Other analysts say the extent of the capacity problem will depend in large part on location. “We already have a supply and demand imbalance,” says Dr. Kazi. At Parkland Memorial Hospital, where he sees some of his patients, “we get many more rheumatology consults and requests to see new patients than we can handle.” Dr. Kazi sees the Dallas-Fort Worth area as a microcosm of the sheer variability in capacity that exists across the United States. “We have rheumatologists that are very, very busy—and saturated,” he says. “And then we have rheumatologists who have availability this week.”
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Explore This IssueJanuary 2014
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The access question is more complicated in the roughly two-dozen states, such as Texas, that have chosen not to expand Medicaid—an option granted by the U.S. Supreme Court in its June 2012 decision that upheld the law’s main tenets. According to a recent analysis by the Kaiser Family Foundation, roughly five million uninsured adults may now fall into a “coverage gap.”2 In essence, they will earn too much to be covered under the highly variable Medicaid caps established by individual states, but too little to receive any federal tax credits to help pay for insurance in the exchanges. With limited options, the report suggests, they are likely to remain uninsured.
Who’s going to absorb the extra patients, who will cherry-pick them, and who will take everybody?—Salahuddin Kazi, MD
Meeting demand also means training more doctors, and Mitchell worries about a pipeline that is already underfunded. Federal support for physician training has been frozen since 1997, and further declines in the clinical income that subsidizes training would place additional pressure on the educational mission of teaching hospitals, Mitchell says.
Another one of the plan’s biggest goals and part of its name—affordability—also seems to vary considerably by geography. A recent analysis by the New York Times, for example, found that 58% of all counties served by the federal-run exchanges offer plans from only one or two insurance carriers. The relative lack of competition in many markets has created some huge cost disparities in premiums between neighboring states—and even neighboring counties.
Although the new mandates were designed to improve insurance standards, they sparked another firestorm when millions of Americans began receiving policy cancellation notices. Because many private insurance plans sold to individuals no longer met the ACA’s minimum requirements, insurers began dropping those plans or asking enrollees to switch to other ones. In November, President Barack Obama bowed to mounting political pressure and announced a reprieve that allows insurance companies to renew existing policies for another year, in an effort to stem the mass cancellations.