When health coverage expansion means longer waits for a doctor

The following originally appeared on The Upshot (copyright 2014, The New York Times Company). I thank Daniel Liebman for his assistance tracking down some evidence for an early draft of this post.

One concern about the Affordable Care Act is that as more Americans get health insurance and start using it, those who already have coverage will have to wait longer for care.

Recent research with a focus on Massachusetts suggests this may actually happen, but may not last long. Several years after the coverage expansion in that state, access to care for other, previously covered residents appears to be no worse than before the expansion.

Coverage expansion would present this potential trade-off if the supply of care (the number of doctors or their productivity) does not expand to meet the greater demand for it from the newly insured.

Increasing coverage is likely to increase demand for care. A longstanding finding in the research literature is that uninsured people avoid and delay care more than insured people do, and that this can harm health. According to Gallup, uninsured Americans are about twice as likely as insured Americans to delay care, and about 30 percent have put off care because of costs. A large body of research on the effects of the coverage expansion in Massachusetts found that it increased access to care for previously uninsured residents. For example, residents in that state were almost 5 percent less likely to forgo care, compared with the expected rate without the expansion.

But improving access to care for the uninsured doesn’t necessarily reduce access for everyone else, according to a new study published in the journal Health Services Research and led by Dr. Karen Joynt of Harvard. The authors found that neither receipt of outpatient services nor quality of care suffered when coverage expanded under the state’s health overhaul, which started in 2007. The findings, which are consistent with previous work by the same authors, are based on analysis of changes in receipt of outpatient care from 2006 to 2009 for elderly Medicare beneficiaries with chronic illnesses in Massachusetts, as compared with those in other New England states.

However, other work seems to conflict with Dr. Joynt’s analysis. In an article also published in Health Services Research, Amelia Bond and Chapin White examined changes in primary care visits from 2005 to 2007 by Medicare beneficiaries in Massachusetts ZIP codes with different rates of the uninsured in 2005. They compared these differences with those from ZIP codes in surrounding states with similar characteristics. Massachusetts showed a larger gap in primary care visits by Medicare beneficiaries, suggesting that the coverage expansion came at the cost of reduced access for those Medicare beneficiaries, and presumably others who also already had insurance.

Historically, large expansions of health insurance for some tends to reduce access to care for others. Just after universal health insurance was introduced in England and Wales in 1948, receipt of care increased for most of the population, but it decreased for people with high incomes, precisely those who probably had good access before universal coverage. A similar thing happened in Quebec after Canada introduced universal coverage. Physician visits increased in general, but decreased for higher-income residents. Waiting times also increased, and more so for higher-income groups.

I am unaware of any similar research pertaining to Medicare. When it was introduced in the United States in 1965, access to care for those 65 and older improved, but we don’t know whether access to care suffered for the rest of the population. Medicare payments at that time were generous, and that may have helped spur the expansion of supply to meet the new demand.

The same cannot be said of the Affordable Care Act, in general. Indeed, it is financed in part by cuts to Medicare. However, the law does include an increase in funding for primary care training and in fees paid for primary care visits under Medicaid, albeit only through this year (Congress is considering extensions).

A potential explanation for the disparate results of the two Massachusetts studies also suggests why the Massachusetts experience may not generalize to other states. The study by Drs. Bond and White included data through 2007, while that of Dr. Joynt and colleagues included data through 2009, two years later. Perhaps health providers in Massachusetts were stretched thin in 2007, just as the new health measures were taking effect in the state. But by 2009, maybe they managed to increase their capacity, either by increasing their numbers or enhancing their productivity to meet additional demand from a larger insured population, perhaps.

For this reason, delays in care should be expected in states that are less able to increase capacity to meet additional demand from a larger insured population, perhaps because they’re not as well supplied with medical schools as Massachusetts, or because providers may not be able to increase their productivity as much as those in Massachusetts may have. Already, the Health Resources and Services Administration judges that there are regions where demand for care outstrips supply. By the organization’s estimate, 20 percent of Americans live in regions where there are not enough primary care doctors; 16 percent where there are not enough dental care providers; and 30 percent in areas where mental health providers are in short supply.

What can be done? Two approaches come immediately to mind. First, it’s generally believed that a substantial fraction (10 percent or more) of health care delivered is wasteful, unnecessary overtreatment. By reducing that waste, we would free up resources to deliver beneficial care to those who would otherwise wait longer for it. Reductions in access to care need not be harmful if they’re purely reductions in care that isn’t of benefit anyway.

Second, we could increase primary-care capacity, for example by increasing the wages primary-care physicians earn (e.g., by increasing what Medicare pays them). Another capacity-building policy would be to allow nurses to do more of the functions that are reserved for primary-care doctors.

That delays in care in Massachusetts didn’t seem to persist beyond a year or two after coverage expansion is comforting. But other states may be able to follow Massachusetts’ lead only if they can develop sufficient capacity to meet the greater demand that the Affordable Care Act is likely to create.


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