• Reducing the number of uninsured is a good thing, not a bad thing

    For some time, we’ve recognized that we have a doctor shortage in the United States. While I’d add the nuance that we really have a primary care physician shortage, the end result is the same. People need to wait a long time to see their doctors. They feel like their physicians don’t spend enough time with them. And they feel like their doctors don’t know them well enough. They have a legitimate concern.

    Fixing this problem isn’t easy. Training more physicians is expensive, and the numbers of residency slots are limited. We could increase the use of other practitioners, but many (including physician groups) often oppose such a plan.

    This is a problem that will potentially be worsened by the Affordable Care Act. Many believe that as up to 30 million uninsured gain increased access, it will strain the system and make things worse. Recently, this argument has been used to oppose the Medicaid expansion:

    Republicans on the House Energy and Commerce Committee sent letters to Medicaid directors in all 50 states and the District of Columbia on Monday seeking information about the program’s expansion under ObamaCare.

    The letters, signed by committee Chairman Fred Upton (R-Mich.) and Reps. Joe Pitts (R-Pa.) and Tim Murphy (R-Pa.), says Medicaid recipients have experienced increased waiting times to see their doctors in recent years, and argue that those problems are likely to worsen under the Affordable Care Act.

    “As scarce resources become even further divided, the most vulnerable Americans could face significant delay in accessing key services and treatments,” the letter reads in part.

    It’s important to understand fully the implications of such an argument. Basically, they are making the point that giving more people Medicaid is problematic because it may make waiting times worse for those who already have insurance.

    But this is an argument against ever reducing the numbers of uninsured. After all, expanding the numbers of uninsured through the most private, free-market solution ever would lead to the same issues. More people would have potential access to the same number of physicians, and wait times would be worse.

    It’s telling, therefore, that no one ever seems to get upset at businesses that begin to offer insurance coverage. Those newly insured will strain the system as well.

    Moreover, if adding people to the insurance rolls will worsen an already problematic system, then a natural conclusion would be that removing people from the insurance rolls would make it better. After all, if we increased the number of uninsured, then wait times for the rest of us would go down.

    No one, of course, makes that suggestion. Making people uninsured to do this would be unthinkable for pretty much all Americans, regardless of their political bent. We recognize that making some people worse off to benefit the rest would be immoral in this situation.

    But that’s really not that different than the argument that some make when they oppose the Medicaid expansion because of access issues. It’s completely reasonable to oppose the Affordable Care Act for a number of reasons. Opposing it because it reduces the number of uninsured is a difficult one to defend.


    • If you’re worried about a doctor shortage:

      – Allow more foreign doctors to immigrate.

      – Increase residency slots, medical school slots, etc.

      – Relax restrictions on who can practice medicine. Of course doctors object – no one like competition.

    • When I hear people making the argument against Medicaid expansion that you describe, they’re usually focused on Medicaid’s lack of cost-sharing. The argument is that when people have no skin in the game at all, they’re more likely to seek out unnecessary care, and that’s why the Medicaid expansion in particular exacerbates our physician shortage problem.

      I don’t agree with that argument (how good are any of us regular folks with no medical training at deciding when it’s worth seeking care, particularly if we have plans that do impose high cost-sharing?), but I can see how a critic of the Medicaid expansion could still support reducing the numbers of uninsured through catastrophic coverage or other plans that have high cost-sharing.

      • Josh, I agree with you that, as a highly educated non-medical person, I don’t really feel like I have a good idea of which medical care I can safely skip. However, I would argue that most people on Medicaid do have skin in the game. The ACA Medicaid expansion in particular is focused on the working poor. For many of them, they don’t have paid sick leave, so when they decide to go to the doctor, there’s a good chance that they are giving up wages that they can’t afford to give up.

        • As a practicing surgeon, I can tell you that patients that have no co-pays will maximize their utilization. It is extremely common and applies to all incomes and insurance coverage. I don’t know where the line should be made, but patients should have some skin in the game (even if it’s just a dollar or two as a copay for medications/procedures/testing).

          Also, the government could easily, dramatically increase the effective MD workforce by reducing the paperwork burden.

          • @Jon, how does the paperwork for government programs (Medicare and Medicaid) compare to paperwork burdens of private insurers? My experience tells me that private red tape is often more extensive, but I’m not a clinician, so you may have a different point of view.

            • they can be similar, but medicare and medicaid set the standard for all insurance companies. they create the rules for reimbursement… sometimes, the rules makes sense, but a lot of the time its just a lot of meaningless check boxes. the system is also extremely complex–there are professions dedicated entirely to there interpretation (not unlike the tax code). myself and two other surgeons, employ one person FULL TIME to do our billing.

              medicare and medicaid often put more barriers in getting approval for surgery, prosthetic, therapy, etc. so, for a surgeon to get paid for a total knee replacement, they must document a, b, c, d… z. there is no real medical reason that these need to be documented, but if they are not, then they can save money by withholding payment. in the end, it becomes a war of attrition of sorts… basically, wear out the provider and they won’t order that test, medication or perform surgery because it is just too much hassle.

