• Tyler Cowen on me on Medicaid Wars

    Tyler Cowen responds to my post about his NYT piece. Go read it to catch up.

    Let me start by saying that I’m going to be as dispassionate as possible here, because it’s too easy to let emotions get in the way.

    Yesterday, I was “annoyed”. That was not entirely directed at Cowen, but at the ideas that often permeate our discussion of health care policy. Krugman refers to them as “zombie ideas“, and I think that’s a pretty good description. Some of those ideas were, by my reading (yes, I read it, carefully, many times), strongly implied by Cowen’s NYT column. In his post, where he has more space to do so, he explains how and why they aren’t. Nuances matter. At the same time, many more people will have read his column than his post. So many won’t read the nuances.

    I did not, as Cowen writes, dispute his main argument. That’s because I don’t or can’t necessarily disagree with most of his points. He gives an accurate description of Medicaid itself. He talks about his belief that Americans will someday vote to rebel against Medicaid.  He says Republicans might try to take it apart. Then he gets into a number of paths we could take to alter the Medicaid expansion. He ends with what he thinks is the “most positive path”, which seems to be a subsidized and mandated catastrophic plan with a free market for everything else.

    None of that is “wrong”; it’s opinion. That’s not what annoyed me, so I didn’t write about it. As I am one of those people who do want conservative engagement with policy, I welcomed the above.

    What bothered me were the little snippets of information along the way supporting his assertions. It’s the little ideas that many “assume” are true. It’s the justifications (often without evidence) that reinforce the ideas that annoyed me, and that’s what I wrote about.

    I’m not going to do a line by line rebuttal to Cowen, because I’m not sure that will be productive. I’d rather shed some light than turn up the heat.

    -I read in Cowen’s piece the idea that single payer systems lead to longer lines. I dispute this. Doctor shortages and an underfunded systems lead to wait times. We always point to Canada, but their wait times (overblown) are because they keep the budget down. You can have a single payer system and no wait time problem (see Medicare). So when you drop in that line, yes, it bothers me. But the larger point is that any increase in patient coverage without increasing the doctor supply will potentially lead to longer wait times. It doesn’t matter if the coverage comes from Medicaid, Medicare, or private insurance.

    -I read in Cowen’s piece the idea that Medicaid has never been popular. What does that mean? Does he mean Republican governors don’t like it? I agree. Does he mean there will be a political battle over it? Sure. But those are not traditional meanings of “unpopular”. The very piece Cowen cites from Ezra Klein says this:

    Medicaid is a bigger program than Medicare, serving more than 50 million people, to Medicare’s 48 million. Nor does it poll substantially worse. A recent Kaiser tracking poll found that 88 percent of Americans wanted either no reduction or small reductions in Medicare funding. At 83 percent, Medicaid was close on its heels.

    I don’t see that as “unpopular”. It doesn’t imply it ever has been.

    -I read in Cowen’s piece the idea that docs don’t accept Medicaid. In support of this in his post, he cites a personal experience in northern Virginia. I don’t dispute his experience. But I can give plenty of anecdotes with private insurance as well. What we care about are data. There’s a doctor shortage in the US, period. Lots of doctors aren’t taking new patients, period. Medicaid isn’t the worst offender here.

    Moreover, this issue is all about reimbursement. Medicaid gives too little. It doesn’t make me an ACA “apologist” to note that the law tries to fix that. It might work.

    -I read at the end of Cowen’s piece a preference for a more free market system on top of catastrophic insurance. I see no evidence for why that would be superior on cost control grounds, though the market does offer more choice. On cost control, I see it as trying to move in the opposite direction of nearly every other country, and they are cheaperuniversal, and often just as good.

    Bottom line – I did use the word “annoyed”, but it was directed at everyone who uses memes like these to support their arguments. They’re the equivalent of “all insurance companies are evil” and “the pharmaceutical companies just want to make money and screw you”. I went out of my way to praise Tyler Cowen in general, and to be polite. “Annoyed” was a reaction to what I wrote about – to these “zombie ideas”. I think we could make our arguments without resorting to them. I wish everyone (including Cowen) would stop using them and stick to facts. Thus, the title of my first post.


    • The real world is no match for Invincible Mao Zedong thought!

      Or Invincible Conservative Dogma, whichever.

