It is likely that increased demand for care from insurance coverage expansions will strain the capacity of many local health systems, especially the capacity for primary care. As is currently the case, newly insured patients who are unable to find physicians willing and/or able to accept new patients, or who encounter long waiting times to see primary care physicians or specialists, are likely to end up in already crowded hospital emergency departments for treatment of relatively minor or non-urgent health care problems. Shortages of primary care physicians could make it especially hard for newly enrolled Medicaid beneficiaries to find a physician, because historically physicians have been less willing to accept new Medicaid patients than privately insured patients (MACPAC 2013; Decker 2012; Cunningham 2011). Such problems were anticipated with the implementation of Massachusetts health reform, although both physicians and hospitals in Boston reported mild to moderate increases in demand that did not overwhelm their capacity (Tu et al. 2010).
However, Boston benefitted from both low rates of uninsured persons before reform (and therefore modest increases in demand from newly insured persons) as well as a relatively large supply of health care providers, including safety net providers. Other communities will see a potentially much larger increase in the number of insured people due to the coverage expansions, and many areas with high numbers of uninsured have a lower supply of health care providers, especially states with large rural areas (Cunningham 2011). The ACA includes a number of provisions to expand health care capacity, including funding for expansion of Federally Qualified Health Centers (FQHCs), “teaching” health centers (hospital residency programs located at FQHCs), nurse-managed health centers, and the National Health Service Corps, which provides scholarships and loans to health care providers to locate in medically underserved areas. Although these reform-related capacity expansions will not directly affect safety net hospitals, increased primary care capacity in the community could increase demand for inpatient and specialty care at hospitals because of more referrals and the overall increase in the number of
people seeking medical care.