Thursday, February 23, 2012

Access and the ACA: looming challenges

Expanded access to health care insurance: this promise of the Affordable Care Act (ACA) is historic as it creates a path to finally eliminate the ugly black mark on the United States as the only wealthy, developed nation without universal access to health insurance[i]. Within Title I of the law, details related to the expansion of private health insurance coverage and the regulation of the private health insurance market are laid out. In Title II, public programs including Medicaid and the Children’s Health Insurance Program are set to expand. Estimates from the Congressional Budget Office (CBO) project that 32 million uninsured Americans will gain coverage by 2019; half of them will obtain private coverage under Title I, while half will obtain coverage through the Medicaid Expansions of Title II[ii]. For a country with nearly 50 million of its people uninsured as of 2010[iii], this legislation takes a large leap forward in providing access to care.

Yet, health insurance is only one piece of the health access puzzle. While insurance reduces the economic barrier to accessing health care services, the barrier of health service availability still looms large on the horizon. Health insurance coverage is not enough to increase access to health care services, but must be coupled with an adequate supply of health care services to meet the demand of the insured. As demonstrated by the RAND Health Insurance Experiment, we can expect that as these 32 million Americans gain coverage, the demand for health care services will increase substantially, placing huge demands on our health care system[iv]. The question becomes: are we prepared to meet that demand?

Current debate around this question has focused on whether or not the physician work force, specifically, the primary care health provider work force, will be adequate to meet the new demand. Drawing on the example of Massachusetts where insurance was mandated in 2006, evidence has shown that health insurance without an adequate number and appropriate distribution of primary care physicians does not lead to health access. Since the mandate, Massachusetts has seen greater wait times for appointments with PCPs and fewer than 50% of PCPs accepting new patients[v]. This has led experts to project that with the advent on national health insurance expansion, the U.S. is on the brink of a primary care crisis. The Association of American Medical Colleges projects that the U.S. will face a shortage of approximately 21,000 PCPs by 2015[vi], while the American Academy of Family Physicians projects a shortage of 40,000 generalist physicians by 2020[vii]. While the actual number is likely to fall somewhere in between, the height of the numbers is worrisome.

Within the ACA, there are some provisions to address primary care physician workforce. These provisions include:
(1) $168 million to go towards training 500 new primary care physicians (PCP) through the creation of new residency spots by 2015,
(2) $5 million for states to create strategies to expand the primary care workforce by 10-25% over ten years to meet increased demand,
(3) $1.5 billion to strengthen the National Health Service Corps (NHSC) and to increase primary care physicians, nurse practitioners, and physician assistants by 12,000 total,
(4) Financial incentives to practice primary care in under-served areas, and financial incentives to care for Medicaid patients in 2013 and 2014.
(5) Provisions to expand the Physician Assistant (PA) and Nurse Practitioner (NP) workforce[viii].

Since health insurance without adequate health care supply does not result in greater access to care, better health outcomes, or reductions in cost, the expansion of the primary care physician workforce is vitally important to the overall success of the ACA. But will the above provisions meaningfully address this imminent problem?

The answer lies in the success of their implementation. The creation of new residency positions for primary care physicians will be helpful only if there are new physicians to fill the spots. In the last several years, family medicine and internal medicine have shown the highest unfilled residency position numbers by U.S. medical graduates. In the case of Family Medicine, 57.8% of all residency spots are filled by international medical graduates[viii]. In addition to continued reliance on international medical grads, the Federal Government is counting on the bolstered funding to the NHSC to incentivize U.S. medical students to choose primary careers in under-served areas by forgiving the loans of students who choose to enter this program. Yet, loan burden, even with debt burdens around $160,000 or higher, pales in comparison to the $3 million lifetime salary gap faced by students choosing a primary care career over a specialist career[ix]. Not to mention, years of research has supported that the choice of specialty career is influenced by multiple factors besides financial incentives, including student and institutional factors[x]. It is not at all clear that these financial incentives will be enough to induce student demand towards primary care careers.

The provisions to increase the number of practicing NP’s and PA’s will also face implementation challenges. To begin with, only one-third of PA’s currently practice within a primary care setting, limiting the effect of this legislation on the primary care shortage. While the majority of NP’s do practice in primary care settings, current estimates suggest that two NP’s are needed to cover the same workload as one PCP[xi]. Additionally, the function of NP’s is constrained by health plan and state restrictions on scope of practice. For the expansion of NP’s to contribute meaningfully to the primary care physician shortage, these constraints will need to be loosened[xii].

Finally, even if government projections are correct and the primary care workforce increases by 12,000 (a very generous estimate), this is not nearly enough to meet the projected 21,000-40,000 PCP shortage. Even more troublesome is that the impact of this shortage is likely to fall heaviest on the 16 million new Medicaid beneficiaries, due to low physician participation in Medicaid and infrequent physician practice presence in low-income communities[xiii].

The ACA is pivotal in the course of health care in the US. Yet, if the ACA is to successfully achieve the goal of expanded access, more must be done in order to bolster the primary care physician workforce. Insurance coverage without physician availability is not enough. While the above provisions are an important starting point for addressing this problem, additional new investments to strengthen the primary care workforce must become the top priority of those hoping to see the ACA succeed.

[i] OECD (2011), Government at a Glance 2011, OECD Publishing, Paris.

[ii] McDonough, John. Inside National Health Reform. University of CA Press and the Milbank Fund, 2011

[iii] United States Census Bureau, Income, Poverty and Health Insurance Coverage in the United States: 2010. Retrieved from on February 19th, 2012.

[iv] Joseph P. Newhouse and the Insurance Experiment Group. Free for All? Lessons from the RAND Health Experiment. Cambridge, Mass.: Harvard University Press, 1993,

[v] Lowry, F. Massachusetts Universal Healthcare Coverage Reveals Serious Shortage of Primary Care Physicians. October 8th, 2009.

[vi] Results of the 2010 Medical School Enrollment Survey. Center for Workforce Studies. AAMC, June 2011.

[vii] AAFP Projects PCP Shortage Could Reach 40,000 By 2020. News. Robert Wood Johnson Foundation, August 17, 2009.

[viii] National Resident Matching Program. AAFP 2012.

[ix] Fact Sheet: Creating Jobs and Increasing the Number of Primary Care Providers. www.HealthrReform.Gov. U.S. Department of Health and Human Services. Feb 20 2012.

[x] Bryan T. Vaughn, Steven R. DeVrieze, Shelby D. Reed and Kevin A. Schulman. Can we close the income and wealth gap between specialists and primary care physicians? Health Affairs, 29 no.5 (2010): 933-940.

[xi] Senf JH, Campos-Outcalt D, Kutob R. Factors related to the choice of family medicine: A reassessment and literature review. J Am Board Fam Pract. 2003 Nov-Dec;16(6):502-12.

[xii] Improving Access to Adult Primary Care in Medicaid: Exploring the Potential Role of Nurse Practitioners and Physician Assistant. Kaiser Commission on Medicaid and the uninsured. The Henry J. Kaiser Family Foundation, March 2011.

[xiii] Fact Sheet: Creating Jobs and Increasing the Number of Primary Care Providers. www.HealthrReform.Gov. U.S. Department of Health and Human Services. Feb 20 2012.

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