Holy Cross Hospital's health center in Aspen Hill, Maryland, is bracing for more business.
The center treats the uninsured, and has been busy since it opened in 2012 with a waiting list of more than 400 people at its clinic. Now, as a result of the U.S. Affordable Care Act, it's mulling adding staff and hours in anticipation of next year's rush of newly-insured patients, many with chronic medical conditions that have gone untreated for years.
Poorly controlled diabetes can cause stroke, kidney failure and blindness. Undiagnosed cancer can translate into complex end-of-life care, and untreated high blood pressure can lead to heart attacks. In effect, the 2010 health law's biggest promise becomes its most formidable challenge: unprecedented access to care for a needy population when the nation is already grappling with overtaxed emergency rooms and a shortage of physicians.
"When you're getting people that haven't had insurance, they have significant health issues," said Kevin Sexton, president and chief executive officer of Holy Cross Health, in a telephone interview. "A lot of people need these services."
About 25 million Americans are expected to gain coverage under the health law, commonly known as Obamacare. Starting Oct. 1, as many as 7 million uninsured Americans will begin shopping for private plans through government-run exchanges, with many people eligible to have their premiums subsidized by taxpayers. On Jan. 1, Medicaid programs for low-income people will be expanded in about half the U.S. states.
Strained System
The increase in newly insured patients arrives at a time when the nation has 15,230 fewer primary-care doctors than it needs, according to an Aug. 28 assessment by the U.S. Department of Health and Human Services. And emergency rooms report being strained with visits that have risen at twice the rate of population growth.
"It's like we're handing out bus tickets and the bus is already full," said Perry Pugno, vice president for medical education at the American Academy of Family Physicians, by telephone. "The shortfall of primary-care access is not an insignificant problem, and it's going to get worse."
Almost half of all uninsured, non-elderly adults had a chronic condition, based on a 2005 report by the Urban Institute and the University of Maryland. One in six with hypertension reported no visits to health professionals in a year.
Most who come to Holy Cross's health center now lack insurance, and have lived for years with serious ailments, according to Elise Riley, the center's medical director. "It's frustrating to see diseases that could have been prevented," she said in an interview in her office.
More demand may lead to months-long waits to see doctors, delays in finding specialists, and strains on hospitals and outpatient clinics, others said.
Patient Access
Ensuring patient access is critical to the Affordable Care Act's success: if the newly insured swamp the medical system, it could hand critics pushing to derail the law another argument to fray public support. Sara Rosenbaum, a health-law professor at George Washington University in Washington, said she doesn't believe it's going to happen.
"It's going to be a slow ramp up," Rosenbaum said in a telephone interview. "It's not like seven million people will get insurance at once. They're not going to all come racing in the door."
While that number of new patients can be debated, the status of those who do come in the door is not.
Patients who have had gaps in health insurance were more likely to have not gone to a doctor when sick or to have skipped getting prescriptions, according to an April 2013 report by the Commonwealth Fund, a New York-based foundation that works for health-care access. The uninsured were less likely to be up-to-date on recommended cholesterol, blood pressure, colon cancer screenings and mammograms.
Massachusetts Overhaul
Massachusetts pioneered health reform in 2006 when it enacted near universal coverage under then governor Mitt Romney. Community health centers and hospitals that care for a larger share of lower-income residents saw a 12 percent jump in patient volume from 2009 to 2010, with almost 100,000 more visits to safety net hospitals during that time, according to a 2012 report by the Kaiser Family Foundation.
David Longworth, chairman of the Medicine Institute at Ohio's Cleveland Clinic, was working in Massachusetts when the state passed near universal health coverage.
"Practices closed and patients would wait for eight to nine months to get in," Longworth said by telephone. "We overwhelmed the primary care health system."
In cities such as Lawrence, Massachusetts, a former textile city that has long been home to a large immigrant community, doctors have coped with rising volume.
Patient Surplus
The Lawrence Family Medicine Residency, which provides primary care and other medical services to a largely low-income patient population, saw an uptick in patients, said Joseph Gravel, chief medical officer and residency program director.
"When you look at the experience in Massachusetts, it's going to be bumpy" when Obamacare rolls out, Gravel said in a telephone interview.
The percentage of family doctors in the state accepting new patients has dropped 19 percent in the past seven years and the percentage of internists accepting new patients has fallen 21 percent over nine years, according to a July report by the Massachusetts Medical Society, an advocacy group for patients and physicians. Only about half of family doctors were accepting new patients this year.
The Cleveland Clinic predicts as many as 90,000 new patients in northeast Ohio if everyone signs up for coverage. The health system is working to ramp up its primary care practices in anticipation.
Exciting Challenge
At Grady Health System in Atlanta, more patients are expected, especially at its six outpatient centers. San Francisco General Hospital and Trauma Center in California has some expanded hours its 19 primary care centers. The centers are located in the hospital and out in the community.
"We anticipate an increase in primary care and specialty," Chief Executive Officer Sue Currin said.
On a recent Friday morning at the Holy Cross clinic in Aspen Hill, Riley donned a white coat and prepared to see patients. While there may be more patients under reform, Riley said an increase in business will be welcome.
"I've very excited," Riley said. "I've been dealing with uninsured patients for a long time. If they get coverage, we can prevent a lot of problems."
