The New York Times has a good article on the difference in lived experiences of the ACA in New Hampshire. The short version is that people who make more than 400% Federal Poverty Level (FPL) are screwed for a wide variety of reasons. The subsidy cut-off means these folks bear the full cost of premiums and thus the full cost of sabotage.
I want to focus on a secondary line though. New Hampshire uses the Arkansas Private Option model for their Medicaid expansion:
Instead of giving its new Medicaid recipients traditional coverage through the program, New Hampshire uses Medicaid funds to buy them private plans through the Obamacare marketplace. The report, by an independent actuarial firm, found that average medical costs for the state’s expansion population were 26 percent higher than for the marketplace’s other customers in 2016.
The firm found this raised average claim costs — a proxy for premiums — for everyone by 14 percent.
There are two drivers that could lead to higher utilization for the Medicaid Expansion population are the population is sicker than the rest of the Exchange eligible population and the lower cost sharing leads to more services for a given level of health. It is most likely a combination of the two.
New Hampshire could significantly lower costs to non-subsidized buyers by shifting the Medicaid Expansion population to Medicaid Managed Care. This would lead to a significant drop in state expenses as New Hampshire Medicaid pays providers 60% of the standard Medicare rates. Medicare rates are often significantly less than commercial and Exchange rates. This will become increasingly important as the states begin to pick up more of the tab for Medicaid Expansion.
It seems like the Private Option in New Hampshire costs everyone except the hospitals and the docs more money than a straight up expansion.
narya
At our FQHC in an early-Medicaid-expansion location (1332 waiver), our patients who are insured with Medicaid visit us more frequently than our patients who are insured with private insurance. In general, they have more medical issues, and, at the same time, our privately insured folks tend to be a bit wealthier than at other FQHCs because we also serve populations that are facing barriers to care other than/in addition to financial barriers. (We can’t tell the difference between market-purchased and employer-supplied insurance, or, at least, I can’t from the data I can grab.) What never fails to dismay me is that the people who are insisting on work requirements don’t seem to see the connections between ill health and poverty–the causal relationships go in BOTH directions, generally in a downward spiral. Not attempting to halt that spiral first is just mean. But we knew that already.
Steeplejack
@narya:
Excellent point.
Ruckus
Can’t have that government betterment, everything has to be done by the private sector. Yes it costs more, yes it’s far less efficient, yes it screws the most of the people who need the service the most but damn it the government is always wrong.
Did I catch the flavor right?
@narya:
Being mean stops poorness. Doesn’t it?
Dr. Bloor
What happens to provider availability and wait times when you suddenly increase the population of patients looking for docs who will take 60 cents on the dollar?
opiejeanne
Somewhat related, maybe, is my question. I just lost my doctor because she lost her Medicare… certification? license? I don’t know the proper term but she can’t treat Medicare patients. Another doctor told me the loss of that seems random, that one day you’re certified and the next you come into work and there’s a notice that you aren’t. Have you heard about this and why is this happening? Or am I being fed a line of BS?
rikyrah
Thanks for this information too, Mayhew
dr. bloor
@opiejeanne: I occupy a very small piece of the healthcare universe, but I’ve never heard of someone just losing cert at random–only when they get dinged for malpractice, fraud, or failing to meet standards for care/documentation, etc.
opiejeanne
@dr. bloor: I can’t imagine her being guilty of any of those, but thanks. Maybe she didn’t document something is the worst thing I think she might have done. She’s still in practice but about to move somewhere else. Right now I’m in limbo with a prescription that I need NOW and no one else in the office seems to know how to get it written. I think I have two days left of the Metformin. I swear, I’m going to take a look at Swedish and Virginia Mason even though they’re a bit of a drive. It has been convenient to deal with this medical group as far as distance is concerned and their hospital is good, but this office and others keeps losing people, NPs, Doctors, assistants and I’m wondering if I shouldn’t seek out a different medical group just to get some stability. My husband’s and my doctors keep moving away to California or Oregon or someplace else and leaving this practice. Kaiser is in the area but our retirement group hasn’t recognized them in Washington state yet. Can’t happen soon enough.
Ohio Mom
This is only tangentially related. One thing I have always wondered about is how New Hampshire ended up such a reactionary place when its next door neighbor Vermont is known for being so forward thinking.
It’s one thing when far-flung states differ wildly — who could be surprised that Wyoming and Hawaii are very different?
But New Hampshire and Vermont started out as the same colony, share the same geography and climate — what made them diverge so?
Ohio Mom
@opiejeanne: That’s a pickle. It shouldn’t be a big deal to get a Metformin renewal, of all meds. It’s not like it’s in protected class or there isn’t a doctor anywhere who isn’t familiar with it.
I mean, I get it when primary care doctors say they don’t want to prescribe say, psychotropic medications because they don’t know enough about them, and send you off to a psychiatrist. But a quarter of the country must be on Metformin.
Ruckus
@Ohio Mom
When I used private practices the docs would change seemingly monthly. For a better deal or a better fit for them. And on the other hand I’ve had 6 PCP in 5yrs at the VA.
opiejeanne
@Ohio Mom: Someone lit a fire under them and they called this morning to tell me to go pick it up at Costco. It was probably my very annoyed exchange with the phone person.