Not if we allow people to take responsibility for their own life. The government will not have to decide if it is obligated to force other citizens to pay a doctor to extend my misery. My children will not have to decide whether to sell their homes to pay a doctor to extend my misery. Much to the dismay of our impoverished medical professionals I plan to just die when the time comes.
It's a viewpoint that has a lot of benefits, I'll fully agree. We all recognize that it needs to be handled carefully (coercion, emotional blackmailing, etc.), but we're striving towards a world where your options for 'checking out naturally' include longer periods of unacceptable degeneration. Now, I fight this trend by asking for people's help finding solutions for the degeneration, but I think that creating the moral permission for a peaceful death is important!
I don't find that my views conflict. I'll fight for both.
Is "you require care which you have no means to pay for" coercive? Or is "I require care for which I have no means to pay, so someone else will have to" coercive?
Note that the doctor will traditionally view this very differently from anyone else...because he is the one being paid.
Well, yes, I guess. I mean, if the person wants to live longer (using available medical technologies) and pure $$$ prevents them, then that's a type of coercion.
But I meant implicit coercion, where we pressure the people to not seek further effective care and opt for a peaceful death instead. The coercion is by framing it in terms of money or "what's best for the family" vs. "the most pleasant way to spend the last little time"
A Reuters article that was picked up by the HuffPo illustrating wellness checks and compliance and outright refusal to participate resulting in higher premiums. It's the carrot and the stick principle. Rather than educate about the importance of routine STD testing coupled with safe sex education, instead penalties might be imposed for refusing to get an STD test. This is a massive invasion of privacy.
Yes, the savings would be tremendous. Yes, it would save lives. Yes, everyone should get tested for data suggests a lot of undiagnosed STDs and then by the time the patient seeks treatment, then their health has declined. But the goal is to assure the patient of their privacy and to persuade not command.
That has implications for any number of undiagnosed illnesses.
U.S. companies are increasingly penalizing workers who decline to join "wellness" programs, embracing an element of President Barack Obama's healthcare law that has raised questions about fairness in the workplace.
Beginning in 2014, the law known as Obamacare raised the financial incentives that employers are allowed to offer workers for participating in workplace wellness programs and achieving results. The incentives, which big business lobbied for, can be either rewards or penalties - up to 30 percent of health insurance premiums, deductibles, and other costs, and even more if the programs target smoking.
Among the two-thirds of large companies using such incentives to encourage participation, almost a quarter are imposing financial penalties on those who opt-out, according to a survey by the National Business Group on Health and benefits consultant Towers Watson (For graphic see link.reuters.com/byr73w)
For some companies, however, just signing up for a wellness program isn't enough. They're linking financial incentives to specific goals such as losing weight, reducing cholesterol, or keeping blood glucose under control. The number of businesses imposing such outcomes-based wellness plans is expected to double this year to 46 percent, the survey found.
"Wellness-or-else is the trend," said workplace consultant Jon Robison of Salveo Partners.
Incentives typically take the form of cash payments or reductions in employee deductibles. Penalties include higher premiums and lower company contributions for out-of-pocket health costs.
Financial incentives, many companies say, are critical to encouraging workers to participate in wellness programs, which executives believe will save money in the long run."
What's the issue?
The poor health habits of many workers, growing rates of chronic disease, and the rising cost of health benefits have created new interest in workplace wellness programs. Employers value these programs as a way to reduce absenteeism and employee turnover, and to offer a benefit that is appealing to many current and prospective employees. Some evidence also suggests that comprehensive wellness programs may pay off for employers by reducing their expenditures for employees' health care.
At the same time, there's debate over how best to structure wellness programs. Should programs offer "carrots"--financial rewards for participating in wellness programs? Should they come with "sticks," or penalties for not participating in them? Should either carrots or sticks be tied to a person's success in meeting health goals, such as managing blood pressure or losing weight?
The Affordable Care Act will, as of 2014, expand employers' ability to reward employees who meet health status goals by participating in wellness programs--and, in effect, to require employees who don't meet these goals to pay more for their employer-sponsored health coverage. Some consumer advocates argue that this ability to differentiate in health coverage costs among employees is unfair and will amount to employers' policing workers' health.
This brief explains trends in wellness programs, details changes in the law starting in 2014, and highlights issues to watch.
What's the background?
