Policy

The Physician Shortage and the Future of the Affordable Care Act: The Coverage without Care Conundrum

Ceslee D. Montgomery

Before the passage of the Patient Protection and Affordable Care Act in March of 2010, the United States was one of only a few industrialized countries without universal access to healthcare.  The legislation, referred to as the “Affordable Care Act” (ACA) or “ObamaCare,” represents the greatest overhaul of the American healthcare system since that of Medicaid and Medicare in 1965. This reform came precisely as the demand for care began to increase, given the growth of an aging and chronically ill population. In fact, the Pew Research Center projects that in 2030, when the Baby Boomer generation reaches 65 years of age, 18% of the nation’s total population will be at the age of retirement or older, compared to just 13% today.1

The healthcare legislation, responding in part to this increase in demand, aims at both the empowerment of the uninsured and the improvement of healthcare for the existing insured population.  The Congressional Budget Office estimates that 27 million Americans will be newly insured in 2017.2 Additionally, insured Americans will have increased access to healthcare through measures such as the coverage exclusion ban, which extends coverage for those under 26 on their parent or guardian’s insurance. Measures that address payment reform like the “80/20 rule,” which states that insurance companies must spend 80-85% of your premium directly on healthcare and quality improvement, are expected to also increase access to coverage.3

Increased access to coverage, however, does not always mean increased access to care.  An imminent threat to the statute’s unprecedented and innovative reform is a simple “supply and demand” problem:  there will be no commensurate increase in either the capacity or the supply of care providers to match the increase in care coverage. The issue of a shortage of physicians and other care providers is not a new one.  Two years before the enactment of the ACA in 2008, the Bureau of Health Professions (BHP) projected a shortfall of approximately 49,000 physicians by 2020.  It estimated that 7,000 physicians were needed in designated under-resourced communities known as Health Professional Shortage Areas (HPSAs) alone, which affects approximately 57 million Americans.4 However, with the increased coverage afforded by the ACA, the 2010 post-reform report by the Association of American Medical Colleges (AAMC) predicted that by 2025, our physician workforce will be 130,600 less than the demand.5  To put that in perspective, that’s a ten-fold increase from 2010 to 2025, and more importantly, an almost three-fold increase from the pre-ACA projection by the BHP.  If in fact, it is true that an equivalent increase in the capacity or supply of care providers will not occur by 2017, Americans may face the conundrum of coverage without care.

Indeed, there is significant evidence to support that efforts to increase care capacity and supply are minimal in comparison to the expected increase in need over the coming decade.  The AAMC has granted accreditation status to 12 new medical schools by late March 2012, bringing the total number of U.S. medical schools to 137—an 11% increase. Furthermore, in 2011, the first-year medical school enrollment increased by 16.6%.  However, even with a projected annual increase of 5,000 first-year medical students, it would take 26 years from the 2016 projection to close in the gap. Even outside of medical school education, the AAMC claims that an increase in medical student enrollment is limited without a commensurate increase in Graduate Medical Education (GME) training positions.  Plagued by inadequate funding for graduating medical students, the AAMC cites that since 2002, residency-training positions had increased by only 8 percent.6

However, experts such as Princeton economist and health policy expert Uwe Reinhardt argue that the existing projections of the physician shortage do not incorporate the team-based redesign of care delivery, called a Patient-Centered Medical Home (PCMH). With the incorporation of PCMH into the current model, more integration of health information technology and coordinated care may ensue. Reinhardt convincingly points to this supposed flaw as an explanation for how outdated models grossly over-project the gap.  His argument is supported by the newly-ACA created and funded quality improvement centers such as the Patient-Centered Outcomes Research Institute,7 the Center for Medicare & Medicaid Innovation,8 and the Agency for Health Research & Quality, a commissioned annual National Quality Strategy.  Ideally these efforts would optimize the caseload of physicians and the nature of care itself. To reach this optimal point, Columbia Business Professor Linda Green proposes delegating care to nurses and other care team members, as well as utilizing electronic health records to aid in the reduction of the administrative burden on doctors. Other healthcare professionals could share in care responsibilities and help reduce workflow waste from administrative tasks and clinical documentation, resulting in greater capacity and thus a reduced physician deficit.9

However, the critical question that remains is to what extent quality improvement efforts will address the physician shortage.  Will the value of quality improvement be realized fully in time, considering that 27 million Americans expect to become newly insured in three years? The ACA was poised to address the physician shortage but, as The New York Times pointed out in a recent February 2013 article, the provision calling for a commission to investigate policy solutions to the projected shortfalls was blocked in Congress.10 Will the fate of the physician shortage come down to whether this commission (or one like it) eventually prevails?

Despite valuable coverage improvements, the ACA may have additionally exacerbated the physician shortage conundrum. A lack of care is dangerous for vulnerable populations, especially the elderly, who have been shown to experience a disproportionate burden of the healthcare shortage. In addition, shortage areas, where 50 million Americans currently have limited access to care, may be stretched even further. Without significant policy changes, the increased demand of the newly insured and the growing aging, chronically ill population introduces a scenario in which adequate care becomes the predominant healthcare woe, replacing coverage.

  1. Baby Boomers Approach 65 – Glumly (Pew Research Center) Website. Available at: http://www.pewsocialtrends.org/2010/12/20/baby-boomers-approach-65-glumly/. Accessed April 9, 2013.
  2. How has CBO’s Estimate of the Net Budgetary Impact of the Affordable Care Act’s Health Insurance Coverage Provisions Changed Over Time? (Congressional Budget Office) Website.  Available at: http://www.cbo.gov/publication/44008.  Accessed April 2, 2013.
  3. Value for Your Premium Dollar: 80/20 Rule and MLR (Healthcare.gov) Website.  Available at: http://www.healthcare.gov/law/features/costs/value-for-premium/index.html.  Accessed April 2, 2013.
  4. The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand, page 70.   Available at: http://bhpr.hrsa.gov/healthworkforce/. Accessed March 2013.
  5. The Impact of Health Care Reform on the Future Supply and Demand for Physicians Updated Projections Through 2025 June 2010.  Available at https://www.aamc.org/data/workforce/reports/. Accessed March 2013.
  6. AAMC Physician Workforce Policy Recommendations September 2012. Available at: https://www.aamc.org/data/workforce/reports/.  Accessed March 2013.
  7. Section 6201 of the Patient Protection and Affordability Act (PPACA). Available at: http://www.healthcare.gov/law/full/. Accessed March 2013.
  8. Section 1115A of the Social Security Act.  Available at: http://www.ssa.gov/OP_Home/ssact/title11/1115A.htm.  Accessed March 2013.
  9. Green L, Savin S, Lu Y. Primary Care Physician Shortages Could Be Eliminated Through Use of Teams, Nonphysicians, And Electronic Communication.  Health Affairs.  January 2013; 1: 11-19.
  10. Health Care Panel Lacking Budget is Left Waiting (The New York Times) Website.  Available at: http://www.nytimes.com/2013/02/25/health/health-care-panel-lacking-budget-is-left-waiting.html?_r=0.  Accessed March 2013.