The Democrats in the House unveiled the outlines of their healthcare reform bill on June 9 that includes a government-backed health plan option. The Dome of the US Capitol BuildingAlready powerful lobbies are lining up against this possibility, with the American Medical Association (AMA) and the America's Health Insurance Plans (AHIP), a lobbying arm of the health insurance industry. The political forces are aligned, with the President and Democratic allies calling for a public option in order to expand coverage and opponents charging that a public option would “dismantle employer-based coverage and significantly increase costs for those who remain in private coverage.” But lessons from Massachusetts and projections from studies conducted by the insurance industry itself tell us that the likeliest scenario will depend on the plan details.

AHIP and Republicans in Congress have pointed to a study conducted by Lewin Group, a consultancy owned by UnitedHealth Group, projecting that a public health plan would result in 119 million Americans moving to a public plan option. Public plan opponents use this statistic to support their case that a public option would drive private plans out of business. The Lewin study, however, is not definitive in that those numbers are dependent on how the public plan is designed. If the public plan is open to all participants and provides lower premiums, for instance, this number could prove to be true. If the plan is designed for uninsured individuals and small businesses only, or if premiums match private options, this number would be significantly less.

Another concern voiced by the AMA is that the government could force doctors who take Medicare now to accept patients who are covered under the public plan. The AMA is concerned that “many physicians and providers may not have the capability to accept the influx of new patients that could result from such a mandate.” The influx of new patients would hit primary care physicians first and there is a growing shortage of PCP's in many areas of the country. In November 2008, The American College of Physicians released a whitepaper noting that from 1997 to 2005, the number of U.S. medical graduates entering family medicine residencies dropped by 50%.

While the declining number of primary care physicians is an issue, other factors are also contributing to patient access. An article in the New York Times reported in April 2009 reported that the number of primary care physicians accepting Medicare is declining due to lower reimbursement rates and the paperwork requirements. The article cited that a survey conducted in Texas found that while 58 percent of the state’s doctors took new Medicare patients, only 38 percent of primary care doctors did.

We know from a 2008 study published in Health Affairs that the same issue was found in Massachusetts, where the state has successfully increased coverage to all but 2.6 percent of residents.

About one in five adults in Massachusetts reported that they were told that a doctor's office or clinic was not accepting patients with their type of coverage or was not accepting any new patients. Difficulties finding a provider were much more common for lower-income than higher-income adults (29 percent/15 percent) and for adults with public and other coverage than those with private coverage (32 percent/16 percent). Adults with public and other coverage were much more likely than those with private coverage to be told that the provider was not taking their type of insurance (24 percent/7 percent) and to face closed panels (24 percent/13 percent).

The study indicated that lower acceptance rates could be attributed partially to lower reimbursement rates. The result in Massachusetts was that emergency room usage for nonemergency conditions did not decline during the 2006-08 due to the lack of available doctors.

An important lesson we can derive from Massachusetts and Medicare is that expanding coverage without addressing primary care physician availability will not likely solve the problem of access to an important part of the healthcare system. The plan must involve incentives for primary care physicians to participate. In addition, the politics of the situation as well as practical considerations will likely result in public health plan coverage for only a subset of the uninsured population at first.