      • Having grown up in a Medicaid-for-all system, I try to minimize the number of times I visit my doctor. If Americans visit their doctors too often because it’s free, does that also mean they spend time with their tax collectors, grocery story clerks, religious advisers, postmen, etc.? You may have no “skin in the game” to limit your torturing these poor victims but they would probably respond the same way my doctor would if I showed up in his office every day: “Get a life!”

        Do these skin in the game advocates actually investigate other countries to see how medical consumers act (I would differentiate between a new expansion of free care from a steady-state system after 40 or 50 years)?

    • It’s the same argument as against the minimum wage. The path to true prosperity is, clearly, slavery, whereby workers are paid no wages (thereby allowing employers to increase hiring) but have their health care taken care of by their employer (thereby keeping the government out of the health care business).

      That access to good wages and good health care increases productivity and prosperity for all is, of course, an accepted right for the upper classes but not the lower ones, in this view.

      As for the supply of doctors, I always found it amusing when professional societies worried about an “oversupply” of their specialty, as if that were a problem for the public and not for their own bottom line.

    • I just think it is funny that there is a obvious free market solution to this problem. Remove the artificial barriers of entry for doctors and let the markets work it out themselves.

    • Foosion is quite right, but he forgets one important option:

      Allow Amerikans to spend their healthcare dollars south of the border, down Mexico way, all the way to Tierra del Fuego.

      Health care in S.A. costs 1/3 what it costs here. If we had anything like a free market here, we could spend our Medicare, Medicaid and Obamacare healthcare dollars overseas, just as we spend our travel dollars, and the network would be virtually infinite, especially compared to the choice of NH residents, whose network is totally limited.

    • I’ve never really agreed either with the argument that “more insured people = worse access to care” is a good argument, and I’ve heard it applied not just to Medicaid but also to those newly gaining private coverage through the exchanges. As the good doctors notes, having more people insured (or having something that works like insurance) is almost indisputably a good thing.

      That said, I’m not sure it’s accurate to say that ‘the most private, free-market solution ever would lead to the same issues,’ for a variety of reasons.

      If, as most of my general view suspect, a free market in health care led to fewer unnecessary visits to the doctor or patients seeking lower-level providers in order to save money, then access would expand for those that need care. And while it takes a long time to train a physician (particularly specialists), it takes less time for a nurse practitioner to be trained.

      Another thing to consider is that for primary care physicians, the amount of time devoted to dealing with insurance reimbursement issues would decline dramatically, at least if primary care is essentially removed from the third-party payment system which many (myself included) suspect would be the end result in a real free market system.

      Likewise we’d expect to see improved efficiencies that expand capacity without requiring new practitioners. One of the things I learned during some of my past research on specialty hospitals is that dedicated operating rooms for, say, orthopedic surgery, can allow more surgeries to be performed in the same facilities. To be sure, at many large hospitals they do have dedicated facilities for some procedures, but at smaller and mid-size hospitals it’s not uncommon for surgical rooms to have to be ‘changed over’ from different types of surgery, eating up time. In a free market we’d presumably see more of these specialty hospital facilities, again expanding capacity without requiring new personnel.

      And this is assuming that a real free market includes the barriers to entry such as a medical or nursing degree that prevent new people from offering their services. For the record I don’t really have a big problem with this (although restrictive scope of practice is an issue for me, i.e. certain limits on nurse practitioners), but I know some free-market health care advocates that would do away with medical licensing in a heartbeat.

    • “Opposing it because it reduces the number of uninsured is a difficult one to defend.”

      These are the folks that think firing people is a way to make your business more successful. These are folks who think that the reason they aren’t making more money is because they have to pay taxes, and not because their business could be more successful.

    • Although I agree with your logic, I can see where the Republicans are coming from with their argument.

      They see increased numbers on the government rolls as a bad thing because as the gov’t gains market share, they gain more power. The more power the gov’t gains, the more control they have over the health care industry.

      As a medical student, I am split on how I feel about this. Do you not think there is anything to be concerned about as far as the gov’t gaining more control in the health arena? (I tend to see more gov’t involvement as bad).

      • What do you mean by “ncreased numbers on the government rolls”? The ACA includes both a Medicaid expansion and an expansion of private insurance, with approximately equal numbers of each. So where is this government control coming from?

        • Increased medicaid enrollment. The increased rolls for “private insurance” are still dependent on the gov’t via subsidies.

          Aaron says “no one ever seems to get upset at businesses that begin to offer insurance coverage.” But some (Republicans) do seem to get upset at the idea of increasing gov’t enrollment.

          My question/statement on gov’t control is more of an extension of the Govt’s increased market share. As any one individual gains market share they gain power/leverage/control over the market. My question is, “Are the republicans not validated to some degree in being concerned about the gov’t gaining an undue amount of power/leverage/control (due to increased medicaid enrollment) over the healthcare industry?”