The Affordable Care Act and Physician Supply
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.
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.
The nation’s physician population is approximately one-third primary care physicians and two-thirds specialists, a composition that is widely agreed to be suboptimal, the report says. There are concerns that this structure has resulted in a primary care shortage, and concerns about a shortage of doctors with particular specialties.
The ACA addresses common barriers to primary care entry and practice. It provides grants and contracts to support primary care training, and encourages physician training in community-based settings to offset the greater orientation toward specialty care in hospital-based residency training. It requires increased Medicare and Medicaid payments in primary care, where there is a large and growing salary gap with specialists, and provides incentives to coordinate care and compensate for administrative duties that specialty physicians do not have.
Additionally, the ACA provides loan repayment for pediatric medical, surgical and mental health subspecialties—specialties known to have shortages—in exchange for providing care in medically underserved areas. The law also authorizes grants to increase training in geriatrics and behavioral health, and provide incentives for general surgeons who practice in medically underserved areas.
The ACA aims to increase physician supply in areas that are now medically underserved, and in those with shortages of health professionals. Many rural areas experience physician shortages, the report says, as do some urban areas with economically disadvantaged populations.
The law includes changes to the National Health Service Corps—a program of HRSA—that may expand the number of providers able to serve in shortage areas in exchange for loan repayment or scholarships. Students from racial and ethnic minorities are more likely to practice in underserved areas, and the law authorizes programs that aim to increase the diversity of the physician workforce by encouraging underrepresented minorities to enter health professions education and supporting them in their studies.
The ACA encourages training in rural areas (and areas with shortages of health professionals or that are considered medically underserved) in order to encourage physicians to practice there at the conclusion of their training. It includes provisions that are intended to reduce isolation and increase contact with colleagues; one example is continuing education programs for health providers in rural areas.
The report concludes: “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.” Many of the ACA-established programs have not yet been implemented, and others may not have an impact for some time.