Most employers who provide health insurance also provide some type of wellness benefit. The 2012 Kaiser Family Foundation and Health Research and Educational Trust annual survey of employer health benefits found that 63 percent of companies with three or more employees that offered health benefits also offered at least one wellness program. In addition, 60 percent of these companies offered wellness benefits to spouses or dependents of employees.
The larger the company, the more likely it was to offer a wellness program; in fact, almost all companies with 1,000 or more employees offered one. Larger employers usually run wellness programs themselves. For small companies, wellness programs are typically run by the same firms that administer the employer's health benefits plan or by another entity referred to as a third-party administrator.
Wellness Program Content: Typical features of wellness programs are health-risk assessments and screenings for high blood pressure and cholesterol; behavior modification programs, such as tobacco cessation, weight management, and exercise; health education, including classes or referrals to online sites for health advice; and changes in the work environment or provision of special benefits to encourage exercise and healthy food choices, such as subsidized health club memberships (Exhibit 1).
The traditional role of privacy and advocacy between the physician and the patient is then lost. It then becomes a function of the employer and the government enforcing a wellness check to lower premiums as a reward, and a penalty for not participating or altering lifestyle. The government and the employer takes the place of physicians and there is NO PRIVACY then. What formerly took place in the physician's office to make discreet inquiry and to persuade the patient that an STD test would be in the patient's interest, if only for peace of mind, then becomes a hammer over their head in order to cut costs. It's treating the patient as a child and as a customer that can be bossed around.
Do you really want the government and your employer to know your medical history and lifestyle??? The ADA then unravels a central function of HIIPA. I do not understand why people would think this is better. As soon as you get the government involved and the employer, without also including very stringent safeguards of privacy, then BOTH know your most intimate details.
Don't get me wrong. We need a better healthcare plan, but as it currently is configured, it MOST benefits the insurance companies and employers NOT the patient.
Yeah, I think normal incentives just don't work with healthcare. We're already incentivised to be healthy, and we're going to balance that with laziness. But we all have the cost/benefits in our heads. Financially penalizing unhealthy living even further doesn't really help, unless it's done in a very under-the-hood kind of way.
That practice was around before the ACA and is driven by employers. Also note the actual premium does not change, just the employer's share of coverage of that premium.
I am eager to see how some of the EEOC lawsuits against these practices pan out as they do seem heavy handed and discriminatory to an extent.
http://forums.civfanatics.com/showpost.php?p=13734518&postcount=585
Go back to this post to see a long list of "wellness checks". It's not business as usual, but has transferred the power back to employers and the government rather than the patient. The patient should always be the one who decides, not the employer, the government, or the medical team.
Otherwise, it's not a benefit, but a code of discipline enforced upon the patient with rewards and penalties.
From 1990 onwards there have been smoking cessation and wellness programs aimed at reducing premiums for employees. There were gymnasiums built, or membership in existing ones, to encourage weight loss, for there is a correlation in both mind and body for routine exercise.
This provision in the ADA is NOT THAT at all. Outing someone who is homosexual, who has some level of persistent depression (who might be managing just fine and not taking medicine), who is whatever, is not the government's or the employer's business.
How could STD testing be done privately and so reduce the amount of transmission of them? Private FREE STD checks. Some churches have created programs where anyone may come in anonymously and get tested with no heavy handedness, but in a supportive environment. Likewise some nonprofit agencies are doing this in a secular manner. When someone finds out they are infected, then as you can imagine, it is shocking and devastating.
There is no reason we can't do that, versus compulsion of testing or penalities for not complying. This idea is private and no one but the patient knows unless they elect to reveal it. The ADA way stigmatizes those who don't test and raises premiums for those who are infected. That is badly done, and a disservice to the patient, and truly to the American people.
You're ascribing a problem to a non-existing provision of the ACA. These are private businesses making decisions about how much of the employee's premium they will cover. You admit employers have done this since the 90's.
Not sure how the ACA "outs" homosexuals or people with depression at work. HIPAA and various other privacy laws and discrimination protections still apply in the workplace, see e.g. the EEOC lawsuits against businesses who the government considers as taking these things too far.
You're ascribing a problem to a non-existing provision of the ACA. These are private businesses making decisions about how much of the employee's premium they will cover. You admit employers have done this since the 90's.
Not sure how the ACA "outs" homosexuals or people with depression at work. HIPAA and various other privacy laws and discrimination protections still apply in the workplace, see e.g. the EEOC lawsuits against businesses who the government considers as taking these things too far.
