Other analysts say the extent of the capacity problem will depend in large part on location. “The truth is that the extent to which there are enough doctors or enough hospital beds is largely a function of geography,” said Dr. Ku. “So, if you’re in an urban area with lots of teaching hospitals, you probably have enough doctors and you probably have enough hospital beds. If, on the other hand, you’re in a poor, rural area, chances are you don’t.” As both insurance and demand for healthcare expand, those areas that were having problems already “are going to be stretched even more,” he said.
Explore This IssueJanuary 2014
The access question is more complicated in the roughly two dozen states that have chosen not to expand Medicaid, an option granted by the U.S. Supreme Court in its June 2012 decision that upheld the law’s main tenets. According to a recent analysis by the Kaiser Family Foundation, roughly five million uninsured adults may now fall into a “coverage gap.” In essence, they will earn too much to be covered under the highly variable Medicaid caps established by individual states, but too little to receive any federal tax credits to help pay for insurance in the exchanges. With limited options, the report suggests, they are likely to remain uninsured.
Otolaryngologists in private practice may be less affected due to the lower proportion of Medicaid patients they see. But doctors affiliated with safety net hospitals could see their institutions squeezed particularly hard between conflicting state and federal Medicaid priorities. During the initial ACA negotiations, hospitals agreed to $155 billion in cuts over 10 years, including sharp reductions in Disproportionate Share Hospital (DSH) payments, in anticipation of a significant decrease in uninsured patients. Despite lower DSH payments, the hospitals expected to recoup the money through more Medicaid or private insurance reimbursements. “The Medicaid expansion being optional throws a kink in all of that,” said Dr. Ku.
The ongoing open enrollment in insurance exchanges will make up part of the total. But in states that are not expanding Medicaid, the number of newly insured patients may not compensate for the DSH reductions, resulting in a net loss that puts some hospitals under additional financial strain. “There will be pressure within the states from hospitals and from the business community to expand Medicaid because, otherwise, they’re bearing the burden of it,” said Robert Berenson, MD, an Institute Fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy.