‘Help Wanted’ For Medicaid Expansion

Despite its complexities and its politics, I support the Affordable Care Act (aka “Obamacare”).  As I’ve written elsewhere, I think it would be both morally and economically wrong for Governor Fallin and the Oklahoma legislature to opt out of the ACA’s vast Medicaid expansion – a position shared by Oklahoma Policy Institute.  So if Oklahoma does the right thing and opts to expand Medicaid for adults with incomes at or below 133 percent of the federal poverty level, what will happen?

Oklahoma faces a serious shortage of primary care access. The Oklahoma Health Care Authority, the agency in charge of administering Medicaid, recently compiled county-by-county maps, color-coded to classify areas of severe physician shortage based on presumptive levels of Medicaid expansion.  At a glance, these maps reveal something we already know: rural areas are hurting for physicians and populous counties seem to have more capacity.  In my opinion, however, the maps don’t paint a full picture of the eventual shortfall.

First, the math in round numbers: There are 600,000 uninsured Oklahomans. Medicaid expansion will cover about a third of them. (The remainder will be obligated under the law to buy insurance on the open market–hopefully, from a robust and economical online insurance exchange–or pay the just-deemed-constitutional penalty, er, tax.)  So far, so good.

But herein lies the problem. Oklahoma’s primary care “system” is already stretched thin. We are at or near the bottom in the number of primary care doctors per capita. A fixed supply of primary care doctors coupled with an enormous increase in demand will result in a huge bottleneck of newly-insured patients who will wait lengthily for appointment slots.

Massachusetts, the state that made “Romneycare” law in 2006, is flush with doctors and academic medical centers. Yet despite an‘uninsurance’ rate of 5 percent (the lowest in the country), Massachusetts struggles to provide access to primary care to its citizens. The Massachusetts Medical Society periodically offers status reports on access to care, as in this 2011 report demonstrating that in spite of achieving ‘near universal’ insurance,

  • 51% of internal medicine practices and 53% of family practices are closed to new patients (due to capacity limitation)
  • Of those that remain open to new patients, the average wait time to see an internist is 48 (business) days, or 9+ weeks
  • Most alarmingly, while 85% of the state’s internists accept Medicare, only 53% accept MassHealth (i.e. Medicaid).

As you can see, even expanding access by giving folks in Oklahoma the coin of insurance doesn’t guarantee entrance to the realm. Sixty-six of our 77 counties contain over 200 designated health professional shortage areas (HPSAs). The venerable New England Journal of Medicine published an article detailing a construct called the “access challenge index.” How’d Oklahoma do? We topped the list as most-challenged to care access if and when Medicaid expands. How can we address the shortage?  It won’t be easy.

Training doctors takes more than a decade. Medical schooling takes four years (after achieving a bachelor’s degree). To become board-certified in internal medicine, family medicine, or pediatrics (primary care fields) takes an additional three years of residency training. Add college time to that, and you’re looking at a pipeline of eleven years minimum to create a doctor.

Couldn’t we train more doctors?

Actually, the number of medical schools in the U.S. and Canada has increased by more than a dozen in the last decade, raising the number of graduates significantly. The problem is at the residency level.  Due to the Balanced Budget Act passed in the mid-1990s, the number of residency slots nationally has been capped at 1997 levels.

Today’s residency graduates are also less inclined to open their own practices, due to increasing overhead, regulatory requirements, and a lower tolerance for risk. Newly minted doctors are more likely to become employees of hospitals or large medical groups.  The rise of “hospitalists,” while a boon to hospital quality and safety (and physician lifestyle), has further diminished the number of doctors practicing office-based primary care.

Look no further than the example in my field, internal medicine. In the program I administer the OU School of Community Medicine (OU-Tulsa), we train an average of 15 internists/year (OSU has eight slots/year). Of the most recent graduating class, four went into subspecialty fellowships (further training in fields like cardiology and nephrology). Nine have chosen to become hospitalists. One decided to practice office-based internal medicine. In Texas.

