The number of people who have gained health coverage because of the Affordable Care Act is staggering. There have been eight million enrollees in the health insurance exchanges and six million new Medicaid beneficiaries. According to ACAsignups.net, all told, between 17 million and 28 million U.S. residents have gained coverage as a result of the ACA.
The Obama administration and other ACA supporters crowed about the large enrollment figures, offering them as evidence that the law is working as intended. However, to paraphrase a common axiom, no good news comes without consequence.
While many agree it is good news that more U.S. residents have access to coverage, the influx of insured residents also means that the focus might need to be redoubled on a pre-existing problem: a shortage of primary care providers.
Scope of the Situation: Concerning, or Dire?
Most observers predict that the ACA will further aggravate anticipated primary care physician shortages, but the question is by how much.
Even before the ACA became law, the Health Resources and Services Administration and the Association of American of Medical Colleges both predicted future shortages. In 2006, HRSA predicted there would be a shortage of between 55,000 and 150,000 PCPs by 2020, while AAMC in 2008 estimated there would be 124,400 too few physicians in 2025.
Since the ACA’s enactment, predictions for an upcoming PCP shortage have ranged from concerning to dire.
For example, the AAMC revised its estimates after the ACA was enacted to project a shortfall of 130,600 physicians in 2025.
Meanwhile, the Heritage Foundation — a staunch opponent of the law — in a report earlier this year wrote that a “potential tsunami of newly insured patients” as a result of the ACA would mean “individuals and families will face longer wait times, greater difficulty access providers, shortened time with providers, increased costs, and new frustrations with care delivery.”
Some are predicting that a PCP shortage could be particularly acute in California. For example, the Robert Graham Center estimates that California will need an additional 8,243 PCPs by 2030, or a 32% increase over the state’s PCP workforce in 2010. According to data from the Heritage Foundation, another large state — Texas — needs 6,260 physicians to close its gap.
No Problem at All?
However, not everyone agrees that there is a looming shortage of primary care providers.
Drew Harris, director of the health policy program at the Jefferson School of Population Health, is one of those people. Writing at the Philadelphia Inquirer‘s “The Field Clinic” blog, Harris lays out a dozen reasons why he believes the U.S. will avoid a PCP shortage, including that:
- Specialists will begin delivering more primary care;
- Telemedicine will be increasingly available;
- The number of retail clinics will continue to grow;
- Electronic health records will be used more; and
- Workplace wellness programs will result in a healthier population.
Meanwhile, other experts predict that new approaches to delivering primary care could alleviate any potential PCP shortage. Researchers from RAND Corporation in a November 2013 report estimated that the use of patient-centered medical homes and nurse-managed health centers could significantly limit fallout from a PCP shortage.
According to the report, if the number of both care models increased, potential primary care shortages could be reduced by half by 2025 without training any new PCPs. Further, the report stated that if medical homes could handle 20% more patients than currently — through the use of patient coordination, more technology and other means — expected PCP shortages could be “nearly eliminated.”
How the ACA Addresses Physician Supply
Although many observers say the ACA will exacerbate the PCP shortage, the law does attempt to address the issue.
For instance, the law provides more than $284 million to a loan-repayment program and scholarship awards for students training to become PCPs. The funding includes grants to 32 states to support state loan-repayment programs.
The ACA also shifts Medicare payments for medical residency training programs in an effort to encourage more slots for PCPs. Although the ACA does not eliminate a cap on the number of residency slots that Medicare subsidizes, the law does redistribute unused slots to hospitals seeking to train additional residents. Further, 65% of those redistributed slots must go to hospitals that meet certain criteria, such as being located in states with PCP shortages, and 75% of the slots must be used for primary care or general surgery residencies.
In addition, the law provides nearly $230 million to increase the number of medical residents, which HHS predicts will result in more than 1,700 new primary care providers by 2015.
Meanwhile, medical schools also are attempting to address the PCP gap. Some institutions are adding community-based primary care training programs, while 17 new medical schools have opened since 2005, including some that have committed to training only PCPs and others that intend to encourage students to pursue primary care for underserved communities through loan forgiveness programs.
However, it could be a while before the effects of such efforts are known. Critics note that it takes years for new PCPs to be trained.
According to a report from the Congressional Research Service, “although the ACA includes a number of provisions that aim to alter physician supply, it is not yet known whether and how these provisions will affect physician supply.”
Does the ACA Go Far Enough To Address Access?
HHS says the physician training-related provisions of the ACA are already working. According to data from HRSA, ACA funding went toward more than 4,500 loan repayment and scholarship awards for current primary care providers and students training to be PCPs in fiscal year 2013 through the National Health Service Corps. HRSA also states that about 1,000 students, residents and other providers in the NHSC’s pipeline are preparing to go into practice.
However, several experts that California Healthline spoke with were skeptical that the ACA efforts would be enough to fully address the expected shortage.
Tannaz Rasouli, director of government relations for the Association of American Medical Colleges, said the ACA’s efforts are “all important provisions” to address the shortage. However, she added, “But they’re certainly not sufficient to address the workforce challenges that our country faces over the next decade as a result of the aging population and the looming retirement of a significant portion of the physician workforce.”
Reid Blackwelder, a physician and president of the American Association of Family Physicians, agreed that the ACA’s provisions to address the provider shortage are a “step in the right direction.”
However, he also questioned the law’s long-term ability to address the issue, noting that much of the success of the physician-supply related provisions is dependent on continued funding. Considering Congress’ current partisan climate, nothing is guaranteed.
For example, Rasouli noted that the increased funding for the NHSC is mandatory over five years, so at the end of fiscal year 2015, “unless there’s an additional investment in [NHSC], appropriators are going to have to find funding to continue the program.”
Both Blackwelder and Rasouli said the ACA missed an opportunity to address the shortage by not lifting the cap on the number of residency slots Medicare subsidizes. Rasouli said, “[T]here needs to be an expansion of the capacity for teaching hospitals to be able to expand physician training,” noting, “[T]hat relies on congressional action to life the cap on physician support for physician training.”
Blackwelder concluded, “We need to continue to look at bigger pictures, including GME funding, and we need some creative ways to changing that GME funding to support primary care more profoundly.”
Around the nation
Here’s a look at other stories making news on the road to reform.
Unintended consequences: The Louisville Courier-Journal looks at an unexpected uptick in newly insured Medicaid beneficiaries visiting emergency departments in hospitals in Kentucky and nationwide, which is the opposite of what many observers thought would happen under the ACA.
Will the opposition end?: Greg Sargent, writing at his Washington Post blog, “The Plum Line,” considers whether Republicans will halt their “guerilla resistance” to the ACA.
A political pickle: The Louisville Courier-Journal analyzes the race between incumbent Sen. Mitch McConnell (R-Ky.) and his opponent, Allison Lundergan Grimes (D), as both struggle to negotiate how they address the ACA to Kentucky voters. Although more than 400,000 Kentucky residents have gained coverage under the ACA, President Obama — and thus, Obamacare — remains unpopular.