Impact on primary care access and health costs is 'uncertain'

"Rather than asking whether the Patient Protection and Affordable Care Act (PPACA) does everything to improve access and lower costs, we should ask how it compares with the status quo," the American College of Physicians' (ACP) senior public policy adviser said in a paper published online today in Annals of Internal Medicine, the flagship journal of ACP. "By this measure, the PPACA is an extraordinary achievement."

Robert B. Doherty, ACP's senior vice president of governmental affairs and public policy, analyzed the Patient Protection and Affordable Care Act (PPACA) in The Certitudes and Uncertainties of Health Care Reform. He noted, "The health reform law is a work in progress, not the end of the story. As it is implemented, changes will be inevitable. Yet that the United States, for the first time in its history, has enacted legislation offering the promise of providing most Americans with access to affordable health care is a cause for celebration."

The PPACA was signed into law on March 23 and is still being reviewed. Doherty pointed out that, "The College hopes that the legislation will advance key policies on coverage, workforce, and payment and delivery system reform that it has developed through a consensus process informed by public policy research."

Emphasizing that the PPACA will result in affordable health insurance coverage for all, Doherty said without the legislation, "the Census Bureau projects that the number of uninsured persons will increase to more than 60 million, or 1 out of 5 U.S. residents. The legislation aims to cover uninsured legal U.S. residents and to increase security for those who already have insurance....The Congressional Budget Office estimates that 95 percent of legal residents in the U.S. - including 32 million who otherwise would have been uninsured - will be covered under the legislation, compared with 83 percent today."

As part of the analysis, Doherty has included a side-by-side comparison of how the law will improve coverage, health insurance security, workforce and physician payment policies compared to the status quo. It also shows the potential of reducing overall cost increases, especially when it is recognized that status quo costs will increase at an unaffordable rate - putting access to insurance out of reach for many.

Doherty continued, "Personally, I see the PPACA as a monumental step toward providing Americans with affordable coverage, but the jury is still out on to what extent it will ensure sufficient numbers of primary care physicians or 'bend the cost' curve."

This is the $2.4 trillion question - which is the amount that the United States now spends on health care, Doherty said. "The CBO estimates that the law will reduce the deficit by $143 billion over the next decade and by more than a trillion dollars over 20 years" but long-term budget forecasting is "notoriously unreliable" and experts are divided on whether the law does enough to control costs.

Will the PPACA improve access to primary care? The U.S. faces a shortage of 35,000 to 44,000 primary care physicians for adults by 2025, Doherty said. "Population growth and aging will increase the workloads of family physicians and general internists by 29 percent between 2005 and 2025. As more people obtain health insurance under the new law, the demand for primary care physicians will probably increase, exacerbating the primary care shortage."

Over time, he noted, the programs, "may help increase the availability of primary care clinicians. But the long training pipeline means that it will be at least four years before one might see an appreciable increase in the numbers of graduating primary care physicians. As a result, newly-insured patients can anticipate difficulties gaining access to primary care, particularly in underserved communities. The PPACA will not solve the primary care crisis. Further changes are necessary to ensure adequate access to primary care physicians."

"From my vantage point as the senior public policy adviser for ACP," Doherty summarized, "I think that we should all take a deep breath, put politics aside for the moment, and evaluate the law's impact objectively. Supporters and opponents alike must humbly recognize that no one knows how this complex legislation will play out."