As I have said many times, the Affordable Care Act is deeply flawed. As a result, it will serve most likely as an incremental step toward America being dragged kicking and screaming toward universal coverage in the coming decades.
The perfect example of how the ACA will fall short can be found in North Dakota. Tens of thousands of people have migrated to the state in recent years, attracted by the near-frantic oil exploration and extraction occurring in the Bakken formation. Oil rig and related jobs pay $80,000 a year or more. Even fast food workers in Williston, the smallish town at the center of the oil activity, command $20-an-hour wages.
Yet despite the vast wealth being extracted in North Dakota, many hospitals report their rates of uncompensated care have increased 20-fold.
The population growth and the work being performed by the migrants have dramatically impacted the region's hospitals. Some of the rural facilities that service the Bakken area are getting flooded with patients, as FierceHealthFinance recently reported.
That makes perfect sense: Oil and gas workers have on-the-job fatality rates eight times the national average. That is tied to the average 2,000 truck trips required to service a well during its first year of operation--and that North Dakota's roads are often crumbling and poorly marked. While train versus truck collisions have dropped by a third nationwide over the past decade, they're up nearly 70 percent in North Dakota during that same time.
In the western part of the state, where oil extraction is the most intense, the combined debt of the 12 hospitals in the region rose 46 percent between 2011 and last year, according to The New York Times.
It is primarily because while the oil companies are shelling out to get warm bodies to work the wells, they're not going much beyond that. The companies treat many of these workers like contractors, who therefore may not be provided health insurance. Of those workers who have benefits, they are often pressured by their employers not to make workers' compensation claims.
North Dakota is the only state in the union that allows businesses to directly pay their employees for workforce injuries, and that can be used to keep claims in line--whether justified or not . So if an injured worker goes to the hospital to seek care, they may not have the means to pay for it. Or if they are covered by workers' comp insurance, they may be worried they will lose their livelihood should they file a claim.
Theoretically, the ACA would address such gaps. Uninsured oil workers could purchase coverage on the insurance exchange beginning this October, and they'll be covered starting Jan. 1, 2014.
However, I don't believe a lot of these migrant workers will be motivated to shell out the money to obtain coverage. Many of them earn too much to qualify for subsidized coverage, meaning they're looking at premiums of $500 a month or more. And many had been out of work for a prolonged period of time before moving to North Dakota--meaning they're still trying to catch up on their bills, or are supporting themselves and a household elsewhere.
Given how ingrained Americans have become to eschew long-term planning for short-term reward, it makes more sense for them to pay the modest tax penalty and cross their fingers.
Not all of this should be laid to rest at the feet of the ACA. The fact that providers are being submerged in uncollected bills in the one truly booming part of the country is the collective result of decades of decision making unduly influenced by the lobbying of big business.
However, if the United States had universal healthcare--like every industrialized nation on the face of the earth--this would become a non-issue.
As Winston Churchill once said, the United States always does the right thing--after trying everything else. I suspect the ACA will be another such attempt on the path toward getting it right. - Ron (@FierceHealth)