One of the more persistent myths about the push for universal health care is its provision will solve our medical care problems and improve our overall health. Well there’s one problem with that – medical care depends on the availability of medical care providers, and we have a shortage of those. So while everyone may have insurance, insurance doesn’t guarantee access.
Massachusetts offers a snapshot of how giving more people insurance naturally drives demand. The Massachusetts Medical Society last fall reported just over half of internists and 40 percent of family and general practitioners weren’t accepting new patients, an increase in recent years as the state implemented nearly universal coverage.
The entire push of the new law is to shift the country from seeking care when they’re sick to seeking preventive care to help prevent sickness. That means a shift from primary care physicians who are essentially gate-keepers (to specialists) to primary care physicians as, well, the primary care source for the patient. One problem – primary care physicians only make up 30% of the physician population. Couple the shift in emphasis with the addition of 30 million newly insured and you can do the numbers yourself.
So how is this going to be reversed? Well here’s the plan:
Yet recently published reports predict a shortfall of roughly 40,000 primary care doctors over the next decade, a field losing out to the better pay, better hours and higher profile of many other specialties. Provisions in the new law aim to start reversing that tide, from bonus payments for certain physicians to expanded community health centers that will pick up some of the slack.
Or, in other words, government plans on incentivizing primary care with “bonuses” and essentially deincentivizing specialists. The obvious hope is some specialists will go back to school and become primary care physicians. But there’s a culture at work within the physician community which is going to resist that. The other hope is more will choose primary care in medical school. Again, that cultural hierarchy will, at least initially, resist that. The hoped for result is a flock of primary care physicians and far fewer specialists. Market forces? Ha! And ignore those doctors who aren’t taking any new patients or are dropping out of the insurance game altogether to charge annual fees for unlimited visits and consultation.
Anyway, the grand plan, once this shift begins taking place, is to take a team approach to your care in something you will lovingly call your “medical home”:
Instead of the traditional 10-minutes-with-the-doc-style office, a “medical home” would enhance access with a doctor-led team of nurses, physician assistants and disease educators working together; these teams could see more people while giving extra attention to those who need it most.
I don’t know about you, but that’s pretty much how my care works now. I see a PA. She refers me to my primary care physician only if there’s something out of the ordinary for which his expertise is needed. Otherwise it is the rest of the team that takes care of me. The only thing this law changes is the number of people out there seeking this sort of care as far as I can tell – and oh, yes – this system has been in place with my physician for years. So somehow I’m missing how what they’ve been doing for years has been inadequate, but now that government thinks it is a good idea and it will suddenly take care of all our problems concerning access, and improved care, etc.
Your “medical home” will also include the following. Now I’m a bit of a student of human nature – but this too seems to be a bit of a fantasy:
Rolling out next is a custom Web-based service named My Preventive Care that lets the practice’s patients link to their electronic medical record, answer some lifestyle and risk questions, and receive an individually tailored list of wellness steps to consider.
Say Don’s cholesterol test, scheduled after his yearly checkup, came back borderline high. That new lab result will show up, with discussion of diet, exercise and medication options to lower it in light of his other risk factors. He might try some on his own, or call up the doctor — who also gets an electronic copy — for a more in-depth discussion.
Tell me – if Don is concerned about such things and willing to search out and consider options to help his condition, don’t you reckon he might already be on WebMD or a similar site right now doing that? And if Don isn’t likely to do such a thing, is this “custom Web-based service” likely to entice him to log on and do so?
That’s the whole fallacy behind preventive care – it assumes that if it is offered it will be sought out and its recommendations followed – without exception. The assumption is that Don, who has never followed the advice of his doctor about his cholesterol will suddenly do so because we’ve shifted the emphasis of his care to prevention and provided him access to information.
And, with the shortage of doctors and increased demands on their time, how likely is Don to really get that “in-depth discussion” he wants from his doctor? Yeah, not very. So how likely is Don to get frustrated with all of this and revert to his old and more comfortable (albeit less healthy) lifestyle? Meanwhile, doc has lots of new patients admitted into the “home” that his “team” is trying to deal with preventively or, doc is simply not taking any new patients because he or she can’t spend the time necessary with those already in the practice.
The point? As with most things centrally planned, it sounds good on paper. But such plans tend to discount human nature. They also tend to be overly optimistic. And lastly, they usually underestimate or ignore the true numbers involved in favor of some fantasy result where everything works as planned despite those numbers. That’s what we see here.
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I loved a tweet that Jon Henke sent out last night during the Obama health care press conference. It had me laughing – “Shorter Obama: you’re either with us or against us”.
In reality the press conference was the retelling of the same old nonsense. We’re going to expand the insurance system, require everyone be taken, no pre-existing conditions, no dropping you or denial of service. We’ll pay for it by finding some savings in waste, fraud and abuse, do health care delivery better than anyone else has ever done it, tax the rich and do it all – every bit of it – cheaper than it’s being done now, because we’re the government and we’re the experts in efficiency.
Tell me that wasn’t the crux of the presser? Anyone left wondering why the majority of Americans are skeptical?
