Other analysts say the extent of the capacity problem will depend in large part on location.
“The truth is that the extent to which there are enough doctors or enough hospital beds is largely a function of geography,” Dr. Ku says. “So, if you’re in an urban area with lots of teaching hospitals, you probably have enough doctors and you probably have enough hospital beds. If, on the other hand, you’re in a poor, rural area, chances are you don’t.”
As both insurance and demand for healthcare expand, those areas that were having problems already “are going to be stretched even more,” Dr. Ku says.
Meeting demand also means training more doctors, and Mitchell worries about a pipeline that already is underfunded. Although medical school enrollment is at a record high, federal support for residency training has been frozen since 1997, meaning that the funded residency slots may not be sufficient to accommodate future graduates. Further declines in the clinical income that subsidizes training would place additional pressure on the educational mission of teaching hospitals, Mitchell says.
Joshua Lenchus, DO, RPh, FACP, SFHM, associate professor of clinical medicine in the division of hospital medicine at the University of Miami, says existing doctor deficits, the ACA’s new demands, and the growing medical training gap could swirl into a “perfect storm” of access problems. Longer delays in accessing primary and specialty care, in turn, could prevent timely interventions earlier during the course of a disease or condition.
“What it’s going to mean for hospitalists is that we’re going to see—over the short-term, maybe even the next three to five years—a real impact on when patients present, in terms of the acuity of their disease,” Dr. Lenchus says. That means sicker patients in the hospital.
Given the massive changes, observers like Mitchell and Dr. Hilger acknowledge that ironing out the rough spots will take time.
“There’s going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care?” Dr. Hilger says. “I think, no matter what your political affiliation, that, in general, the answer is no.”
What it’s going to mean for hospitalists is that we’re going to see—over the short-term, maybe even the next three to five years—a real impact on when patients present, in terms of the acuity of their disease. That means sicker patients in the hospital.
—Joshua Lenchus, DO, RPh, FACP, SFHM, associate professor of clinical medicine, division of hospital medicine, University of Miami, member, SHM Public Policy Committee.
Costs All Over the Map
One of the plan’s biggest goals and part of its name—affordability for those patients—also seems to vary considerably by geography. A recent analysis by The New York Times, for example, found that 58% of all counties served by the federal-run exchanges offer plans from only one or two insurance carriers. The relative lack of competition in many markets has created some huge cost disparities in premiums between neighboring states, and even neighboring counties.
With so many factors influencing costs, both proponents and opponents have found fodder to bolster their case that the law is either making insurance more affordable or sharply increasing premiums. One important consideration, Dr. Ku says, is that all plans must now include 10 “essential health benefits,” such as maternity care and medications, for example, and cannot allow gender to be a rating factor. As a result, he says, the cheapest plans for a relatively healthy young man may cost more now, while costs for a woman or an older person with a chronic condition like diabetes may go down.