The Congressional Budget Office (CBO) forecasts that the Affordable Care Act (ACA) will expand health coverage by approximately 30 million Americans. It is also expected to gradually rein in health-care spending nationwide through its reforms in insurance markets, provider payment and health-care delivery. (For discussion of these, see previous articles from this ACA series, published in the Dec. 20 and Jan. 3 issues of Business Lexington).
The ACA’s coverage of millions more Americans will begin Jan. 1, 2014, when its “play or pay” mandate, requiring everyone to have health insurance, and its Medicaid expansion take effect. Tax penalties to enforce the individual mandate are mild at first; in 2014, they will be a flat $95 or 1 percent of household income, whichever is greater. They increase yearly until after 2016, and then they are indexed to inflation at the greater of $695 or 2.5 percent of household income.
As they increase, the penalties can be expected to induce more Americans to obtain health coverage. With more widespread coverage, the demand for medical attention and health-care services is certain to increase as well. A substantial increase in demand will pose serious challenges to the supply of qualified health-care workers.
The ACA’s provisions for health-care workforce development
Because a primary aim of the ACA is to make quality health care accessible to millions more Americans, the ACA anticipates this increase in demand for health-care professionals and devotes many sections and pages to this potential, indicating an original intent to avert a potential shortfall in supply.
The ACA also seeks to restrain the growth of health-care spending, and it recognizes this goal will be frustrated if an increase in demand significantly outstrips supply.
Basic economics teaches that prices rise when supply runs short. Accordingly, the ACA includes numerous workforce development provisions intended to build and train America’s health-care workers to prevent shortages.
First, it provides various grants and loan programs for training facilities to build primary-care capacity and to attract and retain more people into primary care fields. It offers educational grants and more liberal loan repayment terms for students of primary care, public health and nursing. It distributes additional graduate medical education (GME) residency positions among academic medical centers and allots many to the development and stabilization of primary-care physician services in rural areas.
It also establishes grants for state and community health-care workforce development initiatives and creates an independent 15-member body, the National Healthcare Workforce Commission, to assess and coordinate any national, state and local-level responses to an inadequacy in supply relative to demand for health-care workers.
Second, it authorizes grants to nurse-managed health clinics. These grants recognize that nurses and nurse practitioners are already on the forefront of primary-care coordination and services. And, they recognize the reality of America’s current health-care workforce: nurses outnumber any other primary care provider. In certain rural and underserved communities, nurses may be the only practical way to meet a significant increase in demand for health services in the short term. There are simply too few primary-care physicians or medical students who could be available or trained soon enough to meet any rapid increase in demand.
Potential hurdles to the ACA’s workforce development provisions
While the ACA provides for grants and programs and various other initiatives to build America’s health-care workforce, the stark reality is that all of these must be funded through annual appropriation bills enacted by Congress. This is the rub: To date, such funding has fallen victim to disputes over spending, the federal budget deficit and “fiscal cliff.” The National Healthcare Workforce Commission has not yet met once, due to lack of funding. Thirty-three professional health-care associations and societies recently wrote to Congress, pleading with it not to stall the commission’s functioning any longer, as the ACA’s provisions expanding coverage will take effect very soon.
The ACA’s provision for additional GME residency positions may or may not increase the supply of primary-care doctors in rural areas. A recent study points out that a redistribution of GME residencies was included in a law passed in 2003, but that it did not significantly impact the supply of rural primary-care physician services. The authors of the study do not expect the ACA’s provisions to do differently, unless significant reform is made in how teaching hospitals receive funding for such residencies.
Certain smaller grant provisions in the ACA, however, could help the supply of primary-care physician services in rural areas: Those grants are offered directly to Teaching Health Centers established in actual practices or rural community health centers apart from urban teaching hospitals.
Finally, disagreement over the proper scope of practice for nurse practitioners exists. Only 16 states and the District of Columbia currently allow nurses sufficient independence in practice to provide primary-care services in nurse-managed clinics. While Kentucky, for the most part, permits advanced practice registered nurses (APRNs) the requisite practice-independence, opposition to nurse-managed clinics remains in some quarters.
The American Academy of Family Physicians points out the tremendous disparity in training for nurses versus the lengthy medical education and residency programs required for doctors. The concern is that nurses lacking the training of physicians, yet practicing totally independently from them, will deliver second-class quality in primary-care services. They point out further that independent, non-physician practitioners (such as APRNs) tend to order more costly lab tests and diagnostics than necessary. Even if a nurse practitioner’s fees are lower than a doctor’s, the additional cost of these unnecessary tests and diagnostics make their services more expensive in the end. Neither decreased quality nor increased cost is consistent with the ACA’s goals.
The projected shortage of primary-care physicians
The American Association of Medical Colleges projects there will be a primary-care physician shortage of 45,000 by 2020. Moreover, many primary-care physicians are not evenly distributed among patient populations. The vast majority of internists, for example, practice in urban areas, but rural areas are where primary care is likely to be needed most. However, a recent study disputes the severity of any potential physician shortage based on projected gains in productivity in modern physician practices. For example, this study claims, telemedicine and physician pooling through extenders such as physician assistants and nurses should alleviate any shortage.
Regardless of whether productivity alone could alleviate the projected shortage, there is no question a supply of about 150,000 nurse practitioners already exists, and only about 1,000 of them currently practice in nurse-managed clinics. If differences over the appropriate scope of practice for nurses can be worked out, and if their training levels are sustained or even increased, then the expected shortage in primary-care doctors may be lessened.
As the new 113th Congress approaches round two of “fiscal cliff” negotiations, it is worth considering whether political differences over the ACA are worth courting a disastrous disruption in America’s health-care workforce. If funding is not provided soon to at least some of the ACA’s workforce initiatives, America could face a serious health-care crisis as coverage (and therefore demand) expand, but supply begins to run short.
Even if deficit watchers deem the many ACA workforce initiatives too costly, at the very least, funding should be provided for the National Healthcare Workforce Commission so that it can start functioning. Its cost is only $3 million, a mere drop in the ocean of the budget-deficit calculus. If the commission were up and running, a much-needed independent assessment of an impending physician and primary care shortage could begin, and analysis could proceed as to what measures to take to avert any national or regional crisis. Its minimal cost would seem a worthwhile investment.
Douglas L. McSwain is a partner at the law firm of Wyatt, Tarrant & Combs, LLP. He advises and litigates for clients in areas related to health care, employment, trade, regulatory and constitutional law.