By Salam Abdus and Steven C. Hill
Health Affairs, May 2017
Abstract
Recent expansions in health insurance coverage have raised concerns about health care providers’ capacity to supply additional services and how that may have affected access to care for people who were already insured. When we examined data for the period 2008–14 from the Medical Expenditure Panel Survey, we found no consistent evidence that increases in the proportions of adults with insurance at the local-area level affected access to care for adults residing in the same areas who already had, and continued to have, insurance. This lack of an apparent relationship held true across eight measures of access, which included receipt of preventive care. It also held true among two adult subpopulations that may have been at greater risk for compromised access: people residing in health care professional shortage areas and Medicaid beneficiaries.
From the Introduction
The ways in which population-level increases in insurance coverage affected people who were already insured during the recent insurance expansions depend on three key factors. The first is providers’ capacity and willingness to offer more visits and supply additional services. If providers had excess capacity, then increased demand could easily be met, but many observers have expressed concern that providers could not supply enough additional services—especially primary care services. Concern about reduced access may be most relevant in medically underserved areas—that is, areas already facing shortages of primary care providers.
The second factor is the extent to which the provider market is segmented by the types of insurance patients carry, if any. Some providers, such as federally qualified health centers, primarily serve patients with public insurance and the uninsured. More generally, providers are less likely to accept Medicaid patients than Medicare and privately insured patients. Thus, people who had Medicaid before the ACA-related Medicaid expansions might have been at greater risk of reduced access, especially because Medicaid enrollment increased 25 percent from 2013 to 2014 in states that expanded eligibility for Medicaid.
The third factor is the effects of ACA provisions intended to increase health care capacity. In particular, the act provided funding for expanding the capacity of federally qualified health centers; training more physicians, mid-level practitioners, and nurses; and encouraging more providers to work in primary care and in underserved areas. It also temporarily increased Medicaid payments for some services supplied by primary care providers. The ACA set its capacity-building activities in motion before the biggest eligibility expansions occurred, whereas Massachusetts did not begin to address provider capacity problems until after its insurance expansion. Thus, the efforts to increase supply built into the ACA had the potential to mitigate negative spillovers such as those seen in Massachusetts. Moreover, many of the ACA provisions were designed to mitigate negative spillovers among the groups most likely to be negatively affected: people in medically underserved areas and Medicaid beneficiaries.
From the Discussion
We found no consistent evidence that increased local-area insurance coverage rates reduced access to care among the continuously insured. This remained true even when we restricted our sample to adults residing in geographic Health Professional Shortage Areas or to adults continuously insured by Medicaid.
Our results are consistent with the possibility that funding in the ACA to increase provider capacity mitigated potential negative spillovers, as intended. While we know of no rigorous evaluations of these provisions, data suggest that capacity did expand. ACA funding was used to add sites of care and other expansions of community health center capacity, which was associated with serving more patients. ACA funding for training might have contributed to growth in the number of midlevel practitioners, who can help meet increased demand for primary care. From 2009 to 2014 the number of employed physician assistants rose 19 percent, and from 2012 to 2014 the number of employed nurse practitioners rose 15 percent. ACA funding to expand capacity began to be disbursed shortly after the act passed, before the major insurance eligibility expansions in 2014.
From the Conclusion
Despite concerns, increasing rates of insurance coverage did not appear to reduce access to care among the continuously insured.
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Comment:
By Don McCanne, M.D.
One concern about the increases in the numbers of people insured as a result of implementation of the Affordable Care Act was that people already insured might find that their access to care became impaired because the increased demand for care might overload the delivery system. However, measures to increase capacity in the system, such as expansion of community health centers and increased training of health care professionals helped to alleviate that concern. Thus, “increasing rates of insurance coverage did not appear to reduce access to care among the continuously insured.”
Well designed health care reform includes giving attention to system capacity. Central planning along with separate budgeting of capital improvements is designed to ensure that capacity is adequate and equitably distributed. People who are satisfied with their current insurance need not be concerned that expanding coverage to include everyone – as in an improved Medicare for all – would result in impaired access. Not only would access be assured, they would have better coverage than the best of current plans in the private sector.