      There’s no such thing as conservative engagement with real life, particularly on health care. If the rest of the planet didn’t exist, their critiques of the ACA might be plausible. But, here we are.

      • The absolute conviction in high-deductible / catastrophic insurance paired with paying out of pocket for everything else (or bartering chickens) is built on ideological and moral foundations. If there’s any economics involved, it’s at best theoretical.

      • Yeah, that’s it. How about this: what Krugman calls “Zombie Ideas” are what honest people call straw men arguments.

    • Long time reader here. First time commenter.

      As a side note, you should thank Cowen in some sense. By responding, he has helped bolster your reputation! Not saying it needed it, but you are now a name that has popped up on radars where it wasn’t registering before. Kudos!

      • Greater exposure is a opportunity. Unfortunately, Tyler makes a lot more sense.

        Almost everything sited as a zombie idea or an annoying meme just boils down to reality and basic economics as the distribution of scarce resources. Saying you won’t get lines if you just fund it enough and produce enough doctors is the type of fairy tale thinking common on the left. Especially when the ACA promised to “bend the curve”.

        Bottom line is that everything can be solved if you throw enough money at it, but that doesn’t address reality that the left so likes to claim. It is just that refusal to wrestle with human nature and its reality that is annoying.

    • “I see no evidence for why that would be superior on cost control grounds, though the market does offer more choice.”

      The point would be to find areas, like some drugs and treatments and types of clinical services, where people could Comparison Shop. This could lead to lower prices, and allows, yes, for more choices. For the people who can’t afford even these drugs, we should provide them for them. I don’t know if this would work, but it’s worth a look.

      • That’s the idea behind the medical exchanges that are being put in place, I thought.

      • Until everyone can prescribe their own drugs and surgeries it is pointless to talk of a “free market” in health care. The assymetry of information is too strong. How can a lay person comparison shop something they don’t have the training to understand (and don’t say Googling). A doctor can say you need something in order to live, and any thought of finding a bargain goes out the window. The greatest contribution of the “free market” to health care has been snake oil and its salesmen. Unknowledgeable individual actors cannot hold down health care costs on a large scale, this is simply wishful thinking. In health care the only thing proven to work are very large groups (private or public) with bargaining power and a knowledgable scientific review board.

        I suppose we could allow some free market bargain shopping in some insignificant easy to understand areas if it would make conservatives feel better, but end of life care (the biggest budget buster) is never going to be amenable to comparison shopping.

        • You could effectively comparison shop end of life care options … if you assume reincarnation, and if a means exist for you to transfer wealth to your new self, and if you internalize a rational intertemporal-slash-intergenerational maximization model.

          Seriously though, I have an advanced degree in molecular microbiology and i’m adept at “googling”, so I frequently try to do my own amateur diagnosis/prescription for myself and loved ones. But even with a couple standard deviations above above the average citizen in terms of ability to do that kind of thing, I’m frequently lost. As everyone else said, the information barrier is too high for this to work well in real life for anything but the most basic and routine procedures.

        • Dan nails it. All his points are well known (and formally modelled and empirically tested) to health economists, but they seem to have abolutely zero impact on free market fundamentalists.

        • I too think Dan is right. I’m a physician. I agree the asymmetry of information is too strong for the free market to work well in health care.

          Also, a comment on the popularity of Medicaid. I suppose popularity is important, but the most important thing is that Medicaid provides health care to many people who would not otherwise have it. I see many Medicaid patients. They are fortunate and they are grateful to have medical care. By virtue of that, Medicaid is a successful program. We should expand it as in the ACA. It’s not just unfortunate that Republican governors are denying health care to many residents of their states, it’s a disgrace.

          • There’s no pricing information in the system because it is government regulated and insurance companies use government prices. If a normal business priced their products like hospitals, they would go broke or be sued out of existence. It’s a massive information barrier.

            One could easily comparison shop based on the same procedure, for example, with data and reviews from patients. The information just isn’t there because you can’t do it and the price data that exists is as helpful as prices from the Soviet Union.

            I just looked up lithostrpsy (for kidney stones), with prices up around $20,000 at the high, the low is $8,000. A friend had that in China for about $300. Their labor is cheaper, but not that cheap. In a free market, there’d be a clinic with a trained technician and the bulk of the cost would be the machine. There would be new machines and also older machines to choose from, you’d have different prices for different levels of service, with insurance kicking in if actual surgery was needed or there were serious complications.

