Updated March 08, 2014.

A doctor shortage looms with the passage of health reform. There is little disagreement that our health care system is broken and needs to be overhauled. Currently, more than 45 million Americans have no health insurance, and with a weak economy and increasing numbers of people losing their jobs, that number has been growing.

The Patient Protection and Affordable Care Act, which President Obama signed into law on March 23, 2010, includes mandatory health coverage for people without health insurance.

Adding more than 30 million newly insured people into our health system will make the shortage of primary care physicians (PCPs) worse. There will be many more patients and a lot fewer primary care physicians!

Massachusetts Health Reform – An Example of Increasing Demand for Services

On April 12, 2006, health care reform, including mandated universal health coverage, became law in Massachusetts. At that time more than 625,000 people in the state had no health insurance. By March 2010, more than 400,000 residents had become newly insured, making Massachusetts the state with the lowest rate (2.7%) of uninsured in the U.S.

Not Enough Primary Care Physicians
Within several months of implementing health reform in Massachusetts, the shortage of PCPs became worrisome as echoed in newspaper headlines around the state – “Insured, Low-Income Massachusetts Residents Lack Access to Primary Care Physicians,” “Lack of Primary Care Physicians May Derail Health Care Reform Initiative,” and “New Health Law, Lack of Docs Collide.”

The concerns of the newly insured and other health care consumers about access to primary care services was verified in a report, Physician Workforce Study, published in September 2009 by the Massachusetts Medical Society.

Workforce Study Highlights PCP Shortage
The Workforce Study outlines the difficulty consumers have in accessing primary care services and describes the shortage of PCPs “severe or critical.” The study documents that:

• 40% of family medicine physicians are no longer accepting new patients, up from 30% before reform
• 56% of internal medicine physicians are no longer accepting new patients, up from 31% before reform
• Among PCPS who are accepting new patients, the average wait time for an appointment is more than 44 days.

Of great concern is the level of dissatisfaction among PCPs in Massachusetts. The Workforce Study indicates that nearly 25% of physicians in the state are considering changing their profession. Referring to the PCP shortages, the editors of the Workforce Study conclude, “that patient demands on these specialties have outstripped supply.”

In Massachusetts Patient Demand Exceeds PCP Supply
Prior to health reform, access to primary care services was a problem in areas of the state that were attracting large numbers of retirees, most notably on Cape Cod and in the Berkshire Mountains in the western part of the state, two well-known tourist destinations. Because of a seasonal economy in these areas, many residents had no health insurance and received care from local hospital emergency rooms and free clinics.

With the start of health reform, the already strapped PCPs have not been able to keep up with demand and many physicians have left the area in frustration, making the situation worse.
An example of the issue is the town of Falmouth on Cape Cod. More than 25% of the town’s residents are over 65 and the largest population growth is in people ages 55 to 64. In the year preceding and the year following the implementation of health reform (during which perhaps more than 5,000 people in the Falmouth area became insured) more than a dozen PCPs in the area stopped practicing. Currently, many PCPs in Falmouth are not accepting new patients or have stopped caring for people with Medicare. Open practices have an appointment wait time much higher than the state average.
Access is more difficult for people with Medicaid and the new state-subsidized health plans since most private practices do not accept them.

Lower Income Driving PCP Shortage
Although the shortage is partially due to the aging of PCPs (with more physicians leaving practice than entering) and an increasing percentage of women in the field who tend to work part time and often cut back to raise children, the major cause is clearly economic.
Thomas Bodenheimer, MD summed it up in an article in the New England Journal of Medicine, Coordinating Care — A Perilous Journey through the Health Care System (March 2008.) “With large panels of patients and a growing number of tasks to perform, primary care physicians can no longer provide high-quality short-term, long-term, and preventive care during a 15-minute visit, let alone perform care-coordination functions for which they are not reimbursed.”
Dr. Bodenheimer also noted that it would take a primary care physician more than seven hours each working day to provide all recommended preventive services to patients, and an additional 10+ hours per day to provide high-quality chronic disease management, such as care for people with diabetes, hypertension, asthma, and heart disease.

With low payment from health plans, Medicaid, and Medicare compared to the increasing cost of running a medical office, it is not surprising why physicians are leaving primary care or choosing not to become PCPs while in medical school. In recent years less than five percent of medical school graduates went into primary care!

What Will Happen Nationally?

Although there are some plans in the health reform legislation to increase the number of primary care physicians, none of them will have any impact on the doctor shortages by 2014, the year that most of the coverage mandates go into effect.

If you live in an area that already has a shortage of PCPs and a significant number of people without health insurance, you may experience long waits for appointments. If you move into a new community – especially if you are on Medicare – you may have difficulty finding a doctor who accepts new patients.

Although many more people are getting health care, which is great, Massachusetts continues to struggle with a lack of PCPs and is working to find ways to increase the numbers of practicing physicians.