Special Report: Texas and the PPACA

The U.S. Supreme Court has upheld most serious challenges to the constitutionality of the Patient Protection and Affordable Care Act (PPACA). The court’s decision will have  lasting implications for Texas’ health care delivery system.  Of course, the outcome of the upcoming November presidential election also will have  an impact. Nonetheless, at both  the federal and state levels, all of us must work  aggressively to make  sure that Texas patients have  access  to high-quality health care services in the most appropriate setting.

The PPACA imposes certain requirements on Texans. Large employers with more  than 300 employees, if they offer coverage, must automatically enroll  new  employees in their health benefits plans. Large employers generally must offer benefits or pay a penalty. Individuals must purchase insurance either  through their employer or through an insurance exchange. Texas, like all other  states,  must determine the essential health benefits to be provided in an exchange in conjunction with edicts  from the federal government. Our lawmakers also must decide whether Austin — or Washington — will run the Texas exchange.

Within days of the Supreme Court giving states the option, Gov. Rick Perry announced his opposition to expanding Medicaid under the PPACA to cover  about 1.6 million  more  low-income Texans. Pointing to the record low number of Texas physicians who  are accepting new  Medicaid patients,[106] TMA is also questioning the wisdom of Medicaid expansion. If doctors can’t participate because of the system,  then  Medicaid is broken, and you cannot fix a broken system  simply  by making it bigger. We have  to make  it different.

The state also has an important role that is essentially unaddressed in the PPACA: ensuring we will have  enough physicians to deliver  care that meets  Texans’ health care demands.

Depending on the elections and the will of state legislators around the country, the number of legal nonelderly residents with insurance could  rise from 82 percent in 2012 to 93 percent by 2022. From 2016 on, the Congressional Budget Office estimates that the PPACA would reduce the number of uninsured to 26-27 million.  Around 16-17 million  of the newly  covered persons — most of them  poor adults  without children — would be enrolled in Medicaid. [107]

In Texas, 6.5 million  people lack insurance coverage; that number would drop  to 2.3 million should the insurance exchanges and the PPACA Medicaid expansion come  to fruition. [108] This means that 4.2 million  Texans would have  some  new form of financing to support access  to medical care after 2014. Meanwhile, the supply of physicians (although increasing due  to Texas tort reforms) would be wholly  inadequate to meet  the new demand. In fact, according to the Association of American Medical Colleges, the nation could  face a shortage of as many  as 150,000 doctors in the next 15 years. [109]

Because physicians and emergency departments (EDs) must treat first and ask about coverage later, this shortage will cause  serious ripples throughout our health care system.

One  may look to Massachusetts, as that state’s health reforms might be a precursor to what  could occur  in Texas, on an even  grander scale. Before  it enacted universal coverage in 2004, an estimated 416,000 Massachusetts residents lacked health insurance. [110] By comparison, Dallas County  alone last year had about 660,000 uninsured residents. [111]

Many newly  insured Massachusetts patients continue to use EDs as their primary source of care. Patients with the lowest incomes — and the highest subsidized coverage — used  ED services at a rate one-third higher than  other insured. [112] From 2004 to 2008, hospital ED visits in Massachusetts increased by 9 percent. [113] To control costs, Massachusetts is implementing what  Forbes has called  the first step toward price  controls. Massachusetts could  impose a “luxury tax” on “pricey” hospitals. [114] The hospitals that will be subject  to the tax are those  that charge more  than “20 percent of the state median price  for a given service.”

The number of physicians in Massachusetts has not kept  pace  with the increased number of insured persons. That state is experiencing severe shortages in the number of primary care physicians and those  practicing in dermatology, urology, neurology, and vascular surgery. [115]

If Texas sees an identical 9-percent increase in ED visits, we can expect about 800,000 additional visits per year to our already-crowded emergency departments. [116] Seniors  and other  Texans would then  be competing with the newly  insured for a limited  resource — the time and availability of physicians. Texas already ranks  behind all of the other  most-populous states in the number of patient care physicians per capita. Physicians’ time, especially in primary care, is in high demand. Increased wait times for appointments or practices closed to new  patients will become even  more commonplace. A practice can serve only a finite number of patients safely.

As Senate  Bill 7 authorizes, Texas is beginning to redesign the health care system  through health care collaboratives. However, to build  a system  that avoids  delivering expensive acute  care in hospitals, Texas must first guarantee that office-based physician services are within  reach  of all Texans. The bottom line is this: Access to financing does not equal access  to medical services even  with the increased use of physician extenders. Texas needs more  physicians.


 Healthy Vision 2020 

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