            • “There’s no pricing information in the system because it is government regulated and insurance companies use government prices”

              This makes no sense. First of all, insurance companies do not use gov’t prices. If they did, we would not see the tremendous (within-hospital, across payer) price variation that we do, as documented by Uwe Reinhardt, James Robinson and others.

              Second, if private insurers simply used government prices, we’d have full price transparency since government prices are in the public domain.

            • Austin: re govt prices. You can argue that government set prices aren’t true prices as a market signal. I took the comment to mean that government pricing distorts the market. Govt prices for Medicare/medicaid are prices in the sense that the USSR set prices for shoes/corn. It’s the best guess and not a true price signal. As a result, you have major distortions in the delivery of care and distorted price signals.

              Evidence: Reading through the annual Medpac report gives ample examples of the problems of government pricing. These range from the undervaluation of primary care to overpayments for DME.

            • Sure you can argue that. I agree with it. That’s not how I read the comment though. On the commenter to clarify.

            • “If a normal business priced their products like hospitals, they would go broke or be sued out of existence. It’s a massive information barrier.”

              Airlines price seats sort of like medical corporations, just like 5 people can pay 5 different prices for the same drug or the same procedure, 5 people sitting in a row on a plane are likely to pay 5 different prices.

              Drug companies cut deals with insurers with different prices for each, and when insurers refuses to deal and one charges $50 copay and another a 50% that is $75 which the competing generic costing a $20 copay or a $15 copay, the insurers will issue coupons that are worth the difference between the $50 and $20 for one prescription ($30) and between $75 and $15, ($60). Airlines provide similar routes around corporate deals with travel agents with airline deals on rates and rebates with the frequent flyer programs to get business travelers to work again corporate policy and make them pay more.

              And thousands of other industries have done the same. Railroads were seen as so abusive in its pricing discrimination, farmers forced the Republicans to act and one of their many acts was creating the ICC, which by the 60s was perhaps the most hated agency by conservative economists, and a top priority of Republicans to kill. What is bothersome is Republicans never admitted the ICC failed at the job it was supposed to do, and thus did nothing to address the original problem, claiming getting rid of the ICC would magically produce the transparent pricing the ICC was created to do, and did very well. The ICC required the transport carriers to publish every price with the justification for the prices. Since repeal, pricing is opaque and the basis totally obscure.

        • I think we’re too quick to say that comparison pricing/competition is not possible in health care. To take an example outside of the insurance system: corrective vision surgery. The quality has gone up and the price way down. I’m not sure how it happened exactly, but it would have been very easy to say that no layman has any understanding of eye surgery techniques, the information asymmetries are too great, etc… impossible. Yet somehow it seems to have worked out.

          The other day I was listening to a TV add for a cancer center. It concluded by saying “examine our survival rates at http://www.blahblahblah“. You begin to see how even something like cancer treatment might be validly competitive. I’m not saying this would all work fine, but maybe we just don’t think it through enough. Kenneth Arrow’s article seems to be accepted as the last word on it, but can we be so sure that there aren’t creative solutions to information problems in health care markets?

          • Chris, I dealt with this when it was raised earlier: “To take an example outside of the insurance system: corrective vision surgery. The quality has gone up and the price way down. I’m not sure how it happened exactly…”

            Hasn’t this happened because this is an entirely elective procedure? In other words, the consumer can always walk away at no cost to their pocketbook or health. And I’ll ask the same question: How does that differ from walking away from overpriced chemotherapy?

    • I think it’s worth noting that for choice to be “efficient” in economic terms a whole lot of things must be in play. One is that consumers would have the ability to review the choices and for people who need medical care that’s often the worst time to shop around– kind of like picking the best auto mechanic when you’re broken down— not impossible but often impractical Additonally, for choice to be efficient consumers would have to have level of knowledge about medicine that just ain’t going to happen. As a matter of fact, one of the structural problems we have is the marketing by Pharma to Doctors that influences their own knowledge of efficacy and trade-offs.

    • To Cowen, 10% against Medicare is the start of the revolution. But he forgets that 90% of the people make far less than those 10% do. And they are allowed to vote, for the most part. Perhaps if the conservatives allow a bit more equality in pay then they’ll get that up to 30% or so.

