Republican Scare Stories Of Doctor Shortages Under Obamacare Failing To Come True

We are well into the year and none of the Republican horror stories about Obamacare have come true. There are no death panels. Enrollment through the exchanges has exceeded expectations. Over 80 percent of those purchasing insurance are paying premiums as the Obama administration predicted, and ultimately this might exceed 90 percent. Premiums are not expected to increase next year any more than is traditional on the individual market. The Hill even reports that Republicans are holding off on attacking the Affordable Care Act, although I wouldn’t count on that to continue.

Republicans have also predicted that the Affordable Care Act would lead to a shortage of doctors as more people obtain coverage, contradicting their claims that the uninsured were not signing up for coverage. Opposing health care reform because it might lead to shortages because of more people becoming covered is also a rather cruel answer to the millions who were uninsured. Some Republicans even predicted that doctors would not accept people in the new exchange plans, which is especially absurd considering that these private insurance plans pay doctors more than government plans such as Medicare and Medicaid.

Kaiser Health News reported today that there has not been a problem with shortages of doctors due to the Affordable Care Act:

The headlines were ominous: Good luck finding a doctor under Obamacare. Not enough doctors for newly insured. Obamacare, doctor shortage could crash health system.

Despite these dire predictions, the nation’s primary care system is handling the increased number of insured patients without major problems so far, according to interviews with community health centers, large physician practices and insurers nationwide.

Five months into the biggest expansion of health coverage in 50 years — with about 13 million people enrolled in private insurance and Medicaid under the Affordable Care Act — there are few reports of patients facing major delays getting care, say officials from more than two dozen health centers and multi-group practices, as well as insurers and physician groups in nine big states.

There are some exceptions, particularly in parts of Colorado, Kentucky and Washington state, which had some of the biggest gains in coverage…

Many of the concerns about people experiencing delays grew out the experience in Massachusetts after that state adopted near-universal coverage in 2006. Wait times for a doctor’s appointment rose to an average of 50 days with some as long as 100 days, according to a Massachusetts Medical Society report in 2008.

But Glied notes that Massachusetts’ residents historically had long waits for primary care visits so their experience is not a good indicator.

And unlike the Massachusetts law, the Affordable Care Act gave health providers more than three years to prepare. In that time, the federal government has spent billions expanding community health centers while private practices have added nurse practitioners and physician assistants and adopted electronic health records.

“Despite the widely publicized shortage of primary care physicians, primary care capacity does exist in each state,” said Karin Rhodes, director of the Center for Emergency Care Policy & Research at the University of Pennsylvania School of Medicine.

Rhodes was the lead author of a study published last month in JAMA Internal Medicine in which researchers posing as new patients called about 8,000 primary care practices in 10 states. The vast majority quickly secured appointments although those with Medicaid had a tougher time.

I also discussed that study in a post last month.

Some of the anecdotal reports of difficulty seeing a physician are probably erroneously being attributed to the Affordable Care Act, especially as an already existing shortage in some areas has been exacerbated by other problems recently. As a large number of the newly insured didn’t sign up until late March, I am quite skeptical of those claiming to have experienced problems due to shortages beginning in January. Before blaming the Affordable Care Act, keep in mind the fact that health care utilization began to rise in late 2013 due to factors such as improvements in the economy. People who had been putting off medical expenses were thought to have more money to spend while others obtained new jobs with health insurance.

In addition, new requirements for electronic medical records and the conversion to ICD-10 billing codes have been very time consuming for physicians over the past year, resulting in many doctors not being able to see as many patients as in previous years. Fortunately the conversion to ICD-10 has been postponed another year, but time-consuming transition programs are continuing. While computerization theoretically will increase efficiency, the conversion, with many onerous new requirements, initially results in a considerable drop in productivity.

While many of the Republican scare stories are easily dismissed as ridiculous, there is legitimate reason for concern that increasing the number of people with insurance will worsen already existing physician shortages in many areas, especially in the future when even more people are insured. That would certainly be the case if the Affordable Care Act didn’t also include measures to increase the number of primary care physicians to offset this. Some of the measures in the Affordable Care Act which will help increase the number of primary care physicians can be seen here.

Often people are unaware of how new physicians in an area are a result of the Affordable Care Act. While researching this post I stumbled across this press release for a new Family Medicine Residency Program in San Diego, which has been designated a health shortage area for several years. It reports that, “The training program was made possible by the Affordable Care Act, which created the new Teaching Health Center Graduate Medical Education Program (THCGME) to establish physician training programs in underserved community-based settings.” I was glad that the ACA received credit for the establishment of this program.

Those who studied the Affordable Care Act did not take the Republican scare stories of shortages seriously. In December, Scott Gottlieb, who advised George W. Bush, and  Ezekiel J. Emanuel, an adviser to Barack Obama on the Affordable Care Act, jointly wrote an op-ed in The New York Times entitled, No, There Won’t Be a Doctor Shortage. They explained how changes in health care delivery will offset the increased demand both from the newly insured and an aging population.

The physician shortage has been studied extensively and while increased demand due to newly insured is expected to play a role, other factors are expected to be far more important with regard to the physician shortage. For example, The Manhattan Institute concluded, “Ultimately, the impact of Obamacare on the primary-care physician shortage, rather than just the increase in demand for primary-care physicians, is relatively minor: the insurance expansion will require about 5,000 more doctors in 2025, compared with about 25,000 more physicians who will be required because of demographic changes and population growth.”

The National Center for Health Workforce Analysis found that the aging population is by far has the greatest influence on future projected shortages, accounting for 81 percent of increased demand. They also project that many of the shortages can be alleviated by increased use of nurse practitioners and PA’s, increasing from 23 percent of primary care services in 2010 to 28 percent in 2020. This would still leave physicians as the primary providers of care, decreasing from 77 percent of the primary care services in 2010 to 72 percent in 2020. I don’t think that there is any doubt that NP’s and PA’s can handle this amount of routine primary care. This would reduce their projected shortage of 20,400 physicians in 2020 to 6,400.

While the number of newly insured has already been accounted for in projections (often assuming full Medicaid expansion nation wide), the number of new programs to expand primary care, and other ways to transform health care to make it more efficient, can still be increased over time. Increased government involvement in health care can lead to additional solutions which would not occur if we continued the old, inefficient system. The Affordable Care Act also has provisions requiring insurance companies to maintain panels with an adequate number of physicians. While such requirements might be meaningless if there aren’t enough physicians available, they do protect consumers from problems such as insurance companies limiting the size of their physician panels too drastically in order to reduce costs.

We already have a shortage of primary care physicians in many areas and will face challenges in the future, but the Affordable Care Act should not be blamed for this problem. The impact will vary in different areas, but overall the result of the newly insured should not create major problems for the health care system.

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