Even if the insured population doubles, there won’t be a doubling in demand for health care providers.
The highly anticipated June 28 United States Supreme Court decision left the Affordable Care Act (ACA) intact, with the exception of a key provision that would have penalized states that did not expand their Medicaid program. The Medicaid expansion was slated to provide health insurance to an estimated 17 million low-income Americans, slightly more than half of the 32 million people expected to gain coverage under the law. Expanded insurance coverage was also key to the assumption that the ACA would significantly increase the demand for health care and therefore the demand for health care providers.
Even without the penalty, the Medicaid expansion could proceed as planned, but the governors of at least six states—Florida, Iowa, Louisiana, Mississippi, South Carolina and Texas—have said they will not increase Medicaid enrollment. If all 26 states that challenged the ACA decline to participate in the law’s Medicaid expansion, a recent study found that some 9 million Americans would be left without coverage.
To investigate what impact this change might have on physicians, nurses and frontline health care workers, The Robert Wood Johnson Foundation (RWJF) asked several experts for their views on the Court’s decision. They are:
- David Auerbach, PhD, a policy analyst at RAND Corporation and author of the RWJF-funded book, The Future of the Nursing Workforce;
- Frank Thompson, PhD, a 2007 RWJF Investigator in Health Policy Research and professor at Rutgers University’s Center for State Health Policy;
- Daniel Howard, PhD, director of the RWJF Center for Health Policy at Meharry Medical College; and
- Beth Feldpush, DrPh, vice president for advocacy and policy at the National Association of Public Hospitals and Health Systems, which represents 140 safety net hospitals.
Q: How strong is the connection between the increase in insurance coverage under the ACA and the need for an expanded, more diverse health care workforce?
A: With more patients requesting care at community health centers, physician practices and hospitals, “primary care physicians won’t be able to accommodate the increased demand,” says Thompson. “And whether you’re talking about advance practice nurses, physician assistants or other human capital in the health care system, there will also be pressure to change existing regulations and incentives in ways that will make them an even more important part of health care teams."
Auerbach explains that the ACA produces a need not only for more health care providers, but for a more professionally and culturally diverse workforce. Accordingly, the law offers “about $500 million in grants for residencies and other training funds for primary care physicians, nurses and nurse practitioners…to beef up this part of the workforce,” he says. Just one of the provisions is expected to train an additional 500 doctors by 2015.
To meet increased demand in medically underserved communities, ACA workforce support is also designed to train more providers who will fill positions in urban and rural areas.
That funding is key, says Howard, because, “it’s important for providers to understand the challenges in the patient’s life. Quality of care improves and satisfaction with care improves when there’s cultural competency, and when there are similarities in race and culture between physician and patient.”
Q: What impact—if any—will limited ACA-related Medicaid expansion have on these important workforce provisions?
A: Very little at this point, Thompson says, because Medicaid expansion may be slow, but not limited at all. “When Medicaid was created in 1965, it took two or three years for some states to join, but they did eventually participate. Arizona did not join until 1981. And basically, this is a very good deal for the states,” he says, and predicts that most if not all states will eventually participate in the expansion, “though it will be a political football.”
Auerbach agrees. “Though not always true, many providers would prefer Medicaid-insured patients rather than uninsured patients, so those providers may pressure state policymakers to expand coverage,” he says. Especially since the federal government will pay the entire cost of newly eligible Medicaid beneficiaries starting in 2014, with states eventually paying 10 percent by 2020 and thereafter.
Q: What about institutions that serve the poorest patients and depend heavily on Medicaid dollars?
A: That may be where we see the greatest impact from the Court’s decision to remove the penalty, and that’s exactly what worries Feldpush, an expert on the needs of safety net hospitals. By 2018, the extra federal Medicaid payments hospitals receive for treating the uninsured will be cut by nearly half—nationwide—under the health law, because millions more patients were expected to qualify for Medicaid or other insurance.
“Just because a state chooses not to expand their Medicaid coverage doesn’t mean people are going to seek less care at our emergency departments, but those safety-net hospital funds will still be cut,” Feldpush says. “Safety net hospitals are going to take care of people but something’s going to have to give.”
This may translate into overworked physicians, nurses and health care workers, less money to modernize hospital systems, such as electronic medical records, and fewer health care job opportunities in hard hit states.
Q: If lower than anticipated numbers of people gain insurance under the ACA, will the projected growth in health care jobs slow down or disappear?
Somewhat, but not as much as predicted, suggests Auerbach, who thinks ACA-related health care demand may have been overstated in the first place. He points to recent research that shows that even if the insured population doubles in number, there won’t be a doubling in demand for health care providers. The study compared medical service utilization between two Medicaid eligible groups, those residents who were selected for coverage through a lottery system and those who were not. Researchers found that the group with Medicaid coverage was only 35 percent more likely to have an outpatient medical visit, 30 percent more likely to be admitted to the hospital, and 15 percent more likely to take prescription drugs.
Bottom line: The revised Affordable Care Act may place more pressure on health care providers and institutions that serve low-income populations, but ACA provisions to educate providers and expand the health care workforce appear relatively unaffected by the change in the law.
To learn more about the potential impact of the Supreme Court ruling, read:
- The Doctor Might See You Now: The Supply Side Effects of Public Health Insurance Expansions
- Lines Are Drawn Over Opting out of Medicaid Plan (New York Times)
- A series on the RWJF Human Capital Blog in which RWJF leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act
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