On March 21, 2010, the House of Representatives passed the Patient Protection and Affordable Care Act, and completed what then Senator Ted Kennedy called “the great unfinished business of our society”. In so doing, congress purportedly ensured that every American would have access to quality, affordable health care, as a right and not a privilege.
While the 2700 pages of the bill include a vast array of new insurance and physician requirements, and hosts of new patient entitlements, perhaps nothing has gained more attention than the bill’s mandate for health insurance coverage. In addition to controlling and driving down escalating healthcare costs, the final health insurance reform legislation had the highly publicized goal of care accessibility for all Americans. Apparently, the bill’s architects believed that mandating healthcare insurance would somehow translate into assuring this access to care. In the vernacular of the Left, “insurance coverage” has become synonymous with “care access”. Nancy Pelosi herself stood at the podium and announced, “This bill assures that millions of previously uninsured people are now covered, so that now all Americans have access to healthcare!” Ah, the power of Liberal magic!
Unfortunately, as seems to be the case with so many things that the Democrats control, someone forgot to do the math. America was already facing a significant shortage of physicians prior to the passage of the reform bill. Adding more than 30 million newly insured people into the system will make the deficit far worse.
The Association of American Medical Colleges’ Center for Workforce Studies released new estimates that show physician shortages will be 50 percent worse in 2015 than forecast. "While previous projections showed a baseline shortage of 39,600 doctors in 2015, current estimates bring that number closer to 63,000, with a worsening of shortages through 2025," the group said in a statement.
In addition to the 30-plus million people newly insured as a result of the mandate, the federal government plans to expand Medicaid coverage to low-income adults and to subsidize purchases on the health insurance exchanges. These potential new patient numbers are additive to an already aging population with a steady increase in the incidence of chronic disease.
Although there are some preliminary plans in the reform bill to increase the number of primary care physicians, none of the provisions will have any impact on the doctor shortage by 2014, the year that most of the insurance coverage mandates go into effect. Unfortunately, a nicely laminated insurance card will not mean much to patients without providers to actually care for them. Ultimately, what has been touted by the Democrats as a solution to lack of healthcare access is tantamount to addressing a hunger crisis by passing out gift certificates to Denny’s in a town that has no Denny’s!
To exacerbate the issue further, despite being reassured repeatedly that we will love life in the new world order of healthcare reform, the majority of Americans have significant distrust for the bill, and most are concerned that it will ultimately increase the cost of care while lowering quality and extending wait times.
Physicians, in particular, are unhappy with the bill – So unhappy that many feel that they will retire or look to other avenues for employment. In a survey done in 2010, nearly one-third of all practicing physicians indicated that they would leave the medical profession if the healthcare reform legislation was signed into law. The survey was conducted by the Medicus Firm, a leading physician search and consulting firm, and was published in the New England Journal of Medicine. A majority of physicians interviewed said that healthcare reform would cause the quality of medical care in America to “deteriorate” and that it could well be what sends a sizeable number of doctors out of medicine altogether.
Nearly a third of the over 1,100 doctors who responded to the survey said that they personally would quit the profession or retire early if the bill became law. A whopping 63 percent of physicians said they would not recommend the profession after healthcare reform passed.
In addition to many doctors abandoning their practices entirely, the healthcare reform legislation will likely have a significant impact on practice styles for those who remain in the game. In response to a huge influx of new Medicaid patients and others covered by plans with low reimbursement, physicians will continue to migrate toward hospital-based practices and other employment models where reimbursement is less uncertain. Physicians will also likely reduce or entirely eliminate patients from certain insurance categories, including Medicaid and Medicare. Interestingly, a study co-authored by the American Medical Association, the Association of American Medical Colleges (AAMC), and the Council on Graduate Medical Education (COGME) noted “a strong correlation between the decline in inflation-adjusted physician fees and the decline in average physician hours worked per week”, suggesting that physicians tend to work less the less they are rewarded. Wow. Who knew? While some doctors will simply work less, others will opt to open concierge-type practices in order to avoid third-party payers, and some will move to temporary, locum tenens or part-time work. The cumulative effect however, is the same: They all result in the overall decrease in physician hours and a reduction in patient access to care.
Americans who live in areas that already have a shortage of physicians will likely experience escalating wait times for appointments as the ranks of newly insured patients increase. Those who move into a new community may well have difficulty finding a doctor who accepts new patients, especially if they are on Medicare or another government subsidized plan.
Healthcare was already a financially precarious industry. Well prior to the passage of the reform bill, a large percentage of doctors felt that they would not be able maintain their practices if patient loads continued to increase while reimbursement decreased. The average debt for a medical school graduate is $140,000, and many students rack up school loans approaching a quarter of a million dollars or more. By definition, cost savings on healthcare will not be achieved by limiting access to health insurance, as the insurance mandate does just the opposite. Proponents of the bill maintain that rationing of care is not their goal. Savings, therefore, will have to come from reduced fees to doctors and other care providers. As a result, even if there are still some willing to make the onerous time and work commitment to medical education and training, being a doctor is becoming less and less financially feasible.
It appears that an unintended consequence of the healthcare reform legislation may be a very dramatic decrease in the physician workforce, coincident with an all time high on its demand. This now limited workforce will be relied upon to care for our growing aging population, our escalating numbers of obese and chronically ill, and the tens of millions of patients newly insured through health reform.
Whether or not the Supreme Court overturns the recently passed legislation, no version of health care reform will succeed without an adequate supply of physicians. It is therefore incumbent upon Congress to enact policies that increase the nation's primary care and specialty physician workforce. The medical practice environment must also be changed to ensure a physician workforce that is motivated and robust. Improved and standardize reimbursement processes, serious tort reform, a reduction in medical educational debt, increased clinical autonomy, and reciprocity of state medical licensure are needed to attract new doctors to the profession and to encourage those already in it to remain. If we fail to protect medicine as an honorable and sustainable career and to ensure a rewarding work environment, lack of physicians will be the new form of rationing.
written by Kelly Victory
