• They’re stealing my health care!

    John Goodman has an editorial in the WSJ that’s worth a read:

    Are you having trouble finding a doctor who will see you? If not, give it another year and a half. A doctor shortage is on its way.

    Most provisions of the Obama health law kick in on Jan. 1, 2014. Within the decade after that, an additional 30 million people are expected to acquire health plans—and if the economic studies are correct, they will try to double their use of the health-care system.

    Meanwhile, the administration never seems to tire of reminding seniors that they are entitled to a free annual checkup. Its new campaign is focused on women. Thanks to health reform, they are being told, they will have access to free breast and pelvic exams and even free contraceptives. Once ObamaCare fully takes effect, all of us will be entitled to a long list of preventive services—with no deductible or copayment.

    Here is the problem: The health-care system can’t possibly deliver on the huge increase in demand for primary-care services. The original ObamaCare bill actually had a line item for increased doctor training. But this provision was zeroed out before passage, probably to keep down the cost of health reform. The result will be gridlock.

    Look, there’s nothing inherently wrong with what he’s saying. The issue I take with the piece is that the problem he’s describing has absolutely, positively nothing to do with Obamacare.

    We have a doctor shortage in the United States. There are too many people who want to see a doctor, and not enough doctors to see them. This means that sometimes people have to wait to see a physician. This happens now.

    In the future, under Obamacare, more people will have insurance, and thus more people will try and see the doctor. But we will have the same number of doctors. So it will be harder to get an appointment, and people might have to wait longer.

    But let’s say instead that we replace Obamacare with RomneyRyancare. It’s a conservative’s dream of market forces and consumer shopping and now 30 million more people can afford health care than can today. The exact same wait times will occur.

    That’s because the wait times have nothing to do with how we get more people insurance. They have everything to do with how many people are trying to access the system and how many doctors can service them. Period.

    John predicts that we will see more concierge medicine. In other words, doctors will allow people with money to get in line first, meaning that the people who were helped by Obamacare, and can’t afford the concierge costs, will be second tier. I hate to tell you, but that’s the system we have now. People who can afford care are far more likely to get it than people who can’t. Moreover, if we have RomneyRyancare, there will still be the same forces at work, the same shortages, and I bet that we will still find ourselves in a system where those who can pay more get serviced first.

    This has nothing to do with the means by which we increase access. Unless you are willing to discuss a way to increase the number of physicians in this country, John’s argument is one against decreasing the number of uninsured at all.


    • Your concluding sentence is correct. The Romney-Ryan-Rand alternative isn’t to provide access to the uninsured with an unfettered free market. It;’s to leave them subject to the vicissitudes of such a free-market that’s shown in less-regulated states across America to cause healthcare costs to skyrocket and increase the ranks of the uninsured.

      Texas is the textbook example. They “reformed” malpractice there years ago, yet medical spending still climbs and they have more uninsured than any state in America. The free market kicks the uninsured to the curb and focuses on maximizing profits from the insured , who’s premiums will accelerate even faster with fewer controls on medical excesses.

      Increasing access without increasing supply will undoubtedly reduce access for the currently insured. The bottom line here isn’t financial, it’s moral: Are we willing to sacrifice some of our access – much of it unneeded – so others can enjoy a modicum of medical care?

      And morality doesn’t even register in the free-market “solution” because the uninsured aren’t a problem to them that needs a solution. Simple as that.

    • Zombies never die. The myth that we have much shorter wait times than other countries that all have socialist medicine persists. Wait times for a dermatologist are over 6 months in my area. Over a year for many pediatric specialties.

      What I dont get is how John is able to play both sides of the street on this and not get called for it. Complaining that Medicaid is second rate insurance because docs do not paid enough so they are dropping patients. Docs will not see these new patients coming into the system. At the same time he, appears, to be asserting that his plans would maintain or institute higher doc salaries, while reducing health care spending. I dont see how the economics of this work.


      • To me a 6 month wait to see a dermatologist is an outrage. We should ask ourselves how can this exist? Does no one want to be a dermatologist at the current rate of compensation or is it that the states constricts the supply of dermatologists through excessive licensing? I know MDs who practiced medicine overseas who cannot pass the boards here. I am pretty sure that they would make fine doctors here, but the boards are to restrictive. They create shortages.

        • “To me a 6 month wait to see a dermatologist is an outrage. We should ask ourselves how can this exist? Does no one want to be a dermatologist at the current rate of compensation or is it that the states constricts the supply of dermatologists through excessive licensing?”

          The per capita supply of dermatologists has more than doubled in the last 50 years. Is our skin so much worse than it used to be? Lots of people want to be derms, too many in my opinion. It’s a high-paying, relatively low stress specialty. Compare that to being a primary care doc. Too few derms? We need fewer of them.

          • My derm seems to have it nice. I go in for routine removal of precancers. Seems a job an RN could do. Bill sure is high.

    • “Are you having trouble finding a doctor who will see you? If not, give it another year and a half. A doctor shortage is on its way.”

