Geographic Scope: Nationwide
Services: Health Care & Public Health Planning, Applied Research & Evaluation
Technical Expertise: Primary Care, Safety Net, Health Care Reform
As the Department of Health and Human Services was preparing to implement the major health insurance expansion provisions of the Affordable Care Act, the Health Resources and Services Administration (HRSA) was concerned about the impact that improved insurance coverage would have on access – with a particular focus on assuring that the primary care workforce would have the capacity to meet the increased demand for care by the newly insured, and whether the federal systems for identifying access issues and allocating resources were in a position to respond.
To prepare for this challenge, HRSA’s Bureau of Health Professions (BHPr) contracted with JSI to develop a detailed nationwide community-level estimate of the impact that expanding health insurance coverage would have on the demand for primary care services and provider workforce adequacy from ACA implementation in 2014 through the year 2020.
The project estimated the increase in primary care demand resulting from the expansion of coverage, compared to 'baseline' community level demand in the absence of the ACA. The analysis further compared the baseline and increased demand levels to the current and projected future supply of providers to examine potential provider surpluses/deficits. These estimates were made at a detailed local level covering all Primary Care Service Areas nationally, and comparatively within key areas of known access issues, such as existing Health Professional Shortage Areas (HPSA) and Medically Underserved Area (MUA) designation areas, Community Health Center service areas. The project involved a partnership between JSI and the Urban Institute which built on and integrated prior work by both organizations.
The Urban Institute employed a newly updated version of their highly regarded Health Insurance Policy Simulation Model, adapted to use the American Community Survey (ACS-HIPSM). This model was able to quantify and describe the population transitioning from uninsurance to various forms of coverage in each year following ACA implementation within each of over 2000 Public Use Microsample Areas (PUMAs) nationally. The results reflected the age, gender, poverty level, and health status of the uninsured gaining coverage, as well as the total population, in each area. Separate estimates were made for a full Medicaid Expansion scenario and for one in which states opted not to expand, such that estimates could be varies based on changing state choices in this area.
JSI then developed and applied estimates of the resulting changes in demand for primary care services by these individuals, based on estimates derived from samples of insured and uninsured individuals from the Medical Expenditure Panel Survey (MEPS). A block-level small area estimation method was then applied to sub-allocate the changes within the PUMAs, to produce detailed local estimates of the increases within discrete and incongruent geographical units nationally. These estimates were then combined with our analysis of provider databases listing all physician and non-physician primary care providers. These were translated into a community level visit capacity that could be compared to baseline and increased expressed demand within discrete service areas nationally. Separate analyses were also conducted to examine the potential for a 'pent-up demand' effect, as well as to examine the potential for access to existing federal safety net resources to impact baseline demand.
The results of the project were summarized in an extensive report which highlighted the overall impact of the ACA on primary care supply and demand, and also documented the differential impact that expanded coverage will have in areas targeted by HRSA programs. The results were intended to help HRSA review its process for identifying areas of need, the structure of its workforce and access programs, and develop both short and long-term policy for promoting access in a reformed health care market.