Low-income adults are often served by safety-net providers – public hospitals, Federally-qualified health centers (FQHCs), and free or low-cost clinics – as opposed to private practice community physicians. The Affordable Care Act promises to bring millions more low-income adults from the ranks of the uninsured onto the Medicaid rolls. With this expansion, safety-net providers can expect to see a surge in new patients as those with coverage are more likely to seek care than those without coverage. A recent study from researchers in Texas sought to anticipate the surge expected in Houston, the nation’s 4th largest city.
Houston’s Harris County Hospital District – comprised of 3 hospitals, free clinics, and mobile health units – serves nearly 300,000 individuals annually of whom approximately 70 percent are uninsured.
Data for this study were comprised from two sources. First, the Project Safety Net Clinic Survey explored safety-net providers ability to supply care for the low-income population. Secondly, a combination of the California Health Interview Survey and the Current Population Survey served to approximate demand for health care services. Utilizing this methodology, researchers took the primary care visit rates in California and adjusted it to the Houston population. There were no immediately available data from which to derive a demand model specific to Houstonians.
Next, the researchers compared the supply and demand models in order to determine what percentage of care could be covered by safety-net providers. Estimates from the Kaiser Family Foundation served to provide anticipated surges in demand following the Medicaid expansion under the Affordable Care Act. The first scenario assumed a 73.6 percent increase in demand for services among the low-income uninsured population; the second scenario assumed a more modest 49.4 percent increase in demand.
Over 943,000 primary care visits were provided by safety-net providers in 2008. Of these, 58 percent were supplied by the hospital district, 22 percent by private non-profit clinics, and the remainder by FQHCs or local health departments.
Demand estimates showed that low-income individuals on Medicaid were 20 percent more likely to seek health services than the uninsured. Among those with a primary care visit in the year, low income individuals with insurance averaged nearly three times the number of annual visits (2.65) than those without insurance (0.91). Over 3.1 million primary care visits were made by low-income patients. Thus, safety-net providers were only meeting about 30 percent of health care demand for this at-risk population.
Once the Affordable Care Act’s Medicaid expansions take effect, anywhere from 3.8 million primary care visits to 4.1 million visits may happen under the different scenarios. Were this to occur, the proportion of primary care visits covered by safety-net providers (assuming no increase in supply) would drop to 23-25 percent of the demand for services.
In order for safety-net providers to continue their current proportion (30 percent) of met demand, service capacity would have to increase 2-3 percent annually over the next decade. If a more aggressive approach were undertaken such that all (i.e. 100 percent) of the primary care demand for low-income patients was met by the safety-net providers, growth would have to occur at an astounding 18 percent per year.
How much of the current demand for primary care among low-income Houstonians is being met by private practice physicians? How much demand goes unmet? These questions remain unanswered but are integral to absorbing the oncoming wave of new Medicaid patients arriving in the coming years.
This study only scratches the surface of a problem every state will face in the next few years as millions more Americans gain insurance coverage through Medicaid. With private physicians often unwilling to open their practices to Medicaid patients, safety-net providers must stretch limited resources to care for low-income patients.
Fortunately, payment increases for primary care will be coupled to the Medicaid expansion. Hopefully, private physicians may welcome new Medicaid patients into their practices since the compensation will equal that of Medicare.
What many fail to understand is that although 17 million Americans will gain coverage, up to 3 times as many office visits (not to mention diagnostic tests and procedures) will need to be supplied by providers. Our nation’s hospitals have long been accused of lacking surge capacity in case an epidemic were to strike; our nation’s primary care providers currently lack the surge capacity necessary to care for the rising tide visible just over the health care horizon. Localities, states, and the entire nation better prepare for waves of new patients arriving 2014.
Cedric Dark, MD, MPH