The ADA provision for wellness checks specifically mentions STD checks. Who then must do them: the physician who orders them. Instead of the physician and the patient coming together through quiet disclosure due to TRUST, it then becomes, "Well based upon the ADA, then we should order an STD test. Your lifestyle indicates you're at risk, so therefore you should get one." This is of dubious benefit. If the patient refuses, it's logged on their health record. "Patient refused to comply with mandated STD checks under the ADA."
It's grotesque. That is no longer medicine, and breaks the Hippocratic Oath of doing no harm. The physician then becomes the one who harms the privacy of the patient in the interest of reducing the overall health costs of the nation.
I'm confused. How does requiring STD checks break the oath of doing no harm?
It isn't like we are requiring the doctor to carry out forced sterilizations or anything like that.
I'm confused. How does requiring STD checks break the oath of doing no harm?
It isn't like we are requiring the doctor to carry out forced sterilizations or anything like that.
Medicine in the postmodern period has been about advocacy of the individual patient, not subsuming and subduing the patient's desires for the greater good of the populace. Had the latter been the policy, the government would have immediately outed anyone who is sexually promiscuous (as defined by law) and then forced STD checks. Even during the worst of the hysteria with AIDs, that didn't happen.
A physician has no business telling the patient what they must do. It's a collaboration in which the patient is persuaded that it's in the patient's best interest.
If the patient has Depression, but was undiagnosed before, then is it the physician, the government, and the employer who then must insist that the patient is compliant and take medication? What if there is no outward sign and he/she is doing fine?
Do patients have choice or not? Does choice then result in penalties if not complying? Do Americans want to go there with that new model of medicine? Is it your body, or not?
The ADA provision for wellness checks specifically mentions STD checks. Who then must do them: the physician who orders them. Instead of the physician and the patient coming together through quiet disclosure due to TRUST, it then becomes, "Well based upon the ADA, then we should order an STD test. Your lifestyle indicates you're at risk, so therefore you should get one." This is of dubious benefit. If the patient refuses, it's logged on their health record. "Patient refused to comply with mandated STD checks under the ADA."
It's grotesque. That is no longer medicine, and breaks the Hippocratic Oath of doing no harm. The physician then becomes the one who harms the privacy of the patient in the interest of reducing the overall health costs of the nation.
OK, we are talking about the ACA not the ADA right? Do you mean that insofar as STD checks are among the list of bare minimum of things a healthcare plan must provide to qualify as a bona fide plan under the ACA? (Are they? I am not even sure.)
If so then I guess the leap I am having trouble making is how we blame the ACA for what you're talking about. The ACA is about regulating coverage and pricing. How the medical industry and employers structure incentives and look for certain outcomes within that framework is another problem. It is certainly part of a large problem that many rightfully feel the ACA did not adequately address. But, the granularity of stuff you're talking about--e.g. an employer "outing" an employee or forcing someone to get an STD check--is not fairly laid directly at the feet of the ACA.
OK, we are talking about the ACA not the ADA right? Do you mean that insofar as STD checks are among the list of bare minimum of things a healthcare plan must provide to qualify as a bona fide plan under the ACA? (Are they? I am not even sure.)
If so then I guess the leap I am having trouble making is how we blame the ACA for what you're talking about. The ACA is about regulating coverage and pricing. How the medical industry and employers structure incentives and look for certain outcomes within that framework is another problem. It is certainly part of a large problem that many rightfully feel the ACA did not adequately address. But, the granularity of stuff you're talking about--e.g. an employer "outing" an employee or forcing someone to get an STD check--is not fairly laid directly at the feet of the ACA.
Yeah, I meant ACA. As much as I write, I'm prone to spelling and grammar typos.
The writers of the ACA were a result of collaboration of Employers, Insurance Companies, Congresspeople, Lawyers, and it shows. When you manage money in this manner to aid Public Health, then to manage those costs, then it's largely about getting compliance from the patients.
This is the opposite paradigm from traditional medicine. There, the physician has no idea what is wrong with the patient, but has been schooled in ways to diagnose their symptoms and signs through a conversation. The dialogue then becomes about ways to manage the patient's ailment(s), not impose solutions.
Take Psychiatry. Today it's very screwed up, because it's too expensive to have a psychiatrist talk to patients. It would mean too much face time with them. So psychologists and trained counselors have that dialogue. Even though very educated in levels based upon those roles, they don't have the education of a psychiatrist.
