In “For Many New Medicaid Enrollees, Care Is Hard to Find, Report Says,” Robert Pear discovers something that has long been obvious to our many Community Health Clinic (CHC) clients: having insurance doesn’t mean you can see a doctor. Many if not most doctors won’t see Medicaid patients. CHCs, however, are a class of primary care organization designed specifically for Medicaid patients and the uninsured. We’ve written numerous Health Resources and Services Administration (HRSA) proposals for CHCs, and everyone one of those proposals is supposed to expand access to care. This year’s New Access Point (NAP) program, for example, has $100 million available. Pear apparently does not know that CHCs exist and are funded through HRSA mostly to serve Medicaid patients.
The bigger problem regarding real-world healthcare is the number of doctors. Any discussion about the difficulty of finding care that doesn’t mention the limits on the supply of doctors is specious at best. There have been around 100,000 residency slots since the 1980s. Medical schools stopped expanding long ago. These facts are well-known to experts. Physician Assistants and Nurse Practitioners are to some extent filling in the gap, but in most states they still must practice under a doctor.
Our CHC clients’ biggest problem is rarely recruiting patients—when you subsidize goods or services, people consume more—it’s finding doctors. CHCs usually serve a high-need, difficult-to-treat population. Consequently, physicians often prefer to seek higher pay and lower stress jobs. Although there are lots of people trying to go to medical school—in Educating Physicians: A Call for Reform of Medical School and Residency, the authors note that 42,000 people applied for 18,000 medical school spots, and that at least 30,000 were likely qualified to become doctors—med school and residency act as bottlenecks to this process.
You can give every person health insurance without ensuring that they’ll actually get care, much like you can give everyone a degree without ensuring they have a brain. In the United Kingdom, care gets rationed through wait times. In the U.S., a similar dynamic is happening via provider shortages. While it is laudable that the Affordable Care Act (ACA) significantly increased the number of Americans covered by Medicaid, the landmark legislation did little to increase the number of providers to serve the newly insured. Or, as they used to say in the old days, you can’t shovel ten pounds of shit into a five pound bag. It’s a vulgar phrase but applicable to this article and the overall challenge of helping the newly insured actually access affordable, quality healthcare.