Italo M. Brown, MPH, is a third year medical student at Meharry Medical College. He holds a BS from Morehouse College, and an MPH in epidemiology and social and behavioral sciences from Boston University, School of Public Health. He is a Health Policy Scholar at the Robert Wood Johnson Foundation Center for Health Policy at Meharry Medical College.

In an ad-hoc poll among classmates, I recently inquired about the most important date (in 2013) to a second year medical student. The overwhelming majority of respondents cited their respective STEP 1 exam dates as most important, followed closely by the season finales of ABC’s Scandal and Grey’s Anatomy. While the top three responses are noteworthy, the one date that should bear the most gravity in the minds of medical students across cohorts is October 1st.

This October marks the launch of open enrollment for health insurance exchanges, a much-anticipated provision of the Affordable Care Act (ACA). The ACA seeks to reduce the number of nonelderly uninsured Americans by half; in other words, a projected 20 million new patients will enter the health care system over the next 18 months.

David Grande, MD, MPA, is an assistant professor of medicine at the University of Pennsylvania's Perelman School of Medicine, a senior fellow at the Leonard Davis Institute of Health Economics, associate director of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program and an alumnus of the RWJF Health & Society Scholars program. This is part of a series of essays, reprinted from the Leonard Davis Institute of Health Economics’ eMagazine, in which scholars who attended the recent AcademyHealth National Health Policy Conference reflect on the experience.

It’s a time of unprecedented upheaval in U.S. health care. Big changes are bursting through on virtually every front. Legislators and administrators in Washington and 50 state capitals struggle daily to reinvent their health care systems even as they lack an exact blueprint for the new things they’re supposed to be building.

This was nowhere more evident than at the recent AcademyHealth National Health Policy Conference, where state and federal officials and interest groups lined up to present long lists of policy questions that confront them as they grapple with implementation of the Affordable Care Act and mounting public budgetary pressures.

Managing 'Churn'

For instance, in the “Opportunities & Challenges for State Officials” session, New Mexico’s Medicaid Director Julie Weinberg described the unknowns surrounding how “churn” between private and public coverage will change and how new Medicaid eligibility standards will impact enrollment processes.

When insurance coverage expands under health reform next year, dramatically increasing demand for primary care services, approximately 51 million Americans will be living in primary care shortage areas, according to a study published online in Health Affairs. Seven million people will be in hard hit areas, where the expected increase in demand for providers is nearly twice that of other regions (10% greater than their current supply, as compared to 5%).

The researchers predict the states most likely to have dire physician shortages because of increased demand are (in order) Texas, Mississippi, Nevada, Idaho and Oklahoma. They estimate the nation will need an additional 7,200 primary care providers, or 2.5 percent of the current supply.

The researchers “also found that small areas with a greater need for primary care services and providers, although concentrated in certain states, can be found in forty-seven states,” the study says. “The results of this study suggest that promoting and refining policies related to the distribution of primary care providers and community health centers may be as important as policies aimed at increasing the overall supply of primary care providers.”

The study was conducted by Elbert S. Huang (School of Medicine, University of Chicago) and Kenneth Finegold (Division of Health Care Financing Policy, Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services).

Read the abstract.
Read a Becker’s Hospital Review article about the study.

A report completed this month by the Congressional Research Service (CRS), which conducts analysis for members and committees of Congress, examines how the Affordable Care Act (ACA) will affect the nation’s supply of physicians. In particular, the report focuses on the workforce’s size, composition and geographic distribution.

Size
The health care system cannot work effectively or efficiently without a physician workforce of appropriate size. Too few physicians means delayed care, and too many physicians can mean unnecessary or duplicate care. But measuring the size of the physician workforce—and the future physician population—is challenging, and estimates vary. The CRS report notes that “predicting the timing, content, and effect of policy change is difficult, which adds to the uncertainty of the projections.”