From day one, the counselor may KNOW what the problems are that are causing mental distress. But one never tells the patient, "OK, simples. Do this and you'll be better. Case closed." What that long dialogue of counseling becomes is the patient slowly discovering by meditation and contemplation and dialogue what the nature of their illness arises from. The patient comes to conclusions based upon prompting and inquiry. It's why it's expensive.
Telling some patient that this is mandated as a wellcheck check, then taking their medicine to be in compliance, well that's a major departure from the tradition model for Depression evaluation and management of it. Postmodern Depression treatment with a pill does nothing to alleviate the Depression, only manages the symptoms, and so the Depression will always be there ready to spring forth. Why? A pill requires no alteration in lifestyle that is causing the Depression.
Statistics estimate the possibility of one in ten Americans being situationally Depressed with many having chronic Depression. It's extremely expensive for the American economy, but I don't see anything that shows that wellness checks and causing compliance with taking serotonin reuptake inhibitors will solve it. http://www.healthline.com/health/depression/statistics-infographic
OK. Still don't think you can draw a straight line from ACA to employer outing employee as gay, or requiring STD checks.
The ACA did not fundamentally alter how healthcare works in the US. It simply forced everyone to buy into the program. I definitely have problems with the US healthcare system, and how the ACA is basically just trying to make it less bad rather than actually fixing it--but I think your criticisms, to the extent I understand them, go well beyond the ACA and blame it for things that it really should not carry the blame for.
Wrong. http://www.dol.gov/ebsa/faqs/faq-aca5.html
"Q12: Are all employment-based wellness programs required to check for compliance with the HIPAA nondiscrimination provisions?
No. Many employers offer a wide range of programs to promote health and prevent disease. For example, some employers may choose to provide or subsidize healthier food choices in the employee cafeteria, provide pedometers to encourage employee walking and exercise, pay for gym memberships, or ban smoking on employer facilities and campuses. A wellness program is subject to the HIPAA nondiscrimination rules only if it is, or is part of, a group health plan. If an employer operates a wellness program as an employment policy separate from its group health plan(s), the program may be covered by other Federal or State nondiscrimination laws, but it is not subject to the HIPAA nondiscrimination regulations."
I.E. HIIPA isn't necessarily part of Wellness programs and so your privacy can be violated by the ADA rules.
"Q15: My group health plan offers two different wellness programs, both of which are offered to all full-time employees enrolled in the plan. The first program requires participants to take a cholesterol test and provides a 20 percent premium discount for every individual with cholesterol counts under 200. The second program reimburses participants for the cost of a monthly membership to a fitness center. If I participate in both wellness programs and receive both rewards (the 20 percent premium discount and the reimbursement for the cost of a fitness center membership), is my plan violating the HIPAA nondiscrimination regulations?
No. In this scenario, the first program is subject to the requirements of the HIPAA nondiscrimination regulations because the premium discount reward is based on an individual satisfying a standard that is related to a health factor (having a cholesterol count under 200). Therefore, the first program must meet the five criteria in the regulations, including the 20 percent limit on the amount of the reward. The second program is not based on an individual satisfying a standard that is related to a health factor, so it does not have to satisfy the five criteria in the regulations.
Furthermore, it is permissible to offer both programs at the same time because the rule limiting the amount of the reward for health-contingent wellness programs to 20 percent of the cost of coverage only applies to programs that require satisfaction of a standard related to a health factor.
As previously noted, the Departments intend to propose regulations that use existing regulatory authority under HIPAA to raise the percentage for the maximum reward that can be provided under a health-contingent wellness program to 30 percent before the year 2014 and are also considering what accompanying consumer protections may be needed to prevent the program from being used as a subterfuge for discrimination based on health status. More guidance is expected early next year."
Wellness programs can legally get away with giving the carrot to those who comply and may penalize those who do not. Not only this, but immediately then there is a stigma for refusing to comply with that wellness check, and your private choices are known.
For the cost-conscious health-care consumer, even those seemingly free annual checkups or well-child visits call for some caution.
Dani Roelker, who lives in the Cincinnati suburb of West Chester, found that out the hard way.
She took her 10-year-old twins to their pediatrician’s office in January for their annual wellness checkups. A few weeks later, when she returned to the office for another pediatric visit, a worker told her that she had an outstanding bill of about $27 for what Roelker had thought would be a free visit.
