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Physician Capacity

A little while ago Scott Gottleib and Zeke Emmanuel co-authored an op-ed in The New York Times pooh-poohing the concern about physician shortages.

So certain are they that conventional wisdom is wrong that the piece is headlined, “No, There Won’t be a Doctor Shortage.” Right, and “if you like your health plan, you can keep your health plan — period”. Somehow such bold assertions have lost a bit of their luster over the past few months.

Now, they acknowledge that an aging population and the prospect of 30 million newly insured people may make it seem like there might be a problem, and the Association of American Medical Colleges says their members aren’t able to train enough physicians to fill the need, but what do they know about physician supply? Gottleib and Emmanuel know better.

As Exhibit 1, they look at Massachusetts. They write –

Take Massachusetts, where ObamaCare-style reforms were implemented beginning in 2006, adding nearly 400,000 people to the insurance rolls. Appointment wait times for family physicians, internists, pediatricians, obstetricians and gynecologists, and even specialists like cardiologists, have bounced around since but have not appreciably increased overall, according to a Massachusetts Medical Society survey.

httpv://www.youtube.com/watch?v=yWP6Qki8mWc

Help.
I need somebody.
Help.
Not just anybody.

Risk Adjustments in ObamaCare

Most of the commentators on the exchange roll out caution against the “death spiral,” in which failing to attract the young and healthy raises overall premiums. This further deters low-cost people from enrolling, resulting in even higher premiums.

This is absolutely true in a normal market. But a new report from the actuarial consulting firm Milliman shows how the Affordable Care Act has turned normal market principles on their head.

Here is the problem. Because health insurers are no longer allowed to ask any questions about an applicant’s health, they have absolutely no way of knowing who they are enrolling in terms of past or present illnesses or health conditions. They might attract a group of pretty healthy people or a group of pretty sick people, but they won’t know until people start filing claims. So it is impossible to accurately set premiums, at least for the first few years.

Another problem is that some insurers may attract a whole lot of very sick people while others attract mostly healthy people. In a particular state BlueCross may be known as the best place to go if you have cancer or heart disease, while Aetna may be famous for its discounts on gym memberships. The healthy people will be drawn to Aetna while the really sick people prefer the Blues. If companies could set premiums to accurately reflect their enrolled population, BlueCross premiums would be outrageously expensive while the Aetna premiums would be cheap.

ObamaCare tries to fix these problems in several ways.

The Tyranny of Electronic Systems

Some eight years ago the media was excited that Hillary Clinton and Newt Gingrich had formed an alliance about reforming health care. In 2005 Dana Milbank wrote in the Washington Post about a joint appearance in gushing terms –

Clinton, asked about electronic medical records, deferred, again, to her friend. “Newt has a very dramatic way of saying this,” she said, “which is ‘Paper kills.'” Gingrich sent the praise right back at her, hailing Clinton’s legislation on medical records as a “major breakthrough” in Congress. “This is absolutely the case that Hillary is making,” he said.

Of course, they were not alone. President Bush had already embraced the idea in his State of the Union speech to Congress.

Later, President Obama built the HITECH Act into his 2009 stimulus package and appropriated some $20 billion to make it happen. All promised to get everyone’s complete medical records in digital form by 2014.

Man, this is going to be GREAT! A model of modern efficiency! Bipartisan support! Interoperable! WOWSA!

Now, of course there were the usual naysayers and Gloomy Gusses. I was one of them in this research and commentary I wrote for the Heartland Institute. Dr. Bruce Landes, who comments here frequently, was another. Dr. Scott Silverstein at Drexel University was also skeptical. And Dr. Deborah Peele was very concerned about patient privacy in a digital era.

Most of these concerns were not about whether digital technology is a good thing. Of course it is, or can be, a very good thing. But the track record of top-down, politically imposed solutions is abysmal. And when you add vast amounts of money to the mix, chaos is inevitable. Great Britain went through a similar, though more modest, exercise and recently concluded that the whole thing was a failure, but only after spending some $12 billion.