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Saturday, August 25, 2012

ACA hospitals and doctors part MMMMMMCCCLXXXV

Here Matt Yglesias runs into my ACA squeezes hospitals nursing homes and home health are agencies obsession and I comment (againnnnnnn)

Oh I note the URL
doesn't correspond to the current title

Cutting Medicare Provider Payments Will Probably Hurt Some Patients

One will probably be embarrassed more often if one writes "Will Probably" instead of "May." and one may even regret it. "Might" makes right.  Be gay write "May." (in the sense of cheerful and worry free not that there's anything wrong with it).

OK my comment.

I kinda sorta semi disagree.  I mean I agree that "nothing to worry about" is implausible (never say "never" and most claims including "nothing" are worth approximately that).

But your discussion overlooks a key difference between the Medicaid stinginess which hurts the poor and the ACA stinginess.  the ACA squeezes hospitals nursing homes and home health care agencies not doctors with office practices.

I think this distinction is fundamental.  The argument that squeezing providers will hurt patients always includes the key word "doctor" which means office practices (which means Medicare plan B not Medicare plan A).  The ACA totally absurd forecast of labor productivity growth equal to that of the economy in general (which is really just a way to say we will squeeze you) applies only to plan A not plan B.

So the question I asked myself is are there any hospitals who refuse to see Medicaid patients (note this means they get no money for taking care of Medicare patients either -- the deal the CMS offers is take all of them or leave all of the cash with us).  I googled for about half an hour and found nothing (except a decade old claim about an un-named hospital somewhere in I would guess Rochester NY).
I will link only to my google self search because I have made this claim so many times

Basically even if silly accounting (which distributes sunk costs over procedures) says hospitals will lose money taking care of Medicare patients, they won't be able to turn them alll away without laying off half of their staff, selling half of their equipment and renting out half of their rooms as apartments.  In contrast the decision to sink costs (build new hospitals and wings of hospitals) depends on overall returns where the Medicare cuts are balanced by the reduction is losses from care of the uninsured.

Also hospitals have to provide emergency care.  If an elderly person shows up in  non-Medicare participating hospital's emergency room, he or she can't be released until he or she is stabilized.  Then he or she can't be billed.   If Mitt Romney shows up with an emergency in the emergency room of a hospital which doesn't participate in Medicare, that hospital would have to give him care for free (no matter how little he likes that).

And nursing homes come on, they get most of their income from the CMS.  They aren't refusing Medicaid patients.

I think the ACA was written with full consideration of the doctors not taking Medicaid patients problem and designed so that it would lead to almost no refusals to see Medicare/aid patients.  If there are any, they will be the very top hospitals without active emergency rooms who can fill their beds with patients with private insurance (as in the Mayo Clinic, Stanford U Medical center and *not* the MGH or Johns Hopkins).


run75441 said...


One of the reasons hospitals accepted the ACA was the increased in insured which were formerlly uninsured. The other reason is the growing population of elderly whio will need care. Reject both of those growing numbers and you are doomed to no growth.

save_the_rustbelt said...

Robert my friend:

You have much too much confidence in the ability of the federal government to change a huge and incredibly complex system without triggering all sorts of unexpected consequences.

resisting the machine said...

Quite a few California hospitals have no ERs; more every year- ERs lose money. The most recent figures that I could find are at and show 121 hospitals in LA County with 75 providing some ER services in 2009 (would be fewer today)- a few have only standby which means doc on call, not a place that you should go to. I'm a public sector MD; many hospitals in the area accept Medicaid and Medicare patients as inpatients but typically discharge them without any follow up, even though they may be on a complex and dangerous drug regimen, instructing them to go to the nearest county hospital ER and demand follow up- that clogs our ER and it's often difficult for us to get comprehensive medical records from the gold coast hospital, unless we have a family member go there and make a stink- otherwise we get 6 pages of lab tests, no information as to why doctors did what they did, etc.

The doc fix or SGR is a separate issue (and a disgraceful one going back to 1997, the Democratic 'leadership' stupidly assumed that they could come along in the next few years and fill the holes in the ACA, they didn't foresee the wild and incoherent agitation against 'Obamcare') relating more to outpatient than inpatient care. The ACA makes a partial and secretive effort to curb Medicare Advantage Programs, which are corporate welfare. SCAN agreed to pay a fine for falsifying Medicare advantage accounts in California this week. They should all be closed. Some complaints that Obama had cut Medicare come from cutting Medicare Advantage.

The Ds lack the gonads to make a direct assault on any evil; there are many evils in our profiteering healthcare nonsystem, as long as we depend on profit making insurance companies, we will have big problems. I don’t mean that the govt must be the insurer, if insurance cos were forced to be nonprofits, as many once were, things would improve.

Robert said...

I don't get it rusty. I didn't say that there wonìt be many unexpected consequences. I just said that one consequence expected by many (including the chief Medicare actuary) is unlikely. My clam is very narrow and in no way justifies your erroneous perception of my alleged confidence in something which I have never written.

Of course you might be arguing that if I didn't have such confidence I wouldn't support the ACA. But the horribleness of the current system is enough to convince people who expect the unexpected and know about unknown unknowns to support the ACA.

In any case, your comment doesn't seem to me to respond to my post. I will stop typing now because I am about to get rude.