A more rational concern about the Affordable Care Act

Some of the criticisms of the Affordable Care Act (ACA), or “Obamacare,” suggest that the federal government will dictate who will get care and how that care will be delivered.

In fact, recent ads funded by a group supported by the Koch brothers show our dear Uncle Sam preparing to administer exams himself. One depicts him with a speculum in hand about to perform a vaginal examination. This is fear mongering, as far as I’m concerned.

A more rational concern is whether the ACA and the increased number of patients it brings will create too much competition for the limited number of primary care providers in the USA.

The ACA does have provisions to expand access to primary care so that people covered by Medicare, Medicaid and commercial insurance will not be crowded out of the healthcare marketplace. Here’s how this was done.

First, the bill that was signed into law funded expansion of existing community health centers and added some new ones. The number of centers was greatly increased during the George W. Bush administration, with 1,250 centers serving 20 million people in 2011. The ACA reorganizes and upgrades these centers so they can be deemed “federally qualified” by the Department of Health and Human Services, and by 2016 these centers should serve 40 million Americans.

In 2010, Secretary of Health and Human Services Kathleen Sebelius announced $250 million in federal funding to help provide training to more than 16,000 primary care providers over five years. The Medicare payment gap between specialist and primary care providers would also be reduced through a 10 percent bonus for the same period. Whether these incentives can overcome the overwhelming ethos of subspecialization at academic medical centers remains to be seen.

Some policy makers are starting to note a serious shortfall in providers with medical degrees and are taking a different tack to increase capacity in primary care. They are following some federal efforts already in place to expand primary care by using nurse practitioners (NPs). Modifications of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and the Medicare, Medicaid, and SCHIP Extension Act of 2007 allowed NPs to become care coordinators, especially for people with chronic conditions such as diabetes.

Compared to the daunting regimen for physicians, the training and education of nurse practitioners are inexpensive and can be done more quickly. And time is of the essence. There is a need for more graduates from nurse practitioner programs, since the annual rate of 8,000 has remained unchanged for several years. According to advanced-practice advocates for the nursing profession, before this increase takes place state regulatory restrictions on what NPs can and cannot do must be eased. Currently, 16 states and the District of Columbia have altered their score-of-practice regulations so that NPs can prescribe independently. The trend is headed in the right direction.

By  2016, there will be an estimated 15,000 primary care providers at work, including advanced-practice nurses. I believe that those with coverage today can feel less concerned about being crowded out of services they have received in the past.

Arnold Birenbaum is a professor of pediatrics, Albert Einstein College of Medicine. He blogs at The Doctor’s Tablet.

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  • doc99

    Thank you for making the argument in favor of the Six Dollar Haircut. But then as a PhD, it must be on sound philosophical grounds indeed.

    • NPPCP

      What the doctor actually speaks of is policy catching up with action. Although it is difficult for some to say, NPs all over the country are already practicing under their own license. The argument is not about “should this happen?” It has ALREADY happened. The only constraints are in select states and federal policy that have no actual bearing on patient safety. We all already know that NPs practice, accepting all of the legal responsibility for their actions, in 18 states; and that number will continue to grow. It has happened, will continue to happen, and is working. The “six dollar haircut” is ONE opinion of many – many patients feel like they HAVE been getting one of those cuts for years – that is the other side of the coin. So, the “debate” about whether NPs should or should not accept all responsibility for their actions is old news. We are going to have to move on and get along. Props to Dr. Pho for introducing the moderation policy. The discussions have been so much more constructive, less denigrating, and more enlightening over the last few weeks.

    • Guest

      What concerns me as a patient and parent is that every APRN
      I’ve seen has been lacking in basic clinical skills and medical knowledge. It just amazes me though that in my 39 years on this planet I’ve never had a good medical experience with an APRN. Is our healthcare system so utterly dysfunctional with such poor expectations that these practitioners are considered “good?”

      A recent experience with a pediatric NP was particularly alarming. With her hand on the doorknob as she was exiting she asks at my daughter’s new patient visit “So, she’s basically healthy, right?”

  • fatherhash

    deregulation of NP scope-of-practice as being “headed in the right direction” is not something everyone agrees on. there are arguments for and against that.

    i tend to think a good solution would be a system where NP’s are used with primary care physicians the way that CRNA’s are used with anesthesiologists….for example, having 4 NP’s seeing pts while MD continuously supervises.

