In 2020 and beyond, under the Senate’s BCRA, the working poor will have a very hard time finding primary care providers (PCP) who will schedule appointments with them. Providers, rightly, fear bad debt from high deductible plans. They will discriminate on the ability to pay upfront.
In the NEJM, Karin Rhodes, Genevieve Kenney, and Ari Friedman looked at PCP appointment availability in the from the end of 2012 to Spring 2013. They found that appointments were usually quickly available if the person had insurance and unavailable if they were cash paying patients who could not afford the median price of services.**
The overall rate of new patient appointments for the uninsured was 78.8% with full cash payment at the time of the appointment (Figure 2). The median cost of a new patient primary care visit was $120, but costs varied across the states, as indicated in the figure legend. Only 15.4% of uninsured callers received an appointment that required payment of $75 or less at the time of the visit, because few offices had low-cost appointments and only one-fifth of practices allowed flexible payment arrangements for uninsured patients.
Why does this matter in the BCRA environment?
The baseline plan will be a plan with a $7,500 deductible for a single person. For people with means, paying $120 for a PCP visit is unpleasant but not onerous. If I had to do that this afternoon, I would grumble as I pull out a credit card. I would pay that credit card off tomorrow after I got the transaction points. Not everyone can do that.
Craig Garthwaite raises a good point this morning:
You’re worried about providers not accepting Mcaid. But who will continue to treat those unable to pay for their in-deductible care? (3/4)
— Craig Garthwaite (@C_Garthwaite) June 23, 2017
Primary care providers will seek to minimize their net bad debt.
Michael Chernew and Jonathan Bush looked at how bad debt accumulates as a function of out of pocket expenses at professional offices. 
The median PCP cash visit price is a large payment in the Chernew/Bush schema. Most of it will be paid as people with means take out their credit card, their HRA debit card, or their HSA card and swipe it through the machine. But a simple PCP visit will produce significant chasing and write-downs. The study is limited as it only looked at people who were commercially insured. It excludes most low income people who are in the Medicaid gap on an income qualification basis by design. The average income in the study group is highly likely to be higher than the income of people who would move from Medicaid to benchmark plans. Even so, there is significant chasing and write downs. I would predict that applying 100% first dollar obligations on people with even less income than the study population will lead to more provider bad debt. This is because these programs are income qualified and if a person income qualifies for these programs, they probably don’t have a spare $120 floating around or easy access to cheap, revolving credit.
If we assume that some normal PCP visits will include some extra services that increase the contracted payment rate to $200 or more (very large obligations in Chernew/Bush) significant sums will be written down and off. For provider practice viability concerns, providers will very aggressively screen against people with very high deductible insurance who can’t pay the entire amount of the contracted rate price up front at the receptionist desk. This is a very patient unfriendly system.
Most payment reform models focus on delivering more primary care. The objective is to substitute cheap primary care for expensive specialist, inpatient hospital stays and post-acute rehabilitation. This is the concept behind value based insurance design. VBID is supposed to encourage the routine, low cost, regular maintenance of chronic conditions in outpatient or community settings instead of having people end up in the hospital for preventable admissions.
Yet, under the very understandable incentives of primary care physicians wanting to stay in business, access to primary care for the working poor who would have several thousand dollar deductibles that apply to all services, will be greatly restricted because of the cost barrier. If we want all members of our shared society to have decent health and decent lives, should want people to have easy and ready access to primary care. This bill creates strong business incentives to create barriers to primary care access.
** Rhodes, K. V., Kenney, G., & Friedman, A. (2014). Primary Care Access for New Patients on the Eve of Health Care Reform. JAMA Internal Medicine. Retrieved June 23, 2017.
Raven Onthill
Fractally bad, isn’t it? As we see more and more detail, it looks worse and worse.
Yutsano
Add in that most insurers and specialists won’t accept patients without a PCP referral and this is even worse than junk insurance.
Mike J
The good news is that hospitals can afford a $7500 haircut on a $100,000 surgery, so access to super high dollar stuff shouldn’t be affected as much. Of course you might not live long enough to find out you needed that $100,000 surgery because your everyday doc can’t afford the 100% loss.