Roelker said she was billed because a nurse asked about her son’s attention-deficit-disorder medication, which had been first prescribed in October and had been checked during a follow-up visit in November. January’s appointment also was coded in part as a “medication check.”
“I don’t even think the doctor discussed this substantively with me,” Roelker said. “This is ridiculous.”
The Affordable Care Act now requires most health-insurance plans to cover the entire cost of preventive office visits. So patients can — and often do — feel blindsided when they are billed by their doctor’s office after an annual checkup.
The culprit can be the “Oh, by the way” questions that patients pose about a previously undisclosed health problem while seeing their doctors. But the charges also can stem from a health issue that a doctor discovers during the visit.
“Those problems are not part of a regular well visit,” said Dr. Sarah Sams, who teaches coding through OhioHealth’s Grant Family Medicine residency program in Columbus.
It takes time to do a thorough job with preventive care, Sams said. An illness that comes to a doctor’s attention during a wellness check sometimes must be addressed on the spot, but it can put doctors behind schedule, she said. And if doctors don’t bill for all the services that they’re providing, Sams said, “they’re not going to stay in business.”
If anything, Sams said, doctors and their offices probably underuse the billing code that triggers compensation for problems that the doctors end up evaluating or managing during a wellness visit.
But some patient advocates say such situations increasingly result in overbilling of patients.
Wellness checks as mandated by the ACA are not entirely the same as the wellness checks that are allowed to employers using private insurance and altering premiums as well.
The Affordable Care Act and Wellness Programs
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Implementing and expanding employer wellness programs may offer our nation the opportunity to not only improve the health of Americans, but also help control health care spending.
The Affordable Care Act creates new incentives and builds on existing wellness program policies to promote employer wellness programs and encourage opportunities to support healthier workplaces. The Departments of Health and Human Services (HHS), Labor and the Treasury are jointly releasing proposed rules on wellness programs to reflect the changes to existing wellness provisions made by the Affordable Care Act and to encourage appropriately designed, consumer-protective wellness programs in group health coverage. These proposed rules would be effective for plan years starting on or after January 1, 2014.
The proposed rules continue to support workplace wellness programs, including "participatory wellness programs" which generally are available without regard to an individual's health status. These include, for example, programs that reimburse for the cost of membership in a fitness center; that provide a reward to employees for attending a monthly, no-cost health education seminar; or that provides a reward to employees who complete a health risk assessment without requiring them to take further action.
The rules also outline amended standards for nondiscriminatory "health-contingent wellness programs," which generally require individuals to meet a specific standard related to their health to obtain a reward. Examples of health-contingent wellness programs include programs that provide a reward to those who do not use, or decrease their use of, tobacco, or programs that provide a reward to those who achieve a specified cholesterol level or weight as well as to those who fail to meet that biometric target but take certain additional required actions.
Protecting Consumers
In order to protect consumers from unfair practices, the proposed regulations would require health-contingent wellness programs to follow certain rules, including:
Programs must be reasonably designed to promote health or prevent disease. To be considered reasonably designed to promote health or prevent disease, a program would have to offer a different, reasonable means of qualifying for the reward to any individual who does not meet the standard based on the measurement, test or screening. Programs must have a reasonable chance of improving health or preventing disease and not be overly burdensome for individuals.
Programs must be reasonably designed to be available to all similarly situated individuals. Reasonable alternative means of qualifying for the reward would have to be offered to individuals whose medical conditions make it unreasonably difficult, or for whom it is medically inadvisable, to meet the specified health-related standard.
Individuals must be given notice of the opportunity to qualify for the same reward through other means. These proposed rules provide new sample language intended to be simpler for individuals to understand and to increase the likelihood that those who qualify for a different means of obtaining a reward will contact the plan or issuer to request it.
Ensuring Flexibility for Employers
The proposed rules also implement changes in the Affordable Care Act that increase the maximum permissible reward under a health-contingent wellness program from 20 percent to 30 percent of the cost of health coverage, and that further increase the maximum reward to as much as 50 percent for programs designed to prevent or reduce tobacco use.
Evidence shows that workplace health programs have the potential to promote healthy behaviors; improve employees' health knowledge and skills; help employees get necessary health screenings, immunizations, and follow-up care; and reduce workplace exposure to substances and hazards that can cause diseases and injury. The proposed rules would not specify the types of wellness programs employers can offer, and invite comments on additional standards for wellness programs to protect consumers.
