Editors’ Note: Provisions of the Affordable Care Act (ACA) have taken center stage in recent negotiations to end the federal shutdown and raise the debt limit. Since the Supreme Court upheld the ACA in June 2012, our blog has explored the vast implications and practical changes wrought by this wide-reaching healthcare law. In this post, Einstein pediatrics professor Arnold Birenbaum, Ph.D., explores portions of the law that increase access to primary care.
Some of the criticisms of the Affordable Care Act (ACA), or “Obamacare,” suggest that the federal government will dictate who will get care and how that care will be delivered.
In fact, recent ads funded by a group supported by the Koch brothers show our dear Uncle Sam preparing to administer exams himself. One depicts him with a speculum in hand about to perform a vaginal examination. This is fear mongering, as far as I’m concerned.
A more rational concern is whether the ACA and the increased number of patients it brings will create too much competition for the limited number of primary care providers in the USA.
The ACA does have provisions to expand access to primary care so that people covered by Medicare, Medicaid and commercial insurance will not be crowded out of the healthcare marketplace. Here’s how this was done.
First, the bill that was signed into law funded expansion of existing community health centers and added some new ones. The number of centers was greatly increased during the George W. Bush administration, with 1,250 centers serving 20 million people in 2011. The ACA reorganizes and upgrades these centers so they can be deemed “federally qualified” by the Department of Health and Human Services, and by 2016 these centers should serve 40 million Americans.
In 2010, Secretary of Health and Human Services Kathleen Sebelius announced $250 million in federal funding to help provide training to more than 16,000 primary care providers over five years. The Medicare payment gap between specialist and primary care providers would also be reduced through a 10 percent bonus for the same period. Whether these incentives can overcome the overwhelming ethos of subspecialization at academic medical centers remains to be seen.
Some policy makers are starting to note a serious shortfall in providers with medical degrees and are taking a different tack to increase capacity in primary care. They are following some federal efforts already in place to expand primary care by using nurse practitioners (NPs). Modifications of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and the Medicare, Medicaid, and SCHIP Extension Act of 2007 allowed NPs to become care coordinators, especially for people with chronic conditions such as diabetes.
Compared to the daunting regimen for physicians, the training and education of nurse practitioners are inexpensive and can be done more quickly. And time is of the essence. There is a need for more graduates from nurse practitioner programs, since the annual rate of 8,000 has remained unchanged for several years. According to advanced-practice advocates for the nursing profession, before this increase takes place state regulatory restrictions on what NPs can and cannot do must be eased. Currently, 16 states and the District of Columbia have altered their score-of-practice regulations so that NPs can prescribe independently. The trend is headed in the right direction.
By 2016, there will be an estimated 15,000 primary care providers at work, including advanced-practice nurses. I believe that those with coverage today can feel less concerned about being crowded out of services they have received in the past.
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Dr. Birenbaum – What you say is correct, but incomplete. The need for increased numbers of primary care providers that is being stoked by the ACA is just bringing into the spotlight the realities and deficiencies of American medical care in the 21st Century. I wish you would acknowledge that a significant amount of primary care is already being provided by non-physician clinicians, nurse practitioners (NPs) and physician assistants(PAs). Additionally, there has been a shift in the proportion of medical care services provided by primary care providers towards a growing and increasing proportion of medical care provided by specialists, with increasing proportion of this care also being provided in collaboration with PAs and NPs (along with nurse midwives and nurse anesthetists). This is especially true for the older population, where now more than half of all outpatient care is provided by specialty practices. The reasons for this shift are multiple, including a declining number of primary care physicians and practices, the lack of reimbursement for time (the most precious commodity in primary care) which indirectly encourages primary care providers to shift care away to specialists through increasing referrals, the increasing dependency (& reimbursement) for technology and procedures, and the medical training system which is focused toward tertiary hospital and specialty care rotations. Put this all together with the ACA and you have ‘perfect storm’ . Refocus training and reimbursement, change the incentives and the money toward primary care and the storm can be headed off….