    • I can appreciate how you may see how a government monopoly would be more efficient than an industry of competing firms; however, isn’t it true that the cost of cosmetic surgery and laser eye surgery have gone down while the quality of services has gone up?

      Is there not a valid concern about corruption? As money and power get concentrated, the potential for corruption increases. We’ve seen these effects with financial services and the current ACA waiver process. Heck the process of get the bill passed seemed to be an exercise in corruption. It certainly seemed that one of the motivations for this reform was to ensure the people become dependent on a government program so that those in charge have more power, like politicians getting the elderly to vote based on social security.

      Shouldn’t there have been more emphasis on controling costs instead of transfering money. If the cost was reasonable, wouldn’t there be more coverage? Are there any controls against fraud? Are there any controls for court costs? It seems that there will be an increase in small costs that could be paid out of pocket with the hope that the catestropic costs will decrease, but those benefits could be illusiary. Heck, you mentioned it. What about increasing the supply of Doctors and health professionals? Isn’t basic supply and demand that by increasing demand without increasing supply will either increase the price or create shortages, i.e. queues?

      As far as some of the people in this debate, I think questioning the real concerns of people by either arguing strawmen or questioning others intelligence or motives is an exercise in propaganda of the kind seen in other countries during the great depression. This is more directed at commentors than the author.

      • “isn’t it true that the cost of cosmetic surgery and laser eye surgery have gone down while the quality of services has gone up?”

        And isn’t it true that these are entirely elective procedures? In other words, the consumer can always walk away at no cost to their pocketbook or health. How does that differ from walking away from overpriced chemotherapy?

      • You confuse price with total spending/cost in a market.

        Economist when thinking about market seem to forget that prices and profit seeking is the way to product more in total, and to have more in total in a market by profit seeking lowering price, the total market must expand in total spending.

        The goal of those selling lasik is to generate every increasing total spending. Only if you argue that lasik is a substitute for corrective lenses and that the increased spending in total on lasik will cut total spending on corrective lenses by a larger amount.

        The US health care system by policy was driven to profit seeking as the cost control method, but the costs in the US have since seen faster growth in total spending than in other nations where profits are limited to delivering higher quality/efficiency.

        The profit seeking has driven hospitals to cut off charitable care which was part of its charter granting tax exempt not-for-profit status. This requires the government to pay for the charitable care that was inherent in the public/private partnership of tax exempt corporate charters.

    • On “They’re the equivalent of . . .”
      I don’t think those are really equivalent. Right wingers will be the first to agree, at least at any time they’re not being pushed on it by a left winger, that a corporation’s first and only responsibility is to make money for its stockholders. Now in people terms that kind of personality is widely considered “evil” (greedy, amoral, psychopathic), so describing corporations of whatever sort as evil is no doubt impolite in our society, but it’s not technically inaccurate. The pro-corporate argument isn’t that they’re not evil, it’s that whatever they may want, free market competition operates to force them to do good despite themselves. I have my doubts.

      And “the pharmaceutical companies just want to make money and screw you” . . . well, everything except the “screw you” part is uncontroversial, and that last bit follows the moment it’s in any way more lucrative than the alternative. Developing really good drugs is very expensive and laborious, and may not even be do-able for any given condition at a given time. And sometimes you sink masses of costs in something promising and it turns out to be dangerous. So what are they going to do in those cases? Not make money? So OK, pharmaceutical companies don’t *want* to screw you, and in any case nobody claims that it’s just a bit thrown in to straw-mannify the real argument and make it look more equivalent to the right wing stance. But they don’t care if they screw you, and they have profit-oriented reasons to do so in some cases. It’s the customer as externality, basically.

      This kind of argument may be accused of being an oversimplification. Perhaps it’s an extreme position. Maybe you don’t agree with this sort of position. But it’s hardly a falsification of fact in the way that right wing zombie lies are. This is a false equivalence, and I get annoyed when people are so scared not to be “balanced” when they criticize the right that they defensively reach for something, anything that will let them say the left is like that too. The modern hard left and hard right are not very much like each other. Even if you’re a centrist and agree with neither of them, the notion that they are somehow mirror images is nonsense; they are very different not just ideologically but organizationally and psychologically and in the style of their messages and communication; their strengths and weaknesses are very different. They are far from just doing the same stuff at opposite ends of the spectrum.

