Will There Be Enough Providers to Meet the Need

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ACA Implementation—Monitoring and Tracking
Cross-Cutting Issues:
Will There Be Enough Providers to Meet the Need?
Provider Capacity and the ACA
November 2012
Ian Hill
The Urban Institute
Urban Institute
W
ith support from the Robert Wood Johnson Foundation (RWJF), the Urban Institute is
undertaking a comprehensive monitoring and tracking project to examine the implementation
and effects of the Patient Protection and Affordable Care Act (ACA) of 2010. The project began in
May 2011 and will take place over several years. The Urban Institute will document changes to the
implementation of national health reform in Alabama, Colorado, Maryland, Michigan, Minnesota,
New Mexico, New York, Oregon, Rhode Island and Virginia to help states, researchers and policymakers learn from the process as it unfolds. This report is one of a series of papers focusing on
particular implementation issues in these case study states. In addition, state-specific reports on
case study states can be found at www.rwjf.org and www.healthpolicycenter.org. The quantitative
component of the project is producing analyses of the effects of the ACA on coverage, health
expenditures, affordability, access and premiums in the states and nationally. For more information
about the Robert Wood Johnson Foundation’s work on coverage, visit www.rwjf.org/coverage.
INTRODUCTION
M
uch of the success of Affordable Care Act (ACA)
will hinge on issues surrounding access to care.
Furthermore, the responses to health care reform by
providers, public programs, and payors will directly
affect access, coverage and, ultimately, the sustainability
of reform. The potential entry of millions of newly
insured individuals into health insurance coverage will
undoubtedly strain the capacity of provider systems,
and critical questions surround the extent to which
these systems will be able to respond to the expected
new demand by providing timely access to appropriate
care. This brief will explore this complex issue primarily
drawing on information gathered from 10 states1
participating in the Robert Wood Johnson Foundation’s
health reform implementation monitoring and tracking
project. Discussion is divided into four sections:
•
Background information on the challenge facing the
nation—in terms of expected demand for care among
newly insured, the capacity of provider systems to
respond to this demand, the supply and distribution
of providers, and how all these factors vary state to
state—is presented first.
•
Second, the brief reviews and summarizes key
provisions contained in the ACA designed to address
provider supply and access to care issues.
•
Third, it presents new information on how states are
coping with (or planning to address) the challenge
and describes strategies to increase provider
reimbursement, expand the capacity of community
health centers, enhance the primary care workforce,
and consolidate, redesign, and reform health delivery
systems in an effort to meet complementary goals of
controlling costs, improving quality, and improving
access to care.
•
The brief concludes by examining the outlook for the
future.
THE CHALLENGE FACING THE STATES
P
rior to the Supreme Court’s ruling on the
constitutionality of the ACA—and before the Medicaid
expansion component of reform was ruled optional for
the states—estimates were that upwards of 30 million
individuals would gain coverage under the reform law,
either through Medicaid or subsidized coverage in health
ACA Implementation—Monitoring and Tracking: Cross-Cutting Issues
2
insurance exchanges.2 The size of coverage increases
under Medicaid, however, vary considerably by state. For
instance, states like New York, with a history of generous
Medicaid eligibility, anticipate that there will be only about
a 15 percent increase on top of current enrollment. In
contrast, Alabama, Colorado and Virginia—states with
historically restrictive income eligibility rules—could
see their programs grow by up to 48 percent.3 Other
provisions of the law will also add to coverage; for
example, Alabama will see a 63 percent reduction in the
number of uninsured when all sources of new coverage
are considered.
45,000 primary care physicians in the next decade.4 But
most studies of provider capacity focus on doctors and
not other types of primary care providers, such as nurse
practitioners and physician assistants—which currently
make up one-quarter of the primary care workforce—and
data show that the pace of growth in these professions
has outpaced population growth in recent years.5 Of
note, a recent synthesis of the literature suggested that
the sheer numbers of providers may be adequate, but
that it is the manner in which they are deployed that is
insufficient. That is, if health systems did a better job of
utilizing existing resources through more efficient practice
models and better coordination, they could better meet
patients’ needs.6
“…most stakeholders with whom we spoke
during our site visits were very concerned
about provider capacity to serve the newly
insured.”
