“Obamacare” is now a reality.  Last week’s US Supreme Court Ruling has huge implications for the future of our nation, and even bigger implications for the physician assistant profession.  In this article I’ll give you the Cliff Notes version of the new law, why it came about, and what it means for the you.  If you already understand the new health care reform, you can jump to my predictions for the profession below.

A Thumbnail Sketch of the Health Care Crisis

First, the big picture.

  • For years the cost of health care has been increasing much faster than anyone’s ability to pay for it, including the government.  Ten years ago, the federal government spent 17% of its budget on health care.  This year, it’s up to 22%.  At its current rate, by the end of the decade it will hit 25%.  Most economists agree that this pace of growth is unsustainable.  Where does it all go?  Uncle Sam spends this money primarily on two programs: Medicare (a health care program for all adults over 65, and others who are permanently disabled), and Medicaid (a health care program for those who have limited income and resources).
  • Employers are similarly unable to keep up with the cost of insuring their employees.  Health care costs have caused the failure of many small businesses that can’t bargain effectively for lower rates.
  • Rising costs left approximately 50 million Americans without health insurance this year.
  • Health insurers have been unable/unwilling to allow coverage for those with pre-existing conditions, because these people are sicker and therefore more expensive to insure.  This has reduced competition that is needed to help control costs.
uninsured with and without health care reform

The Affordable Care Act will provide health care for 32 million people.

What is the Affordable Care Act (ACA)?

  • In an effort to reduce the financial burden on the federal government, the Obama administration introduced the Patient Protection and Affordable Care Act.  The ACA was a sweeping health care reform bill that was signed into law by President Obama on March 23, 2010 and upheld by the US Supreme Court’s landmark 5-4 ruling on June 28, 2012.  The high court ruled that most of the ACA’s provisions are constitutional and therefore may be implemented.
  • The largest and most important provision of the act is the so-called “individual mandate,” which will effectively require all Americans to purchase health insurance by taxing those who do not do so by the 2014 deadline.  The individual mandate was intended to bring healthy citizens into health care so that their relatively inexpensive health care needs could help to compensate for the more expensive care of those who are older, or who have pre-existing conditions.
  • The end result of the individual mandate is that an estimated 32 million Americans who have no health insurance will get it.
  • The federal government will subsidize insurance for those who cannot afford health insurance for the time being.
  • There are many other provisions of the law, including the expansion of Medicaid, the establishment of insurance exchanges where consumers can “shop” for health insurance, prevention of insurance companies from dropping patient coverage capriciously, and payment for preventive medical care.

 How Will The ACA Affect the Physician Assistant Profession?

The ACA will significantly increase the number of Americans who have health care – this represents a major expansion of the health care industry.  No one is sure yet how all of these 32 million new patients will be cared for.  If you’ve gone for a check up lately, you’ve seen how busy doctors are already.

Projection #1: The already huge demand for PAs will increase dramatically.

Why?   Doctors cannot fill this provider gap.  But, you might wonder, “Can’t they churn out more doctors by opening more medical schools, just as they are doing with PAs?”

In a word, no.

The shortage of doctors isn’t about not having enough medical schools.  It has to do with a different bottleneck.  What limits the speed of doctor training is the residencies that they are required to complete after medical school.  Ironically, the money that funds residencies comes from Medicare – one of the already financially troubled programs that the federal government is working on with this law.  For this reason, no one expects much increase in the number of doctors in the coming decade.

Physician assistants, on the other hand, do not do residencies.  They graduate from PA school and go to straight to work.  Their education is far less expensive.  Although there is a nearly 20-year-long projected shortage of physician assistants, the rate at which new PAs are being licensed is increasing annually, as new PA programs are established.  Even better, the new health care reform law provides money for new physician assistant training programs.  The end result?  PAs are in a much better position than doctors to fill the health care gap.

Projection #2: More than ever, PAs will be needed for primary care and pediatrics

When you speak of preventive health care – things like vaccinations and annual check ups which under the new law will now be covered – you’re talking about primary care and pediatrics.  For the profession as a whole, this is good news.  All PAs are trained as generalists, even if they end up specializing after their schooling.  But if you were hoping to work in a specialty such as ophthalmology or surgery, this news might not benefit you much.  Specialists will still be needed.  But supply and demand may begin to improve the salary of those in primary care, and this could mean slowing of the salary increases for those in specialties.  One of the aims of the reform is to reduce the overall amount of expensive (and sometimes unnecessary) specialist care by replacing as much of it as possible with primary care.  But if your heart is set on a particular specialty, don’t panic; equalizing primary care and specialist pay could take a long time, if it happens at all.

Projection #3: There will be less need for PAs in specialties like cardiology, pulmonology, and endocrinology.

These are specialties that in addition to providing specialist care, often provide primary care as well.  If you have severe emphysema, for example,  it sometimes makes sense to have a pulmonologist provide your general medical care, since most of your visits are likely relate to your lung disease.  But with more primary care and preventive care being delivered and increased scrutiny about what problems are sent to specialists, this practice will become less common.  There are likely to be fewer patient visits to see these specialists, and therefore less demand for PAs in these areas.

Projection #4: More than ever, PAs will be needed in mental health.

Traditionally, insurance coverage for mental health care has lagged far behind that of illnesses like diabetes and high blood pressure, but that is likely to change.  Recently passed “parity” laws make mental health conditions equivalent to those that have been traditionally considered more “medical,” and they will be paid for equivalently as well.  Not only will mental health be treated more like a physical illness, most of those with mental illnesses will finally have health insurance. If you have an interest in psychiatry, the world will be your oyster.

Projection #5: Emergency medicine will change for the better and the worse. 

With a new emphasis on primary and preventive care, and growth in health care overall, there will be fewer ER visits from patients who need help with chronic conditions like arthritis and allergies.  These patients will still have chronic health problems, but they will have better access to resources that are more appropriate than the emergency room.  If you work in the ER or plan to, this probably sounds great.  But what isn’t so clear is how these changes might affect the overall number of ER visits per year, and therefore the demand for Emergency Medicine PAs.  The new law eliminates some of the penalties for patients going to out-of-network emergency rooms, and generally makes ER access easier.  But again, the hope is for fewer visits from patients with non-emergent conditions.  The hope is that emergency care might slowly return to its original purpose: preventing death and disability, and not its too-frequent one: 24/7 pharmacy and outpatient care.

Why Do You Need To Know This?

Even if health care policy and politics doesn’t interest you much, you would do well to learn about it.  This is great material for a PA school interview question, and understanding these issues can make your motivation to become a PA more convincing.  What’s more, this is going to be your field – the more you know, the more you can influence it.