On November 20, 2012, the federal government released a number of important and long-awaited proposed rules implementing the Affordable Care Act. Earlier posts examined proposed rules on market reform and rate review and essential health benefits, actuarial value, and accreditation. A third set of proposed regulations released by the Departments of Health and Human Services, Treasury, and Labor on November 20 relate to employee wellness programs. The agencies also released a study of wellness programs and a wellness program fact sheet.
Wellness programs are authorized under the Affordable Care Act as an exception to the general prohibition on health status underwriting. As of January 1, 2014, no health plan in any market will be able to underwrite based on health status. A limited exception, however, is authorized for wellness programs, which can grant rewards or impose surcharges based on an enrollee’s medical condition if certain requirements are met. This proposed rule sets out those conditions in greater detail.
Wellness programs were initially authorized by the Health Insurance Portability and Accountability Act of 1996. HIPAA prohibited group health plans from determining eligibility or varying premiums based on health status; however, it allowed premium discounts or rebates or modification of cost sharing of up to 20 percent of the cost of an employee’s coverage for participation in a health promotion or disease prevention program if certain requirements were met.
The Departments published final HIPAA wellness program rules in 2006. These in turn formed the basis for a wellness program exception to the ACA prohibition on health status discrimination for group health plans, which will, effective January 1, 2014, allow rewards or surcharges of up to 30 percent of the total cost of plan coverage (or 50 percent with approval of the HHS Secretary) for approved wellness programs. The proposed rules implement this provision.
The ACA does not allow wellness programs in the individual market, but it does authorize a 10-state demonstration project for wellness programs in the individual market beginning no later than July of 2014. The proposed rule does not address this program. The ACA amendment does not apply to grandfathered plans, but since it merely extends the HIPAA program, the proposed rule will apply to ACA grandfathered plans as well, since they are subject to HIPAA.
Again, all of this was already there as all of your links point out. The extent to which wellness checks might be abused by employers due to new ACA rules could be an issue, sure.
Since the bulk of new enrollees are Medicaid, you may have insurance, but you may not be able to get treatment from a physician since so many are unwilling to take on more Medicaid patients due to extremely low reimbursement versus potential malpractice lawsuits. http://www.forbes.com/sites/merrill...rt-forcing-doctors-to-see-obamacare-patients/
"Patient access to doctors is approaching a perfect storm of decreased physician supply, more demand for medical care—especially after Obamacare kicks in—and doctors increasingly refusing to see low-paying Medicare or Medicaid patients. If the “promise” of Obamacare’s access to health care is to be kept, government will eventually have to force doctors to accept Obamacare-covered patients. Because such a step would represent such a radical departure from physician autonomy, you might call it the “medical nuclear option.” [See a related piece on Medicare and Medicaid reimbursement cuts here.]
To begin with, the U.S. is already facing a doctor shortage. The Association of American Medical Colleges warns that the nation will face a shortage of 91,500 physicians by 2020. With respect to family physicians, a study published in the Annals of Family Medicine predicted a primary care physician shortage of 52,000 by 2025.
There are several reasons for the shortages. An aging population needs more medical care. Doctors are retiring in large numbers, fed up with the bureaucratic challenges and red tape imposed by government and health insurance. Plus, federal funds for training doctors can lead to shortages in some areas of the country.
Second, the implementation of Obamacare will likely exacerbate the doctor shortage. People who have been uninsured for a while who then get coverage tend to use significantly more health care for the first few years. If Obamacare results in an extra 30 million-plus people getting coverage—though at this point it isn’t clear whether, given the cancelations, higher premiums and the young and healthy potentially not enrolling, more people will ultimately have coverage—the demand for doctors will grow significantly, even as the relative number of doctors declines.
Third, a growing number of doctors are refusing to take new Medicaid or Medicare patients, and there is every reason to think the same will happen under Obamacare.
The Centers for Medicare and Medicaid Services (CMS) recently reported that 9,500 doctors who had previously accepted Medicare patients refused to do so in 2012. And the American Academy of Family Physicians says that doctors willing to accept new Medicare patients declined from 83 percent to 81 percent (most will continue to see Medicare patients they currently treat).
With respect to Medicaid, a study in the health policy journal Health Affairs found that 33 percent of primary care physicians weren’t accepting new Medicaid patients. But that figure can vary significantly by state. The Texas Medical Association says that only about a third of Texas doctors are willing to take all new Medicaid patients.