Debates on sufficiency aside, most analysts agree
that the current supply of providers is mal-distributed.
Research has shown that physician shortages are more
likely in rural and frontier areas than urban/suburban
areas, in low-income communities, and in communities
with higher proportion of minority populations.7 Among
our study states, for example, New Mexico has 32 of its
33 counties designated as either Health Professional
Shortage Areas (HPSAs) or Medically Underserved Areas
(MUAs);8 in Alabama, this is true in 60 of the state’s 67
counties.9
Regardless of this variation, most stakeholders with
whom we spoke during our site visits were very
concerned about provider capacity to serve the newly
insured. The focus of this concern was mainly on primary
care, but shortages of specialists and behavioral health
providers were also frequently mentioned.
Interestingly, however, there is considerable
disagreement among health policy researchers and
provider organizations on the extent of the problem.
The common belief is that there are simply not enough
providers across the country to serve the population; for
example, the American Association of Medical Colleges
projects that the United States will face a shortage of
There are also new data that suggest that problems of
mal-distribution will get worse before they get better.
According to the Center for Studying Health System
Change, states currently with the smallest number
of primary care providers per capita (in the South
and Mountain West) are projected to have the largest
increases in Medicaid enrollment as a result of the ACA.10
Meanwhile, those states with the largest number of
primary care providers per capita (in the Northeast) will
see only modest Medicaid enrollment increases.11
ACA PROVISIONS OF RELEVANCE
I
t is fair to say that the ACA focused considerable
renewed attention on primary care, emphasizing that
it is critically important to individuals’ health, and that
it should be supported and strengthened in the U.S.
reformed health care systems if we are to achieve the
goals of lower cost, improved quality, and expanded
access. Indeed, a great many provisions in the law
were designed to promote primary care and bolster the
primary care workforce.
Some components of the law were focused on payments
to providers, with the goal of creating incentives to
promote increased participation in public programs
among existing providers. Insufficient provider
participation in Medicaid—a problem in many, if not
most states—is often attributed to low reimbursement
rates; indeed in 2008, a study found that Medicaid
payments for primary care services were 66 percent
of Medicare rates.12 In response, the ACA increased
Medicaid payments for primary care services provided by
ACA Implementation—Monitoring and Tracking: Cross-Cutting Issues
3
physicians in family medicine, general internal medicine,
pediatric medicine, and subspecialties who provide
primary care services, to 100 percent of Medicare rates.13
This rate bump, however, only lasts for two years—2013
and 2014.14 Despite its short duration, some have
estimated that the number of physicians willing to accept
new Medicaid patients could increase by up to 11 percent
as a result of this ACA provision.15
Other parts of the ACA provide increased funding to
safety net providers that traditionally serve low income
individuals and families. For example, the reform law
provides $11 billion for Federally Qualified Health Centers
“…the ACA focused considerable renewed
attention on primary care, emphasizing
that it is critically important to individuals’
health, and that it should be supported and
strengthened in the U.S.’s reformed health care
systems if we are to achieve the goals of lower
cost, improved quality, and expanded access.”
providers—including primary care physicians, nurse
practitioners and physician assistants—by 2015 with
medical school loan repayment, in return for providers’
commitments to practice in underserved areas for a given
period of time.18 Moreover, the law includes funding for a
variety of workforce training and development initiatives
for doctors, nurses, and other health professionals.
