ACA: Despite all the change, some things just remain the same

Obamacare has resulted in more Americans (and possibly some foreign nationals) getting Health insurance coverage. In fact, a recent Gallup poll has shown that the uninsured rate is lower than it has been since Gallup has been asking the question. The drop has been dramatic:



This is a survey of consumers, and because of that, the drop Gallup shows may be more dramatic than reality. But it has clearly dropped, and done so significantly.

One thing the architects of Obamacare had on their minds was how would these newly insured patients act when compared to the already insured population? The theory was that they would act a lot like they always had, and, as a result, be more expensive for insurance companies to cover. To counteract this influx of more expensive patients, the ACA had several means of protecting the insurers from the high costs associated with these newly insured people. The Individual Mandate was one way to balance out the influx of expensive patients with a population of younger, healthier and less expensive people. Obamacare also included some other risk mitigation provisions, including a temporary Reinsurance program, the creation of temporary Risk Corridors and a permanent Risk Adjustment provision. (A Primer on Risk Mitigation in the ACA).

Well, we have some data.

The architects of Obamacare were right to be concerned. According to the pharmacy benefit company Prime Therapeutics, its members enrolled in an exchange-based policy had a 13.6% higher prescription medication usage and usage of specialty medications was 16.4% higher than their commercial members. Prime’s experience was not unusual. Another pharmacy benefit company, Express Scripts, found that those enrolled in Exchange policies were 4.5 times more likely to be taking HIV drugs and more than twice as likely to be taking Hepatitis C medications.

Hospital ER visits are apparently on the rise as well. From Modern Healthcare:

Patient emergency room visits rose sharply at hospitals with the highest ER use in 2013, the last year before the Affordable Care Act‘s insurance expansion kicked in, according to Modern Healthcare magazine’s latest By The Numbers.

And many of the hospitals with the busiest ERs in 2013 are reporting even higher volumes in 2014 despite the nation’s declining uninsured rate.

“We’re seeing a failure of access to care,” said Dr. Howard Mell, a practicing ER physician in northeast Ohio and spokesman for the American College of Emergency Physicians.


Analysts say that trend of rising ER visits across the nation will continue until the newly insured become more familiar with the process. “More people have insurance, but the cultural norm has been to wait until they’re sick to seek care,” said Dr. Mitchell Morris, a provider consultant at Deloitte Consulting. “As they get educated, ER use will go down over a period of years.”

The culture will eventually have to change to keep more expensive ER visits down, but it is the access to care that will continue to haunt the ACA’s goal of reducing health care costs. There just aren’t enough doctors available for this new and sicker population, especially considering that the population of the country is aging.

Again, Modern Healthcare:


The number of physicians in the U.S. is growing, but not quickly enough to meet the needs of an aging population, according to a new Association of American Medical Colleges study (PDF) which projects a shortage of 46,000 to 90,000 doctors by 2025.

Of course this problem of the newly insured being more expensive will not go away, but actually get worse. Two of the three risk-mitigation programs in the ACA will expire. And when that starts to happen, debates over the financing of this program will affect all of us as government struggles to find a solution and funding. It is all about the money, and when these special programs expire, consumers will start screaming about the accelerating costs of health insurance. Some things just never change.