Why are doctors increasingly rejecting Medicare and Medicaid patients? Low government reimbursement rates. And that is where Obamacare comes in. News stories are already emerging that doctors will be paid significantly less for treating Obamacare patients than they would make from non-Obamacare private insurance, and perhaps even Medicare.
The New York Post recently reported on a very troubling survey from the New York State Medical Society, which found that 44 percent of New York doctors are not participating in Obamacare. Worse yet, three-fourths of those who are participating are being forced to because of existing insurance contracts. Only one-forth of those participating volunteered to do so."
Finding a doctor who takes Obamacare coverage could be just as frustrating for Californians in 2015 as the health-law expansion enters its second year.
The state's largest health insurers are sticking with their often-criticized narrow networks of doctors, and in some cases they are cutting the number of physicians even more, according to a Times analysis of company data. And the state's insurance exchange, Covered California, still has no comprehensive directory to help consumers match doctors with health plans.
This comes as insurers prepare to enroll hundreds of thousands of new patients this fall and get 1.2 million Californians to renew their policies under the Affordable Care Act.
Even as California's enrollment grows, many patients continue to complain about being offered fewer choices of doctors and having no easy way to find the ones that are available.
Map and database: Find Obamacare doctors in California
Map and database: Find Obamacare doctors in California
Some consumers have been saddled with huge medical bills after insurers refused to pay for care deemed out of network. These complaints have sparked a state investigation and consumer lawsuits against two big insurers.
Mary Edwards, a 63-year-old librarian in Mar Vista, was excited about a Health Net PPO she picked out last fall because it offered a wide selection of doctors at a reasonable price. But it turned out that several physicians listed on her plan didn't accept the insurance or weren't taking new patients.
"This is part of the Affordable Care Act that doesn't quite work yet," Edwards said. "This game of who's in and who's out is tiresome."
If individuals lost group coverage, but obtained new coverage under either another employer group plan or one in the individual market, they would then be counted in the enrollment figures for those submarkets. Similarly, if individuals transitioned to Medicaid, they would be counted in the Medicaid enrollment figures reported by the Centers for Medicare and Medicaid Services (CMS).
As Table 1 shows, during the first half of 2014, net total enrollment for all three segments of the private coverage market increased by almost 2.5 million individuals. That was because reduced enrollment in employer-sponsored coverage offset 61 percent of the gain in individual-market coverage during the first half of 2014.
Changes in Medicaid and CHIP Enrollment
The PPACA required states to expand Medicaid eligibility to all individuals with incomes below 138 percent of the federal poverty level and not otherwise eligible for Medicaid under prior rules. Those individuals are able-bodied, working-age adults, the vast majority of whom do not have dependent children. However, in June 2012, the U.S. Supreme Court ruled that Congress could not force states to adopt that expansion. Since then, 27 states and the District of Columbia have chosen to adopt the expansion.
Table 2 shows the changes in Medicaid enrollment during the first and second quarters of 2014, along with the net changes for the combined six-month period.
According to the CMS reports, for the District and the 24 states that had the expansion in effect during the first half of 2014, and for which data are available, total Medicaid enrollment increased by 3,669,809 individuals in Q1 2014 and by a further 2,047,168 individuals in Q2 2014, for a total of 5,716,977 during the first half of 2014.[3]
The law also changed the standards for determining eligibility for individuals who qualify for Medicaid coverage under prior law. Consequently, most of the states that have not adopted the Medicaid expansion also experienced some increase in enrollment. According to the CMS reports, for 24 of the 25 states that either did not adopt the expansion or did not have it in effect during the first half of 2014, Medicaid enrollment increased by 355,674 individuals during the first half of 2014.[4]
Thus, for the 48 states and the District for which data is available, Medicaid and Children’s Health Insurance Program (CHIP) enrollment increased by a total of 6,072,651 individuals in the first half of 2014.
Bottom line: many could have already gotten Medicaid and SCHIP without Obamacare, but the expansion added an additional amount into the worst American health insurance available. Since many physicians won't take it, then it really doesn't matter that you have it.
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The ADA then unravels a central function of HIIPA. I do not understand why people would think this is better. As soon as you get the government involved and the employer, without also including very stringent safeguards of privacy, then BOTH know your most intimate details. 