In particular, the Prevention and Public Health Fund
allocates $5 billion between 2010 and 2015, and an
additional $2 billion each year after 2015, to increase the
number of primary care residency positions, support
physician assistant and nurse practitioner training in
primary care, and establish nurse-managed health
clinics that would assist with the training of new nurse
practitioners.19
Finally, there are many ACA provisions that, while not
directly focused on provider reimbursement, supply,
or training, do promote reforms in the way health care
services are delivered. For many of these, the goal
is to emphasize the efficient and effective provision
of primary and preventive care by supporting grants
and demonstration projects for Accountable Care
Organizations, Collaborative Care Networks, and Patient
Centered Medical Homes, among others.20
(FQHCs) over the five year period from 2011 to 2015.16,17
The ACA also addresses primary care workforce and
supply issues, specifically by increasing funding for the
National Health Service Corps (NHSC) by $1.5 billion
over five years. The goal is to assist an additional 15,000
The following section follows the above-mentioned
framework to describe how the study states were
planning for and responding to provisions in the ACA
related to primary care provider reimbursement,
investments in FQHCs, bolstering the primary care
workforce, and working to reform and improve health
care delivery systems.
STRATEGIES TO ADDRESS PROVIDER SUPPLY
AND ACCESS
During our interviews in the 10 study states, we asked
state officials, policy-makers, providers, insurers, and
other stakeholders about the access to care situation
in their states, their perceptions of potential effects
of the ACA’s provisions designed to bolster provider
participation and supply, and any strategies states were
implementing in response to the law to improve access to
care and health system performance. Insights we gained
are summarized below.
1. Increasing primary care
reimbursement
When we spoke with state officials about whether they
had increased Medicaid provider reimbursement in
recent years or were planning to in response to the
ACA, they were quick to point out that, due to the Great
Recession and resulting severe budget pressures,
most states had been cutting reimbursement rates not
increasing them. Maintenance of effort rules embedded
in the ACA and the American Recovery and Reinvestment
ACA Implementation—Monitoring and Tracking: Cross-Cutting Issues
4
Act (ARRA) took eligibility cuts off the table, in terms of
cost containment strategies, leaving payment policies as
one of the few levers left available for program savings.
Even Maryland, which had passed state rules to bring
its Medicaid rates to parity with those of Medicare, had
postponed implementation of the fee increases due to
budget deficits.21
To be sure, virtually all the stakeholders with whom we
spoke welcomed the ACA’s primary care fee increase
and, in particular, the 100 percent federal funding
provided for the increase. But none were committed to
extending these higher fees beyond 2014, nor were many
very optimistic that a temporary fee hike would have
much effect on provider participation in Medicaid, much
less the supply of providers in the state. At best, most
informants believed that the rate increase would help to
maintain providers’ participation in the program or stem
departures from the program.
2. Increasing funding to Community
Health Centers
Further expanding the capacity of community health
centers was viewed as a more promising, long-term
solution to access pressures, according to state officials
and other stakeholders with whom we spoke. The past
decade has been kind to FQHCs, as annual federal
funding grew from about $1.2 billion in 2001 to $2.2 billion
in 2010 (prior to passage of the ACA).22 Once again, the
ACA expanded funding by another $11 billion over five
years, roughly doubling annual funding levels.
Across the board, FQHC representatives, state
primary care associations, and other health
system stakeholders opined that the ACA was
a clear “win” for these safety net providers.
Across the board, FQHC representatives, state primary
care associations, and other health system stakeholders
opined that the ACA was a clear “win” for these safety net
providers. More broadly, they saw FQHCs as very wellpositioned to play a key role in meeting new demand for
services among individuals and families gaining coverage
under health reform. Health center administrators in
Colorado, for example, said they expected to double their
capacity in the next few years, not only due to increases
in federal grants, but also because 40 percent of their
clients are now uninsured and many will likely to qualify
for expanded Medicaid. With Medicaid coverage, these
clients would carry with them advantageous cost-related
prospective payment reimbursement.23 FQHCs are
also strong examples of the primary care medical home
model, and many we spoke with are busy enhancing that
model, building care coordination capacity in anticipation
of serving new populations.
There were, however, some concerns expressed that
FQHCs should not, as a side effect of the ACA, lose focus
of their role as a safety net provider for the uninsured.
FQHC managers and advocates for the poor in many
states reminded us that 20 million or more individuals will
not get coverage under the ACA and FQHCs will need
to maintain their ability to serve these most vulnerable
groups. Indeed, serving persons with incomes up to 400
percent of the poverty level may not be consistent with
the mission of a safety net system.
