I know that there are millions of Americans who are content with their health care coverage — they like their plan and, most importantly, they value their relationship with their doctor. They trust you. And that means that no matter how we reform health care, we will keep this promise to the American people: If you like your doctor, you will be able to keep your doctor, period. (Applause.) If you like your health care plan, you’ll be able to keep your health care plan, period. (Applause.) No one will take it away, no matter what. My view is that health care reform should be guided by a simple principle: fix what’s broken and build on what works.”
I’ve seen a number of Obamacare supporters arguing that the President’s promises about keeping plans and doctors carried a silent qualifier to the effect of “if they’re compliant with the new regimen.” Somewhat less frequent but still common are remarks to the effect that people whose plans have been cancelled should have known better, or that they’re stupid to want to keep their crappy plans. Probably they should have known (although Obama supporters who are ordinarily incensed with people who don’t take the President at his word are now incensed with people who did). Maybe they are stupid. Regardless, we wouldn’t be having this discussion if the President hadn’t lied — and it was a lie — repeatedly. Supporters of the legislation thought that the illusion of choice was critical to the success of the effort. The promises were an epic bait-and-switch, rivalled only by the disappearance of the vaunted “public option.”
In the excerpt from Obama’s 2009 address to the American Medical Association, the line about keeping one’s health care plan, period, is, I suppose naturally, subordinate to the line about keeping one’s doctor, period. Can you spot the silent qualifier in that clause? Yeah, me neither. And with the furor over the cancelled plans on temporary hiatus, awaiting the verdict on the state of the federal exchange in nine days and the verdict of insurers and regulators on extending the plans, the problem of losing one’s doctor is about to take center stage.
Obamacare includes some valuable reforms. Like many things of value, they come with a price tag. Abolishing pre-existing condition exclusions means that rates go up for healthier people who previously got a break on their premiums because insurers didn’t have to pay for sick people. Mandating broader coverage means that rates go up for everybody who doesn’t already have that level of coverage. Eliminating annual and lifetime spending caps means insurers have to charge more because they’ll be paying out more. One way that insurers are trying to keep their rate increases as small as they can is limiting the number of health care providers available to people who buy plans on the exchanges — the narrow networks we’re hearing more and more about. These measures wouldn’t be necessary, or even possible, in a health plan with a customer pool that included everyone in the country, but they’re essential for insurers with much smaller customer pools to stay competitive in the system created by Obamacare.
Accordingly, the chances are good that a significant number of people will find their doctors or other providers missing from the networks offered by the more affordable plans on the exchanges. Obamacare supporters are fond of citing polls showing that some people are okay with switching doctors if doing so saves them money. No doubt this is true, but another way of putting it might be that some people are resigned to switching doctors if they can’t afford to keep the current one — younger adults more so than older ones, and healthier adults and families more so than less healthy ones. In a sane health care system, people wouldn’t be forced to make that choice, and of course people who can afford to pay more in order to stay with their current physician don’t have to make that choice.
In any event, as we get closer to the deadline for purchasing coverage that can go into effect on January 1 of next year, we’ll be hearing more about people who either can’t afford to keep their doctors or, in situations like the one in New Hampshire, whose doctors are simply not available through the exchanges at all.
Structurally, the problem may turn out to be a benefit for the insurance companies in the exchanges — this is not surprising, as insurers wrote much of the law — because the people most likely to eschew savings in favor of their doctors will be people who are older and have long-term relationships with their doctors, and people who are sicker and want to maintain continuity of care. Fewer older folks and fewer sick folks participating in the exchanges are good news for insurers, just as the pre-existing condition exclusions and higher rates for older customers were in the bad old days.
Politically, the increasing attention paid the narrow networks is going to be more bad news for the President and those Democrats in Congress who were spooked already by the cancellations fuss. I have said and will continue to say that Republicans, who are collectively the Rob Ford of America, can never be relied upon to refrain from torching themselves as they did in October with the government shutdown and near default. However, also as previously noted, it only took a month for Democrats to hand their political advantage back to Republicans plus a generous tip for their trouble.
If Democrats are lucky and everybody with a cancelled plan gets it extended or gets something satisfactory thorough the exchanges, the noise over that will subside not long after the end of the year because what’s done or not for 2014 will have been done or not. The problem with people losing their doctors is going to linger throughout the open enrollment period, which ends March 31, and for as long after that as Republicans can milk it.
The next open enrollment period begins on October 15 of 2014, to be accompanied by a new wave of cancellation notices for 2015 that will be going out to many employers along with the people who got their individual plans extended under the Obama fix. At the same time, we’ll begin learning whether the difficulties of this enrollment period resulted in higher-than-expected exchange premium increases for 2015. These things will be occurring against the normal backdrop of hysteria associated with the only month that really matters during the general election campaign season.
Another problem may surface in the interlude between March 31 and October, that being the way that geography and economic/social class affect the choices available to people buying insurance on the exchanges. Or maybe that only bothers me. Regardless the resolution of the other issues, this one is hardwired into the system. The elections next year may offer some hint about how long that system will prevail.
UPDATE … Bloomberg News says that although the administration have yet to announce the change, the beginning of the next open enrollment period has been pushed back a month to November 15, 11 days after the mid-terms. The move doesn’t defuse the issue of cancellation notices arriving a few weeks before the elections, but it does mean that any increases in premium costs won’t show up on the insurance exchanges until after the elections. One suspects they’ll be leaked, though.
UPDATE 2 … USA Today has a story up addressing the geographical disparity in prices and the intra=plan disparities in coverage.
UPDATE 3 … The date by which exchange customers have to buy a policy in order for coverage to start January 1 has been pushed back to December 23 from the original December 15 deadline. That should help a bit.