Obamacare’s Impossible Expectations
By John C. Goodman • Wednesday October 10, 2012 10:39 AM PDT • 5 Comments
Suppose that Congress passed a law requiring all health plans to pay for an hour of free conversation every year between patients and doctors. The logical question would be: where are the doctors going to find all the additional hours to provide this service? The same question is relevant for the Affordable Care Act. It promises almost everyone in the country access to annual physicals, mammograms, Pap smears, prostate cancer (PSA) tests, colonoscopies and other services most are not now getting—with no deductible and no co-payment.[1] Who is going to deliver these services?
The Demand for Free Preventive Care
There’s an even more important question: when millions of Americans line up for additional preventive care, how will this affect cost, quality and access to care? In a 2003 study researchers at Duke University Medical Center estimated that it would require 1,773 hours a year of the average doctor’s time—or 7.4 hours every working day—for the average doctor to counsel and facilitate patients for every procedure recommended by the US Preventive Services Task Force.[2] And remember, every so often a screening test turns up something that requires more testing and more doctor time. The current supply of medical personnel cannot come anywhere close to providing what has been promised.
In addition, screening tests and similar services add to healthcare costs, rather than reduce them.[3] And sick patients may be crowded out in the process. Patients in higher-paying plans seeking preventive services could displace the more urgent needs of sick patients in lower-paying plans. The most vulnerable patients will be the elderly and the disabled on Medicare, poor families on Medicaid, and newly insured enrollees in subsidized private plans sold in the health insurance exchanges.[4]
Impact of Concierge Doctors
A major increase in demand and no change in supply will cause increased waiting for care almost everywhere, and one place patients will turn is to concierge doctors. In return for an annual fee, patients receive increased access and additional services.[5] Whereas a doctor in a regular practice typically has about 2,500 patients, however, a concierge practice usually has only about 500 patients. The more doctors that opt out of conventional care for concierge care, the greater the rationing problem becomes for everyone left behind. This could result in a two-tiered system in which those with more financial resources have concierge care, and everyone else is subjected to rationing by waiting.
The Administration’s Options
For its part, the Obama administration is caught on the horns of a dilemma. While it wants to be seen as the champion of preventive care, a vast increase in this kind of coverage will increase healthcare costs and crowd out access to care for those who have more serious medical needs. Even before healthcare reform, the Association of American Medical Colleges was predicting a 21,000 primary care physician shortfall by 2015, while the Health Resources and Services Administration at HHS estimated a shortage of between 55,000 and 150,000 physicians by 2020.[6]
The Obama administration knows the problem and is quite worried about it. Is there anything it can do to ameliorate the situation?
Apparently, Health and Human Services Secretary Kathleen Sebelius plans to use $250 million targeted for “prevention and public health” in the Patient Protection and Affordable Care Act for physician training instead.[7] The funds would train 500 physicians, 600 physician assistants, and 600 nurse practitioners. Also, she plans to raid pots of “stimulus” money created under the American Recovery and Reinvestment Act to subsidize the training of doctors and nurses. All told, the administration now claims it will train 16,000 primary care providers by 2015.[8]
However, this initiative will not create any new medical residency slots, which are required before a medical graduate can practice medicine. Thus, it is unlikely that any additional physicians will be trained. Moreover, virtually all of the medical students and nursing students who will be subsidized are already enrolled in medical training programs.
The Affordable Care Act is bad medicine for the ailments of American healthcare. For a better approach, please consult my Independent Institute book, Priceless: Curing the Healthcare Crisis.
Notes:
[1] Timothy Jost, “Implementing Health Reform: Preventive Services,” Health Affairs Blog, July 15, 2010.
[2] Damon Adams, “Who Has 7-Plus Hours a Day to Put Toward Preventive Care?” American Medical News, April 21, 2003.
[3] Louise B. Russell, “Preventing Chronic Disease: An Important Investment, but Don’t Count on Cost Savings,” HealthAffairs28 (2009): 42–45. doi: 10.1377/hlthaff.28.1.42.
[4] John C. Goodman, “For the Vulnerable, Expect Less Access to Care,” John Goodman’s Health Policy Blog, November 16, 2011.