Ruckus
A PCP also frequently finds an issue before it becomes acute and requires massive intervention to possibly resolve. A monetary and quite possibly life saving answer to a question not as often asked as it should be.
Zelma
Just curious – what will this do to the spreading urgent care/walk-in clinics? Will they be able to refuse care if folks don’t have insurance?
Of course, the bottom line is that many people will be unable to find any kind of consistent care and will get sicker and some will die.
low-tech cyclist
So if I understand correctly, the logic of Mitch-care is to push people off Medicaid and onto these $7500-deductible, 58%-AV policies.
Congressional Republicans must really HATE the working poor.
They’re gonna have to settle for PCP (the drug*) instead of a PCP (doctor).
*Is that stuff still around? Haven’t heard of it in decades. It was kind of a 1970s thing.
David Anderson
@Zelma: Most current urgent cares already require payment in full for the baseline visit before you are taken to the examination room. Minimal change.
piratedan
what’s even more telling… we’re on the cusp of a revolution in medical treatments, molecular medicine, based on your own personal genetics and the ability to tailor treatments and medicine to combat your illness will only now be available to the very rich. What we’re going to see here is Elysium brought to life, health will be a privilege for the wealthy and another separator between the very few and everyone else.
NJDave
I hope I’m the first to point out that David, and this blog, got another shout-out from Michael Hilzak at the LA Times.
Sab
I didn’t think they could make things much worse than status quo ante Obamacare, but both Houses of Congress seem to be doing just that.
I’m glad I got my life-saving surgery done last year so that I probably will survive until medicare kicks in.
Yutsano
@low-tech cyclist:
It has a new name but I forgot what it was.
@David Anderson: Huh. Maybe it’s because all ours in this area are run by the hospitals but the urgent care clinics here all charge my insurance with nothing up front
japa21
@Sab: I mentioned that yesterday. This situation is going to make the pre-ACA days look good. Concerning Medicare, my biggest concern is that they may start limiting what that has to cover as well. I am sure they will drop the no copay colonoscopy and yearly wellness check up.
Ohio Mom
To my amateur ears, this sounds like it will contribute to the ongoing shortage of PCPs by adding to the hassles of being one.
Also, I’d have to pull out some old EOBs, but $120 sounds low to me. But maybe I am thinking of visits to specialists.
Ruckus
@Sab:
Don’t want to harsh your mellow but they are fucking with Medicare as well. The reporting is that this bill alone does some substantial damage. I’d bet if this is successful (from their standpoint of course) there will be lots of damage to any program that uses taxed money to help people who need it, no matter how those taxes are paid. IOW pretty much everything. Remember it’s tax credits/rate cuts for rich people, so they pay less. Far less. There will be less money to go around and anything that helps non rich people will face the chopping block because of revenue neutrality. Basically it’s how can we screw you while helping our paymasters/selves.
rikyrah
Eric SchneidermanVerified account @AGSchneiderman
The @SenateGOP’s #HealthcareBill is an unconstitutional attack masquerading as reform. If signed by @POTUS, I’ll sue to protect New Yorkers.
…
The @SenateGOP #HealthcareBill imposes an unconstitutional burden on women seeking to exercise a protected right. #StandWithPP
…
The @SenateGOP #HealthcareBill continues the House’s unconstitutional targeting of New York’s Medicaid funding.
…
When the House passed #Trumpcare, I warned it was unconstitutional. Outrageous that @SenateGOP keeps same legally indefensible provisions.
…
So let me repeat in case @SenateGOP needs a refresher: I won’t tolerate #Trumpcare’s unconstitutional attacks on NYers. If signed, I’ll sue.
Ruckus
@Yutsano:
You have insurance to charge. Even with the additional 20 million who now have insurance that didn’t 4 yrs ago there is still a substantial portion who don’t have. They pay cash up front. Take away the mandate that insurance covers PCP and you will too, until you reach your deductible.
Dr. Ronnie James, D.O.
