With 32 million Americans gaining health care coverage in the coming years — and demanding services as a consequence — the next challenge is addressing the supply side of the equation. Once these folks start putting their freshly minted insurance cards to use, who will actually perform the blood-pressure checks, treat the cancers and monitor the diabetes? Family physicians, who are on the front lines of this surge in demand, are already in short supply, as are nurses, whom the new law identifies as critical players in meeting some of the expected new demand for services. By 2020, when most of the currently uninsured will have been fully brought into the health care system, the American Academy of Family Physicians predicts a shortfall of 40,000 in the ranks of primary-care providers to treat them.
One way to address that gap would be to make primary-care medicine a more attractive field — not just for physicians but also for nurse practitioners who receive an additional one to two years of training to expand their range of care into areas like anesthesia. The new law calls for appropriations over five years to fund further training programs, scholarships and loan repayments for those entering primary care. But even if new students take up those offers this year, they won't be ready to treat patients for three to seven years. The law would also temporarily boost what primary-care providers receive for treating patients insured by Medicaid, the plan that will pick up nearly half of the newly covered.
In the long run, addressing the shortage of primary-care providers will take much more than money. "What is clear to me is that we cannot fix the problem by adding 32 million people to the mix and not changing the way we deliver care," says Susan DeVore, president and CEO of Premier Healthcare Alliance, a coalition of 2,300 not-for-profit hospitals dedicated to improving health care performance.
So what would fix the problem? Ideally, policy should address not just the question of who delivers care but also how and where services are provided. The new law, for example, recognizes that doctors can't be the only ones to provide care and that hospitals and physicians' offices can't be the only places where people receive health services. The law is expected to ultimately spend $11 billion to create more health centers based in communities and schools as well as nurse-managed clinics. It will also enhance the government-salaried National Health Service Corps of primary-care physicians, nurse practitioners and physician's assistants who target underserved regions and receive loan repayments or scholarships to subsidize their medical education.
The funding will also support programs like the "medical home," a team-based approach to delivering health care that breaks down the traditional hierarchy in which all health decisions are made by the physician. Instead, a medical home disperses responsibility across a range of providers and facilities, which allows existing hospitals and clinics to accommodate the increased demand for services without costly investments in capacity building.