Access to care following health care reform: Lessons from Massachusetts

In March of this year, President Obama signed into law the Affordable Care Act. In 2006, Massachusetts enacted state health reform that included some similar elements to decrease the number of uninsured in the state including increased coverage and the individual mandate.

We are now 4 years status-post the passage of the health care legislation in MA. What lessons can we learn for the national health care reform from Massachusetts?

430,000 uninsured Massachusetts residents have now been granted insurance since 2007 when the law came into effect. However, access to primary care remains a huge problem in Massachusetts especially in the more rural areas of Western Massachusetts. Data published by the Massachusetts Medical Society in October show that 54% of Family Physicians and 49% of General Internists in the state are not accepting new patients. The average wait time for an appointment with a new primary care provider is 44 days.

Anecdotally, as a medical student in Massachusetts, I have witnessed the family medicine clinic attached to the main teaching hospital (incidentally, where my personal PCP is) cut evening and weekend hours due to a shortage of physicians. Earlier this year when I called to make an appointment for an acute problem, I was offered a visit in 2 weeks. [Side note: I grew up in Canada and, when I was sick, I frequently called at 9 am when my family doctor's office opened to receive an appointment later that same morning. ]

I emailed my physician instead... but, how many people in the same situation, would go to the Emergency Room?

In Massachusetts, we have witnessed an increase in emergency room and urgent care utilization following the passage of health care reform. This not only increases costs but also undermines doctor-patient continuity and fragments care. This situation is even more acute in the rest of the nation. Massachusetts has the 3rd highest PCP to population ratio with 107.8 PCPs per 100,000 vs. an average of 79.4 per 100,000.

So, what can we do?

Can we rely on IMG grads to provide where US grads will not? How can we collaborate with other medical staff like nurses, MAs, and PAs, to increase efficiency and provide better care to more? Are PCMHs or ACOs the answer? We are increasing PCP payment and increasing PCP and underserved residency slots but is this enough and is it timely (given that it takes almost a decade to train a physician)? These are all questions we need to answer if national health care reform is to be effective...