@Ohio Mom: yeah the ACA was working out great for PCPs. MillionaireCare, should it pass…not so much.
Mart
On the XM radio just now the news noted that 5 R’s are against Trumpcare (hahaha), that the bill will remove the (soul crushing) mandate, and some other things. The reporter then said the bill will protect pre-existing conditions, and then said it will allow states to drop mandatory coverage, including protecting pre-existing conditions. Really kind of hurt my head. Nothing about tax cuts for the rich, millions losing coverage, slaughtering medicaid, etc.
smintheus
A law professor wrote an important piece on the disturbing and bizarre provisions for state waivers in the Senate bill. He argues that it permits a single crazy governor to destroy some of the most important ACA provisions for every person living in the US…such as essential benefits, and annual/lifetime caps…and that once those waivers have been granted, it is impossible under the Senate bill to revoke them.
StringOnAStick
My younger sister wants to move back to this state to care for our parents, but she’s 55 with significant pre-existing conditions and has no savings. She is hoping to find a part-time job that covers health insurance, which is a pipe dream; maybe our older sister will take pity on her and put her on the payroll, but maybe not too. I told her to find out what going on COBRA would cost; she’s a state employee but with budget cuts and furloughs her net income has dropped while her insurance costs have risen so I have no idea what her COBRA would be. And after 18 months of COBRA, then what?
She wants to move back home to take care of 2 FOX-addled, long time Birchers who believe the ACA is the devil incarnate. They want her to move back home, but the people they vote for and what they believe are exactly why she may not be able to do so. She can’t go without health insurance,not with the level of physical problems she has, and going back to the cowardly old world of denials for pre-existing conditions is a death sentence for her.
Anyone between 50 and 65 in this country is always balanced between a rock and a hard place over this, even if they have a good job since losing that job means finding another one is very, very difficult just based on age alone. What the rethugs are proposing here is hugely expensive costs for someone like her coupled with poor actuarial value, something a person with no savings can’t deal with effectively. This proposal takes someone who is nominally lower middle class, puts their lives in a blender, and dumps them out as disabled working poor at the other end, provided her physical problems even let her work. Plus no disability coverage is no doubt coming down the pike next. This must be some of that winning the mango moron was going on about in the election.
trollhattan
Yesterday it was only the “This bill is too liberal” R senators carping about Mitchcare but today, this happened.
Josh Marshall rule dictates “moderate Republicans always fold” but every dent in the armor is welcome, at present.
smintheus
@StringOnAStick: You should tell your younger sister that she needs to tell your parents that they’ll have to contact their senators and convince them to vote against the Senate bill. If they won’t do that, then let them take care of themselves.
Brachiator
@Zelma:
I have not been able to find (and have not really had time to look for) info on the positive or negative impact of urgent care clinics on health care. I know that here is Southern California, for example, a Kaiser Medical facility added a section for urgent care patients. It always seems to be busy when I walk by when going for my own medical appointments or pharmacy pick ups.
There was also a recent study about how ER visits are still high.
Here’s part of the problem: Surveys show only 40 percent of doctors in the state treat 80 percent of Medi-Cal patients, largely because California has one of the lowest provider reimbursement rates in the country.
The ACA was a good beginning at dealing with health care. Sadly the GOP plan reverses gains and does nothing to improve anything.
gene108
Pulling hundreds of millions of dollars out of the economy, which pays for services, in order to give a tax cut to the rich, who will not spend their money, is the sort of thing that will eventually kick off a recession.
It’ll be a domino effect. First rural providers go down and then those, who supply to rural providers go down, and then people, who provide services to the suppliers go down and so forth and so on.
Eventually demand will drop and other companies start contracting.
Plus with the repeal of Dodd-Frank just needing to clear the Senate before Lord Smallgloves signs it, we could really be looking at the next Great Depression.
rikyrah
WOMEN ON BIRTH CONTROL COULD BE BARRED FROM WORKING IF MISSOURI LAWMAKERS GET THEIR WAY
6/23/17 AT 9:43 AM
Missouri’s Senate is considering legislation that would allow employers and landlords to discriminate against women who use birth control or have had abortions. The bill, which has the support of the state’s governor, Eric Greitens, was approved by the Missouri House Tuesday.
