If too few sign up, however, a state’s risk pool may be imbalanced toward costlier patients, causing insurance premiums to rise and creating a vicious cycle that destabilizes the market and makes more expensive insurance less attractive to younger people. It’s too early to say whether the exchanges can meet the Congressional Budget Office’s prediction of seven million enrollees by the end of the 2014 enrollment period (and 13 million by 2015).1 But analysts say the composition of the risk pool—something that should be clearer this spring—may provide a glimpse of the ACA’s long-term financial viability.
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Explore This IssueJanuary 2014
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Instead of a consistent pattern across the country, the exchanges also will be shaped by local market forces, such as the number of competitors and the extent to which cheaper plans will try to limit access to more expensive providers. In exchange for lower premiums, some of these insurers are offering “skinny networks” that give consumers more limited options for providers. “A primary objective in the marketplace is to offer the cheapest plan possible, and to do that the insurers are going to look at who are the least expensive providers,” says Christiane Mitchell, director of federal affairs for the Association of American Medical Colleges.
“I think the challenge is who’s going to absorb the extra patients, who will cherry-pick them, and who will take everybody?” says Salahuddin Kazi, MD, associate professor of medicine in the division of rheumatic diseases at the University of Texas Southwestern Medical Center in Dallas. Rheumatologists who are already flush with patients can afford to be selective and watch from the sidelines. Doctors starting a new practice, however, may be much less choosy. “Will that become an unsustainable business model for them?” he asks.
And with the rise of accountable care organizations and practice consolidation, Dr. Laing says some independent doctors could be frozen out of exchange-based insurance plans altogether. On the flip side, he says, “everyone says there’s going to be way more patients than there are doctors, that we’re not going to be able to keep up with demand. Ultimately, I don’t know that anybody is going to starve.”
Increased emphasis on teamwork and delegation of tasks that don’t require a physician’s level of training is something that’s going to get a lot more attention moving forward.—Ann O’Malley, MD
A Question of Access
How the healthcare system will accommodate the influx of newly insured, in fact, remains one of the biggest unknowns. Mitchell says the existing doctor shortage—almost evenly split between primary and specialty care—is already worsening due to the sheer number of Baby Boomers entering Medicare. At the same time, she says, one in three doctors in the U.S. is now over the age of 60. Whether through Medicaid or the marketplace, the ACA’s coverage expansion will exacerbate the shortages. “It’s not to the level of the Boomers entering Medicare, but it certainly is having a major impact on access issues, and exacerbating the shortage, again, across specialties,” she says.