By James A. Kidney
What if you needed a doctor and there was none? What if you suspected you had cancer, or suffered a stroke, or had a bad lingering cough, and your doctor could only see you in six or seven weeks?
For many, whether you have a good insurance plan or no plan at all, this is the case now. A 2014 study reported the average wait time for an appointment with a family physician was 66 days in Boston, 23 in Seattle, 26 in New York and 19 in Houston.
A combination of doctor shortage, overwork and low pay for Medicare and Medicaid patients is driving the growth of “concierge care” in which you pay an annual fee to guarantee you talk to a doctor when you need one. It is creating a multiple-tier system of care in which many physicians reject Medicare patients, or even all health insurance, and instead see patients on a cash basis at high fees. A patient can file his or her own claim. Good luck getting paid.
This is often the case now. It will continue to be the case whether the Affordable Care Act is preserved or not.
Whatever happens to Obamacare, the debate over health care in this country is typical of the way Congress has operated under Republicans and Democrats the last 40 years, i.e., “solutions” will be half-baked and ill-conceived. If they work at all, they will be hampered by constrictions imposed by ideology and campaign contributions. Mostly, they will leave voters unhappy and blaming their government, enforcing Tea Party antagonism.
We have an Internal Revenue Service overseeing an extremely complex tax code avoided by millions in an underground economy or by thousands of multi-millionaires hiring accountants to apply obscure and perhaps non-existent loopholes. Meanwhile, the IRS enforcement budget gets cut and cut again and again. Instead of simplicity and policing, we have complexity and laxity. And huge losses to the commonweal.
Our complicated welfare “safety net” of Medicaid, CHIPS, SNAP, TANF and 76 more programs for single parents (two-thirds of whom are white) doles out billions in a hodge podge of rules and regulations that complicate life for the truly needy but provide many fraud routes for the legendary “welfare queens” and able-bodied capable of holding a real job. Funds to police the system are low, the enforcement cops disrespected and harassed.
Our plans for medical coverage — the largest sector contributing to the gross domestic product, employing one out of nine people and accounting for 35 percent of job growth since 2007 — are similarly botched, whether by lightweight Democrat plans arising from typical timidity or Republican plans forcefully crushing the lower and middle classes.
Obamacare has provided health care to millions of previously uninsured. It has had large, measurable, positive effects on care. But it relies on tweaking traditional insurance models, affords the insurance companies insufficient profit and made promises (“you can keep your doctor”) that it can’t keep while costs go up more quickly than expected. Experts in the field can identify many other flaws. Due to Republican refusal to address and fix flaws in the ACA, it is failing in parts of the country.
The flaws in Obamacare were recognized early-on. As one commentator wrote in 2011, “Congress’s decision, for political and ideological reasons, to maintain the fundamental structure of the US health care system is the ACA’s major, perhaps fatal, flaw. It contributes to a multitude of more specific flaws.”
A straightforward single payer plan, or one combining more direct government support with private insurance (as is the case in several European countries), would not satisfy Republicans or even timid Democrats. So, as with nearly everything else coming from Congress, the country has a plan with flaws built-in to pass something by compromise. Democratic pols are mute about the fixes needed, if they ever get into power again, or the compromises necessary to make a solid, sustainable program.
In any event, a huge but unspoken problem with all the health care proposals is this: They focus exclusively on demand. There is no focus on supply, meaning the supply of doctors, physician assistants, nurse practitioners, and other health care personnel needed to diagnose, treat and care for millions of Americans if they did receive decent health coverage.
The National Center for Health Statistics reported in April 2017, using data from 2005 to 2015 — years before Obamacare through the year in which Obamacare was most robust — reported that the ACA resulted in fewer people having difficulty accessing needed medical care due to cost. But even in 2015, about one in every 10 adults aged 18 to 64 had difficulty accessing care. The worst was in the South, with 11 percent having difficulty. In the richer Northeast, 7.7 percent had problems.
A collection of data reported last year that 36 percent of physicians refuse to see Medicaid patients and 27 percent do not see Medicare patients. Fifty-four percent said their morale is “very or somewhat negative” and 47 percent reported accelerating their retirement plans. They reported working an average of 53 hours per week. An astonishing 81 percent reported working at capacity or being overextended.
The most thorough and accessible analysis of physician need is provided by the Association of American Medical Colleges (AAMC). Its 2017 update report on physician supply and demand projects continued increase in demand and shortfall in supply of physicians. Depending on scenarios applied, the shortfall could be between 40,800 and 104,900 physicians by 2030. This assumes increases in the number of physician assistants and advanced practice registered nurses, who are increasingly sharing the burden of primary patient care. Among specialties, the greatest shortfall is in specialized surgical practices.
Part of the reason for these shortfalls is the retirement of baby boom doctors. Others are a shortening of hours or rejection of new patients by physicians who already feel overburdened by their practice. Another reason is that the population aged 65 and over is projected to grow by 55% by 2030 — the very segment with high demands for health care.
Anti-immigration sentiment and stiff requirements for foreign-trained physicians to practice in the U.S. will aggravate the doctor shortage. Currently, about a quarter of active U.S. physicians are foreign-born and trained. They are especially concentrated in underserved area.
Providing improved access to health care would be a big driver of the doctor shortage. If everyone had the care that white, insured Americans living in metropolitan areas had, an additional 96,800 physicians would be required, according to the AMC report. Where will they come from?
Absent reliance on loosened standards for foreign-trained doctors and importing our supply of physicians, American medical schools must expand and the cost to students reduced. “Graduate medical education” in hospitals, such as residency programs, are largely funded by programs under Medicare and patient or insurance payments to hospitals. But going to undergraduate medical school is not funded so easily. Nearly 80 percent of graduating students have outstanding educational loans, most of them well into six figures. Obviously, this debt discourages graduates from going into the less lucrative specialties such as family practice, where the need is greatest, and makes becoming a physician less likely for the talented poor and middle class, who may already have large debt from their undergraduate education.
There are programs which will subsidize students or forgive their loans in return for spending the early part of a medical career in underserved geographic or medical areas. The AAMC reported that nearly 40% of graduating medical students in 2015 planned to participate in such programs. However, President Trump’s proposed 2018 federal budget and Education Secretary Betsy deVos have suggested cutting the public service loan forgiveness plan, a program that forgives student debt in many public service fields, including medicine, in return for 10 years of public service.
The doctor shortage is not a new or surprising issue. It has been projected for many years. Nevertheless, the Affordable Care Act offered nothing to address the issue. It instead encouraged a greater demand by providing cheaper and more available health insurance, without also addressing doctor supply.
Supply and demand is a basic rule of economics. A related concept is elasticity — how quickly supply can adjust to increased or reduced demand. Educating a doctor takes at least a decade, including four years of undergraduate school and another four years of medical school, plus a minimal residency program. That makes for a very inelastic supply, which means the issue must be addressed well before the need arises.
Our lawmakers do not recognize supply and demand. The Republicans will solve the problem by effectively smothering the demand side, not by reducing it (even Trump presumably does not believe he can cure disease of the masses with his small hands-on blessings), but by making the supply unavailable to many. Democrats want to recognize the demand, but have done nothing to address the supply.
As we have noted here recently, governing has not been in fashion in Washington for many years, especially responsible governing in which ideology is set aside so that practical solutions can be adopted which might actually solve a problem.
Delivery of good health care to those who need it (everyone) is a difficult subject with many obstacles. But one thing is clear: If you offer care to millions more people, you need to train doctors, physician assistants, nurses and others to provide it. Even congressmen and senators should be able to understand that — one hopes.