[5] Devon M. Herrick, “Concierge Medicine: Convenient and Affordable Care,” National Center for Policy Analysis, Brief Analysis No. 687, January 19, 2010.
[6] Julian Pecquet, “Investment in Healthcare Workforce Announced as Doctor Shortage Looms,” Healthwatch, The Hill’s Healthcare Blog, June 16, 2010.
[7] Doug Trapp, “Primary Care Gets Boost with $250 Million in HHS Grants,” American Medical News, July 1, 2010.
[8] “Fact Sheet: Creating Jobs and Increasing the Number of Primary Care Providers,” Health Reform.Gov, December 12, 2010.
[Cross-posted in Psychology Today]
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Federal influence over medical school enrollment: Two generations ago the federal government provided funding to medical schools on a per-student basis. The schools became addicted to this funding. The catch was that the schools could not increase enrollment. If they increased medicals student class size, they would lose their funding. This kept annual new enrollment at under 16,000 throughout the 1990s and 2000s.
The Obama administration realized that when ObamaCare is fully implemented in 2014, tens of thousands of physicians will retire early or switch to concierge care. The administration therefore allowed medical schools to admit more students. Just over 18,000 were admitted last year. But, this will not help. These students will not graduate until 2015, and will not complete their residency training until 2018 at the earliest. And, since Medicare is not funding additional residency slots, the additional 2,000 graduates will take residency positions that would have been filled by foreign medical graduates. There will be no net increase in newly trained physicians, and everyone using ObamaCare can expect longer waits for non-emergent care. The longer waits mean that some patients will get much worse before their appointments, and they will seek emergency care. This will overload the already strained system.
MingoV | Oct 10, 2012 | Reply
There should be a Constitutional Amendment separating Medicine from the state except in the testing of competency and that should be done on a State by State basis. As this will probably never occur,the only thing I see happening in the next 5 or 10 years is that there will be some kind of single payer health plan,along the lines of Medicare and similar to Britain, that will be rammed down everyone’s throat. Of course the 10% or so who can afford it will be allowed to have their own private plans. With that said,it is obvious that America,today,is totally fiscally bankrupt and in the future,as is happening in much of Europe today, the average American will face long lines,long waits, and the withholding of care with older people just being sent home to die. The resources will just not be there. This is what happens when the average American thinks that they are “entitled” to something for nothing,in this case free or subsidized health care,and are running to jump on the government gravy train.
libertarian jerry | Oct 10, 2012 | Reply
Most of this “preventive care” is really just early detection.
Almost all effective prevention is lifestyle-based: health-promoting (primarily whole plant-based) diet, regular activity/exercise, no smoking, limited alcohol consumption, stress management, and belonging–being connected to life by love, a sense of community, and a commitment to a noble purpose.
Also, early detection fails the cost-benefit test. See: “Early Detection Testing?
Chance of Harm Is 100%: Chance of Benefit Is < 1 in a 1000"
Porkulus | Oct 11, 2012 | Reply
You can educate yourself to do much to see to your own health through study using the public library system and medical sites on the Internet. Then you will know “what” to look for, and in some cases, are likely to detect things that your “overworked” doctor might not detect. We already have a shortage of primary care physicians and this will grow much worse under Obamacare. Waits to see a doctor will grow much longer, especially for general practitioners. And if you do manage to get a doctor to see you, it is likely he or she will be so rushed for time that a thorough examination will be virtually impossible to obtain... Then there is the issue that under our current medical philosophy, doctors spend a great deal of time on unnecessary office visits and lab tests, which will increase the problem of getting to see a doctor in any reasonable period of time. This could be corrected by repeal of prescription laws as Libertarians such as myself have suggested, but selling the idea to the general public will be difficult at best unless things get so bad that people start to realize their doctor simply doesn’t have the time any more to do all these things...
Jerome Bigge | Oct 11, 2012 | Reply
Very true... but each person must be free to decide these things for him or herself, evaluate the relevance to their own needs and those of their legitimate dependents... and then to accept and live with the consequences of those decisions and choices – both good and bad.
MamaLiberty | Oct 12, 2012 | Reply