In the United States, the private sector has always played a dominant role in the delivery of health care services, due to our American sense of self-reliance and avoidance of government regulation.1 We have steadfastly resisted attempts to establish the federal government as the controlling power of the health care system.
Yet in 2010, Congress passed the Affordable Care Act (ACA)—considered to be the most significant regulatory overhaul of US health care since the passage of Medicare and Medicaid. The ACA has a staged implementation (starting in 2014) that will drastically affect the practice of medicine over the next three to five years. Knowledge of the key provisions of this act and its anticipated impact on care is essential for PAs and NPs to optimize the opportunities and deal with the challenges presented by this program.
Most of us would agree that the ultimate goal for the US health care system is to provide affordable, high-quality health care services to everyone, while preserving the entrepreneurial benefits of a private practice medical system. For the past 30 years, the media buzzwords have been low cost, high quality, and universal access.2 Yet it seems nearly impossible to achieve all three together. Most economists agree you can have two, but not all three, at the same time.
The US spends a significantly higher percentage of gross domestic product on health care than most other countries, but there are questions whether the incremental benefits outweigh the overall costs to our economy. One in five citizens in this country has poor access to health care, and an estimated 33 million people will be added to the insured rolls once the ACA is fully implemented. (This does not include an estimated 25 million undocumented immigrants who will need health care and who are currently excluded from ACA coverage but are legally entitled to access emergency care at US hospitals.) Who will care for them?
The country will need 16,000 new health care providers to achieve an “ideal” provider-to-patient ratio of 1:2,000—or at a minimum, 8,000 new providers to achieve an “acceptable” ratio of 1:4,500. The American Association of Medical Colleges’ Center for Workforce Studies predicts a shortage of 45,000 primary care physicians and 46,000 surgeons and specialists by the year 2020.3
The ACA is basically insurance reform and expansion funded by massive transfer payments and tax increases and backstopped by an expansion of the Medicaid system. Considered actuarially unsound by most health care economists, the program will require substantial new sources of revenue, coupled with decreasing expenditures, if it is to achieve its aims. One of the fundamental problems is that American medicine has had mixed experiences with cost-cutting efforts and centralized planning administered by government entities.
Most providers (physicians, PAs, and NPs) have practiced in a volume-based environment: The more you do, the more you get paid. Since the 1980s, hospitals and physicians have been reimbursed on mutually incompatible payment schemes for federal patients; hospitals are paid on a case-rate or fixed episode-of-care basis, while physicians have been paid based on volume. The most recent studies by Medicare over the past two years show no significant change in outcomes or cost from capitation-based payment schemes such as Accountable Care Organizations (ACOs).
There is no doubt that the ACA will cause major changes. However, the program continues to be in a state of flux and under attack. The presumption that health care will significantly improve continues to be debated in a country that has an inadequate primary care infrastructure. Clearly, the shortage of primary care providers means access will likely be a major short-term problem—particularly given the aging of our population.
Additionally, there is no malpractice reform on the horizon, because it is irrelevant to the matter at hand (being less than 1% of health spending), and it is unclear whether the medical community will be able to alter its practice sufficiently to meet the challenges of providing more evidence-based, cost-effective care with a changing focus from treatment to prevention. Lastly, finding motivators for the US population to participate in promoting its own health, by adopting a healthier lifestyle, will continue to be a major challenge.4
In the face of these significant changes, what can we, as PAs and NPs—and particularly the leaders of our professional associations—do? Some may say nothing—others may say we should stand for something. My ideas for our national and state associations are outlined in the box.
We also need more research across the board: robust data on clinical and other outcomes measures associated with patient-centered medical homes, retail clinics, and community clinics; and research that clarifies and tests ACOs and other financing models that shift away from fee-for-service and more toward payments that support the key tenets of primary care.