Known as SB 5, the bill was first passed by the Senate on June 14 following a special session called by Greitens. His aim was to overturn an ordinance that prevents employers and housing providers from punishing women for their reproductive health choices, according to a report by Feministing, a feminist website.
The ordinance was passed by the city of St. Louis, and Greitens had said it made the area into “an abortion sanctuary city.” The Senate seemed to agree with him, as did the House, which on Tuesday passed an expanded version of SB 5 that included more anti-abortion restrictions. Given the Senate’s vote on June 14, it it seen as likely to approve the updated version of SB 5. This would mean that landlords could refuse to offer housing to women based on their reproductive health choices, while employers could fire female staff members who were using birth control, or refuse to hire them. And while of course this isn’t information most landlords or employers have access to, under SB 5 they could ask women what forms of reproductive health care they are using.
http://www.newsweek.com/womens-rights-birth-control-abortion-missouri-discrimination-628538
rikyrah
Coats Tells House Investigators President Trump Seemed Obsessed with Russia Probe
JUN 22 2017, 6:08 PM ET
Dan Coats, the director of national intelligence, told House investigators Thursday that President Trump seemed obsessed with the Russia probe and repeatedly asked him to say publicly there was no evidence of collusion, a U.S. official familiar with the conversation told NBC News.
Coats’ account is not new — it largely tracked with his story as previously reported by NBC News and other media outlets, the official said.
http://www.nbcnews.com/news/us-news/coats-tells-house-investigators-president-trump-seemed-obsessed-russia-probe-n775756
rikyrah
Keep on talking smack about Bobby Three Sticks.
………………………………
Trump: It’s ‘Very Bothersome’ That Comey And Mueller Are ‘Good Friends’
JUNE 23, 2017 7:05 AM
In an interview with “Fox and Friends” set to air in full on Friday morning, President Donald Trump complained that special counsel Robert Mueller and former FBI Director James Comey are “good friends.”
“He’s very, very good friends with Comey, which is very bothersome, but he’s also — we’re gonna have to see,” Trump said when asked if he is going to fire Mueller in an excerpt published Thursday evening.
The President claimed that “the people” hired by Mueller to work on the Russia probe “are Hillary Clinton supporters.”
http://talkingpointsmemo.com/livewire/trump-comey-mueller-good-friends
D58826
Short answer to the problem – if your poor don’t get sick. If you do get sick then die quickly (and preferably out of sight so as not to offend the sensibilities of the 1%)
LurkerNoLonger
@rikyrah:
I think I’m in love. How will I tell my wife?
sharl
This has probably been linked in comments in an earlier post, but in case not…
Vox’s Congressional reporter Jeff Stein interviewed Rev. William Barber: Rev. William Barber: Obamacare repeal would be the greatest moral failing since slavery. Rev. Barber already has protest projects in the works; it’s as though he isn’t surprised by what has transpired.
In that interview I also learned of Lincoln’s short-lived Freedman’s Bureau for newly freed slaves, and the also short-lived Freedman’s Bureau Hospitals [why short-lived? You’ll never guess {/snark}].
So not the first time government health care support has been attacked, only this time it’s a very scaled up effort.
trollhattan
@rikyrah:
Oh, is that the same “Fox and Friends” as this one?
Keep rogering that rooster, Fox.
Crashman06
@trollhattan: A nice sign but Josh is right. Absolutely cannot trust this; who knows what kind of sweetener could be thrown in to change his mind.
D58826
@trollhattan: Well of course people with something to hide walking the front door, esp when you are 6’8” tall. It’s only honest people who need to be smuggled into the Trump Tower incognito and thru the backdoor. Surely the faux folks at faux news could have asked that great faux expert on being sneaky in spy novels – Sen. Tom Cotton.
dr. bloor
@Mike J:
Actually, the bad news is that many hospitals can’t actually afford to take a $7500 haircut on $100,000 procedure/stay.