    • I read in Cowen’s piece the idea that single payer systems lead to longer lines

      Another point regarding this that almost everyone in America seems to miss is that lines are longer in Canada because everyone has comprehensive medical coverage.

      The American system makes the lines shorter by failing to provide any medical insurance at all to about 1 in 6 people, and by by providing inadequate (i.e. non comprehensive) coverage to a large portion of the remainder.

      What made the whole “death panel” thing particularly ridiculous is that many Americans obviously don’t understand that health care is ALREADY rationed in the US, unlike in Canada or any other country with a universal system, it’s just that the rationing is done through the denial of coverage by private insurers.

      Of course if fewer people have access to health care those that do will, all things being equal, receive treatment more quickly. This is just another aspect of the social darwinism inherent in so many aspects of social relationships in the US that Americans try very hard to pretend not to see.

    • Tyler Cowen seems to have suckered a fair number of reasonably intelligent people into believing he’s arguing in good faith.

      • Agreed. I thought Aaron was just trying to be respectful, but Cowen’s unhinged opinion doesn’t deserve any respect.

    • I currently Comparison Shop for Drugs & other Services that I have to pay for under my Plan. It’s not that hard. I’m not sure claiming it would be peanuts w/o actually giving such a proposal a good whiff qualifies as a valid objection. For Medical Services that aren’t easily shopped or can’t be shopped at all, we can have the Govt bargain for & pay for them. So:

      1) Where Shopping is Possible, we have it.
      2) Where Shopping is Not Really Possible, the Govt will provide it.

      I do not like the current Hybrid System we have for Health Care. I agree we should tinker with it as best as we can if that’s all we can do, but the current system is a trade off between Special Interests that keeps our system Expensive & Inefficient.

    • Preventative health care is what saves money in the long run. Check ups, prevention and control of chronic conditions such as hypertension, etc. That is exactly what the kind of system Cowen proposes stinks at and single payer systems do well (e.g. France), and it is why France has both lower costs and better outcomes.

    • (1) “Doctor shortages and an underfunded systems lead to wait times…We always point to Canada, but their wait times (overblown) are because they keep the budget down. You can have a single payer system and no wait time problem (see Medicare).”

      Isn’t that the whole point? People who like Medicare more or less as it is propose to fix its unsustainable spending trajectory by keeping the budget down. And once you do that, as you say, you end up with underfunded systems and shortages. So what do you propose to do to bring down the cost of Medicare without keeping the budget down? Isn’t Canada supposed to be one of the models for single-payer?

      (2) “There’s a doctor shortage in the US, period.” Wait, what? Isn’t the cause of doctor shortages efforts to keep the budget down? And who is the biggest buyer in the US medical care market, the entity in the best position to ensure this?

      (3) “On cost control, I see it [freer markets in non-catastrophic insurance] as trying to move in the opposite direction of nearly every other country, and they are cheaper, universal, and often just as good.” It’s hard to think of markets that governments intervene in more thoroughly than the health care and health insurance markets. Consider the influence of Medicare, Medicaid, the VA, COBRA, the employer-provided health insurance deduction, the various tax provisions for HSAs, the anti-trust exemption for health insurers, the maze of state and local regulations, the ban on interstate competition for insurers, and on and on and on. Acting like we freer markets would give us more of what we already have (expensive, selectively accessible health care) is to completely abstract away from everything that underlies those phenomena we all agree are regrettable.

      The standards of argument here are pretty poor. Try this instead:


    • Tyler Cowen and (though I love you Incidental Economists Aaron and Austin), you will all 3 still have tenure after ACA Medicaid expansion is implemented. (I really hope you guys do have tenure….) While I think Mr. Cowen is a Republican apologist and has no idea of the salience for patients and providers underlying his critique of the ACA. These salient factors will “trickle down to patients” (in a way that Reaganomics never ever did in terms of wealth) in terms of wait times and difficulties finding certain specialists and even finding hospitals for non-emergent surgeries depending on where they live. This is due to the low rates of the “Medicare” Medicaid rates.
      The government decided to fight and fund 2 NO-BID wars for 10 years while lowering taxes. That same government can not come to health care providers who have invested $100-$300K individually and millions collectively to build mostly non-profit hospitals and ask us/them to accept less for health care services. We have been preparing for the Baby Boomer’s needs. Until recently, the government was not planning at all.

