Richard W. Dehn, MPA, PA-C, DFAAPA
As this blog is being written, Congress and the President-elect are preparing to defund key components of the Affordable Care Act (ACA), which would cripple major parts of the legislation and lead to substantial changes to the American healthcare delivery system. The current plan is to defund the financial underpinnings of the ACA using the budget reconciliation process, and eventually replace it
at some time in the future with an undetermined alternative. Whether this will actually happen is difficult to predict but let’s assume for the moment this is indeed future course of events.
The most likely first action aimed at repealing the ACA will be the elimination of the taxes and other revenue sources that are fundamental to the ACA’s operations. These revenue streams fund two major pillars of the ACA: subsidies that make it possible for many Americans to buy health insurance plans, and the federal funding that gave the states the ability to greatly expand the number of patients covered by Medicaid. Current projections in the news media estimate that this action alone will result in a loss of health insurance for 20 million Americans who recently had gained it.
JAAPA published an
editorial by Editor-in-Chief Reamer L. Bushardt, PharmD, PA-C, DFAAPA, that covers the nuts and bolts of what the repeal of the ACA might entail. If you haven’t read it, I highly suggest you do.
The PA profession has experienced remarkable and consistent growth over the last two decades. In fact, since the 1970s, there have been only two notable time periods where growth in the profession was not vigorous. The first occurred beginning in 1980 with the release of the Graduate Medical Education National Advisory Committee (GMENAC) report that predicted physician surpluses. That period lasted until the managed care delivery model gained popularity among third-party payers beginning in the late 1980s. The second occurred in the late 1990s, and was shorter in duration with less effect than its predecessor. My opinion was that it was caused by provider geographic maldistribution and provider demand changes resulting from the managed care funding model reaching a critical mass that produced reduced provider demand. The GMENAC years were notable in that the report caused a retrenchment in all medical education (including reductions in medical school and GME enrollment) such that it was common to hear discussions of whether the PA profession had a future. No data are available from that time that would address PA supply and demand or salaries; however, during this time, PA enrollment was flat and almost no new PA programs were established.1 In contrast, the stagnant PA demand period of the late 1990s was very mild, at most lasting only a few years, mostly occurred only on the East Coast, affected primarily new graduates and those changing jobs who were unwilling or unable to move to new geographic locations, didn’t affect PA program or enrollment growth, and resulted only in stagnant growth in new graduates’ starting salaries from 1997-1998.2
Multiple factors obviously account for the profession’s impressive growth over the last two decades—the emergence of healthcare teams, increasing demand for healthcare from an aging population, and an increase in the expectation that citizens have a right to healthcare. Since the mid-1990s, there has been a persistent interest in increasing the number of PA programs and students, mostly by educational institutions that have noticed the profession’s growth and the societal factors driving it. In the last decade, many other healthcare professions have observed these factors and also concluded that more providers are needed. Allopathic and osteopathic medical schools and NP programs have also increased in number and enrollment. With the election of Barack Obama in 2008, the consensus was that healthcare would be reformed with a system that would provide medical care for most of those uninsured at the time, and that this was simply going to be yet another huge factor that would require an even bigger future medical workforce. Over the last 8 years, I have spoken to dozens of educational and healthcare system administrators who indicated that from their perspective they saw no end to the future demand for healthcare providers, and in particular PAs.
However, even before the 2016 election, some had begun to predict an end to current high demand for healthcare providers. Medical schools, PA programs, and NP programs have experienced problems providing clinical training sites for increasing enrollment, indicating that there is likely a ceiling to the student capacity of the current healthcare delivery system. Additionally, some workforce experts had begun to publish warnings of an impending surplus of providers—these two articles were written and published before the 2016 election, when repeal of the ACA was considered unlikely by most.3,4
Over the last 6 years, the healthcare industry has been ramping up to provide for patients using the ACA as a blueprint—in fact, vast amounts of money have been invested in a long-term effort to reshape the American healthcare delivery system. Now, many of these investments could be abandoned before being completed. The exit of 20 million patients from the healthcare delivery system will be a substantial event with many unpredictable and likely unintended consequences. Of course, from our pre-ACA experience we know that some of these patients won’t really exit the healthcare system; they will just end up in the ED. Any many will just simply avoid seeking care as long as possible. So, primary care clinics will need fewer providers, as will many areas of hospital care. However, a boom is likely in emergency medicine jobs. With substantially fewer patients in the system overall, however, the number of providers needed probably will decrease, and this decrease could happen relatively quickly as demand rapidly diminishes in response to patients losing their healthcare coverage.
I’m of the opinion that our education systems were on track to meet and possibly exceed the need for healthcare providers sometime in the next 5 years. I anticipated that the increasing scarcity of clinical training sites would be the limiting variable that would modulate the current enrollment growth to eventually adjust to the supply-demand curve of the future. Now, considering the unexpected factor of the defunding and repeal of the ACA following the 2016 election, demand for medical providers may actually suddenly decrease, moving the point of market saturation closer to the present. Could the PA profession be facing its third period of growth retrenchment?
1. Simon A, Link M, Miko A. Thirteenth Annual Report on Physician Assistant Educational Programs in the United States, 1996-97. Association of Physician Assistant Programs, May 1997.
2. Simon A, Link M, Miko A. Fifteenth Annual Report on Physician Assistant Educational Programs in the United States, 1998-99. Association of Physician Assistant Programs, May 1999.
3. Salsberg E, Quigley L.
Are we facing a physician assistant surplus?
4. Hooker RS.
When will physician assistant supply exceed demand?
Richard W. Dehn is a professor in the College of Health and Human Services at Northern Arizona University's Phoenix Biomedical Campus, chair of the university's Department of Physician Assistant Studies, and a professor in the Department of Biomedical Informatics at the University of Arizona College of Medicine in Phoenix. The views expressed in this blog post are those of the author and may not reflect AAPA policies.