The worse news is that the patient isn’t getting through the front door until that $7500 is guaranteed somehow.
D58826
@trollhattan: OH there is a much simpler explanation – he has a signed first edition of ‘The Art of The Deal’. Page 277 says make an
unreasonably tough opening bid.Your opponent will be so impressed that he will smile, offer you coffee and never once tell your constituents how quickly and at what a cheap price you sold them out for. It’s just knowing how to do the deal.
D58826
@dr. bloor: Hopefully the ER is off to the side so the victim, I mean patient, can die out of sight on the rear parking lot. Otherwise he might scare the horses.
StringOnAStick
@smintheus: These are people who told me to “get the hell out of our house” 2 years ago when I suggested that they needed to start hiring help to care for their home and yard maintenance needs. After 59 years of dealing with their very, very conditional “love” that is based entirely on if you agree with what they are yelling at you about, I’ve decided to take that “get the hell out” demand seriously and leave the field to my other sisters. My therapist agrees. One sister is of the approved political party (first Limbaugh supporter I’d ever known; never heard of him before she brought him up in the early ’80’s) and the one who wants to move back and help them is a democrat but can keep it hidden much better than I can, probably because she is so desperate for their approval that she’d paint herself blue if that was what they told her they wanted.
There are a lot of people here that post stories that tell me they themselves are good parents or were lucky enough to have had good parents. I am left wondering exactly what that would be like.
RepubAnon
So, Trump just passed a big de-facto tax on doctors and hospitals. Next up, a bill stating that private hospitals can turn away poor people…
Ohio Mom
@StringOnAStick: Your poor little sister. I hope she finds the self-esteem to take care of herself first and decides to keep that government job. It has to be a better bet than anything else she would find after moving. Especially since health coverage is crucial for her.
I had one okay-enough parent and one who deserted us. Much later he wanted to meet his grandson. I agonized over it but could not see any advantage to making contact with him. In the words of my uncle, “Parenthood is more than donating sperm.” Or supplying a womb, I’d add.
Why am I not surprise to hear that the sibling who can not be counted on to hire the youngest is a Dittohead?
Mnemosyne
@StringOnAStick:
Ugh. I had/have a lot of issues with my parents, who were pretty screwed up by their parents, but at least my parents weren’t actively toxic like yours. I’m sorry.
Mnemosyne
@Ohio Mom:
With the caveat that I am by no means an expert, it seems like most families with toxic and/or narcissistic parents produce at least one kid who is just like the parent(s), usually termed the Golden Child. I’m guessing the Dittohead fulfills that role in String’s family.
Earl
@StringOnAStick: I know I’m not a nice person, but that’s super funny. Your parents are actually (gasp) bearing a… (OH NOES) consequence for their behavior! I’m sure the whining will be audible from Mars.
Ohio Mom
@Mnemosyne: In a twist on that theory, I’d say my SIL fulfills the role of the golden child. She grew into it, has been a real natural at the role — my MIL is the narcissist and increasingly adores SIL the more obnoxious she becomes.
This is a useful way of looking at this dynamic for me, thank you.
StringOnAStick
@Earl: Yeah, I see the humor in that for sure.
My younger sister thinks they are great parents. Then again, she’s had 2 marriages to obnoxious narcissists too. She’s basically a good person with self esteem issues who apparently thinks this move will finally get her the parental attention none of us ever got b
Carlito Brigante
@Ohio Mom:
$120 is low for an initial visit.
Carlito Brigante
We have what amounts to an open account with our local medical system. My daughter and I have moderate medical issues that are controlled with medication, frequent testing, and more office visits. But this maintains us in good health. My wife works at a large public university. We have a high deductible plan with an HSA that the university poorly funds. So every month we write a check for services and never get the bill paid down before another charge comes up.
I spent ten years as a Managed Care and Health Plan Attorney and ten years as a HIPAA Privacy and Security Consultant. I took my first look at healthcare reform in 1991. I could not have imagined that things could have deteriorated so much in the intervening years. We missed the boat by rejecting Managed Competition in 1994.