    • Oooooh! I listened to your podcast and I get it now! I worked on NIDA funded trials as a low level minion so I know exactly what you two are up against. I thought you two were medical school faculty. (In psychiatry we call that fantasy projection.) Now I see even more so why you might get irritated when people spout off with no proof of what they are saying…. The grant funded world plus publish or perish without tenure!?! It sounds like you guys are on a 4 month cycle from hell.
      This blog is an invaluable service to economists, public health policy advocates, health providers and the media. Thank you for your work and patience in keeping it going.
      I also hope it is a channel back into your academic world (I know how insular it is, a lot of my friends from undergrad went there and I almost did) from the outside world. We are the health care providers expected to execute these economic policies so maybe it is good if you hear our addled, non-expert ramblings. I know that resistance is futile….

    • I am coming in late, but I am enthused by what Orthodox said about
      different prices possible for lithotripsy.

      American health care has a real Cadillac effect. In so many areas, the only products and the only caregivers are the best that money can buy.

      An American who earns $35,000 a year can buy food, clothes, a place to live, often a car, and life insurance, without a dime of federal help.
      Maybe a little help from family on the car payments.

      But he cannot afford health insurance without massive government aid.

      One big reason is that this American can buy cheap food, cheap clothes, live in an old house and drive a used car.

      Obviously some parts of health care are outliers. There is no cheap brain surgery, and no used drugs, or cheap ways to set a broken bone.

      If we had a medical system that treated emergency care as a public good, funded by taxes like the fire department, and if we had Medicare Part A for major surgery available to anyone —

      then darn near everything else could come in cheap versions and expensive versions.

      A person could get a dr’s exam for $150 and take $4 drugs, or they could get an excecutive physical at Mayo for $6,000.

      You could get almost all of your ambulatory care for cash, and for a lot less cash than the ACA is talking about for insurance premiums. Instead of your and/or the govt paying $500 a month for health insurance, you could set aside $100 a month and be just fine.
      (especially by the standard of 99/9% of human history.)

      As you can tell, I am excited about providing health care in all price ranges, leaving aside emergencies and life-saving treatments.

      Bob Hertz, The Health Care Crusade

    • You can’t say the evidence suggests a free market in healthcare will raise costs, because there hasn’t been a free market in healthcare to produce such data in the first place.

      Unless, of course, you’re making an a priori argument, in which case intuition can tell us that with more competition, prices will be lower, not higher.

      Then there is the obvious “civilized man” based argument that says even if privatizing healthcare will make it more expensive (which it won’t), individuals still have a right to decide with their doctors what services will be provided and what prices will be paid.

      If prices go up immediately, then we know the state was ripping off healthcare providers and/or artificially reducing supply to patients. Even here, the initial higher prices will increase profits, and thus attract more investment, more doctors will be able to be hired, and the long term effect will be higher healthcare supply and prices falling back down. This is what we want, isn’t it? Lots of supply at lower prices? Yes, the initial cost will be steep, but who will bear the costs for past folly? There’s only us.

      If prices go down immediately, then we know the state was ripping of consumers and/or artificially increasing supply to patients.

      I don’t understand why people look to non-free market healthcare examples around the world, and believe themselves knowledgeable of free market data to make judgments on whether or not free market in healthcare are superior to socialized healthcare. Do we not know from the horrible 20th century communist experiment that socialism doesn’t lead to as good of outcomes as individual freedom?

      • How about Medicare Advantage? Private competes with public, spends more, costs more?

        And now removing the Medicare Advantage supplement and going back to the level playing field is “cutting”.

        People look to the rest of the world, because as I said above, they’re often just as good, universal, and much cheaper. It’s not that hard to understand.

    • If I had five seconds of confidence that America could pass and stick to a national fee schedule, I would prefer that to any free market arrangement.

      Shopping around for the cheapest doctor is a poor use of time and in some cases is damaging to health.

      Right how Medicare and Medicaid do have natrional fee schedules, and the elderly are blissfully removed, in large part, from hassling over prices.

      But I see no chance for persons under 65 to get back to affordable low-deductible policies. We can have a whole new set of postings on this, and I would like to see it — but for the moment, consumer power is the best protection for the person with a $4000 deductible.

    • It may be worth noting that two years ago there was not one primary care physician in Washingtonian’s Top Doctors who took private insurance. I called each and every one on a lark.