How Have Providers Responded to the Increased Demand for Health Care Under the Affordable Care Act?

How Have Providers Responded to the Increased Demand for Health Care Under the Affordable Care Act? U.S. Health Reform—Monitoring and ImpactBy Jane B. Wishner and Rachel A. BurtonNovember 2017Support for this research was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation. U.S. Health Reform—Monitoring and Impact2Roughly 20 million previously uninsured people have gained health insurance since the enactment of the Affordable Care Act (ACA).1 To understand how health care providers met the increased demand for services, researchers from the Urban Institute conducted interviews with health care stakeholders in five communities that saw some of the largest percent increases in the number of insured people after the ACA’s coverage expansions took effect: Detroit, Michigan; Lexington, Kentucky; Sacramento, California; Spokane, Washington; and Morgantown and nearby northeastern counties in West Virginia (which we refer to collectively as West Virginia). All five communities were in states that expanded Medicaid.These interviews showed that as the demand for health care services increased, providers responded by expanding their staff, including hiring more advanced practice clinicians (such as nurse practitioners) and care coordinators; opening new or expanding existing health care sites; and/or extending their office hours. The number of urgent care and retail clinics also grew. Telemedicine has not expanded substantially, but respondents said that other payment and delivery reforms increased efficiency and helped providers meet the increased demand. Despite these changes, gaps in provider capacity persist. Respondents reported that health professional shortages that predated the ACA—including significant shortages of primary care professionals in some communities—were exacerbated by increased demand from newly insured patients. Respondents in all five communities reported that the most significant unmet health care needs were behavioral health services (especially treatment for opioid use disorder), adult dental services, and specialty services (which varied by community).To increase capacity, providers relied on revenue—particularly Medicaid revenue—from newly insured patients, and many federally qualified health centers (FQHCs) received assistance through ACA-funded grants. But respondents expressed doubts about their ability to maintain infrastructure enhancements and adequate capacity to meet patients’ needs if Medicaid funding is scaled back, as was proposed in several congressional efforts to repeal and replace the ACA in 2017 (and is likely to be proposed again). Respondents also identified persistent health care professional workforce shortages as a major ongoing challenge.With support from the Robert Wood Johnson Foundation (RWJF), the Urban Institute is undertaking a comprehensive monitoring and tracking project to examine the implementation and effects of health reform. The project began in May 2011 and will take place over several years. The Urban Institute will document changes to the implementation of national health reform to help states, researchers and policymakers learn from the process as it unfolds. Reports that have been prepared as part of this ongoing project can be found at www.rwjf.org and www.healthpolicycenter.org. SUMMARYBACKGROUNDThe ACA expanded Medicaid coverage to nonelderly adults with incomes up to 138 percent of the federal poverty level and provided income-based premium tax credits and cost-sharing reductions to individuals purchasing private health insurance in the new ACA marketplaces. In 2012, the Supreme Court issued a ruling that effectively made the Medicaid expansion optional for states.2 As of September 2017, 31 states and the District of Columbia had adopted the Medicaid expansion.3 Roughly 20 million previously uninsured people have gained health insurance coverage since the ACA was passed.1,4 U.S. Health Reform—Monitoring and Impact3To help health care providers handle the anticipated influx of newly insured patients, the ACA included several initiatives designed to increase provider capacity.5 The ACA included $11 billion to expand the capacity of community health centers, which primarily serve low-income patients and charge fees on a sliding scale based on patients’ ability to pay.6 These ACA funds were available to support ongoing operations; set up new care delivery sites; renovate existing sites; and expand the provision of preventive, behavioral health, and oral health services.7 The ACA also included initiatives to train and attract new primary care providers to underserved areas of the country (e.g., through scholarships and loan repayment programs)8 and provided temporary increases to Medicaid and Medicare payment rates for primary care services.9,10Nevertheless, before the major coverage expansions took effect, there was concern that the existing supply of health