3. Expanding the primary care
workforce
We did not see an abundance of activity in the study
states aimed at expanding the supply of primary care
providers. Still, there were interesting and promising
efforts in some states. In Michigan, for example, the
emphasis was on long-term strategic planning. There,
Governor Snyder tasked the state Department of
Community Health to develop a new State Healthcare
Workforce Plan.24 In three of the study states—Colorado,
New Mexico and Oregon—we learned of state programs
that essentially mirror the federally-funded. These
programs all offer medical school loan forgiveness in
return for commitments to practice in underserved areas.
Interestingly, they do so not only for physicians, but also
for nurse practitioners, physician assistants, and nurses.
Colorado’s program is noteworthy due to its funding
base—which is primarily philanthropic rather than statefunded—as well as for its size—the program provides
loan repayment for 200 health professionals, matching
the size of the federally-funded NHSC program that also
supports 200 primary care providers in Colorado.25
Efforts to expand “scope of practice” laws—that broaden
the scope of services non-physician providers can
provide independent of physicians—were often stymied
by the medical professions, according to key informants
in most of our study states. Still, in Virginia, legislation
was passed in the 2012 session that will allow nurse
practitioners to practice in separate locations from their
ACA Implementation—Monitoring and Tracking: Cross-Cutting Issues
5
team physician, such as free clinics, community health
centers, and nursing homes.26 Minnesota policy-makers
created a new certification level for Emergence Medical
Technicians, called Community Paramedicine, which
will allow these providers to render certain treatments
to chronically ill individuals in their homes to avoid
costly ambulance and emergency room (ER) services.
Minnesota also became only the second state to certify
the practice of Dental Therapists, who are mid-level
practitioners working under the supervision of licensed
dentists.27
Finally, we observed a few examples of what might be
called “feeder” programs designed to orient students
and young people to possible careers in primary care
medicine. In Alabama, a state with large underserved
rural areas, there are two small but interesting efforts.
First, the Rural Health Scholars program offers summer
school sessions for high school students featuring
coursework on health careers in rural areas. Second,
the Minority Rural Health Pipeline program targets
undergraduate college students from underrepresented
communities and provides academic financial assistance
to these students as they complete their pre-med
requirements.28
4. Improving efficiency, quality and
access through health system reforms
Perhaps the most exciting set of strategies about which
we learned were those designed to reform health delivery
systems in ways that offer promise to improve access
by enhancing the efficiency, coordination, and quality of
service delivery.
In the private sector, we consistently heard of increasing
consolidation among physician practices, with solo
providers and small groups merging with larger
groups. We also heard of the growing trend of hospital
employment of physicians—with such arrangements
established for up to 50 percent of all physicians in states
like Oregon and Virginia.29 For doctors, the explanation
for this trend had more to do with a desire to “get out
of the business side” of health care, avoid having to
individually shoulder the burden of adopting electronic
health records, benefit from hospitals’ market strength
in negotiating reimbursement rates, and seeing a “safer”
and more stable future in the employ of hospitals.
For hospitals, though, we learned that the aim was to
become larger, with more primary care capacity to
provide a steady base for referrals.
Beyond this, whether driven by the ACA or a more
fundamental desire to become more integrated, hospitals
described how greater primary care capacity would
enable them to develop medical home capacity, use
a mixture of physician and non-physician providers
(like nurse practitioners, physician assistants, and care
coordinators) to more efficiently provide care, and better
compete in reforming health systems. These hospital
“Perhaps the most exciting set of strategies…
were those designed to reform health delivery
systems in ways that offer promise to
improve access by enhancing the efficiency,
coordination, and quality of service delivery.”