The ACA authorizes funding for additional medical residency training programs through the Health Resources and Services Administration (HRSA) and the ACA’s own Prevention and Public Health Fund. It requires that Medicare-funded residency training slots be redistributed from hospitals that are not using them or that have closed, to hospitals seeking to train additional residents. It also includes provisions designed to increase physician productivity and the volume of physician services available. The law encourages care coordination—in medical homes and accountable care organizations, for example—and expands the non-physician workforce that can augment or substitute for physician services.

Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows and grantees. Some recent examples:

As part of its 25th anniversary celebration, Nurse.com recognized RWJF Senior Adviser for Nursing Susan B. Hassmiller, RN, PhD, FAAN, as a “pillar” of the New York/New Jersey nursing community. Hassmiller serves as director of the Future of Nursing: Campaign for Action. Nurse.com also honored Beverly L. Malone, RN, PhD, FAAN, a member of the RWJF Nurse Faculty Scholars National Advisory Committee and CEO of the National League for Nursing––one of the organizations leading RWJF’s Academic Progression in Nursing (APIN) program.

The New York Times reports on a new analysis by the RAND Corporation, co-authored by Arthur Kellermann, MD, MPH, FACEP, an alumnus of the RWJF Clinical Scholars program and the RWJF Health Policy Fellows program. The analysis finds that “the conversion to electronic health records has failed so far to produce the hoped-for savings in health care costs and has had mixed results, at best, in improving efficiency and patient care.” The article also quotes RWJF Investigator Award in Health Policy Research recipient David Blumenthal, MD, MPP. Read a post Kellermann wrote for the RWJF Human Capital Blog about health care spending.

Investigator Award recipient and RWJF Generalist Physician Faculty Scholar program alumnus Peter Ubel, MD, wrote an article for Forbes about a study he co-authored with RWJF Scholars in Health Policy Research alumnus Brendan Nyhan, PhD, and Jason Reifler, PhD, that finds the “death panel” myth––that the government would decide who was “worthy of health care” under the Affordable Care Act––has persisted, and may even grow with time. The Washington Post Wonk Blog also reported on the study. Read a post Ubel wrote for the RWJF Human Capital Blog.

The Robert Wood Johnson Foundation (RWJF) Human Capital Blog published more than 350 posts in 2012. On Friday, we shared five of the ten most-read posts published on this blog in 2012. Today, as we prepare to usher in a new year, we report on the top five.

Isolation in America: Does Living Alone Mean Being Alone? In this provocative piece, Eric Klinenberg, PhD, recipient of an RWJF Investigator Award in Health Policy Research, discussed his well-reviewed book, “Going Solo: The Extraordinary Rise and Surprising Appeal of Living Alone.” It looks at the health problems associated with social isolation. Klinenberg calls the increase in people living alone the country’s “biggest demographic change since the baby boom.” His post attracted the biggest audience on this blog in 2012.

Supreme Court Ruling Offers a Sense of Hope. This very personal piece by Thomas Tsang, MD, FACP, an alumnus of the RWJF Health Policy Fellows program, was the second most-read post on this blog in all of 2012. Tsang reacted to the U.S. Supreme Court ruling upholding key elements of the Affordable Care Act from the perspective of immigrant families like his own. Tsang said he hoped the ruling would allow “the country [to] start healing together and work on finding better solutions for future generations who believe that life is indeed better here in America—as my parents and I still do.”

Legal Experts Were Completely Stunned by John Roberts’ Health Care Opinion.  This post by RWJF Investigator Mark Hall, JD, also addressed the U.S. Supreme Court’s health reform ruling.  “We all knew it would be close, but we never saw this coming,” he blogged about the Chief Justice’s vote to uphold the highly controversial individual mandate. It was the third most-read post on the RWJF Human Capital Blog in 2012.

Eileene Shake, DNP, RN, NEA-BC, is CEO of the Foundation for Nursing Excellence. The Robert Wood Johnson Foundation Human Capital Blog asked scholars and experts to consider what the election results will mean for health and health care in the United States.

