In the health care reform debate, one of the features Congress is considering is an individual mandate, which would require everyone to get health insurance. But if most of the 49 million uninsured Americans get access to coverage after reform, will there be enough doctors to care for them?
We asked our Urban Institute experts: how can our health care system meet this new demand?
Robert A. Berenson, Institute Fellow
Health policy researchers are engaged in a heated academic debate about whether the United States has enough physicians. It’s academic because government doesn’t do much one way or other to increase or restrain the supply of doctors. That needs to change. The clearest need is for more primary care physicians—and nurse practitioners and physician assistants—to provide first-line care for those newly insured, along with the current population of well-insured patients. In some metropolitan areas, even Medicare beneficiaries can’t find a new primary care doc.
First, we should recalibrate the Medicare fee schedule—which doubles as the payment model for private insurers—to better reward primary care services. That way, primary care would be more attractive to medical school graduates, many of whom have $200,000 of medical education debt. A reinvigorated loan-forgiveness program for physicians practicing primary care in underserved areas would help too. So far, health reform proposals have not directly confronted the primary care physician shortage issue.
Sharon Long, Senior Fellow
Massachusetts’s health reform initiative has resulted in record levels of insurance coverage in the state and improved health care access for many. With more people seeking and using care under health reform, some have reported difficulties obtaining care and finding doctors who can see them. Most likely, the state’s longstanding provider shortages got worse after health reform as the newly insured sought care for the first time, those with newly covered benefits tried to use those benefits, and both groups sought follow-up care.
Massachusetts has, with some success, undertaken strategies to attract and retain health care professionals, including primary care physicians. There is also hope that changing the payment system to emphasize the coordination of care, as has been proposed, will create a more efficient and effective health care delivery system, reducing the state’s need for as many additional providers.
Nurses can contribute greatly to improving care under any health system reform. Expanding health coverage will strain current services. The newly insured will have pent-up demand, especially for a “medical home,” which provides primary care and can organize referrals—a role often shortchanged as physicians become increasingly specialized. Backed up by doctors and other clinicians, nurse practitioners are well-prepared to help fill today’s frequent service gaps.
Three types of policy change are needed to support such expansion:
The uninsurance rate in Washington, D.C., is already low after a 2001 locally funded coverage expansion. D.C.’s eight-year experience in improving access for newly insured residents offers lessons for national health reformers. If current resources are to meet the inevitable increase in demand, patients must be redirected away from hospital emergency rooms and toward providers in the community, preferably those who both offer primary care and coordinate other care as needed.
Providers, in turn, must make quality and continuity of care their goals, especially for patients with chronic conditions. Payment flows must support these changes. The lesson from D.C.’s hard-won progress? Coverage expansion marks the start of the transition to better health care; health system reform is the necessary next step.
Howard Gleckman, Resident Fellow
Congress can take several steps to improve access to long-term care: provide new incentives to train health care professionals in geriatrics and train direct-care workers, improve care coordination for those with multiple chronic diseases, and create a broad-based insurance-like financing mechanism so people can afford nonmedical long-term care services. Such steps could also help get Medicaid out of the long-term care business. While Medicaid remains a major payer, states should be encouraged to expand their home and community care programs.
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