providers, by virtue of their scale and large resources,
were relatively better equipped (compared to physicians)
to adopt such structural changes. Already integrated
systems—like Kaiser Permanente and Denver Health
in Colorado—told us how they are increasingly using
telemedicine to serve rural and remote populations
and text messaging as a tool for prevention, reminding
patients to take their medicines, come in for physical
exams, and keep their appointments. Providers in these
systems even hold “e-visits” with their patients, meeting
via Skype to discuss needs and progress when a face-toface visit is either impossible or not required.30 Similarly,
the larger health systems in Virginia, such as Sentara and
VCU, are developing telemedicine and transport services
to compensate for provider shortages and increase their
capacity to serve rural areas.31
In the public sector, we witnessed considerable activity
in Medicaid programs, where statewide initiatives were
playing out at the regional and local levels with the
complementary goals of containing costs, improving
quality, and increasing access to care. For example,
two of our study states—Colorado and Oregon—are
implementing Accountable Care Organization-type
initiatives. In addition, Alabama is developing a patient
centered medical home initiative, while Maryland is
establishing a consumer-operated and oriented plan
(CO-OP).
•
Colorado’s Accountable Care Collaboratives (ACCs).
Launched in 2011, Colorado’s ACCs represent
a quasi-managed care model aligned with ACO
principles. Seven Regional Care Collaborative
organizations have been established across the
state, each working with a team of Primary Care
Medical Providers within their region, all supported
ACA Implementation—Monitoring and Tracking: Cross-Cutting Issues
6
by a Statewide Data Repository that collects
utilization and cost data and monitors quality. Each
of these three entities receives a per-member,
per-month (PMPM) payment from Medicaid, while
providers also receive fee-for-service reimbursement
tied to incentives for reducing ER visits, imaging,
and hospital readmissions. The state will introduce
gains-sharing and a hold-back next year, and hopes
to introduce global payments to further promote
efficiency and effectiveness in years to come.32
•
•
Oregon’s Coordinated Care Organizations (CCOs).
In Oregon, health plans, hospitals, physician groups,
and counties will merge at the regional level to form
CCOs that share responsibility and risk for the full
medical, dental, and behavioral health needs of
patients. CCOs are being designed to work under
global payment arrangements and will be held
accountable for outcomes based on performance
benchmarks. The state hopes that CCOs will alleviate
the impact of sharp increases in Medicaid enrollment
on primary care capacity by streamlining and
improving the efficiency of the health care system.
Implementation of the CCO model is slated for the
end of 2012.33
Alabama’s Patient Care Networks (PCNs). Modeled
after the PCN initiative in North Carolina, Alabama’s
PCN was launched in 2011 and is now present in
three regions of the state. Networks of primary care
physicians are supported by regional not-for-profit
organizations that assist practices in becoming
comprehensive medical homes, in providing care
coordination and other supports to high-need
patients, and in improving quality. Doctors receive
enhanced PMPM coordination fees plus shared
savings based on their performance. While a nascent
initiative at this time, Alabama hopes to emulate the
experience of North Carolina—where 95 percent
of all primary care physicians in the state now
participate in its Medicaid PCN—by expanding the
program statewide by 2014.34
•
Maryland’s Consumer-Operated and Oriented Plan
(CO-OP). The Evergreen Project in Maryland relies
on medical homes, payment reform, and the use
of evidence-based protocols to make insurance
more affordable for working class families. At the
foundation of the CO-OP are networks of salaried
providers or “teamlets,” made up of a primary care
doctor, family nurse practitioner, care coordinator,
health coach, mental health/substance abuse social
worker, and local office staff person situated in
storefronts in moderate-income neighborhoods.
In addition, salaried high-volume specialists and
contracted low-volume “Super Specialists” will be
available at regional specialist centers. Although
the CO-OP is currently only underway in Baltimore,
officials hope to slowly expand the initiative statewide
within the next five years.35
OUTLOOK FOR THE FUTURE
I
n summary, a broad range of health system
stakeholders—across the 10 states and representing
both private and public sector interests—agree that the
success of health care reform will hinge on the degree to
which health systems will be able to provide good access
to quality care. Critically, these stakeholders also fear that
these systems will be greatly challenged in being able to
provide such access. Not surprisingly, we learned of no
“silver bullets” to solve provider supply problems. ACA
provisions to boost primary care reimbursement provide
welcome, short-term relief, but do not seem designed
to provide a long-term solution to provider participation
shortfalls. Increased funding for the NHSC, coupled with
state-level initiatives of similar design, hold promise to
bolster the supply of primary care providers long-term,
but will not address shortfalls in the immediate term
after implementation of the ACA. FQHCs are certainly
well positioned to absorb much of the demand for
primary care of the newly insured, but are not plentiful
enough to address all of it. Finally, new service delivery
reforms in Medicaid and the private sector hold great
promise to improve access through more coordinated
use of resources—both physician and non-physician—to
improve quality while controlling cost and, over time,
even improve provider participation in Medicaid. But
the promise of such initiatives will need time to be fully
realized.
