While the federal contribution will, in time, drop to no lower than 90 percent, finding even 10 percent of expansion’s cost will be no small task for states, with their frequent boom-or-bust budget cycles, that were already faltering in maintaining pre-ACA Medicaid obligations – not the least of which is an aging society’s long-term care costs.

These facts regarding the accessibility of ACA “coverage” – which should trouble anyone committed to the former idealism behind healthcare reform – should not be obscured by ACA cheerleading.

Williams, an Olympia, Washington attorney, is a frequent healthcare writer.