      Okay, but isin’t this a good problem to have, or at least a less bad one. The alternative, and the one we face today, is that people are not seeking health care when they should because they know they can’t pay for it. So now problem are going undiagnosed and untreated.

      Having a shortage of doctors is a problem we can tolerate and solve. Having people drop dead because of undiagnosed illness is a far worse problem.

      Just my opinion, Jack

    • When we talk physician shortages, shouldn’t we distinguish between specialists and primary care docs? My recollection is that the US has many more specialists per capita than most other countries, but we do have a real primary care shortage. I don’t have a citation for that at the moment, but if I find something I’ll add it on as a reply.

    • It should be noted that Goodman supports medical licensure reform a la Milton Friedman.

      • That’s fine, but the thrust of his piece is still that Obamacare is going to precipitate the shortage, not that decreasing the number of uninsured and making it easier to see the doctor will. Free market reforms will do the same.

    • Yes, more patients will exacerbate shortage. Both parties want more patients (or so the GOP says). Set number of residency slots part of the problem.


    • We have a doctor shortage in the .

      And supply side “shortages” can cause spiraling costs. So why are we not getting the states to make it easier to become a medical serve provider before we ask the Federal government to start paying for more medical care?

      • To do primary care, you don’t have to go to medical school (nurses, PA’s). Or, in some cases, subscribe to the modern concepts we call “medicine” (chiropractors, naturopaths). Yes, some of these have limited scopes of practice or ultimately work under a license of a doctor but they do expand the available resources. States are expanding who can be a “doctor”. Whether this is a good idea remains to be seen.

        So, while we might have a doctor shortage, it’s less clear if we have a provider shortage.

        • Because of status quo bias and other biases it may be that we need to make it easier to become a MD to we are to effective deal with the MD “shortage”. I think the same for PAs, NPs, RNs, LPNs. Now I may be wrong, Massachusetts is allowing PAs and NPs to do more and that might also work, pushing more and more work down to less restrictive, lower paid personnel. Notice that in Massachusetts spiraling costs are now being blamed on the politicians and so they are now making these sensible moves that should have been made years ago.

          The problem must be dealt with if government pays or the system remains partly private.

    • There are two major unstated premises hereL

      1. The first is that here is that people who have first dollar coverage will demand as much healthcare as people who have high deductible plans. The RAND experiment settled that one long ago.

      2. The second is that compensation levels and working conditions will have no effect on physician supply (number of practicing doctors * hours-worked-per-doctor). The supply of new doctors is demand-insensitive and there’s no indication that will change any-time soon, but physicians respond to incentives like anyone else and they’ll work extra hours and/or prolong their careers when it’s worth their while to do so. It also assumes that there are no means by which physicians could/can increase their patient volume using new technologies, practice organization, coordination with mid-level providers, etc, etc, etc.

      The extent to which we’ll have a functional shortage of physicians will depend at least to some extent – I’d say a significant extent – on the mechanisms that we use to coordinate supply and demand.

    • If anyone has more on this subject I would love to see it.:


      • No offense Jay but that blog post is a bunch of crap.
        “One explanation is the restriction on the number of medical schools, and the subsequent restriction on the number of medical students, and ultimately the number of physicians.”

        What restrictions on the number of medical schools are there? Seriously, what stops anyone from opening a new medical school?

        “There are 130 medical schools in the U.S. (data here), which is 22% fewer than the number of medical schools 100 years ago (166 medical schools, source), even though the U.S. population has increased by 300%.”

        100 years ago there were crappy medical schools that turned out “physicians” who killed people. Then came the Flexner Report and a lot of crappy medical schools closed. But let’s look at what happened in post-war America. I went back to a textbook, Introduction to Health Services, 4th edition published way back in 1993, but it has some very interesting information on medical schools. According to Table 10-3, Number of Allopathic Medical Schools, in 1966 there were 88 Med. Schools which graduated 8,759 students. By 1981 there were 126 med schools which graduated 15,667 students. Obviously there was a huge increase in med schools and graduates in only 15 years time. Where was the AMA?

        “Consider also that the number of medical students in the U.S. has remained constant at 67,000 for at least the period between 1994 and 2005, according to this report, and perhaps much longer.”

        And yet there are more physicians than there used to be because… we import them. One quarter of all practicing physicians in the US are foreign medical graduates. The supply of physicians per capita by 61% between 1970 and 2006. Where was the AMA? If the AMA is trying to act like a cartel, they’re doing a crappy job.

        And the comparison between law schools and med schools? What do you need to open a law school? Some rooms and a lawyer to teach them. What do you need to open a new med schools? Labs, hospitals, patients, medical equipment,many different kinds of specialist physicians to teach many different courses. The reason there are more law schools than in the 60s is that they’re cheap to open. The reason more med schools haven’t opened is that it’s hugely expensive to start one.

        If Milton Friedman knew what he was talking about when he wrote the book, and I doubt it, it isn’t applicable now.