How well these various efforts come together to support
strong access to care remains to be seen. But the level of
focus, attention and activity surrounding access issues
that we observed in the 10 study states is encouraging.
ACA Implementation—Monitoring and Tracking: Cross-Cutting Issues
7
About the Authors and Acknowledgments
Ian Hill is a Senior Fellow in the Health Policy Center at the Urban Institute. The author is grateful for the very helpful
comments received from John Holahan and Linda Blumberg, and the editorial assistance of Eva Hruba and Margo
Wilkinson. Support for this paper was provided by a grant from the Robert Wood Johnson Foundation.
The author benefited from the 10 state reports and interview notes developed from 10 site visits conducted under
the auspices of this project. Aside from himself, these site visits were conducted by Urban Institute and Georgetown
University colleagues, including Fiona Adams, Linda Blumberg, Randall Bovbjerg, Vicki Chen, Sabrina Corlette, Brigette
Courtot, Teresa Coughlin, Stan Dorn, John Holahan, Katie Keith, Kevin Lucia, and Shanna Rifkin.
About the Robert Wood Johnson Foundation
The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the
nation’s largest philanthropy devoted exclusively to health and health care, the Foundation works with a diverse group
of organizations and individuals to identify solutions and achieve comprehensive, measurable, and timely change. For
40 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that
affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the
care they need, the Foundation expects to make a difference in your lifetime. For more information, visit www.rwjf.org.
Follow the Foundation on Twitter www.rwjf.org/twitter or Facebook www.rwjf.org/facebook.
ACA Implementation—Monitoring and Tracking: Cross-Cutting Issues
8
ENDNOTES
1. The 10 study states are: Alabama, Colorado, Maryland, Michigan, Minnesota, New Mexico, New York,
Oregon, Rhode Island and Virginia.
2. Congressional Budget Office. “Letter to the Honorable Nancy Pelosi Providing Estimates of the Spending
and Revenue Effects of the Reconciliation Proposal.” Washington, DC: Congressional Budget Office, 2010.
http://www.cbo.gov/ftpdocs/113xx/doc11379/AmendReconProp.pdf
3. Blavin F, Buettgens M and Roth J. “States Progress Toward Health Reform Implementation: Slower
Moving States Have Much to Gain.” Washington, DC: Urban Institute, 2012. http://www.urban.org/
UploadedPDF/412485-state-progress-report.pdf
4. Association of American Medical Colleges Center for Workforce Studies. “The Impact of Health Care Reform
on the Future Supply and Demand for Physicians Updated Projections Through 2025.” Washington, DC:
Association for American Medical Colleges, 2010. https://www.aamc.org/download/158076/data/updated_
projections_through_2025.pdf
5. Steinwald AB. “Primary Care Professionals: Recent Supply Trends, Projections, and Valuation of Services
Expected” (Testimony Before the Committee on Health, Education, Labor, and Pensions, U.S. Senate,
Washington, DC, February 12, 2008.) http://www.gao.gov/new.items/d08472t.pdf
6. Dower C and O’Neil E. Primary Care Health Workforce in the United States. Princeton, NJ: Robert Wood
Johnson Foundation, 2011. https://folio.iupui.edu/bitstream/handle/10244/983/070811.policysynthesis.
workforce.rpt.pdf
7. Dower and O’Neil, 2011.
8. Coughlin T, Lucia K and Keith K. ACA Implementation-Monitoring and Tracking: New Mexico Site Visit
Report. Washington, DC: Urban Institute, 2012.
