What happens when you add 100,000 new patients to Connecticut’s health care market but don’t increase the number of physicians?
Delays in getting a doctor’s appointment? A rush on elective surgeries? Better overall preventive care, leading to fewer emergency-room visits?
We may be about to find out.
Tuesday marks the opening of a new online marketplace for health insurance in Connecticut for policies that take effect Jan. 1.
That will create an influx of formerly uninsured patients into the health care system, but what that will mean is a matter of conjecture. The answer could depend in part on the number of people who sign up for coverage, and in part on the health of those new enrollees.
Connecticut’s new online marketplace, or public exchange, called Access Health CT, estimates that its potential customers are roughly 345,000 uninsured people, or about 10 percent of the state population. The U.S. Census Bureau this month put the state’s uninsured rate at an even lower figure: 8 percent.
Not all of the uninsured will buy insurance this fall for coverage next year. Young, healthy people may opt to pay a penalty, which is relatively inexpensive next year compared with the cost of insurance. Also, people who aren’t citizens can’t get a tax subsidy and therefore health coverage won’t be as affordable as it is for a citizen. So many undocumented immigrants could remain without health insurance.
Access Health CT hopes 80,000 to 100,000 people will sign up by the time open enrollment ends March 31, 2014. In addition, an estimated 20,000 to 30,000 may learn through the exchange that they qualify for Medicaid.
Some health experts say it could take longer to get an appointment with a primary care physician, though there’s disagreement on the matter. It’s possible that longer waits would occur only in places that are expected to have a high rate of newly insured people, such as New Haven or Hartford.
It is unlikely that the new patients will cause a rush on elective surgeries, such as hip replacements. And many hope that emergency departments will be relieved of some unnecessary visits.
Under one scenario, if there is a rush on primary care and it causes delays, some people may go to urgent care clinics instead. Doctors and hospital administrators, however, hope that mid-level providers — nurse practitioners and physician assistants — will help meet any increased demand for primary care, at least to a degree.
“A lot of these types of arguments are predicated on certain types of assumptions — that there’s massive, pent-up demand. We don’t know if that’s true or not,” said Jason Madrak, chief marketing officer for Connecticut’s online marketplace, or public exchange, called Access Health CT.
“We could sign people up; it doesn’t necessarily mean that they’re going to be running for the nearest clinic on Day 2 of their coverage.”
‘Strain On The System’
Mark Schuster, a South Windsor health insurance agent for 23 years in Connecticut, said that, now, “It’s a cattle call going into the doctor’s office to even get an appointment.” He said he believes people who buy plans on the exchange will discover that the network of doctors isn’t as robust as other commercial plans, and they will be the ones having difficulty getting into a doctor.
Most people won’t see a major difference, said Zack Cooper, a Yale University assistant professor of public health, health policy and economics.
“I don’t think that’s going to affect people who are fully insured,” Cooper said.
The noticeable difference will be for people who are now uninsured and go “from absolute misery to having health care,” he said. “The rest, OK, maybe you see on the margin a day or two longer wait.”
Cooper said the drama we’ve seen on television about the Affordable Care Act is partisan politics and not the likely result of new health policies.
Some primary care physicians are expecting to be busier with the new crop of patients, and they say delays are likely.
“This is going to be a strain on the system,” Dr. C. Todd Staub, an internist in Litchfield and chairman of ProHealth Physicians, which has nearly 350 medical providers in more than 80 locations across the state.
What’s not clear is to what degree people will wait longer to see a doctor. An extra day? More?
“We don’t really know what the primary care infrastructure is in our state,” Staub said. “Surprisingly, we don’t have good data on that.”
When people have access to good primary care, visits to hospital emergency departments decline, Staub said. Many doctors, hospital executives and insurers hope that broader coverage will translate to reduced hospital expenses, which could curb the growing cost of medical care overall. Some people now end up in an emergency room for routine treatment that could be handled at a less expensive urgent-care facility, or by a primary care doctor.
“Detecting acute and chronic illnesses earlier should lead to better outcomes, hopefully, keeping people out of emergency rooms by addressing their health issues sooner, or by giving them the access to primary care,” said Dr. Robert Nardino, an internist at Yale-New Haven Hospital’s Saint Raphael campus and governor of the Connecticut chapter of the American College of Physicians.
There is a general trend among hospitals, insurers and the Affordable Care Act to emphasize wellness, preventive services and better coordinated management of chronic diseases like diabetes. If a nurse calls you after a surgery to make sure you are taking your medicines and following through on physical therapy, that is part of a general trend within health care.
People in Connecticut are likely to notice lots of differences in health care in coming years, though not all of those changes are a direct result of the Affordable Care Act.
For example, hospital mergers will continue for simple economic reasons. Large hospital systems have greater bargaining power than smaller ones when they negotiate with insurers for reimbursement rates on medical treatment.
It may be difficult for patients and casual observers to sort out what is related to Obamacare and what isn’t.
“Everybody is lumping everything together. People have a very difficult time distinguishing one aspect of it to another and there are a lot of interdependencies,” Jess Kupec, CEO of Saint Francis HealthCare Partners, which includes Saint Francis Hospital and Medical Center in Hartford.
If you’re planning to have hip surgery, or some other elective procedure, there is probably no need to rush and schedule that operation before Jan. 1, according to hospital executives.
It’s not as though the new patients will crowd hospitals with demand for elective procedures, said Dr. James P. Cardon, chief clinical integration officer at Hartford HealthCare, the parent company for Hartford Hospital and other hospitals in the state.
When Massachusetts implemented a statewide health care program, which acted as a model for the Affordable Care Act, people didn’t rush to get care, Cardon said.
“It wasn’t everybody rushing in to get hip surgery and heart surgery,” Cardon said. “It was much more the basic kind of stuff that people just need, deserve and should be able to get access to.”
Doctors and hospital executives disagree about whether Connecticut’s experience will be similar to Massachusetts’ experience. Cardon suspects it will be.
The biggest change could be in the way employer offer health care coverage to workers.
Health care costs are a major burden on employers. Some health insurers and policy experts predict that a number of employers will stop providing health care directly to workers, instead opting to pay a lump sum to an employee who could then shop for coverage on a private health exchange. A private exchange would have a similar buffet-style list of health care options, though it would not have federal subsidies, which are only available on one public exchange per state, like Access Health CT.
“We already have a private exchange product in Connecticut,” said Michael Wise, president of ConnectiCare, a Farmington-based health insurer. It allows an employer to establish a set amount, or defined contribution, to workers’ health care. Employees then choose from a number of different plans.
“That typically expands the selection of products from the two or three that an employer might offer to a range of 10,” he said.
The exchange also has introduced new health insurers to Connecticut. Harvard Pilgrim has offices in Hartford with plans to join the exchange in 2015. This year, people can buy a plan from HealthyCT, a nonprofit health insurer. Healthy CT is a newly formed Consumer Operated and Oriented Plan established by the Affordable Care Act.
“There’s more choice this year than there was last year,” said Ken Lalime, CEO of HealthyCT.