Doc shortages to deficits: Reform reality check

Arthur Caplan, Ph.D. • E-mail

It can be hard to separate the fact from the fiction of the myriad claims and questions separating health care reform. Some charges — that reform means the end of private insurance — are quite simply bogus. Other worries — that more insured Americans could worsen doctor shortages — are more justified.

As President Barack Obama’s health care reform plan faces a possible delay from opponents including Republicans, some conservative Democrats, health insurers and many pharmaceutical companies — it’s time to sort out the scare tactics from reality.

Claim: If millions of Americans become newly insured, there won’t be enough doctors and nurses to handle them.

Reality check: This truly is a problem but it's coming anyway. If current trends continue, the shortage of primary care physicians will reach 40,000 in a little more than 10 years, according to the American Academy of Family Physicians. Medical schools are only graduating about half the needed number of primary care doctors.

The overall shortage of doctors may grow to 124,400 by 2025, according to a study by the Association of American Medical Colleges. In a recent report, the researchers warn, "if the nation moves rapidly towards universal health coverage" which would be likely to increase demand for primary care and reduce immediate access to specialists, the shortages "may be even more severe.”

We need more primary care providers whether reform happens or not. We will need them sooner if reform does happen. What to do? Two simple ideas — forgive all medical school loans for any student willing to go into primary care and practice for a minimum of 20 years and extend more authority to nurses, pharmacists, physician-assistants and other health care professionals to help fill in the primary care gap.

Claim: Any public program will kill private insurance plans.

Reality check: This is not going to happen. The centrality of a public plan in Obama’s health reform push is to insure that an affordable basic package of services is available to all Americans, regardless of their health problems or health status. By pooling a large number of currently uninsured people into this plan, along with some others currently holding insurance, the cost of insurance should come down.

Video   Health care overhaul July 22: Health and Human Services Secretary Kathleen Sebelius responds to the RNC’s latest ad regarding health care reform. MSNBC

There will be many Americans who won’t want the public plan. They will want better coverage, or might even be able to get a cheaper plan by sticking with a one that just covers certain hospitals or doctors. 

Still, it is hard for private insurers to compete with government plans, if for no reason other than the lower administrative costs a public plan can offer. That's why more thinking needs to go into what sort of public plan the government should offer. My suggestion is a pretty bare bones public plan to start. 

Americans like to believe, and their insurers and medical organizations like to tell them, that everyone gets the same quality of care in America regardless of income. This is pure fantasy — as anyone who has visited both the Mayo Clinic and the troubled Martin Luther King-Harbor Hospital in Los Angeles, to pick two places at random, could quickly attest.

Congress needs to keep the basic plan basic. Otherwise, it will not be affordable and it may be too attractive to those who might otherwise buy private insurance. 

Another point about public plans to consider: We do have not-for profit insurers in many parts of the nation — Blue Cross Blue Shield and Kaiser Permanente, for example. Any chance of working out the public plan together with these already existing not-for profit insurers?

Claim: Health reform is moving too fast.

Reality check: Sen. Jon Kyl, R-Ariz., recently addressed this idea when he said, "President Obama was right about one thing: He said if it's not done quickly, it won't be done at all. Why did he say that? Because the longer it hangs out there, the more the American people are skeptical, anxious and even in opposition to it."

Well, the senator has a point but not for the reason he thinks. The longer reform stalls, the more the forces of the status quo can try to kill it.

That said, there is nothing magical about passing reform by August. The critics won't be all that much more empowered if reform gets finalized by the end of the year. But it had better not take much longer. The Washington lobbying crowd can crush anything in town given enough time and money.

Claim: Reform will result in the government rationing health care.

Challenges to reform Abortion and liability coverage could play a bigger role in derailing health care reform than any other issue. Here are some solutions to these real challenges. — Abortion Is abortion in or out of the public plan? Abortion coverage could prove to be a deal breaker that few are explicitly discussing. I am pro-choice, but I am not willing to hold tens of millions of Americans hostage to abortion being covered in the public plan. Instead, provide adequate coverage for contraception and adolescent sex education. Now is the time to put both sides to the test on this issue. — Liability What happened to fixing medical liability? Defensive medical practice is a prime cause for exploding health care costs. Add some liability reform into the public package where a consumer can take the public package, but must forfeit the right to sue for malpractice in favor of a mandatory arbitration system for allegations of substandard care. And make corresponding adjustments in the insurance premiums for health care providers who take on patients with public insurance.

Reality check: This is perhaps the scariest argument about health care. Even supporters of reform acknowledge rationing could happen. 

The main flaw with this criticism is that it implies we are not rationing health care now, that rationing will become a new feature in the post-reform American health care scene.

Rationing is already a daily part of the current system. How? By denying coverage to about 20 percent of the population, including a large number of children. These uninsured Americans either get no care, put off care until they are really sick, or simply use the emergency rooms of hospitals where they wait hour-after-hour to get care.

If that is not an unfair form of rationing, what is? 

Another form of health care rationing that exists now is the out-of-pocket fees patients have to pay, either due to high deductibles or generally lousy insurance coverage. Some doctors are simply opting out of the health insurance mess to set up boutique, concierge or cash-only medical practices — which results in another form of rationing.

Can we limit exploding costs by some form of rationing other than telling parents not to take their sick children to the doctor?

Claim: Health care reform will increase long-term federal spending on health care, thereby ballooning an already rapidly escalating deficit.

Reality check: Congressional Budget Office Director Douglas Elmendorf told the Senate Budget Committee in early July that the reform bills now circulating in Congress will lead to greater federal spending in future years. The Obama administration and some Democratic proponents of reform wished very hard that Elmendorf would go away. However, his caution has to be taken seriously. 

Records show White House health care talks Visitor records obtained Wednesday by The Associated Press show that top aides to President Barack Obama have met often with lobbyists and Democratic political strategists. NYT: Medical debt spurs more bankruptcies NYT: Health bill revives abortion groups Poll: Americans conflicted over health overhaul For Reid, Dodd, clout cuts both ways

The financing of reform to provide access to those who lack it needs to be strengthened. One way is to put a new income surtax on the wealthy, defined as households earning more than $350,000 a year. More sensible would be to start to tax those health benefits which are now enjoyed by the middle- and upper-class tax-free.

The issue of containing costs is more important. Obama has been talking a lot about pushing information technology into the health care system to make it more efficient and safe and collecting more data on what works, and what does not, in terms of tests and therapies. 

The IT push will not show that much in the way of cost-savings, even though it needs to get done. Collecting data on what works is fine, but that won’t save any money if we cannot agree that those things which are only marginally beneficial or completely experimental are not going to get reimbursed unless whoever wants them buys broad coverage from private insurers. Politicians don’t like to talk that way but proponents of reform need to ‘fess up on cost-containment.

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