9. Hill I, Lucia K, Keith K , et al. ACA Implementation-Monitoring and Tracking: Alabama Site Visit Report.
Washington, DC: Urban Institute, forthcoming.
10. Cunningham PJ. “State Variation in Primary Care Physician Supply: Implications for Health Reform Medicaid
Expansions.” Washington, DC: Center for Studying Health System Change, 2011. http://www.hschange.com/
CONTENT/1192/.
11. Cunningham, 2011.
12. Brickling-Small D and Thorsness R. “Implementing the Medicaid Primary Care Rate Increase to Improve
Access to Care.” Hamilton, NJ: Center for Health Care Strategies, Inc., 2012. http://www.chcs.org/usr_doc/
Implementing_the_Medicaid_Primary_Care_Rate_Increase__092812.pdf
13. Patient Protection and Affordable Care Act, Pub. L. No. 111-148, Section 1202.
14. The law also provides a 10 percent reimbursement bonus to Medicare physicians who provide high volumes
of primary care services; to qualify for this increased reimbursement, primary care services must account
for 60 percent of a physician’s charges. This provision, too, is limited in duration and is only effective through
2015.
15. Brickling-Small and Thorsness. 2012.
16. Patient Protection and Affordable Care Act, Pub. L. No. 111-148, Section 5601.
ACA Implementation—Monitoring and Tracking: Cross-Cutting Issues
9
17. For FY 2011, Congress cut this funding for FQHCs by $600,000, bringing the year’s appropriation to
$400,000; Katz A, Felland LE, Hill I, et al. “A Long and Winding Road: Federally Qualified Health Centers,
Community Variation and Prospects Under Reform.” Washington, DC: Center for Studying Health System
Change, No. 21, 2011. http://www.hschange.com/CONTENT/1257/
18. Patient Protection and Affordable Care Act, Pub. L. No. 111-148, Sections 5207, 5316, 749A.
19. Patient Protection and Affordable Care Act, Pub. L. No. 111-148, Section 4002.
20. Patient Protection and Affordable Care Act, Pub. L. No 111-418, Sections 3022, 3502, 10333.
21. Blumberg L, Courtot B, Hill I, et al. ACA Implementation-Monitoring and Tracking: Maryland Site Visit Report.
Washington, DC: Urban Institute, 2012.
22. Katz et al. 2011.
23. Hill I, Courtot B, Bovbjerg R, et al. ACA Implementation-Monitoring and Tracking: Colorado Site Visit Report.
Washington, DC: Urban Institute, 2012.
24. Dorn S, Courtot B and Rifkin S. ACA Implementation-Monitoring and Tracking: Michigan Case Study Report.
Washington, DC: Urban Institute, forthcoming.
25. Hill et al. 2012. “Colorado Site Visit Report”
26. Blumberg L, Holahan J and Chen V. ACA Implementation-Monitoring and Tracking: Virginia Site Visit Report.
Washington, DC: Urban Institute, 2012.
27. Courtot B, Dorn S and Chen V. ACA Implementation-Monitoring and Tracking: Minnesota Site Visit Report.
Washington, DC: Urban Institute, 2012.
28. Hill et al. forthcoming. “Alabama Site Visit Report.”
29. Coughlin TA and Corlette S. ACA Implementation-Monitoring and Tracking: Oregon Site Visit Report.
Washington, DC: Urban Institute, 2012; Blumberg et al. 2012. “Virginia Site Visit Report”
30. Hill et al. 2012. “Colorado Site Visit Report;” Courtot et al. 2012. “Minnesota Site Visit Report”
31. Blumberg et al. 2012. “Virginia Site Visit Report”
32. Hill et al. 2012. “Colorado Site Visit Report.”
33. Coughlin and Corlette. 2012. “Oregon Site Visit Report.”
34. Hill et al. forthcoming. “Alabama Site Visit Report.”
35. Blumberg et al. 2012. “Maryland Site Visit Report”
ACA Implementation—Monitoring and Tracking: Cross-Cutting Issues
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