The access-related complexities of recent coverage expansions are seen in research on newly covered Medicaid enrollees, whose use of both primary care and the emergency department decreased.


March 22—Improving access to care has been a long-standing goal of healthcare policy makers and was a primary mission of the Affordable Care Act (ACA). But recent research presented divergent evidence on whether access has improved in recent years.

Among the positive signs in the latest Commonwealth Fund Scorecard on State Health System Performance was that from 2013 to 2015, 39 states reduced their share of adults who went without care in the previous year because of costs, while the national share declined from 16 percent to 13 percent.

In the same time frame, 17 states increased both their share of adults with a usual source of care and the share of “at risk” adults who had obtained a routine physician visit in the past two years. However, 31 states had no improvement on the last measure and three had decreases.

The positive access-related trends contrasted with a 2017 Merritt Hawkins survey of physician appointment wait times, which found deteriorating access in the form of wait times to see a physician. Specifically, the survey found an average 24-day wait for appointments in five medical specialties in 15 large metro markets that have been surveyed since 2004. That average wait was 30 percent longer than in 2014 and longer than in any of Merritt Hawkins’ previous surveys.

The average wait times for cardiology, dermatology, and family medicine were all the lengthiest since Merritt Hawkins began tracking those numbers. In obstetrics-gynecology and orthopedics, the appointment times were lengthier than in 2014 but shorter than in 2009.

“As a physician who focuses on the care of patients, this is just alarming,” Deane Waldman, MD, director of the Center for Health Care Policy at the Texas Public Policy Foundation, said about the growing wait times.

The Merritt Hawkins authors speculated that the increased wait times could stem from the fact that an estimated 20 million people gained insurance through the ACA, with more people likewise obtaining employer-sponsored insurance in a recovering economy.

Care delays such as a 109-day average wait time to see a family medicine physician in Boston were especially concerning, Waldman said in an interview, because a major goal of the ACA was to enhance primary care access to prevent health conditions from becoming exacerbated.

“All of a sudden we have all of these people who are insured, which is great, but we don’t have a corresponding increase in providers,” said Delphine O'Rourke, a managing partner with Hall, Render, Killian, Heath & Lyman.

The U.S. shortage of 21,800 physicians is projected to increase to 65,500 in 2020 and to as many as 90,400 by 2025, according to the Association of American Medical Colleges.

States and hospitals have sought to expand the scope of practice of nurses and physician assistants in recent years to help increase access, but such efforts haven’t kept up with increasing demand from an aging and sicker population, O'Rourke said in an interview.

“We need more physicians focused on the needs of the elderly, and we just can’t keep up,” O'Rourke said.

Cost Obstacles

One of the biggest obstacles to access is cost, and data indicate some cost barriers may be coming down. For instance the latest affordability data from the Centers for Disease Control and Prevention (CDC) reported that the percentage of pre-Medicare age people who are in families having problems paying medical bills decreased from 21.3 percent (56.5 million) in 2011 to 16.2 percent (43.8 million) in the first six months of 2016.

However, other affordability data are less encouraging. Thirty-three percent of U.S. adults said they did not fill a prescription, see a doctor when sick, or get recommended care because of the cost, according to a recent Commonwealth Fund survey of adults. That rate was unchanged from the same survey in 2010. The share going without care slightly worsened to 37 percent in 2014 before returning to the 2010 level.

The CDC report also indicated that healthcare affordability specifically for those with private health insurance worsened in 2016, with more adults having difficulty paying their medical bills.

That finding comes as the average deductible for American workers enrolled in insurance offered through their employer has increased significantly, according to an employer health benefits survey by the Kaiser Family Foundation (KFF). Employee deductibles averaged $1,478 in 2016, a 12 percent increase since 2015 and a 49 percent increase since 2011.

Care Locations

Another part of the access equation is the availability of providers that can meet patients’ needs. The physician survey is only the latest indication that timely access continues to be an issue.

A primary goal of the ACA was to decrease unnecessary use of high-cost emergency department (ED) care by increasing access to office-based physicians. Although some states have reported declines in ED use, others have found sharp increases by the newly insured—especially Medicaid enrollees.

For instance, Medi-Cal enrollees’ ED use increased by 78 percent as enrollments increased by 58 percent. The enrollees’ ED encounters increased from 800,000 in the final quarter of 2013 to nearly 1.4 million in the final quarter of 2015, according to the California Office of Statewide Health Planning and Development. In that time frame, California added 4.5 million Medicaid enrollees for a total of 12.3 million, according to federal data.

Similarly, in Kentucky, another Medicaid expansion state, the share of ED visits by Medicaid enrollees increased from 30.2 percent of total visits in 2012 to 46.9 percent in 2015, according to recent data from the Foundation for a Healthy Kentucky.

The complexity of the relationship between ACA coverage expansion and access to care was seen in new research on a population added to Medicaid managed coverage in Oregon. A study published in Health Affairs found primary care visits—and other “markers of access”—declined among the newly covered, but so did ED visits.

The authors theorized that the unexpected reduction in both primary care and ED use stemmed from the use by managed care plans of “a variety of nontraditional support services and transition programs,” such as community health workers, “to engage their Medicaid enrollees outside of the clinic setting.”

Meanwhile, some expect access problems to worsen under proposed legislation, the American Health Care Act (AHCA), to partially repeal and replace the ACA. The AHCA is projected to reduce insurance coverage by 24 million over 10 years compared with the ACA, according to the Congressional Budget Office.

“They will not even get through the front door,” O'Rourke said. “What they will be doing though is going through the emergency room.”

If that happens, alternative care sources where prices are known in advance—like urgent-care centers and drugstore clinics—could be big winners under the AHCA, she said. 


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Wednesday, March 22, 2017