Rhetoric and Reality—The Obamacare Evaluation Project: Access to Care and the Physician Shortage

President Barack Obama's first term was defined by the battle over, and the passage of, the Patient Protection and Affordable Care Act, the landmark health-reform legislation known popularly as Obamacare. Along the way, Obama, the law's supporters, and independent analysts such as the Congressional Budget Office (CBO) made specific claims or projections about how the law would affect consumers, patients, and businesses.

Now, three years after Obamacare’s passage, many key provisions of the legislation are beginning to be implemented. Whether implementation succeeds or fails will be strongly influenced by the reactions of states, providers, insurers, businesses, and consumers to the law’s provisions and to the thousands of pages of new health-care regulations.

Rhetoric and Reality is a project of the Manhattan Institute's Center for Medical Progress that is designed to offer an ongoing, objective, and accessible perspective on the law's performance in light of key claims or projections made about it. Our project will examine the law's effect on Americans in five overarching areas: health-care costs, insurance coverage, employment, access to care, and consumer-driven health plans. Additional topics may be added.

Each evaluation will be based on the best available data and will be revised as new or more authoritative data become available. Each evaluation will come with a letter "grade" on the law's performance, using the following scale:

A = Very strong likelihood that the reforms will achieve their intended goals

B = Moderate evidence that the reforms will achieve their intended goals but a need for future analysis

C = Weak evidence that reforms will achieve their intended goals or growing evidence of unintended
consequences

D = Little or no evidence that the reforms will achieve their intended goals and significant evidence of unintended consequences

F = Undeniable evidence that the reforms will produce effects contrary to their intended goals

I (Incomplete) = Insufficient evidence to support a final judgment on the effects of the reforms

The Obamacare expansion of insurance coverage will, on net, increase the number of individuals with insurance by some 25 million. A little more than half of the newly insured will have insurance from Medicaid (about 13 million), while most others will gain coverage through private insurance purchased on state-run or federally run healthinsurance exchanges.

Irrespective of the source of coverage, it is axiomatic that demand for health-care services increases when the formerly uninsured gain coverage. While some of this increased demand may be due to legitimate need (particularly for those with serious preexisting conditions who have been unable to obtain regular access to care because of lack of insurance), many of those who will be covered will be young and relatively healthy (39 percent of the uninsured are between the ages of 18 and 34) or will be those who rate their health as "good" or "excellent" (60 percent of the uninsured). Yet because they will gain (or be required to purchase) expansive coverage that insulates them from significant costs associated with health-care services, their demand for health-care services will increase beyond its optimal level.

This demand is obviously a concern in a nation that already spends 18 percent of its GDP on health care, but it also presents challenges for a health-care system where access to certain services—such as primary care—is significantly strained. It is this last dimension—access to care—that has been given relatively little thought in the popular debates over the Affordable Care Act (aka Obamacare).

Indeed, if seriously or chronically ill patients face increased competition for physicians' attention from the newly insured, it is possible that worsened health and increased costs could be the short-term result of Obamacare's insurance expansion.

The main focus of our analysis is assessing access to primary-care physicians under the health-care law. The reason for this focus is twofold: first, we already know that we will be facing a primary-care shortage in the coming years, so understanding the role that Obamacare plays in affecting the shortage is important; second, much of the law was motivated by the argument that expanding access to inexpensive (or free) preventive care and primarycare physicians would ultimately bend the curve of health-care spending.

Our analysis indicates that population growth, demographic changes, and an expansion of insurance spurred by Obamacare will contribute to a significant shortage in primary-care physicians over the coming decade. We project that by 2025, the United States will experience a shortage of roughly 30,000 primary-care physicians—with about 16.5 percent (4,950 physicians) of this shortage being driven by the expansion of insurance coverage under Obamacare, while the remaining 83.5 percent (25,050 physicians) will be due to population growth, aging, and various demographic shifts.

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