Medicaid Expansion: Will increased coverage actually lead to increased care?

Although the Supreme Court ruled that Obamacare’s Medicaid expansion could not be mandatory for states, as of now, the governors of 24 states and the District of Columbia have decided to go along. (New Jersey’s Governor Chris Christie announced yesterday that he would be the 24th.)

But the question remains: will more individuals covered by Medicaid result in more individuals actually receiving medical care?

It is estimated that the Medicaid expansion could provide coverage for up to 15.1 million people who are currently uninsured. While this effort will help achieve the goal of reducing the number of uninsured individuals in the United States, it is unclear how the medical community will accommodate the increased number of patients seeking treatment.

According to the Association of American Medical Colleges, the United States will face a shortage of 90,000 doctors by 2020, and more than 130,000 doctors by 2025. These shortages are driven by a growing, aging population, a 15-year freeze on Medicare funding for residency training positions, and an increase in the number of insured individuals.

States in the south and mountain west regions are at higher risk for shortages than other states because they currently have smaller Medicaid programs that will face greater expansion under health reform. They also have a lower ratio of primary care physicians per capita, which contributes to the concern.

For example, Florida currently has 44,804 doctors, but it is estimated that 5,600 of them will retire within the next five years. Despite the opening of three new medical schools in the state, Florida isn't graduating as many doctors as it needs to meet demand, even assuming they all choose to remain in the state. And this estimate is without the Medicaid expansion, which is expected to add more than one million patients to doctors’ waiting lists. Medical school graduates must also complete a residency before they can practice. Governor Rick Scott's budget includes $80 million to train 700 new residents this year, in the hope that they will remain in state, as a substantial percentage usually do. However, this will still fall short of fulfilling the demand for medical care in the state. And, of course, there is no guarantee that those residents will stay in Florida.

It is also possible that many prospective doctors will be hesitant to enter the profession in coming years. A New England Journal of Medicine study found that the number of medical school graduates will soon exceed the number of residency spots. If there are fewer residency spots than medical school graduates, it seems likely that fewer prospective doctors will be willing to invest over $200,000 to attend medical school when there is no certainty of employment post-graduation.

There is also concern that the Medicaid expansion could drive down physician reimbursement. Although the federal government is picking up the tab for the first three years, it is unclear how states will try to offset their costs when they are required to cover 5% and then 10% of the expansion after that. Physicians worry that states may resort to a reduction in physician reimbursement to cover their portion.

And how will quality of care be affected? Many physicians already feel logistical and financial pressures to see as many patients as possible in a given day. When the number of patients waiting to see one doctor increases substantially, how can that physician provide adequate care to each of the patients he or she sees?

The likely result, unless the physician workforce expands significantly, is a long waiting list to see your physician. While the efforts to increase the number of advanced practice nurses and physician assistants are laudable, we still need more doctors. If we cannot add more physicians to the workforce, it will not matter how many are insured or uninsured. Better coverage will not necessarily equal more care.

By Erica B. Cohen