    • southerndoc1

      “while MD continuously supervises”
      And who’s going to want to go through the hell of med school, internship, and residency to do that?

      • fatherhash


        but in all seriousness, i’m having trouble finding solutions just doing simple math. if there aren’t enough MD/DO’s in primary care(and if the supply just can’t get to the demand), what other systems would be optimal?….how do you make the math work? i keep hearing the phrase, “using every provider at the top of their training”….do we really need a PCP MD/DO spending even 10minutes taking a hx and ROS and diagnosing and treating a viral URI and then documenting all that?

        • southerndoc1

          Ah yes, the truly patient-centered “if the high school dropout answering the phone decides you’re ‘simple,’ you’re not allowed to see your doctor” model of health care.
          So the Wegeners that self diagnoses as sinusitis sees the mid-level, and the doctor sees nothing but demented 93 year old nursing home residents on 23 meds and with 10 new problems all day long, five days a week. And supervises 4 NPs.
          Everyone’s a winner, right?

          • fatherhash

            is that how the system works in anesthesiology? the MD is seeing the complex cardiac cases only while the CRNA’s are running simple cases unsupervised?….or that the MD is running the complex cases(“all day long, five days a week”) while he/she is also supervising 4 CRNA’s?

            besides, you didn’t answer the math question of not enough supply and too much demand….you’re simply shooting down possible solutions(not that i agree completely with the solution i threw out). it seems you want every sinusitis patient to be seen by an MD to r/o Wegeners….i’d like that too, but do the math.

          • southerndoc1

            Believe it or not, doctors go into medicine because they like treating patients. This is especially true in primary care. Tell us that our job is now going to be primarily supervisory and administrative (the medical home model), and we’re out of here (taking our liability insurance with us).

            The math: if you want more primary care docs, you make more primary care docs. The quickest way to do that is to stop the exodus into urgent care, hospital medicine, administrative work, part-time work, early retirement, etc. But nobody seems interested in doing that. I just don’t think telling patients in the most expensive health care system in the world that they’re not allowed to see a doctor is much of a solution.

            Not to mention that NPs and PAs are now shunning primary care also. I guess we have to soon start telling patients that they’re only allowed to see a medical assistant.

          • fatherhash

            i actually agree with you.

            personally speaking, i can see myself in a system where i am supervising OR a concierge medicine system….in fact, i am in the process of going into concierge medicine for the exact reasons you state. i enjoy pt interactions(most of the time, haha) but can not stand the present system requiring excessive bureaucratic work and 10-minute office visits. pt interactions are not as enjoyable when you have 4 other patients waiting and are an hour behind….especially when each visit begins with a “sorry for the wait.”

            for most of my medicare pts, i feel that i need at least 30min-1hr to address everything(without having to have them come back for multiple appts)….but the present FFS system doesn’t allow that.

          • fatherhash

            btw, i understand that the concierge medicine route will worsen the math equation since each MD is now seeing only 500pts vs 2500pts.

          • NPPCP

            What about the states that require no supervision? Unless a medical system mandates it and the NP is willing to work under it, there are only 34 or so states (at this point) that you would be able to “supervise” in. In many places, such as my clinic, a supervisor would be a duplicative cost. I have been open for over 5 years, NPs only, no lawsuits, more business than I can handle, and an enviable group of specialists I utilize when needed for questions or referrals (as any good primary care would do), and more new private pay, insurance based, and Medicare/Medicaid patients showing up every day.

          • buzzkillerjsmith

            Urgent care: 1.5X the money, a tenth of the paperwork.

  • Tiredoc

    Regardless of your political persuasion, by passing the ACA we hired an elephant as a shoe saleman. It doesn’t matter how nice the store is, or how comfortable the chairs, or if the temperature is right. It doesn’t even matter if the shoes are nice. No matter what, the elephant is going to make a mess.

    My recommendation is to stay out of the store for a while if you can.

    • James_04

      I wish I could. My policy is one of those that will be cancelled, because it doesn’t cover maternity, addiction treatment or children’s dental (which, as a healthy gay womb-less childless 50-year-old man who neither drinks nor takes drugs, I was just fine with). Obamacare has turned the individual market into a real mess.

      • Tiredoc

        Maybe you should reconsider the not drinking.

        A patient of mine works as a mercenary in some truly nasty places in the world. His company, an American one, is switching from a U.S.-based insurance policy to one that flies its people to receive their treatment in Dubai if possible. This includes flying them from the United States when they are on leave.