The 2012 election is over and now, as health care leaders, we are trying to figure out how to move forward with implementing the Affordable Health Care Act (ACA).  Yes, there will be an influx of Americans entering the health care system who did not have access to health care in the past. The impact on nursing will be significant as nurses are being recognized as important to providing care to the large number of new patients entering the system.  Nurses will be key players working on interdisciplinary teams to redesign how health care is delivered. Nurses and advanced practice nurses will need to practice to the full extent of their education in order to care for the increased number of citizens entering the health care system.

There will be less resistance to implementing the ACA and more emphasis will be placed on how to implement it.  Hospitals are already putting processes in place to reduce readmission rates for patients with chronic disease.  New programs are being implemented to manage health care after the patient is discharged to reduce readmission rates. Nurses are following up with patients to ensure they are taking their medications, checking their blood pressure, and following their therapeutic diets. It is important to note that there will still be some resistance to implementing the ACA from states that do not feel they can afford to pay for the health care program. 

Carolyn Montoya, RN, MSN, CPNP, is a fellow with the Robert Wood Johnson Foundation (RWJF) Nursing and Health Policy Collaborative at the University of New Mexico. A PhD Candidate, Montoya serves on the New Mexico Medicaid Advisory Committee, an advisory body to the Secretary of the state’s Human Services Department and the Director of the Medical Assistance Division Director. The RWJF Human Capital Blog asked scholars and fellows from a few of its programs to consider what the election results will mean for health and health care in the United States.

Human Capital Blog: Do you think there will be fewer challenges to the Affordable Care Act and more attention to how to implement it?

Montoya:  Now that the election is over, the reality is that the Affordable Care Act (ACA) will not be repealed. As we go forward with the ACA in place, a strong emphasis should be placed on evaluation. Outcome measures, such low rates of diabetes complications or increased immunization rates, will be essential in terms of being able to establish what aspects of the ACA are working and which ones need to be revised.

Frank J. Thompson, PhD, is a professor at the School of Public Affairs and Administrations and at the Center for State Health Policy at Rutgers, The State University of New Jersey.  Thompson is a 2007 recipient of a Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research, studying Medicaid: Political Durability, Democratic Process and Health Care Reform.  The RWJF Human Capital Blog asked scholars and fellows from a few of its programs to consider what the election results will mean for health and health care in the United States.

Human Capital Blog: What do you think the election will mean for the country’s health care system?

Thompson: It means that the country can go forward with implementing the Affordable Care Act (ACA).  My research focuses on Medicaid—the federal grant program to the states that insures some 65 million low-income people. Under the ACA, Medicaid is slated to cover most people with incomes up to 133 percent of the poverty line as of 2014. In the recent election, the differences between the two parties on the ACA and Medicaid were stark. The Romney-Ryan ticket pledged not only to repeal the ACA but to convert Medicaid to a block grant and to cut funding for the program by more than 30 percent over ten years. The degree to which a Romney administration would have achieved these objectives remains an open question. But the reelection of President Obama curtails the likelihood of major Medicaid reductions over the next four years.

The United States will need 52,000 additional primary care physicians by 2025 to meet demand that is growing due to three trends: population growth, population aging and insurance expansion. That is a key finding from a study published in the November/December issue of the Annals of Family Medicine. The researchers estimate that population growth will account for the majority of the needed increase in primary care doctors.

Given the current number of visits to primary care physicians and an expected population increase of 15.2 percent, the researchers predict that office visits to primary care physicians will increase from 462 million in 2008 to 565 million in 2025. This trend will be especially evident among people 65 and older, a segment of the population that is expected to grow by 60 percent. Population growth will require an additional 33,000 physicians, the study says, and aging another 10,000.

Insurance expansion under the Affordable Care Act will also require additional physicians, the researchers find. Eight thousand physicians will be needed to meet that growth.

The 52,000 additional primary care physicians would represent a 3 percent increase in the workforce.

Read the study.