Given the issues facing us in the production of more doctors, we simply must look elsewhere to expand primary care access.

One answer is a vast expansion of other, non-physician providers: physician assistants (PAs) and nurse practitioners (NPs). These individuals are trained in a shorter timeframe and are able to handle most of what a primary care doctor can provide. In addition, the cost of their education is significantly less. The School of Community Medicine at OU and TU have combined to create a very successful and competitive PA program that is now three years old.

The other way to expand access involves changes in how care is delivered.  We are slowly but surely moving away from the model of one patient, one doctor to team-based care, group visits for patients with chronic disease, and a greater leveraging of technology (so-called “mHealth,” i.e. using mobile platforms) to substitute for traditional office visits.

As the passage of the Affordable Care Act and the ensuing Supreme Court battle have demonstrated, we are in a period of great upheaval in American health care. Oklahoma is at a crossroads, and it’s imperative that we embrace opportunities to confront the challenges that will determine our collective health future.

John H. Schumann, MD is a general internist and medical educator at the University of Oklahoma School of Community Medicine in Tulsa, OK . He is also author of the blog, GlassHospital (@GlassHospital). This post originally appeared on the Oklahoma Policy Institute (OK Policy) Blog.

4 replies »

  1. I take it from your comment and your affiliation with a right wing group whose homepage features a “debt crisis (!!) clock” that you are opposed to the Affordable Care Act.

    I had to look it up since a) I’d never heard of it and b) your comment was just a string of ‘facts’ devoid of any argument.

    None of what you state above or take from the Health Affairs article is troubling. Well, at least to me. By historic standards, 7.4% health care inflation is actually on the lower side.

    As for 19.6% of GDP, well, we’re not all that far from there at present. If health care is going to comprise 1/5th of our economy, let’s at least include as many Americans as we can in the spend-a-palooza. More bang for the bucks we put in, right?

  2. A Health Affairs study (http://bit.ly/MIzYve) showed that the full implementation of the health care reform law and an aging population will result in a significant increase in spending. According to the study, spending will jump 7.4% in 2014 when the health care law is scheduled to be fully implemented. This is partially due to the aging of the baby boomer population, which will result in greater consumption of expensive health care services and products.
    Also, the health care reform law will allow millions of Americans to gain coverage through subsidized insurance plans purchased through government-run exchanges, augmenting consumption.
    By 2021, health care spending is projected to be 19.6% of GDP. The government share of the spending also would be greater, at nearly 50%.

  3. Thanks for the comment, Brian. However, I find your critique illogical.

    1. Medicaid does work. For only the most recent example, see

    2. Medicaid is vastly preferable to a system that leaves people uninsured. Whether patients are seen at FQHCs, in the ER, or in practices at Academic Medical Centers (to give only a few examples), not only are outcomes better, but little to no debt is assumed by patients. As you know, medical costs are a leading cause of personal bankruptcies in the U.S. Again–as only the most recent example, see:

    3. Lastly, the point about doctors unwilling to accept Medicaid is not evidence that Medicaid doesn’t work. It’s evidence that practitioners choosing to forgo the system find reimbursements too low. Perhaps an analogy to something that you’d understand better will help you: Baseball.

    Our first place team (the US health care system) is struggling midseason with injuries–a depleted bench and pitching staff (doctors not going into primary care, retiring, not accepting Medicaid). To fight for the pennant, we’ll need new players: a deeper bench, a full pitching rotation, utility players (more personnel in primary care). Stars (specialists) will only get us so far.

    Batter up!

  4. Severe disconnect in your own logic – you point to both the flaws in Mass, and the shortages in Drs in OK, and the trend for practitioners NOT to accept Medicaid – but position that MORE Medicaid is the solution ? This thing has a forty year history of proving it doesn’t work; all the PPACA has done is allow the IRS the purse strings to a failed model.