The law’s medical malpractice reform provision also is a missed opportunity, Dr. Setzen said. Physicians have stressed that a cap on noneconomic damages is another important part of health system reform, but the act includes no such limit. The measure authorizes funding for five-year state demonstration programs to develop, implement and evaluate alternatives to the current system. “I don’t see how that is going to do anything meaningful in a reasonable timeframe,” Dr. Setzen said.
Explore This IssueMay 2010
Dr. Setzen and others expressed concern about the law’s Medicaid eligibility expansion. Many doctors accept Medicaid patients because they believe they have an obligation to those patients, he said. The payment rates are so low, however, and the administrative burden is so high that providing care to Medicaid patients is essentially equivalent to charity care, he said.
The law increases primary care physicians’ Medicaid payment rates to the Medicare level, but that provision doesn’t apply to specialists, such as otolaryngologists, Drs. Setzen and Johns noted. The low reimbursement level for specialists raises questions about how many of them would be able to afford taking on newly covered Medicaid patients, Dr. Setzen said.
The combination of the Medicare payment cut threat, low Medicaid reimbursement rates and physicians’ medical malpractice issues could limit the health system reform law’s success, Dr. Setzen said. “When you take an already burdened system and there is such a strain with respect to workforce and you introduce 32 million people, access by necessity is going to be limited,” he said.
The act establishes a National Health Care Workforce Commission that will evaluate whether the demand for health care workers is being met and recommend solutions. “That’s something we’re very interested in—how the commission will be structured, what it will do,” Dr. Johns said.
Fear and uncertainty exist in the medical community about the new law’s implications, Dr. Setzen said. “A lot of people are waiting to see how this unfolds.”
It is unclear how the individual mandate and the penalties for businesses that don’t provide coverage will pan out, Dr. Setzen said, pointing out that some individuals and employers could opt to pay the fines rather than buy insurance. “Because the penalties are low and incremental, I think a lot of patients will pay the penalty in the first and second years and still show up in the ER,” he added.
Given the budget crises in the states, physicians also worry whether the state health insurance exchanges are financially sustainable. If the states can’t afford to operate the exchanges, they could become a federal responsibility, Dr. Setzen said. “Is the government the best entity to run the health care system? I’m not convinced of that,” he said. It’s also unclear whether some states will want to create exchanges, Dr. Johns noted. If they don’t, the federal government can step in and develop them. “How that will work and whether that will work remains to be seen,” he said.