Coverage is Not Care

A few thoughts on the American Health Care Act (HR 1628, plus amendments) that was passed by the House last Thursday:

1) Senate Republicans are composing their own bill. Assuming it passes (a big if under the Senate's complex procedures), the House and Senate will have to reconcile their respective versions. There is zero chance that HR 1628 will be sent to President Trump in its present form. (As a matter of academic interest, see WSJ analysis if the House bill does become law.)

2) House Democrats mocked their Republican counterparts, suggesting that the latter would be thrown out of office in 2018 by the vote repealing supposedly popular Obamacare. Be careful, Dems, losers who believe they have no life after November, 2018 may ram the whole conservative agenda down your throats in the next 18 months.

3) House Republicans were divided over both how and how much to fund hard-to-insure people with pre-existing conditions, but the Senate Republicans' thorniest issue seems to be over Medicaid expansion.

20 million Americans gained health insurance after Obamacare was passed. Most were added under Medicaid. Politifact:

[Senator Rand] Paul said the vast majority of people that got insurance under Obamacare got it through Medicaid. About 20 million people gained coverage and about 14.5 million of those were under Medicaid or CHIP. But a sizeable fraction of that 14.5 million were eligible before the Affordable Care Act took effect. One estimate said about a quarter of them were previously eligible. Another estimate put it as high as half.

There is some guess work behind all the reports. Medicaid might account for slightly more than half of those who gained coverage. Most people wouldn’t say that amounts to the vast majority, but it is likely still the majority.

The numbers tell the story: if Obamacare is great coverage, then Medicaid (Medi-Cal in California), with more than half the Obamacare additions, must also be great. In 2012 the Mercury News detailed why many doctors do not accept Medi-Cal patients. In a 2015 follow-up editorial the Mercury News said the problem is getting worse:

But it’s becoming increasingly clear that the influx of 2.7 million Californians to the Medi-Cal roles [sic] is putting a strain on the state’s medical system....It’s not hard to discern why so many California doctors are loath to treat Medi-Cal patients. The paltry $16 reimbursement rate for a primary care visit makes it difficult for physicians to justify the appointment.

12 million Californians, about 30% of the population, are covered under Medi-Cal. They are putatively "covered," but are they getting health care?