Forecasting the impact of the Affordable Care Act requires researchers to head into the unknown.
“Let me start saying that nobody really knows what the impact will be. Everyone is estimating and making assumptions,” said Ignacio Navarro, assistant professor at California State University Monterey Bay and a researcher helping Monterey County forecast the potential impact of the ACA.
“The methodologies are new. People are coming up with ways to count this,” he added.
For their part, Navarro and other researchers from CSUMB used Census data and surveys of doctors, emergency rooms and clinics to estimate the number of new doctors needed in Monterey County safety-net clinics once the ACA goes into full effect.
They found that countywide, clinics need 10 more doctors to handle new patient demand sparked by expanding Medi-Cal and subsidizing insurance for low-income people. Currently those centers have about 36 full-time physicians providing care to 85,027 patients.
Critics said the numbers reflect a problematic imbalance. There are already too few to assist those currently receiving Medi-Cal or otherwise using safety net clinics that help the uninsured, said Carlos Ramos, a member of a coalition hoping to ensure the transition to the Affordable Care Act goes smoothly.
If the report had included patients’ perspectives, he said, researchers would have known that.
“The lack of engagement just says there is a disconnect between what people experience and the report,” Ramos said.
In the report, researchers assumed that each doctor would have about 2,000 patients. The national standard is 1,500 patients per doctor, according to the report. Using those numbers, researchers Kim Judson and Navarro estimated the number of doctors needed to deal with new demand.
According to the numbers in the study, there are currently 2,349 Medi-Cal or uninsured patients for every doctor who works in a facility that caters to those patients. That’s well over the patient load recommended in the report.
“Are we kind of ignoring existing capacity needs?,” Monterey County Supervisor Jane Parker asked the research team at a recent public meeting.
At a Seaside meeting on the report, residents said it sometimes takes months to see a physician.
“People felt that sometimes patient experience wasn’t in accordance with providers perception of being able to get appointments,” Navarro’s co-researcher and fellow CSUMB professor Judson said, recounting the meeting. “There were concerns that our estimates were too low, that we didn’t look at the under-insured.”
Resolving the discrepancy between provider and patient perception will need to be part of the next round of research, she said.
Navarro and Judson estimated that as many as 55,000 people could be newly insured under the Affordable Care Act, either through Medi-Cal or by the California Health Exchange subsidized coverage.
“There are some unknowns in forecasting,” Navarro cautioned. “How many of these new individuals will seek services in the clinics? No one knows exactly the proportion who will enroll and seek services, even though there are efforts right now to try to enroll as many people as possible.”
In one likely scenario, only about 75 percent of the newly insured would be new patients. The other quarter of the newly insured have already been in clinics in Monterey County seeking care as uninsured patients and thus would not count as “new” demand for health care.
And under that scenario, Navarro said, only 50 percent of those eligible for new services end up at the safety-net clinics. That number was drawn from research done in Berkeley and other places, which examined the number of people who took up private insurance, and assumptions about the percentage of patients who will seek providers.
But the Affordable Care Act is completely new, Navarro said.
In order for the program to work, healthy people must sign up for health insurance. To make that happen, Navarro noted, an unprecedented campaign encouraging people to sign up for insurance programs and Medi-Cal is underway. If the campaigns work as officials hope, assumptions about health insurance and Medi-Cal enrollment based on past behavior will prove useless.
“This is new and unknown,” he said. “There’s never been a push to enroll people in Medicaid. We may have some people who would qualify now but don’t enroll that do enroll after hearing ads.”
If that estimate is off and every person with new access to care taps into the program, the county would need at least 25 more doctors, a number existing facilities can’t even accommodate.
According to Judson and Navarro’s survey, many Monterey County clinics have plans to expand. Those existing plans and existing space are enough for the 10 extra doctors the report suggests the region will need.
Clinica de Salud Del Valle de Salinas already operates a dozen health care clinics, including vision and dental care, in the region. They hope to help bring the county’s services up to demand, officials there said.
The new doctors will work for clinics including those run by Natividad Medical Center, Monterey County and others, as well as Clinica de Salude del Salinas Valley.
However if the critics are right, the expanded capacity coupled with increase demand may only continue the existing backlog. It’s a topic Navarro hopes to tackle in his next round of research.
He’d also like to do further research on the estimated more than 20,000 undocumented workers in the county who don’t have health insurance and won’t be covered by the Affordable Care Act.
The most recent study was the first to find a methodology, using Census data, to estimate – even if imperfect – the size of the population that is both uninsured and undocumented, Navarro said.
How this group accesses medical care will impact safety-net providers in Monterey County, who likely won’t be reimbursed for providing those services.
Navarro would also like to continue to probe findings that, contrary to most people’s expectations, the uninsured use emergency rooms for health care much less than those on Medi-Cal.
Is that because Medi-Cal patients are encouraged to use emergency rooms for follow up visits or simply have higher risk factors? Does Monterey County’s large undocumented and uninsured population account for relativity small number of uninsured emergency room visits? No one knows.
“The research answers a lot of questions,” Navarro said. “But it creates a lot of questions, too.”
And, it will continue, as officials try to develop an image of where Monterey County is now to be ready for implementation of expanded health coverage offerings in 2014.
The next step will likely be the patient survey exploring concerns over existing capacity from a patient perspective.