And of course we had the usual canards out there. The claim that preventive medicine is cheaper than medicine as it is being practiced now. Take a moment to read this post by a doctor who lays out the con in minute detail. Here’s another view. Here’s a fact no one seems willing to deal with – the vast majority of all health care costs come in the last 6 months of life. No one has beaten death yet. Ergo that fact isn’t going to change unless the entity with the money refuses to pay up. So while preventive care may extend life, the cost of preventive care is more expensive and the end result remains the same.
As for paying for it, the whole appeal, of course, was to give the allusion to the middle class that he and the Dems were all for soaking the rich to cover the cost, even talking about how taxing millionaires met his “principle” on that.
But as Mickey Kaus points out, you have to listen carefully:
I don’t want that final one-third of the cost of health care to be completely shouldered on the backs of middle-class families who are already struggling in a difficult economy. And so if I see a proposal that is primarily funded through taxing middle-class families, I’m going to be opposed to that …
Kaus points out that those two words, in “Wash-speak” mean he’s open to a middle-class tax to pay for the “new” and “improved” health care (49% isn’t “primarily”, right?).
And then there’s the dawning understanding around much of the country that this isn’t about reforming health insurance at all (something that might be appealing to most). It is about a fundamental change in how health care is delivered. As the Republicans have begun saying, it is “experimenting” with your health care.
Can I guarantee that there are going to be no changes in the health-care delivery system? No. The whole point of this is to try to encourage changes that work for the American people and make them healthier. And the government already is making some of these decisions. More importantly, insurance companies right now are making those decisions. And part of what we want to do is to make sure that those decisions are being made by doctors and medical experts based on evidence, based on what works. Because that’s not how it’s working right now. That’s not–that’s not how it’s working right now.
Yes the government is already making some of those decisions. And the unfunded liabilities of the government system threaten to bankrupt us.
But the point remains that peppered all through the statement and answers was the phrase “health care delivery”. That is one of the things driving down the approval ratings on the legislation. Its one thing to say, “hey we’re going to eliminate pre-existing conditions, portability issues and denial of service while making sure everyone has insurance”. It is an entirely different thing to say “we’re going to tinker with and change the way your health care is delivered”.
Now suddenly the government is in territory few want it in. And that’s the overreach that Obama and the Democrats have committed that is driving the health care legislation approval numbers down. Which gets us into the politics of this.
Obama said “this isn’t about me”. But in fact it is all about him and maintaining his credibility. But his problem, as usual, is he’s outsourced his signature agenda item to Congress. Peter Wehner discusses the result:
On virtually every important issue — from the stimulus package, to cap-and-trade, to health care, to taxes, and more — Obama is ceding the agenda to the barons on Capitol Hill. And they will lead him over a cliff.
Why this is taking place is hard to know. It may be that Obama and Company are over-learning the lessons of the Clinton and Carter years, when relations with Democrats on the Hill were strained. It may be that Obama doesn’t like to immerse himself in the nitty-gritty of policy and is more comfortable deferring to those who do. It may be that the liberals on the Hill actually reflect what Obama himself — whose record as a legislator was, after all, markedly liberal — favors. It may be that Obama’s lack of experience is now showing through. Or it might be a combination of all four.
Regardless of the cause, the result will be damaging, and maybe even debilitating, to the Obama administration. All the campaign’s promises — about practicing a new brand of politics, finding middle ground, embodying hope and change — seem so old, so dated, and so cynical. Obama is turning out to be Salesman-in-Chief. But what he’s trying to peddle — an unusually liberal agenda and legislation that ranges from ineffective to downright harmful and reflects the desires of leading Congressional Democrats rather than the needs of the country — ain’t selling.
No, it’s not, thus the reason for the presser. As I pointed out yesterday, it is obvious at points he has no idea what is or isn’t in the bill. But what he does have a firm grasp on are his talking points, even if, as the days and weeks go by, they’re shot away or, at best, left hanging tattered and limp.
Speaking of politics, I love the attempt to take on the Republicans as the bad guys (one of the main Democratic talking points for days has been that the Republicans have brought no alternative to the table) and then this:
So, for example, in the HELP committee in the Senate, 160 Republican amendments were adopted into that bill, because they’ve got good ideas to contribute.
I’m not noting this with particular approval, I’m simply noting how this gives lie to the talking point.
To conclude, for anyone who has looked into the issue and followed the debate, such that is has been, Obama’s performance was anything but impressive. It was a mix of tired talking points and a con job – careful rhetoric that implied one thing while really saying something else (the middle-class tax increase being a perfect example).
But that doesn’t mean that some form of health care legislation won’t pass. I think, unfortunately, it will. And that is all about him and politics and he knows it. So do the Democrats. Clinton, Reagan, and GW Bush all passed their signature legislation before the first August recess in their first term. That isn’t going to happen in Barack Obama’s case. But he and the Democrats know that something they can call health care reform must pass or, as Obama is reported to have said, it will destroy his presidency.
To our eternal sorrow the fact that he’s right means the Democrats will do whatever is necessary to pass something to maintain his viability.