Demand to outpace doctors

By Steve Jacob

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The new federal health reform law is expected to create 32 million more insured Americans, according to the Congressional Budget Office. The federal government plans to expand Medicaid to low-income adults and subsidize purchases on the health-insurance exchanges when it requires most Americans to carry insurance in 2014, unless the Supreme Court rules against the mandate.

However, an insurance card will not mean much to patients without providers to care for them.

Iowa will have 125,000 more insured residents because of reform, according to an Urban Institute analysis.

A primary-care physician is the first contact for people with undiagnosed illnesses. The United States has the about the same number of physicians per capita as other industrialized nations but far fewer primary-care physicians than specialists. They make up 50 percent of the physician work force in most other developed nations, compared with 35 percent here.

The number of U.S. specialists per capita has risen dramatically since 1965, while the ratio of primary-care physicians has remained relatively constant. Specialists earn as much as three times more income. The outlook is for more of the same in the decade to come.

Massachusetts reformed its state health care system in 2006, giving the nation a glimpse of what is to come when access to health insurance is expanded without expanding the supply of primary care. The average wait for a non-urgent appointment rose from 17 days in 2005 to 48 days in 2011. Fewer than half of family physicians there accept new patients, compared with 70 percent four years ago.

Massachusetts has about 108 primary-care physicians for every 100,000 residents, compared with only about 76 per 100,000 in Iowa. This ultimately suggests an even longer wait in Iowa.

The primary-care workload is expected to increase by nearly 30 percent between 2005 and 2025 because of a flood of baby boomers becoming Medicare beneficiaries and the newly insured because of the reform law.

However, the supply of primary-care physicians is expected to rise no more than 7 percent. The math screams for a health care access crisis in the next 15 years. And in Iowa, 1 out of 4 physicians is age 60 or older.

Physicians tend to cluster in areas where supply is high rather than where the need is greatest. They like affluent areas with well-insured patients, high-tech hospitals and civic amenities.

Health reform may rectify the lack of insurance, but it will exacerbate a new form of rationing: the doctor is not in.

Steve Jacob of Fort Worth, Texas, is a veteran health care journalist and author. Comments: steve@unitedstatesofhealth.com.