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, 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. 
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.  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. 
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.  By comparison, Dallas County alone last year had about 660,000 uninsured residents. 
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.  From 2004 to 2008, hospital ED visits in Massachusetts increased by 9 percent.  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.  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. 
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.  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