        This made sense to him. It actually kind of makes sense to me.

  • Dave Mittman, PA, DFAAPA

    One wonders if the author ever heard of PAs and the fine work we do? He writes like there are only two types of clinicians who can deliver primary care? Check with the millions of patients who saw the close to 100,000 PAs last year.
    What is that exclusion about?

    • safetygoal

      I love my PA! Thanks for mentioning them, Dave!

  • goonerdoc

    Sigh…..yet another one of these articles. More meaningless infighting between MD’s and NP’s. Make it stop.

  • SarahJ89

    The older I get the more I value a good PCP and the more I think that pay gap should be tightened up by waay more than a mere 10%.

    • NPPCP

      Thank you Sarah. You are too kind! We appreciate that!!

  • SarahJ89

    I’m not sure how or why you left out the influence of the insurance industry.

    • John Smith

      Sarah, I was only speaking to the good Doctor’s comments about fear mongering wrt the government dictating “who will get care and how that care will be delivered”, the coming shortage of PCPs, and my view on how the ACA factors into those things (or doesn’t).

      Pretty much every actor within the healthcare industry is influential, except for patients and nurses. Cracking that egg requires a much much larger discussion of how the laws we pass have unintended and sometimes quite undesirable consequences (the rise of influential special interest groups, for example). That discussion falls well outside the context of the article above and the medium of a comment board.

  • Dee Fee

    I worked in a medical clinic for 16 years with both NPs, PAs, and physicians. Numerous times a PA/NP would see a patient, diagnosis, and send the patient out the door with a followup the next day with a physician. The patient would then have two office visits to pay. This is WRONG! If the PA/NP cannot diagnose or needs the patient to follow up to make sure, the patient should only pay one office visit. If the patient had seen the physician first, there would only be one office visit.

    • fatherhash

      was the pt seeing the PA/NP because the doctor was too booked up to work-in that day? i assume the doctor hired/pays the PA/NP for that reason. in which case, who pays the PA/NP if only charged for one office visit?….or are you saying that the doctor should just work for free on the followup visit?


    Many MANY customers are okay with this. I say, choose who you will. Some prefer pineapples, some prefer apples. It’s okay.


    We are absolutely on the same page. It completely angers me that patients are forced to see ANY provider. In a free market (which health care is not), you choose your provider and pay the price the market will bear. I know that is not happening in this system. However, if a patient wants to see an NP (my patients are all here, at this point at least, out of choice) they will be able to do so. If a patient ever showed up saying their insurance company only allowed them to see me (an NP) and they weren’t happy about it, I would show them the door (kindly) and recommend they purchase different (perhaps more expensive) insurance. I will never see someone who doesn’t want to see me. Everyone who wants to see a physician and can pay the price the market will bear (such as direct pay) should be able to do so. Medical homes are useless, a joke, we all agree on that. Thank you for the response and clarification Mandy!

  • Lemmethink101

    Physicians who oppose nurse practioners or others who can practice independently will find themselves miserable when they are no long fit to practice medicine, and when trying to find a physician to treat, they can’t afford it or can’t find one. Or am I wrong on physicians zero troubles taking care of themselves, having access to medicares, and could afford fees artififcially inflated to outrageous amount.

    • Deceased MD

      Yes I would say that’s a double whammy.

  • Disqus_37216b4O

    “recent ads funded by a group supported by the Koch brothers…”

    Yes, yes. We hate the Koch brothers. I get it. Let’s get our “5-minute hate” on.

    Does this blog regularly mention which ads (and studies, and think tanks) are funded by groups supported by George Soros?

    And if not, why not?

  • Guest

    We had to throw everyone – 320 million of us — into a big barn in order to get care for maybe 20 million uninsured Americans?

    This isn’t about classism, it’s about bringing 300 million people down to the lowest common denominator in the name of “faaaaairness”. Sure, people like me will lose the plans we liked, but we should be happy to pay more and get less, to sit around waiting in a huge barn rather than keep the doctors that we liked, because if EVERYONE can’t have the healthcare they want (and were paying for themselves, out of their own paychecks), then NO-ONE should.

  • SarahJ89

    I do NOT want anyone hunting me down to give me a flu shot or any other “recommended” treatment. It’s my body and I’m the one who has to live in it. What you describe sounds like a factory and I want no part of it.