The Case for Seeing a Nurse Instead of a Doctor

Eight million more Americans just got insurance, many for the first time. Who will treat them all? Nurses.

America is changing—it’s getting grayer, fatter, and more medicated. But luckily, it’s also getting a lot more insured.

A few days ago, the Obama administration announced that eight million people signed up for health insurance under the Affordable Care Act, but that’s just the beginning.

Partly as a result of the ACA’s expansion of Medicaid, the health insurance program for the poor, Medicaid enrollment is projected to grow by 11 or 12 million each year until 2024.

So who is going to treat these people?

There’s no way to know how doctors will respond to the surge in demand. Some pundits are predicting bread lines for biopsies, particularly in areas that already face a shortage of doctors. Others think more doctors will refuse to see new Medicaid patients, as already about a third do. Another theory is that doctors will increasingly assign routine tasks to nurses and physician assistants, thereby freeing themselves up to do more complicated procedures.

According to a new study, that third option might be the best way to go.

We don’t know which of these paths any given doctor will choose when faced with a wave of newly insured Obamacare patients. But a new study from the National Bureau of Economic Research tracked what happened when dentists in several states were faced with the same quandary.

Dental insurance isn’t a mandatory benefit for adults under Medicaid, but some states provide it anyway. The NBER paper looked at the way dentists adjusted to an influx of Medicaid patients in states where the program was expanded to include dental care for adults, using responses from the Survey of Dental Practices collected between 1999 and 2011.

What they found should come as a relief for those worried that the ACA will lead to long waits for doctors or fewer doctors participating in Medicaid.

As it turns out, in states that added the dental benefit, more dentists started participating in Medicaid—there was an average increase of about 15 percent.

Medicaid dental coverage by state (dark gray) and year (NBER)

As we might expect, more people also wanted to see the dentist in those states. To squeeze everyone in, dentists worked an extra half hour per week, their appointments with each patient became about a minute shorter, and patients had to wait an average of an extra half-day for an appointment. The dentists also made more money—between $15,477 and $20,480 more a year.

But the study also found that while the dentists saw about three additional patients per week, their hygienists saw four or more extra patients. And that’s the key to how the dentists managed the uptick in patients: They just relied on their assistants more.

Even though dental hygienists are trained to do everything from teeth cleanings to x-rays to, in some cases, diagnosing tooth problems, only about two-thirds of the dentists in the authors’ sample employed a hygienist. In states that added the Medicaid dental benefit, however, dentists were more likely to have hygienists working for them.

What’s more, states that allowed the hygienists to practice more like regular providers—with greater autonomy and with the ability to bill Medicaid directly—were less likely to see an increase in wait times with the Medicaid expansion. It seems like dentists were simply shuttling some of their new patients directly to the hygienists, and the states that made that process easier had the smoothest adjustment.

This study presents a strong argument for more liberal “scope of practice” regulations. Allowing physician assistants and nurses to take on more responsibility would help ease the burden on primary care physicians when Americans take their brand-spankin new insurance cards for a spin. Nurse practitioners, for example, can already practice independently in 16 states, but others require them to get sign-offs from doctor-supervisors as they treat their patients.

Attempts at streamlining the state laws have gotten tangled in fights between nurse lobbying groups, who say nurse practitioners are just as competent as doctors, and doctor lobbying groups, who say that their advanced medical training makes them better providers. We’ll see if doctors’ groups stick to that position when faced with more patients, less time, and too few other doctors available.

The surge in insured people from Obamacare very well might strain doctors’ ability to see everyone. But if the experience of these dentists is a guide, that might simply mean we’ll start getting our basic medical needs met by nurses, physician assistants, and other non-doctor doctoring types.