Health Care Access a Pressing Concern for States, Providers

Published October 27, 2010

New concerns about the ramifications of President Obama’s health care law are arising as state policymakers realize the law may decrease health care access and push more patients into already overcrowded emergency rooms. Potential doctor shortages were already a pressing issue before ObamaCare, and now more hospitals and critics are concerned that, given the experience in Massachusetts, the new regime could lead to ER overcrowding and dramatically increased wait times for care.

Turning Patients into Freeloaders

Christie Herrera, director of the Health and Human Resources Task Force at the American Legislative Exchange Council in Washington, DC, explains the debate occurring at the state level.

“The Missouri Hospital Association charges that, without a requirement to purchase health insurance, people will become ‘freeloaders’ who impose their costs on taxpayers and clog emergency rooms,” Herrera said. “Although the cost of treating the uninsured is borne by those of us with health insurance, researchers estimate these costs to be just 2-3 percent of overall health spending” at present.

Herrera maintains increasing numbers of such freeloaders will show up in the emergency room.

“The most recent study from the National Center for Health Statistics shows that people on Medicaid—a program that, thanks to Obamacare, will add 300,000 Missourians to its rolls—are more than twice as likely to visit the emergency room as the uninsured,” Herrera said.

Insurance Doesn’t Mean Access

Herrera said the Massachusetts experience provides a cautionary note.

“Massachusetts, a state that imposed an individual mandate in 2006, has seen its ER use climb by 17 percent since their reform was enacted,” Herrera said. “One Massachusetts survey reported that although the newly insured had insurance coverage on paper, 90 percent of them did not have access to care from a non-ER provider.”

According to the Massachusetts Medical Society, the average wait to see a primary care doctor in the state is now 36 days. Prema Popat, president of the Massachusetts-based Tuerck Foundation for the Study of Economics, Law, and the Humanities, says the reform’s design inevitably increases such burdens.

“It was simply a fallacy—a convenient one for supporters of health care reform—that increased insurance coverage would lead to a decline in inappropriate ER use,” Popat said. “This wasn’t a secret. Numerous studies and reports warned that ER use wouldn’t necessarily decline. Why? First, contrary to popular belief, uninsured people are not the primary drivers of ER use. Second, reliance on the ER is frequently due to a shortage of primary care and urgent care providers.”

Physician Shortages, ER Pressure

Popat says the White House won an argument with a more compelling narrative, not on the facts.

“Simply adding more people to the insurance rolls without addressing the supply of primary and urgent care would obviously put more pressure on ERs,” Popat said. “But the narrative that the law’s supporters spun was much more compelling. They claimed the uninsured wait until they are very sick to get health care and they often seek care in the ER. If they had insurance, they would have their own doctor, so wouldn’t go to the ER, and they could see their doctor before they got sick.”

Popat also says ObamaCare could worsen the physician shortage.

“The Massachusetts Department of Health Care Finance and Policy (DHCFP) issued a report which highlighted the problem,” Popat said. “The good news is that between 2006 and 2008, the rate of Massachusetts residents without a primary care provider decreased to 11 percent from 12.2 percent. The bad news is that it’s gotten harder to actually get in to see the doctor. The same DHCFP report showed that almost one-quarter (22 percent) of residents reported difficulty in obtaining care.”

More Insurance, Less Access

The report found new patients had to wait on average six weeks (44 days) for a doctor’s appointment for primary care. Popat says these wait times have been increased by physicians leaving the state.

“This isn’t just because more people have obtained insurance coverage,” Popat said. “Between 2006 and 2007, approximately 1,200 physicians, both specialists and primary care providers, left Massachusetts to practice in other states.”

According to Popat, fewer primary care practices were accepting new patients. From 2005 to 2009 there was a 22 percentage point decline in internal medicine practices accepting new patients in Massachusetts, from 66 percent to 44 percent.

“The dirty little secret of health care reform is that 2009, residents with public insurance—Medicaid or a subsidized product from the Commonwealth Health Insurance Connector—had a harder time accessing primary care,” Popat said. “The rate of physicians accepting Medicaid fell between 2005 and 2009, to 67 percent for family practice physicians and 60 percent for internal medicine. The news is even worse for the Connector: Only 38 percent of family and internal medicine general practices reported accepting Connector products.”

Lessons Unlearned

Popat says Congress and the President would have done better to learn from the experience at the state level in designing the new law.

“It’s not easy to generalize from the Massachusetts experience, but I think it is safe to say that the new national law is in many ways modeled after our state’s program, and therefore we can expect some of the same effects,” Popat said. “I have no question that the same access problems will be seen after full implementation of Obamacare.”


Sarah McIntosh, esq. ([email protected]) is a constitutional scholar writing from Lawrence, Kansas.