The crisis over wait times and access to care within the Department of Veterans Affairs health system has raised questions about whether similar problems could occur in the broader health care system as government-subsidized coverage spreads throughout the country.
Though millions of uninsured Americans will get more care than they do now, policy experts say coverage isn’t the same as access, and lower-income Americans may experience barriers in some markets.
VA health care is limited by an annual budget, unlike the coverage provided by the health care law. As more people enroll, either through an expansion of Medicaid or through private plans whose cost is subsidized, doctors and hospitals will get more paying customers.
In general, they’ll respond to this growth in demand by increasing the supply of their services, which will help keep waiting times from ballooning.
“If the insurance payments are there, somebody’s going to show up to take them,” predicts Timothy Jost, a law school professor who serves as a consumer advocate on a panel that advises the National Association of Insurance Commissioners about the health care overhaul law.
The bureaucracy running the VA hasn’t been able to match its supply of clinical services to growing demand by veterans for care, either because it is underfunded in the annual appropriations process, because the VA has squandered resources, or both.
Analysts differ over which factor is to blame, but they agree that the automatic increase in spending under entitlement programs helps fuel supply and makes it easier to keep up with growing demand.
“There is a huge difference between the VA and the system that is being established under the Affordable Care Act,” Jost says. “The VA is a budget-limited service.
“If you look worldwide, what you see is that in countries where you have budget-limited national health services, you’re much more likely to see services rationed by wait times than countries where you have social insurance or private systems where you’re likely to have higher costs but less in the way of wait times,” he adds.
Joseph Antos, a health policy expert at the American Enterprise Institute, says, “Clearly if you’re working on a budget you’re going to have a problem” matching supply and demand.
Paul Ginsburg, a health care financing expert who is a professor at the University of Southern California, underscores that the difference is between the “government provision” of care in the case of the VA and “government financing” of care under Obamacare.
Community health centers can expand when demand increases under the health law because more dollars come into the privately run centers as more people come in for care, he says.
But with the supply of providers not likely to change much soon and the number of people getting coverage expected to grow much more quickly — the Congressional Budget Office estimates the 8 million people getting coverage on exchanges this year will increase to 22 million in 2016 — isn’t some increase in waiting times inevitable?
“Yeah, I think for primary care, but I think the market can adjust to it,” says Joshua Sharfstein, the Maryland secretary of Health and Mental Hygiene. “We have a lot of specialists, but a lot of specialists do some primary care. And I think they’re going to increasingly find that attractive.”
Sharfstein also notes that Kaiser Permanente has just announced it will serve Maryland’s rapidly expanding Medicaid population by offering a managed care plan in that market. “They built a huge center in Bowie,” he points out and, “they have a huge one in Montgomery County, another one in Baltimore City.”
But some entitlement programs may not pay rates doctors find attractive. And government policy has failed to produce an adequate supply of primary care physicians, some analysts say. That could mean long waits for care in places such as California, where Medicaid rates are among the lowest in the nation and where lawmakers just decided against erasing a recent 10 percent cut in order to help balance the state’s budget.
Anthony Wright, executive director of Health Access California, says the difficulties Medicaid enrollees in the state have historically had finding doctors have been addressed by a requirement that managed care plans give medical appointments within 10 days of a request for one.
But it’s unclear how well plans are complying with that standard. And Wright says he’s worried about whether they will meet it with so many people enrolling in California’s expanded Medicaid program. “We’re very focused on this,” he says.
Thanks to increased funding under the health care law, community health centers have expanded in California and elsewhere to meet the expected growth in demand for care. For instance, the expansion money has helped the St. John’s Well Child and Family Center in South Los Angeles respond to a 40 percent increase in patients over the past year, says CEO Jim Mangia.
The health law has fueled “a huge number of people seeking to access health care services who had never accessed it before,” he says. But Mangia and other center directors say a big shortage of primary care doctors is making it hard for them to add to staff. “There needs to be much more investment in training and residency slots for primary care,” he says.
Dean Germano, CEO of the Shasta Community Health Center in Redding, Calif., says Medicaid enrollment has grown 20 percent in the county, as has the demand for services at his center. It’s the source of care for Medicaid managed care enrollees but has had to place a freeze on the adult enrollees it treats, Germano says.
Medicaid managed care enrollees are supposed to establish a relationship with a primary care provider, but the center has had 5,000 enrollees assigned to it that it has yet to see. “We’re going to have to change the cottage industry” of one doctor treating one patient, he says. “We’re going to have to find ways to serve groups of people.”
He also says the government needs to fund more primary care residency slots through Medicare. “It will find it’s equilibrium,” Germano predicts. “The problem is it requires government to do something.”