Part Three: Managing the ACA’s Increased Demand for Health-Care Services


The Congressional Budget Office (CBO) forecasts that the Affordable Care Act (ACA) will expand health coverage by approximately 30 million Americans. It is also expected to gradually rein in health-care spending nationwide through its reforms in insurance markets, provider payment and health-care delivery. (For discussion of these, see previous articles from this ACA series, published in the Dec. 20 and Jan. 3 issues of Business Lexington).

The ACA’s coverage of millions more Americans will begin Jan. 1, 2014, when its “play or pay” mandate, requiring everyone to have health insurance, and its Medicaid expansion take effect. Tax penalties to enforce the individual mandate are mild at first; in 2014, they will be a flat $95 or 1 percent of household income, whichever is greater. They increase yearly until after 2016, and then they are indexed to inflation at the greater of $695 or 2.5 percent of household income.

As they increase, the penalties can be expected to induce more Americans to obtain health coverage. With more widespread coverage, the demand for medical attention and health-care services is certain to increase as well. A substantial increase in demand will pose serious challenges to the supply of qualified health-care workers.

The ACA’s provisions for health-care workforce development

Because a primary aim of the ACA is to make quality health care accessible to millions more Americans, the ACA anticipates this increase in demand for health-care professionals and devotes many sections and pages to this potential, indicating an original intent to avert a potential shortfall in supply.

The ACA also seeks to restrain the growth of health-care spending, and it recognizes this goal will be frustrated if an increase in demand significantly outstrips supply.

Basic economics teaches that prices rise when supply runs short. Accordingly, the ACA includes numerous workforce development provisions intended to build and train America’s health-care workers to prevent shortages.

First, it provides various grants and loan programs for training facilities to build primary-care capacity and to attract and retain more people into primary care fields. It offers educational grants and more liberal loan repayment terms for students of primary care, public health and nursing. It distributes additional graduate medical education (GME) residency positions among academic medical centers and allots many to the development and stabilization of primary-care physician services in rural areas.

It also establishes grants for state and community health-care workforce development initiatives and creates an independent 15-member body, the National Healthcare Workforce Commission, to assess and coordinate any national, state and local-level responses to an inadequacy in supply relative to demand for health-care workers.

Second, it authorizes grants to nurse-managed health clinics. These grants recognize that nurses and nurse practitioners are already on the forefront of primary-care coordination and services. And, they recognize the reality of America’s current health-care workforce: nurses outnumber any other primary care provider. In certain rural and underserved communities, nurses may be the only practical way to meet a significant increase in demand for health services in the short term. There are simply too few primary-care physicians or medical students who could be available or trained soon enough to meet any rapid increase in demand.

Potential hurdles to the ACA’s workforce development provisions

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